Hair Transplantation, Fourth Edition (PDFDrive)

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Foreword
You have opened a remarkable book. Here is the fourth edition of a well-known text focused on the special techniques used in hair
replacement surgery. To believe this new edition consists simply of the addition of new material to an older text would be a grave
underestimation of what this new text has to offer.
The primary subject of this text is hair transplantation, although related subjects and other methods for hair replacement are also
well covered. All forms of surgical hair restoration have become increasingly complex in the past two decades. This is particularly
true with the very specialized techniques used in hair transplantation. Multiple variations have evolved for each single step in the
transplant procedure and most of these variations are successfully practiced somewhere in the world. Hair transplant surgery has
been transformed so greatly that anyone practicing 20 years ago would scarcely recognize the techniques and philosophy presented
in this new edition. To give perspective to this degree of change, consider the following synopsis of transplanting history.
In 1979, when the first edition of Hair Transplantation was published, there was essentially a single, universal technique for
transplanting hair. Round ‘‘plug’’ grafts were removed directly from the donor area and transplanted to the anterior scalp in carefully
arranged rows. Scientific discussions of the day focused on various ways to harvest the plugs and how best to arrange the rows.
Research appeared to be simply a search for ‘‘the one right way’’ to most efficiently transplant plugs in rows. The ease of surgery
for the surgeon tended to take precedence over the final results for the patient. No one seemed to recognize that the limitations of
transplanting were the unnatural appearance of the plugs and rows themselves. The plugs produced odd tufts of hair and nothing
in nature grows in rows. When the first edition of Hair Transplantation appeared, the surgery was considered so simple that several
surgeons openly wondered, ‘‘How can there possibly be enough information to fill a book?’’
Hair replacement surgery has since undergone revolutionary changes, reinventing itself, or perhaps we should say slowly inventing
itself, as a true surgical specialty. Gone are the plugs and rows. Also gone are most of the flaps and reduction procedures that were
once used so commonly as a substitute for hair transplantation. The surgical skill of artfully transplanting hair has emerged as the
champion in the arena of hair replacement surgery. Each step in the transplanting procedure has undergone imaginative and dramatic
changes. Now every surgeon can first choose from multiple ways to harvest donor hair, then create a great variety of grafts and
recipient sites, and select from any number of insertion techniques. By carefully selecting from the many variations, the surgeon
is able to create his own personalized procedure designed to give the optimal result to each individual patient. The changes to this
surgical procedure over the last 20 years are so great and so varied that surgeons are now apt to wonder ‘‘How can all this information
possibly fit into a single book?’’
So often a surgical text is found to be disconcertingly narrow in focus. An author may purposely present his method and his
philosophy as if no other approach exists. The readers of such texts are often left blind to the alternative ideas that are excluded.
Walter Unger has guided this text to be inclusive in nature and not exclusive of alternative ideas or techniques. A large number of
prominent surgeons from around the world were recruited to contribute to the core content. While many of these authors may
disagree on the optimal way to surgically correct hair loss, each has been allowed to clearly describe his individual approach and
technique. This forthright, open presentation of the subject, gives exceptional value to this text. This inclusive approach to the
subject is one of the special qualities that allow me to describe this book as remarkable.
Dr. Unger’s recruitment of Ron Shapiro as a co-editor for this edition also gives special value to the text. Few surgeons can
possibly match the experience and contributions of these two individuals. Together they have molded the many and varied written
contributions into a clear presentation of the material for the reader. Both editors and other invited experts have added valuable
commentary throughout the text to give the reader a balanced and proper perspective of the many ideas presented.
Anyone interested in hair replacement will find this edition extraordinary. A beginning surgeon will find no better text to serve
as a foundation for building a successful and fully understood practice of hair replacement. Experienced surgeons have always used
Hair Transplantation as their primary source of reference and this edition will add greatly to their sphere of understanding. This
iii
iv Foreword
particular quality of giving a wide breadth of information for the novice plus great depth of referenced information for the experienced
surgeon is also extraordinary.
As I stated initially, this fourth edition of Hair Transplantation is remarkable. The dedicated work over many years by Walter
Unger to produce this text, a work of love for science and the subject, is also remarkable. Truly remarkable.
James Arnold, M.D.

Pescadero, California, U.S.A.
Preface
The young know the rules, the elders know the exceptions.
This book’s goal is to present both rules and exceptions. The contributors have been chosen on that basis. Rules are far easier to
learn, convey, and promote than complicated exceptions, but without the latter, rules are synonymous with dogma.
One of the most disturbing trends in hair replacement surgery in the last decade has been a tendency to combine dogma with
false advertising. Either one of these is bad enough. Their increasingly common marriage and the apparent relative impotence of
ethical physicians to counter the effects of this union were among the major stimuli that led me to undertake a fourth edition of
this textbook. The ‘‘cloaking’’ of misrepresentations, with professions of high-sounding idealism, whether by Internet ‘‘guardians’’
of the public or physicians, is particularly offensive. It should never be forgotten that dogma is the handmaiden of both the
establishment and the revolutionaries. It is the enemy of rational evolution and true progress.
My co-editor, Ron Shapiro, and I have done our best to present fairly, and extensively, all sides of current debates in our field.
The contents of this book will amply demonstrate that there are reasonable rationales for different techniques in hair transplanting.
There will always be those among us who believe and advertise that they have found the ‘‘Holy Grail’’ or, in today’s parlance, the
‘‘gold standard’’ of treatment that makes all other treatments obsolete or worse. These physicians, well meaning or not, provide
the ammunition for members of the public to attack our profession. More importantly, the ‘‘single solution to all problems’’ debases
the treatment of our patients. Someone once said that for every complex problem there is a simple solution—and it is always wrong.
Moreover, there are so many variables in any supposedly ‘‘single’’ technique that the concept of a homogeneous one with inevitable
advantages and disadvantages is absurd. The Chaos theory teaches that even a tiny change early on in a mathematical calculation
can have enormous consequences on the final result. This is just as true in medicine as it is in mathematics. There are innumerable
opportunities for those tiny differences in hair transplanting technique—some of them unrecognized even by their practitioners—to
produce results that vary substantially, despite the ‘‘same’’ approach having been used. Hopefully one day physicians, the media,
and Internet websites will recognize all of the preceding and will begin to truly help the public by reflecting this complex reality.
I believe as strongly in the benefits of change as I do in the detriments of dogma. One of life’s golden rules is that one is either
growing or dying. You cannot really stay the same. Hair restoration surgery, fortunately, continues to be a rapidly evolving procedure.
Over the three and a half years it took to assemble this text, for example, many of the contributors somewhat altered their views
and approach to the subject they discuss. (Summaries of such changes have been included as addendums to their sections or in the
last chapter of the text.) But everything new is affected by ‘‘the law of unintended consequences.’’ The authors of new concepts
are sometimes prophets and sometimes false gods. It is a good idea to remember that.
Most importantly, as you read the contents of this book, I urge you to try hard to understand the reasoning behind the recommenda-
tions of those with whom you disagree. None of the authors are fools, visually impaired, or liars. Whether or not you ultimately
agree with them, within the conflict of their ideas and yours are the seeds of change and real progress.
This textbook would not have been possible without the enormous patience of my wife, Marcia, and our eight children. I am
grateful beyond measure for their love and their acceptance and forgiveness of the time I stole from them to accomplish this task.
I must also thank all the contributors and especially my co-editor Ron Shapiro for their time and effort. Without their help the
authority and breadth of this text would not have been possible. In addition, my daughters, Dr. Robin Unger and Zoe Unger, were
invaluable aids in its final review and ‘‘polishing.’’
Lastly, but far from least, I must thank my secretary Murphy for the countless hours and frustrations that she endured. I am not
sure the book would have been finished before it was out-of-date without her taking turns with me on organizing and supervising
everyone concerned with its production.
Walter P. Unger
v
Contents
Foreword James Arnold iii

Preface Walter Unger v
Contributors xi
1. History and Patient Relationship 1

1A. How It All Began: Autografts in Alopecias and Other Selected Dermatological Conditions 1
Norman Orentreich
1B. The History of Hair Transplantation Walter P. Unger 7
1C. The Physician-Patient Relationship Richard C. Sheill 16
1D. The Future of Hair Restoration Surgery Russell Knudsen 20
2. Basic Science 25
2A. Hair Anatomy and Histology Paul T. Rose, Ron Shapiro, and Michael Morgan 25
2B. Anatomy of the Scalp Paul T. Rose, Matthew L. Leavitt, and Mont J. Cartwright 33
2C. Surgical Anatomy of the Scalp Gerard E. Seery 37
2D. Differences in Gene Expression in Bald and Non-Bald Dermal Papillae Moon-Kyu Kim and 42
Jung-Chul Kim
2E. The Promise of Cell Therapy: Tissue Engineering Applied to the Treatment of Alopecia 44
Jerry E. Cooley
3. Androgenetic Alopecia 49
3A. Classification of Androgenetic Alopecia Rolf E. A. Nordström 49
3B. The Incidence and Degree of Androgenetic Alopecia at Various Ages in Men and Women 51
Walter P. Unger
3C. Does the Recipient Site Influence the Hair Growth Characteristics in Hair Transplantation? 56
Sungjoo Hwang, Jung-Chul Kim, Seok Jong Lee, Gun Yoen Na, and Do Won Kim
3D. Current Views on Pathogenesis and Medical Treatment of Male Pattern Baldness 60
David A. Whiting
4. Hair Loss Unrelated to Androgenetic Alopecia Eric L. Eisenberg 67
5. Basic Principles and Organization 81

5A. Planning and Organization of the Recipient Area Walter P. Unger and Michael L. Beehner 81
5B. Effect of Medical Therapy on Surgical Planning Russell Knudsen 146
5C. Hair Transplant Goals Based on Natural Hair Patterns William M. Parsley 151
vii
viii Contents
6. The Initial Interview 165

6A. My Personal Approach to the Interview Walter P. Unger 165
6B. Patient Expectations and Surgical Options Based on Age, Ethnicity, and Sex Robert T. Leonard 170
6C. Non-Physician Interviews: Advantages/Disadvantages and Ethical Control Matthew L. Leavitt 173
7. Preoperative Phase 189

7A. Preoperative Preparation and Instructions Walter P. Unger 189
7B. Additional Comments on Preoperative Preparation Bernard H. Cohen 194
7C. Conventional and Non-Conventional Medications in Hair Transplantation Jonathan L. Nelson 196
7D. OSHA and Laboratory Screening James A. Harris and Ron Shapiro 200
7E. Antibiotic Use in Scalp Surgery John Karl Randall 202
7F. Emergency Intervention in Hair Restoration Surgery Carlos Puig and Ron Shapiro 204
8. Anesthesia 225
8A. Overview of Anesthesia Bradley R. Wolf 225
8B. Techniques for Limiting the Amount of Epinephrine in Large Hair Restoration Surgeries 245
Robert M. Bernstein and William R. Rassman
8C. Unger’s Technique for Anesthesia Walter P. Unger 250
8D. Supraorbital and Supratrochlear Nerve Blocks in Hair Transplantation David J. Seager and 254
Cam Simmons
9. Graft Survival, Growth, and Healing Studies 261

9A. Studies of Hair Survival in Grafts of Different Sizes Michael L. Beehner
Additional Hair Survival Studies and Conclusions Walter P. Unger 261
9B. Light and Electron Microscopy of Follicular Unit Grafting: Studying Iatrogenic Injury of 279
Follicles Marcelo Gandelman and Paulo Alexandre Abrahamsohn
9C. Hair Survival of Partial Follicles: Implications for Pluripotent Stem Cells and Melanocyte 281
Reservoir Jung-Chul Kim and Yung-Chul Choi
9D. The Effects of Dehydration, Preservation Temperature and Time, and Hydrogen Peroxide on Hair 285
Grafts Jung-Chul Kim and Sungjoo Hwang
9E. Wound Healing and Revascularization of the Hair Transplant Graft: The Role of Growth 287
Factors David Perez-Meza
10. Donor Harvesting 301

10A. The Donor Area Walter P. Unger and John Cole 301
10B. The Unger Approach to the Donor Area Walter P. Unger 337
10C. The Cole Approach to the Donor Area John Cole 342
11. Graft Preparation 349

11A. A Personal Approach to Ergonomics in Graft Production Guillermo Blugerman and 349
Diego Schavelzon
11B. Classic Microscope Dissection of Follicular Units David J. Seager 355
11C. Combining Microscopic Slivering with Backlighting and Loupe Magnification to Efficiently Produce 363
Grafts Paul T. Rose and Ron Shapiro
11D. Impulsive Force Graft Preparation E. Antonio Mangubat 372
11E. Preparation of Multi-Follicular Unit Grafts Walter P. Unger 380
12. Recipient Site Grafts and Incisions 383

12A. The History of the Follicular Unit Micrografting Technique: A Personal View Bobby L. Limmer 383
12AA. The Rationale for Follicular Unit Transplantation Robert M. Bernstein and William R. Rassman 388
12B. Pitfalls of Follicular Unit Hair Transplantation and How to Avoid Them David J. Seager 408
12C. Micro-Minigrafting: The Substance and Theory for Its Use William H. Reed 418
12D. Follicular Unit Transplantation Alone or Follicular Units with Multi-FU Grafts: Why, When, and 435
How? Ron Shapiro
12E. Recombinant Follicular Units: Concept Formalization James A. Harris 469
12F. Why ‘‘Mixed’’ Grafting: Follicular Units and Multi-Follicular Unit Grafts Walter P. Unger 475
12G. How I Use Multi-FU Grafts Walter P. Unger 503
12H. Hair Transplantation in Women Walter P. Unger and Robin H. Unger 516
12I. Lasers in Hair Restoration Surgery Carlos Oscar Uebel 524
Contents ix
13. Graft Insertion and Placement 533

13A. Placing Grafts: An Overview of Basic Principles and Current Controversies Ron Shapiro 533
13B. ‘‘Stick and Place’’ Method of Planting David J. Seager 539
13C. Insertion of Multi-FU Grafts Walter P. Unger 549
14. Postoperative Phase 553

14A. Bandaging Walter P. Unger 553
14B. Management of the Postoperative Period William M. Parsley 555
14C. Complications of Hair Transplantation Jerry E. Cooley 568
15. Transplanting Areas That Need Special Consideration 579

15A. Eyebrow, Eyelash, Mustache, and Pubic Area Hair Transplantation Yung-Chul Choi and Jung- 579
Chul Kim
15B. Transplantation of Temporal Points Melvin L. Mayer and David Perez-Meza 584
15C. Hair Transplantation in Asian Patients Kenichiro Imagawa 591
15D. Hair Restoration in Black Patients Melvin L. Mayer 595
15E. Hair Transplantation in the Transsexual Male Richard C. Shiell 602
15F. Transplanting Into Scar Tissue and Areas of Cicatricial Alopecia Paul T. Rose and Ron Shapiro 606
16. Personal Techniques 611

16A. Microstrip Grafting Patrick Frechet 611
16B. A Personal Hair Restoration Technique from Brazil Arthur Tykocinski and Ron Shapiro 620
16C. Optimal Strategies in Hair Transplantation Jörg Hugeneck and Claudia Moser-Prawetz 626
16D. Surgical Refinements and Artistic Creativity in Hair Restoration Shagufta Khan and Sajjad Khan 635
16E. The Punctiforme Technique Carlos Oscar Uebel 641
16F. The Hair Transplant Procedure in My Office Arturo Sandoval-Camarena 650
16G. The No-Touch Technique Konstantinos J. Minotakis and Ron Shapiro 657
17. Correction of Cosmetic Problems in Hair Transplanting Walter P. Unger 663
ALOPECIA REDUCTION AND FLAPS
18. Basic Science and Principles of Reductions and Flaps 689

18A. Scalp Surgery: Mechanical and Biomechanical Considerations Gerard E. Seery 689
18B. Classification of Scalp Laxity Rolf E. A. Nordström 697
18C. The Science of Skin Stretch and Tissue Expansion James E. Vogel 698
19. Alopecia Reduction Procedures 709

Introduction to Alopecia Reduction Gerard E. Seery 709
19A. My Approach to Alopecia Reduction Martin G. Unger 710
19B. My Approach to Alopecia Reduction Mario Marzola 737
19C. The Complications of Alopecia Reduction Robert V. Cattani 749
19D. Galea Fixation: Alopecia Reduction Surgery Gerard E. Seery 751
20. Scalp Extension 765

20A. Scalp Extension Patrick Frechet 765
20B. Tips for the Novice in Scalp Extension Ciro De Sio 785
21. Flap Procedures 795

Introduction to Flap Procedures Gerard E. Seery 795
21A. Pedicle Flaps in the Surgical Treatment of Alopecia José Juri 796
21B. Microsurgical-Free Flaps Kitaro Ohmari 801
21C. Microsurgical-Free Temporo-Parieto-Occipital Flap José Juri 808
21D. My New Expanded Scalp Flap Technique Richard D. Anderson 812
21E. Scalp Expansion for Traumatic and Iatrogenic Alopecia Mark D. Epstein 820
21F. Complications of Flaps—Avoidance and Treatment Patrick Rabineau 828
x Contents
22. Setting Up an Office 831

22A. Building a Hair Restoration Surgery Practice Paul C. Cotterill 831
22B. The Surgical Suite Walter P. Unger 833
22C. Instrumentation and Supplies Used in Hair Restoration Surgery Sharon Keene and Ron Shapiro 835
22D. Surgical Assistants James A. Harris and Shanee Courtney 851
22E. The Phototrichogram: An Objective Macro-Photographic Evaluation Method Pierre Bouhanna 857
22F. Standardized Photography Barry E. DiBernardo and Gregory M. Galdino 860
22G. Digital Photography and Office Automation E. Antonio Mangubat 870
22H. Measuring Hair Density and Mass Frank G. Neidel and Petra Bretschneider 876
23. Some Things New, Some Things Old 887

23A. The Hair Loss Profile and Index: A Classification System for Pattern Balding Bernard H. Cohen 887
23B. Analysis of Hair Characteristics in Koreans Using Phototrichograms Jae-Hak Yoo 892
23C. The Coronal Incision Recipient Site Victor Hasson 898
23D. Comments on Hair Transplanting Emanuel Marritt 901
23E. The Best Possible Hairline: A Tip Martin E. Tessler 904
23F. Long Term Follow-Up of Patients Walter P. Unger 905
23G. Closure of the Donor Zone Felipe Coiffman 911
23H. Medico-Legal Issues in Hair Replacement Michael Neff and Paul T. Rose 913
Epilogue: Addendums to Chapters and Recent Developments 921

A. Mayer’s and Keene’s Study Comparing FU Growth with Different Planning Densities Walter P. Unger
B. Kolasinski’s Studies Walter P. Unger
C. Our Duty as Physicians Catello Balsamo
D. The Effect of Recipient Site Factors on Transplanted Scalp Hair Walter P. Unger
E. Efficacy of Finasteride, Minoxodil, and Ketaconazole Shampoo for the Treatment of MPB Walter P. Unger
F. Androgenetic Alopecia David Whiting
G. The Promise of Cell Therapy Jerry E. Cooley
H. The Hair Loss Profile and Index Bernard H. Cohen
I. The KMI-Finger Mounted, Rotating Graft Reservoir Sharon Keene
J. Raising the Overly Flat Hairline Michael L. Beehner
K. Mirror Image Concept in Hair Transplantation Michael L. Beehner
L. Hair Transplantation in Black Patients Walter P. Unger
Index 931
Contributors
Paulo Alexandre Abrahamsohn, M.D. Department of Histology and Embryology, Institute of Biomedical Sciences, University
of São Paulo, Brazil
Richard D. Anderson, M.D. Scottsdale Health Care Hospital and private practice, Scottsdale, Arizona, U.S.A.
Catello Balsamo, M.D. Private practice, Modena, Italy
Michael L. Beehner, M.D. Associate Clinical Professor, Dermatology, Albany Medical College, Albany, and private practice,
Saratoga Springs, New York, U.S.A.
Robert M. Bernstein, M.D. Associate Clinical Professor of Dermatology, Columbia University, and private practice, New York,
New York, U.S.A.
Guillermo Blugerman, M.D. Private practice, Buenos Aires, Argentina
Pierre Bouhanna, M.D. Assistant Clinical Professor, Hair Pathology Center Sabouraud, Hôpital Saint Louis, Paris, France
Petra Bretschneider, M.D. Department of Dermatology, St. Bernard Hospital, Kamp Lintfort, Germany
Mont J. Cartwright, M.D. Private practice, Abilene, Texas, U.S.A.
Robert V. Cattani, M.D. President of the American Board of Hair Restoration Surgery, and private practice, New York, New
York, U.S.A.
Yung-Chul Choi, M.D. Togo Clinic, Seoul, Korea
Bernard H. Cohen, M.D. Clinical Professor, Dermatology and Cutaneous Surgery, University of Miami School of Medicine,
Miami, and private practice, Coral Gables, Florida, U.S.A.
Felipe Coiffman, M.D., F.A.C.S. Professor of Plastic Surgery, National University of Colombia, and Chief, Laboratory of Basic
Surgical Training Fundación, Sante Fe de Bogotá, Colombia
John Cole, M.D. Private practices, Atlanta, Georgia, and New York, New York, U.S.A.
Jerry E. Cooley, M.D. Private practice, Charlotte, North Carolina, U.S.A.
Paul C. Cotterill, B.Sc., M.D. Private practice, Toronto, Ontario, Canada
Shanee Courtney, R.N. Private practice, Littleton, Colorado, U.S.A.
xi
xii Contributors
Ciro de Sio, M.D. Istituto Dermopatico dell’Immacolata, Department of Plastic Surgery, Rome, Italy
Barry E. DiBernardo, M.D., F.A.C.S. Clinical Assistant Professor, Plastic Surgery, University of Medicine and Dentistry of
New Jersey, and Director, New Jersey Plastic Surgery, Montclair, New Jersey, U.S.A.
Eric L. Eisenberg, M.D., F.R.C.P.(C) Toronto Western Hospital, University Health Network, Lecturer in Dermatology, University
of Toronto, and private practice, Toronto, Ontario, Canada
Mark D. Epstein, M.D., F.A.C.S. Private practice (Plastic Surgery), Stony Brook, New York, U.S.A.
Patrick Frechet, M.D. Private practice, Paris, France
Gregory M. Galdino, M.D. Resident in Plastic Surgery, Johns Hopkins Hospital and School of Medicine, Baltimore, Maryland,
U.S.A.
Marcelo Gandelman, M.D. Department of Histology and Embryology, Institute of Biomedical Sciences, University of São Paulo,
Brazil
James A. Harris, M.D., F.A.C.S. Assistant Clinical Professor, Department of Otolaryngology/Head and Neck Surgery, University
of Colorado Health Science Center, Denver, and private practice, Englewood, Colorado, U.S.A.
Victor Hasson, M.D. Private practice, Vancouver, British Columbia, Canada
Jörg Hugeneck, M.D. Moser Medical Group, Vienna, Austria, and Bonn and Augsburg, Germany
Sungjoo Hwang, M.D. Director of Dr. Hwang’s Hair Clinic, Seoul, Korea
Kenichiro Imagawa, M.D. Private practice, Yokohama, Japan
José Juri, M.D. Director, Clinica Juri de Cirugia Plastica, Buenos Aires, Argentina
Sharon Keene, M.D. Private practice, Tucson, Arizona, and Shapiro Medical Group, Minneapolis, Minnesota, U.S.A.
Sajjad Khan, M.D. Private practice, San Diego, California, U.S.A.
Shagufta Khan, M.D. Private practice, San Diego, California, U.S.A.
Do Won Kim, M.D. Department of Dermatology, Kyungpook National University School of Medicine, Taegu, Korea
Jung-Chul Kim, M.D., Ph.D. Professor, Immunology and Dermatology, Hair Research Center, Kyungpook National University
School of Medicine, Taegu, Korea
Moon-Kyu Kim, M.D. Kyungpook National University, Taegu, Korea
Russell Knudsen, M.B., B.S. Private practice, Sydney, Australia
Matthew L. Leavitt, D.O. Director, Medical Hair Restoration, Heathrow, Florida, U.S.A.
Seok Jong Lee, M.D. Department of Dermatology, Kyungpook National University School of Medicine, Taegu, Korea
Robert T. Leonard, Jr., D.O. Assistant Clinical Professor, Dermatology and Family Practice, University of New England College
of Osteopathic Medicine, and private practice, Cranston, Rhode Island, U.S.A.
Bobby L. Limmer, M.D. Clinical Professor of Dermatology and Adjunct Clinical Faculty of Plastic Surgery, University of Texas
Health Science Center; Consultant in Dermatology, Brooke Army Medical Center; and private practice, San Antonio, Texas, U.S.A.
E. Antonio Mangubat, M.D. Private practice, Seattle, Washington, U.S.A.
Emanuel Marritt, M.D. Clinical Instructor, Division of Hair Transplantation, Department of Otolaryngology/Head and Neck
Surgery, University of Colorado Health Sciences Center, Denver, Colorado, U.S.A.*
*(Retired 2000).
Contributors xiii
Mario Marzola, M.B., B.S. Private practice, Adelaide, Australia
Melvin L. Mayer, M.D. Regional Director with Medical Hair Restoration, and private practice, Poway, California, U.S.A.
Konstantinos J. Minotakis, M.D. DHI Medical Group, Athens, Greece
Michael Morgan, M.D. Departments of Pathology and Dermatology, University of South Florida, and James Haley VA Hospital,
Tampa, Florida, U.S.A.
Claudia Moser-Prawetz, Moser Medical Group, Vienna, Austria, and Bonn and Augsburg, Germany
Gun Yoen Na, M.D. Department of Dermatology, Kyungpook National University School of Medicine, Taegu, Korea
Michael Neff, Esq. Professor of law, Southern California University for Professional Studies, Santa Ana, California; Adjunct
Instructor, Pasco-Hernando Community College, New Port Richey; and Essex Committee Member, Regional Medical Center,
Bayonet Point, Florida, U.S.A.
Frank G. Neidel, M.D. Private practice, Düsseldorf, Germany
Jonathan L. Nelson, M.D. Dermatology Resident, Mount Sinai Hospital, New York, New York, U.S.A.
Rolf E. A. Nordström, M.D., Ph.D. Professor, Plastic and Reconstructive Surgery, and Chief of Nordström Hospital, Helsinki,
Finland
Kitaro Ohmori, M.D. Chief Director, Department of Plastic and Reconstructive Surgery, Tokyo Metropolitan Police Hospital,
Tokyo, Japan
Norman Orentreich, M.D., F.A.C.P. Clinical Professor, Department of Dermatology, New York University School of Medicine,
New York, New York, U.S.A.
William M. Parsley, M.D. Associate Clinical Professor, Department of Dermatology, University of Louisville Medical School,
Louisville, Kentucky, U.S.A.
David Perez-Meza, M.D. Latin American Director, Medical Hair Restoration, Maitland, Florida, U.S.A.
Carlos Puig, D.O. Private practice, Houston, Texas, U.S.A.
Patrick Rabineau, M.D. Private practice, Paris, France
John Karl Randall, R.Ph., M.D. Randall Dermatology & Cosmetic Surgery Center, West Lafayette, Indiana, U.S.A.
William R. Rassman, M.D. Private practice and founder of New Hair Institute, Los Angeles, California, U.S.A.
William H. Reed, II, M.D. Private practice, La Jolla, California, U.S.A.
Paul T. Rose, M.D. Associate Professor, Department of Dermatology, University of South Florida Medical Center, and private
practice, Tampa, Florida, and Shapiro Medical Group, Minneapolis, Minnesota, U.S.A.
Arturo Sandoval-Camarena, M.D. Private practice, Guadalajara, Mexico
Diego Schavelzon, M.D. Private practice, Buenos Aires, Argentina
David J. Seager, M.B., B.S. Director, The Seager Hair Transplant Center, Toronto, Ontario, Canada
Gerard E. Seery, M.D., F.R.C.S. Private practice, Carmichael, California, U.S.A.
Ronald Shapiro, M.D. Director, Shapiro Medical Group, Minneapolis, Minnesota, U.S.A.
Richard C. Shiell, M.B., B.S. Private practice, Melbourne, Australia
Cam Simmons, M.D. Private practice, The Seager Hair Transplant Center, Toronto, Ontario, Canada
xiv Contributors
Martin E. Tessler, M.D. Private practice, Southfield, Michigan, U.S.A.
Arthur Tykocinski, M.D. Private practice, São Paulo, Brazil
Carlos Oscar Uebel, M.D. Associate Professor, Division of Plastic Surgery, PUCRS University, Pôrto Alegre, Brazil
Martin G. Unger, M.D., F.R.C.S.C. Chief of Plastic Surgery, One Medical Place Hospital, and Director, Unger Cosmetic Surgery
Center, Toronto, Ontario, Canada
Robin H. Unger, M.D. Private practice, New York, New York, U.S.A.
Walter P. Unger, M.D., F.R.C.P.(C), F.A.C.P. Clinical Professor, Department of Dermatology, Mount Sinai Medical School, New
York; Visiting Professor, Dermatology, Johns Hopkins School of Medicine, Baltimore, Maryland; Associate Professor, Department of
Dermatology, University of Toronto, Toronto, Ontario; and private practices in Toronto, Ontario, Canada, and New York, New
York, U.S.A.
James E. Vogel, M.D. Assistant Professor, Division of Plastic Surgery, Johns Hopkins Hospital and School of Medicine, and
private practice, Baltimore, Maryland, U.S.A.
David A. Whiting, M.D., F.A.C.P., F.R.C.P.(Ed) Clinical Professor of Dermatology and Pediatrics, University of Texas South-
western Medical Center, and Medical Director, Baylor Hair Research and Treatment Center, Dallas, Texas, U.S.A.
Bradley R. Wolf, M.D. Private practice, Cincinnati, Ohio, U.S.A.
Jae-Hak Yoo, M.D. Department of Dermatology, College of Medicine, Sungkyunkwan University, Seoul, Korea
1
History and Patient Relationship
1A. How It All Began: Autografts in a normal graft was transplanted to a normal site; (2) a normal
graft was transplanted to an affected site; (3) an affected graft
Alopecias and Other Selected was transplanted to a normal site; (4) an affected graft was
Dermatological Conditions* transplanted to an affected site.
Wherever feasible, the grafts were transposed in clockwise
Norman Orentreich
fashion (Fig. 1A-3c).
Care was taken to set the grafts so that the possible growth
Skin autografts have been employed in animals to study hair of the hair would be in the desirable direction (Fig. 1A-3b).
growth (2–4, 7–9), pigment formation (1,2,5–7), wound heal- Hemostasis was obtained by direct pressure for 20 to 30 min-
ing (10–11), and immunity(12). Exchange autografts were per- utes.
formed in man to study vitiligo (13–15), amyloidosis (16), mor- Fixation of the graft was accomplished by fibrin clot, Telfa
phea (16), scleroderma (13), acrodermatitis chronica (perforated plastic dressing), Scotch tape, adhesive tape, collo-
atrophicans (16), allergic eczematous dermatitis (17), fixed drug dion (Fig. 1A-4a), or sutures (Figs.1A-3a, b, and c). The 6-mm
eruptions (18–22), and hyperidrosis (23). The effects of auto- and 8-mm grafts rarely required sutures. The 12-mm grafts were
grafts have been observed after plastic repairs for lupus erythe- all sutured in place. The sutures were inserted near the graft
matosus (24). and carried over the graft. No suturing was done into or under
Autografts to the eyebrow, hand, scalp, and other areas at the graft. Sutures and other dressings were removed after the
times have shown not only the hair growth desired on such sixth to ninth day (Fig. 1A-3d). Photographs were taken before
grafts but also, occasionally, the development of unwanted hair and after the procedures, and at about monthly intervals there-
(25–41). after.
The experiments were performed in studying the following
METHOD maladies affecting hair growth:
Multiple transpositions of skin punch free grafts were per- Disorder Number
formed in order to study some factors in the pathogenesis of Alopecia prematura 52
certain dermatological disorders, especially the alopecias. After Alopecia areata 9
local anesthesia, and appropriate surgical preparation of the Alopecia cicatrisata 3
skin, which included washing, shaving, and cleansing with alco- Woolly hair nevus 1
hol, four full-thickness circular excisions were made with
punches of 6-mm, 8-mm, and 12-mm diameter (Fig. 1A-1).
Two of the circular grafts were excised from a site of persistent Alopecia Prematura
disease, represented by the circle, and two circular specimens The 52 subjects with alopecia prematura (common male pattern
were excised from a normal site (Fig. 1A-2). baldness) were white men, aged 19 to 50 years. The longest
The grafts were removed; and it was ascertained that the follow-up period in the study was 21⁄2 years (Fig. 1A-7b). In
excision was carried below the hair follicles. Each graft was some of these patients, grafts were repeated on several occa-
trimmed of excess fat, and of the galena aponeurotica if present. sions.
The grafts were then transplanted in the following manner: (1)
Alopecia Areata
*
Reprinted from Annals of the New York Academy of Sciences 1959; 83: There were four women and five men, including one African
463–479. American, with alopecia areata. Their ages varied from 22 to
1
2 Chapter 1
Figure 1A-3 This is a patient with alopecia areata: (a) an ‘‘alo-

Figure 1A-1 Punches of various diameters. pecia-to-alopecia’’ graft; (b) a ‘‘hair-to-alopecia’’ graft held in
place with sutures; (c) the four autografts after transplantation in
clockwise fashion; (d) the graft after the sutures have been re-
moved.
42 years. The follow-up period was 1 to 11⁄2 years. In one of

the patients, the experiment was repeated.
Alopecia Cicatrisata
Three white women, aged 50, 54, and 58 years, had alopecia
cicatrisata. Clinically and according to the history, they were
probably ‘‘burned-out’’ cases of pseudopelade of Brocq. The
follow-up period in these patients was 11⁄2 years.
Woolly Hair Nevus

One African-American woman, aged 37 years, with woolly hair
nevus, was observed for 1 year.
Psoriasis and Vitiligo

Two female patients with vitiligo and one with psoriasis were
observed for more than 1 year. One of the patients with vitiligo
had the grafting procedures performed twice, in different sites,
of course.
RESULTS
Of a total of 284 punch grafts, only one of the punch grafts
failed to take. This was in a patient with alopecia areata in
whom a graft with hair fell out of the recipient alopecia site.
Figure 1A-2 The large circle represents the site of persistent This graft had been covered with collodion. Its loss was noticed
disease. Punch grafts are taken at A, B, C, and D. Grafts 1, 2, 3, the next day, and the graft was replaced by a new hair graft
and 4 are transplanted: 1 to B, 2 to C, 3 to D, and 4 to A. that took without difficulty.
Generally, the grafts developed a superficial crust that fell
off in 1 to 2 weeks (Fig. 1A-7a, arrows 1 and 7). In 2 to 3
History and Patient Relationship 3
when the transposed grafted skin maintains its integrity and

characteristics independent of the recipient site, it is donor dom-
inant; when the transposed grafted skin takes on the characteris-
tics of the recipient site, it is recipient dominant.
Alopecia Prematura
Donor dominance was observed in all of the cases of alopecia
prematura. ‘‘Hair to hair’’ grew hair; ‘‘hair to bald’’ grew hair;
‘‘bald to bald’’ remained bald; and ‘‘bald to hair’’ remained
bald.
The grafts containing hair continued to grow in the area of
alopecia that was of the same texture and color and, apparently,
at the same rate and with the same period of anagen that gov-
erned the nature of the hair of the donor site [after 21⁄2 years’
follow-up, the hair was still growing (Fig. 1A-7)].
In several patients, grafts growing hairs were implanted at
the edge of a receding hairline. In the 2 years of observation
after the grafting, the hairline continued to recede at its preor-
dained pace. The grafts, however, continued to show hair
growth, with greater and greater distances manifested between
the hair of the grafts and continued recession of the hairline.
Moreover, the hair growth of the grafts appeared unimpaired
(Fig. 1A-8).
The subject presented in Figs. 1A-7b, c, and d shows the
growth of the hair in the graft 21⁄2 years after its transposition
to the left frontal scalp. The right frontal scalp lacks hair because
this area was used as a control.
Alopecia Areata
Attempts to choose persistent and circumscribed sites of alope-
cia areata occasionally failed when there was rapid extension
of the disorder to involve all four graft sites (Fig. 1A-9). Occa-
sionally, spontaneous hair regrowth would occur, and therefore
dominance was partial. However, in alopecia areata, unlike alo-
pecia prematura, only sparse and weak hair growth took place
Figure 1A-4 (a) The hair-bearing graft shaven of visible hairs in both the ‘‘hair-to-hair’’ grafts and the ‘‘hair-to-alopecia’’
in its recipient site. It is covered with collodion; (b) the hairs being grafts. The ‘‘alopecia-to-alopecia’’ and ‘‘alopecia-to-hair’’
shaved 2 weeks later. grafts did not grow hair.
Alopecia Cicatrisata
Two cases of alopecia cicatrisata showed a relative donor domi-
weeks, and without exception, the hairs were shed from hair- nance; the hair growth, however, was very sparse. Only two
bearing grafts. Fig. 1A-4 shows the hair-bearing graft, shaven velluslike hairs, 1 cm. in length, regrew from the 15 terminal
of visible hairs, in its recipient site, covered with collodion. hair follicles of the transplant. These have persisted for more
Figure 1A-4b shows these hairs 2 weeks later. Occasionally, than 1 year. One patient, however, had excellent terminal hair
all the hairs are shed with the crust. Many of these hairs were growth, indicating donor dominance (Fig. 1A-10).
examined microscopically. Figures 1A-5a, b, and c show micro-
photographs of such hairs shed in patients with alopecia areata. Woolly Hair Nevus
They all show the features of telogen. Many have the shape
that might be described as a ‘‘shepherd’s crook’’ (Figs.1A-5a The patient with the woolly hair nevus developed a keloidlike
and b). reaction in all the grafts and, of course, no hairs grew. The
In grafts in which hair regrowth occurred, the hair appeared result was therefore inconclusive in regard to growth of hair.
above the surface 2 to 3 months after the procedure. Figure 1A-
7a shows grafts in different stages of hair growth. In a few Psoriasis
months, the line of union between the donor graft and the recipi-
ent site became almost invisible. The patient with psoriasis (Fig. 1A-11) developed an iso-
I suggest that the terms donor dominant and recipient domi- morphic response (Koebner phenomenon). All four grafts be-
nant (Fig. 1A-6) be used to describe the following conditions: came psoriatic.
4 Chapter 1
Figure 1A-5 These microphotographs show types of hair shed from the grafts; (a and b) hairs of the shepherd’s-crook type.
Vitiligo Pigmented skin to pigmented skin remained pigmented. Pig-

mented skin to vitiligo skin became vitiliginous. Vitiligo skin
The multiple transposition experiment was performed in two to vitiligo skin remained vitiliginous. Vitiligo skin to normally
white women with persistent vitiligo. They were followed for pigmented skin became pigmented (Figs.1A-12a, b, and c).
more than 1 year. Recipient dominance was observed in all
sites in both patients.
DISCUSSION
The use of autografts as a research tool has helped our under-
standing of many physiological and pathological phenomena
of the skin. Previous studies occasionally failed or produced
contradictory results. Moreover, confusion resulted from trans-
plants that failed to take or that were only partially successful.
Therefore, the multiple controls of the present technique were
instituted.
To achieve a successful transplant, sufficient nourishment
(vascular recipient bed), primary tissue contact (pressure with
postoperative immobilization), asepsis, and control of excess
bleeding are necessary.
The first nourishment of the graft is plasma. There is an
early anastomosis of small capillaries, and then new capillaries
proliferate into the older vessels. Vascularization of a graft usu-
ally occurs in 3 days (42), connective tissue attachment in 2
weeks, and fat layer appearance in 3 weeks. Sensation (pain,
temperature, tactile) develops in a variable period of time
(months to a year), usually starting at the periphery and proceed-
ing toward the center of the graft. The 6-mm and 8-mm grafts
develop sensation within 2 months. It would be interesting to
observe whether in the larger grafts (12.mm and more) signifi-
cant difference in hair growth and sensations, as between the
periphery and the center, become noticeable. This work is now
in progress.
For alopecia prematura, these studies would seem to indicate
Figure 1A-6 The stippled areas represent the sites of persistent that the determinants of growth of strong scalp hair or of bald-
disease: (a) where the punches were made; (b) the grafts after they ness lie within the local skin tissues of a full-thickness graft
were transplanted in a clockwise fashion: (c) the fate of the grafts and suggest that the pathogenesis of common male baldness is
after a period of time. inherent in each individual hair follicle. Probably, each individ-
Figure 1A-7 A patient with alopecia prematura: (a) grafts at various stages after transplantation. Grafts 1 and 7 show crusts 1 week
after grafting. Grafts 2, 5, and 6 show healing 1 month later. Grafts 3 and 4 show hair growth 6 months later; (b) hair growing on the
patient’s left frontal scalp. (c) A close-up view of the right frontal scalp. This was used as a control area and stayed bald; (d) a close-up
view of the left frontal scalp area, where the grafts have continued to grow strong scalp hairs for the past 21⁄2 years.
ual follicle is genetically predisposed to respond or not to re- receding hairline. It is traditionally accepted that pressure and
spond to androgenic and/or other influences that inhibit its avascularity may result in alopecia. Clinically, this is best seen
growth. This would explain the frequent clinical finding of iso- over some sebaceous and epidermoid cysts of the scalp (45).
lated normal-growing terminal hairs in areas of male pattern Although donor dominance was noted in alopecia areata, it
baldness. The results of the present experiment certainly pin- was only partial. Even the hair-to-hair grafts failed to grow
point and agree with the statement that ‘‘the capacity for devel- normal hair in any of the cases. It is possible, therefore, that
opment of baldness appears to be controlled by factors, resident trauma alone may precipitate development of some of the le-
in localized areas of the scalp’’ (43). sions or some of the variants of alopecia areata. In all grafts
This study would seem to refute theories of the pathogenesis bearing scalp hair, the hairs are always shed as a result of free
of ordinary human baldness based solely on the ‘‘chronic activ- grafting, and then anagen begins. It is stated that ‘‘in alopecia
ity of the scalp muscles (via branches of the facial nerves) that areata the hair bulb appears to be restrained from proceeding
lead to shearing stresses in the dermis of the scalp and conse- beyond the comparable stage of anagen IV (in the mouse) and
quent ischemia’’ (44). fails to produce morphologically normal hair’’ (46). This may
Although only 21⁄2 years have passed since the performance explain the failure of our hair-to-hair graft to grow more than
of these autografts, there is evidence that local factors outside weak, sparse hairs, because the hairs are now all in relatively
the hair follicular apparatus are not significantly related to alo- early anagen. In order to arrive at more definite conclusions
pecia prematura (male pattern baldness). In cases of receding concerning alopecia areata, larger grafts are now being em-
hairlines in which hair-growing grafts were implanted at the ployed.
periphery of the hairline, these grafts continued to grow normal The results in alopecia cicatrisata indicated donor domi-
hair, separated by 1 cm to 2 cm from the front of the continually nance. The poor growth of hair-to-alopecia grafts in alopecia
6 Chapter 1
Figure 1A-8 A patient with alopecia prematura. The arrow in- Figure 1A-10 A patient with alopecia cicatrisata. The arrow
dicates the site of the graft taken from a hair-growing area in the indicates the site of a hair-to-alopecia graft performed 1 year ago.
posterior scalp. Two years ago, this graft was implanted at the edge Terminal hair growth is shown.
of the receding hairline (dotted line). Note receded hairline. Graft
continues to grow hair.
The patient with psoriasis developed an isomorphic response

(Koebner phenomenon). This may possibly be circumvented in
cicatrisata may be explained by the poor vascularity of the recip- the future by the use of grafts large enough to leave the center
ient site. free of this reaction to physical trauma.
The experiment in woolly hair nevus of an African-Ameri- Patients with vitiligo, unlike those with alopecia, show recip-
can woman failed because of the hypertophic keloidlike reaction ient dominance. Apparently, systemic factors and/or deeper
produced by the procedure. seated structures and tissues determine the local reactions. It is
The shepherd’s–crook-shaped hair that is shed from grafts possible that the nerves, blood vessels, and/or lymphatics gov-
with hair requires biopsies to explain their formation. One may ern the ulterior skin changes.
speculate that the hair papilla apparently rises into the dermis This finding parallels the results and theories of others
from the subcutis and carries the hair bulb with it faster than (12–24) in regard to certain other dermatological lesions, such
the hair shaft is released from its follicle, thus bending back on as those of fixed drug eruption, allergic eczematous contact
itself. dermatitis, and chronic discoid lupus erythematosus. It is clear
Figure 1A-9 A patient with alopecia areata. There was rapid extension of the disorder to involve all four grafts sited.
Figure 1A-11 This patient with psoriasis shows the isomorphic

phenomenon of Koebner after grafting.
that there may possibly be far-reaching significances of the

techniques used here for elucidating the pathogenesis of skin
disorders and for understanding the factors determining their
localization.
Table 1A-1 shows recipient or donor dominance of dermato- b
logical conditions after autografts are used. The dominance
probably differentiates between those conditions in which the
factors responsible for the production of the skin lesion reside
in the skin itself and those in which the deeper tissues determine
the localized reactions in the skin.
SUMMARY
The technique of multiple transposition of full-thickness auto-
grafts is described.
Sixty-eight patients were studied, including 52 with alopecia
prematura, 9 with alopecia areata, 3 with alopecia cicatrisata,
1 with woolly hair nevus, 1 with psoriasis, and 2 with vitiligo.
The term donor dominance is introduced for skin autografts c
that maintain their integrity and characteristics after transplanta-
tion. Figure 1A-12 A patient with vitiligo: (a) the crusts 1 week
The term recipient dominance is introduced for skin auto- after grafting; (b) complete healing 1 month later; (c) recipient
grafts that develop the characteristics of the recipient sites. dominance. The upper arrows indicate the site of the first series of
In the cases of alopecia areata, partial donor dominance oc- grafts. The four sites below the arrows are a second series of grafts
curred, but hair regrowth in all the grafts was stunted. that were transplanted in clockwise fashion.
In the cases of alopecia cicatrisata, a form of donor domi-
nance occurred. However, some interference of hair growth due
to the scarring was observed.
In the patient with woolly hair nevus, a keloidlike reaction
prevented all hair growth. pared by the author in 2000. I have made a few changes and
In the patients with vitiligo, recipient dominance occurred. added several additional physicians to the original publication.
In the patient with psoriasis, an isomorphic phenomenon These individuals should have been included in the first article
was observed in all grafts. but, for reasons outlined in the Introduction, were not.
1B. The History of Hair INTRODUCTION

Transplantation I have been asked to write a history of hair restoration surgery.
Walter P. Unger It is inevitable when one is given such a task that some individu-
als will be forgotten, because of their brief role in expanding this
The following is reprinted with the permission of the Journal field , or that some will think they should have been included but
of Dermatologic Surgery and Oncology, for which it was pre- were not, or that the space devoted to one or another of these
8 Chapter 1
Table 1A–1 Characteristic Autograft Dominance in hair for alopecia of the scalp, eyebrow, moustache, and pubic
Dermatological Conditions Studied to Date
areas.
Alopecia prematura Donor Despite the foregoing, however, the idea of hair restoration
Alopecia areata Donor surgery for male pattern baldness (MPB) clearly belongs to one
Alopecia cicatrisata Donor of dermatology’s most distinguished and accomplished memb-
Hair growth cycle Donor ers—Dr. Norman Orentreich. As at one time all roads led to
Localized amyloidosis Donor Rome, no discussion of the origins of hair transplantation as a
Vitiligo Recipient treatment for MPB or of any of the men who first practiced
Allergic eczematous dermatitis Recipient this technique can begin without homage to this extraordinary
Fixed drug eruption Recipient clinician and scientist who gladly—and from the begin-
Lupus erythematosus Recipient ning—shared his knowledge with colleagues all over the world.
Morphea Recipient As is so often the case in science, his discovery of donor domi-
Acrodermatitis atrophicans Recipient nance (a term he originated) of MPB was accidental. According
Psoriasis Isomorphic response to Dr. Hiram Sturm, who was working with him at the time,
Dr. Orentreich was doing a study on vitiligo, using a transfer
of punch skin grafts in an attempt to determine whether vitiligo
was donor or recipient area dominant. The patient and Oren-
treich noted that a punch graft that had been taken from a hair-
individuals will be deemed inappropriately short or long. Nu- bearing area and placed into a non-hair-bearing area grew hair
merous physicians have played substantial roles in expanding at the new site. Subsequently, according to Sturm, in Oren-
the field of hair transplanting, but space limitations prevent me treich’s busy hair clinic, a persistent patient with severe frontal
from describing their backgrounds and contributions as fully MPB asked, ‘‘Isn’t there anything you can do for me? I’ll try
as I would have liked. I ask for their understanding. Prominent anything!’’ Hair transplantation to treat MPB was ‘‘born’’ that
among them are Robert Auerbach, Jay Barnett, Robert Berger, day, when 10 4-mm grafts were removed from the patient’s
Nick Brandy, Jim Burks, George Farber, Robert Fosnaugh, hair-bearing occipital area and transferred into 10 punch graft
Leonard Lewis, Mario Marzola, Hillard Pearlstein, Sorrel Re- sites in his alopecic frontal area. The year was 1952. Oren-
snick, Henry Roenigk, Paul Straub, Carlos Uebel, and John treich’s first paper on hair transplantation was submitted to the
Yarborough. Like most English–speaking people, I have also Archives of Dermatology. The reviewers said that the reported
been handicapped by my native tongue, reading only scientific results were ‘‘not possible,’’ and the paper was therefore re-
articles published in English. I hope that nobody worthy is left jected. Ultimately, it was published by the New York Academy
out because of not having published in English. A history must of Sciences in 1959, and the rest, as they say, is history.
also end somewhere, so I have arbitrarily not included those The true ‘‘fathers’’ of hair restoration surgery for MPB all
who entered the field after 1975—with two exceptions. Finally, emerged as a result of collaboration or friendship with Dr. Oren-
I have not dealt with practitioners of flap surgery or tissue ex- treich. The list includes Dr. Hiram Sturm (1955), Jim Burks
pansion. Flap and tissue expansion experts such as Jose Juri, (late 1950s), Bluford (Blu) Stough (early 1960s), Jean Arouete
Louis Argenta, Reed Dingman, Bernard Alpert, Ernest Mand- (1961), Sam Ayres III (1961), Robert Fosnaugh (1961), Jay
ers, Sheldon Kabaker, Toby Mayer, Richard Fleming, and Ri- Pinski (1961), Patrick Rabineau (1963), Robert Auerbach
chard Anderson have played important roles in hair restoration (1963), Robert Berger (approximately 1963), and Hillard
surgery, but only a small percentage of patients are appropriate Pearlstein (approximately 1965). The latter three worked with
candidates for flaps and/or tissue expansion, and our space here Dr. Orentreich in his private clinic, and, in fact, it was they
is limited. who taught many, if not most, of the ‘‘visitors’’ between1965
and 1970, –including O’Tar Norwood, Pierre Pouteaux, Ri-
chard Shiell, and me.
HISTORY A second and larger wave of hair transplant surgeons came
in the period from 1970 to 1975. They learned their craft either
The history of hair restoration surgery begins in Wurzburg, at Dr. Orentreich’s office or from those who had been taught
Germany, with a doctoral thesis written in 1822 by J. Dieffen- there. Many of the most important teachers and several of the
bach. His teacher, Carl Unger, suggested he investigate the con- ‘‘giants’’ of hair transplanting are in this group. They include
cept of autotransplantation of hair, feather, and skin in animals Robert Limmer, Rolf Nordstrom, Manny Marritt, Martin Unger,
and fowl—which Dieffenbach proved possible with the use of Tom Alt, Ted Tromovitch, Sam Stegman, Harold Pierce, Mar-
goose quills as trephines. (I have struggled—unfortunately in vin Chernovsky, Henry Roegnick, Edward Krull, Douglas
vain—to confirm a familial relationship to Carl Unger, who Torre, Wayne Simmonds, Fred Castro, Charles Vallis, Pierre
lived within a few hundred miles of the home city of my father’s Bedard, and the Blanchard brothers. Brief biographies of some
family.) For more than a century after that, examples of hair of the foregoing follow.
transplantation were sporadically published, primarily in the
medical literature of Germany, England, France, and Japan. In
most cases, the reports describe the successful transposition of BIOGRAPHIES
relatively large grafts or pedicle flaps. Notable exceptions were Norman Orentreich
a German paper on eyelash transplantation of single hairs writ-
ten in the early 1900s and Okuda’s 1939 paper, which appeared A towering figure in dermatology for most of his 52 years in
in the Japanese Journal of Dermatology, on punch grafting of practice, Dr. Orentreich has consistently been on the cutting
edge of innovations in the field of dermatology and cosmetic year before moving to Atlanta, Georgia, in 1958. Dr. Sturm
surgery—hair transplanting being only one of a seemingly end- remains there and is now practicing with his son, Richard.
less list. He was one of the founding members and the first Although Hiram has always been a teacher, he was particu-
president of the American Society of Dermatologic Surgery larly active for two decades in teaching dermatological surgery
(ASDS), which now includes more than 2500 members. In addi- as well as hair transplanting. It was he—as chairman of a medi-
tion, he is a member of the editorial boards of many dermatolog- cal meeting—who invited me to deliver my first paper on hair
ical publications, advisor to numerous medical facilities, and transplanting to an audience of dermatological surgeons. As
member of more than 50 medical societies. with Dr.Orentreich, his interest and proficiency in dermatology
Dr. Orentreich received his medical degree in 1948, and, extends far beyond hair transplanting. In particular, he was an
after becoming a dermatologist, joined the Skin and Cancer early activist in developing and promoting dermabrasion, and
Unit of the New York University (NYU) postgraduate medical has served as the president of the Atlanta Dermatologic Society
school, where he spearheaded the establishment of the first med- and the Georgia Society of Dermatologists and as chairman of
ical hair clinic in the United States, and where he has been the dermatology division of the Southern Medical Association,
a clinical professor for many years. He is the director of the the Noah Worcester Dermatologic Society, and the ASDS.
Orentreich Foundation for the Advancement of Science, a
biomedical research organization that he founded in 1961. Sam Ayres III
Under his guidance, this foundation has produced countless sci-
entific publications of significance in the areas of aging, cancer, Dr. Ayres received his medical degree in 1944 from Stanford
and dermatological research. Currently, he practices with his University and became a diplomate of the American Board of
son and partner, Dr. David Orentreich, who joined his practice Dermatology in 1949. He worked in association with his father,
17 years ago, and his daughter, Dr. Catherine Orentreich, who Samuel Ayres, Jr., until 1962. Thereafter, he had a solo practice
joined them 7 years ago. limited to dermabrasion, chemical peeling, and hair transplanta-
tion. Eventually, he limited his practice to the latter specialty
and continued until he was forced to retire because of a nearly
Hiram Sturm fatal illness incurred while traveling in China in October 1993.
Hiram Sturm graduated from the University of Tennessee He learned the procedures of hair transplanting from Norman
School of Medicine and, after serving as a naval flight surgeon Orentreich and began doing them in 1961, working in his office
during the Korean War, he applied for and was accepted to a with his wife and without any other assistants.
3-year basic science/fellowship training program at the NYU His meticulous work and results were admired by all, and
Skin and Cancer Clinic in New York City. One of the young he became ‘‘hair transplanter to the stars’’ as well as a ‘‘star’’
professors with whom he worked was Dr. Norman Orentreich. among hair transplant surgeons. At the Los Angeles County/
As indicated earlier, Dr. Sturm assisted Dr. Orentreich in the University of Southern California Medical Center, he estab-
experimental work that led to the development and publication lished the dermabrasion clinic in 1955 and the hair transplanta-
of the data that formed the basis of hair restoration surgery; tion clinic in the early 1960s. He is the author of a large number
moreover, he worked in Dr. Orentreich’s private office for a of published articles and textbook chapters on dermabrasion,
chemical peeling, and hair transplantation. His paper entitled
‘‘Conservative Surgical Management of Male Pattern Bald-
ness,’’ which was published in the Archives of Dermatology
in November 1964, should be ‘‘must’’ reading for every hair
transplant surgeon. Although for the most part he employed
Figure 1B-1 Dr. Norman Orentreich, the ‘‘father’’ of hair

transplantation, at about the same time he began transplanting. Figure 1B-2 Hiram Sturm, MD, 1969.
10 Chapter 1
3.5-mm diameter grafts and thought they were optimal, he often steadily increasing number of hair transplants and taught the
used 2.5-mm and 3-mm punches, and at times ‘‘a 1.5[-mm] or technique to his colleagues. He developed a scalp tourniquet
2.0-mm punch, providing grafts containing only two or three for controlling bleeding, which allowed him to do 100 or more
follicles, placing them in a random fashion immediately anterior grafts per session, well before most transplant surgeons were
to the frontal hairline, which has previously been established able to master such large sessions, and he popularized the proce-
by the 3.5-mm grafts.’’ Thus he described micrografting and dure with the public as well as with those in the medical profes-
minigrafting decades before they were generally accepted and sion in Europe. Always highly regarded, in 1989 he published
named. In the same paper, he noted ‘‘taking advantage of local- his first textbook on hair transplanting, entitled Manuel Pra-
ized bunching of the follicles when obtaining the grafts,’’ draw- tique de Greffes de Cheveux. He has been and remains one of
ing attention to what would later be referred to as follicular the major figures in the field of hair transplanting in Europe.
units, and he omitted pressure bandaging in many of his pa-
tients. Every article I have seen that has been written by this Patrick Rabineau
man and every lecture I have attended that he has given have
stimulated me as no works of any other writer or speaker in Dr. Rabineau began transplanting in 1963, after visiting with
the field of hair transplantation have ever done. If Norman Ore- Norman Orentreich. He, Jean Arouete, and Pierre Pouteaux,
ntreich was the originator of the technique, certainly Sam Ayres form the triumvirate of early European leaders of hair trans-
III was the perfectionist whom all of us strove to mimic. planting. Dr. Rabineau was born in 1926 in Oran, Algeria. He
completed his undergraduate studies at the University of Paris
and his dermatology training at the St. Louis Hospital in Paris.
Blu Stough He has been president of both the French Society of Dermato-
In the early 1960s, Dr. Stough heard that a dermatologist in logic Surgery and the French College of Scalp Surgery, and,
New York City, Norman Orentreich, was transplanting hair. He for the last 20 years, he has been an assistant professor of derma-
thought this procedure could not only help him with his own tology. At age 70 years , he is still carrying out a variety of
MPB, but might also be an important adjunct to his practice. cosmetic dermatological procedures, but 70% of his time is
After two or three visits to Dr. Orentreich’s office, Dr. Robert spent on hair replacement surgery. He has written numerous
Berger performed the first hair transplants on him, and he re- articles and has lectured on hair transplanting at countless meet-
turned to Hot Springs, Arkansas, ready to begin his own hair ings.
transplanting practice—beginning with several local physicians The story of how he began hair transplanting is reminiscent
who were anxiously awaiting his help. of those of many of the early hair transplant surgeons; in brief,
By the early 1970s, he began teaching the technique, organ- it includes a reluctant surgeon and a determined patient. His
izing the first hair transplant symposium sponsored by the first patient was a policeman who had already had his first
ASDS (of which he was one of the original founders) and the transplant carried out by an American surgeon, but he wanted
American Academy of Facial, Plastic and Reconstructive Sur-
gery in Hot Springs, Arkansas. Subsequently, he chaired at least
a dozen more hair restoration symposia that were the breeding
ground of many of the next wave of hair transplant surgeons.
Physicians from around the world came to these conferences
to learn the latest developments in the technique.
Dr. Stough’s list of honors is long and includes the presi-
dency of the American Association of Cosmetic Surgeons as
well as membership, at one time or another, on the boards of
virtually all of the dermatological surgery societies. His son,
Dr. Dowling (Dow) Stough, who worked with him in private
practice for a number of years, has in turn become one of the
most influential members of the community of hair restoration
surgeons. (More about him appears later.)
Jean Arouete
Dr. Arouete began his medical studies in 1952, with the inten-
tion of becoming an orthopedic surgeon.However, his stepfather
was a very famous dermatologist, Edwin Sidi, and he influenced
his son to become a dermatologist. During his medical studies,
Dr. Arouet developed considerable experience in general sur-
gery and plastic surgery, and soon after starting his dermatology
practice, he was appointed chief of the department of dermato-
logical surgery at the Rothschild Foundation. In 1961, when
Orentreich visited Paris at the invitation of Sidi, he discussed
his initial work on hair transplanting with Arouete. A few days
later, excited by what he had heard, Arouete carried out his Figure 1B-3 Dr. Patrick Rabineau, approximately 1978, with
first hair transplant procedure. Subsequently, he performed a the hair-line and hair we’d all love to have.
additional grafting. After putting his patient off several times,

Patrick called Norman Orentreich and went to visit him in New
York, staying for 3 weeks to learn his technique. (He considers
Norman not only his master in hair transplanting but also in
dermabrasion and the use of silicone in soft tissue augmenta-
tion.)
James Bernard Pinski

One of dermatology’s intellectual stars, Dr. Pinski’s history
includes being president of his graduating class in high school
and of his junior class and the student council while he was in
medical school. His other academic honors are too numerous
to mention here. Fortunately, he decided to become a dermatol-
ogist, and he became a diplomate of the American Board of
Dermatology in 1964.
His interest in hair transplantation was first tweaked by Dr.
Howard Maibach during his residency in San Francisco in the
early 1960s. After reading Norman Orentreich’s original article,
Dr. Pinski began performing hair transplantation during his resi-
dency and during his military service in Heidelburg, Germany.
He did this primarily on his own, learning by trial and error.
Later, after beginning his practice in Chicago, he visited derma-
tological offices, where hair transplantation was being per-
formed and gathered ‘‘pearls’’ from each office, modifying his Figure 1B-4 Dr. Pierre Pouteaux in a relaxed mode after sailing
procedure accordingly. He has actively taught the technique in Tangiers.
of hair transplantation and scalp reduction over the years by
publishing articles and textbook chapters and by conducting
numerous courses nationally and internationally as well as tak-
ing part in many more. He is currently a clinical professor of O’Tar Norwood
dermatology at Northwestern University Medical School. Like
Orentreich, Sturm, Stough, Limmer, and, now, me, he has been Dr. Norwood’s influence on hair transplanting is as broad and
doubly blessed by having one of his children, Kevin, join him as deep as that of anyone who has ever been in the field. As
in his dermatology and hair transplanting practice. Richard Shiell has said, ‘‘His presence in hair transplant surgery
is everywhere.’’ He graduated from the University of Arkansas
Medical School in 1957 and pursued his dermatology residency
Pierre Pouteaux at the University of Oklahoma, where he trained from 1961 to
Dr. Pouteaux studied medicine at The French University in 1964. During his residency, he visited Dr. Blu Stough and Dr.
Norman Orentreich to have his own hair transplanted. He per-
Algeria and trained in otolaryngology and maxillofacial sur-
formed his first hair transplant on one of his patients during his
gery. During the War of Independence in Algeria, he moved
first year as a dermatology resident in Oklahoma City in 1961.
to Paris to specialize in cosmetic surgery of the face. In 1967,
It seemed so simple that he carried out three to four grafts
he heard of hair transplantation and telephoned Dr. Orentreich’s
on an unsuspecting welfare patient. The man had come in for
office to see whether he could arrange to observe the procedure.
something else and Dr. Norwood just told him that he ‘‘had to
Typically, he was welcomed with open arms and was impressed do this little operation’’ on his scalp. He never saw the patient
by all he saw. He began slowly, carrying out ever increasing again. He began transplanting seriously sometime between
numbers of procedures until, finally, his practice was limited 1965 and 1970.
entirely to hair transplantation. At the time he began his work, The list of his honors in dermatological surgery seems end-
only Dr. Jean Arouete and Patrick Rabineau were engaged in less. Some of the highlights include being a founding member
hair transplanting in Europe. Dr. Pouteaux spoke English and of the ASDS, author of the first textbook on hair transplant
Italian quite well and had the novel idea of opening clinics in surgery (1973), and developer of a classification of MPB that
London and Milan, which he visited once every 3 months to is used even today. He was founder, editor, and publisher of
interview potential patients. He soon became widely known for Hair Transplant Forum International from 1990 to
the procedure. He was active in lecturing and received many 1995—probably the most important publication in the field of
physicians in his office, passing on to them what he had learned hair restoration surgery today—and was co-founder with Dow
over the years. When he sent me his biography, he insisted that Stough of the International Society of Hair Restoration Surgery.
I mention his head nurse, Denise Leleue, who worked with him He, Richard Shiell and this author are the only individuals to
for 25 years and to whom he gives credit for a large part of his have been awarded both the Golden Follicle and Manfred Lucas
success. Unfortunately, Dr. Pouteaux was forced to retire from awards by the International Society of Hair Restoration Sur-
practice in 1997 after three operations on his spinal column. geons (ISHRS) which recognizes outstanding achievements in
12 Chapter 1
mera district of Australia—‘‘an oasis of perhaps 200 houses

and a few shops in the vast Australian wheat lands.’’ The exact
date was Thursday, September 27, 1967. His patient was a suc-
cessful balding businessman in his mid-30s who had seen an
article on hair transplanting in a Readers Digest magazine. Once
again, a persistent patient forced a reluctant doctor to do his
first transplant. During Dr. Shiell’s next trip to Melbourne, he
went to the University medical library and looked up three arti-
cles on hair transplanting; they were written by Norman Oren-
treich, Sam Ayres III, and Philip Lebon. ‘‘Armed with his do-
it-yourself manual of three brief papers,’’ he went to a nearby
supplier and bought the suggested instruments. He hoped that
the patient would change his mind, but on the appointed day
he appeared, and Richard carried out his first transplant, consist-
ing of 35 4-mm round grafts taken from the occipital area and
transplanted to the vertex area, where he thought ‘‘they would
be the least likely to cause the fellow cosmetic problems in the
future.’’ Bleeding was copious, and the operation took approxi-
Figure 1B-5 Dr. O’Tar Norwood in 1969 prior to his own hair mately 3 hours. When Richard’s wife asked him how the opera-
transplantation. tion went that day, he replied: ‘‘It was o.k., darling; it made a
bit of a change, but you wouldn’t want to do that for a living!’’
For better or worse, however, word soon got out that the
procedure was available in Australia, and within 2 years, Ri-
clinical hair restoration surgery. His wife, Mary-Ann, was a chard gave up his general practice and moved to Melbourne.
major influence in his career. Sadly, she passed away several He began attending meetings and lecturing in the early 1970s.
years ago, but she is remembered and missed by all of us who He also started writing articles that, combined with the lectures,
were lucky enough to have known her. became the cornerstone of the learning experience of countless
hair transplant physicians. As with other members of this pi-
Charles Vallis oneer’s list, his honors, papers, and lectures are myriad. Among
his more important writings are the second edition of Hair
Charles Vallis, a plastic surgeon, began hair transplanting in the Transplant Surgery, which he co-edited with O’Tar Norwood
late 1960s. I do not have much of his biographical information in 1984. He was as well the editor of Hair Transplant Forum
because I was unable to contact him. However, in the late 1970s, International from 1995 to 1998. Under his stewardship, ‘‘The
he published a textbook on hair restoration surgery and began Forum’’ became the preeminent mode of communication for
lecturing on the subject at plastic surgery meetings. Most plastic hair transplant surgeons throughout the world.
surgeons who began hair transplanting during the 1970s and One cannot think of the term giant in hair transplanting with-
1980s did so because of their contact with him, but the technique out Dr. Shiell’s name immediately coming to mind. The breadth
apparently appealed to few of them until the last 10–15 years. of his experience and analytical assessment of all techniques
and approaches, his openness to new ideas, his friendliness, and
Richard Shiell his eagerness to teach are legendary.
Richard Shiell began transplanting hair as a 29-year-old general
practitioner in the tiny town of Rupanyup in the Victorian Wim- Marcelo Gandelman
Marcelo Gandelman received his medical degree in 1965 from
Sao Paulo University in Brazil. Since his early training, he has
been deeply involved in hair transplantation. Just after his grad-
uation, he learned hair transplantation at Dr. Norman Oren-
treich’s office. He began hair and eyebrow transplantation on
burn patients in 1967 while he was a plastic surgery resident
at the university’s hospital. Seeing the results, his bald col-
leagues were soon asking him to perform that new surgery on
them, offering their suggestions to help improve his technique.
They also protected him from a professor opposed to his work
who said that hair transplantation was frivolous and that hair
could never regrow.
In 1968, tired of drilling by hand, Dr. Gandelman adapted
the handpunch to the dentist’s motor of his brother-in-law and
began his private practice in hair transplanting. Dr. Gandelman
carried out many hair transplant courses in Brazil. In 1970,
he learned Juri’s flap technique from Dr. Abel Chajchir from
Figure 1B-6 Dr. O’Tar Norwood with Mary-Ann in 1977. Argentina. In 1976, Dr. Felipe Coiffman, a well-known surgeon
from Colombia, taught Dr. Gandelman the strip method of har- 30 chapters on hair transplanting to other textbooks. I have been
vesting donor hair. From that time on, Dr. Gandelman aban- active on the boards of a large number of professional societies
doned punch harvesting and began to plant square grafts in and publications, and, at present, I serve on the executive board
round holes. In 1981, Dr Gandelman published, in Annals of of The American Board of Hair Restoration Surgery and as
Plastic Surgery, an article on a narrow 8-mm wide pedicleflap chairman of the Committee on Standards for Hair Transplanting
and a new bilateral 2-cm wide bilobed-flap for the frontal hair- of the American Academy of Dermatology. I am currently presi-
line. dent of the Canadian Association of Hair Restoration Surgery
What really strengthened Dr. Gandelman’s interest and ac- (CAHRS). In 2000, I joined the faculty of Mt. Sinai Medical
tivities in hair transplantation was his first meeting with O’Tar School in New York, where I am a clinical professor of derma-
Norwood. Norwood introduced him to some of the best practi- tology and director of the division of cosmetic dermatological
tioners in hair transplantation. By inviting Dr. Gandelman to surgery. In addition, I continue to be an associate professor of
write for the Hair Transplant Forum in 1990, Dr. Norwood medicine (dermatology) at the University of Toronto (since
expanded his horizons and gave him the opportunity to publish 1972) and have been appointed Visiting Professor (Dermatol-
his own ideas alongside those of the people he had long ad- ogy) at Johns Hopkins Medical School, Baltimore.
mired. Dr. Gandelman is one of the pioneers of motorized punch Richard Shiell has called me ‘‘the outstanding giant of our
transplantation, elliptical harvesting, new eyebrow/eyelash re- profession in this first half century.’’ This is far too kind an
construction methods, and the non-mist motor for hair and assessment of my importance—but, anyway, it is nice to be
dermabrasion surgery. able to quote it here. I recently became a member of the lucky
He continues to teach hair restoration surgery to residents ‘‘club’’ of hair restoration surgeons who have had one or more
and graduates as well as present papers about hair restoration of their children enter their practice. My daughter, Robin, joined
surgery at international meetings and workshops. Dr. Gandel- me in 2001.
man has published more than 50 papers about hair transplanta-
tion in books, videotapes, and journals. He is a member of many Jules Nataf
plastic surgery and hair restoration societies in the United States
and other countries. In 1998, he received the Platinum Follicle Jules Nataf (1917–1988) graduated as a head and neck plastic
award from the ISHRS and was president of the ISHRS in 2001. surgeon from the Paris Medical School Hospital. He initially
practiced in Casablanca, Morocco, and then moved to Nice,
Walter Unger France. Late in the 1960s, he became fascinated with the con-
cept of hair restoration surgery and started performing the pro-
I began transplanting in 1967. I observed the procedure per- cedure in his Nice clinic. By 1972, he had published an article on
formed on a fellow resident during my dermatology residency. hair transplant surgery in a French dermatology journal. There
He asked me to accompany him to Norman Orentreich’s office followed a string of articles on innovations in hair transplanting.
and to drive him back after he had received his hair transplant. These included the use of large fusiform grafts imbedded in
Subsequently, I assisted at several hair transplants at the Skin incisions made in the anterior hairline, the transposition of a
and Cancer Hospital, but I was not impressed with the results. long vertical temporal flap on a superior-parietal pedicle, an
My first hair transplant patient had type VI MPB. He was re- anteriorly transposed flap for the treatment of vertex alopecia,
ferred to me by a dermatologist with whom I was working. This and a variety of other flaps and navicular flaps, including a
patient was one of those individuals who combed rather sparse long retroauricular flap. In 1987, he wrote a chapter in the sec-
hair from a very narrow rim of hair, forward and across over ond edition of Hair Transplantation on the long temporal verti-
the bald area, using spray to hold it down in a pathetic attempt cal flap and several of his other ingenious scalp flap designs.
to make himself look as if he had a head of hair. I told him Dr. Nataf was as much an artist, sculptor, painter, bookbin-
that he was a poor candidate for the procedure and outlined all der, ceramist, and sportsman as an outstanding physician. Per-
the disadvantages that he would encounter in trying to grow a haps his greatest contribution to hair restoration surgery, how-
presentable head of hair. The patient returned three times more, ever, was the training of his young dermatologist nephew, Pierre
finally persuading me to carry out the procedure. To my horror, Bouhanna, who, in his own right, has become a major figure
the result was as bad as I thought it would be. The patient, in the field. Since 1977, Dr. Bouhanna has been totally dedi-
however, was thrilled. cated to scalp surgery and the invention of hair evaluation meth-
If I had not started to treat a second patient who had heard ods . He has written more than 90 articles on these subjects
about the first one, I probably would never have done another and the medical treatment of MPB. He has also published eight
hair transplant. This second patient was a very good candidate, books, in French, English, Spanish, Portuguese, and Italian,
with fine, dense, blond hair and a relatively good donor-to- about MPB and its treatment. These include an exhaustive text-
recipient area ratio. By the time I saw the mess that I had pro- book and atlas of Hair Replacement Surgery (Springer-Verlag,
duced in the first individual, I was well along in the treatment 1998), Hair and Scalp Pathology (Masson, 1999), and The
of the second, and I saw that indeed there could be a future for Newest Treatments for Male and Female Common Baldness,
hair transplanting. (Springer, 2000). He is also president of the French Medical
I delivered my first paper on hair transplanting in 1972, at and Surgical Society of Scalp, coordinator of the University
the invitation of Hiram Sturm. I had tried a number of innova- Diploma of Hair and Scalp Pathology and Surgery at Paris VI
tions and thought that it was worthwhile to present my results. University , and an advisory expert to the French Ministry of
Subsequently, I have delivered at least 100 more papers at var- Health. In 1982, he developed the phototrichogram, an objec-
ious meetings, written more than 92 articles for medical jour- tive method for the evaluation of hair count and density in
nals, edited and written most of three textbooks, and contributed androgenetic alopecia. It was first published in Montagna’s text-
14 Chapter 1
book (Salas,1983) and then in the second and third editions of and honors fill two and a half pages, and one hardly knows
my textbook. Last but not least, he is wise enough to go skiing where to begin or end listing them. They include membership
in the Alps every month and to play golf in Burgundy together of the advisory board of the ISHRS, chairman of the governing
with his wife and five children. His uncle and late surgery council of the American Society of Hair Restoration Surgery
teacher, Jules Nataf, who is never far from his mind, taught in 1995, membership on the advisory boards of the Italian Soci-
him that ‘‘the most important thing in scalp surgery is not only ety of Hair Restoration Surgery, the Japanese Society of Hair
being able to use the various surgical procedures for the correc- Restoration Surgery, the American Board of Cosmetic Surgery,
tion of hair loss but to establish, above all, a good doctor/patient and honorary membership on the board of governors of the
relationship.’’ European Society of Hair Restoration Surgery. A list of the
meetings that he has attended or chaired is almost without end.
Rolf Nordstrom Few surgeons have spent more time than Martin in teaching
both hair transplanting and AR.
Rolf Nordstrom is professor and chief of the department of
plastic and reconstructive surgery at the University of Helsinki. Tom Alt
He began hair transplanting in approximately 1974 and almost
immediately started doing scientific studies on hair survival in Tom Alt began hair transplanting in 1972, after visiting Blu
grafts of various sizes placed into recipient sites of various sizes Stough and then Norman Orentreich and Jim Burks. From the
and in various patterns. Subsequently, he did similar critical beginning of his dermatology practice, he was interested in der-
studies on the long-term effect of alopecia reductions (AR) that matological surgery and cosmetic dermatological surgery be-
have provided useful fodder to the group of hair restoration cause he ‘‘foresaw the advance of government control in medi-
surgeons who are not in favor of AR. (Rolf still carries out cine’’ and simply wanted to be ‘‘out of it.’’ For many years,
AR regularly and finds the procedure very useful). In 1981, he he was a fixture on the circuit of surgeons who went from
published a paper describing single hair grafts and used the meeting-to-meeting teaching hair transplantation and AR. In
term micrograft for the first time. Three years later, this publica- addition, he has written numerous articles on the subject and
tion was followed by an article by Manny Marritt, and some was one of the editors of two editions of a textbook on dermato-
years later still, Dr. Carlos Uebel started using, writing, and logical surgery—the second one published in 1998. He contin-
speaking about micrografting. ued in clinical practice until late spring 1999, when he retired.
Dr. Nordstrom is the author of more than 300 publications He was active in many professional societies, including serving
on scalp surgery, surgical hair replacement, tissue expansion, as a board member of the American Society of Dermatology
cleft lip and palate, and other fields of plastic surgery. Eighty- Surgery and as president of the American Academy of Cosmetic
eight of the papers describe original studies and reviews in Surgery.
the field of hair transplantation. He is also the editor of six
international textbooks and monographs on various subjects. In Robert Limmer
1997, he received the Platinum Follicle Award for the best
scientific research in hair pathophysiology and anatomy from Dr. Limmer graduated from the University of Texas Medical
the ISHRS. Nobody has done more to advance the scientific School in 1968 and became a diplomate of the American Board
basis on which we do hair restoration surgery than Dr. Nords- of Dermatology in 1973. He began hair transplanting in the
trom, and nobody is more respected by his colleagues. early 1970s, and for many years his practice has been limited
entirely to this field. He began experimenting with various
Martin Unger forms of smaller grafts in the 1980s until, finally, on October
21, 1988, he carried out the first pure follicular unit transplant.
Dr. Martin Unger, my brother, graduated from the University He waited to report the results of this work until 1991, when
of Toronto in 1968. He obtained a fellowship in general surgery he was absolutely certain that he had a procedure that was fool-
in 1973 and trained in plastic surgery at Queen’s Victoria Hospi- proof. The paper was published in Hair Transplant Forum In-
tal, East Grinstead, England, from 1973 to 1975. He is a member ternational.
of the American Board of Cosmetic Surgery and the American The first physician to adopt and practice follicular unit trans-
Board of Hair Restoration Surgery. He began hair transplanting planting outside of his office was Dr. Marcelo Pitchon of Brazil.
while in East Grinstead and in 1978 published an article describ- Others (in sequence of training with him) were doctors Agha
ing AR, entitled ‘‘The Management of Alopecia of the Scalp by of Cairo, Egypt, Tom Rosanelli, Edmund Griffin, David Seager
a Combination of Excisions and Transplantation.’’ The article, (1995), Bill Parsley and O’Tar Norwood (1996), Mario Marzola
which I co-authored, was initially rejected by the Journal of and Michael Albom (1998), and at least 75 other physicians who
Plastic and Reconstructive Surgery in 1976 as ‘‘representing spent 1 to 3 days with him but whom he hesitates to describe as
nothing new’’ (shades of Orentreich’s first rejection), and thus having had hands-on training. Follicular unit transplanting has
we lost the right to claim the first published paper on the subject. taken the entire field of hair transplantation by storm. There
Since that time, my brother has become one of the staunchest are many who believe this is the future of hair transplantation,
continuing supporters of AR, having written 34 articles or chap- whereas others believe it is an important advance but not the
ters on the subject for various medical journals and textbooks. end of the evolution of the procedure. It is certainly, however,
He has served as a member of the board of numerous medical one of the most important innovations in hair transplanting since
societies in the United States and Canada and is an editorial its inception, and Dr. Limmer is destined to be remembered as
advisor to several medical journals. His medical achievements its founder.
Dr. Limmer has a distinguished history in general dermatol- more user friendly (see Chapter 20). I believe that for properly
ogy as well. A list of society and association offices held, selected patients, it is potentially one of the most important
professional organizations to which he belongs, and scientific innovations in hair transplanting.
presentations that he has given, fills many pages. He has also In 1996, Patrick received the Golden Follicle Award from
published 66 scientific papers or chapters and is a clinical pro- the ISHRS. He also founded and was the first president of the
fessor in the division of dermatology at the University of Texas European Society of Hair Restoration Surgery (ESHRS), a rap-
Health Center at San Antonio. His son, Bradley Limmer, joined idly growing organization that is quickly attaining prominence
him in his practice of hair transplantation 5 years ago. throughout the world. Patrick’s hobbies include swimming and
listening to music. Because of his extensive writing and speak-
Manny Marritt ing schedule, he also enjoys just resting.
Dr. Marritt obtained his medical degree at New York University

Dow Stough
in 1967, and completed a psychiatry residency from 1968 to
1972. In 1975, he decided to specialize in hair transplanting. Dr. Dow Stough, Blu Stough’s son, began hair transplanting in
At that time, he visited the offices of seven physicians, including 1985 under the tutelage of his father. He joined his father in
Peter Goldman, Jay Barnett, Norman Orentreich, Sam Ayres private practice after becoming a diplomate of the American
III, and me. In fact, he stayed with me for periods of 1 to 2 Academy of Dermatology and immediately started practicing
weeks on two separate occasions, absorbing everything that he and innovating hair transplantation and AR. In 1987, he, to-
could and watching me more closely than I think anyone ever gether with O’Tar Norwood, founded the ISHRS, an organiza-
has before or since. Subsequently, he started his practice in tion that has become the foremost international association of
Denver and rapidly developed a legendary skill, producing ex- hair restoration surgeons in the world. In addition, in 1996 he
traordinary results with the old, ‘‘standard’’ 4-mm grafts. Since edited one of the standard reference textbooks on the subject.
1993, he has been a clinical professor of hair transplanting in Dr. Stough has been president of the ISHRS and a member of
the department of otolaryngology head and neck surgery at the the board of the American Board of Hair Restoration Surgery,
University of Colorado. He has written 13 articles and three He is an editor of the Journal of Dermatologic Surgery. Al-
chapters for various texts on hair transplantation, and, despite though he came into the field far later than the other members
relatively few publications, is one of the most well- respected in this historical survey, his clear and growing importance has
theorists and members of the hair restoration surgery commu- merited his inclusion in this history.
nity. His speaking talents have also made him a favorite of the
media, and he has appeared on numerous radio and television
shows as well as in local and national lay publications. He is CONCLUSION
so articulate (and often funny) that his lectures were always
among the highlights of the meetings he attended. He retired Once again, I must apologize to anyone who has been inadvert-
in 2000. ently omitted from this history. It would have been a pleasure
to have also noted many of those who have entered the field
Patrick Frechet in the last 10 to 15 years and who are rapidly assuming the
mantles of those discussed earlier. Although most of the leaders
Patrick Frechet lived in Paris for most of his childhood before in the teaching and practicing of hair transplanting in its first
moving to London for a short while. He returned to France to two decades were dermatologists, the new group is a more var-
study medicine at Montpelier—the oldest medical school in ied breed, coming from backgrounds in plastic surgery, otolar-
Europe. There, he met his wife, Jaleh, who was also starting yngology, orthopedic surgery, family practice, emergency med-
her medical studies. Within a few years, they were married icine, and other fields. They also come from many countries
and had a daughter—their only child. Patrick initially was a where hair transplanting has developed over the last 10 to 15
cardiologist and Jaleh was a dermatologist. However, a very years. They include James Arnold, Marc Avram, Michael
close relative of theirs developed a severe psychological prob- Beehner, Robert Bernstein, Guillermo Blugerman, Pascal
lem because of hair loss, and their interest in hair restoration Boudjema, Robert Cattani, Y.C. Choi, John Cole, Paul Cotterill,
surgery was stimulated. In January 1979, Patrick went to one Yves Crassas, Shelly Friedman, Constantine Giotis, Robert
of Blu Stough’s symposia on hair transplanting and alopecia Haber, Takeshi Hirayama, Sheldon Kabaker, J.C. Kim, Russell
reductions. (He believed then—and continues to do so—that Knudsen, Ray Konior, Matt Leavitt, Tony Mangubat, Bill Par-
a combination of both techniques makes sense.) On his return sley, Marc Pomerantz, William Rassman, William Reed, Tom
to Paris, he and Jaleh began working together in this new field, Rosanelli, Daniel Rousso, Arturo Sandoval-Camarena, David
constantly trying to improve their results. Jaleh retired from Seager, Carlos Uebel, James Vogel, Bradley Wolf, and others.
this joint effort after 12 years. In 1992, Patrick first described This new group which, of course, most prominently also in-
what he termed scalp extension, a process whereby, with present cludes the co-editor of this text, Ron Shapiro, is putting the
techniques, up to 15 cm of alopecic skin can be excised within technique on a far firmer scientific footing. The camaraderie
60 days. It was a revolutionary concept, but because the end of individuals from different countries and many different areas
result was a slot defect that required mastery of a relatively of interest and training is, I believe, unique in medicine. It is
difficult triple-flap procedure, few practitioners have followed hoped that its benefits will serve as an example to other fields
in his footsteps, despite his extensive lecturing and writing of medicine. (Reprinted with permission. March 2000. Derma-
about the technique. He has altered his technique to make it tologic Surgery, 26:3:181-189)
16 Chapter 1
1C. The Physician–Patient about it. They are sincere, friendly people to whom all humanity
is naturally attracted, and this sincerity builds a strong founda-
Relationship tion for the future relationship that becomes stronger every day
Richard C. Shiell as the promised cosmetic results gradually come to fruition.
Even if problems arise they are forgiven, and the surgeon is
INTRODUCTION permitted to correct the faults without losing the patient’s re-
spect. The majority of physicians can learn from the success
Thousands of pages have been written in books and journals of these individuals and so improve their own relationships with
about surgical technique. Nearly all of this material is their patients.
superseded within a few years and replaced by updated skills
and techniques that frequently prove to be equally fragile. At
the present time, with an overemphasis on science, drugs, and HOW DO YOU BUILD AND MAINTAIN A
surgical techniques, almost nothing has been written about one STRONG PHYSICIAN–PATIENT
of the most important skills of all—the ability to build a strong RELATIONSHIP?
physician–patient relationship.
This skill, once acquired, can be transferred to any surgical We should think of this as a three-stage process
technique and, in fact, to any field of human endeavor. Its power 1. The preliminary phase
does not degrade with the passage of time and the fickleness 2. The first meeting
of fashion.The relationship, once established, should ensure that 3. The continuation process
patients will remain faithful to their doctors and not wander off
to consort with other physicians who, for example, may have
eye-catching advertisements. It will ensure that patients will The Preliminary Phase
recommend their doctors to their associates, friends and fami- The patient may hear of the doctor’s fame and skill long before-
lies. Furthermore, it is a powerful buffer against litigation if hand and only years later come for consultation. The referral
any problem should ever arise from some surgical procedure. may be by another doctor’s or patient’s word of mouth or as a
The importance of this skill in doctors has been recognized result of some article read in the press or seen on television.
since the earliest recorded history and is known as bedside man- The relationship can be terminated abruptly or strengthened
ner. Doctors are seldom seen by the domestic bedside anymore further according to the reception that patients receive when
and medicine is probably the poorer because of it. Home visita- they telephone the doctor’s office. Although most patients have
tion gave the doctor a unique opportunity to assess patients in average or more than average self-confidence, some patients
their own domestic environments. Hospital clinicians often with male pattern baldness (MPB) are embarrassed to speak to
have bedside manner in abundance, and those who can sincerely anyone about their problem. Others may even resort to comb-
stroke the brow of frightened, sick patients and pronounce that over techniques or shave their scalps to try to declare to the
they will soon be well again are worshipped by their patients. world that they have no problem with baldness. The first contact
They are frequently rewarded by the patients’ rapid return to with the doctor’s receptionist may be the first occasion that
good health and their continued devotion. the patient has ever mentioned his concern about hair loss to
anyone.
EARLY LESSONS It is essential that the receptionist be knowledgeable and
sympathetic to the inquirer and have ample time available to
In my early years in hair transplant practice, I was continually answer all questions without hesitation. Sometimes a mother,
amazed by how some patients from other hair restoration sur- wife, or girlfriend makes the initial contact but it is equally
geons were frequently discontented with their results, even if important to gain the confidence of this third person so that the
they were quite acceptable by the standards of the day. Others warmth of reception and goodwill can be communicated to the
had results that were at the lowest end of the acceptability scale, patient. It is good practice to post the patient an informational
yet they were happy with their new appearances and spoke of brochure and audiovisual material in advance of a consultation.
their surgeons in glowing terms. I have since learned that there This further reinforces the doctor’s image and provides objec-
are difficult patients who can never be satisfied, and there are tive material about the procedures that are performed at the
other happy individuals who seem to be satisfied by any favora- clinic. It also saves time on the day of the consultation and
ble change in their appearance. The great majority are objective provides accurate printed data to which the patient can perma-
enough to distinguish between good results and bad; however, nently refer. Misunderstandings between physician and patient
this judgment process is heavily tempered by their personal are far less likely to occur if there is a written record of what
relationship with their surgeons. If they like and respect their the physician intends to do and can accomplish.
doctors, they can do no wrong. If the doctor alienates them by
some thoughtless action, the seeds are sown for a deteriorating
The First Meeting
relationship that can end by the loss of the patient from the
physician’s practice or even in litigation. Consultation techniques obviously vary widely according to the
culture of the country and the expectations of the patient. This is
HOW DO THEY DO IT? discussed in greater detail elsewhere in this book. In Australia,
patients like a friendly and informal approach, with the doctor
It must be admitted that some doctors seem to have a natural rising to greet the patient, and extending a firm handshake.
ability to bond with their patients and do not have to even think Personal names are used by both doctor and patient. In some
more conservative countries, this approach would be considered will look a great deal younger when you gain more hair.’’
a dreadful liberty and breach of etiquette. In some countries, Words with negative connotations, such as blood, bleeding,
doctors who have worked closely for decades still use surnames pain, unsightly swelling and black-eyes should be de-empha-
and titles when addressing each other, and for a patient to use sized. Although many patients ask, ‘‘How is the operation done,
a physician’s personal name would be unthinkable. Whatever Doc?,’’ they may not, in fact, want all the fine details. These
the initial approach, it is essential to greet the patient warmly, can be dealt with in a brochure, if the physician so chooses.
to smile and look him directly in the face, and to show genuine There are legal requirements within state legislaturesthat dictate
interest in his problem. The doctor should not mumble or look the warnings that must be given to patients before surgery, but
out the window while going through a patter routine that has it is important that this information be provided in a manner
been performed a thousand times before. The doctor should ask that does not unduly frighten the patient. Juggling legal require-
the patient how he heard about hair transplantation and his own ments, sensitivity, and common sense, can be a difficult act to
work in particular. The patient should be asked how he felt perform.
about his hair loss when it first started to occur. It is also a
good time to ask him about his work, family, hobbies, and
sporting activities. This not only breaks the ice but provides the THE MEDICAL HISTORY
doctor with valuable information about the patient’s probable
It is essential to take a medical history from the patient. This
psychological, social, and financial state. It may give the physi-
may not have much bearing on the patient’s eventual suitability
cian more information about the patient’s health, wealth, and
for hair restoration surgery, but, once again, it will reinforce
sexual preference than would any direct questioning. A few
the patient’s view that the physician is caring and thorough .
minutes should be spent asking about the hair cover of all his
Occasionally, a patient may be taking drugs that may cause
immediate male relatives as far back as grandparents. This in-
excessive bleeding or react with the anesthetic or vasoconstric-
formation is probably not as important as it seems to the patient,
tors (e.g., aspirin or other anticoagulants, anti-inflammatory
but it can be useful, and it certainly creates an impression of
drugs, beta-blockers). It is important and comforting to be fore-
thoroughness that patients often appreciate and remember. Oc-
warned if the patient has a cardiac condition so that appropriate
casionally, when working with patients younger than 25 years
preventive measures can be taken, but this does not necessarily
of age, a history of advanced MPB may cause the doctor to be
disqualify him from hair restoration surgery.
extra cautious in case selection or choice of operative procedure.
In my experience, hay fever and mild-to-moderate asthma
This is particularly relevant in individuals who have a history
are the most frequent medical complaints, with diabetes next
of late evelopment of types VI or VII MPB. These individuals
on the list. None of these conditions disqualify the patient from
are those most likely to run out of available donor hair in later
hair surgery. and, in fact, hemophilia and the consumption of
years. Of course, it is now hoped that with modern drug therapy
anticoagulant medication are about the only conditions that ab-
it will be possible to prevent the expansion of baldness to this
solutely disqualify someone. Active disease processes, includ-
extent, or that with cell therapy unlimited amounts of hair will
ing hepatitis or immune deficiency disorders, may cause the
be available for transplantation. However, there is a high rate
surgeon to advise the patient to wait until his health improves
of noncompliance with long-term medical therapy, and cell
before contemplating surgery, but they do not usually lead to
therapy for hair may not be perfected for many decades.
lifelong disqualification. A history of past surgery is remarkably
The accuracy of the information about hair cover of relatives
uncommon. An occasional tonsillectomy and appendectomy
is open to serious doubt, so it can only be taken as a rough
turn up and, increasingly, many hair surgeons find that a past
guide to a family history. It is interesting to see the variation
history of cardiac bypass surgery is more frequently obtained
of opinions about the hair cover of uncles and grandparents if
than any other type of surgery if the patient is older than 40years
you interview husbands and wives separately or two brothers
of age. This perhaps confirms the hypothesis that men with
on different days. Even the hair of close relatives such as fathers
crown baldness have a higher incidence of coronary heart dis-
and brothers is subject to considerable subjective variation be-
ease (1).
cause so much depends on the patient’s personal definition of
the concept of full hair and baldness. For instance, a young man
of 30 years of age with type IV baldness may claim that his THE PHOTOGRAPHS
younger brother has full hair cover, even though the clinician
may assess the 25-year-old brother as being in the early stages An album of before and after photographs is essential to any
of the same type IV baldness. Another problem is that patients cosmetic surgery consultation, although these are often best
subconsciously make allowance for age, so that a 50-year-old demonstrated on a computer. These days, a PowerPoint presen-
father of a 25-year-old man may be said to have full hair when tation is a common choice. The photographs should show a
in reality the father may have early type V alopecia. If a wife wide range of ages and hair types and reveal the hairline region
or girlfriend queries this assessment, the patient usually says, combed back to critically expose it. Photographs showing a
‘‘Well, I mean that he has great hair for his age.’’ front view and the top of the head with the hair parted through
It is important to remember that the patient is at the doctor’s the transplanted area and combed as naturally worn are also
office not just because he has hair loss but also because he has very worthwhile. Photographs of comb-over hairstyles with
a psychological problem about his missing hair. The physician concealed hairlines are no longer acceptable to the more edu-
must keep this constantly in mind and use phrases that do not cated potential hair replacement patients of the 21st century. If
reinforce any psychological stress that the patient currently has the physician has been highly recommended to the individual
about himself. The positive aspects of hair restoration should and has made a convincing presentation, the photographs serve
be emphasized. Positive phrases should be used, such as, ‘‘You as ‘‘icing on the cake’’ for the already highly motivated patient.
18 Chapter 1
LENGTH OF THE FIRST CONSULTATION his physician for a lifetime, may have many additional proce-
dures, and may refer other patients. Some may become the
This greatly depends on how much preparation the patient has physician’s best friends. Some of the more extroverted patients
been given before his meeting with the surgeon. If he has read may agree to meet with anxious prospective patients to discuss
a comprehensive brochure or viewed a videotape, 30 minutes hair transplantation with them and to allow them to inspect their
are usually ample. If he has also been seen by a skilled hair own transplants. As with a marriage, however, there has to be
consultant, 15 minutes is probably more than enough to check some work put into the relationship. It is good if the doctor can
the patient’s medical history and the physical characteristics of remember some personal details about the patient’s hobbies and
the patient’s scalp and hair. As indicated earlier, however, it is about his wife and children. If the doctor’s memory is not up
wise to spend extra time talking to the patient about his life, to the challenge, a note can be made in the patient’s history
interests, family, sports, and hobbies. This not only tells the file.
physician more about the patient’s psychological profile but
also enables the patient to learn more about the physician. It
Other Points
thus cements ‘‘the second row of bricks’’ in the physician-
patient relationship, the first being the physician’s getting to 1. The physician must have comprehensive, printed, post-
know the patient and showing a true interested in doing what operative instructions. These, if accurate and well writ-
is best for him. ten, will impress the patient with his doctor’s thorough-
ness and skill in predicting the sequence of events after
the surgery and will increase his sense of security.
THE ROLE OF SALES CONSULTANTS 2. It is good policy to call the patient on the night of sur-
gery or the day after (or to have your nurse call him).
The argument is that the doctor is not a professional salesman,
3. The patient generally returns for suture removal after 7
and, if he is allowed to spend too much time with the patien’t
to 12 days. It is a good policy for the surgeon to spend
sales figures will fall. This is a valid argument if sales figures
a few minutes chatting with the patient and inquiring
and clinic incomes are the most important considerations. If
about his postoperative experiences.
ultimate patient satisfaction is the goal, it is my opinion that
4. It is also a wise policy to have a postoperative review
the doctor must play a major role in the consultation and set
after 3 to 6 months. At this visit, the physician can check
aside ample time for this. It is, of course, possible to achieve
for postoperative hair loss and other unusual problems
a compromise, and some clinics seem to achieve a good balance
such as inclusion cysts or excessive scarring as well as
with the patient seeing both the consultant and the physician.
assess the graft hair growth.
In some hair clinics, a trained consultant or salesman makes
5. The maximum density of new hair growth is generally
the initial contact with the patient, and the doctor may only see
achieved at 12 to 18 months after surgery; therefore, the
the patient at a later stage of the interview, when all the basic
patient should be asked to return for a complimentary
technical details have been covered. In some regions, the sales-
checkup. This visit also provides a good opportunity to
man is not permitted to quote a price, whereas in other jurisdic-
assess the need for and timing of further surgery.
tions this is permissible. By putting another person between the
6. A clinic newsletter, issued once or twice each year, will
receptionist and the doctor, time is certainly saved, but a critical
keep patients acquainted with what the doctor is doing
opportunity to build the physician-patient relationship is lost.
and with progress in the field of hair restoration.
The patient may be left with the impression that the doctor is
too busy to spend much time discussing the very questions that
to a new patient may consider to be the most important of his SOME INTERESTING AND INSTRUCTIVE
whole life. ANECDOTES
A Tale of a Relationship that Went Wrong
THE CONSULTATION—TO CHARGE OR NOT
TO CHARGE? A patient having her second hair transplant procedure had a
partial breakdown of her donor site suture line. It was probably a
At present, much is spoken about this, and many hair transplant result of the combination of a relatively rigid scalp and overtight
clinics provide free consultations. Often, this is a result of com- closure. Unfortunately, the patient lived in a different city, 500
petition from nearby competitors, so each surgeon must decide miles from the surgeon. She discussed the problem on the tele-
what works best. It is my belief that the doctor as a professional phone with the surgeon, and although he would be happy to
and expert in the field should charge for the initial consultation. see her when she would next be in town, two weeks later, he
The doctor’s time is valuable, and by not charging even a token suggested that she see one of his friendly colleagues in the
amount, the professional image is lowered. Of course, many meantime. Instead, she sought advice from a relative who was
patients are ‘‘shopping-around’’ for the cheapest price these a plastic surgeon. He was most unsympathetic regarding her
days, and if surgeons wish to participate in the game of ‘‘chase plight and very critical of the work done by the original hair
the price,’’ that is their prerogative. restoration surgeon. Although attempts were made by the origi-
nal surgeon to follow up this case and make peace with his
The Continuation Process patient, the psychological damage had been done, and the lady
wanted no further direct contact with him. She continued to
Once a good physician-patient relationship has been forged, it attend the plastic surgeon’s nurse for dressings, and the ulcer-
is important to maintain it.A contented patient may stay with ated area healed with a residual scar measuring 2 cm by 3 cm.
Outcome
The patient sued the hair transplant surgeon, and a financial
settlement was eventually arranged after several years of legal
negotiations between attorneys and much stress for the surgeon.
A Disaster Need Not Lead to Litigation

In the early 1990s, many patients were left with a pronounced
‘‘slot’’ after serial central scalp reductions (Figs.1C-1 & 2). The
new Frechet triple flap procedure seemed to offer a wonderful
solution to this problem, and, indeed, in the hands of its devel-
oper, Patrick Frechet, results were outstanding. Unfortunately,
insufficient warning had been given to surgeons about the po-
tential danger posed by previous scalp surgery. Donor area scar-
ring, even if several centimetres from the flaps, had deleterious
effects on the scalp circulation and the chances of flap survival.
The patient, who had a heavily scarred donor region as a result
of 400 old 4-mm grafts, returned the day after surgery with
suspiciously darkened flaps. The surgeon’s worst fears were
realized when these became necrotic, and, eventually, the
greater part of all three flaps was lost. This resulted in an open
wound approximately 6 cm in diameter (Fig. 1C-3).
The patient was seen regularly over the next 6 months, and
appropriate dressings and débridement was performed person-
ally by the surgeon. The patient was given as much support as Figure 1C-2 Patient with slot that was produced by five alope-
possible over the succeeding months, and he built up a close cia reductions. 300 4-mm grafts were done in an unsuccessful at-
friendship with the surgeon as the vast area of nearly 30 square tempt to hide the slot. This figure shows the patient immediately
cm gradually healed inward from the perimeter (Fig. 1C-4). before a planned Frechet triple flap procedure.
The Outcome
Not only did the patient not sue the surgeon, but also he later
sent two of his sons along for hair transplantation.
Figure 1C-1 Patient with type VII male pattern baldness before Figure 1C-3 Patient 6 weeks after unsuccessful triple flap pro-
first alopecia reductions. cedure with 6 cm of necrosis.
20 Chapter 1
Editor’s Comment
Dr. Shiell brings to this chapter more than 30 years of experi-
ence in the art of dealing with patients. He is well respected
and known for his friendly demeanor and wonderful rapport
with patients. He makes a number of comments about the physi-
cian–patient relationship that are applicable not only to the field
of hair restoration but also to all areas of medical practice. Much
of what he has said is common sense. The state of modern
medicine has put a strain on the physician–patient relationship.
Young physicians may start out enthusiastic, attentive, and car-
ing, but often end up overworked and stressed. The justifiable
fear of malpractice claims has made many physicians more
cynical and distant. Patients, on the other hand, have become
frustrated with the increased socialization of medical care and
decreased personal attention associated with many medical care
systems. These factors have contributed to a downward spiral
in the relationship formed between physician and patient. It
has been shown time and again that maintaining good personal
relationships with patients can positively affect the quality of
medical care as well as avert complaints against the physician.
Physicians would do well to heed the advice of Dr. Shiell, who
after 30 years is still able to rise above the problems of the
modern medical system and maintain a good rapport with his
Figure 1C-4 Healed area after 5 months of wound care and patients. The trick is to put oneself in the position of the patient,
personal attention by patient’s physician. The lesson is that a good to remember to care, and to realize that sometimes just a little
physician-patient relationship was maintained in spite of the clini- effort in this regard can go a long way.
cal course. Ron Shapiro, M.D.
1D. The Future of Hair Restoration

Lessons to Be Learned from These Cases
Surgery
The most serious case above had by far the best outcome,
largely because the surgeon was able to maintain a close and Russell Knudsen
harmonious relationship with the patient throughout the prob-
lem period and beyond. An atmosphere of genuine empathy I have been asked to assess the current state of our specialty and
was established because the surgeon, instead of being defensive, to offer some personal thoughts on the future of our profession.
frankly discussed the circumstances surrounding the problem
and made special efforts to be accessible to the patient not
only for care but also for emotional support. Patients who have TREPIDATION
complications need to know that their doctor truly cares about If our techniques and results are better than ever, what chal-
their plight and shows it with actions as well as words. lenges exist that threaten our specialty? I see four main chal-
It is gratifying to see how patients are willing to accept lenges: firstly, increasing medical litigation (with increasing
the fact that their doctors are only human and can make small insurance premiums; secondly, governmental regulation of
mistakes, even if these lead to substantial problems. A satisfac- right-to-practice; thirdly, Internet advertising practices; and
tory outcome may be obtained providing there is a previously lastly, loss of professionalism of our specialty. In my view, the
well-established patient-physician relationship and providing first three challenges stem from the changing public perception
the physician can convince patients by showing genuine con- of our professionalism as physicians/surgeons. Increased patient
cern and willingness to help. education and autonomy, together with increased marketing and
advertising, have repositioned cosmetic surgery. The public
SUMMARY (and other members of the medical fraternity) are increasingly
asking; ‘‘Is cosmetic surgery medicine or business?’’ In other
Physicians should take good care of the patients they have. Not words, do we have patients or customers?
only is it the right thing to do, it is the smart thing to do because There has been a global rise in an entrepreneurial approach
the flow of new patients is variable. Most of a physician’s cur- to health care. In cosmetic surgery, the hype is similar to that
rent patients will require additional procedures in future years, used to market other lifestyle products. We need to ask our-
and, if a good relationship with them can be maintained, most selves whether ethical standards are a casualty of the promotion
will remain faithful to their doctor, in spite of the advertising of cosmetic surgery. Is our specialty seen as part of the beauty
and promotional campaigns of competitors. industry rather than a procedure to meet health needs? However,
on the other hand, should not patient autonomy include the appears to be a Wild West mentality operating, with common
freedom of adults to purchase these treatments, provided the derision of individual surgeons and techniques. The legal juris-
advertising surrounding them remains within the ethical bound- diction over such claims is unclear. Discussion groups on hair
aries of truthfulness? sites are dominated by opinions; scientific rebuttal is derided
With regard to advertising, the Australian Medical Associa- as self-serving or protectionist. Some commercial sites claim
tion’s position states, ‘‘The promotion of a doctor’s medical to be consumer oriented but accept product advertising with
services, as if the provision of such services were no more than minimal critical control.
a commercial product or activity, is likely to undermine public In the near past, eponymous websites with acronyms mim-
confidence in the medical profession.’’ Traditionally, the medi- icking professional societies such as the ISHRS (International
cal profession prohibited advertising in its codes of ethics. This Society for Hair Restoration Surgery) have appeared as con-
was to minimize the opportunity for patients to be misled by sumer advocates. Negative messages such as, ‘‘Can you trust
claims of superiority of a technique or individual. Historically, your surgeon?’’ and ‘‘The only safe choice in hair restoration’’
in many countries, family physicians were seen as ‘‘gatekee- abound. Again, on these Internet sites, claims of lack of self-
pers’’ to specialist services. The demise of paternalism, in both regulation and absence of accountability of our specialty are
society and the professions, has encouraged increasing criticism made. Ironically, one website that derides the ISHRS as having
of this model. Ironically, the modern gatekeepers to the public no standards for membership has its own code of ethics that
appear to be self-appointed Internet entrepreneurs. paraphrases the ISHRS code of ethics almost word for word
The development of the entrepreneurial model of medicine except for Article 7: ‘‘When communicating with the public,
has encouraged both medical and nonmedical entrepreneurs. members will not use disparaging remarks that could be re-
Advertising and marketing are usually comparative and success garded as detrimental to the practices of ISHRS members.’’
is frequently due to the size and momentum of the advertising A number of North American members of ISHRS are listed
budget. Interestingly, I believe the evolution of modern hair as members on this website. The website claims that it is ‘‘The
restoration surgery has inadvertently aided this process. The Only Safe Choice in Hair Restoration’’. Are consumers to be-
development of total micrografting, or follicular unit transplan- lieve there are no known safe hair restoration surgeons outside
tation (FUT), involves a less hands-on approach by the surgeon, North America? Or are these the only safe surgeons in North
especially if ‘‘stick and place’’ is practiced (see Chapters 12D America? The acceptance of member advertising by this com-
and 13B). This has created time leverage for the surgeon that mercial, ‘‘independent,’’ consumer-protection site, raises ques-
has demonstrable financial rewards. Ironically, or perhaps inev- tions about potential conflict-of-interest issues. Isn’t this not
itably, some medical assistants and nonmedical entrepreneurs just a marketing group? Surely, we can do better than this? Or
have come to regard doctors as nonessential to the procedure, does fear of mega-advertising groups mean that the end justifies
or, at best, as having a limited role. Perhaps doctors need to the means?
reclaim the operation? In other words, adopt a more personally The fourth challenge is the perceived loss of professionalism
hands-on approach. What other surgery allows such delegation of our specialty. Physicians have dual roles as healer and profes-
of operative procedure? sional, which are linked by codes of ethics governing behavior
The first challenge, as mentioned earlier, relates to increas- and empowered by science. Professionalism entails a societal
ing medical litigation. This increase in medical litigation is contract that allows physicians autonomy and the privilege of
partly the result of increased patient education and autonomy, self- regulation. In return, our obligation to society is to guaran-
which has empowered the patient to seek redress for injury or tee competence, provide altruistic service, and conduct our af-
perceived injury. Balancing this should be our increased care fairs with morality and integrity. Societal attitudes to profes-
in promoting the benefits and likely outcomes of hair restoration sionalism have changed from supportive to increasingly critical,
surgery, which leads to more realistic patient expectations. This with physicians being criticized for pursuing their own financial
is crucial because unrealized patient expectations are the great- interests and failing to self-regulate in a way that guarantees
est cause of medical litigation in our field. competence. A charter on medical professionalism was devel-
The second challenge is increasing government scrutiny and oped in collaboration among the European Federation of Inter-
regulation. Internationally, there is recognition that cosmetic nal Medicine, the American College of Physicians, the Ameri-
surgery is largely unregulated. Australia, New Zealand, France, can Society of Internal Medicine, and the American Board of
and the United Kingdom (England) have in the past few years Internal Medicine. This was published in both the Annals of
either proposed or enacted, regulations restricting the right to Internal Medicine and the Lancet (1).
practice, or promote, cosmetic surgery. This trend will continue The charter on medical professionalism cites three funda-
and spread unless we are seen to be serious about regulating mental principles: first, primacy of patient’s welfare; second,
ourselves. patient autonomy; and, third, social justice. The charter also
The third challenge is Internet advertising practices. The espouses a range of professional responsibilities that include
typical Internet user is male, postpubertal, and educated. Per- commitment to ensure professional competence, to improve
fect! Regular advertising, in print or broadcast media, is prohibi- quality of care, to contribute to scientific knowledge, and to
tively expensive for single practitioners and is dominated by maintain trust by managing conflicts of interest. These core
high-volume group practices. How do single physicians com- responsibilities involve taking the following actions: conduct
pete? In contrast, Internet advertising is relatively cheap and self-regulation, define and organize the education and standard-
targeted to those who are genuinely interested. Perfect! Or is setting process for current and future members, and fulfill the
it? In my view, Internet advertising on commercial hair sites obligation to engage in both internal assessment and external
is a double-edged sword. Websites are unregulated and there scrutiny of all aspects of professional performance.
22 Chapter 1
PERIL 2. Butcher EO. Hair growth in skin transplants in the immature

albino rat. Anat Rec 1936; 64:161–170.
Let us consider the issues that put us at peril in our field. First, 3. Butcher EO. Hair growth and sebaceous glands in skin trans-
in my view, is complacency. We have not reached the end- planted under the skin and into the peritoneal cavity in the rat.
point in development of our techniques. Further improvement Anat Rec 1946; 96(2):101–108.
4. Butcher EO. Fate and activity of autograft and homograft of skin
is inevitable if we remain open to new ideas. Second, an adver-
in white rats. AMA Arch Dermatol Syphilol 1037; 36:53–56.
tising and marketing free-for-all environment encourages entre- 5. Fessler A. Pigmentation and transplantation. Br J Dermatol 1941;
preneurial efforts that may jeopardize standards. We must com- 53:201–214.
mit to more honest advertising. Third, leverage is a financial 6. Lewin ML, Peck SM. Pigment studies in skin grafts on experi-
ideal, not a patient ideal. The employment of assistants who mental animals. J Invest Dermatol 1941; 4:483–509.
perform most of the procedure and the increasing use of 7. Seevers CH, Spender DA. Autoplastic transplantation of guinea
nonmedical consultants threaten our credibility as physicians. pig skin between regions with different characters. Am Naturalist
How can consultants properly advise patients on the need for 1932; 66:183–189.
8. Giiadially FN. The effect of transposing skin flaps on the hair
prescription medication such as finasteride? Last, a continuing
growth cycle in the rabbit. J Pathol Bacteriol 1957; 74:321–325.
perceived loss of professionalism. Internet users have stated; 9. Osborne MP. Complete scalp avulsion: rational treatment. Am
‘‘Secret techniques are acceptable because hair restoration sur- Surg 1950; 132:198–213.
gery is more big business than big medicine.’’ In other words, 10. Taylor CA, Gerstner R, Converse JM. Preservation of skin grafts
we are perceived as selling to customers rather than treating by refrigeration for reconstructive surgery. Plast Reconstr Surg
patients. 1956; 18:275–285.
11. Carrel AJ. The preservations of tissue and its applications in sur-
gery. JAMA 1912; 69:523–527.
OPPORTUNITY 12. Haxthausen J. The occurrence of human antibodies in allergic
eczema investigated through parabiosis experiments of guinea
I believe we can arrest this slide in respect. We have an opportu- pigs. Acta Derm Venereol 1943; 24:286–297.
nity, but action is required. Medical professionalism must be 13. Comel M. Modificazioni delle alterazioni cutanee della vitiligo
taught explicitly. Setting and maintaining standards is crucial. e della sclerodermia in zona trapianto cutaneo Dermatologica
Recertification and revalidation are now regarded as profes- 1948; 95:366–372.
sional obligations. Self-regulation measures must be fair, objec- 14. Spencer GA, Tolmach JA. Exchange grafts in vitiligo. J Invest
Dermatol 1953; 19:1–5.
tive, and transparent. 15. Haxthausen H. Studies on the pathogenesis of morphea, vitiligo
I believe that self-regulation can be a two-level process in and acrodermatitis atrophicans by means of transplantation exper-
hair restoration surgery. First, at the specialty level, with in- iments. Acta Derm Venereol 1947; 27:352–368.
volvement of the ISHRS, the ESHRS (European Society of Hair 16. Sagher F. Experimental study on the absorption of the amyloid
Restoration Surgery) and the ABHRS (American Board of Hair in localized amyloidosis by skin grafting. AMA Arch Dermatol
Restoration Surgery), for example. These bodies can be respon- Syphilol 1946; 63:342–348.
sible for setting formal standards of practice. Second, at the 17. Haxthausen H. Pathogenesis of allergic eczema elucidated by
professional level, the relevant medical boards can retain retransplantation experiments on identical twins. Acta Derm Vener-
sponsibility for disciplinary matters. eol 1942; 23:438–457.
18. Naegli O, De Quervain F, Stadler W. Nachweis des cellulaeren
For our specialty to be involved in self-regulation, we must Sitzes der Allergie beim fixen Antipyrinexanthem (Autotrans-
develop a core curriculum of knowledge for training in hair plantationen, Versuch in vitro). Klin Wochschr 1930; 9:924–928.
restoration surgery, preferably with international support. 19. Urbach E, Sideravicius B. Zur Kritik der Methoden der passiven
Standardization is desirable. We must accept peer-review certi- Uebertragung der Ueberempfindlichkeit. Klin Wochschr 1930;
fication. The currently offered (by the ABHRS) certificate of 9:2095–2099.
added qualification seems a step in the right direction, as it is 20. Wise F, Sulzberger MB. Drug eruptions. I. Fixed phenolphthalein
open to all physicians who wish to practice. Let us remember eruptions. AMA Arch Dermatol Syphilol 1933; 27:549–567.
that self-regulation is preferable to external regulation. 21. Loveman AB. Experimental aspect of fixed eruption due to allur-
We stand at the crossroads in deciding our future. We have ate, a compound of allonal. JAMA 1934; 102:97–101.
22. Knowles FC, Decker HB, Kandle RP. Phenolphthalein dermatitis.
the power to improve public perception of our specialty. We An experimental study including reproduction of the eruption in
need the collective will to act. We also need to think big. Surely skin transplants. AMA Arch Dermatol Syphilol 1936.
it is better to increase the number of people who are knowledge- 23. Hurley HJJ, Shelley WB. Acquired amotional sweating in trans-
able about hair restoration surgery, who currently make up only plants. AMA Arch Dermatol 1957; 75:815–818.
a fraction of the concerned balding population, rather than fight 24. Chargin L. Recurrence of lupus erythematosus in grafted skin.
over a smaller number of such individuals? AMA Arch Dermatol Syphilol 1950; 61:532.
United we stand, divided we fall. 25. Barsky AJ. The scalp. The eyebrow. In Principles and Practice
of Plastic Surgery. Vol. 395. Baltimore, MD: Williams & Wil-
kins, 1950:137–140.
REFERENCES 26. Conway H, Berkeley W. Chromoblastomycosis (mycetoma form)
treated by surgical excision. AMA Arch Dermatol Syphilol 1952;
How It All Began: Autografts in Alopecias and 66:695–702.
Other Selected Dermatological Conditions 27. Delak Z. Successful replacement of the completely avulsed scalp.
Br J Plast Surg 1955; 8:55–56.
1. Butcher EO. Pigmentation of hair on transplanted skin in hooded 28. Dorrance GM, Bransfield JW. Immediate covering of denuded
rats. AMA Arch Dermatol Syphilol 1945; 52:347–350. area of skull. Am J Surg 1942; 58:236–239.
29. Goxanes CJ. Contribucion al extudio de la blefaroplastia. Arch 42. Converse JM, Rapaport FT. The vascularization of skin autografts
Ofal Hispano-Am 1905; 5:229–245. and homografts. Ann Surg 1956; 143:306–315.
30. Hoff F. Storungen in her Harmonie der Fettverteilung. Dtsch Med 43. Hamilton JB. Patterned loss of hair in man: types and incidence.
Wochenschr 1941; 67:671–703. Ann NY Acad Sci 1951; 53(3):708–728.
31. Hoff F. Beobachtungen an Hauttransplantaten. Klin Wochenschr 44. Szasz TS, Robertson AM. The theory of the pathogenesis of ordi-
1953; 31:56–57. nary human baldness. AMA Arch Dermatol Syphilol 1950; 61:
32. Kazanjian VH. Repair of partial losses of scalp. Plast Reconstr 34–38.
Surg 1953; 12:325–334. 45. Scott Ban, Scott EJ. Response of hair roots to chemical and physi-
33. Lamont ES. A plastic surgery transformation. West J Surg Obstet cal influence. In: Montagna W, Ellis RA, eds. The Biology of
Gynecol 1957; 65(3):164–165. Hair Growth. New York: Academic Press, 1958:447.
34. Matthews DM. The eyebrow. Eyelashes. In: Surgery of Repair.
2nd ed.. Springfield. Ill: Thomas, 1946:28–271.
35. Meister E. Scalp avulsions: attempt to restore hair growth. Bt J The Physician–Patient Relationship
Plast Surg 1955; 8:44–48.
36. Paletta FX. Avulsion of the entire scalp. Mo Med 1956; 53(3): 1. Lotufo PA, Chae CU, Ajani UA, Hennekens CH, Manson JE.
191–192. Male pattern baldness and coronary heart disease: the Physicians’
37. Vallis CP, Humphreys SP. Treatment of extensive defect of scalp Health Study. Arch Intern Med 2000; 160:165–171.
and skull. J Intern Coll Surg 1956; 26(2):249–252.
38. Wunn SK. Free pattern skin graft in total scalp avulsion. Plast
Reconstr Surg 1951; 7:225–236. The Future of Hair Restoration Surgery
39. Gussenbauer K. Ueber Scalpirung durch Maschinengewalt. Z
Heilk 1883; 4:380–392. 1. Brennan T, Blank L, Cohen J, et al. Medical professionalism in
40. Straith CJ, McEvitt WG. Total avulsion of scalp; review of prob- the new millennium: a physician’s charter. Lancet 2002; 359:
lem with presentation of case of skin graft in which thrombin 520–522.
plasma fixation was used. Occup Med 1946; 1:451–462. 2. Brennan T, Blank L, Cohen J, et al. Medical professionalism in
41. Davis JS. Scalping accidents. Bull Johns Hopkins Hosp 1911; the new millennium: a physician’s charter. Ann Intern Med 2002;
16:257–362. 136:243–246.
2
Basic Science
2A. Hair Anatomy and Histology

Hair-Peg Stage (Fig. 2A-1c)
Paul T. Rose, Ron Shapiro, and Michael Morgan
The hair-peg stage is the next stage of development. During
this stage, the epithelial cells of the hair germ grow downward
INTRODUCTION and form a column that seems to propel the mesoderm down-
ward.
Humans are born with approximately 100,000 hair follicles on
the scalp. These hairs play a role in thermal regulation, spread
of products derived from sweat glands, provide protection from Bulbous-Peg Stage (Fig. 2A-1d)
the environment, and encourage social and sexual interaction. Subsequently, three areas of swelling appear as the column ex-
Hair follicles are derived from a combination of different tends downward. This constitutes the bulbous-peg stage. The
embryological tissues. Each follicle is a unique and complex most superior swelling will become the apocrine gland. The
structure that exhibits a cyclical life cycle during which various middle swelling develops into the sebaceous gland, whereas the
structures of the hair follicle are altered. New research has given lowest becomes the bulge area to which the arrector pili muscle
us a better understanding of hair follicle, development, struc- will attach. During this stage, the epidermal cells at the advanc-
ture, and cycling. These topics are discussed in this chapter. ing base of this column surround a portion of the underlying
mesodermal cells, forming the dermal papilla.
EMBRYOLOGY The First Primordial Hair (Fig. 2A-1e)

Hair follicles begin to develop by the completion of the second At this point the cells at the base of the column that surround
month of pregnancy (1–4). The earliest events in the develop- the dermal papilla (the matrix region) begin to actively prolifer-
ment of the hair follicle involve the interaction of mesoderm ate, and this initial hair shaft enveloped by an inner root sheath
and ectoderm (Fig. 2A-1). begins to move upward. Above it, the central cells of the follicu-
lar peg appear to degenerate, and the emerging hair seems to
push out the plug so a hair canal can be formed.
Pregerm Stage (Fig. 2A-1a) These first primordial follicles are spaced at a distance of
between 274 nm and 350 nm apart over the skin’s surface (5).
The very first signs of a hair follicle are an aggregation of
As development continues and the skin expands, these primor-
mesenchymal cells in the superficial level of the dermis and a
dial follicles become separated. When a critical distance is
simultaneous thickenin
reached, a new bud appears in the developing space. This criti-
g of basal epidermal cells immediately
cal distance and hence the density and patterning of hair varies,
above it (5). This is called the pregerm stage.
depending on the region of the body. What signal(s) initiates and
controls the development and placement of hair follicles over the
Germ Stage (Fig. 2A-1b) body has been debated. Early studies indicated that the first signal
for hair formation came from the dermis, but more recent data
At this point, the basal epidermal cells become elongated and have suggested that transcription factors are expressed in the
start to bulge downward as the hair germ, while, at the same primitive epithelial cells at the site of follicle formation as the
time, the underlying mesenchymal cells begin to replicate to distance between the primordial hairs increases.
form the rudiment of what will become the dermal papilla. This The very first hair buds are seen to develop on the eyebrow,
stage of development is referred to as the germ stage. upper lip, and chin at 9 weeks’ gestation. This development
25
26 Chapter 2
c e
Figure 2A-1 (a) Stages of embryology—pregerm stage. (b) Stages of embryology—germ stage. (c) Stages of embryology—peg stage.
(d) Stages of embryology—bulbous stage. (e) Stages of embryology—primordial hair.
spreads to other regions of the fetus, including the scalp, and whereas the inferior segment is transient and undergoes cyclical
by 22 weeks, the entire initial population of follicles is com- regeneration.
pleted. On the scalp, these initial lanugo hairs are shed by the
eighth month in a synchronized advancing wave from the fron- Infundibulum
tal area to the occipital area. This initial population of lanugo
hairs is followed by a second coat of lanugo hairs that are shed The upper region, or infundibulum, of the follicle consists of
in a more or less synchronized wave pattern by the third or the area from the opening of the sebaceous duct to the follicular
fourth month after birth (6). This synchronization is lost with opening on the surface of the skin. It contains the fully formed
the successive population of hairs, and by the end of the first hair shaft as it exits the epidermis. The epithelium of the epider-
year of life, an asynchronous population of follicles in all stages mis is contiguous with the wall of the infundibulum.
of the growth cycle exists (7). It is generally believed that no
new hair follicles develop after birth. Isthmus
The middle region, or isthmus, begins at the opening of the
GROSS ANATOMY AND HISTOLOGY OF THE sebaceous duct and continues down until it reaches the insertion
TERMINAL HAIR of the arrector pili muscle. At the level of the insertion of the
arrector pili is the bulge area. This area is very obvious in the
Viewed in longitudinal section, the hair follicle is anatomically embryonic follicle but only intermittently obvious in the adult
divided into an upper, middle, and lower region. These three follicle. The bulge is now thought to contain stem cells impor-
regions are respectively termed: the infundibulum, the isthmus, tant for the regeneration of the follicle. In the past, it was long
and the inferior segment (Fig. 2A-2). The infundibulum and thought that the cells responsible for hair shaft regeneration,
isthmus make up the permanent portions of the hair follicle, namely, follicular stem cells, resided solely in the bulb area.
Basic Science 27
HISTOLOGY OF THE TERMINAL HAIR

FOLLICLE
The following histological components of the hair follicle are
discussed:
● dermal papilla
● hair matrix
● hair shaft (made up of medulla, cortex, and hair cuticle)
● inner root sheath (made up of cuticle, Huxley’s layer,
and Henle’s layer)
● the surrounding hyaline membrane and perifollicular fi-
brous sheath
It may be helpful to refer to Figs. 2A-3 to 2A-5 while reading
this section. Figs. 2A-3 and 2A-4 are schematic diagrams of
the histological components of the hair follicle. Figure 2A-5 is
a cross-sectional histological photograph of the hair follicle at
the levels of the isthmus.
Dermal Papilla
As the name suggests, the dermal papilla is part of the dermis
and is mesodermal in origin. The papilla is surrounded by the
matrix cells of the hair bulb. At the distal aspect of the hair
bulb, the papilla connects with a fibrous sheath that surrounds
the hair follicle. This fibrous sheath is separated from the follic-
Figure 2A-2 Major regions of hair follicle. ular epithelium by a glassy, PAS positive hyaline basement
membrane.
The dermal papilla contains specialized fibroblasts with
powerful hair follicle inductive properties (14). The dermal pa-
pilla is needed for initiation of a new hair cycle and for normal
However, this thinking has changed. Montana and Parakkal hair growth. It is believed to regulate matrix cell division and
were among the first to postulate that cells responsible for devel- the caliber of the hair produced (45). Androgen receptors have
opment of the hair follicle reside in the outer root sheath rather clearly been demonstrated in the dermal papilla. The papilla
than the hair bulb (8). Subsequent studies have revealed that has been associated with the production of a large number of
the bulge area also contains epithelial stems cells that are able growth factors and growth factor receptors that may play a role
to regenerate the hair follicle during anagen (9–14). The stem in hair growth (45).
cells of the bulge area may, in addition, be recruited to generate
epidermal and sebaceous gland cells (14). Matrix Cells
What triggers the interaction of the stem cells of the bulge
area with the dermal papilla to form a new anagen hair is un- The matrix cells are located directly above the papilla. These
cells are undifferentiated, actively dividing and immunologi-
known. It may be that there are biochemical signals or regula-
cally ‘‘privileged (16). Melanocytes are present between the
tory genes that trigger the interaction. The bulge area appears
basal cells of the matrix. Melanin produced by the melanocytes
to be inundated with nerve endings as well as Merkel cells (15).
is incorporated into new hairs by the process of phagocytosis.
Such a network may be involved in providing signals for hair
The matrix cells differentiate into the multiple components of
growth and cycling. the hair follicle, including: the hair shaft (HS), the inner root
sheath (IRS), and the outer root sheath (ORS).
Inferior Segment These latter three structures (HS, IRS, ORS) can be seen as
three concentric cylinders embedded within each other (Fig.
The inferior segment of the hair follicle is the area from the 2A-6). The histology of these three structures is discussed in
base of the follicle to the insertion of the arrector pili muscle. his more detail later. A hyaline membrane and perifollicular dermal
area is transient and cyclically regenerates itself in a controlled sheath surround these structures.
fashion.
The bottom-most portion of the inferior segment is referred Hair Shaft
to as the hair bulb and contains the rapidly dividing undifferen-
tiated matrix cells and melanocytes. The hair bulb surrounds The innermost cylinder is the hair shaft, which in turn is made
the dermal papilla. The combination of the hair bulb and the up of three layers: a) the medulla, b) the cortex, and c) the hair
cuticle.
dermal papilla with its associated nerves and blood vessels con-
stitutes the hair root. A pad of elastic tissue known as the Arao- 1. Hair Shaft Medulla. The medulla is the most central
Perkins body may develop under the dermal papilla. layer of the hair shaft and probably arises from matrix
28 Chapter 2
Figure 2A-3 Diagram of hair follicle histology (longitudinal view).
cells directly above the papilla. In the suprabulbar re- overlapping cuticle cells (18,19). They are arranged in
gion, the cells of the medulla begin to show vesicles in a shingled type of array and later become keratinized
their cytoplasm. At the level of the epidermis, the cells and point upward so they can interlock with the down-
of the medulla appear to dehydrate and the vacuoles ward-projecting cuticle cells of the surrounding inner
become air filled. The protein composition of the me- root sheath.
dulla contains trichohyaline. Terminal hairs usually The hair shaft is the only part of the hair follicle to exit the
contain a medulla or a partial medulla, but vellus hairs epidermis.
and finer hairs do not (17).
2. Hair Shaft Cortex. Lateral to the medulla are the corti- Inner Root Sheath
cal cells of the hair shaft, which are fusiform in shape
and arranged longitudinally parallel to the shaft. They The inner root sheath (IRS) surrounds the hair shaft. It exists
become tightly packed and keratinized as they move only in the inferior segment of the hair follicle, traveling from
upward. Keratinization inside the cell involves the pro- the bulb up to the beginning of the isthmus, which, as noted
duction of various keratin fibrils. Microfibrils and ma- earlier, is marked by the insertion of the erector pili muscle.
crofibrils are embedded in an amorphous matrix of high Beyond the erector pili muscle, the keratinized IRS deteriorates
sulfur-containing proteins that support these keratin fi- and is replaced by keratin from the outer root sheath (ORS).
brils. The macrofibrils are cylindrical and measure be- The IRS is also made up of three layers. From inside out
tween 0.1 ␮ and 0.4 ␮m in diameter (18). It is the cortex they are: (a) the IRS cuticle, which is one cell thick, (b) Huxley’s
cells that impart the mechanical properties of hair. Pig- layer which is three or four cells thick, and c) Henley’s layer
ment is present in some cortical cells. This pigment was which is also one cell thick. As the cells in the IRS keratinize,
initially produced by melanosomes in the matrix and they give rigidity to this sheath, supporting the IRS function
then acquired by matrix cells through phagocytosis. as a mold for the enclosed and developing hair shaft. Racial
These pigmented matrix cells later differentiate into pig- differences in shaft cross-section (flat in those of African de-
mented cortical cells. cent, round in Asians, and ellipsoidal in Europeans) are pro-
3. Hair Shaft Cuticle. The cuticle is the outermost layer duced by the asymmetric formation of the IRS. The IRS is
of the hair shaft and is composed of 6 to 10 layers of tightly moored to the hair shaft by the overlapping of cells
Basic Science 29
Figure 2A-4 Diagram of bulb area histology (longitudinal view).
from their adjacent cuticle layers. The hair shaft and IRS move duct. It is thinnest at the level of the hair bulb and thickest
upward together, slipping along the surrounding innermost at the isthmus. The outer root sheath contains melanocytes,
layer of the ORS. neurosecretory cells (Merkel cells) and Langerhans cells (45).
These melanocytes are amelanotic, suggesting that they are in-
Outer Root Sheath active (20). They may be activated by trauma such as dermabra-
sion (21).
The outer root sheath (ORS) surrounds the IRS. It travels from Outside the outer root sheath a vitreous, PAS positive hya-
the bottom of the hair bulb to the opening of the sebaceous line membrane layer is evident. Collagen bundles from the der-
Figure 2A-5 Cross-sectional photograph of bulb isthmus region.

30 Chapter 2
of the sebaceous gland. Fibers may innervate local structures

to form a plexus of nerves at a level between the papillary
and reticular dermis. From this point, nerves may emanate to
innervate the papillary dermis and epidermis (24–26). Hordin-
sky and Ericson have reported that perifollicular blood vessels
are not well innervated (27). They also demonstrated that cells
in and around the dermal papilla stain, with a pan-neuronal
antibody, and that substance P can be detected at the bulge area,
and perifollicular nerves and vessels. Such observations provide
more evidence that suggests there may be neural signals that
influence hair physiology.
Hair follicles have an abundant blood supply. Vasculariza-
tion is pronounced in the upper and lower portions of the folli-
cle, with vessels penetrating the papilla.
HAIR GROUPINGS (FOLLICULAR UNITS)

Figure 2A-6 The hair shaft, inner root sheath, and outer root
sheath seen as concentric cylinders embedded within each other. The spacing or positioning of hairs is particularly noteworthy.
The initial spacing varies from 274 nm to 350 nm and
changes as the skin surface expands (5). Interestingly, the
embryological patterning resembles the positioning of scales
evident in lower vertebrates (9). The pattern disappears as
mis surround this layer to form the perifollicular fibrous root the hair and glands develop.
sheath. In 1998, Headington published a paper describing the
Headington has noted that reduction in volume of the outer transverse anatomy of hair follicles (22). He demonstrated
root sheath (ORS) coincides with alteration in the basement that hairs at the level of the sebaceous duct appear to exist
membrane zone (22). Such changes in the keratinocytes of the in groupings, which he termed follicular units. Headington
outer root sheath, at a point below the insertion of the sebaceous defined a FU as consisting of two to four terminal follicles
duct, indicate telogen. and one or more vellus hairs as well as the sebaceous lobules
and insertion of the arrector pili of the dermal follicles (Figs.
2A–7a, b, c).
KERATINIZATION The density of these units was shown to be approximately
one per square millimeter, although it has been shown that fol-
Keratinization of the hair follicle occurs in a sequential fash- licular unit density (FUD) can vary from as high as between
ion. The first layer to keratinize is the Henle layer, permitting 110 fu/cm2 –and 120 fu/cm2 to as low as 80 fu/cm2. Cole has
a sturdy covering to envelop the soft central structure of the shown that FUD in ‘‘virgin’’ donor areas is generally highest
hair. The cells are keratinized by tricohyaline granules. Next, in the midoccipital region and least in the supra-auricular
the cuticle of the inner root sheath and hair shaft keratinize. area(28) (see also Chapter 10 ). In a normal adult scalp, a 4-
Like the Henle layer, the inner root sheath keratinizes by mm biopsy contains 12 to 14 FUs. This may represent approxi-
means of tricohyaline granules. After this, the Huxley then mately 20 to 30 terminal hairs. Although the hairs may cluster
keratinizes also by tricohyaline granules. The hair cortex is as FUs, each hair in the unit arises from a single follicle.
then keratinized by a process that does not involve keratohya- A study of hair groupings in primates by Perkins and
line or trichohyaline granules. The nuclei of these cortical associates revealed that various types of groupings existed
cells degenerate and the cells fill with keratin fibrils. The
(29). They demonstrated eight specific categories. An unorga-
medulla is last to cornify.
nized pattern was observed in the bald area of the stump-
The keratinized inner root sheath (IRS) extends to the
tail macaque. The only primate studied that did not possess
insertion of the erector pili muscle. At this point, trichilemmal
an organized pattern of groupings was the human being.
keratin of the outer root sheath (ORS) replaces it and lines
the wall of the isthmus until it reaches the entrance of the Perkins concluded that as the organisms progress phylogeneti-
sebaceous duct (1,23). From this point on, the infundibulum cally, the hair groupings become more random.
is lined by surface epithelium, keratinized by keratohyaline The patterning and placement of hair follicles appears to
granules. be under several mechanisms of control (30–32). Various
genes, lymphokines, and other biochemical modulators have
a role. These correspond to the regulatory controls evident
in studies of various species. Homeobox genes such as Hox
INNERVATION AND BLOOD SUPPLY
D 11, Msx-1, and biochemical modulators such as lymphoid
Hair follicles are innervated by nerves that course from the bulb enhancer factor I, insulin-like growth factor, fibroblast growth
to the epidermis. Some hair follicles possess a ‘‘hair- factor V, epidermal growth factor, and hedgehog, as well as
end organ.’’ This anatomical structure is made up of a many others, appear to play important roles in these aspects
‘‘collar’’ of nerves that surrounds the hair follicle at the level of hair development (33–37).
Basic Science 31
Figure 2A-7 (a) Follicular unit groupings seen in a cross-sectional histological view through the scalp. (b) Follicular unit (FU) groupings
seen in a close-up photograph of the surface of the scalp. The three-haired FU circled in red is the ‘‘powerhouse’’ of follicular unit transport
(see Chapter 11).
VARIATIONS IN MORPHOLOGY AND Vellus vs. Terminal Hair

PHYSIOLOGY
Hairs may be termed vellus or terminal hairs. At puberty,
Hair follicles show significant morphological and functional vellus hairs are replaced by terminal hairs in certain areas
heterogenicity with different body sites, races, and age. Ex- of the body (axilla, pubis, and face), and this change occurs
cepting bilateral symmetry, hair follicles and their shafts vary by means of androgenic hormones. Terminal hairs and vellus
from site to site on the body with respect to shaft length, hairs are classified in the following way (6). Large hairs,
color, curl, thickness, cycling, and androgen sensitivity. often pigmented and medullated with a diameter exceeding
32 Chapter 2
determined by its cross-section. The conformation of the hair

shaft can be straight, wavy, or helical. Asians commonly have
straight hairs, whereas blacks usually possess helical hairs that
curve beneath the skin surface. Whites have hairs that may be
of any type (38,39). In whites, the caliber of terminal hair has
been shown to vary from 0.060 mm to 0.084 mm (60 to 84
microns). In Asians, the caliber is higher and averages 0.1mm
(100 ␮).
Hair Color
The color of hair is imparted by melanocytes (40). Melanocytes
are positioned above the papilla in the basal layer of the bulb.
As cells forming in the shaft pass these resident melanocytes
on their way up, they pick up melanin in a process thought to
be similar to that seen in the epidermis. Dark brown or black hair
has a high concentration of ellipsoid melanocytes that produce
eumelanin. Red and blond hair is characterized by spherically
shaped melanocytes that produce pheomelanin. Gray or white
hairs have decreased numbers of melanocytes that are often
incompletely melanized.
HAIR CYCLE
Each hair follicle goes through the hair cycle 10 to 20 times in
a lifetime, every cycle recapitulating much of the embryological
c development (41). The hair cycle is classically composed of
three distinct phases: anagen (growth), catagen, and telogen
Figure 2A-7 Continued. (c) One-haired, two-haired, and three- (resting). (Fig. 2A-8). A fourth ‘‘exogen’’ stage has been de-
haired follicular unit groups. scribed and is discussed briefly later. Studies have shown that
much like the shedding of hair by other mammals, human hair
is shed in a somewhat seasonal fashion (42,43). Anagen lasts
from 3 to 10 years, catagen 2 to 3 weeks, and telogen 3 to 4
months. In the human scalp, the cycle is asynchronous. At any
.03 mm and growing to more than 1 cm in length, are one time, an average of 13% of the hair is in telogen, although
classified as terminal hairs. Small hairs, with no pigment or it can range from 4% to 24%. Only 1% is in the catagen phase.
medullary cavity and a diameter of less than .03 mm and a Although the morphological changes of each stage are recog-
length less than 1 cm, are classified as vellus (downy) hairs. nized, it is not known which cells control the cycle.
Depigmented hairs that are less than .03 mm and have been At the end of the growth, or anagen, phase, the hair follicle
miniaturized by androgenic alopecia or any other cause can receives an unknown signal to enter the catagen phase. The
be classified as velluslike hairs. The term vellus hairs is often matrix cells cease proliferating and the production of melanin
used to include both true vellus hairs and velluslike hairs. terminates. Melanocytes withdraw their dendrites and become
Terminal hairs are rooted in the subcutaneous tissue, but indistinguishable from matrix cells. The dermal papilla con-
vellus hairs are rooted in the dermis. The diameter of a tracts and is released from the follicle. The middle portion of
vellus hair shaft is usually less than the diameter of the the follicle constricts and the lower portion expands to become
accompanying IRS. With terminal hairs, the diameter of the the ‘‘club.’’ This lower portion retracts up to the level of the
hair shaft exceeds the thickness of the accompanying thinner erector pili muscle, leaving a thin band of undifferentiated epi-
root sheath. It is not always possible to differentiate between thelial cells (streamer) (44). The mechanism of retraction is
true vellus hairs and velluslike hairs that result from miniaturi- thought, in part, to be due to apoptosis (controlled cell death)
zation caused by conditions such as androgenic alopecia. It (45). Another hypothesis is that the connective tissue sheath
is sometimes useful to differentiate intermediate hairs, be- around the lower portion of the follicle is rich in smooth actin-
tween .03 mm and .06 mm in diameter, which may represent containing mesenchymal cells and that these cells ‘‘squeeze’’
early miniaturization of terminal hairs as seen in androgenic the follicle upward (46). During catagen, there is also noted
alopecia. The ratio of terminal to vellus hairs in a normal to be a thickening of the basement membrane and volumetric
scalp is 7:1. reduction of the outer root sheath (22). Although the exact signal
for the induction of catagen is not known, fibroblast growth
Variations of Hair Density, Caliber, and Form with factor V has been implicated, because in animal models without
Race this factor, catagen is delayed.
During telogen, the band of epithelial cells moves upward
Hair characteristics vary with race. Whites generally have the and forms a short projection from the club hair. This projection
greatest amount of scalp hair, followed by Blacks and then is the secondary hair germ. The papilla follows the course up-
Asians. Some authors think that the shape or form of hair is ward. Histologically, one also notices loss of the IRS in telogen.
Basic Science 33
Figure 2A-8 Human hair cycle.
The most popular theory today is that stem cells from the bulge quality and density has yielded a variety of new and innovative
area migrate to the secondary hair germ, but dermal stem cells procedures These advances would not be possible without a
are also present in the papilla and dermal sheath (46). At the thorough understanding of the anatomical and histological
beginning of a new anagen phase, the secondary hair germ structure of the scalp and hair folliclé.
begins to proliferate. The lower aspect of the column continues
to grow downward and surrounds the hair papilla. A new hair THE LAYERS OF THE SCALP
bulb is formed and anagen progresses.
It may be that that there are biochemical signals and various The scalp is composed of five distinct layers (Fig. 2B-1). These
regulatory genes that allow the dermal papilla to interact with layers are often referred to by the acronym SCALP, taken from
the stem cells present in the bulge area and/or other sites. The the first letter of each level: Skin, subCutaneous layer, Aponeu-
bulge area appears to be inundated with nerve endings as well rotica, Loose connective tissue, and Pericranium. Specifically,
as Merkel cells. Such a network may be involved in providing these levels of the scalp are best characterized as follows:
signals for hair development or in initiation of interacting mo-
lecular pathways that control hair cycling.
During telogen, the old hair shaft is held tightly within the
bulbous base of the follicle. However, on receiving some type
of signal, proteolytic enzymes may convert the plump telogen
hair bulb into a slenderized, more spear-shaped exogen bulb,
which facilitates shedding of the hair. This hairless exogen
phase may last for many weeks or even months (47). Alter-
nately, the hair shaft may remain in place until a new anagen
hair develops.
2B. Anatomy of the Scalp

Paul T. Rose, Matthew L. Leavitt, and Mont J.
Cartwright
INTRODUCTION
Figure 2B-1 Cross-section of layers of scalp tissue often re-
Hair restoration has undergone a dramatic evolution since it ferred to by acronym SCALP: Skin, SubCutaneous Layer, Aponeu-
was discovered in the 1950s. The desire for superior aesthetic rotica, Loose connective tissue, Pericranium.
34 Chapter 2
● Skin – The skin is the most superficial layer of the scalp

and consists of the epidermis (superficial layer) and the
dermis (deep layer). It varies in thickness, ranging from
3 mm to 8 mm. The hair follicle and adnexal structures
course through these layers. The bulb of hair follicles
may be found in the upper subcutaneous layer before
passing through the dermis and epidermis. The follicle
is surrounded by a rich end organ network of nerves and
capillaries.
Each hair shaft that penetrates the skin grows from its own
individual follicle. Multiple follicles exist together in natural
groupings termed follicular units (FU). Each follicle has a
slightly conical, or funnel-shaped, opening in the epidermis.
The angularity of hair growth cannot be determined without
specific examination.Although the direction of this angle tends
to be the same in contiguous areas of the body, both the angle
and the direction of the hair shaft can change within 2 cm or
less. Therefore, making incisions for flaps or harvesting punch Figure 2B-2 Diagram of muscles in scalp. Anterior: supraor-
grafts requires great care so that as few follicles as possible are bital margin along the frontal muscle (Fm) process zygoma. Lateral:
transected as the hair shaft angles vary. auricular muscles (A.m.m.)—the upper border external auditory
The skin provides a relatively stable environment for the meatus along the mastoid process. Posterior: superior nuchal line
hair follicle sheath. The dermis contains the arrector pili mus- wraps around the insertion of sternocleidomastoid muscle and the
cles, whose origin is between the epidermis and the dermis origin of the trapezoid. G.A. refers to the galea aponeurotica and
at the papillary layer. These muscles insert into the follicular O.M. refers to the occipital muscle.
sheath.Their action is to elevate the hair in response to cold, to
the fight-or-flight reflex, or to other conditions that direct blood
away from the skin. When one is cold or afraid, these muscles
contract, causing the hair to stand erect and compress the seba-
extending to the external auditory meatus along the mastoid
ceous glands, producing cutis anserina, or goose flesh. The
process (1).
sebum secreted from these glands lubricates the hair shaft and
The tensile strength of this layer makes it useful for suturing
carries away debris generated in the follicle. Sweat ducts also
when doing various types of scalp reduction and flap procedures
pass through the two layers of skin from sweat glands in the
are performed. However, this same tensile strength can some-
subcutaneous layer. times become an obstacle in scalp surgery, making it difficult
● SubCutaneous Layer – The subcutaneous layer of the to close scalp defects without tension. The use of scalp expan-
scalp is a layer of superficial fascia that lies in between ders and scalp extenders under the galea can help alleviate this
problem.
the skin above and the galea aponeurotica below. It con-
sists primarily of fat and a network of fibrous septa. This ● Loose connective tissue (subgalea fascial) – This level
fibrous network creates stability between the top three of scalp is thin and (relatively) avascular except for the
layers of the scalp and allows them to move together as emissary veins that connect the scalp with the intracra-
a unit over the deeper subgaleal layer of loose connective nial venous system (2).
tissue. The main arteries, veins, lymphatics, and nerves ● The loose connections in this layer allow for the free
of the scalp are located at the bottom of this layer just movement of the scalp. The avascular nature affords ease
above the galea. of undermining with minimal bleeding.
● Aponeurotica (epicranium, galea) – The galea aponeuro-
Although rare, scalp infections can occur. These infections can
tica is the musculoaponeurotic layer of the scalp; a strong
arise at the level of the loose connective tissue. At this level,
tendonlike structure interposed between the frontal mus-
the infection can progress via the emissary veins that course
cle in the forehead and the occipital muscle in the neck.
through the parietal foramina. From this location, the infection
It is the skull’s ‘‘deep fascia.’’ The galea represents the can involve the meninges. Additionally, because the frontalis
continuation of the frontalis muscle anteriorly and the muscle attaches to the skin rather than the underlying bone,
occipitalis muscle posteriorly. Collectively, the galea space exists that allows for the spread of infection of other
and these two muscles are termed the epicranius muscle. fluids into the eyelids and the root of the nose
The aponeurotica is bounded anteriorly by the supraorbital mar- ● Pericranium – This is the periosteum that is attached
gin along the frontal process of the zygoma and the upper border to the skull and is the deepest layer of the scalp. Like
of the zygomatic arch (Fig. 2B-2). Posteriorly, it is bounded by periosteum of other bones, it is very adherent to the un-
the superior nuchal line. It wraps around posteriorly above the derlying skull. In the region of the cranial sutures, it is
insertion of the sternocleidomastoid muscle and the origin of the extremely adherent because strong fibrous attachments
trapezoid. Laterally, its upper border is the auricular muscles, to the dura mater exist.
Basic Science 35
ARTERIAL SUPPLY courses along the retroauricular groove adherent to the perios-
teum of the mastoid process. Superiorly, the artery travels deep
The scalp is one of the most vascular areas of the body (Fig. 2B- to the posterior auricular muscle as the auricular artery. It sup-
3). Understanding the arterial supply is of critical importance to plies the cranial surface of the ear and finally anastomoses with
the hair restoration process, especially when performing the branches at the superficial temporal artery.
more complex scalp reduction and flap procedures. Knowledge The occipital artery originates from the external carotid at
of the blood supply helps the physician avoid injury to major the inferior margin of the digastric muscle. It divides into an
vessels and unwanted intraoperative blood loss. Compromising ascending branch, a descending branch, and a transverse branch
the blood supply by overtransplantation can lead to poor growth at the nuchal border of the splenius capitis and sternocleidomas-
or even necrosis. toid attachments. These branches provide blood supply to the
The vascular supply to the scalp is derived from five paired lateral half of the posterior scalp. It is important to note that
arteries that arise from the internal and external carotid systems lack of proper visualization and/or inadequate attention to the
and which travel in the subcutaneous layer of the scalp. The depth of the incision while donor harvesting is taking place
external carotid system provides the blood supply primarily to may result in injury to the occipital artery or one of its branches.
the lateral and posterior scalp via three branches: (1) the superfi- If the occipital artery is transected during surgery, it should be
cial temporal artery, (2) the posterior auricular artery, and the closed with either electrocautery or suturing of the vessel (3).
(3) occipital artery. The internal carotid system provides the The supraorbital and supratrochlear arteries exit the orbit
blood supply to the frontal scalp via two end branches of the from respective foramina or sulci as terminal branches of the
ophthalmic artery: 1) the supratrochlear artery and 2) the supra- ophthalmic branch of the internal carotid. The supratrochlear
orbital artery. artery arises at the medial eyebrow approximately 2 cm from
Remarkably, experience has shown that the scalp can remain the midline.The supraorbital artery exits lateral to the supra-
viable even when only two of the arterial branches remain intact. trochlear and ascends into a similar subcutaneous plane. These
The superficial temporal artery is easily found in the tem- vessels anastomose with each other as well as the superficial
poral region traveling in the superficial layers of the galea just temporal and auricular arteries to form a rich vascular bed in
deep to the subcutaneous fat. It is a terminal branch of the the frontal scalp.
external carotid. It usually branches into the transverse facial There are no arteries supplying the scalp that traverse the
and temporal artery as it extends superior to the zygoma; how- cranium. All main arteries travel just superior to the galea in
ever, its branching pattern may be quite variable. This artery the subcutaneous layer. The subcutaneous layer of the scalp is
anastomoses with the supraorbital and supratrochlear arteries a particularly poor plane for dissection because of the presence
anteriorly as well as the retroauricular and occipital arteries of these large vessels and fibrous septa, which interfere with
posteriorly. blood vessel constriction.
The posterior auricular artery comes off the external carotid The existence and course of these main arteries as well as
artery superior to the digastric and stylohyoid muscles and their rich anastomoses explain why scalp flaps often survive
well (2). This high degree of vascularity also accounts for the
extremely low incidence of infection associated with scalp sur-
gery.Infection in hair transplantation is almost nonexistent.
The high degree of vascularity can, however, lead to profuse
blood loss. Bleeding from lacerations of the scalp can be diffi-
cult to manage because the vessel does not tend to retract.
Rather, the dense connective tissue surrounding vessels in the
subcutaneous layer acts to hold vessels open. In the case of
scalp reduction, and especially scalp lifting procedures, large
amounts of blood can be lost quickly. The surgeon must be
prepared to control the bleeding either by using cautery or de-
vices such as Rainey clips when undertaking extensive scalp
surgery.
Studies conducted in the past few years suggest that the
vascularity of the subgaleal tissue may be similar to that of the
subcutaneous tissue. Tremolada and associates have demon-
strated that the temporal vessels not only develop a subcutane-
ous plexus 10 cm to 14 cm above the zygoma but also send
perforators to the subgaleal fascia at this level. Perforant vessels
located at the frontoparietal area enter every 5 mm to 10 mm,
thus providing a rich plexus of vessels.
Figure 2B-3 Diagram of the arterial network in the scalp. Five- An artery can be located either by palpating it or by using
paired arteries travel in subcutaneous layer. In the lateral scalp: a Doppler flowmeter. Arteries with triphasic or even biphasic
external carotid artery (E.c.a.) (three branches): 1. superficial tem- waveforms are adequate to support flaps. The use of the Doppler
porary artery frontal (S.t.a.) (transverse facial), parietal branch flowmeter is particularly indicated in patients who may have
(P.b.) (middle temporal); 2. postauricular artery (P.a.a.); 3. occipital aberrant vascularity (i.e., history of extensive trauma, previous
artery (Occ.a.), Internal carotid artery (I.c.a.); 4. supratrochlear scalp surgeries, or radiation therapy). Particular care must be
(St.a.); 5. supraorbital (So.a) taken when designing and creating flaps on a scarred scalp
36 Chapter 2
because neovascularity through a scar may be minimal. Thus,

scalp flaps traversed by scars should not generally be used,
because their blood supply may be inadequate.
VEINS OF THE SCALP

Veins usually follow the arterial network and most often drain
into jugular veins (Fig. 2B-4). Emissary veins perforate the skull
bone and branches of the ophthalmic artery; these veins drain
into the intercranial veins (1).
INNERVATIONS OF THE SCALP

The innervations of the scalp are both sensory and motor (Fig.
2B-5) (2). The sensory input is primarily derived from the three
divisions of the trigeminal nerve: ophthalmic, maxillary, and Figure 2B-5 Innervation of the scalp. Distribution similar to
mandibular. The motor innervations of the scalp are primarily that of the arterial network. Sensory ability is provided by all three
supplied by branches of the facial nerve. It is particularly impor- branches of the cranial nerve and upper cervical nerves. Abbrevia-
tant for the hair restoration surgeon to understand the sensory tions refer to: supraorbital nerve (So.n); upratrochlear nerve (St.n);
pathways of the scalp because procedures are often performed zygomaticotemporal branch nerve (Zt.b.z.n.); (lesser occipital
under local anesthesia with field or nerve blocks. The sensory nerve). greater occipital (G.o.n.); posterior auricular (P.a.n.)
innervations are such that a caudal block creates a field of anes-
thesia cranially (4).
● Supraorbital and supratrochlear nerves–These nerves
Sensory Innervations supply the sensory innervations to the forehead and fron-
tal scalp as far back as the crown. They are terminal
Sensory branches have a distribution similar to that of the arte-
sensory branches of the ophthalmic nerve, which is the
rial network. The major innervations of the scalp are described
(superior) division of the trigeminal nerve. The supraor-
as follows:
bital nerve exits the scalp through the supraorbital fora-
men. The supraorbital nerve supplies a greater degree
of innervation to the scalp than the supratrochlear nerve.
These nerves are common sites of nerve blocks.
● Zygomatic nerve–This nerve is a branch of the maxillary
(middle) division of the trigeminal nerve, which exits
the skull through the infraorbital foramen. The zygo-
matic nerve quickly divides into two branches named
the zygomaticofacial and zygomaticotemporal nerves.
The zygomaticotemporal nerve provides the sensory in-
nervation for the anterior temporal scalp. The zygomati-
cofacial nerve supplies the innervation for the malar
area.
● Auriculotemporal nerve–This nerve supplies the sensory
innervation to the temporal and temporal parietal scalp
as well as part of the anterior ear. It is a branch of the
mandibular (inferior) division of the trigeminal nerve. It
is located adjacent and deep to the superficial artery and
vein.
● Greater auricular nerve–This nerve supplies sensory in-
nervation to the postauricular area as well as part of the
occipital area. It is an extension of the cervical plexus,
which is formed by the anterior rami of the second, third,
and fourth cervical nerves.
Figure 2B-4 The vein network in the scalp. Veins usually fol- ● Lesser occipital nerve–This nerve supplies sensory in-
low arteries and most often drain into the jugular veins. Emissary nervation to the majority of the posterior occipital area.
veins perforate the skull bone (and branches of the ophthalmic It is also a branch of the cervical plexus.
artery) and drain into intercranial veins. Superficial temporal vein
frontal (S.t.v.) (transverse facial); anterior auricular (A.a.v.), post- Motor Innervation
auricular vein (p.a.v.); occipital artery (occ.v); supratrochlear
(St.v), supraorbital (So.v); internal jugular vein (i.j.v.); external The facial nerve (seventh cranial nerve) arises from the pons
carotid (e.c.v.). and supplies most of the muscles of facial expression. It has
Basic Science 37
five major branches: temporal, zygomatic, buccal, mandibular, 2C. Surgical Anatomy of the Scalp
and cervical. The temporal branch of the facial nerve supplies
motor innervation to the frontalis muscle, upper portion of the Gerard E. Seery
obicularis oris muscle, and corrugator supercilli It is considered
one of the most vulnerable branches of the facial nerve because ANATOMY
of its location. It exits under the parotid gland and crosses the
zygomatic arch before innervating the frontalis muscle. The The scalp is a five-layered tissue comprised of collagen, elastin,
posterior auricular muscles and the occipital portion of the epi- blood vessels, nerve fibers, and lymphatics with mucopolysac-
cranius muscle are also supplied by branches of the facial nerve. charide ground substance, tissue fluid, hair follicles, and seba-
The temporalis muscles receive innervation through the anterior ceous and sweat glands (Fig. 2C-1).
and posterior deep temporal branches of the mandibular division
of the trigeminal nerve. Skin
During punch grafting and scalp reduction, many of the su-
perficial sensor nerves of the scalp are at least partially severed The scalp skin, the first layer, is thicker than skin elsewhere
but usually without permanent consequence. The motor nerves on the body, ranging from 3 mm (vertex) to 8 mm (occiput).*
in the occipital muscles are rather deep and are rarely injured. It contains hair follicles, sebaceous and sweat glands, and is
Major sensory nerves are usually not injured during the course firmly bound to the deeper tissues.
of the scalp surgery because scalp reduction and grafting proce-
dures are not ordinarily undertaken near them. An exception to Subcutaneous
this occurs with extensive scalp lifting. In this procedure, the
branches of the occipital nerves may be sacrificed. Techniques The second, or subcutaneous, layer is notable for its rich net-
have been advocated to attempt to preserve the neurovascular work of anastomosing arteries, veins, and lymphatics (Fig. 2C-
bundles in the occipital region. 2). Subcutaneous fat is divided into multiple small compart-
The occurrence of hypoesthesia lasting as long as a few ments by fibrous septa. The arteries are attached to the deep
months after scalp surgery is common, and patients should be so layers of the dermis, and the profuse hemorrhaging often seen
warned. This numbness is presumably a direct result of surgical in superficial wounds of the scalp is attributed to a relative
trauma. A few postoperative patients may have areas of perma- inability of the arteries to retract because of their attachment
to the dermis and fibrous septa (2). The practical application of
nent numbness or paresthesias, but the condition creates no
this is that manual compression and immediate suture, without
significant problem for them. Inducing tumescence in the occip-
attempting to grasp bleeding points with hemostats, may be the
ital area before donor harvesting elevates the skin away from
most effective way of controlling bleeding from superficial
the deeper nerves and vessels and may decrease the risk of
scalp lacerations.
injury.
In addition to the neural network in the scalp, a fine lattice
of sensory nerves envelops the entire length of the follicle. Vascular Considerations
Large nerve fibers from the deep dermis or subcutaneous tissue The scalp is supplied by a system of anastomoses between
approach from all quadrants and converge on the hair follicle branches of the external and internal carotid arteries (Fig. 2C-
at the level of the subcutaneous duct. Vellus hairs possess verti- 3). The blood supply is centripetal, that is, the larger trunks run
cally oriented nerve fibers, the terminal branches forming a medially and centrally from the periphery, becoming smaller
palisade underneath horizontally oriented nerves.This perifolli- as they enter a system of free anastomoses with their fellows.
cular network of nerves and end-organs greatly extends the This and their spatial or depth location are of critical importance
range of cutaneous sensory perception. to the surgeon. The arteries are cutaneous and classically de-
scribed as running in the subcutaneous tissues.
The fact that scalp is not supplied by musculocutaneous per-
forators (3) is of enormous practical importance for surgeons,
LYMPHATIC DRAINAGE as surgical transection of subcutaneous vasculature, and particu-
larly of larger trunks in the periphery of the scalp, has dire
The lymphatic fluid from the scalp drains into the pericervical
consequences for the blood supply of tissues both adjacent to
complex of lymphatics. This so called ring consists of the sub-
and distant from the transection site. The importance of this
mental, submandibular, mastoid, parotid, and occipital nodes. will be discussed later.
The drainage from these nodes enters into the deep cervical In all likelihood, scalp also derives at least some minimal
lymph nodes. blood supply from bone perforators deriving from meningeal
Editor’s Comment vessels. This would explain the survival of areas of surgically
circumscribed scalp. The belief that scalp has a superabundant
The reader is referred to Chapter 5A for a discussion on the blood supply and consequently is very forgiving of surgical
anatomical characteristics of the skull and how they relate to indiscretions may need to be reconsidered. This has particular
planning in hair transplantation. Deciding on the proper place- relevance to hair restoration surgery.
ment of that subject was complicated by the fact that it both
anatomy and planning were involved. We believed the more
important component was the latter and hence its inclusion there *
Reprinted with the permission of Dermatol Surg 2002;581–587. Published
rather than here. (WU) by Blackwell Publishing Inc.
38 Chapter 2
Figure 2C-1 Cross-section of the scalp. Note the location of the subcutaneous vascular plexus.
In 1980, Klemp and colleagues (4) evaluated scalp subcuta- a factor in explaining why the diameters of transplanted hair
neous blood supply in subjects with male pattern baldness become significantly reduced in the post-transplant state (7).
(MPB) and concluded that blood supply is reduced in bald tis-
sues relative to controls. In 1990, Toshitani and associates (5), Neurological Considerations
using Doppler flow meter and thermography studies, demon-
strated relatively reduced flow in the central scalp of MPB pa- The sensory nerve supply of the scalp is similar to the vascular
tients. anatomy in that it is centripetal, subcutaneous, and of a similar
In 1996, Goldman (6) reported details of a study that mea- distribution. Incisions in the peripheral scalp that transect vital
sured scalp transcutaneous pO2 in subjects with MPB. Signifi- larger vascular and nerve trunks result in extensive, hypesthetic,
cant microvascular insufficiency in regions of the scalp that poorly vascularized tissues and should be avoided. Where
lose hair and an associated relative tissue hypoxia were found. avoidance is not possible because of the specific goals of the
These findings have particular relevance to hair restoration sur- surgery, a knowledge of the exact anatomical location of the
gery, with the possibility that relative local hypoxia in bald major neurovascular trunks is imperative (as is magnification)
areas may play a part in the pathophysiology by which age, if these structures are to be spared during surgery. A corollary
genetics, and androgens interact to cause MPB. It may also be of the above is that incisions in the central scalp are associated
with minimal neurovascular trauma, making their use the pre-
ferred choice where a choice exists.
Figure 2C-2 Neurovascular anatomy of the scalp. Figure 2C-3 The location and extent of the galea aponeurotica.
Basic Science 39
Galea Aponeurotica congenital absence has been reported (Stough D., personal com-
munication). Its surface is densely adherent to the subcutaneous
The galea aponeurotica (Fig. 2C-4) (8), or third layer of the tissues, thus making dissection in this plane difficult and
scalp, should be considered only when taken in conjunction bloody.
with the occipitofrontalis muscle, which has occipital and fron- The galea is significantly resistant to stretching and is be-
tal bellies separated by the aponeurosis into which the muscle lieved by some surgeons to be the main factor standing in the
bellies are inserted. The occipitalis bellies arise from the lateral way of meaningful scalp resection. Although this conclusion is
three fourths of the highest nuchal lines and the mastoid and understandable, the argument is made here that the galea is
pass forward into the aponeurosis. The galea, also called the enormously beneficial in that it limits the harmful effects of
epicranial aponeurosis, lies over the vertex between the bellies surgical overstretching. Consequently, it is likely that it is actu-
of the occipitofrontalis muscle. It fades out laterally by blending ally protective and facilitates complication-free scalp surgery.
with the temporal fascia. The anterior frontalis muscle arises The belief that the relative inability of galea to stretch limits
from the front of the aponeurosis and is inserted into the upper the extent of surgical resection and has led to the surgical proce-
part of the orbicularis oculi and the overlying skin of the eye- dure of galeotomy, or linear galeal transection, done in an at-
brow. Scalp skin is firmly bound down to the muscles and tempt to surgically limit its restrictive effects. Raposio and asso-
aponeurosis. The occipitalis muscle is supplied by the posterior ciates (9), in a study designed to measure the compliance of
auricular nerve and the frontalis by the superior zygomatic flaps in sagittal scalp reduction, describe making three relaxing
branch of the facial nerve. The occipital belly pulls the scalp incisions in the galea, each 12 cm in length and parallel to a
back in certain individuals, but usually only anchors the aponeu- sagittal scalp reduction incision. The compliance of the flaps
rosis. Contraction of the frontalis elevates the eyebrows and
to stepwise loading was measured by dynamometer. The aim
produces the horizontal wrinkles in the forehead.
of the study was to assess the quantitative effects of galeotomies
The subaponeurotic space extends beneath these muscles
on the biomechanical properties of a scalp flap to quantify the
and aponeurosis over the vault of the skull. It is limited behind
surgery related benefits provided by the procedure. It was con-
by the attachments of the occipitalis to the highest nuchal lines
cluded that the mean gain in length of the flap per galeotomy
and at the sides by blending with the temporal fascia. In front,
was 1.67 mm. This corresponds to a mean 40% reduction of
the space extends down beneath the orbicularis oculi into the
the closing tension obtained with each galeotomy.
eyelids. Bleeding may track down in this space and produce
This confirms the clinical impression of the usefulness of
the ubiquitous periorbital hematoma, or ‘‘black eye.’’
galeotomy for obtaining wound closure in cases where it would
The galea is a dense, inelastic membranous or fibrous sheet
otherwise be difficult or impossible. The procedure, however, is
normally 1 mm to 2 mm in thickness. It is better developed
not without a downside and is prone to traumatize subcutaneous
in some individuals than others, and the occasional case of
structures and produce troublesome bleeding. It is associated
with an increased incidence of hematoma and infection. By and
large, galeotomy has fallen into disuse.
Subgaleal Layer/Space
The subgaleal compartment, the fourth layer of the scalp, is
bounded by galea above and has pericranium as its floor. It is
largely avascular, containing only a filmy layer of loose fi-
broareolar tissue. It is of enormous surgical importance and is
a space that readily lends itself to surgical dissection.
The scalp may be considered as being comprised of two
anatomically different parts: the part that overlies the subgaleal
space and the part that does not. The former extends from the
superior nuchal lines (to which the occipitofrontalis muscle and
galea aponeurotica attach) and proceeds cephalad into the fore-
head. The lateral limit of this space ends where the galea blends
with the temporalis fascia. That part of the scalp overlying the
subgaleal space has the standard five layers: skin, subcutaneous
tissue, galea, subgaleal loose areolar layer, and pericranium.
The remainder of the scalp has three layers: skin, subcutaneous
tissues, and deep fascia (e.g., the deep fascia that overlies the
trapezius and sternomastoid muscles).
The anatomic difference between the two areas has great
practical importance, as it is this that largely determines the
widths of tissue amenable to surgical removal. Generally speak-
ing, where five layers of scalp exist, wide excisions are possible;
where three layers exist, the width of tissue amenable to removal
Figure 2C-4 Diagrammatic representation of the lines of mini- is relatively restricted. The five-layered scalp is notable for hav-
mum tension (Langer’s lines). ing the subgaleal fibroareolar layer, which allows the scalp to
40 Chapter 2
slide or glide on the pericranium. It is this property that allows separable via the subgaleal space. It is usually of similar thick-
enhanced excision relative to the remainder of the scalp. ness to the galea and is easily bluntly dissected from the outer
The orientation of the lines of minimum tension (Langer’s table of the skull as an intact sheet (contrary to descriptions in
lines) also play a major part in determining the width of the textbooks, which state it to be bound down and densely adherent
excision (Fig. 2C-5). These topics are discussed in some detail at the skull suture lines).
later. It must also be remembered that some scalps have rela- Pericranial dissection from bone is bloodless other than the
tively poorly developed fibroareolar layers (i.e., ‘‘tight scalps,’’ occasional, easily controlled, minimal bleeding from the rare
in which the gliding phenomenon is minimal). The extent of bone perforator. Subperiosteal stripping is simple, easily ac-
this is easily determined by simply placing the pulps of the complished, and safe.
examining fingers on the scalp and moving it on the underlying Over the course of the work, multiple periosteal flaps of
pericranium. various sizes were raised in different locations, thereby denud-
As was mentioned earlier, the blood supply to the scalp is ing the outer table of the skull of periosteal cover. On reexplora-
cutaneous; that is, the vessels enter from the periphery and run tion months later, the denuded areas were covered with tissue
medially in the subcutaneous tissues. This means that if surgical indistinguishable from pericranium.
dissection is confined to the subgaleal plane during recon- Pericranial thickness varied from one individual to another
structive procedures, the blood supply to the tissues is not com- and from one skull location to another in the same individual,
promised in any way. This in turn means that large flaps can but the impression is that the pericranium in the frontal areas
be safely raised without delaying procedures (10). (Remember, may be slightly thinner than on the crown.
however, that incisions in the peripheral scalp that transect arter- The pericranium is capable of retaining sutures even when
ies may grossly limit blood supply to areas both adjacent to subjected to significant tension. Incorporating a pericranial flap
and remote from the locus of transection. This is in contrast to in deep wound closure seemingly contributed to the production
tissues supplied by musculocutaneous perforators). The ideal of fine linear scalp scars. It was apparent that the pericranium
scalp incision is midline because this allows access to the subga- is a very serviceable tissue and probably is underutilized in
leal space while inflicting minimal arterial and nerve trauma. reconstructive and cosmetic craniofacial surgery.
Pericranium
The pericranium is the fifth and deepest layer of the scalp. The
DISCUSSION
pericranium is not well described in textbooks of anatomy. The The scalp is subject to a multiplicity of conditions amenable to
following description is based on more than 700 pericranial surgical treatment, including benign lesions (sebaceous cysts,
dissections I have performed (11). The pericranium is a dense nevi, keratoses, hemangiomas, and others), malignant lesions
membranous or fibrous sheet (Fig. 2C-5) loosely fused on its (basal cell and squamous cell carcinoma, melanoma), burns,
outer aspect to the galea aponeurotica, from which it is readily congenital malformations, hair restoration, and a variety of mis-
cellaneous conditions including neurofibromas, aneurysms, tur-
ban tumors, and others. The list is quite extensive. It is reported
that 72% of automobile accident victims sustain head injuries,
making scalp trauma a leading cause of emergency room visits
(12). Because of this array of conditions requiring scalp surgery,
its lineage can be traced to general surgery, plastic surgery,
neurosurgery, dermatologic surgery, craniofacial surgery, and
hair restoration surgery—none of which seem to claim or want
dominion.
Neurosurgeons and craniofacial surgeons may see the scalp
as a barrier that must be breached in order to gain access to the
brain and craniofacial skeleton. To plastic surgeons the scalp
is a tissue in which incisions may be hidden and flaps devel-
oped. Hair transplantation surgeons are inclined to view it as
a passive tissue in which hair is surgically transplanted and/or
rearranged. General and dermatologic surgeons often make little
distinction between hairless skin and scalp in their choice of
surgical methodology.
This fragmentation of scalp surgery through the various spe-
cialties and an element of tunnel vision on the part of some
surgeons who, interested only in scalp surgery as it relates to
their own particular specialty, may contribute to the high inci-
dence of complications that are a feature of present-day scalp
surgery. Such complications include stretched unsightly hairless
scars, distorted hair patterns, hair loss, insensate scalp, and plas-
Figure 2C-5 The pericranium raised as an intact membranous ticized or stretch-atrophied tissues, virtually all of which are
sheet. Note that comparative thickness of the pericranium and galea avoidable if certain simple parameters of surgery are observed
aponeurotica. (13).
Basic Science 41
Incisions/Excisions disposed in scalp overlying the vault of the skull and allow
generous excision of tissue cut in a vertical axis. Conversely,
Lines of cleavage in the skin were first described by Langer in there is an associated relative limitation in excision widths in
1881 and reinvestigated by Cox in 1941 (14). The lines are the horizontal axis (because here Langer’s lines are crosscut),
believed to be due to collagen bundles arranged in parallel in but this is more than offset by the laxity provided by the fi-
the dermis, although this has not been confirmed by electron broareolar layer in the five-layered scalp.
microscopy (15). Where crease lines exist, their direction gener- As Langer’s lines proceed downward or caudad into the
ally coincides with the lines of minimum tension. These tend occipital scalp, they increasingly assume a horizontal orienta-
to be longitudinal in the limbs and scalp, and circumferential in tion, and in the lower part of the occipital (hair transplantation
the neck and trunk. The lines of minimum tension are surgically donor area) are entirely horizontal. This facilitates a relatively
important for two main reasons: elliptical excisions achieve the wider excision in this area than would otherwise be the case,
greatest width of tissue removal when made parallel to the lines, but this does not nearly compensate for the absence of the ‘‘glid-
and incisions made along or parallel to the lines heal with a ing’’ subgaleal fibroareolar layer present in the upper donor
minimum of scarring, whereas incisions made across them heal area. This has particular relevance to the donor area in hair
less well. transplantation. Here the upper donor area (i.e., above the supe-
These findings have led to the concept of collagen transec- rior nuchal lines) has five layers and allows relatively wide
tion scarring, which is the unsatisfactory scarring that results excision strips, whereas the lower part (below the superior nu-
when incisions are made across collagen bundles. Conse- chal line) has three layers only and excision is relatively re-
quently, knowledge of the orientation of collagen in the skin stricted (Fig. 2C-6). Maximum-width excisions are possible
is clearly to the surgeon’s advantage. It is likely, however, that when made parallel to the lines of minimum tension and where
present knowledge of collagen orientation may still be rudimen- five layers of scalp are present.
tary. In light of this, the argument is made that, where possible,
surgical incisions in scalp tissue should be made in a vertical
Biomechanics
axis, except in the occipital hair transplantation donor, for
whom a horizontal axis paralleling crease lines is preferred. The ability of skin to recover from stretch resides in its elastin
Although much has been made of the problems of collagen component. When skin stretches the elastic fibers elongate in
transection, it is probably as important not to transect elastic the direction of the stretching force, allowing the convolutions
fibers. Fortunately, as collagen and elastin generally run in par- in collagen to straighten out. The resulting elongation is a func-
allel, incisions that spare one spare the other. Ideally incisions tion of progressive displacement of ground substance and tissue
should also parallel the directional orientation of hair in order fluid that accompanies collagen realignment. This continues
to avoid hair follicle transection. until there is a structure of parallel collagen fibers that resists
further extension) provided the elastic limit is not exceeded
(17).
Scalp Laxity
The elastic limit of skin is that point at which the components
The extent of surgical scalp excision possible is predominantly commence to rupture and the stress/strain ratios no longer apply.
a function of scalp laxity. The more lax the tissue, the greater
the surgical excision.
Scalp laxity has two very distinct components. First is the
ability of the scalp to slide or glide on the underlying pericra-
nium. This is facilitated by the loose fibroareolar tissue in the
subgaleal compartment, which allows the scalp to be moved on
the cranium, often for a distance of several centimeters. This
has nothing to do with tissue extensibility or stretching and is
due to simple mechanical movement of the scalp on the pericra-
nium (16). In a scalp with a high capacity to slide/glide, an
excision width of 5 cm or more may be made and closure ob-
tained without any undermining or stretching. Operations that
take advantage of the scalp’s capacity to glide rather than stretch
are virtually complication free and result in negligible topo-
graphic distortion of the tissues. The analogy of pulling a carpet
over a polished floor comes to mind. The carpet and the furni-
ture are moved but their topographic relationships to each other
are not changed nor are the physical components of the carpet
altered. Scalp surgery that utilizes the scalp’s facility to glide
is highly effective and minimally traumatic to tissues.
The second component of scalp laxity is its elasticity or
ability to elongate (loosely termed, ‘‘stretch’’). It is reiterated
that this is independent of the sliding phenomenon. Some scalps
are highly elasticized, and even in the presence of the relatively Figure 2C-6 Schematic of a hair transplantation donor area.
inelastic galea are capable of reasonably significant elongation. Lower deeply shaded area has three scalp layers only. Lightly
Lines of minimum tension (Langer’s lines) are largely vertically shaded area above has five layers.
42 Chapter 2
It is accompanied by adverse tissues changes. The elastic limit maximally at the wound site and adjacent tissues. The more
for skin elastin is generally about 100% and for collagen 10%; tension, the greater the deleterious effect on wound healing and
stated differently—when skin elongates more than 100% of its the viability of tissues.
resting length, the elastic fibers rupture. The impaired elastin In order to effect wound closure, it is necessary to counteract
is no longer able to return the collagen to its normal resting the tension vector forces tending to keep the wound open. Al-
state, even when stress is removed. This results in permanent though closure may be possible by overpowering the tissues
irreversible adverse consequences for the tissues called plastici- with tension clamps, big needles, heavy sutures, large ‘‘bites,’’
zation, better known to surgeons as stretch atrophy (thin, dry, and muscular exertion, the price paid for this in terms of tissue
brittle, poorly vascularized skin). This is commonly seen after viability may be prohibitive. It is believed that the modalities
serial scalp excision, particularly if traction closures have been of wound closure, passed down from one generation to another,
done. Stretch-atrophied tissues are relatively unsatisfactory for are in dire need of rethinking.
subsequent surgery (18). This is particularly the case in hair Simple skin edge to skin edge suturing ensures that tension
transplantation. is borne by the skin alone. Layered closure is helpful, to some
Skin stretching also attenuates blood vessels, thus decreasing extent, in fractionating tension into increments of force evenly
tissue perfusion. If allowed to continue unchecked, it will ulti- distributed throughout the wound. A layered skin closure, how-
mately exceed the critical closing pressure and stop perfusion. ever, does not lessen the total force on the tissues necessary to
Lesser degrees of stretch reduce circulation. Elongation of the effect closure.
nerves and lymphatics causes pain and edema, respectively. In 1994, I embarked on a clinical research project (20) to
Non-undermined skin is better able to withstand the ill effects determine how deleterious effects of tension in wounds could
of tension stretching than undermined skin (19). be ameliorated or prevented. This yielded information that went
beyond the initial goals of the study. Data were derived pertain-
ing to the adverse effects of widespread undermining; the bene-
Undermining
fits of directing tension forces into nonundermined tissues; the
The question about the advisability or necessity of undermining practical utility of maximally using the scalp’s capacity of glid-
inevitably arises. It is believed that modest judicious undermining on the pericranium rather than stretching; and perhaps most
ing is usually indispensable for optimal wound closure. Exten- important of all, the concept of deep plane fixation (which facili-
sive undermining, however, may be ineffectual and associated tates removal of greater amounts of tissue while allowing re-
with problems. Undermining, particularly when extensive and duced tension wound closure). Deep plane fixation is explained
blind, is potentially harmful as it opens tissue planes to infec- in a series of articles published in Dermatologic Surgery
tion, has the potential for traumatizing blood vessels and nerves, (11,13,19,21).
results in extensive scar formation throughout the undermined
area, and allows tension forces to be conducted into areas re-
mote from the wound. It is also ineffectual, as explained later. CONCLUSION
I have found that in very lax scalps, it is possible to remove The features of surgical anatomy of the scalp deemed most
5-cm widths at the midsagittal ellipse level and yet easily close relevant to facilitating complication-free surgery are detailed
the wound without any undermining. Conversely, in tight and discussed. It is believed that optimal scalp surgery is consis-
scalps, removing 5 cm and achieving closure is impossible re- tently possible if the simple parameters of surgical practice de-
gardless of the extent of undermining. This led to the conclusion tailed in this chapter are respected.
that the more important factor, by far, in determining the extent
of tissue amenable to excision is not the extent of undermining,
but the degree of laxity. It was also concluded that the extent
of undermining and tissue amenable to removal are not linearly 2D. Differences in Gene Expression
related. in Bald and Non-Bald Dermal
In a clinical research study (11), two groups of identical Papillae
operations were described, one with undermining of 15 cm and
the other with only 5 cm of undermining. The excision width Moon-Kyu Kim and Jung-Chul Kim
in each group was identical—39 mm. There was no significant
difference in stretch-back. This suggested that the extra under- INTRODUCTION
mining of 10 cm bilaterally contributed nothing in terms of
increase of tissue excision amounts. Male pattern baldness is a gradual balding of the scalp, which
This conclusion is scientifically supported by Raposio and occurs commonly in men. The gradual transformation of termi-
colleagues (9), who in an excellent article on tensiometric mea- nal hair follicles to smaller vellus ones with a much shorter
surements in serial scalp reduction, reported ‘‘the benefits of growth period occurs in well defined patterns (1,2) and is be-
an extensive (15 cm) undermining were minimal as compared lieved to require both androgens and the appropriate genetic
with those obtained with 5-cm undermining.’’ tendency (3,4). This belief is supported by the absence of any
frontal recession in XY individuals with complete androgen
insensitivity. (i.e., lacking functional androgen receptors) (5).
PRACTICAL CONSIDERATIONS Apart from this requirement for circulating androgens and ap-
propriate receptors within the follicle cells, little is known about
At its simplest, integumental surgery comprises excision and the cellular or molecular mechanisms involved. No permanent
suturing. The tension generated at wound closure is manifested treatment is currently available for androgenic alopecia except
Basic Science 43
for corrective hair transplants (6). The success of such trans- genes.Seventy-five percent of the clones were identical to
plants, as well as the varying responses of hair follicles to andro- known human sequences.
gens depending on their original body site, seems to indicate that It is interesting to note that many clones were identical or
the mechanisms involved depend on factors within the specific nearly identical to known genes and occurred multiple times
follicles (4). were also found to encode extracellular matrix proteins includ-
ing type I collagen, fibronectin, osteonectin, type VI collagen,
and BIGH3 (Table 2C-1). This indicated that extracellular ma-
BACKGROUND trix proteins are the major proteins of dermal papilla cells. This
finding is considerably different from that of cDNA libraries
In normal hair growth, the papilla nurtures the matrix cells, from other tissues, such as brain and heart. These results suggest
stimulating their rapid proliferation with secreted growth factors a high degree of specificity in gene expression of the dermal
such as insulin-like growth factor (7). In return, the matrix cells papilla. However, because sequence homology searches
secrete growth factors, which stimulate the papilla (8). Some- showed that a large number of the cDNA clones from dermal
how this process of mutual stimulation and support becomes papillae encode proteins expressed in different tissues (e.g., type
disturbed in androgenetic alopecia. The dermal papilla is a mes- I collagen, fibronectin, osteonectin, actin-beta, SM22-alpha,
enchyme-derived structure situated at the base of the hair folli- glyceraldehyde-3-phosphate dehydrogenase, etc., in Table 2C-
cle. It is known to play an essential role in the induction and 1), only a small fraction of the clones are likely to be dermal
maintenance of hair growth (9,10). One study showed that the papilla-specific. Several clones, such as bone morphogenetic
papillae from balding areas of the scalp were markedly different protein 1, catenin, connective tissue growth factor, inhibin,
in vitro from those found in non-balding areas (11). The balding nerve growth factor, pigment epithelial-differentiating factor,
papillae were smaller and did not grow as well in cell culture placental bone morphogenic protein, thrombospondin, trans-
as the non-bald papillae. Therefore, balding may simply be a forming growth factor beta, nexin, and frizzled-2 may be in-
result of the androgen-mediated demise of the dermal papilla. volved in the growth and differentiation of dermal papilla cells
How do androgens affect the dermal papilla? The androgen (15,16).
effect involves the uptake of circulating testosterone by scalp Although we have not yet identified novel genes involved
hair follicle cells, where it is converted by the enzyme steroid in hair development or dermal papilla-specific genes, our com-
5-alpha-reductase to dihydrotestosterone (DHT). DHT then pilation of partial sequences of randomly selected cDNA clones
binds to the nuclear androgen receptor and activates androgen- is an important first step in classifying genes expressed in der-
response genes. Five-alpha-reductase has long been regarded mal papilla.
as an important part of the mechanism because it provides local Some genes are differentially expressed between balding and
amplification of testosterone by converting it to DHT, which non-balding dermal papilla cells. Expression of heat shock pro-
binds to the androgen receptor with greater affinity than that tein 27 kDa, caldesmon 1, and Y-box binding protein 1 gene
of testosterone (12). is elevated in balding dermal papilla cells compared with non-
Hair follicles in balding areas are better equipped to enhance balding dermal papilla cells. However, expression of type VI
the androgen effect than hair follicles in non-balding areas be- collagen, smooth muscle protein SM22 alpha, and TGF-beta-
cause they have more 5-alpha-reductase and androgen recep-
tors. In addition, balding scalp contains less aromatase, which
converts testosterone to estradiol (13).
The exact molecular relation between androgens and balding Table 2D–1 Gene Expression Profile in Dermal Papilla Cells
is not fully understood. There are questions that have yet to be
Gene Frequency (%)
answered. For example, there are two forms of 5-alpha-re-
ductase, both of which exist in the human hair follicle (13). Collagen, type 1, alpha 1 3.3
Why then do patients with congenital absence of 5-alpha-re- Fibronectin 3.1
ductase type II not become bald despite the presence of 5-alpha- Osteonectin 1.6
reductase type I? How do we explain the existence of baldness Collagen, type 1, alpha 2 1.6
in a woman who was found to have no endogenous andro- Actin, beta 1.5
gens?(14) Smooth muscle protein SM22, alpha 1.3
glyceraldehyde-3-phosphate dehydrogenase 1.2
Actin, gamma 0.9
Collagen, type VI, alpha 1 0.9
IDENTIFYING GENE EXPRESSION Plasminogen activator inhibitor 1 0.9
Identification and cataloging of cDNA clones in dermal papilla BIGH3, TGF-beta induced gene product 0.8
cells are the first steps toward identification of genes, which Collagen, type VI, alpha 2 0.7
are responsible for male pattern baldness. We have constructed Ferritin, heavy polypeptide 0.7
cDNA libraries from cultured dermal papilla cells, which were Translation elongation factor 1 alpha 0.7
Actin, alpha, smooth muscle 0.6
derived from balding and non-balding scalp. We initiated a
Annexin II 0.6
cDNA-sequencing project to characterize the pattern of gene
Ferritin, light polypeptide 0.5
expression in balding and non-balding dermal papilla cells. We
Highly basic protein, 23 kDa 0.5
have analyzed 6000 cDNAs randomly selected from the librar- Pyruvate kinase M2 0.5
ies. Of the sequences determined, 25% represented sequences Ribosomal phosphoprotein PO, acidic 0.5
of new genes that were not related to any previously reported
44 Chapter 2
induced gene product mRNA is decreased in balding dermal amounts of donor skin. Furthermore, cells could be stored fro-
papilla cells. These genes can be explored by in situ hybridiza- zen for future treatments, if necessary.
tion and immunohistochemical examination with antibodies The concept of culturing hair follicle cells in vitro and reim-
created against recombinant proteins. Functions of the genes planting them is best described as cell therapy, or tissue engi-
important for hair development could also be examined by cell- neering, applied to hair loss. The use of the term ‘‘cloning’’ is
based and animal–model-based functional analysis. These actually not appropriate when describing the process of expand-
genes may also be useful for the study of genetic linkage of ing hair follicles in vitro. Cloning, from the Greek word ‘‘twig’’,
male-type baldness in human models. means to create an exact genetic replica by asexual means. Sci-
It has already been shown that genes can be applied to the entists may refer to cloning a gene, cell, or whole organism,
skin, whereby they enter the follicle and change hair color (17). but tissue-engineered organs and tissues are not generally re-
It is possible that in the future genes will be able to be applied ferred to as clones.
to the scalp, which will stimulate hair growth. Although potent Tissue engineering is a burgeoning area of medical research
5-alpha-reductase inhibitors, which inhibit DHT formation, are and biotechnology ventures. Engineered tissues, which may be
successful at preventing androgenetic alopecia, their ability to used in the future for treating various genetic conditions and
actually regrow hair after significant balding has already oc- degenerative diseases, are listed in Table 2E-1.
curred is probably limited. Gene therapy may produce the opti- Tissue engineering has been defined as an interdisciplinary
mal treatment for androgenetic alopecia. field that applies the principles of engineering and life sciences
to the development of biological substitutes to restore, maintain,
and improve the function of damaged tissues and organs (1).
This dynamic field relies on the skills of the cell biologist,
2E. The Promise of Cell Therapy: biomedical engineer, and surgeon to create an implantthat can
Tissue Engineering Applied to function as a biological substitute.
the Treatment of Alopecia
Jerry E. Cooley SOURCE OF CELLS
The source of the cells used for tissue engineering purposes
INTRODUCTION may be either autologous, allogeneic, or xenogenic. For many
Given the results now achievable with modern small graft hair conditions other than hair loss, allogeneic cells (from a human
transplantation, one may wonder why there is a need for alterna- donor) provide the greatest advantages in terms of availability
tive therapies. Although the use of large numbers of small grafts and cost-effectiveness. Of course the use of allogeneic cells
can produce very natural looking results and provide satisfying raises the possibility of graft rejection by the patient’s immune
outcomes for many patients, there are still several drawbacks system. Scientists are currently developing techniques to mask
that should be acknowledged. The most important limitation of allogeneic cells so they can escape immune detection. Using
all hair transplant procedures is the finite supply of donor hair. allogeneic cells for hair loss may also be possible because some
As a result of this problem, the surgeon must carefully plan portions of the hair follicle (e.g., dermal sheath) appear to be
how this limited number of hair follicles will be used to create ‘‘immunologically privileged’’ and can naturally escape immu-
an aesthetic result, which will continue to look good over time, nologic detection (see discussion later).
given the possibility of ongoing hair loss. In fact, many of the However, the use of allogeneic cells for hair restoration may
current debates and disagreements among hair transplant sur- never be suitable because of the difficulty in matching the hair
geons exist because of this limited supply of donor hair. characteristics (i.e., color, curl, and caliber) of the donor with
There are other possible drawbacks to consider with conven- the patient, assuming the principle of donor dominance would
tional hair transplantation. The donor scar may be quite long still apply. The use of xenogenic sources of cells (i.e., other
if a large case has been done, and in some patients, the scar will mammals) is not practical for obvious reasons.
be unacceptably wide. To achieve satisfying density, several
sessions may be necessary. For the patients, this means several
lengthy surgical procedures. And finally, even with the use of
micrografting, creating a natural result on close-up inspection Table 2E–1 Disease States for Which Cell Therapy Is
may still be a challenge in select patients. Currently Available or Is Being Developed
Organ System Condition

CELL THERAPY Cardiovascular Aneurysm, heart valve disease,
One could overcome these problems by having the ability to myocardial inf.
create new hair follicles instead of just surgically redistributing Gastrointestinal Intestinal failure, hepatic failure
Endocrine Diabetes, hypoparathyroidism
existing follicles. By using the techniques of tissue engineering
Hematopoietic Immunodeficiency, cancer
(cell therapy), which are successfully being applied to so many
Genitourinary Renal failure, urinary reflux
other diseases, one could theoretically achieve this goal. It is
Muskuloskeletal Bone fractures, arthritis
conceivable that cell therapy could be performed in a single Nervous system Spinal cord injury, Parkinson’s disease
treatment, provide satisfying density, produce extreme natural- Skin Burns, ulcers, soft tissue defects
ness, and avoid the problems associated with excising large
Basic Science 45
CONCEPTUAL FRAMEWORK a dynamic interaction of epidermal and dermal components and

that the dermal papilla is essential for hair growth. Using the
Therefore, the most viable approach is the use of autologous rat whisker as a model, British researcher Roy Oliver showed
cells taken from the patient and expanded in the laboratory. that the dermal papilla would restore hair growth when im-
Although several research groups around the world are actively planted into follicles in which the papilla had been removed
performing research in this area at this time, there is little in the (2). Oliver subsequently showed that the intact dermal papilla
published literature to date. Because of the inherent commercial could also induce new hair follicles when implanted into skin,
value of successful research, the importance of protecting intel- which normally lacks follicles (3).
lectual property may overshadow the impetus to publish. How- Carrying this research further, Jahoda, Reynolds, and Oliver
ever, based on what has been published and our current under- reported in 1993 that the cells of the rat whisker dermal papilla
standing of the physiology of the hair follicle, a theoretical could be grown in vitro and that the cultured cells could induce
scenario of how tissue engineering may be used for hair loss hair growth when implanted into incisional skin wounds of the
can be constructed (Fig. 2E-1). rat (4). Presumably, the implanted cells were interacting with
The use of tissue-engineered cells to treat hair loss is concep- native epithelial cells to recreate hair follicles and produce a
tually quite simple, but there are numerous questions that must hair shaft. The process by which implanted cultured dermal
be answered. For example, exactly which cells of the hair folli- papilla cells would induce hair growth is conceptually similar
cle must be expanded in vitro and used for implantation? What to what happens during fetal development of the hair follicle
are the best culture conditions in which to grow the cells? Will (Fig. 2E-2).
these cells lose their power to induce hair follicle formation One important finding of Jahoda’s research was that after
after being grown in culture for an extended period of time? If several passages in culture, the cells lost their ability to induce
implanted cells can regenerate hair, will the regenerated hair hair growth when reimplanted. Presumably, the cultured cells
be aesthetically acceptable and match the patient’s existing were changing over time, becoming more like fibroblasts and
hair? Will the hair persist or will it experience accelerated less like hair-inducing papilla cells. The limitation of carrying
aging? Is there any risk of tumor formation from the implanted papilla cells through multiple passages could be a major obsta-
cells? What are other possible safety concerns? cle for the development of a treatment for hair loss. The success
of using the cultured hair follicle cells to treat hair loss will
in large part depend on the ability to expand their numbers
BACKGROUND RESEARCH
significantly before reimplantation so that only a few hairs
Although there are no published reports on whether implanted could give rise to thousands of hairs. If the cells lost their ability
cells can regenerate hair follicles in humans, there are several to induce hair growth after several passages in culture, achiev-
studies showing that this is feasible in animals. The basis for ing this goal would not be possible. However, it has been found
this research began in the fundamental investigation of normal that the inductive capacity of cultured dermal papilla cells can
hair growth. It had been known that hair growth results from be maintained if they are cultured under the right conditions.
Inamatsu found that if media fluid taken from keratinocyte cell
cultures is added to the papilla cell cultures, they could retain
their hair-inducing properties for up to 70 passages (5). Jahoda
also found that high passage papilla cells can be rejuvenated
and produce follicles if they are placed in contact with epithelial
germinative cells, a specialized cell type that is present at the
base of the anagen hair bulb and in close contact with the papilla
(6). These findings suggest that papilla cells can be expanded
in large quantities and still retain their hair-inducing properties.
Furthermore, the dermal sheath may prove to be another
source of cells for hair induction. It had been known from prior
Figure 2E-1 Conceptual framework for a cell-based treatment

for hair loss. A small piece of skin containing hair follicles is
removed from the occipital scalp. The cells of the hair follicle Figure 2E-2 Fetal development of the hair follicle involves a
necessary for inducing follicle regeneration are isolated and grown complex interaction of epithelial (upper arrows) and mesenchymal
in culture, where they rapidly divide and multiply. The cells are (lower arrows) components. In cell therapy, the implantation of
then reimplanted in the skin, where they induce new follicle forma- dermal papilla cells into the epidermis and subsequent induction
tion resulting in new hair growth. of hair follicles mimics this natural process.
46 Chapter 2
studies that the sheath could attain hair-inducing properties if ues. The public is keenly aware of these possibilities, and many
placed in contact with the germinative epithelial cells described surgeons receive frequent inquiries from patients as to when
earlier (6). In a preliminary study reported in 1999, Jahoda and cell therapy will become available. Whether cell therapy stays
Reynolds showed that in humans the dermal sheath could be in the realm of science-fiction or becomes a medical reality will
implanted in the skin and could induce hair growth. Even more depend on the results of ongoing studies. The prospect of having
remarkably, these researchers used allogeneic dermal sheath an unlimited supply of donor hair available to treat hair loss
(i.e., taken from another person) in the test subject without will continue to spur tissue–engineering-based research.
stimulating immune rejection for at least 6 weeks and possibly
longer (7). The sheath appears to lack cell surface antigens, Editor’s Comments
which would identify it as foreign and may therefore be immu- Unfortunately, the lawyers of the financial sponsor of the stud-
nologically privileged (8). Whether cultured dermal sheath cells ies on cell therapy for androgenetic alopecia, whom I have been
could be used as a reliable source of cells and kept in cell banks involved with for more than 3 years at the University of To-
remains a question for future research. ronto, are in that group of individuals who feel ‘‘the importance
Another important question is whether tissue-engineered of protecting intellectual property’’ is more compelling than
hair will be cosmetically acceptable. The animal studies to date the need to talk about and publish results. This has led to an
have not characterized the regenerated hair to determine how awkward silence on my part and on the part of my co-investiga-
closely it matches the donor hair from a cosmetic standpoint tors, who include Dr. Daniel Sauder, currently professor and
(e.g., color, curl, caliber). The regenerated rat whiskers have chairman, department of dermatology at Johns Hopkins Univer-
been described as grossly appearing to be similar to the original sity. Such studies are expensive to carry out and time consum-
whiskers. Presumably, regenerated hairs in humans would also ing. What should, therefore, be clear is that enough progress
look similar or identical to the parent hairs, but this would must have been made that further studies are warranted. We
obviously be an important point to establish. Furthermore, the have had approval from the ethics committee at the University
regenerated follicles must be oriented so that the hair grows at of Toronto to conduct human studies since the fall of 2000.
the proper angle and direction. Unforeseen technical problems delayed these studies until late
spring 2001. Although most of our results cannot be commented
REGULATORY HURDLES on, I have been allowed to state the following:
In addition to the scientific challenges facing the use of im- ● There have been absolutely no negative side effects
planted hair follicle cells, there are also legal and regulatory when patients’ cultured cells have been injected into
hurdles to be overcome. In the United States, the U.S. Food their scalps
and Drug Administration (FDA) would regulate implanted hair ● Patients for further studies have already been prese-
cells as a biologic therapy(9) and has proposed a comprehensive lected. Unfortunately, there is no opportunity at this time
regulatory framework for cell-based therapies (10). According for new study subjects to become involved
to this proposal, a cell-based therapy for hair loss might require ● The sponsor of the study has no need of any help in
intermediate regulatory scrutiny by the government. Simply ex- funding the studies, and there is no point for anyone to
panding the cells in vitro would constitute morethanminimal contact Dr. Sauder or me in this regard. He has told me
processing and require closer scrutiny than therapies using only that he intends to donate most, if not all, of any financial
minimally processed cells. On the other hand, because this ther- gain he might attain from these studies to his alma mater
apy would presumably be autologous, there would be fewer – the University of Toronto., and I believe this is his
requirements than for an allogeneic therapy, which would carry intention For those interested in isolating and culturing
the risk of transmitting infectious diseases from the donor. Fur- follicular papillae, an excellent reference article is ‘‘Sim-
thermore, this treatment would require less oversight because ple and rapid method to isolate and culture follicular
it would be considered homologous (i.e., the regenerated hairs papillae from human scalp hair follicles’’ by Magerl, M.,
would be serving their natural structural function of replacing S Krauser., R. Paul, and D. J. Tobin., in Experimental
hairs lost to the balding process) as opposed to a nonhomolo- Dermatology 2002, 11:381–385.
gous therapy in which the cells serve a novel function.
The standard for demonstrating safety and efficacy of any
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1919–1944. Rockville, Md.
3
Androgenetic Alopecia
3A. Classification of Androgenetic more or less symmetrical. These areas of denudation extend no
farther posteriorly than approximately 2.0 cm anterior to a line
Alopecia drawn in a coronal plane between the two external auditory
Rolf E. A. Nordström meatus. Hair is also lost or sparse along the midfrontal border
of the scalp, but the depth of the affected area is much less than
There are two useful classifications of MPB: that of Hamilton in the frontotemporal region.
(1) and that of Norwood (2). Hamilton reported, after examining
200 scalps and repeating the process 3 months later without Type III
reference to previous notations, that the results of the two classi-
fications were identical in 199 of 200 subjects. Norwood does Type III represents the minimal extent of hair loss considered
not consider his percentage of identical classifications to be sufficient to represent baldness. Type III scalps have deep fron-
nearly as high as that obtained by Hamilton, but because his totemporal recessions that are usually symmetrical and are
study involved 1000 patients, it has become the more commonly either bare or very sparsely covered by hair. These recessions
used of the two, and it is the one employed in this text (Figs. extend farther posteriorly than a point that lies approximately
3A-1a and 3A-1b). Such a classification of MPB patients, even 2.0 cm anterior to a coronal line drawn between the two external
though only approximate, is essential for an organized and sys- auditory meatus.
tematic study and for comparison of results with various surgi-
cal methods, as well as for planning the surgical program for Type III Vertex
each patient. (See also Chapter 23A.)
The following description of Norwood’s classification is re- In this type, the hair is lost chiefly in the vertex. There may be
printed with permission of both the author and the publisher of some frontal recession, but it must not exceed that seen in type
his text, Hair Transplant Surgery (Charles C. Thomas, 1984). III. This type of baldness is most common with advancing age,
It should be recognized that although Norwood’s classification but, in some patients, it may occur early and occasionally pre-
is useful, most patients do not fit perfectly into his categories cedes significant frontal loss.
and patients do progress to more extensive hair loss as they
age. Thus, if the classification is to be employed for long-term Type IV
planning, one should use the class that most likely will represent
the ultimate extent of hair loss that can be expected in the The frontal and frontotemporal recession is more severe than
patient at age 75 years, for example. in type III. Also, there is a sparseness or absence of hair on the
vertex area. These areas are extensive but separated from each
NORWOOD CLASSIFICATION OF MALE other by a bridge of moderately dense hair that joins the fully
PATTERN BALDNESS haired fringe on each side of the head. Type IV should not be
confused with type III vertex in which the loss is primarily on
Type I the vertex.
The essential feature of type I is minimal recession along the
anterior border of the hairline in the frontotemporal region. Type V
Type II The vertex region of alopecia remains separated from the fron-
totemporal region of alopecia. The separation is not as distinct
The anterior border of the hair in the frontotemporal region has as in earlier stages because the band of hair across the midscalp
triangular areas of recession that are usually, but not always, is narrower and sparser. Both the vertex and frontotemporal
49
50 Chapter 3
Figure 3A-1 (A) Standards of classification of the most common types of male pattern baldness (MPB). (B) Standards of classification
for type A variant MPB.
areas of alopecia are larger. Viewed from above, types V, VI, DESCRIPTION OF STANDARDS FOR
and VII are all characterized by areas of alopecia that are out- CLASSIFICATION OF TYPE A VARIANT OF
lined by hair on the temporoparietal and occipital areas of the MALE PATTERN BALDNESS
scalp, forming the shape of a horseshoe.
The type A variant (see Fig. 3A-1b) is distinguished by two
major features and two minor features. The major features must
Type VI be present to make the type A designation. The minor features
are not necessary but are frequently present.
The bridge of the hair that crossed the midscalp in the previous
The major features are as follows:
type is now gone. The frontotemporal and vertex regions of
alopecia are confluent; in addition, the entire area of alopecia 1. The entire anterior border of the hairline progresses pos-
has increased laterally and posteriorly. teriorly without leaving the usual island or peninsula of
hair in the midfrontal region.
2. There is no simultaneous development of a bald area
Type VII on the vertex. Instead, the anterior recession just keeps
Type VII is the most severe form of male pattern baldness. All advancing posteriorly to the vertex.
that remains is a narrow horseshoe-shaped band of hair that
The minor features are as follows:
begins laterally just anterior to the ear and extends posteriorly
on the sides and quite low on the occiput. This hair is usually 1. Scattered sparse hairs frequently persist in the entire
not dense and is frequently fine. The hair is also extremely area of denudation.
sparse on the nape of the neck and in a semicircle superior to 2. The horseshoe-shaped fringe of hair that remains on the
both ears. The anterior border of this band on each side of the sides and back tends to be wider and to reach higher
head recedes posteriorly to just anterior to the ears. on the head than non-type-A variant patterns.
Androgenetic Alopecia 51
Type Il A Senile Alopecia

The entire anterior border of the hairline lies on the forehead. Senile alopecia occurs in all scalps, in both men and women,
The usual midfrontal peninsula or island of hair is represented with age. The role of androgens is uncertain. The decrease in
by only a few sparse hairs. The area of denudation extends no density involves the entire scalp.
farther posteriorly than 2.0 cm from the original midfrontal line.
Persistent Anterior Fringe
Type IlI A Some individuals have a totally or almost totally preserved fron-
The area of denudation is almost to, or may actually reach, the tal hairline, but baldness posterior to this and in the vertex re-
midcoronal line. gion. This type of alopecia can be quite extensive and yet still
be associated with total preservation of the frontal hairline.
Type IV A
The area of alopecia is now past the midcoronal line. There
3B. The Incidence and Degree of
may be a considerable amount of thinning posterior to the actual Androgenetic Alopecia at
hairline. Various Ages in Men and Women
Walter P. Unger
Type V A
Type V A is the most advanced degree of alopecia described Norwood’s study of 1000 adult men (1) who were classified
with this variant. If it becomes more extensive, it cannot be by the type of male pattern baldness (MPB) they had at various
distinguished from the usual types V and VI. The area of alope- ages is a classic and is discussed by Nordstrom in the previous
cia has not reached the vertex. section of this chapter. It revealed several important phenomena
that are worth emphasizing:
1. The incidence of cosmetically significant MPB (types
OTHER TYPES OF ANDROGENETIC III, IV, V, VI, and VII) increases steadily with age (see
ALOPECIA Fig. 3B-1a and Table 3B-1a and b).
2. Type III vertex is more common in older patients, with
The possible variations of androgenetic alopecia are infinite. only 10% of individuals 39 years or younger, and (in
Designation of all minor types would not only be impossible his study) no individual 29 years of age or younger
but would also reduce the usefulness of the classification. There demonstrating this pattern. Less than 50% of patients
are, however, several reasonably well-defined variations that with type III alopecia also developed type III vertex,
deserve special mention. The common feature of all these types and, in addition, the percentage did not go higher, except
of alopecia is that, instead of the areas involved becoming to- in those who passed age 80 years.
tally bald, they seem to reach a certain point of decreased den- 3. Types VI and VII alopecia occur in a total of 10% of
sity, after which further progress is barely perceptible. Gener- men aged 50 to 59 years, 23% of men aged 60 to 69
ally, to qualify for these designations, the hair should be sparse years, 22% of men aged 70 to 79 years, and 30% of
enough that the scalp is plainly visible on casual inspection. men aged 80 years (see Table 3B-1b and Fig. 3B-1a).
With present-day technology of alopecia reduction
Diffuse, Unpatterned Alopecia (AR), scalp extension, follicular unit transplanting
(FUT), micro-slit grafting, micro-minigrafting, and total
In the diffuse, unpatterned type, there is a general decrease in excision techniques in the donor area, virtually all pa-
the density of hair, without any definite pattern, although it is tients with less than types VI or VII alopecia could
usually more marked over the top and front. This type is com- receive treatment for their entire area of MPB, and some
mon in women. individuals with type VI can also. They may choose to
do this by most commonly aiming for lower transplant
Diffuse, Patterned Alopecia densities (by using grafts that will produce natural-look-
ing results with lower hair densities) or by employing
The patterns in this type of hair loss are essentially the same AR or scalp extension, or a combination of these op-
as in more common MPB, but the areas involved do not become tions. This means that, at worst, by the age of 80 years,
totally bald; the hair decreases only in density. This also occurs 70% of men or more should be able to receive treatment
in women. for any bald area that might develop—a figure that
should be remembered when one debates whether at-
Male Pattern Baldness with Persistent Mid-Frontal tempting to treat most, or the entire area, of MPB with
Forelock hair transplanting represents an overly aggressive posi-
tion.
The persistent midfrontal forelock variant can be of any degree 4. It might be said by those who believe this position is
of severity and is essentially like common MPB, except for the overly aggressive or optimistic, that the inclusion of
persistence of the midfrontal forelock. types I and II distorts the percentages of those individu-
52 Chapter 3
Table 3B–1a Number of Individuals and Types of Alopecia 65 years or older and 273 were 70 years or older. Norwood’s
in Norwood’s Study
study included 179 men 70 years or older, and Hamilton’s had
Aged 50–59 60–69 70–79 80 even fewer individuals in that age group.
My study results are shown in Table 3B-2. Patients were
Group A subdivided into the following age groups: 65 to 69 years; 70
Types III, IV, V ⫹ 1/2 of VI 75 70 47 35 to 74 years; 75 to 79 years and older than 80 years. The degree
Group B of alopecia (types I to VII Hamilton/Norwood) was noted for
Types VII ⫹ 1/2 of VI 9 26 17 19 each. The implications of this latter study are discussed in Chap-
ter 10, but interestingly, the incidence of types VI and VII MPB
in my patients aged 70 to 79 years was higher than those re-
ported by Norwood and Hamilton; 38.3% for patients aged 70
als seen by a hair restoration surgeon in his practice, to 74 years and 35.6% for those aged 75 to 79 years. Some
because few men with types I and II are, in fact, seen studies suggest that there are increased rates of cardiovascular
for hair transplanting. If this were true, excluding types disease in men who have earlier and more severe MPB (4). The
I and II would result in a higher percentage of patients explanation for why their percentages of types VI and VII MPB
seen who will develop types VI or VII MPB. were so low at the time they did their studies.could be that their
However, even if one assumes that individuals with types I and study subjects might have died before they got to those stages.
II alopecia would never be seen by hair transplant surgeons Perhaps modern medicine is now keeping men alive longer and
and, to balance that unlikely eventuality, includes half of those allowing them to reach more advanced stages of MPB. In any
with type VI, the profile shown in Table 3B-1a would emerge case, it would appear that 60% to 65% of men would have type
from Norwood’s study. V or less MPB if they lived to be 79.
Referring to Table 3B-1a, Group A represents 89%, 73%, In contrast to my study, which was limited to older patients,
73%, and 65% of all patients in Norwood’s study group with Rhodes and colleagues studied the prevalence of MPB in men
more than types I or II alopecia, but excludes one half of those 18 to 49 years of age (5). They compared their findings with
with type VI and all of those with type VII MPB between ages those of Norwood and Hamilton, and these comparisons are
50 and 59 years, 60 and 69 years, 70 and 79 years, and 80 shown in Fig. 3B-2 and Fig. 3B-3, as well as in Table 3B-3
years, respectively. Because most men do not live to age 80 and Table 3B-4. They found that the overall proportion of men
years, this means that 73% of the men most likely to be seen by with MPB was greater than that reported in either of the other
hair transplant surgeons might quite reasonably aim to receive two studies. Most striking was the fact that a much larger pro-
treatment for the entire area of their eventual MPB (with the portion of men had predominantly frontal baldness, as suggested
figure going down to 65% if they do live to 80 years or more). by the higher percentage of men classified as having a type A
Hamilton did a study somewhat similar to Norwood’s, in variant hair loss pattern. Their study, although based on letters
which he assessed 312 individuals (2). A comparison of the sent out to 5000 patients, resulted in only 342 replies and, in
incidence of the types of MPB in the two studies shows substan- fact, involved only 266 men who were actually examined, so
tial similarities in the rate of progression of MPB, but Hamil- their results may or may not be valid.
ton’s figures were consistently 20% to 30% higher than Nor- The incidence of female pattern hair loss (FPHL) is more
wood’s (see Fig. 3B-1b). Thus, the prognosis noted in the difficult to establish than its male counterpart, and its diagnosis
foregoing discussion may be somewhat less positive than the is more challenging. This is because of less obvious patterns
suggested conclusions. To get a better idea of whose percent- of hair loss than those in men and because of the frequency
ages were more likely to be correct, Hamilton’s or Norwood’s, with which other types of hair loss occurs. In brief, it is the
I carried out my own study and published the results in 1994 great mimicker, and it should be included in the differential
(3). In that study, which involved 328 men, all subjects were diagnosis of diffuse hair loss in any woman (6).
Table 3B–1b Incidence of Male Pattern Baldness in 1000 Men by Type and Age
Age (yr)
Type 18–29 (%) 30–39 (%) 40–49 (%) 50–59 (%) 60–69 (%) 70–79 (%) 80 (%)
Type I 110 (60) 60 (36) 55 (33) 45 (28) 29 (19) 18 (17) 12 (16)

Type II 52 (28) 43 (26) 38 (22) 32 (20) 24 (16) 20 (19) 11 (14)
Type IIIa 14 (6) 30 (18) 37 (20) 34 (23) 22 (15) 16 (16) 12 (16)
(3V) (15V) (15V) (10V) (7V) (8V)
Type IV 4 (3) 16 (10) 15 (10) 21 (9) 17 (12) 13 (13) 9 (12)
Type V 3 (2) 10 (6) 13 (8) 15 (10) 22 (15) 13 (13) 9 (12)
Type VI 2 (1) 4 (3) 7 (4) 10 (7) 19 (13) 11 (11) 10 (13)
Type VII 0 2 (1) 5 (3) 4 (3) 16 (10) 11 (11) 14 (17)
Total 185 (100) 165 (100) 165 (100) 156 (100) 149 (100) 102 (100) 77 (100)
a
Numbers in parentheses under type III represent type III vertex individuals.
Figure 3B-1 (A) Incidence of different degrees of male pattern baldness compared by age. (B) Differences in incidence of male pattern
baldness between Hamilton’s and Norwood’s studies, with Hamilton’s findings being consistently 20% to 30% higher.
Three patterns of hair loss have been described in women: at any age, developed more than type IV (Fig. 3B-4a).
More recently, Venning and Dawber examined 564
1. A more or less male pattern, or frontoparietal pattern women older than the age of 20 years. They reported
as described by Hamilton (2) and later by Norwood: (1) that 13% of premenopausal women had Hamilton types
Hamilton examined 214 women in his study and found II to IV MPB, whereas 37% of postmenopausal women
at least type II MPB in 79% of them after puberty. had this degree of hair loss (7).
He noted that the bitemporal recessions seen in type II 2. A centrifugal pattern of hair loss was first discussed by
tended to be less prominent in women than in men and Ludwig (8): It consisted of hair loss over the caudal
were likely to go unnoticed until the women were in scalp. In contrast to Hamilton, he emphasized the essen-
their late twenties. Type IV MPB occurred in 25% of tially intact frontal fringe in these individuals. This type
women by the age of 50 years, and 50% had type IV of hair loss was arbitrarily divided into three degrees
by age 60 years. Type IV was defined as consisting of severity as shown in Fig. 3B-4b. In Dawber’s and
of (a) deep frontotemporal recessions extending farther Venning’s study of 564 women, they carefully wetted
posteriorly than 3 cm posterior to a coronal plane be- the vaultal hair and observed from above. When this was
tween the two external auditory meatus and (b) some done, they found that 87% of premenopausal women
midfrontal hairline hair loss. No women in his study, showed vaultal thinning of Ludwig patterns types I to
Table 3B–2 Unger Study of 328 Men over 65 Years
Age (years)
Type 65–69 (%) 70–74 (%) 75–79 (%) 80⫹ (%)
I 2 (3.6) 5 (6.2) 4 (5.5) 2 (1.7)

II 9 (16.4) 7 (8.6) 7 (9.6) 12 (10.1)
III 4 (7.3) 15 (18.5) 18 (24.7) 11 (9.2)
IV 10 (18.2) 16 (19.8) 8 (11.0) 10 (8.4)
V 6 (10.9) 7 (8.6) 10 (13.7) 16 (13.4)
VI 13 (23.6) 19 (23.5) 16 (21.9) 37 (31.1)
VII 11 (20.0) 12 (14.8) 10 (13.7) 31 (26.1)
Total 55 (100) 81 (100) 73 (100) 119 (100)
Note: in age group 65–69, if one excludes types I and II, 33 of the remaining 44 (75%) have types III–VI (83.3% Nor-
wood); in age group 70–74, if one excludes types I and II, 57 of the remaining 69 (82.6%) have types III–VI (82.8%
Norwood); in age group 75–79, if one excludes types I and II, 52 of the remaining 62 (83.9%) have types III–VI; in
age group 80⫹, if one excludes types I and II, 74 of the remaining 105 (70.5%) have types III–VI (74.0%
Norwood).
54 Chapter 3
Figure 3B-2 Proportion of men with little or no, moderate, and extensive male pattern hair loss in the Dayton, Hamilton, and Norwood
studies.
III! As noted earlier, 13% also had Hamilton types II 3. A ‘‘Christmas tree’’ pattern was first described by Olsen
to IV (7). Thus, a large majority of women older than (9) (Figs. 3B-5a & b). She noted that women with hair
age 20 years had at least some form of patterned hair loss did not necessarily manifest diffuse hair loss over
loss, in their opinion. Postmenopausal women showed the entire vaultal scalp; instead, they might have in-
an increased tendency to have more of a male pattern creasing hair loss toward the frontal scalp ‘‘with en-
of hair loss, with 63% (195/310) showing Ludwig croachment on, and sometimes breach of, the frontal
types I to III and 37% showing Hamilton types II to hairline.’’ She found this pattern of hair loss, with ac-
IV. centuation of frontal loss, to be more common than the
Figure 3B-3 Proportion of men with moderate and extensive male pattern hair loss in the Dayton, Hamilton, and Norwood studies.
Table 3B–3 Occurrence of Male Pattern Hair Loss from 3 Studies: Norwood/Hamilton Classification
Dayton study (n ⫽ 266) Norwood (n ⫽ 533) Hamilton (n ⫽ 220)
18–29 30–39 40–49 18–29 30–39 40–49 15–29a 30–39 40–49
Little or no hair loss (%)

Type I 41 (60) 16 (18) 22 (20) 110 (60) 60 (36) 55 (30) 6 (5) 3 (5) 0
Type II 12 (18) 14 (16) 17 (15) 52 (28) 43 (26) 38 (21) 84 (69) 27 (49) 22 (51)
Moderate hair loss (%)
Type III 2 (3) 5 (6) 4 (4) 14 (6) 30 (18) 37 (20) 7 (6) 1 (2) 1 (2)
Type IIIv 4 (6) 7 (8) 5 (4) 0 3 (2) 15 (8) — — —
Type IV 2 (3) 6 (7) 12 (11) 4 (3) 16 (9) 15 (8) 18 (15) 7 (13) 10 (23)
Type V 0 4 (5) 9 (8) 3 (2) 10 (6) 13 (7) 2 (2) 3 (5) 0
Extensive no hair loss (%)
Type VI 1 (1) 11 (12) 12 (11) 2 (1) 4 (2) 7 (4) 3 (2) 8 (15) 7 (16)
Type VII 2 (3) 10 (11) 17 (15) 0 2 (1) 5 (3) 1 (1) 4 (7) 1 (2)
Frontal no hair loss (%)
Type A 4 (6) 15 (17) 12 (11) — — — 1 (1) 2 (4) 2 (5)
variants
Total (%) 68 (100) 88 (100) 110 (102) 185 (100) 168 (100) 180 (101) 122 (101) 55 (100) 43 (99)
a
Note that lower range includes 15–29-year-old men in the Hamilton study.
Ludwig pattern, and much more common than the Ham- for transplanting. Therefore, they may or may not be
ilton patterns. (I agree with those opinions). Olsen’s acceptable candidates for transplanting.
description also provided an important physical clue for 2. Many of these women develop small (2 mm to 5 mm)
differentiating pattern hair loss from telogen effluvium oval or irregularly shaped areas of total alopecia that
in women. In a series of 163 women with obvious but are scattered within the areas of diffuse thinning. I first
not severe patterned alopecia, more than 70% of the reported this finding in the 1987 edition of Hair Trans-
patients had this pattern of hair loss (10). Early hair plantation (11). It subsequently was reported by several
loss was characterized by only a slightly widened part, other investigators (12–14). Such areas can be punched
whereas at the other end of the scale, those rare women out with appropriately sized trephines and replaced with
with severe Ludwig III loss had diffuse and tremen- hair-bearing grafts. This will produce a greater increase
dously decreased hair density but never developed total in hair density without graft noticeability, because of
alopecia. Some men also develop Christmas tree or Lud- the surrounding hair, than will attempts to fill them with
wig patterned hair loss. follicular units or slit grafts.
3. In women, there appear to be two main peaks of onset
Four other characteristics of patterned hair loss in women are
of pattern hair loss: the third and fifth decades. Those
important to hair restoration surgeons:
having earlier onsets tend to develop more severe de-
1. Such women also frequently have or may eventually grees of hair loss, and this should be borne in mind
develop decreased hair density in temporal, parietal, and when a decision is made about treating women in their
occipital areas that are normally used as donor areas late teens or twenties (6).
Table 3B–4 Proportion of Type A Variantsa (Percentages in Table Computed as Percentage of Each Total Age Group)
Dayton study (n ⫽ 266) Hamilton (n ⫽ 220)
Type 18–29 (%) 30–39 (%) 40–49 (%) 15–29 (%)b 30–39 (%) 40–49 (%)
Type Ia — — — 1 (1) 1 (2) 1 (2)

Type IIa 0 3 (3) 3 (3) — — —
Type IIIa 1 (1) 2 (2) 0 — — —
Type IVa 0 0 2 (2) 0 1 (2) 1 (2)
Type Va 3 (4) 10 (11) 7 (6) — — —
Type VIa — — — 0 0 0
Total 68 88 110 122 55 43
(100) (100) (98) (100) (100) (100)
a
Norwood reported that 3% were Type A variant without regard to distribution of age or type (n ⫽ 30/1000).
b
Note that lower age range includes 15–29-year-old men in the Hamilton study.
56 Chapter 3
Whatever the true nature and incidence of patterned hair loss

in females, hair restoration surgeons are seeing more of them
who are inquiring about transplanting. As discussed in Chapters
5A and 12H, I have found most of these patients to be acceptable
candidates for this type of surgery. Despite the changes in hair
transplanting techniques that have made this so, and despite
writing often and widely about the effectiveness of hair trans-
planting in treating women with female pattern hair loss, many
medical practitioners who specialize in the diagnosis and treat-
ment of hair loss still seem to be unaware of, or unimpressed
with, this fact. Olsen, in a supplement to the Journal of the
American Academy of Dermatology that was devoted to FPHL,
did not even mention the possibility of hair transplanting for
its treatment (6). In another textbook devoted to women’s der-
matology, hair transplantation was barely mentioned as a treat-
ment for androgenetic alopecia and was declared ‘‘in general,
of only limited benefit for women’’ (17). The irony is that the
author had written a chapter on hair transplanting in women in
that textbook as well as for two editions of Olsen’s own text-
books that demonstrated how effective transplantation is at
a present. Clearly, hair restoration surgeons have their work cut
out for them in re-educating medical practitioners.
3C. Does the Recipient Site

Influence the Hair Growth
Characteristics in Hair
Transplantation?
Sungjoo Hwang, Jung-Chul Kim, Seok Jong Lee, Gun
Yoen Na, and Do Won Kim
b
INTRODUCTION
Figure 3B-4 (a) Hamilton’s grading for androgenetic alopecia.
(b) Ludwig’s pattern of hair loss in females. In 1959, Dr. Orentreich suggested the term donor dominance
in androgenetic alopecia to convey that the hair in the grafts
continued to grow in the area of alopecia (the recipient area)
and that it maintained the same texture and color and, appar-
ently, grew at the same rate and with the same period of anagen
4. To confuse matters further about the incidence of FPHL,
that governed the nature of the hair in the donor site (1). With
Norwood has reported that only 190 of 1006 women he
this concept in mind, there have been many developments in
examined, had what he would consider female pattern
hair restoration surgery, and, more recently, hair transplantation
alopecia (15). Although he thought that it was ‘‘quite
has been employed not only for the treatment of androgenetic
common … reaching almost 30% in women over 30
alopecia but also for other hairless areas such as the eyebrows
years of age’’ (Table 3B-5), his is a considerably lower
and the pubic area (2,3). It is believed that the hairs in the latter
percentage than reported by either Hamilton or Venning
sites will maintain their growth characteristics as in transplanta-
and Dawber. He also believes that androgen-dependent
tion for androgenetic alopecia, but there have been few studies
MPB is a different disease from female pattern hair loss.
done to confirm this assumption. We therefore carried out a
In his study, he found that FPHL begins when women
series of studies designed to evaluate whether hairs would keep
are in their late 20s and peaks after 50 years of age,
their original growth characteristics after transplantation to a
when testosterone levels are falling, suggesting that it
new anatomical site:
is not androgen dependent. (see also later.) Birch, Lalla,
and Messenger have written that evidence exists for
FPHL being either androgen dependent or androgen in-
dependent in different individuals. They summarized METHODS AND RESULTS
their current view of the condition as follows: ‘‘Female Study I
pattern hair loss is probably a multifactorial, genetically
determined trait, and it is possible that both androgen- To evaluate the hair growth characteristics of a recipient site
dependent and androgen independent mechanisms con- other than the scalp, we transplanted hair from the author’s
tribute to the phenomenon’’ (16). occipital scalp to his lower leg.
Figure 3B-5 Photos of ‘‘Christmas tree’’ pattern of hair loss as discussed by Olsen: a) moderate b) severe. (Photos courtesy of E.
Olsen.)
In March 1998, an elliptical strip (1 cm ⳯ 2 cm) was har- recipient area (lower leg) and the donor site (occipital scalp).
vested from the occipital scalp, and 93 hairs were transplanted Twenty hair specimens were collected from each group and
to the medial aspect of the lower leg using a KNU implanter. attached to a glass slide with double-sided and one-sided cello-
At 6 months and at 3 years after transplantation, Iris scissors phane adhesive tape. The length and diameter of the hairs (in
were used to cut—as close to the skin surface as possible—20 millimeters) were measured by means of a microscope equipped
hairs among surviving hairs on the lower leg (recipient area) with an ocular micrometer (4,5). At 3 years, the number of
as well as 150 to 200 occipital scalp hairs. After 4 weeks, the surviving hairs in the recipient area was counted. Student’s t-
same hairs were cut again in a similar fashion from both the test was used to also analyze the difference in the hair growth
Table 3B–5 Incidence of Female Androgenetic Alopecia in 1006 Caucasian Females (Norwood)
Age Group No. of patients No. with female

(yr) examined androgenetic alopecia Percentage
20–29 121 4 3
30–39 196 34 17
40–49 251 39 16
50–59 144 33 23
60–69 154 39 25
70–79 80 22 28
80–89 60 19 32
Total 1006 190 19
58 Chapter 3
Table 3C–1 The Growth Rate and Shaft Diameter of the Transplanted Hairs on the Lower Leg and Occipital Scalp
Hairs
Growth rate (mm/month) Shaft diameter (mm)
Follow-up Lower leg Occipital scalp Lower leg Occipital scalp
At 6 months 7.9 ⫾ 1.3 a

15.5 ⫾ 0.9 0.084 ⫾ 0.013 0.087 ⫾ 0.015
At 3 years 8.2 ⫾ 0.9b 16.0 ⫾ 1.1 0.086 ⫾ 0.018 0.088 ⫾ 0.016
, : p ⬍ 0.05
a b
rate and the diameter of the shaft. When p was less than .05, B, but the growth rates of these groups were much lower com-
the difference was considered significant. pared with that of the occipital hairs (Table 3C-2).
Study III
Results
It was found that survival and growth rates differed according
The survival rate was 60.2% 3 years after the transplantation. to the location of the recipient site. To evaluate whether or not
The surviving hairs on the lower leg showed a significantly this resulted from follicular damage during graft preparation,
lower growth rate, but the same diameter as the occipital hairs. 20 hair specimens were collected from both recipient (frontal)
However, the results were equal both at 6 months and 3 years scalp and donor (occipital) scalp in male patients with androge-
post surgery (Table 3C-1). After 3 years, the longest hair was netic alopecia 1 year after they had undergone hair transplanta-
measured at 12 cm during the follow-up examination (Fig. 3C- tion. There were no significant differences in the growth rate
1). and the shaft diameter between the transplanted hairs and the
donor hairs (Fig. 3C-3).
Study II
DISCUSSION
After finding the unexpected results noted above, we harvested
some of the transplanted hairs from the leg and transplanted 20 In the first study, the survival rate was 60.2% in the lower leg
of them to the left side of the nape of the neck that was near at 3 years after surgery. This was a much lower survival rate
the occipital scalp (group A). As a control study, 24 occipital than the rate we typically see compared with hair transplantation
hairs were transplanted to a comparable area on the right side in androgenetic alopecia (92%) (6). The hair also showed a
at the same time (group B). At 6 months after surgery, the marked decrease in the growth rate—half that of the donor
survival rate, growth rate and shaft diameter were measured area hair. There may be many factors involved that cause these
(Fig. 3C-2). There were no significant differences in the growth differences. It may be that the differences in thickness of the
rate, survival rate, and diameter between group A and group epidermis, dermis, subcutaneous tissue, blood supply, and other
factors may play a role in causing the differences in the survival
and growth rates. Even considering these possible factors, the
hair shaft diameter did not change at all, so we suspect that the
volume of the surviving hair follicles does not decrease after
transplantation to a new site, regardless of the anatomical site.
We previously reported that the rate of hair growth changes
after eyebrow transplantation in patients with madarosis due to
leprosy (7). In that study, there was no significant correlation
between the hair growth rate and the period of time after its
transplantation. Also in this study, the surviving hairs on the
leg showed the same growth rate both at 6 months and at 6
years after surgery. Therefore, based on these results, it appears
that the cause of slowed growth rate is not due to adaptation to
the recipient site over a long period of time, but that it apparently
occurs immediately after transplantation and maintains this low-
ered growth rate in the recipient site.
On the human scalp, the duration of anagen has been esti-
mated to be between 2 and 6 years, and on the leg from 19 to
26 weeks (8). Expected length of the surviving hair on the
author’s lower leg was approximately between 31 cm and 32.4
Figure 3C-1 Shows transplanted hairs on the lower leg. After cm by calculation (7.9 mm to 8.3 mm/4 weeks ⳯ 3 years).
3 years, the longest hair was measured at 12 cm during the follow- Interestingly, the longest among them was about 12 cm during
up examination. a 3-year follow up examination. This suggests that the anagen
a b
c d
Figure 3C-2 (A) Hair transplantation from the lower leg to the left side of the nape of the neck. (B) Hair transplantation from the
occipital scalp to the right side of the nape of the neck. (C) The surviving hairs at 6 months after transplantation, Lt. (D) The surviving
hairs at 6 months after transplantation, Rt.
Table 3C–2. The Growth Rate and Shaft Diameter of the

Transplanted Hairs on the Nape and the Occipital Scalp Hair at 6
Months After Transplantation
Growth rate
Group (mm/month) Shaft diameter (mm)
A 9.0 ⫾ 1.2 0.087 ⫾ 0.009

B 9.3 ⫾ 1.1 0.086 ⫾ 0.010
C 15.8 ⫾ 0.9 0.085 ⫾ 0.010
Group A: Surviving hairs on the nape from previously transplanted hair on
the lower leg
Group B: Surviving hairs on the nape from the occipital scalp.
Group C: Occipital scalp hairs.
Figure 3C-3 There was no significant difference in the growth
rate (A) and the shaft diameter (B) between the transplanted hairs
(frontal scalp) and the donor hairs (occipital scalp).
60 Chapter 3
period on the leg decreased to 14.5 months or less (120 mm / tografts in Alopecias and other Selected Dermatological Condi-
8.3 mm). Therefore, we think that the cycles of transplanted tions,’’ published that year in the Annals of the New York Acad-
hair may change according to the anatomical location of the emy of Science, he put forth the concept that in androgenetic
recipient site. alopecia ‘‘the transposed grafted skin maintains its integrity and
After finding these surprising results, we wondered whether characteristics independent of the recipient site.’’ He called this
the hair would recover from the lowered growth rate and sur- phenomenon donor dominance, and since its first proclamation,
vival rate when it was retransplanted to a location near the there has been no concept more fundamental or immutable in
original donor site (group A). The survival rate of group A was the field of hair restoration surgery. The term he coined was
95% (19/20) and that of control (group B) was 91.7% (22/ an appropriate one, for it has dominated our thinking in hair
24), respectively. These rates were much higher than those that transplantation for the past 40 years. At least until now!
occurred in the lower leg (60.2%). Stated differently, it appeared The first inkling that donor tissue was not omnipotent came
that the hair recovered from the lowered survival rate when it from Dr. Norwood’s clever observation that transplanted hair
was retransplanted to the nape of the neck. In addition, the hairs took on the characteristic wave of the hair that originally grew
in group A and group B showed a much lower growth rate, at that spot. Just the fact that transplanted hair could wave spoke
similar to that of hair transplanted to the leg. We previously for recipient site influences, because a surgeon is not capable
reported that the growth rate of transplanted eyebrow hairs de- of orienting each hair so that it will grow in perfect spatial
creased compared with occipital hairs (7.72 vs. 10.43 mm/ harmony with its neighbor.
month) (7). Therefore, it is suspected that hair survival rate and The second challenge came in 1999, when Dr. Lee trans-
growth rate are influenced by the anatomical location of the planted hair from the scalp into the eyebrows of patients who
recipient site. had alopecia caused by leprosy. He showed that the graying
The question was raised: Is the lowered growth rate due to and growth rates of the transplanted hair gradually conformed
follicular damage during graft preparation (9,11)? To answer to the eyebrows rather than to the scalp that was its origin.
this question, an observational study was conducted on patients The present study of Hwang and colleagues mounts the third
with androgenetic alopecia after hair transplantation. There formidable challenge to Dr. Orentreich’s famous hypothesis. In
were no significant differences in the results; therefore, we think this work, Dr. Hwang and his group provide additional evidence
that the lowered growth rate on the leg and neck was not due that the recipient area can influence hair growth rate, cell cycle,
to follicular damage occurring during hair transplantation. and even graft survival. They showed that hair transplanted
It is considered that the follicle may influence the physiology from the occipital scalp (the author’s) to the lower leg took on
of many cutaneous structures and tissues, such as the sebaceous the growth characteristics of leg hair and then partially reversed
gland and the subcutaneous fat (12). Conversely, as a result of itself when retransplanted to the nape of the neck. There was
our studies, we think that the physiology of transplanted hair no placebo effect. There is firm scientific proof of recipient site
follicles may be influenced by the recipient area’s cutaneous influences.
structures. The early hair transplanters in Japan must have had some
appreciation for these effects as they began to transplant scalp
hair to the pubic region in the 1930s and 1940s. As surgeons
CONCLUSION are becoming more creative in finding new areas of the body
According to the results, we think that: to take hair from and new places to put it, the influences of the
recipient region are taking on additional significance. It would
1. The survival rate and growth rate of the transplanted be gratifying if the coarse hair taken from a bald man’s beard
hairs is influenced by the recipient site. during a facelift could be placed on top on his bald pate and
2. The cycles of the transplanted hairs may change accord- if it could grow to approximately the same quality as his original
ing to the recipient area. hair. And it would be comforting to the female patient who has
3. The hair growth rate may change immediately after had an eyebrow transplant to know that the hair growth will
transplantation according to the recipient site and is slow and that she can eventually stop trimming it. (Reprinted
maintained afterward. with permission of the Journal of Dermatologic Surgery, Sep-
4. The volume of transplanted hair follicles may not tember 2002, 28(9): 795–799.)
change regardless of the recipient site. Robert Bernstein, M.D.
Therefore, we think that the recipient site influences the growth
characteristics of transplanted hairs. The scalp is the same gen-
eral anatomic area—whether one is speaking about the donor
area or the recipient area. Therefore, although hair transplanted 3D. Current Views on Pathogenesis
from the donor area grows in the recipient area for as long as and Medical Treatment of Male
it would in the donor area, this should not be construed as proof Pattern Baldness
of donor area dominance. The fact that transplanted donor area
hair has been shown in these studies to take on some of the David A. Whiting
characteristics of hair in the recipient area strongly suggests the
opposite—a significant role for recipient area influence. DEFINITION
Comments Male pattern baldness is the most common type of non-scarring
In 1959, Dr. Norman Orentreich provided the scientific basis hair loss affecting the superior portion of the scalp in men. It
for the field of hair transplantation. In his landmark paper, ‘‘Au- results from a genetically determined, end-organ sensitivity to
androgens (1,2). It is often referred to as simple baldness, male trance, because convincing evidence for a dominant inheritance
pattern alopecia, hereditary alopecia, or, nowadays, male andro- is sometimes lacking (15). A multifactorial or polygenic form
genetic alopecia (3,4). of inheritance may be more likely (16), implying an interaction
of several genes with environmental factors (17).
CLINICAL DESCRIPTION
ETIOLOGY
Male pattern baldness (MPB) is characterized by progressive
thinning of the hair on the superior scalp and crown, with rela- Genetic factors have been mentioned (18). They are obviously
tive sparing of the occipital and lateral areas of the scalp, with important, because a family history of MPB can be obtained
or without seborrhea (5,6). There is a significant reduction in in most patients.
the length of the anagen, or growth phase, of the hair cycle The other important factor in MPB, or androgenetic alopecia,
(7,8). The net result is that the terminal hairs in the affected is the influence of androgens. The essential role of androgens
areas become finer, shorter (9,10) and lose color. This process was demonstrated in studies of male eunuchs, in whom male
may be continuous, but more often occurs in a stepwise fashion. pattern alopecia was seen after the administration of male hor-
It may be rapid or slow. The end-product is a depigmented mones (1). Urinary levels of 17-ketosteroids (1) and serum lev-
miniaturized hair that is velluslike and could be classified as a els of testosterone are the same in MPB as in non-balding indi-
secondary vellus hair. viduals (19). The concept of an end-organ hypersensitivity has
With progressive miniaturization of terminal follicles, bald- been introduced to account for the fact that some androgen-
ing becomes apparent. Careful examination of the area of thin- dependent tissues react abnormally to normal levels of circulat-
ning shows increased numbers of small hairs averaging 1 cm ing androgens (20,21). For peripheral androgenism to occur,
in length, with tapered tips and therefore not the result of a two factors are necessary; one is the genetic factor that causes
haircut. the hairs on the superior scalp and anterior temporal areas to
A decrease in the number of groups of three hairs, the ‘‘trio be more susceptible to the action of androgens than hairs on
arrangement,’’ is also present (11). Hair-pull tests may show the back and sides of the scalp (3); the other is the local metabo-
that more telogen hairs are easily detachable over the superior lism of normal levels of circulating androgens in the piloseba-
aspect of the scalp than on the occipital and lateral areas of the ceous apparatus (22). It is possible that local metabolic factors
scalp. This confirms the increased telogen/anagen ratio that is enhance the metabolism of small amounts of androgens, con-
characteristic of androgenetic alopecia (12) due to a decreased tributing to the end-organ hypersensitivity that is considered to
growth phase but an unchanged resting phase. Cyclic hair loss in exist in androgenetic alopecia (23). Although levels of total
excess of 100 hairs a day is often characteristic of androgenetic circulating androgens remain within normal limits in most cases
alopecia. of androgenetic alopecia, the ratio of free-circulating androgens
The percentage of males with androgenetic alopecia is re- to transfer proteins may sometimes be increased (24). (Subse-
lated to family history and age. Generally speaking, MPB can quent confirmation of this single report is lacking.)
be expected to occur in 25% of men aged 25 to 30 years, 40% The current concept of peripheral androgen metabolism in
of men aged 40 years, and 50% of men aged 50 ears or older. the pilosebaceous apparatus is that circulating testosterone and
The onset of MPB can occur at any time after puberty and is androstenediol enter the effector cells in the sebaceous glands
common in the late teens. and the hair bulb are then reduced by the enzyme 5-alpha-
The sequence of hair loss usually starts with deepening bi- reductase to 5-alpha-dihydrotestosterone (25). This activated
temporal recession. This results in a type M-pattern of the fron- form of testosterone becomes bound to a specific receptor pro-
tal hairline (2). It is usually followed by loss of hair over the tein to form a complex that enters the nucleus. This complex
vertex, which, sooner or later, results in a bald patch. Gradually, interacts with chromatin to initiate protein synthesis. Dihy-
these two thinning areas enlarge and, usually, eventually meet drotestosterone is the androgenicregulating factor in the pilo-
each other at the midscalp. Sometimes, the hair loss is more sebaceous apparatus, and it increases the mitotic activity of
diffuse over the crown and midscalp, resembling female pattern sebocytes and modulates the activity of follicular matrix kera-
alopecia. At other times, it stays localized to the vertex. The tinocytes (26,27). Cellular androgen metabolism can be reduced
rate and degree of progression of hair loss is influenced by either by decreased reduction of testosterone to dihydrotestost-
genetic factors. MPB may eventually appear to stabilize at some erone, or by a lack of androgen receptor. The complex mecha-
point along the Hamilton/Norwood scale between type III and nism leading to the loss of hair remains obscure. It has been
type VII. It can range from a mild type III pattern of alopecia suggested that 5-alpha-dihydrotestosterone has an inhibitory ef-
(which consists of simple bitemporal recession) to a type VII, fect on the activity of adenylate cyclase, so that mobilization of
the most severe form of alopecia. This severe form of alopecia energy supplies and the amount of cellular cyclic-AMP (cAMP)
consists of total hair loss from the hairline through the crown, diminish (28). This has been thought to cause shortening of the
but with residual hair in the occipital and lower parietal and hair cycle and, therefore, an increased transition of anagen hairs
temporal regions in the pattern of a monk’s tonsure (2,13). In into telogen hairs and, later on, into miniaturized hairs. Thus,
many instances, hair loss does not stabilize and MPB relent- terminal hairs are turned into vellus hairs, which finally cease
lessly advances in stages for the lifetime of the patient. Scarring growing altogether. An increase in dihydrotestosterone activity
is not a feature of androgenetic alopecia. can also result in seborrhea, acne, and hirsutism. Hairs on the
The degree of progression of MPB appears to be dependent occipital and periauricular areas of the scalp do not respond
on the family history. Inheritance is usually considered to be with shortening of the anagen cycle to similar levels of dihy-
autosomal dominant (14), but with a variable degree of pene- drotestosterone. In fact, hairs in these areas are unaffected by
62 Chapter 3
male pattern alopecia and can be used for hair transplantation INVESTIGATION AND DIAGNOSIS
into affected areas, where they show donor dominance and re-
tain their resistance to miniaturization (29,30). A possible expla- The well-known clinical appearance of male pattern alopecia
nation for this might be the presence of increased activity of 5- and the presence of a family history usually make the clinical
alpha-reductase, leading to increased concentration of 5-alpha- diagnosis of androgenetic alopecia easy. In general terms, the
dihydrotestosterone in hair follicles in areas affected by MPB. relative loss of hair over the superior aspects of the scalp, with
This supposition was confirmed by a paper in which higher sparing of the hair over the occipital and temporoparietal areas
levels of 5-alpha-reductase and androgen receptors, and lower of the scalp, unaccompanied by clinical inflammation or known
levels of aromatase, were demonstrated in affected scalp hair dermatoses, is diagnostic (1). Close inspection of areas of appar-
follicles in men and women with androgenetic alopecia (31). ent thinning should reveal short hairs scattered throughout the
It was also shown in men and women with androgenetic alope- area. The pattern and degree of alopecia is variable. The short
cia that androgen receptors and 5-alpha-reductase levels were hairs represent the miniaturization of terminal hair as the alope-
higher and aromatase levels were lower in the affected frontal cia proceeds.
scalp than in the unaffected occipital scalp. Note that there are The actual evaluation of male pattern alopecia is helped by
at least two types of 5-alpha-reductase in humans: (32) type 1 use of a grading scale. The one developed by Hamilton and
5-alpha-reductase occurs in sebaceous glands and the piloseba- modified by Norwood is in common use (2,13). Types I and
II on this scale represent normal prepubertal and postpubertal
ceous apparatus. Type 2 5-alpha-reductase occurs in the prostate
individuals, whereas types III through VII represent degrees of
and also in the outer root sheath of the hair follicle and in the
MPB ranging from bitemporal recession to total balding of the
dermal papilla (33). It is also found around other portions of the
vertex. The Savin scale has been developed recently to assist
follicles. In male pseudohermaphrodites with 5-alpha-reductase
in grading patients for medical or surgical treatment. This in-
deficiency who do not develop MPB, the defective 5-alpha-
volves an 8-point scale measuring the degree of midvertex den-
reductase is of the type 2 variety (32). The metabolism of testos-
sity of hair (41). Each of these scales enables the clinician to
terone to dihydrotestosterone can be diminished by 5-alpha-
evaluate the progression of hair growth and response to therapy
reductase inhibitors (34). To actively suppress this process in more accurately.
the pilosebaceous apparatus may require inhibition of both types Occasionally, the diagnosis is not so easy because of an
of 5-alpha-reductase. unusual pattern of male androgenetic alopecia; or because of
the additional presence of a diffuse alopecia owing to various
causes; or because of a patchy alopecia caused by alopecia
HISTOPATHOLOGY areata, tinea capitis, trichotillomania, or cicatricial alopecia. In
all of these conditions, if diagnostic difficulty exists, scalp biop-
The histopathology of androgenetic alopecia reflects the patho- sies may be useful. Adequate amounts of tissue should be taken
genesis. A variable number of terminal hairs miniaturize and and, frequently, vertical sections of scalp biopsies can usefully
ascend up the hair follicle to become secondary vellus hairs be supplemented by horizontal sections (42).
(2,3). First, this is marked by the presence of residual angiofi-
brotic tracts that replace the old lower terminal follicles, com-
monly known as streamers or follicular stelae (35,36). There is TREATMENT
a concomitant increase in vellus hairs in the papillary dermis. The four basic options in the treatment of MPB are to withhold
In general, the total number of hairs remains the same and the treatment until significant deterioration occurs or to provide
decreasing number of terminal hairs is balanced by the increas- medical treatment, surgical treatment, or a hairpiece.
ing number of vellus hairs (37,38). This change can be measured The only medical treatments now approved by the U.S. Food
in horizontal sections of scalp biopsies by changes in follicular and Drug Administration (FDA) are topical minoxidil 2% and
counts (39). There is a change in the terminal/vellus hair ratio 5% and finasteride 1 mg daily.
from the normal value of 6:1–8:1, to 4:1 or less, usually down Interest in the hypertrichotic effects of minoxidil, a potas-
to as low as 1:1 in the established case of male pattern alopecia sium channel opener and vasodilator, was stimulated when a
(39). This is accompanied by an increase in the number of case of hypertrichosis, caused by the oral hypertensive drug
follicular streamers. Mild lymphohistiocytic inflammation is minoxidil, was described in 1979 (43). Several cases of male
found around the upper follicle in approximately one third of pattern alopecia were described, in 1980 (44) and 1981 (45),
normal controls and in one third of cases of androgenetic alope- in which alopecia was reversed by oral minoxidil taken for
cia. However, moderate inflammation is found in another one hypertension. In fact, anecdotal evidence of hair growth from
third of cases of androgenetic alopecia, but not in normal con- topical minoxidil has been forthcoming since 1973. The first
trols (39). There is no obvious explanation for this lymphohisti- report of hair growth from topical minoxidil in alopecia areata
ocytic inflammatory change, but causative factors could include appeared in 1981 (46). In 1987, the results of a multicenter trial
seborrheic dermatitis; actinic damage; or the comedogenic, irri- of the application of topical minoxidil for 12 months in MPB
tating, sensitizing, or otherwise toxic effects of various hair were published (47). A dense regrowth of hair was seen in 8%
cosmetics and grooming agents, including shampoos, condi- of cases, moderate regrowth was seen in 31% of cases, minimal
tioners, fixatives, hair dyes, and permanent waves. In 10% of regrowth was seen in 36% of cases, and no regrowth of hair
cases, there is a reduction in the total number of hair follicles was observed in 25% of cases. However, these pooled results
(40). Whether this indicates a severe degree of androgenetic should be contrasted with the fact that of the centers in which
alopecia or, possibly, some overlap with senescent alopecia is the studies were conducted, 19 of 27 showed no statistically
not entirely clear. significant hair regrowth (48). In addition, Rushton and associ-
ates used trichograms to show the lack of validity of these initial and that some stabilization of hair loss can be anticipated, at
results (49). They pointed out that in the aforenoted studies, the least for a time, in approximately 80% of patients. Some re-
center point of the study area was located by an unscientifically growth of hair can be expected in 56% of patients, although in
variable method, and that visual hair counts differed substan- most of them, the regrowth is minimal.
tially from trichogram counts in which hairs in the study area It has been suggested that topical minoxidil is effective in
were plucked, counted, and compared with the preceding visual regrowing hair in most people, and that an increase of hair
hair counts. The same investigator also became more accurate growth to the order of 15% to 20% can be expected (De Villez,
with experience, thereby invalidating the results in another way. R. L., personal communication, 1993). This implies that in early
Long-term follow-up into the third year of minoxidil treat- cases for which hair loss is slight, this regrowth will be adequate
ment of some cases showed that twice-daily maintenance of enough to make a visible difference. However, in patients classi-
topical minoxidil therapy was necessary (48). In one long-term fied as types V, VI, or VII, Hamilton-Norwood, in whom con-
study, sustained hair growth of some degree was observed in siderable alopecia is present, such a degree of regrowth will
onethird of patients, with some evidence of prevention of further not make an appreciable difference. It is now clear that long-
loss in others (50). Topical minoxidil (2%) was approved for term stabilization of hair loss implies hair growth as evidenced
the treatment of male androgenetic alopecia in the United States by the almost invariable hair shedding that follows minoxidil
by the FDA in 1988. In 1990, a 5-year follow-up of topical withdrawal.
treatment of male pattern baldness with 2% and 3% minoxidil The search for improved formulations of topical minoxidil
was published (51) In this study, hair growth peaked at 1 year, continues. Two percent topical minoxidil is available over the
slowly declined over 5 years, but remained above baseline. The counter for treatment of androgenetic alopecia in men and
regrown hairs fell out within 4 to 6 months after the drug was women, and, since 1997, a 5% solution of topical minoxidil has
stopped (52). In 1990, an Australian study of topical minoxidil, been available over the counter for hair growth in androgenetic
used for 48 weeks in male androgenetic alopecia, showed a alopecia in men. Two hundred and ninety-three men aged 18
12% incidence of moderate regrowth (53). In 1991, 2% topical to 49 years old with mild-to-moderate thinning at the vertex
minoxidil was also approved by the FDA for the treatment of were treated twice daily for 48 weeks with the 5% solution, the
female pattern androgenetic alopecia. In the preceding trials, 2% solution, and placebo. The hair counts were 45% higher in
256 women completed a 32-week trial; 13% showed moderate the 5% minoxidil group than in the 2% minoxidil group and
regrowth, 50% showed minimal regrowth, and 37% no regrowth almost five times as high as those receiving placebo. Further-
of hair (53–55). Minoxidil studies in both male and female ( more, the effect of the topical minoxidil was evident at 2 months
(51,55–57) androgenetic alopecia showed an appreciable plain the 5% group as opposed to 4 months in the 2% group. The
cebo effect. This placebo effect in hair growth studies may well effects of the 5% topical minoxidil were also measured by hair
be the basis for the spurious claims of hair-growing properties weight in a 96-week, double-blind study of four groups of nine
for many patent remedies and hair tonics. The diagnostic and men with androgenetic alopecia. Three groups received 5% top-
predictive value of horizontal sections of scalp biopsy speci- ical minoxidil, 2% minoxidil or placebo. The fourth group re-
mens in male pattern androgenetic alopecia was studied recently ceived no treatment (58). In this hair weight study, the 5%
(39). Results in patients treated with 2% topical minoxidil minoxidil was better than the 2% and 30% better than the pla-
showed a trend toward less hair regrowth in those with below- cebo group. The study showed that minoxidil increased hair
normal hair follicle density, or with significant, perifollicular, weight diameter and rate of growth. Initial studies of 5% topical
lymphohistiocytic, inflammatory change. minoxidil in female androgenetic alopecia were inconclusive,
Unpublished data are available from my review of 736 con- and further studies are still being evaluated. The 5% topical
secutive cases of MPB seen at the Baylor Hair Research and minoxidil is currently available over the counter for men but
Treatment Center in Dallas. Of these cases, 619 (84%) of the not for women. It is possible that different vehicles and different
total were treated with topical 2% minoxidil, and 82 cases (11%) percentages of minoxidil may enhance penetration and improve
of the total were treated with transplant surgery. Analysis of therapeutic effects. Combinations of other drugs with topical
the patients treated with topical minoxidil showed that 37% minoxidil have been studied. Claims have been made that topi-
were aged 15 to 29 years, 50% were aged 30 to 44 years, and cal retinoic acid has enhanced the effects of minoxidil (59),
13% were aged 45 to 69 years. Of these patients, 19% were but there are no well-controlled trials that substantiate this. A
type II Hamilton-Norwood scale, 33% were type III vertex, combination of finasteride and minoxidil has been shown to
25% were type IV, 17% type V, 5% type VI, and 1% type VII. regrow hair in stumptail macaques better than either drug alone
The length of treatment was less than 1 year in 78% of cases, (60). Other drugs with known hypertrichotic effects have been
2 to 3 years in 18% of cases, and 4 to 5 years in 4% of cases. tested, but no significant therapeutic trials of such agents have
Analysis of the patients with male androgenetic alopecia treated yet been published. No further new drugs for enhancing hair
for 2 to 5 years with topical minoxidil showed that shedding was regrowth in male pattern alopecia have yet been approved by
decreased in 79%, was unchanged in 19%, and was increased in the FDA.
2% of cases. Hair regrowth in these patients was estimated as In view of the known effects of androgens in male pattern
minimal in 51.5% and moderate in 4.5% of cases. Hair regrowth alopecia, there has always been a great deal of interest in finding
was adversely affected by an increased age of the patient older a suitable topical or systemic antiandrogen that can be used
than 40 to 50 years, and by an increased degree of balding safely and effectively in males. Topical progesterones or estro-
greater than type IV Hamilton-Norwood. The duration of the gens, or combinations thereof, have been tried, but any reports
history of male pattern alopecia did not appear to affect the of therapeutic success are more anecdotal than scientific.
results from minoxidil. In summary, it appears that 2% topical Finasteride 1 mg daily was approved for the oral treatment
minoxidil still maintains an effect over periods of up to 5 years, of androgenetic alopecia in males by the FDA in 1997. This
64 Chapter 3
drug has now been tested in androgenetic alopecia for at least available. The results of trials of an apparatus employed to
6 years. Finasteride is a 5-alpha-reductase inhibitor that largely deliver intermittent courses of pulsed electrical stimulation to
affects the type 2 enzyme with some small effect on type 1 5- patients with androgenetic alopecia have not yet been published,
alpha-reductase (61,62). This drug was developed after family but the device was not approved by the FDA. More basic re-
studies of patients with an inherited absence of 5-alpha-research into the complex physiological mechanisms of the nor-
ductase, which has now been shown to be the type 2 5-alpha- mal hair cycle is needed before really effective stimulation of
reductase (63,64). Male patients with this defect showed ambi- hair growth can be developed.
guity of external genitalia at birth, but they virilized after pu-
berty. These patients did not develop MPB or prostatic hyper-
plasia. Because oral finasteride decreases dihydrotestosterone REFERENCES
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seriously affecting sexual function (65). Long-term studies with
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66 Chapter 3
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Francisco, 1992. hair count in men with androgenetic alopecia, after application
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noxidil 2%) for female androgenetic alopecia. Proceedings from men with frontal male pattern hair loss. J Am Acad Dermatol
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mazoo. Michigan: The Upjohn Co., 1993. 68. Whiting DA. Advances in the treatment of male androgenetic
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56. Whiting DA, Jacobson C. Treatment of female androgenetic 69. Whiting DA, Waldstreicher J, Sanchez M, Kaufman KD. Mea-
alopecia with minoxidil 2%. Int J Dermatol 1992; 31:800–804. suring reversal of hair miniaturization in androgenetic alopecia
57. Jacobs JP, Szpunar CA, Warner ML. Use of topical minoxidil by follicular counts in horizontal sections of serial scalp biop-
therapy for androgenetic alopecia in women. Int J Dermatol sies: Results of finasteride 1 mg treatment of men and post meno-
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4
Hair Loss Unrelated to Androgenetic Alopecia
Eric L. Eisenberg
INTRODUCTION or even male members of the family. Even under these circum-
stances, it is important to investigate the possibility of iron
Although male pattern baldness (MPB) is certainly the most deficiency and to determine whether suggestive signs and symp-
common type of hair loss encountered in the field of surgical toms are present for endocrine disease. It is not unusual to
hair restoration, there is a large variety of scalp disorders leading diagnose iron deficiency as a solitary cause of diffuse hair loss,
to hair loss that may sometimes be confused with MPB or may especially in the presence of increased telogen hair shedding,
be amenable to surgical correction. Hair loss can occur as a although there are certainly cases in which the iron deficiency
result of metabolic changes such as endocrine disease and iron may contribute to hair loss of a hereditary nature. In cases of
deficiency, or after severe emotional or physical stress such as recent progressive hair loss associated with iron deficiency, es-
a serious illness. However, in the latter two situations, hair loss pecially if there is no history of hereditary thinning, hair trans-
is most often of a temporary nature and partial or complete plantation should be postponed until a therapeutic trial of at
regrowth occurs spontaneously. When correction of the under- least 6 months of iron supplementation has been tried to prop-
lying metabolic problem does not result in a return to adequate erly evaluate its therapeutic benefits on hair regrowth.
hair density, hair transplantation can be considered.
Hair loss of a permanent nature that is unrelated to metabolic
changes or heredity is almost always secondary to the destruc- Thyroid Disease
tion of the hair follicles. This can occur as the result of severe Thyroid disease, although less common than iron deficiency as
cutaneous infections, inflammatory disorders, autoimmune and a cause of hair loss in women, should always at least be consid-
neoplastic processes, and physical trauma, including iatrogenic ered in the evaluation of women with diffuse thinning. Although
causes such as radiation-induced alopecia. As in all areas of this cause of hair loss can often be corrected with early interven-
medicine, there is also a subset of disorders that are well recog- tion and proper thyroid management, full regrowth of hair may
nized clinically but are poorly understood from an etiologic not occur. In this situation, as with incomplete hair regrowth
standpoint. This is the group of idiopathic scarring alopecias. after correction of iron deficiency, hair transplantation can be
Hair transplantation is generally only undertaken in situations considered as long as there is an adequate donor-recipient hair
that result in permanent hair loss. This chapter is a brief review density ratio and an appropriate donor-recipient area ratio (See
of some of the more common nonhereditary causes of such loss, Chapter 5A).
which may be amenable to surgical correction. Emphasis is
placed on their recognition, diagnosis, and treatment, but a fuller
Polycystic Ovary Syndrome
description of them as well as less common causes of hair loss
is available in references 1 to 3. Polycystic ovary syndrome (PCOS) is a familial disorder that
may affect up to 10% of females during their reproductive years.
It is characterized by hyperandrogenism, as well as hyperinsuli-
METABOLIC DISORDERS nemia, which occurs primarily on the basis of peripheral insulin
Iron Deficiency resistance (4). PCOS is a poorly understood entity often consid-
ered to be synonymous with chronic idiopathic hyperandrogen-
Young women who have diffuse central thinning and preserva- emia, and may represent 95% of cases of hyperandrogenism in
tion of the frontal hairline are often quickly diagnosed as having women (5). Although this disorder was initially described by
a female pattern of hereditary hair loss. There is often a family Stein and Leventhal in 1935 as a syndrome of amenorrhea asso-
history of hair loss affecting a mother, sister, or grandmother, ciated with enlarged polycystic ovaries, hirsutism, and obesity,
67
68 Chapter 4
PCOS is recognized today as a much more diverse condition tional or physical stress, or after commencement of drug ther-
in which menstrual patterns and the ultrasonographic ovarian apy. Frequently, more than 100 hairs are shed each day, and
appearance can be variable. Other clinical manifestations of this this period of hair loss can extend over a period of 3 months
disorder may include acne, acanthosis nigricans, and alopecia. or occasionally longer, usually if the drug is continued or if the
As in any syndrome, the degree of clinical expression of these period of significant stress is both severe and persistent. Clearly,
manifestations may vary. if the amount of daily hair loss is excessive and this hair loss
From the hair transplant surgeon’s perspective, the presence extends over a period of several months, there can be a dramatic
of alopecia in a woman consulting about hair restoration should change in a person’s appearance. There are many different
prompt an initial directed inquiry to exclude or confirm the causes of TE, and some of the most common ones are listed
possibility of endocrine-related hair loss. When this history rein Table 4-1.
sults in a reasonable index of suspicion, appropriate androgen A chronic idiopathic form of TE has been described more
testing should be performed, including a free and total testoster- commonly in middle-aged women (9). Clinically, there is often
one level as well as dehydroepiandrosterone sulfate (DHEA-S) significant telogen shedding over the entire scalp, resulting in
levels. This testing also helps to exclude conditions that can be diffuse thinning but also often associated with severe bitemporal
confused with PCOS, including Cushing’s syndrome, virilizing recession. The onset may be sudden, with large amounts of hair
tumors, acromegaly, and hyperprolactinemia. Any abnormality shedding in a patient who has not had previous hair loss. This
or suspicion of abnormality should prompt further endocrine shedding often runs a fluctuating course over a period that can
investigation. It is important to note that isolated normal andro- last from 6 months to 6 years or more. Hair shedding in some
gen levels do not exclude PCOS because intermittent hyperan- people may be affected to a greater degree by seasonal changes.
drogenemia may occur variably during different menstrual cy- Generally, chronic TE is self-limiting. Ultimately, there is reten-
cles, and this may be of significance to genetically predisposed tion of a cosmetically acceptable amount of scalp hair, as long
hair follicles (6). as there are no other coincidental causes of hair loss, such as
It is interesting as well as potentially significant that some androgenetic alopecia. A patient who manifests this pattern of
investigators have associated polycystic ovaries and premature hair loss in the absence of significant laboratory findings should
MPB (in male family members younger than age 30 years) with be reassured that there is a good prognosis for regrowth. In
one allele of the steroid metabolism gene CYP17, which is select cases, hair transplantation can be considered only when
considered to be the rate-limiting step in androgen synthesis the chronic TE ends and when it becomes apparent that there
(7). In this study, the authors concluded that variation in the is inadequate regrowth of scalp hair.
A2 allele of this gene is a significant factor responsible for Postpartum TE is a relatively common cause of diffuse hair
modifying the expression of polycystic ovaries and MPB in loss in women. This usually begins 3 weeks to 3 months after the
certain families. This has led to the suggestion that premature woman gives birth, and regrowth can be delayed until several
MPB may be the male phenotype of PCOS. Furthermore, there months after the onset of shedding. Unfortunately, there is fre-
are other significant associations between androgen and insulin quently incomplete regrowth. Often (although not always), sub-
pathways that may be of etiologic significance to MPB, but sequent pregnancies will be associated with a recurrence of the
these associations go beyond the scope of this review (4). TE and progressive thinning occurs. In some cases, there is a
In summary, young women who manifest hair loss should family history of hereditary thinning, although in other cases
receive a thorough clinical assessment to determine whether there is no history of hair loss. Similarly, many chronic illnesses
there is sufficient reason for further endocrine investigation be- associated with severe and protracted physical or emotional
fore any surgical intervention is considered. It should also be stress may induce permanent thinning through persistent TE in
kept in mind that the presence of PCOS does not exclude the the absence of a family history of hereditary hair loss. Once
possibility of hair transplantation as long as the usual preopera- again, hair transplantation becomes an option in properly se-
tive criteria are met. Furthermore, it may be clinically helpful lected cases.
to question young men with early onset MPB about the presence
of PCOS-related clinical features in their female family mem-
bers. The opposite also applies: it may be relevant to question Table 4–1a Common Causes of
women consulting about hair replacement regarding the pres- Telogen Effluvium
ence of significant early onset MPB in their immediate male
family members. This type of inquiry can only help to broaden Early stage of androgenetic alopecia
our appreciation of the potential significance of this presumed Prolonged and high fever
association. Acute blood loss
Childbirth
Acute psychiatric illness
Telogen Effluvium Drug therapy
“Crash” dieting
Telogen effluvium (TE) is a term that refers to a pronounced Significant emotional or physical illness
shedding of normal club hairs, which occurs after actively grow- Widespread skin disease
ing anagen follicles are shifted into the resting or telogen state Discontinuation of the birth control pill
after a brief passage through the transitional catagen phase (8). General anesthesia
Although TE is clinically recognized more commonly in Hypothyroidism
women, it is common in men as well. Generally, TE occurs 1 Surgical interventions
to 3 months after the acute onset of any serious disease (espe-
a
cially if it was associated with a high fever) or significant emo- (References 1–3, 8.)
Hair Loss Unrelated to Androgenetic Alopecia 69
Occasionally, diffuse frontal telogen shedding may occur as

the initial sign of MPB in young men. This may take place in
the absence of a distinct male pattern of recession and can easily
be confused with the diffuse shedding seen in some cases of
alopecia areata (see ‘‘Autoimmune and Neoplastic Disorders’’
section) or TE of other origins. The diagnosis of MPB may
come into focus only when a distinct pattern of frontal recession
becomes apparent. It has been my observation that the transition
from diffuse shedding to patterned hair loss can be fairly rapid.
Unlike the categories of hair loss that are discussed next,
the examples cited earlier show no clinical evidence of scarring.
Moreover, early recognition may reduce or eliminate the need
for surgical intervention. Thus, because there is no obvious clue
to point the hair transplant surgeon in a particular diagnostic
direction, it is especially important to be aware of them.
INFECTIOUS DISEASES Figure 4-2 Folliculitis decalvans. (Courtesy of Bradley R.

Wolf, M.D.)
Most simple infections of the scalp are either self-limiting or are
easily treated with appropriate antibiotic, antifungal, or antiviral
therapy. In addition, hair follicles are in general very resistant
to destruction. However, occasionally, the severity of the infec- cussed later in this chapter in the ‘‘Idiopathic Scarring Alope-
tion, the timing of the treatment, or the resistance of the organ- cia’’ section). At the periphery of these zones of central alope-
ism to the chosen medication is such that an infection may cia, inflammatory papules and pustules are frequently noted.
persist and become so severe that destruction of hair follicles Although Staphylococcus aureus can often be cultured from
occurs. Hair loss may be focal, or, if the infection has spread these inflammatory lesions, this bacterium is not universally
over a large portion of the scalp, it may result in a more diffuse recognized as a primary culprit in the pathogenesis of these
and/or patchy alopecia. Common infections that in rare in- disorders. Both conditions are more common in young men
stances can cause this type of hair follicle destruction include and seem to more commonly affect the parietal and occipital
herpes simplex and herpes zoster and severe staphylococcal or portions of the scalp. However, folliculitis decalvans is marked
other bacterial infections that result in the formation of ab- by the presence of follicular papules or pustules at the advancing
scesses. Uncommon fungal infections that are associated with edge of the expanding alopecia. Tufted folliculitis, as the name
severe inflammation (kerion formation) can also result in scar- implies, often appears with clusters of hairs compressed into a
ring alopecia (Fig. 4-1). Even with appropriate medical treat- small tuft. This tuft of hairs seems to emerge from a single
ment, these infections may cause destruction of hair follicles, follicular opening. This is believed to occur as a result of fibrous
resulting in patchy alopecia. contraction of the interfollicular tissue and the formation of a
Folliculitis decalvans (Fig. 4-2) and its clinical variant, tufted larger solitary follicular opening. The resulting tuft of hairs
folliculitis(10) (Fig. 4-3) are persistent and progressive inflam- (which tend to be retained telogen hairs) gives the appearance of
matory disorders associated with an expanding, irregularly a doll’s hair, as has been seen when dense donor grafts undergo
shaped, central scarring alopecia (these conditions are also dis- compression after being placed into a small recipient opening.
Figure 4-1 Kerion. Figure 4-3 Tufted folliculitis.

70 Chapter 4
Both folliculitis decalvans and tufted folliculitis are unfortu-

nately, generally progressive in spite of occasional temporary
improvement with a systemic antibiotic alone or in combination
with topical or intralesional corticosteroids.
In general, in an area of scalp infection that has led to scar-
ring alopecia, it is recommended to wait at least 6 months be-
yond resolution of the infection before considering surgical in-
tervention. This period provides a reasonable interval for any
surviving hair follicles to grow. In addition, it provides a ‘‘com-
fort level’’ with regard to the possibility of a recurrence of the
infection. Such areas of alopecia can be managed successfully
by simple excision and/or with a variety of grafting techniques.
INFLAMMATORY DISEASES
Although the primary trigger responsible for the initiation of
these disease processes is not as well understood as is the case
with infectious etiologies, disorders in this category more com-
monly persist over an extended period of time. In some cases,
they eventually burn out and become amenable to hair restora-
tion, but in other situations, the process is never completely
extinguished and therefore may never allow the patient the pos-
sibility of surgical intervention. Examples in this category in- Figure 4-5 Discoid lupus erythematosus.
clude lichen planopilaris (Fig. 4-4), discoid lupus erythematosus
(Fig. 4-5), coup de sabre morphea (Fig. 4-6), sarcoidosis (Fig. 4-
7), necrobiosis lipoidica diabeticorum, and alopecia mucinosa.
Once again, an accurate diagnosis, which usually can be ob-
tained by biopsy of an active lesion, is essential before a surgical cess, random in its distribution. It is in the later stage of disease
plan can be contemplated. inactivity that patients often consult hair restoration surgeons.
Lichen planopilaris is one of the more common causes of Although this surgery can be undertaken, harvesting the donor
scarring alopecia and deserves special consideration. This idio- area may become technically demanding because the scarring
pathic inflammatory disorder often initially appears with ran- process can significantly affect the traditional donor fringe. Sur-
domly scattered inflammatory erythematous to violaceous and geons must often be quite selective in choosing one or more
pruritic papules, which can affect any part of the scalp (see Fig. donor sites. In addition, it may be necessary to partially excise
4-4). If treatment is initiated in the earliest stages, destruction scar tissue while harvesting donor hair to reduce the amount
of hair follicles can sometimes be prevented and the secondary of the occipital alopecia.
scarring alopecia may be avoided or minimized. However, in A condition referred to as frontal fibrosing alopecia has been
many cases, patients do not obtain a rapid diagnosis and treat- proposed as a variant of lichen planopilaris (11). This condition
ment. The destruction of hair follicles is, like the disease pro- affects predominantly the frontal hairline in postmenopausal
Figure 4-4 Lichen planopilaris with standard 4.0-mm test Figure 4-6 Coup de sabre morphea. (Reprinted with permission
grafts growing. from the American Academy of Dermatology. All rights reserved.)
white women (Fig. 4-8a), but, commonly, it also affects the

temporal areas as well as the eyebrows. The scarring is typically
subtle, without the more apparent sclerosis seen in classical
lichen planopilaris. The first case of this scarring alopecia oc-
curring in a man has recently been reported (12), and an addi-
tional case that caused the loss of previously transplanted frontal
hair in an elderly man has also been described (13) (Fig. 4-
8b,c). Furthermore, an entity referred to as fibrosing alopecia
in a pattern distribution may also represent a variant of the more
commonly recognized lichen planopilaris (14). In this condi-
tion, an inflammatory scarring alopecia develops within the cen-
tral scalp (Fig. 4-9). Currently, because so few cases have been
described, this condition cannot yet be accepted as a distinct
type of scarring alopecia (15).
Discoid lupus erythematosus (DLE) is the most common
cutaneous manifestation of lupus erythematosus. Its hallmarks
Figure 4-7 Sarcoidosis involving the temporal scalp. are erythema, scaling, follicular plugging, telangiectasia, and
atrophy (see Fig. 4-5). Although considered an autoimmune
disorder because of its tendency to produce scarring and its
b c
Figure 4-8 (a) Frontal fibrosing alopecia involving the frontal hairline, temporal area, and eyebrows. (Courtesy of Francisco Jimenez-
Acosta, M.D.) (b) Man, 63 years old, seen 18 years after grafting of frontal hairline. (c) At age 78 years, he is shown 3 years after the
onset of frontal hair loss caused by frontal fibrosing alopecia. (Courtesy of Richard Shiell, M.D.)
72 Chapter 4
Figure 4-9 Fibrosing alopecia in a pattern distribution. (Courtesy of Bernard P. Nusbaum, M.D.)
similarity to lichen planopilaris in the burned-out stage, it is purposes. First, they give both the surgeon and the patient the
being grouped in this section. Most commonly, DLE is present opportunity to see whether the disease will reactivate as a result
in the absence of systemic lupus erythematosus and so usually of surgical trauma. Second, they provide an opportunity to assess
occurs in otherwise healthy men and women. Although active the viability of the transplanted grafts within that particular scar.
lesions of DLE affecting the scalp generally do not present Third, this approach may enhance a centrally directed revascu-
much diagnostic difficulty and would unlikely be targeted for larization of the scar by incorporating more viable donor tissue
hair transplantation, patients with inactive or burned-out into the generally more avascular scar tissue. This in turn may
patches may be considered for surgical correction. enhance the potential for growth of hair transplanted at a later
Unlike infectious processes, which generally reach the date. It is important to note that reactivation of the inflammatory
burned-out stage relatively rapidly, many inflammatory disor- disorder should be looked for by the surgeon and patient not
ders may persist or be intermittent for months or even years just in the recipient area but in the donor area as well. The
before becoming inactive. When, then, is it safe to perform salient features of inflammation as described earlier should be
transplantation on patients who suffer from an inflammatory discussed with the patient, who should be directed to bring to
disorder of the scalp that has caused alopecia? Although there the attention of the transplant surgeon any signs of disease activ-
is certainly no precise answer, a general guideline of approxi- ity as soon as they occur. Rapid treatment—primarily with topi-
mately 1 year after the resolution of any active disease (most cal and/or intralesional corticosteroids such as triamcinolone
commonly characterized by redness, itching, scaling, or swell- acetonide cream 0.1% to be used two to three times per day
ing) can be considered a reasonable time frame. However, cir- and/or 3.33 mg/mL solutions injected every 3 to 4 weeks into
cumstances vary from case to case, which may justify a shorten- active lesions—provides the greatest potential for preventing
ing or lengthening of this time frame. permanent destruction of hair follicles in the area.
Once the decision is made to consider hair transplantation If it is possible to satisfactorily excise most or all of the
in this type of scarring alopecia, it is equally important for the areas of scar secondary to inflammatory and autoimmune dis-
physician to inform the patient that the inflammatory disorder ease, such a course eliminates the possibility that a recurrence
that caused the alopecia may become reactivated at any time of disease might destroy hair that has been transplanted into
in either the recipient or donor areas. This may result in loss the scar. Excision of a portion of a scarred area can also make
of the newly transplanted hair or previously unaffected scalp it small enough that it becomes cosmetically unimportant. Exci-
hair. Occasionally, the transplanting itself may cause reactiva- sion is therefore almost always preferable to transplanting under
tion of some of these disorders (e.g., lichen planopilaris). The the aforementioned conditions.
surgeon should then be prepared—either acting alone or in con-
cert with a dermatologist—to deal with the disease reactivation AUTOIMMUNE AND NEOPLASTIC DISORDERS
and attempt to minimize any further hair loss. Because of the
uncertainty with regard to the potential for reigniting the disease One of the most common hair loss disorders encountered in
process, I recommend that hair transplantation be undertaken dermatology is alopecia areata (AA). Typically, this appears
initially with a relatively small number of grafts implanted at the with coin-sized patches of alopecia, which can be scattered ran-
periphery of the area of scarring. These test grafts serve several domly on the scalp (Fig. 4-10) or on any hair-bearing part of
Figure 4-10 Alopecia areata with white hair growth Figure 4-11 Pilar (trichilemmal) cyst.
the body, including the beard. This recurring condition is most

often amenable to medical treatment, and the prognosis for com- and should not compromise growth of the transplanted hair. In
plete regrowth is excellent in most cases. Intralesional cortico- unusual situations where there is significant thinning of the skin
steroid injections are the most common and generally most ef- as a result of prolonged compression, it may be necessary to
fective treatment. In more severe cases, this type of hair loss de-epithelialize the grafts or possibly even tunnel the grafts
can rapidly affect the entire scalp (alopecia totalis), and in rare beneath the galea to allow them to be adequately implanted.
cases, the entire body (alopecia universalis). Because the areas of alopecia induced by cystic tumors are
On rare occasions, AA can be fairly stable and fixed in its generally small and often camouflaged by surrounding hair, the
distribution over an extended period of time and may be unre- surgeon can be afforded the option of using standard grafts to
sponsive to all forms of medical treatment. In such a case, one achieve greater density, if desired. Certainly, as is the case with
may consider hair transplantation within these patches of non- almost all other types of alopecia, micrografts or minigrafts
scarring alopecia. If there is any doubt about the diagnosis, pre- may also be selected in this situation.
operative assessment should include a scalp biopsy of any active Most other benign noncystic tumors of the scalp generally
area. The patient should also be advised that the newly trans- require excision, resulting in a surgical scar. This scar is gener-
planted hair is also subject to future hair loss as a result of a ally narrow, but in some cases, depending on the size of the
recurrence of the immunologic events responsible for AA. tumor, it can be quite wide and may be difficult to camouflage
by the surrounding hair. In these situations, hair transplantation
can yield good or excellent coverage.
BENIGN AND MALIGNANT GROWTHS
Pilar Cyst Other Benign Growths
A wide variety of benign and malignant tumors can affect the The most common benign tumors found on the scalp include
scalp and result in hair loss. Most common among the benign sebaceous and epidermal nevi (Fig. 4-12) and hemangiomas.
tumors of the scalp is the pilar (trichilemmal) cyst (Fig. 4-11). These are almost always initially encountered in children and
This cyst initially appears as a small elevation on any part of are often treated before adulthood. In the case of larger seba-
the hair-bearing scalp and may gradually increase in size over ceous and epidermal nevi, surgical excision often results in wide
time. As it grows, there is a compression effect on the overlying scars, which in some cases prompt parents to consult for hair
follicles that manifests itself clinically as thinning hair. At this transplantation on behalf of their child. Spontaneous involution
point, the hair loss and/or the tenderness or visibility of the or laser treatment of larger hemangiomas occasionally results
enlarging cyst often motivate the patient to have the cyst rein atrophic scars, showing complete alopecia. These areas of
moved. This is generally done by making a small incision over hair loss can often be managed by a combination of simple or
the central portion of the cyst and expressing the cyst lining serial surgical excision and hair transplantation.
and contents through the small opening.
Unfortunately, in some cases in which the cyst has been Malignant Tumors
present for many years, the hair does not return, and a perma-
nent, clinically nonscarring compression-induced alopecia re- The most common malignant neoplasms of the scalp include
sults. The skin in this area is sometimes of normal thickness, but basal and squamous cell carcinomas (Figs. 4-13 and 4-14).
in some cases, the skin may be thinned as a result of prolonged These are almost exclusively related to chronic sun damage on
compression from the underlying tumor. These patches of alo- a scalp that has often already lost the protective cover of hair
pecia can be managed surgically by excision, or hair transplan- as a result of heredity. Although these tumors once were seen
tation can be undertaken. In the absence of scarring. the vascu- almost exclusively in men or women older than 60 years of
larity and viability of the affected skin is essentially normal age, they are now being seen more frequently in much younger
74 Chapter 4
Figure 4-12 Sebaceous nevus. Figure 4-14 Actinic keratoses with squamous cell carcinoma
of the frontal scalp.
age groups. For this reason alone, it is important for hair trans-
on the age of the patient and the medical circumstances, x-ray
plant surgeons to be alert to the potential presence of these
treatment may also be used. Each of these therapeutic modalities
tumors—especially in individuals of Celtic heritage—or scar-
results in some degree of scarring and atrophy, and in some
ring resulting from their removal in the generally younger popu-
cases, telangiectasia may occur. In the more common situations
lation of men and women seeking hair transplantation surgery.
where surgical management is undertaken, hair transplantation
It also should be noted that the scalp is not infrequently a site
within the scar tissue is possible, although results may vary
of metastatic spread of a primary occult neoplasm (Fig. 4-15).
depending on the quality of the scar. The outcome may be
Accurate histopathological assessment of the excised tumor is
somewhat less predictable in x–ray treatment-induced areas of
essential to avoid inappropriate grafting into an area of scarring
scarring associated with greater dermal atrophy and telangiecta-
secondary to excision of a metastatic tumor.
sia (Fig. 4-16). In this situation, initial electrocautery or laser
The most common treatment for primary malignant tumors
ablation of the telangiectasia can be undertaken before surgical
is surgical, either by simple excision, curettage and desiccation,
correction of the alopecia is considered.
or Mohs micrographic surgery. In some situations, depending
Figure 4-15 Metastatic (lung) squamous cell carcinoma to the

Figure 4-13 Basal cell carcinoma in sideburn occipital scalp.
Figure 4-16 Basal cell carcinoma, x-ray-induced, at the frontal Figure 4-17 Traction alopecia secondary to chronic use of hair
hairline, with adjacent atrophy and telangectasia following x-ray curlers.
treatment of previous basal cell carcinoma at the same site.
icant frontal recession and sometimes frontotemporal thinning

TRAUMATIC ALOPECIA as a result of many years of intentional twisting of frontal scalp
hair, which was covered and contained by the turban (Fig. 4-
Traction Alopecia 18). This traction alopecia is also clinically of a nonscarring
One of the most common causes of hair loss triggered by physi- nature and can be corrected by hair transplantation. Because
cal injury to hair follicles is traction. Traction alopecia is usually the hair loss is usually limited to a relatively small (usually 5
seen in young women who tightly braid their hair for reasons cm or less) fringe, the use of one to three hair micrografts is
related to cultural traditions or hair styling preferences. It most preferred for this critical frontal hairline. It is noteworthy that
commonly involves the frontal area, although it can extend into a family history of hereditary thinning cannot be accurately
the temporal regions as well (Fig. 4-17). Over a period of several documented in many young men whose relatives wear turbans
years, traction results in the death of hair follicles and an in- because they are unable to recognize hereditary thinning in their
crease in interfollicular spacing. In addition, tightly pulling back relatives.
the frontal hair over an extended period of time, even in the
absence of braiding, will result in progressive recession of the
frontal hairline. In some cases, the recession is severe enough
that a woman so affected will have the hairline of a man with
advancing male pattern hair loss. Without a proper history and
awareness of this type of hair loss, the clinical presentation
might be misinterpreted as an unusual male pattern of hair loss,
or even as a case of frontal fibrosing alopecia. Although there
is essentially no chance of regrowth of the hair lost years after
the traction alopecia occurred, appropriate recommendations to
these young women can prevent further hair loss for themselves
and may, through education, eliminate this type of acquired hair
loss in their children. Hair transplantation can be very successful
in lowering the receded frontal hairline to a position that is
appropriate for a normal female. Furthermore, in less severe
cases without frontal recession, micrografting can easily and
rapidly reestablish an appropriate frontal hairline density in
areas of interfollicular thinning caused by braiding or traction.
One particular type of traction alopecia that I have encoun-
tered is secondary to the use of turbans. Men who decide to Figure 4-18 Turban-induced traction alopecia of frontal and
abandon the use of traditional religious turbans may note signif- temporal hairlines.
76 Chapter 4
Physical Injury A variant of classical trichotillomania is the isolated patch

of alopecia resulting from stress-induced repetitive habitual rub-
A multitude of physical injuries can result in hair loss. These bing of a particular area on the scalp. In these cases, there is
range from work-related or other accidental causes resulting in complete loss of all hair within the patch, without evidence
permanent patchy alopecia as a result of hair follicle destruction of breakage or peripheral exclamation mark hairs (Fig. 4-20).
to the most severe injuries, which can result in complete scalp However, the skin is thickened or lichenified (lichen simplex
avulsion. In less severe cases, although there may be histologi- chronicus) as a result of habitual rubbing, and, in some cases,
cal evidence of scarring, there is often little atrophy clinically, small alopecic plaques or nodules (‘‘picker’s nodule,’’ or pru-
and these patches of alopecia can be successfully transplanted. rigo nodularis) may result. These changes can simulate local
An exception would be patients with severe chemical or thermal inflammation, infection, or a tumor. Such areas of lichen sim-
burn injury that results in significant atrophy or contracture in plex chronicus and prurigo nodularis can often be effectively
the area of alopecia. Here again, proper selection and prepara- treated by appropriate counseling and intralesional corticoste-
tion of grafts is critical to potential graft survival (see Chapter roid therapy such as triamcinolone acetonide 5 to 10 mg/mL
11). However, it should be noted that a small number of severely to thin the lichenified or nodular skin changes and reduce or
damaged scalps, with particularly thin scars or very poor donor- eliminate the itching that helps to drive the habitual rubbing of
to-recipient area ratios, might not be successfully transplanted. the affected skin. The prognosis for recovery in these cases is
If the benefits of grafting are in doubt, the use of test grafting generally better than that in the classical cases of trichotillo-
is recommended. Furthermore, in some circumstances, the use mania. However, in some situations, hair regrowth may not
of alopecia reduction, with or without scalp expansion or exten- occur if there is permanent damage to the underlying hair folli-
sion (see Chapters 20 and 21), may be beneficial in reducing cle as a result of chronic inflammation and secondary fibrosis.
the size of the area of alopecia, with or without subsequent
grafting. Radiation
Radiation of the scalp for the treatment of cutaneous neoplasms
Trichotillomania (see Fig. 4-16) or brain tumors can result in permanent hair
One special disorder worthy of discussion is trichotillomania. loss. Depending on the size of the alopecia that results, as well
as upon the thickness and general integrity of the skin, hair
This intentional plucking or breakage of hair can be encountered
transplantation alone or in combination with alopecia reduction,
in both children and adults and is indicative of significant psy-
with or without tissue expansion, may be an appropriate thera-
chological problems. Trichotillomania usually appears with ir-
peutic option. Temporary solitary patch radiation-induced alo-
regular patches of hair loss, but close examination reveals nu-
pecia may occur approximately 2 weeks after neuroradio-
merous broken-off short hairs of variable length (Fig. 4-19). In
logically guided endovascular embolization of cerebral arteries,
some cases, confusion with AA may occur, especially where
with hair growth occurring approximately 3 to 4 months later
there is convincing denial on the patient’s part. The irregular (16). This should not be confused with alopecia areata or perma-
shape of the patches, the absence of the typical peripheral ‘‘ex- nent scarring alopecia of different origins.
clamation mark hairs’’ often seen in AA, and a skin biopsy
at the border of an expanding area of hair loss are helpful in
IDIOPATHIC SCARRING ALOPECIA
distinguishing the two conditions. The presence of classical tri-
chotillomania is a contraindication to hair transplantation. Pa- Pseudopelade of Brocq
tients with this type of hair loss should be referred for psycho-
logical assessment and treatment. Pseudopelade of Brocq remains a poorly defined clinical condi-
tion associated with a scarring alopecia. Classical descriptions
Figure 4-19 Trichotillomania. (Courtesy of Edwin S. Epstein, Figure 4-20 Inflammatory prurigo nodularis with secondary
M.D.) alopecia.
refer to irregular patches of cicatricial alopecia appearing like and acquired alopecia areata (AA). Unlike AA, which as noted
‘‘footprints in the snow’’ (Fig. 4-21). For some clinicians, this earlier should only rarely be transplanted, congenital circum-
entity may represent the end-stage of a variety of more specific scribed alopecia is usually amenable to hair restoration surgery.
causes of hair loss, such as lichen planopilaris and discoid lupus This category includes triangular alopecia as well as the very
erythematosus. For others, it may be a more specific condition rare aplasia cutis congenita.
in which scarring alopecia appears without apparent previous
inflammation. Triangular Alopecia
Central Centrifugal Scarring Alopecia Triangular alopecia is a relatively uncommon condition that is
generally detected early in childhood. It usually appears at or
Within the broad category of what has been referred to as central near the frontotemporal triangle; the often triangular base di-
centrifugal scarring alopecia, a variety of descriptive entities rected anteriorly (Fig. 4-22). In some cases, the patch may be
have been grouped because they appear to share clinical and oval rather than triangular. The affected area may be completely
histological features as well as a similar natural course of pro- alopecic or may retain fine hair. In these cases, the skin appears
gression (15). They include follicular degeneration syndrome, normal, without evidence of atrophy. Hair transplantation can
pseudopelade, folliculitis decalvans (see Fig. 4-2) and tufted readily be undertaken to correct triangular alopecia, and excel-
folliculitis (see Fig. 4-3) (see discussion earlier in this chapter lent cosmetic results can be achieved.
in the ‘‘Infectious Diseases’’ section). As can be seen from the
preceding discussion, a variety of names have been introduced Aplasia Cutis Congenita
in recent years to describe what may be distinct or perhaps
interconnected scarring disorders affecting the scalp. Although Aplasia cutis congenita presents at birth with ulcerations that
detailed descriptions of these disorders are beyond the scope are usually located on the vertex. These heal, producing atrophic
of this review, recognition of the existence of these types of or occasionally hypertrophic scars (Fig. 4-23). Typically, the
primary scarring alopecia should be part of the knowledge base scars have a circular or irregular shape. Depending on the nature
of physicians caring for patients with hair loss because all of of the scar tissue, hair transplantation may be considerably more
them are chronically intermittent with implications that have challenging and produce less than ideal cosmetic results. Exci-
already been discussed. Rapid referral to a dermatologist experi- sion of the patch of alopecia with or without subsequent grafting
enced in these disorders is part of complete care, which may into the surgical scar may be preferable (17).
ultimately include surgical hair restoration.
Ehlers-Danlos Syndrome
UNCOMMON CAUSES OF ALOPECIA AND Some experienced hair transplant surgeons have described
SPECIAL CONSIDERATIONS inexplicable wide scarring in the donor area and have wondered
There are several congenital patchy hair loss disorders that whether this type of scarring might be a manifestation of a
should be recognized to avoid confusion with the more common minor form of the Ehlers-Danlos syndrome (18). Although
many subgroups have been categorized within this syndrome
based on genetic, biochemical, and clinical characteristics, the
major clinical features include skin fragility and a propensity
Figure 4-22 Triangular alopecia near anterior temporal hair-

Figure 4-21 Pseudopelade of Brocq. line. (Courtesy of Richard C. Shiell, M.D.)
78 Chapter 4
Figure 4-24 Psoriasis at frontotemporal recession.
psoriasis resulted in rapid control without compromise to the

recently transplanted hair.
Figure 4-23 Aplasia cutis congenita with extensive hypertro-
phic scarring.
DIAGNOSIS
When the hair transplant surgeon is faced with a patient who
is concerned about hair loss unrelated to androgenetic alopecia,
a thorough history and general review of systems should be
to bruising, skin hyperextensibility, joint hypermobility, a sus- undertaken. In cases of active shedding, a hair-pull test done
ceptibility to osteoarthritis, and the formation of wide ‘‘fish by the physician to assess the significance of the telogen hair
mouth’’ and thin ‘‘cigarette paperlike’’ scars. It has been sug- loss as well as a hair count performed at home by the patient
gested that the definition of Ehlers-Danlos syndrome should can be done to estimate the severity of the hair loss. As a general
include at least findings involving both skin and joints (19). For rule, it is considered within normal limits to shed up to 100
this reason, it is this author’s opinion that the simple presence of hairs daily. A drug history is important because numerous medi-
a wider than usual scar in the donor area should prompt the cations may cause increased hair shedding, and in some cases,
surgeon to look for another explanation for this outcome. Wide may be partially or totally responsible for the hair loss observed
scars might more readily be explained on the basis of the width (Table 4-2). This drug-induced hair loss can occur as a result
of donor tissue removed, the donor site selected, the tension on of telogen effluvium (see discussion earlier in this chapter in
the wound closure, prior surgical harvesting at that site, and the ‘‘Metabolic Disorders’’ section) or as a result of anagen
individual factors including excessive physical activity in the effluvium. Anagen effluvium occurs when cell division in the
postoperative period with increased tension on the wound site, rapidly dividing hair matrix cells is abruptly halted. This anagen
as well as perhaps a personal predisposition to poor healing. shedding of constricted and broken hairs typically occurs rap-
idly (days to weeks) after exposure to antineoplastic agents, but
regrowth occurs more rapidly with cessation of the offending
Psoriasis drugs. The hair follicles resume growth without passage through
the resting, or telogen, phase of the hair cycle.
Although psoriasis frequently affects the scalp, permanent hair More uncommonly, hair shaft abnormalities with structural
loss can only rarely be attributed to this disease. On the other defects may be responsible for broken-off hairs. Microscopic
hand, reactivation of psoriasis in remission or new onset pso- evaluation of the hair shaft can generally provide a rapid diagno-
riasis can sometimes occur after hair transplantation. Recogni- sis in these cases. As indicated earlier, when there is a reasona-
tion of this generally chronic inflammatory disorder is important ble index of suspicion based on the history and clinical presen-
because its appropriate treatment usually results in rapid control tation, appropriate blood testing for iron deficiency, thyroid
(Fig. 4-24). Although psoriasis does not often present much disorder, other endocrine diseases, or lupus erythematosus
diagnostic difficulty for those who encounter it regularly, should be undertaken (Table 4-3). In addition, cultures for fun-
awareness of this ‘‘complication’’ of hair transplantation is im- gus or bacteria should be performed when indicated.
portant so that such treatment can be instituted. I have seen a In the presence of a scarring alopecia, it is of primary impor-
patient who developed psoriasis within the transplanted area. tance to establish a correct diagnosis. In some situations, the
He had been misdiagnosed as having a chronic scalp infection scalp disease may appear inactive and this may deceive the
after the surgery, and had already been subjected to several surgeon who may then attempt hair restoration. As noted earlier,
months of oral antibiotics. Appropriate treatment of his scalp there are circumstances in which surgery may, in fact, reactivate
Table 4–2a Drugs Associated with Hair Loss only be undertaken if one is thoroughly familiar with the natural
course of the disease as well as with the medical treatment
Anticoagulants (e.g., heparin, warfarin)
Anticonvulsants (e.g., carbamazepine, valproic acid) options. When properly timed and coordinated with medical
Antifungals (e.g., ketoconazole, terbinafine) treatment, surgical intervention can be complementary.
Anti-gout agents (e.g., allopurinol, colchicine)
Antineoplastic/immunosuppressant agents (e.g., cyclophos-
REFERENCES
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Antipsychotics and antidepressants (e.g., fluoxetine, lithium) Hair Loss Unrelated to Androgenetic Alopecia
Beta-blockers (e.g., atenolol, propranolol)
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‘‘burned out’’, because many types of scarring alopecia may ding in middle-aged women. J Am Acad Dermatol 1996; 35:
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adequate. Care should be taken to avoid rough handling of the ing alopecia: a frontal variant of lichen planopilaris. J Am Acad
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13. Shiell R, Kossard S. In press and personal communication from
time and locations are at new and active borders of the area of Dr. Shiell.
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further specific investigations.
5
Basic Principles and Organization
5A. PLANNING AND Process of graft production (i.e. cut ‘‘to size’’ vs. deliber-
ately cut to contain a specific ‘‘number of hairs or follicular
ORGANIZATION OF THE units’’)
RECIPIENT AREA
The reality of the situation is that, all too often, a great deal
Walter P. Unger and Michael L. Beehner of inconsistency and lack of specificity exists when grafts are
described in the literature or at conferences. Frequently, all that
This section, written primarily by Walter Unger and Michael is stated is that ‘‘micrografts’’ or ‘‘minigrafts’’ are used. This
Beehner, essentially represents the views held by both authors. lack of specificity has, in our opinion, contributed to some of
No two individuals have the same opinions on all matters, how- the confusion that exists when trying to compare the variety of
ever, and differing opinions are noted in the text. The sources different techniques that have developed over the years.
of photographs and schematic drawings from the files of both A generally agreed upon graft terminology would greatly
authors are similarly identified by initials in brackets at the end simplify communication between physicians and help eliminate
of the legends beneath them. Ron Shapiro elaborates on our some of this confusion. A classification system should separate
mutual views regarding the location and construction of the grafts into groups that share common properties of clinical
hairline zone in Chapter 12. In order to avoid too much repeti- significance, i.e., that could influence results. It should be sim-
tion in this text, we provide a somewhat less detailed overview
ple enough to be functional yet complete enough to be useful
of these subjects here. We recommend reading Shapiro’s com-
by being inclusive of the grafts commonly used today.
ments in Chapter 12 immediately after completing this chapter.
Table 5A-1 proposes a graft classification system that we
feel fits these requirements. It builds on past terminology but
is more specific with respect to the shape (cut to fit a slit, slot,
GRAFT TERMINOLOGY
or round punch) and number of hairs (or follicular units) of the
Ron Shapiro and Walter P. Unger grafts. It also acknowledges, to some degree, whether grafts are
cut ‘‘to size’’ or deliberately cut to contain a specific ‘‘number
When hair restoration surgery (HRS) was first popularized by of hairs or follicular units’’.
Orentreich, the primary graft used was the ‘‘standard’’ 4-mm When changes occur as rapidly as they have in the field of
round punch graft. However, over the past 10 years we have HRS, it is difficult to create a classification system that is per-
seen the introduction of much more diversity with respect to fect, all-inclusive or will satisfy everyone. However, we feel
the size and shape of grafts, as well as the techniques used to the system proposed in this text is functional and reflects most
create and insert these grafts. Grafts used today vary signifi- of the grafts currently being used today. This classification sys-
cantly and can be described with respect to a number of different tem and the various groups within it are discussed in more detail
variables including: below.
Number of hairs per graft
Number of follicular units per graft Grafts Cut ‘‘To Size’’ vs. the ‘‘Number of Hairs’’
Graft shape (linear, rectangular, round, chubby, skinny)
Size and type of the recipient site used (i.e. needle, slit, slot The terms cut ‘‘to size’’ or cut to the ‘‘number of hairs’’ have
or punch incisions). Although, technically, this variable been used to describe two broad populations of grafts. We feel
refers to the recipient site and not the graft, in actual prac- it is important to acknowledge this distinction because of differ-
tice, grafts are often referred to in this manner ences between them that could influence results.
81
82 Chapter 5
Table 5A–1 Graft Terminology
Recipient
Graft type Hairs FUs site Cut “to size” or cut to “number of hairs”
MICROGRAFTS
Micrograft(a) 1–4 1 or less Needle/ Cut to number of hairs(a)
—(General Term) Micro-slit
Follicular Unit (FU)(a) 1–4 1 Needle/ Cut to number of hairs(a)
—(Specific Term) Micro-slit
Follicular Family (FF)(b) 5–6 2 Needle/ Cut to number of hairs(a)
Micro-slit
MULTI-FU GRAFTS
MICRO-SLIT GRAFTS(c)
Double FU (DFU) 3–5 2 Slit Cut to number of FUs
Triple FU (TFU) 5–8 3 ⬙ ⬙
Quadruple FU (QFU) 6–12 4 ⬙ ⬙
TRADITIONAL SLIT GRAFTS(c)
Small Slit Graft 3–5 ⬃2 Slit Cut to size
Medium Slit Graft 5–8 ⬃3 ⬙ ⬙
Large Slit Graft 6–12 ⬃4 ⬙ ⬙
SLOT GRAFTS(d)
Small Slot Graft 6–8 ⬃4 Slot Cut to size
Medium Slot Graft 8–12 ⬃6 ⬙ ⬙
Large Slot Graft 10–16⫹ ⬃8 ⬙ ⬙
ROUND GRAFTS(e)
Small Round Graft 5–8 2–3 Punch Cut to size
Medium Round Graft 8–14 4–5 ⬙ ⬙
Large Round Graft 14–30⫹ 5–12⫹ ⬙ ⬙
(Includes “Standard”
Punch Grafts)
a Micrograft is a general term and refers to either an intact FU or part of an FU (created when hairs are vertically split-off from an intact FU). The term FU
graft is more specific and refers to an intact FU. Most of the time, micrografts (whether they are intact FUs or part of an FU) are delibertaely cut to contain
a specific “number of hairs”. An exception occurs when micrografts are cut “to size” by an automatic graft cutter.* This device produces standardized grafts
that are all 1 mm ⫻ 1 mm in size. These micrografts deemed cut “to size”, contain an average of 1 to 3 hairs, and can consist of either intact or partial FUs.
b Follicular Family (FF) grafts consist of two individual FUs that are spaced so close together that it is difficult to tell if they are two separate FUs or a single
FU with a greater number of hairs. The distance between FUs in a follicular family is estimated to be ⬃ 0.2 mm or less. FFs are similar to FU grafts in that
they are deliberately cut to the number of hairs and fit into similar sized needle or micro-slit incisions as those used for 4-hair FUs.
c Slit grafts are cut thin and flat to fit into slit incisions. Ideally, they should be one FU wide with the hairs (or FUs) lined up one behind the other. Traditional
slit grafts are cut “to size” and designated as small, medium, or large, based on the average number of hairs (or FUs) they contain. The average distance be-
tween FUs in a traditional slit graft is ⬃ 1mm. A micro-slit graft, on the other hand, refers to an increasingly popular type of slit graft that is cut with mag-
nification to deliberately contain an exact number of intact FUs. By “cherry picking” the more closely approximated FUs, it is possible to create a popula-
tion of micro-slit grafts that are smaller than traditinal slit grafts with equivalent number of hairs. The distance between FUs in micro-slit grafts can range
from 0.5 mm to 1mm.
d Slot grafts are cut “to size” in order to fit the shape of a slot incision. They are typically rectangular in shape and approximately two FUs wide. To prevent
compression, slot grafts require the removal of tissue with a “slot punch”.
e Round grafts are cut “to size” in order to fit into round recipient sites created with “punches”. However, since most of these grafts are currently created
from strips of donor tissue, they are more square-shaped than round. From a practical standpoint, large round grafts are seldom used any more. The origi-
nal “standard” 4-mm punch graft is a member of the large round graft group. Although it has been called a “standard” graft for many years, and becaue it is
so rarely used today, this is now a misnomer.
Note: Micro-slit grafting denotes the use of DFU, TFU, or QFU; slit grafting denotes the use of the older type of cut-to-size slit grafts; minigrafting denotes
the use of slot and/or small to medium round grafts. The above definitions describe what is meant by the terms used in this text. Many practitioners using the
same terms may mean different things. If the terminology described here is generally adopted, communication between different practitioners will be greatly
clarified and simplified.
*See Chapter 11D.
Basic Principles and Organization 83
Cutting Grafts ‘‘To Size’’ Recently, the term chubby vs. skinny has been applied to FU
grafts. In the early years of total Follicular Unit Transplantation
Refers to the process where a physician instructs his assistants (FUT), grafts were often made skinny and extensively trimmed
to cut a population of specific sizes and shaped grafts he/she of as much epithelium and extra tissue, as possible. This exten-
believes contains on average a desired number of hairs (or fol- sive trimming created very tiny fragile grafts with unprotected
licular units). The average number of hairs (or follicular units) hair shafts that were potentially more susceptible to graft trauma
contained by a selected size graft will vary depending on the and especially dehydration. In addition, unseen telogen follicles
density of hair in the donor area. When cutting grafts ‘‘to size’’, were at risk of being discarded in this process. This may have
a physician has to factor in the donor hair density and adjust contributed to some of the poor densities seen with early total
the size of the graft to ensure it will contain the ‘‘average’’ FUT. A modification in the technique has been the preparation
number of hairs (or follicular units) desired. Grafts cut ‘‘to of chubby or pear-shaped FU grafts, which still includes trim-
size’’ may contain, within them, both whole and partial follicu- ming away of excess epithelium but leaves more tissue around
lar units. Examples of grafts typically cut ‘‘to size’’ include the inferior and mid-portion of the graft. We believe the term
most (but not all) of the multi-FU grafts created to fit a slit, chubby is a misnomer, as these grafts are still smaller than FU
slot, or punch site. grafts with equivalent amounts of hair where deliberate shaping
and trimming of the graft does not occur. However, they defi-
Cutting Grafts to the ‘‘Number of Hairs’’ nitely contain more tissue than the older stripped or skinny FU
grafts.
Refers to the process where the physician instructs his assis- The question is often asked, ‘‘What is the difference between
tants, preferably with the aide of magnification, to locate, isolate a micrograft and an FU graft?’’ To some degree it is a matter
and dissect a population of grafts that contain an exact number of semantics. The term ‘‘micrograft’’ is a more general term
of hairs or intact follicular units. Examples of grafts cut to ‘‘the and can refer to a graft that contains either a single intact
‘‘number of hairs’’ include follicular unit grafts and generic 1- follicular unit or part of a follicular unit (created when hairs
to 2-hair micrografts split off from larger grafts. are vertically split off from an intact follicular unit). On the
Ongoing arguments exist about the clinical differences be- other hand, the term FU graft is more precise and specifically
tween grafts cut by one of these two methods. Some of the refers to a graft that contains a single intact follicular unit.
controversial questions include, ‘‘Are grafts cut to the ‘‘number On a small scale there may be no clinical difference in the
of hairs’’ more vulnerable to the effects of transection and waste survival rate or aesthetic appearance of an individual 1 or 2-
than grafts cut ‘‘to size?’’, ‘‘How necessary is microscopic hair intact FU graft when compared to an individual 1 or 2-
magnification when cutting follicular unit grafts to the ‘‘number hair micrograft split off from an intact follicular unit. However,
of hairs?’’ Unless an attempt is made to at least distinguish on a larger scale when greater numbers of micrografts are de-
between these two methods of graft production, these and other sired, creating grafts as intact follicular units may take on clini-
controversial questions will not be answered. These issues are cal significance for reasons discussed in more detail in Chapters
discussed in greater detail in Chapter 11C. 11 and 12.
Another point should be mentioned for the sake of complete-
ness. Micrografts are usually cut to the ‘‘number of hairs’’ and
MICROGRAFTS not ‘‘to size’’. An exception occurs when micrografts are cut
‘‘to size’’ by an automatic graft cutter. (See Chapter 11D.)
From a historical perspective, the first micrografts originally This device converts a 1mm wide strip of donor tissue into a
referred to the 1- and 2-hair grafts trimmed away from larger standardized population of grafts that are all 1 mm x 1 mm in
grafts for use at the hairline. Sometimes these 1- or 2-hair grafts size. These micrografts contain an average of 1 to 3 hairs, and
were intact follicular units and other times they were part of a can consist of either an intact or partial follicular unit. Physi-
follicular unit (created when the hairs were vertically split off cians should specify if they are using micrografts created from
from an intact follicular unit). Little attention was paid to keep- an automatic graft cutter.
ing follicular units intact. Two other terms being used more frequently today should
be mentioned and defined. These are the terms Follicular Fam-
Follicular Unit Grafts (FU grafts or FUs) ily graft and Follicular Pairing.
With the observation that hair seems to cluster together in natu- Follicular Family Grafts (FFs)
ral groupings of 1 to 4 hairs, came the practice of creating
micrografts that kept these natural groupings together. These The follicular family graft has been described by Seager and
have been called FU grafts or FUs. Recently, there has been also by Tykocinski who called it a ‘‘follicular grouping’’.
some controversy over whether it is proper to call these grafts (Chapter 16B). They are the same entity and we prefer the term
‘‘FUs’’ because the true histological definition of a follicular follicular family. Naturally grouped follicular units in the donor
unit, described by Headington, was based on anatomy at the area are on average spaced approximately 1 mm apart (ranging
mid-dermis level of the follicle. However, in the field of HRS, from 0.2 mm to 1.2 mm) and it is usually fairly obvious, on
it is generally accepted that the term FU grafts refers to a graft casual observation, that each follicular unit is an individual
that has kept intact the natural groupings of hair as seen on the entity. FFs on the other hand, consist of two individual follicular
surface of the scalp. It is a functional term and we feel it should units that are spaced so close together (⬃.2 mm or less) that
continue to be used because it describes what is actually being they appear to potentially be a single unit. From a practical
used. standpoint, an assistant cutting grafts often has trouble being
84 Chapter 5
sure if the entity consists of two separate follicular units or a gradually lost its specificity and usefulness. For example, a
single unit with a greater number of hairs. (See Chapter 16B minigraft could refer to a small slit graft containing as little as
Fig. 3). three to five hairs, a slot graft containing from six to ten hairs,
Tykocinski estimates that approximately 14% of the follicu- or a round graft containing as many as 10-15 hairs. It should be
lar units in a normal donor scalp may be close enough together obvious that these various types of grafts have different clinical
to be considered a follicular family. However, the percentage properties that could influence results. Clearly, there has been
of follicular units that qualify as being FFs can vary depending a need to be more specific when referring to this diverse popula-
on how strictly one adheres to the distance used to define the tion of grafts that contain more than one follicular unit.
proximity of the two individual follicular units that compose
an FF. Since the decision is made by ‘‘eye-balling’’ and not Proposed Terminology
by strict measurement, there is some subjectivity associated
with this decision. When we are strict and use the definition We propose using the term Multi-Follicular Unit (Multi-FU or
described above (⬃.2mm or less), we find that our estimate MFU) grafts, (instead of the term minigraft), to refer to the
differs from Tykocinski’s and only 5% to 10% of the follicular diverse population of grafts that contain more than one follicular
units qualify as being FFs. unit (excepting follicular families for reasons explained earlier).
Although FFs can often contain 5-6 hairs, they often share This heterogeneous population of Multi-FU grafts is further
many similarities with larger 4-hair FU grafts (i.e. they are sub-classified with respect to their shape (whether they are cre-
similar in anatomical size, will fit into similar size micro-slits, ated to fit a slit, slot or round incision) and whether they are
and can be placed at similar densities). We have placed FFs in small, medium, or large (based on the average numbers of hairs
the category of micrografts rather than the category of multi- or follicular units they contain).
FU grafts due to these similarities Most Multi-FU grafts are cut ‘‘to size’’ and therefore may
contain both complete and partial follicular units. However an
exception exists with respect to slit grafts, where a further dis-
Follicular Unit (FU) Pairing tinction is made between traditional slit grafts which are cut
Some physicians have described the practice of placing two ‘‘to size’’ and an increasingly popular trend of cutting smaller
intact FU grafts into a single linear incision. Shapiro has called ‘‘micro-slit’’ grafts with magnification to contain a specific
this process ‘‘FU pairing’’ (see Chapter 12D) and Harris has number of intact follicular units.
called it ‘‘Recombinant FU grafting’’. (See Chapter 12E). With
‘‘Traditional’’ Slit Grafts
this technique, a 2-hair graft can be artificially created by com-
bining a pair of 1-hair FUs; a 3-hair graft can be created by These grafts have customarily been cut ‘‘to size’’. They are cut
combining a 1- and 2-hair FU; a 4-hair graft can be created by thin and flat in order to fit into slit incisions. Ideally, they should
combining a pair of 2-hair FUs. The minimal tissue and small be one follicular unit wide with the hairs (or follicular units)
size of FU grafts allows for the process of FU pairing. This lined up one behind the other, thus decreasing the potential for
technique initially arose in situations where more 1-hair FU lateral hair compression and the need for removal of recipient
grafts were created than needed, while at the same time, it was area tissue. Traditional slit grafts are designated as either small,
preferable to have a greater number of 2- to 3-hair FU grafts medium or large, based on the average numbers of hairs or
in selected areas where higher density is desired. Over time, the follicular units they usually contain:
technique has developed into a deliberate method of increasing ● Small slit grafts - 3–5 hairs or ⬃2 follicular units.
density. ● Medium slit grafts - 5–8 hairs or ⬃3 follicular units.
● Large slit grafts - 6–12 hairs or ⬃4Ⳮ follicular units.
MULTI-FU GRAFTS (MFUs) (FORMERLY One property of slit grafts cut ‘‘to size’’ is that the average
CALLED MINIGRAFTS) distance between the individual follicular units within the graft
will be a function of the hair density of the donor tissue. In
History of the Term ‘‘Minigraft’’
patients with normal donor hair density, this inter-graft follicu-
From a historical perspective the term minigraft originally re- lar distance will average about 1 mm (with some being higher
ferred to grafts that were created from standard grafts by either and some being lower). The most common traditional slit grafts
splitting them in half (split grafts) or quarters (quartered grafts). used today are small slit grafts and medium slit grafts with very
With the onset of using a slit-recipient site, the term slit graft few physicians using large slit grafts.
arose to initially refer to split and quartered grafts when they
were placed into slit incisions. Micro-Slit Grafts
Later, with the introduction of strip harvesting came the abil- Recently, with the increased use of microscopic or other forms
ity to produce a much greater variety of smaller grafts with of magnification, there has been a trend toward cutting slit grafts
different shapes and sizes. Some were cut thin and flat to fit that deliberately contain a specific number of intact follicular
slit incisions, others more square-shaped to fit round recipient units rather than ’’to size’’. When slit grafts are created in this
sites created by small punches, while still others more rectangu- manner, instructions can be given to search for and ‘‘cherry
lar-shaped to fit slot-shaped recipient sites. pick’’ the more closely approximated pairs of follicular units
Although these new grafts were very heterogeneous with (i.e. those that have an inter-follicular distance ranging from 0.5
respect to their size, shape, and number of hairs, they all contin- mm to 1 mm. This, in turn, allows the creation of a population
ued to be lumped together under the single category of ‘‘mini- of slit grafts that are smaller than traditional slit grafts with
grafts’’. As a result, the term ‘‘minigraft’’ and ‘‘minigrafting’’ equivalent numbers of hairs and for this reason we call them
‘‘micro-slit’’ grafts. Micro-slit grafts are designated as Double ● Small round grafts - are defined as containing from 5-
Follicular Units (DFUs), which contain two intact FUs, Triple 8 hairs (⬃2 to 3 follicular units) and typically fit into a
Follicular Units (TFUs), which contain three intact FUs, and round recipient site created by a 1.5 mm in diameter
Quadruple Follicular Units (QFUs), which contain four intact punch.
FUs. ● Medium round grafts - are defined as containing from
The most popular micro-slit graft used today is the DFU. In 8-14 hairs (⬃4 to 5 follicular units). They generally fit
this text, unless otherwise specified, the term slit graft will refer into a round recipient site made with a 2 mm diameter
to traditional slit grafts cut ‘‘to size’’ and the term micro-slit punch. In our experience, it is not unusual for patients
grafts will refer to the population of smaller slit-grafts deliber- with higher than average donor hair density to contain
ately cut with magnification to contain a ‘‘specific number of 12-14 hairs per 2 mm2 graft.
follicular units’’. ● Large round grafts - are arbitrarily defined as contain-
ing from 15 to 30 hairs (⬃5–12Ⳮ follicular units) and
Slot Grafts require a punch recipient site greater than 2 mm in diam-
eter (ranging from 2.5 mm to 4 mm in diameter). The
Slot grafts are usually cut to size and ideally should be two original standard 4 mm punch graft fits into this group
follicular units wide and rectangular in shape to fit slot-shaped of a large round punch graft.
incisions. Slot grafts are wider and contain more epithelium
than slit grafts and therefore have a greater potential for From a practical standpoint, large punch grafts are seldom used
compression of adjacently situated follicular units. However, anymore. Small and medium punch grafts are still used by some
the removal of recipient tissue with a slot punch creates an physicians in select patients with the intent to create higher
incision that matches the shape and size of the graft and elim- localized density. For the sake of completeness, it should be
inates this potential for compression. The most common slot mentioned that smaller punches are also available; they range
punches manufactured and used today are the Redfield (Hitzig) from .75 mm to 1.25 mm in diameter and these have been used
slot punches, which come in 2.5 mm, 3.8 mm, and 4.8 mm for micrografts in the past but are also seldom used today.
lengths. We therefore divide slots grafts like other multi-FU
grafts into small, medium and large as follows: GRAFT TERMINOLOGY SUMMARY
● Small slot grafts - 2.5 mm in length and 5-8 hairs or It is interesting to note that when one talks about grafts contain-
⬃4 follicular units) ing from 4-6 hairs they could be referring to an FU graft, an
● Medium slot grafts - 3.85 mm length and 8-12 hairs or FF graft, a DFU micro slit graft, or a traditional small slit graft
⬃6 follicular units cut ‘‘to size’’. Although each of these grafts may contain similar
● Large slot grafts - 4.1 mm length and 10 to 16+ hairs numbers of hairs, they differ in respect to their anatomic size.
or ⬃8 follicular units. This, in turn, bestows different clinical characteristics with re-
spect to the size of the incision used and how close they can
From a practical standpoint, the most commonly used slot grafts safely be placed in a single session. This is one reason why we
today are medium and small slot grafts with very few physicians cannot use graft terminology that is only based on the number
using large slot grafts. of hairs per graft.
In a similar fashion, we cannot simply refer to grafts by their
Round Grafts anatomical size because variations in donor hair density will
create significant differences in the actual amount of hair var-
The original round graft was the large ‘‘standard’’ punch graft ious sized grafts contain. Just saying ‘‘micrograft’’ and ‘‘mini-
first described and popularized by Orentreich. These grafts were graft’’ is obviously not specific enough. The graft terminology
harvested with a round punch (3.5 mm to 4.0 mm in diameter), system proposed here is built on accepted past terminology yet
contained from 15 to 30 hairs (depending on donor hair density), more specific with respect to size and shape of the grafts. It
and were placed into slightly smaller round punch recipient reflects what is commonly being used today and, if used, will
sites (3.25 mm to 4.0 mm in diameter) While they have been help us better evaluate different techniques.
called "standard" grafts for many years, because they are so When discussing degrees of androgenetic alopecia (AGA)
rarely used today, this is now a misnomer. or male pattern baldness (MPB), we use the nomenclature for
With the onset of strip harvesting came the ability to create men as described by Norwood. For women, the nomenclatures
smaller round grafts that could fit into round recipient sites is that of Norwood and Ludwig. Descriptions and schematic
made with smaller trephines or punches. Because these grafts drawings of the various types of AGA and MPB can be found
were created from strips of donor tissue (rather than being har- in Chapter 3.
vested with a round punch), they were actually more square- The nomenclature for the recipient area is based on Beehn-
shaped than round. Round grafts (like slot grafts) have enough er’s descriptions below.
epithelial tissue to require the removal of recipient tissue to
prevent compression of the follicular units within the graft.
A NOMENCLATURE SYSTEM FOR THE ZONES
Round grafts are also classified as cut ‘‘to size’’ and therefore
AND LANDMARKS OF THE BALDING SCALP
the specific size punch needed to obtain a desired average num-
ber of hairs per site will vary with donor hair density. Michael L. Beehner
Today, as with other multi-FU grafts, we attempt to divide
round grafts into small, medium, and large, based on the average In January of 1998, I first published a rough draft of a nomencla-
number of hairs or follicular units they typically contain: ture system for the zones and landmarks of the balding scalp in
86 Chapter 5
Hair Transplant Forum International (1). At that time, feedback that ascends along the anterior border of the temporal hair (Fig.
was invited and, over the course of the next 2 years, a large 5A-1). At the suggestion of Unger, in this chapter we also de-
number of prominent hair restoration surgeons, both publicly scribe and refer to a slightly expanded frontal transplant zone
in Hair Transplant Forum International and privately in con- (Fig. 5A-1), which represents a more practical and functional
versations with the author, agreed with the essentials of the design for actually transplanting the frontal area, because when
initial proposal. In Dermatologic Surgery, in 1998, this new surgeons transplant the frontal portion of the scalp, they regu-
nomenclature system was incorporated into a major article, larly extend the area transplanted a short distance posterior to
‘‘Standardizing the Classification and Description of Follicular the previously described frontal region and into the anterior
Unit Transplantation and Mini-Micrografting Techniques,’’ by midscalp. The two posterolateral corners of the frontal trans-
Bernstein and 17 collaborators, who set out to define more plant zone are located on a line drawn between the left and right
clearly the terminology used in hair replacement surgery (HRS) tragus, (rather than between the left and right frontotemporal
(2). Various minor suggestions were made by several of the corners) and its posterior border is curved, thus producing a
physicians earlier consulted and were incorporated into the final commonly seen hair loss pattern in men. Furthermore, trans-
proposal, which was published in Dermatologic Surgery in planting the frontal region only as far posteriorly as the fronto-
2001 (3). temporal corners is not a satisfactory minimum cosmetic goal
In this discussion, I first describe the three major zones of for the vast majority of patients, whereas transplanting poste-
the classical area of MPB. I then define the subzones, which riorly as far as the inter-tragal line often is.
lie within these major zones. Finally, some remarks are made 2. Midscalp: The midscalp is the relatively horizontal area
delineating various common terms for various landmarks and at the top of the head, bordered laterally by the temporoparietal
various arrangements of residual hair that can be present in a hair-bearing fringes, anteriorly by a line drawn across from one
man with MPB. The terminology identified in this chapter is frontotemporal corner to the other, and posteriorly by a curved
used throughout the textbook. line which passes through the vertex transition point (see later)
and which leaves a normally shaped vertex (crown) area poste-
Definition of the Three ‘‘Major Zones’’ of the Bald rior to it. The vertex transition point is a midline point on the
Scalp scalp where the horizontal plane starts to become vertical (Figs.
5A-1), (5A-2).
1. Frontal region: The frontal region is that area of the normally 3. Vertex (Crown): The vertex, or vernacularly termed
hair-bearing scalp that lies between the anterior hairline and a crown, is the most posterior area of MPB; it extends from the
line drawn between the two frontotemporal corner points and posteriorly curved occipital fringe of hair anteriorly to complete
is the area that projects out anteriorly beyond the body of hair a mirror image of its posterior aspect, thus creating a circular
Figure 5A-1 In the above diagram, the frontal transplant zone, as proposed by Unger, is outlined in relationship to the other two zones.
It is a slightly expanded version of Beehner’s frontal region and represents a more practical and functional design for actually transplanting
the frontal portion of the scalp. The posterior lateral corners of this frontal transplant zone are aligned with a coronal line drawn between
the left and right tragus, rather than from the left and right frontotemporal corners. Its posterior border is curved, thus producing a common
hair loss pattern seen in men. (MB)
minimize detectability (i.e., FU and DFU). The majority of the

midscalp, namely, the larger, more horizontal and more midline
region, normally contain hairs directed anteriorly and slightly
to the left or right. These hairs overlap to multiply the visual
effect of density in the midscalp. Because of this overlap, hair
in the midscalp area appears densest after transplanting, and if
larger multi-FU grafts are used, they should be placed in the
more horizontal portion of the midscalp, which permits the
smallest degree of detectability.
Vertex (Crown)
As noted earlier, in defining the vertex zone in a Norwood type
III, or IV, or type V male vertex, the posterior concave border
of the vertex projects anteriorly into a mirror image, thus creat-
ing the semblance of a complete circle or oval. In these types
of MPB, the location of the midscalp’s posterior border is the
projected anterior border of the vertex. In fact, in most men
Figure 5A-2 A clinical photograph with lines demonstrating with type IV and type V MPB, the anterior outline of the vertex
the location of the major zones of a patient with male pattern bald- usually naturally ends precisely at the posterior border of the
ness. (MB) mid parietal bridge, or the remnant thereof. Also, in the majority
of men with the three types of MPB listed above, this designated
vertex area occupies the classic tonsure position, thus straddling
both the horizontal and vertical planes. In balding men with
Norwood types VI and VII patterns, the vertex is large and
or oval form. Wherever this anterior convex border of the vertex circular (or somewhat oval), and its most posterior point is the
falls, it becomes, by definition, the posterior border of the mids- midline of the superior border of the occipital fringe; its most
calp region. The hair direction in the vertex is characterized by anterior point, however, is arbitrarily designated at the same
a whorl arrangement (see later in this chapter), and hair loss location as the vertex transition point (see below and Fig. 5A-
can range from a small, early-thinning vertex with a minimal 2). Rather than straddling both the horizontal and vertical planes
degree of hair loss to a large vertical wall of alopecia as seen in the most advanced forms of MPB, the alopecic vertex occu-
in an advanced Norwood type VI or VII male. pies essentially only the vertical plane, because its posterior
border extends further inferiorly than in types IV and V, and,
therefore, the anterior border of its anterior mirror image is
Discussion of Major Zones farther posterior than in types IV and V MPB.
Frontal Region In transplanting the vertex, the hair transplant surgeon
should bear in mind three things: first, as mentioned earlier,
This is the least controversial area of the scalp to name, because the transplanted hairs must be placed in a whorl arrangement;
most hair transplant surgeons already use this term. This region
second, this area, because of its relatively vertical plane, is
obviously includes a transitional frontal-hairline zone, which
highly detectable to viewers, thus requiring a good deal of art-
is discussed later in the chapter. Typically, the hair transplant
istry in transplanting if it is to appear natural; and third, although
surgeon uses a central density approach in this area, beginning
we often see what looks like a relatively strong border of occipi-
anteriorly with a sparse and fuzzy hairline zone and transi-
tal fringe hair, on closer inspection, especially with wet hair, a
tioning to more density centrally. This approach can be accom-
plished in pure Follicular Unit Transplantation (FUT) by using peripheral zone of see-through hair frequently exists (Fig. 5A-
FUs with three to four hairs in the more central region and 3a,b). Most men eventually progress to lose this see-through
smaller, one to two-hair FUs in the peripheral areas. By compar- hair, thus enlarging the entire circular area of alopecia more
ison, in follicular unit/multi-FU grafting, the central density laterally and inferiorly. This progression paradoxically moves
approach is accomplished by placing multi-FU grafts centrally the posterior border of the midscalp more posteriorly as the
and FUs in the frontal hairline and frontolateral borders (see new, more inferior border of the occipital, hair-bearing fringe
also Chapter 12). is projected anteriorly as a mirror image. In addition, if the see-
through areas are not transplanted at the same time as the more
obvious areas of thinning are treated, the patient eventually will
Midscalp be left with an island of transplanted hair surrounded by an
This region is, for the most part, relatively horizontal in its alopecic zone.
orientation, but because its borders are defined as the two lateral
fringes and the anterior aspect of the circular or oval crown,
Vertex Transition Point
parts of the midscalp are not horizontal; rather, they tip outward
and assume a slightly vertical plane. These nonhorizontal re- This is a newly designated location on the scalp. As stated
gions of the midscalp are thus more visible to the casual ob- earlier, it is the midline point on the posterior half of the scalp,
server, and extra care must be taken in transplanting them to where the horizontal starts to become vertical. Its location is
88 Chapter 5
Figure 5A-4 The outline and landmarks of the Frechet triple-

flap procedure. Point ‘‘A,’’ which is the superior point of the exci-
sion, coincides with the vertex transition point at its anatomical
correlate. (MB)
vertex, the vertex transition point actually resides within the

vertex rather than at its most anterior point.
There are three practical uses for the vertex transition point:
1. Most importantly, it represents for many of our younger
or extremely alopecic patients a natural stopping point for trans-
planting, given, respectively, an uncertain or poor donor/recipi-
ent area ratio. Transplanting as far posteriorly as the transition
point results in the appearance of a full head of hair when the
patient is viewed frontally and laterally. Only posterior viewing
reveals an area of alopecia.
Figure 5A-3 (a) Patient before first hair transplant with the
2. When a frontal forelock design is used in transplanting,
hair dry. (b)The ‘‘true’’ vertex. Although we often see what looks the vertex transition point represents the posterior limit of an
like a relatively strong border of occipital fringe hair (Fig. 5A-3a), extended, somewhat oval, frontal-midscalp forelock design.
on closer inspection, especially with the hair wet, there is frequently This design corresponds to the natural evolution of the balding
a peripheral zone of see-through hair, as is shown in this photo- pattern in some men whose oval forelock of hair often extends
graph. Most men eventually go on to lose this see-through hair. to the vertex transition point.
The transplanting plan must, therefore, include its treatment, or the 3. When drawing the design for the Frechet triple flap correc-
patient will eventually develop a circular alopecic area surrounding tive procedure for the residual posterior slot that results from
a hair-bearing central vertex. (WU) repeated midline alopecia reductions (ARs), Richard Shiell has
pointed out that the vertex transition point is the most superior
point of the design (see Chapter 20). Fig. 5A-4 shows the outline
and landmarks of the Frechet triple flap procedure. Point A,
which is the superior point of the excision, coincides with the
arbitrarily chosen by the surgeon as the point that best fits this vertex transition point as its anatomical correlate.
definition and the concepts outlined earlier. There is necessarily
a subjective element to its placement because there are so many Three Sub Zones within the Three Major Zones
different varieties of head shapes and contours. Obviously, its (Fig. 5A-5)
location is more precise on a head with an abrupt change in
head contour than on one that slopes gradually. We believe 1. Frontal Hairline Zone: As already mentioned, this narrow
there is value in having a specific name for this point when zone is part of the frontal region and extends from one fronto-
communicating about our procedures, transplant designs, alope- temporal corner to the other. It serves as a transitional zone from
cia reductions, and so forth. the hairless forehead into the relatively denser hair posterior to
The purpose for its designation is not necessarily to define it. Arnold has noted that in its natural state, this zone is often
the anterior most point of the border of the vertex (although, slightly wider in its lateral aspects than it is towards the midline.
as noted earlier, in most men with Norwood types VI and VII A further description of the characteristics of the natural hairline
MPB, that would be the case). Rather, it is simply a reference zone is found later in this chapter.
point to indicate where a change in direction of planes occurs. 2. Lateral Crease Zones or Ledges: These are the narrow
Thus, in many men with a somewhat higher, more horizontal areas of scalp that lie along the two lateral sides of the scalp.
Figure 5A-5 The three subzones within the three major zones are the hairline zone, the crease or ledge zones, and the posteroparietal
triangle zones. (MB)
This zone is characterized by two distinguishing features: first,

its plane and orientation lie at a transitional location of the scalp,
where it is neither horizontal nor vertical. Second, when there
is residual hair present in this area, it diverges in two directions:
the hair in the inferior portion angles somewhat anteriorly and
inferiorly, and the hair in the superior portion gradually swings
in a more anterior direction (Fig. 5A-6). The zone in which this
divergence of hair direction occurs represents the natural part
area of the hair. This has practical implications for hair restora-
tion surgeons because they must recreate this divergence with
very small grafts. The reasons are (1) this area is clearly exposed
to the eye of the observer, and (2) the fairly marked change in
hair direction occurring within this relatively narrow zone can
only be recreated without injury to closely spaced follicles if
recipient sites (and therefore grafts) are quite small. Thus, this
zone is best treated exclusively with FUs or a combination of
FUs and DFU grafts.
3. Posterior Parietal Triangle Zones: If one outlines the
circular or oval vertex zone on an individual with Norwood
type VI MPB and then delineates only the relatively horizontal
Figure 5A-6 The black crayon marks outline the area to be
portion of the midscalp, which has an oval contour posteriorly,
transplanted in this patient. Note the half-moon shaped lateral
there still remains in each posterolateral corner of the mid-
hump and the arrows denoting intended hair direction. The lateral
scalp a more or less triangular zone. The plane in this zone crease zone occupies the inferior aspect of the lateral hump. It
progresses vertically, tipping out, as it were, toward the ob- is characterized by two distinguishing features. First, its plane
serving eye and thus becoming more easily noticeable than and orientation lie at a transitional location of the scalp, where
the more horizontal portion of the midscalp. These two trian- it is neither horizontal nor vertical. Second, when there is residual
gular zones comprise the posterior parietal triangles (Fig. hair present in this area, it diverges in two directions. The hair
5A-5). Because they are more easily visible and contain in the inferior portion angles somewhat anteriorly and inferiorly,
changing planes and hair directions, they should also be whereas in the superior portion it gradually swings toward a
transplanted with small grafts (FUs or FUs combined with more anterior direction. Both the lateral crease and the hump
DFU). When transplanting a frontal-midscalp forelock design are best treated exclusively with FUs or a combination of FUs
(Fig. 5A-7), these triangular zones become scatter zones into and DFUs.
90 Chapter 5
Figure 5A-8 A frontal-midscalp design. The posteroparietal

triangles seen in Fig. 5A-5 and in this schematic drawing should
be transplanted with FUs or a combination of FUs and DFUs.
When a frontal-midscalp transplant pattern is designed, these
triangular zones become scatter zones into which FUs are placed,
with or without DFUs, in order to create a visual blur between
the transplanted area and the strong parietal fringe laterally.
(MB)
which FUs, with or without DFU, are placed to create a

visual blur between the denser hair in the forelock and the
strong parietal fringe laterally.
Summary
The three most common patterns for transplanting the alopecic
scalp in MPB are as follows:
1. Frontal transplant pattern (Fig. 5A-1)
2. Frontal/midscalp transplant pattern (Fig. 5A-8)
3. Complete fill-in of frontal/midscalp/vertex regions
This is, however, by no means an exclusive list of options. Many
variations of the three patterns may be used by the surgeon, as
called upon by unique patient needs and existing situations.
COMMON SCALP LANDMARKS AND TERMS

1. Temporal Point: The sharply angulated projection of
hair at the anterior aspect of the temporal fringe (Fig.
5A-2).
2. Frontotemporal Recession or Gulf: The non–hair-bear-
ing skin that lies between anterior temporal fringe and
Figure 5A-7 (a) Outline of a small, oval frontal forelock,
with lateral scatter zones. (b) The patient in Fig. 5A-7a had an the lateral border of the frontal hairline (Fig. 5A-2).
isolated frontal-forelock (IFF) transplanted in the frontal area to 3. Frontal Tuft: The relatively narrow zone of hair that
break up the broad expanse of alopecia. The above photograph juts out from a wall of midscalp hair (or mid parietal
demonstrates the results after two sessions of hair transplantation. bridge) and has on each side a wide and deep frontotem-
(c) The outline of a large/medium oval forelock or cadre de poral gulf (see type III vertex and type IV MPB sche-
cheveaux with lateral scatter zones. (MB) matic drawings in Chapter 3).
4. Frontal Forelock: A natural (or transplanted) zone of
hair in the anterior aspect of the scalp, which is sepa-
rated from the adjacent fringe hair by an ‘‘alley’’ of
alopecia or thinning hair. It is said to be a frontal fore-
lock if the majority of its area lies anterior to a line
drawn between the two frontotemporal corners (Fig. eyebrow line is almost a full centimeter superior to the
5A-7a–7b). and is a frontal-midscalp forelock or a cadre glabella.
de cheveaux (4) if its configuration is such that the ma-
As noted earlier, this proposed nomenclature system represents
jority of its area lies posterior to this line (Fig. 5A-7c).
a uniform method for all hair transplant surgeons, dermatolo-
5. Anterior Temporal Fringe: The border of hair that occu-
gists, nonsurgical hair replacement consultants, and hair stylists
pies the anterior aspect of hair that extends inferiorly
to use in referring to the various zones and landmarks of the
and more or less vertically from the frontotemporal cor-
balding scalp. Until now, these areas have usually been referred
ner to a point approximately level with the external me-
to with imprecise and often contradictory names. The nomen-
atus of the ear (Fig. 5A-9).
clature system discussed in this chapter has been presented
6. Superior Temporal Fringe: The superior border of hair
twice by me (M. B.), with the opportunity for feedback, to the
that is expected to be permanent and that extends from
international hair transplant community. The terms and defini-
the frontotemporal point posteriorly to a point that lies
tions represent a distillation of the surgeons’ suggestions with
on a line drawn vertically from the tragus (Fig. 5A-9).
the original proposal.
7. Parietal Fringe: The superior border of permanent hair
that extends posteriorly from a line drawn vertically
from the tragus to the beginning of the occipital fringe.
AESTHETIC PRINCIPLES
8. Occipital Fringe: The border of hair that surrounds the
alopecic or thinning vertex laterally and posteriorly Walter P. Unger and Michael L. Beehner
(Fig. 5A-9).
9. Hairline Height: Most commonly refers to the distance Introduction
from a midline point on the frontal hairline to the gla-
bella. Some hair transplant surgeons, including the au- With present donor harvesting methods and the routine use of
thor, prefer to measure the hairline from the midfrontal large numbers of small grafts, it is possible to create excellent
hairline down to a line running across the top of the hair transplant results, which appear far more natural than those
eyebrows (the supra-eyebrow line). They find this latter of 10 years ago. However, the surgical and artistic skills needed
measurement a more exact and reproducible one. How- to achieve this level of results in all patients, on a consistent
ever, because this measurement procedure is used by a basis, are not easily attained. Hair transplantation is not a me-
minority of hair restoration surgeons, it is important to chanical exercise in transplanting hair to an area where there
designate specific measurements from the supra-eye- is none. Rather, it is a complex task that requires an understand-
brow line if a hairline height is measured superior to ing of the natural course of MPB; thorough, long-term surgical
this line. The distinction is important because the supra- planning; and the sensitivity of an artist. For the sake of simplic-
Figure 5A-9 A schematic drawing defining the various areas of the alopecic scalp fringe border. (MB)
92 Chapter 5
ity, and because currently approximately 80% to 90% of hair who is 23 or 43, the ‘‘marks’’ that they make on him are vir-
transplant patients are male, most of the comments in this partic- tually permanent ones that cannot easily be erased; so it be-
ular chapter apply to the planning and organization of hair trans- hooves us to take great care to do no harm as we make perma-
plantation in males. A detailed chapter on the topic of surgical nent cosmetic additions.
hair restoration in females follows further in the text; however, In conceptualizing the plan for any given patient, the surgeon
some general comments are made concerning this subject at must consider the three major areas of the alopecic scalp and
the end of this discussion. whether it is appropriate to include all or part of each of these
areas within the area to be transplanted. As noted earlier, these
Function three areas are: the frontal region (or, for purposes of transplan-
tation, the slightly expanded frontal transplant zone), the mids-
The aesthetic function of hair is to provide a complementary calp region, and the vertex. The various planning approaches
balance to the other facial structures, so that the eye of the for these areas are covered in more detail further on. Although
observer is drawn neither toward nor away from any single these three regions are discussed separately, that does not mean
feature but perceives the entire head and face as a pleasant, that the entirety of each region must either be filled in or ex-
natural, and balanced whole. The most important goal of surgi- cluded from the plan. As already mentioned, often a portion of
cal hair replacement is to re-establish the aesthetic balance that the anterior midscalp rather than its entire area is transplanted
was lost in the balding process (5). Because MPB is progressive along with the frontal region in a given patient; and, similarly,
throughout life, it is important to place hair in a pattern that the posterior aspect of the midscalp is often included in a project
looks age-appropriate as a man grows older. The exceptions that primarily features restoring hair to the vertex.
are those rare patients with family histories of limited areas of
MPB posteriorly, who appear to be destined for the same types
of MPB and who retain unusually full, youthful hairlines, which KEY BACKGROUND FACTORS IN PLANNING
the surgeon is convinced will remain for the duration of their The Initial Decision: To Proceed or Not to Proceed
lives.
For each patient who requests surgical hair restoration, there
The Purpose of Hair Restoration Surgery are two major decisions that must be made: The first is deciding
whether the patient is a suitable candidate for hair replacement
Why does a man come to a physician for surgical hair replace- surgery; and, assuming that he is, the second is choosing the
ment? This is a crucial question to ask about each new patient. plan that is most appropriate for his treatment.
Most commonly, the patient says one of three things bothers Before getting into the actual ‘‘architectural’’ planning of
him most: loss of frontal hair, loss of hair in the vertex, or the hairline or other scalp zones, it is first necessary to consider
overall diminishment in density of hair. Most men seen by hair all of the background information concerning a patient that,
restoration surgeons are concerned primarily about loss of hair taken together, allows the surgeon to formulate an appropriate
in the frontal region. When they look in the mirror, they see overall plan of hair restoration. Experienced hair restoration
they are about to lose the frame of their face. From an aesthetic surgeons intuitively process all of these factors while speaking
point of view, the framing of the face with hair is by far the with and examining patients; then they create a plan with which
single most important goal that hair transplantation can accom- they feel comfortable. The outline that follows attempts to sepa-
plish for the patient. Besides concern with the loss of hair or rate and to define all of these factors.
density in one of the scalp areas mentioned, there are two other
underlying psychological reasons that motivate men to look into Factors Contributing to the Initial Hair
hair transplantation: the first is to look and feel younger; that Transplantation Decision and Plan
is, to restore the self-image that a man held in his younger years
and is reluctant to let slip away. The second, which is often Norwood, in 1992, categorized the factors that affect the plan-
related to the first, is to increase self-confidence. Both, not ning of hair transplantation into six major ones—type of MPB,
inconsequentially, can profoundly affect how a man relates to hair color, curl, caliber, donor hair density, and amount of donor
others in the business and social spheres of his life. Because hair—and three minor ones—amount of remaining terminal
of the devastating effect hair loss has on some men, a few hair in the recipient area, amount of vellus hair in recipient
have unrealistic expectations and requests. It is the surgeon’s area, and skin color (6).
responsibility to counter these expectations by advising what We have expanded his list and have divided these input
is appropriate, possible, and safe in the context of projected considerations into 7 major categories and 13 minor ones.
future hair loss. Among the major factors, the first two—age and donor/recipi-
When restoring a man’s hair, it is aesthetically important to ent area ratio—are by far the most important. However, any
consider how the results will look not only viewed anteriorly, one of these major factors, if sufficiently deficient or abnormal,
but also laterally and posteriorly. As MPB progresses, and the is enough to veto any plans to proceed with surgery or to alter
hair-bearing fringe recedes, the transplanted hair placed adja- them considerably. The major factors are reviewed separately
cent to or within these temporarily hair-bearing areas becomes in some detail. Following that, each of the minor ones is covered
visible. Hair restoration surgeons should, therefore, be as much briefly.
artists and prophets as technicians. They must remember that the
1. MAJOR FACTORS
easel upon which they ‘‘paint’’ constantly alters as the scalp’s
natural hair distribution pattern changes over the course of each A. Patient’s age
man’s lifetime. Whether surgeons happen to work on a patient B. Projected eventual donor/recipient area ratio
C. Patient’s preferences and goals poral areas and after taking into account the patient’s age and
D. Patient’s medical health family history, can usually reliably determine the portion of
E. Patient’s psychological state the donor area that comprises safe, or permanent, donor hair.
F. Hair characteristics Obviously, the younger the patient, the more conservative the
G. Capabilities of surgeon and assisting staff surgeon must be in making this determination. Besides the
2. MINOR FACTORS square area of projected safe donor hair, almost equally impor-
tant are its density and hair caliber. These qualities also can
A. Family history of MPB be roughly determined by simply lifting up the donor area hair
B. Quality of the surrounding fringe
and looking through it. However, as noted earlier, it can be
C. Thickness of the scalp
valuable to assess more accurately these parameters as well as
D. Supporting temporal hair
the number of FUs per surface area, the number of hairs per
E. Patient’s suitability as a candidate for AR
FU, whether or not there is a dramatic dropoff in density on
F. Unique anatomy of patient’s head (e.g., size, con-
the side of the scalp, and the percentage of miniaturized hairs
tour, orientation, forehead structure)
present. All of the these parameters and their implications are
G. Patient’s willingness to tolerate detectability dur-
discussed in detail in Chapter 10.
ing various stages of the hair transplant process
An important entity to rule out during this part of the exami-
H. Means of camouflage available
I. Scalp elasticity and laxity nation, especially in the younger patient, is a hair loss pattern
J. Presence of whisker hair that has been labeled diffuse non-pattern alopecia (8). In these
K. Patient’s present hair loss treatment strategy patients, thinning hair is not only present in the usual areas of
L. Patient’s hair styling preference MPB, but also to some degree throughout the usual donor area
M. Patient’s financial capability and time constraints (Fig. 5A-10). Patients with this pattern of hair loss are not candi-
dates for hair transplantation, because fewer hairs are available
for transplantation and because this form of MPB is typically
MAJOR FACTORS
rapidly progressive (9). In addition, donor scars are obviously
Age harder to camouflage in later years.
2. Size of the recipient area: While examining the patient’s
Since MPB is intermittently progressive throughout life, the age scalp, the surgeon should note the areas of complete baldness
of the patient is the single most important piece of information and those areas that are thinning. A schematic drawing of the
guiding the surgeon’s decisions. When speaking to a 20-year- Norwood hair loss types (see Chapter 3A, Fig. 1) or the one
old man during a consultation, we often tell him that the ‘‘crys- described by Shapiro in Chapter 12D (Fig. 5) is useful for com-
tal ball is very cloudy’’ and that nobody can be certain of how municating to patients the relation between their present stage
he will look when he is 40 or 50 years old. It is, of course, of hair loss and the ultimate, anticipated extension of their MPB.
impossible to foretell the eventual extent of MPB in any given With this information, patients are usually willing to accept a
individual, and there is, no doubt, a small percentage of individ- more conservative plan than they initially desired. Estimating
uals whose prognosis—if it were known at the time of the the eventual area of alopecia is more important than identifying
initial consultation—would rule them out as candidates for hair
the present hair loss pattern. For many men older than 45 years
transplanting. There are others whose objectives are incompati-
of age, determining this is relatively easy. In most such patients,
ble with their eventual donor/recipient area ratio. This has led
the temporal and parietal fringes are unlikely to drop much
some physicians to arbitrarily choose the youngest age before
further. If there is residual hair on the caudal aspect of the head,
which they refuse to treat patients. For some, this age is 21
however, it is often reasonable to expect it gradually to thin out
years; for others, 25 years, 30 years, or even 35 years (7). We
believe no such rigid age limit should be set. Certainly, the
older the patient is when treatment begins, the less likely the
surgeon will be to miscalculate which objectives are possible
and which are unwise or improbable. Transplanting in younger
patients is discussed in more detail later in this chapter.
At the other end of the spectrum, there is no upper age limit
after which transplanting is contraindicated. The main criterion
for such work is that the patient’s general health and overall
objectives are compatible with each other. We have operated
on several patients in their 80s whose results were the same as
those we expected to achieve in younger men. While age is
an important factor, to consider when deciding the method of
transplantation, good medical judgment is a more important
one, when a decision is being made to accept or reject someone
for hair transplanting.
PROJECTED EVENTUAL DONOR/RECIPIENT

AREA RATIO
1. Donor supply: An experienced hair restoration surgeon, after Figure 5A-10 Diffuse non-pattern alopecia in a 22-year-old
examining the existing hair in the occipital, parietal, and tem- man. (MB)
94 Chapter 5
and disappear. Wetting the hair makes this concept more clear consideration is especially important when surgeons are dealing
to the patients. with younger patients. All of these matters should be agreed
The hair restoration surgeon ideally should take a more con- on and understood before a transplanting plan is made and be-
servative approach with a younger man in his 20s or early 30s, fore the surgeon begins treatment of any patient. This subject
especially if he has Norwood types III-vertex IV, or V MPB. is covered in more detail in Chapter 6.
Norwood’s and Unger’s studies, respectively, indicate that only
13% to 21.9% and 11% to 13.4% of men who reach age 80 Medical Health
develop a type VI or type VII stage of MPB (see Chapter 3).
Nonetheless, it is wise to assume that a younger patient will The patient’s overall medical health is obviously important to
probably progress to a Norwood type VI balding pattern unless consider before beginning a series of hair restoration procedures
there is a particularly good family history and findings on physi- that can extend over many years. In particular, cardiovascular
cal examination to suggest otherwise. As the two studies men- and immune systems should be satisfactory. The presence of
tioned show a small percentage of these men will even progress any unstable or newly diagnosed medical condition is reason
to a Norwood type VII MPB, with a highly disparate ratio be- enough to postpone transplant surgery; such conditions would
tween donor and potential recipient areas. Ominous signs that obviously include any new hormonal or endocrinological
point to this latter possibility are: (1) a father or maternal grand- changes. The patient should then be reevaluated for transplant
father with a Norwood type VII pattern, (2) the presence of surgery at a later time when the problem in question is stable
sparse, wiry, peri-auricular hair, sometimes referred to as whis- and controlled. Examples of at-risk patients are HIV-positive
ker hair (10); (3) the absence of dense hair elsewhere in the patients, patients who have undergone kidney transplantation,
fringe; (4) a higher than average number of miniaturized hairs or those with recent cardiovascular disease. There is currently
in potential donor areas; and (5) MPB beginning in a teenager. a debate among hair restoration surgeons about whether preop-
erative blood screening should be done before hair transplant
Patients’ Preferences and Goals surgery is performed. The merits of these two positions are
discussed elsewhere in this text.
It is important to know from the outset what patients want. We have both operated several times on men who had under-
They are usually clear about which area of hair loss concerns gone prior multiple-graft, coronary bypass surgery. In such in-
them most. The frontal region is the easiest area to deal with stances, we first obtained the approval of the patients’ cardiolo-
and is almost always amenable to hair restoration surgery. The gists and then we took appropriate precautions before and
request to transplant the vertex, on the other hand, is often a during the procedure (see Chapters 7 and 8). Dr. Unger has
more perilous one with which to comply; this area of the scalp also operated on an HIV-positive patient who had no detectable
has the potential to become excessively large and thus can con- circulating virus, an excellent immune component profile, and
sume enough donor tissue to make impossible a future trans- a past history of other, more invasive cosmetic procedures, all
plant in the frontal and midscalp areas, which most patients without associated complications. Dr. Unger routinely asks
ultimately consider more cosmetically important. Oddly HIV-positive patients to obtain a letter from their physician,
enough, a small percentage of men who have both frontal and unequivocally stating that in the physician’s professional opin-
vertex hair loss are disproportionately preoccupied with having ion there is no significant increased risk to proceeding with hair
the vertex area transplanted. transplanting. If the primary physician is unwilling to send such
How dense does the patient want the final result of his trans- a letter, the patient may then be rejected ethically for surgery
plant to be? Will he be satisfied with see-through or less-than- (in many although not all jurisdictions.) In any case, the patient
full hair density? The surgeons must always emphasize that is then fully aware of the refusal of his primary physician and
with hair transplantation they are creating the illusion of a full will approach surgery with more caution.
head of hair. It is impossible to recreate the original density the As noted elsewhere in this text, it is always a good idea to
patient had as a teenager because the operator only redistributes have direct communication with a patient’s personal physician.
a limited amount of hair (see also Chapter 10). During the initial If the patient decides to proceed with surgery, we routinely
visit, the surgeon should also determine the patient’s expecta- write to his doctor and dentist—with consent of the patient.
tion of where he wants the hairline placed. If his expectation The physician and dentist are both asked to contact us if they
is a hairline that is too low or too flat, or one that is unnatural know of any reason why their patient should not undergo hair
in any other way, the surgeon must explain why such a course restoration surgery or if there is any other information of which
is unwise. If the patient is still unwilling to change his initial we should be aware. Many internists, family physicians, subspe-
objectives, the surgeon should refuse to proceed with the treat- cialists, and dentists are not familiar with what hair transplant
ment. surgery involves. Thus, it is helpful to let them know the drugs
There are a number of other potential conflicts in expecta- that are used and their amounts, the duration of the procedure,
tions that should be addressed. These include (1) requests to and a brief review of what is involved with this type of surgery.
thicken the temporal hair or to move its anterior border further This is not only good medical practice; it also solidifies profes-
anteriorly; (2) how many sessions will be required to complete sional relationships and even provides good public relations for
the work; c) how much time will be lost from work; d) in what our specialty.
direction the transplanted hair will be placed; e) the length of
the healing process; f) the permanence of the results. It is impor- Psychological State of the Patient
tant, with regard to the last consideration to advise patients that
whatever density is achieved initially, it will naturally decrease A large majority of the patients who meet with any hair restora-
over time as the donor hair density gradually decreases. This tion surgeon are reasonable individuals who easily grasp the
concept of the limited availability of hair resources and can, priately believe, are caused, directly or indirectly, by their hair
therefore, accept realistic goals. Unfortunately, however, some loss. Such patients usually have psychiatric pathology that a
patients are psychologically unfit to go through with a transplant head covered with hair cannot cure.
procedure. These include the following: 3. Patients with unrealistic expectations: We referred to this
1. Angry patients: anger may be directed at his parents, fate, type of patient earlier. Usually, such patients are younger men
or the last doctor who performed a hair transplant on them, and or those who have worn a hairpiece for many years. They often
whom they vilify unfairly during the consultation. Such patients request an inappropriate hairline or expect total and sometimes
can be exceedingly difficult to please. In some cases, there are dense hair coverage, including the vertex, despite the fact that
reasons to suspect that if you proceed with surgery, the patients their age and donor/recipient area ratio make satisfying such a
will appear in another doctor’s office the next year, complaining goal unlikely.
about you. It is best to avoid angry men until they mature and 4. Patients with trichotillomania: Another group of patients
reach a more reasonable and unemotional view of their hair who should not be transplanted, regardless of whether or not
loss. there is accompanying hereditary hair loss, are those with tri-
2. ‘‘Blamer’’: These are individuals who have come to a chotillomania, an anxiety disorder in which patients repeatedly
point where they focus all of the problems in life on MPB. pull on their hair (see Chapters 4 and 6A). Close examination
Family situations, jobs, reclusive avoidance of social situations, of the ends of the short hairs present reveals that the hair shafts
and unhappy personal relationships—all of these they inappro- have been broken.
Figure 5A-11 (a) A patient before transplanting. The black crayon mark denotes the location of the planned hairline. His fine textured
hair and white hair were both particularly advantageous. (b) The same patient 14 months after his first transplant in 1991, which consisted
of 350 medium and large slit grafts. No micrografts were used in construction of this hairline zone. The transplant also included placing
grafts within the persisting hair in the frontal area; thus, if the patient were destined to lose that hair in the future, he would not be left
with an unnatural distribution of hair. (c) The same patient 12 months after his second session, which consisted of 323 small slit grafts
and medium slit grafts as well as only 50 micrografts. The patient had dyed his hair red. To maintain the same appearance of naturalness
and density that was achieved after one session when his hair was white, a second session had been necessary. (WU)
96 Chapter 5
5. Patients with body dysmorphic disorder (BDD): Finally, tant. It is worthwhile pointing out that the finer the hair caliber,
there is a small number of patients who have a condition referred the more natural a single session looks, despite the fact that the
to as body dysmorphic disorder (BDD), which is discussed in density of the hair appears less than that of transplanted, coarser
Chapter 6A. These individuals should never be accepted for hair. This is especially true if the recipient area is alopecic, for
treatment. as MPB progresses, the hairs become finer and finer with each
cycle of hair loss and regrowth. Thus the caliber of the hair
Hair Characteristics decreases in pace with the apparent thinning. The greater the
thinning, the finer the hair becomes, and hence relatively low-
There are five commonly accepted characteristics of hair that density transplanted hair appears more natural if the hair has a
are important to consider. The surgeon must project mentally lower caliber than if it has a higher one (5) (Figs. 5A-11 to 13).
how these physical features of the hair will affect the transplant
results. They are discussed in considerably more detail in Chap- Color Contrast of Hair to Skin
ters 10 and 12, but are reviewed here briefly because of the
important role they play in planning. They are: It has long been said that the less contrast there is between hair
and skin colors, the thicker the hair looks. The evolution of
1. Caliber FUT has demonstrated that this is not quite true. It is more
2. Color contrast with skin accurate to state that the less contrast between the color of the
3. Curl hair and skin, the less noticeable any alopecic gaps between
4. Wave hairs become. Put differently, the less the color contrast between
5. Frizziness hair and skin, the more even and more natural the hair coverage
appears to be, and, therefore, there is the illusion of more hair
Caliber of Hair (Figs. 5A-11 & 13). When surgeons work with larger types of
More than any other physical factor, the caliber of the hair shaft grafts, the hair density of the grafts contrasts markedly with
contributes most to the final fullness and perceived bulk of the the correspondingly larger alopecic or thinning spaces between
transplanted result. Cole has calculated that an increase in hair them—all the more so when the color differences are greatest.
diameter of a mere 0.01 mm increases hair bulk by an astound- As a result, there is the illusion of less hair in a patient with a
ing 36% (11). The caliber of hair varies greatly from one patient high color contrast. This continues to be true for grafts that are
to another. It is usually fairly consistent within a narrow range larger than one FU but does not appear to be true for FUT. The
in the same individual; however, the temporal and inferior oc- spaces between the FUs in recipient areas treated exclusively
cipital areas generally contain the finest caliber hair in nearly with FUs are so small that the unevenness of the hair coverage
all individuals. Hair caliber is greatest in the posterolateral as- and, therefore, its apparent density are minimally affected by
pect of the occipital area and generally decreases slightly as hair to skin color contrast (Fig. 5A-14). In fact, sometimes in-
one moves anteriorly through the parietal and temporal areas creasing this contrast, especially if the hair is quite fine-tex-
or posteriorly toward the midline of the occipital area (see Chap- tured, increases rather than decreases the apparent hair density.
ter 10). Donor areas with finer caliber hairs are particularly Coloring white hair also frequently makes the hair fibers
advantageous for construction of hairline zones, whereas higher slightly thicker and, therefore, further increases the appearance
caliber hairs are obviously advantageous where bulk is impor- of hair density.
Figure 5A-12 (a) A female patient before transplantation. Her hair has been wetted with Betadine to better demonstrate its sparseness
within the frontal and midscalp areas. (b) The same patient two years after a transplant session in 1996 consisting of 262 micrografts, 300
small slit grafts, and 135 medium slit grafts. The photographs of this patients demonstrate not only the efficacy of transplanting in females
but also that darker hair, if it is fine-textured, looks natural after a single session, even if grafts larger than a single follicular unit are
employed. (WU)
Figure 5A-13 (a) A patient before transplanting. (b) The same patient 12 months after a hair transplant session consisting of 150 small
slit grafts and 320 medium slit grafts. No follicular units (FUs) were used. The hair has been parted for critical evaluation. Although a
totally alopecic vertex area is usually treated exclusively with FUs, if the hair is fine-textured enough and/or there is little contrast between
the color of the hair and skin (as in this white-haired man), multi-FU grafts can be used without producing any noticeable plugginess. The
less the color contrast between hair and skin, the less noticeable the alopecic spaces between the multi-FU grafts are, and the more even
and natural the hair coverage appears to be; hence, there is the illusion of more hair. (WU) (See color insert.)
On the other hand, as indicated above, if a surgeon works the graft used, the greater the proportion of the hairs
with grafts that contain more than one FU, the less contrast that remain safely within the body of the graft.
between the skin and hair colors, the denser the same amount 2. As is discussed in Chapter 12, a surgeon can achieve
of hair appears. This is especially useful to remember when the greater hair density by using larger grafts.
hair is very light-colored in Caucasians, and even more so when 3. When there is minimal color contrast between hair and
it is fine-textured, for the following reasons: skin, there is a minimal ‘‘price’’ of possible ‘‘pluggi-
ness’’ to be paid in return for using larger grafts.
1. It is easier for a technician to miss a light-colored, fine
hair or its matrix and thus accidentally to cut it away Thus, for Caucasians, if grafts larger than one FU are used, the
as part of the excess tissue than if it is darker. The larger most advantageous hair colors in descending order are white,
Figure 5A-14 (a) An intraoperative photograph of a patient showing recipient sites for 1519 follicular units (FUs). Recipient areas
treated exclusively with FUs are much less negatively affected by hair-to-skin color contrast than when multi-FU grafts are employed. In
fact, sometimes increasing this contrast, especially if the hair is quite fine-textured, increases rather than decreases the apparent hair density.
(b) A frontal view of the same patient 5 months postoperatively. Note the natural appearance of the hair after a single session despite the
fact that the hair is brown.
98 Chapter 5
Figure 5A-15 (a) A patient before transplanting in 1996. (b)The same patient shown in Fig. 5A-15a 4 months after his second transplant.
A total of 650 micrografts, 300 small slit grafts, and 625 medium slit grafts were used in the two sessions. The results are quite natural
and the hair looks reasonably dense after two sessions because of its fine texture and medium brown color. (WU)
Figure 5A-16 (a) A patient before transplanting in 1988. (b)Seven years after the first transplant session and 12 months after the third
transplant session to the frontal area shown in Fig. 5A-16a. Sessions two and three were carried out in pace with the rate at which the
persisting hair shown in Fig. 5A-16a had been lost. As a result, nobody noticed that this patient was having hair transplantions carried out,
and his hair gradually got thicker rather than sparser. All of the hair shown in this photograph has been transplanted, because all of the
original hair had been lost at this point. (c)A frontal view of the same patient shown in Fig. 5A-16b and taken at the same time. It
demonstrates an irregular hairline and irregular density of hair within the hairline zone, as is seen in natural hairlines. No plugginess was
ever noticed during the course of this patient’s treatment despite the use of small and medium slit grafts because (1) some persisting hair
existed in the recipient area at the time of the first session and, therefore, camouflaged any tendency to detectability; and (2) subsequent
sessions were carried out in pace with the loss of the original hair. (WU)
salt and pepper, light brown, red, dark brown, and black. Exam- over the years at the same pace as the patient loses his original
ples of men who were transplanted, who possessed each of persisting hair, so that by the time it is completely gone, he is
these hair colors, are shown in (Figs. 5A-11, 13, 15, 16, 17, 18). left with the high hair density these grafts provide and the alope-
Despite the preceding facts, when some original hair persists in cic spaces between them are much smaller, thus minimizing
the recipient area, and a combination of FUs, slit grafts, and the possibility of looking pluggy (Figs. 5A-16) (18). Of course,
round grafts containing no more than five or six hairs are used, when the skin color is relatively dark, darker hair is desirable.
even intensely dark hair can produce excellent cosmetic results Black patients, for example, get excellent results with dark hair,
in a Caucasian after a single session (Fig. 5A-18). In addition because of its favorable minimal contrast against their dark skin
to producing more density, an often overlooked benefit of using (Fig. 5A-19).
grafts with more than one FU in a hair-bearing recipient area
is that the ostensible ‘‘disadvantage’’ of seeing these grafts Curl and Wave
more easily than FUs on close inspection becomes an important The more curl or wave to the hair, the denser and fuller the
advantage in subsequent sessions. This is because the surgeon hair appears to be. Thus, at its optimum, the dense curls of
can more easily discern whether an area has or has not been black patients’ hair produce remarkably dense-looking results
treated and, in addition, the new grafts can be placed in the (Fig. 5A-19), and a natural wave to the hair not only increases
most optimal locations relative to the previously transplanted the naturalness but also increases the apparent fullness and den-
grafts (12). Further transplanting can be carried out gradually sity (Fig. 5A-17 and 20).
Figure 5A-17 (A) A patient before hair transplanting in 1995. The black line denotes the limits of the hairline zone. This patient with
black, fine, wavy hair wanted thick hair frontally even though he had been told that if larger grafts were used to produce the desired density,
he would have insufficient donor tissue left to transplant the vertex area, which was already thinning. His response was that he would wear
a hairpiece on the vertex area, but he wanted natural, thick hair frontally. (B) Nine months after the second of two sessions. The first
session consisted of 299 micrografts, 175 small slit grafts, 227 medium slit grafts and 50 - 2mm round grafts. The second session was
very similar. The hair is combed as it is normally was. A hairpiece was worn on the vertex area at the time of this photo. (C) A frontal
view photograph of the patient taken at the same time as the photograph in Fig. 5A-17B. (WU)
100 Chapter 5
Figure 5A-18 (a) A patient before transplanting. (b)A front view of the patient taken 1 year after the first session consisting of 280
FUs, 350 DFUs and 222 TFUs. Note the absence of process detectability. This patient was an entertainer who worked under bright lights.
No one noticed at any time that he was undergoing transplanting. (c)A side view of the same patient before transplanting. (d)A side view
of the patient 5 months after his second session (similar to the first), with the hair worn in his normal style. Process detectability is more
theoretical than actual when grafts larger than one follicular unit (FU) are used, especially if the hair is fine-textured and some hair persists
in the recipient area when treatment begins. As long as transplanting is carried out at the same pace as the patient loses his original hair,
by the time that hair is completely gone, the individual has both the high density appearance that multi-FU grafts provide and minimal
likelihood of graft detectability during the course of treatment. (WU)
Frizziness it does seem to exist independently of the five listed above,

Hair is said to be frizzy when it possesses a visibly irregular although it undeniably borrows from and incorporates them.
surface and, therefore, flows unevenly. The individual hairs lay Another way to describe this sixth characteristic is to say that
‘‘roughly’’ upon each other, with more space between them, it is the subjective impression of the hair’s appearance. Some
men (and women) have what observers may term beautiful hair.
and they thus give an appearance of increased density. In addi-
Such hair flows nicely; it has an attractive amount of body to
tion, the more frizzy the hair is, the more natural it looks, be-
it—without being too coarse or too fine (Fig. 5A-22). Usually,
cause alopecic spaces between hairs are blurred by the frizz.
the density of such hair is higher than average. Its exit from
Even after a single session of microslit grafting or micro-mini-
the skin is almost imperceptible and it is pleasing to see. Also,
grafting in an alopecic area, results can be remarkable (Fig. 5A- it often possesses a slightly multicolored or multitoned aspect,
21). sometimes with a touch of gray mixed in or multiple shades of
brown. In looking back and recalling many people who have
Intrinsic Beauty had such lustrous hair, there are a number of accompanying
To this list of hair characteristics, Beehner would add a sixth features that have usually not been present. It is uncommon for
one: intrinsic beauty. This is a more elusive characteristic, but such hair to be seen in individuals with hyperelastic scalps.
Figure 5A-19 (a) A 55-year-old African-American man before transplanting. (b)The same patient after two sessions, showing the
density effect of curly black hair. (MB)
Figure 5A-20 (a) An intraoperative photograph of a patient during his first session in 1999, which consisted of 426 micrografts, 216
small slit grafts, 287 medium slit grafts, and 111 medium slot grafts. (b)The same patient shown in Fig. 5A-20a before transplanting, with his
hair combed back for a critical evaluation of the thinning area. (c)The same patient shown in Fig. 5A-20a 6 months after his first transplant,
with the hair combed back for critical evaluation. Notice the absence of process detectability despite the use of multi-FU grafts. (d)The same
patient shown in Fig. 5A-20b 6 months after his first transplant. The hair looks relatively thick despite his having undergone only a single
procedure because of the use of larger types of multi-FU grafts, and particular, slot grafts. In addition, the fact that the patient’s hair is wavy
makes it appear thicker, whereas the fine texture creates a more natural effect after only a single session. (WU)
102 Chapter 5
Figure 5A-22 (a) A formally alopecic patient after four ses-

sions of micro-minigrafting. This patient typifies the results seen
in individuals with lustrous hair. (b)A close-up of the hairline after
four sessions. (MB) (See color insert.)
In transplanting hyperelastic scalps, the hair’s exit site at the

epidermis is often difficult to conceal owing to the contraction
of the skin around the graft. Also, oily scalps are less likely to be
associated with such hair. Although there are some exceptions,
excessively curly hair and/or coarse hair usually do not project
this quality either. Very fine hair occasionally flows with a
natural, lustrous effect, although it usually takes a large amount
of such hair to produce the appearance to which we have been
referring.
Capabilities of Surgeon and Assisting Staff

Figure 5A-21 (a) A patient before transplanting. The black
line denotes the anterior limits of the hairline. (b)A close-up of the If the patient would benefit most ideally by having a type of
recipient area before the first treatment in 1987. (c)This patient hair restoration surgery that a surgeon does not perform, it is
shown 9 months after a single session consisting of 150 micrografts, ethically responsible to refer him to a physician who performs
200 small slit grafts, and 212 medium slit grafts. The good density the desired surgery well. Likewise, if the surgeon only rarely
and naturalness after only a single session owes a great deal to the performs a given procedure that is inherently quite surgically
frizzy nature of this patient’s hair. This is because the alopecic challenging, it is again best to refer the patient to someone who
spaces between the grafts are blurred by the frizz. (WU) performs it on a regular basis. Given the fact that the more
invasive scalp excision techniques and flaps are much less com-
monly carried out at present, the decision regarding whether or
not to treat a patient can relate more to the size and scope of cautious when there is a family history of type VII MPB (Fig.
the procedure than to its invasiveness. 5A-23). On the other hand, the family history of hair loss should
never prompt the surgeon to embark on an overly ambitious
transplant plan in a relatively young man, regardless of how
MINOR FACTORS little hair his male relatives have lost. Family history, therefore,
Family History of MPB is somewhat helpful, but too many factors affect the evolution
of MPB to use it as an absolute guide.
It is valuable to know the hair loss pattern of the patient’s father,
brothers, maternal grandfather, and uncles, insofar as it helps Quality of the Surrounding Fringe Hair
the surgeon decide on the upper limits of the hair replacement
plan. If, for example, a patient has the same hair loss pattern When the superior border of the fringe hair in the temporal,
that his father possessed at a similar age, it is reasonable to parietal, and occipital areas is indistinct in a younger patient
assume that the patient’s MPB will progress in a similar fashion without a clear, relatively strong line of demarcation, it is rea-
and to a similar degree. It cannot be overly stressed, as has sonable to suspect that such a man can expect early and some-
been noted previously, that the surgeon should be especially times marked progression of MPB (Fig. 5A-24). The younger
the individual in which this is found, the worse the prognosis
for the ultimate extent of MPB should be. This thin, indistinct
upper fringe is often associated with whisker hair around the
ears. (See below and Fig. 5A-25.)
Scalp Thickness
Little has been said or written in the past about this attribute
of the scalp. We believe that the thickness of the scalp should
be factored into how a hair transplant project is planned and
technically performed. The thicker a scalp is, the easier it is to
use limited depth transplanting techniques, especially if thick-
ness is combined with tense tumescence of the recipient area
Figure 5A-23 (a) A posterior view of a 23-year-old man whose

vertex area was thinning and who requested transplantation of this
area. (b)The 58-year-old father of the patient shown in Fig. 5A-
23a. On close examination, it was apparent that the son was likely Figure 5A-24 A poorly defined occipital and parietal fringe
to develop the same balding pattern as his father. When this was borders the more obviously thinning area in this 23-year-old pa-
pointed out to the patient, he elected to defer transplanting and to tient. When the superior border of the fringe hair in the temporopa-
save his donor tissue for the frontal area. It cannot be overly stressed rietal and occipital areas lacks a distinct line of demarcation in a
that one should be especially cautious in treating the vertex area younger patient, then it is reasonable to suspect that such a man will
when there is a family history of types VI and VII male pattern develop early and sometimes marked progression of male pattern
baldness. (WU) baldness. (MB)
104 Chapter 5
patient’s capabilities or determination to achieve maximum re-

sults.
Supporting Temporal Hair

Careful evaluation of the anterior temporal hair is helpful in
planning the position of the front hairline and the density of
the frontal region as a whole. The position and density of this
temporal hair must be considered in the context of the patient’s
age, because the anterior border tends to recede and its hair
density decreases as a man ages. However, if a man of mature
age has dense temporal hair that projects significantly anteri-
orly, the surgeon may be somewhat more aggressive in setting
a lower hairline and creating a dense frontal region. Such tem-
poral hair serves to hold up the frontal protrusion of hair and
Figure 5A-25 A patient with whisker hair. A high percentage gives an overall pleasing, aesthetic balance to the face and the
of men with whisker hair progress to an advanced type of male hair that frames it. Of course, if the temporal hair is likely to
pattern baldness, and hair transplanting objectives must be altered be sparse in the future, a goal of creating dense frontal hair is
accordingly. (WU) not wise.
Patient’s Potential as a Candidate for Alopecia

Reduction
(see Chapter 12). Making recipient sites in this way places the Whether or not the patient is a good candidate for an AR impacts
recipient sites above the relatively large blood vessels that re- the overall hair replacement plan in a number of ways: Most
side in the subcutaneous tissue. Preserving this underlying vas- importantly, an AR obviously reduces the area of alopecic scalp,
culature allows for a more aggressive approach with closer spac- thus leaving a smaller area that requires grafting. This topic is
ing of grafts. A thick scalp, if it is also relatively lax, is also considered in more detail later in this chapter and also in a
ideal for AR. chapter that is devoted to AR. (Chapter 19)
Patient’s Financial Capability and Time Constraints Unique Anatomy of the Patient’s Head
It is obvious that a hair restoration surgeon should embark on The overall size of the head may affect the number of grafts
a surgical plan only if the time requirements and cost involved that are required to fill in the typical area of MPB. The forehead
with the procedure(s) are within the range a patient can reason- contour and its height also play an important role in determining
ably afford and tolerate. It is a disservice to the patient, for the best position and contour for the frontal hairline. Sharply
example, to use up his available funds with a single, large proce- sloping foreheads look good even with relatively high hairlines,
dure that requires subsequent similar sessions before a com- whereas more vertical foreheads usually look best with hairlines
pleted look is achieved. Usually, it is unwise to use slit grafts, that extend into the zone in which the vertical forehead is chang-
slot grafts, or round grafts unless at least two or preferably ing to the more horizontal top of the head. In addition, there is
three sessions in the same area are contemplated. The fewer great variability among men in the width of the head and in
the desired number of sessions, the smaller the proportion of the distance by which the frontal region projects anteriorly from
the alopecic area the surgeon should attempt to treat and the the midscalp area. All of these factors must be considered before
smaller the grafts should be. One of the advantages of FUT is the surgeon establishes an overall plan for transplanting.
that it looks natural after only one session. Thus, patients with
limited time and financial resources may find sessions of FUT Patient’s Willingness to Tolerate Any Detectability
the most advantageous way to proceed, because sessions can During Early Stages
be spread further apart without the scalp’s looking at all pluggy
in the intervals. On the other hand, FUT is generally a more Many patients, by temperament or because of their particular
expensive way to transplant hair than, for example, micro- occupation, express an overriding desire that, in addition to
minigrafting, so sessions may have to be smaller, with less increasing recipient area hair density, no one detect that they
hair transplanted, than if micro-minigrafting is employed. are undergoing hair transplantation. Because most physicians
At the opposite end of the scale are those for whom cost, believe that they can ultimately produce more density by includ-
number of sessions, and types of procedures to be undertaken ing larger grafts—which, by their very nature, are more likely
are all secondary to achieving a particular goal, as is the cost to be more noticeable than smaller ones—it is important for
of large sessions of FUT. Such patients are more amenable to the surgeon to know the patient’s sensitivity to detectability in
traveling to other cities and doctors, where specialized services, the early stages of transplantation. Marritt has referred to these
such as scalp extension and AR, with which local surgeons may conflicting objectives as the issue of product vs. process (12).
not be experienced or comfortable, can be carried out success- Thus, a patient who wishes to keep the procedure completely
fully. Each patient, however, should have all the alternatives secret is primarily concerned with the process, the potential
described to him/her, in case the surgeon might misjudge the graft detectability, whereas another man, who, for example,
plans to wear his nonsurgical hairpiece until the transplants are Patient’s Current Hair Loss Treatment Strategy
completed, is more likely to be primarily concerned with the
final product, hair density (Fig. 5A-17). Obviously, a man’s It helps to be aware of and to incorporate, if appropriate, what-
hair characteristics and the amount of persisting hair in the ever method of hair loss prevention the patient has been using
recipient area affect how easy or difficult it will be to achieve before transplant surgery. If a patient has been using either
this goal of undetectability. The subject is discussed in greater topical minoxidil or oral finasteride, a discussion concerning
detail in Chapter 12F and G. Generally, as long as modern hair strategy should be carried out with him regarding whether to
styling techniques can camouflage any temporary graft detecta- stay on these medications or not, and when to stop them. Ob-
bility, patients choose whatever type of graft achieves their viously, if the patient has used either of these over a reasonable
density objectives in the fewest sessions. amount of time, it is wise to continue them, at least until the
first one or two transplant sessions have grown out. By doing
so, the patient does not risk having a sudden loss of hair caused
Means of Camouflage Available During Early by the withdrawal of the medication. On the other hand, begin-
Stages of Transplanting ning either or both of these medications around the same time
Many hair transplant patients are already using some method as transplanting starts can leave all involved confused as to
of camouflage for their hair loss. This method can continue which actually produces the noted improvement. For this rea-
to be used during the early months of the transplant process. son, with the possible exception of the first 5 postoperative
Common examples are the comb-over of temporoparietal hair weeks, when Unger recommends the use of 3% minoxidil to
that is swept over the thinning or alopecic area, a nonsurgical accelerate healing, he prefers that patients who are not using
hairpiece, a job situation that allows the wearing of a baseball minoxidil or finasteride defer starting them until at least 6
cap or hardhat, or the use of a camouflage product, such as months after the last transplant is carried out in the area of
Toppik, Couvre, or Derm Match (13). Any of the these choices existing hair loss. These medications may then be started in an
provide the surgeon and patient ‘‘cover to work under,’’ so that effort to slow further loss or to reverse loss in both transplanted
the emphasis of the transplant can be focused more on the final and untransplanted areas (see Beehner’s Addendum to this chap-
product created than on an excessive concern with the process ter). It should also be obvious that, if a patient depends on a
and its early appearance. Fortunately, with improvements in comb-over to cover his bald area, it is important, at least in the
multi-FU grafting and micrografting in the past few years, both early sessions, not to harvest any of the long hairs used to create
process and product have improved greatly. the comb-over.
Scalp Elasticity and Laxity Patient’s Future Hair Styling Preference

The elasticity of the scalp is important to note in the initial It is useful to know how the patient will prefer to style his hair
examination of a prospective hair transplant candidate. It should once the transplanting is completed. Men who have been bald
be distinguished from the amount of scalp mobility, due to other for many years usually say that they have not even thought about
factors that are discussed in Chapter 10. Elasticity can affect this and are usually open to suggestions. Unless the patient is
many things. If the scalp is hyperelastic, the possibility of a emphatic that he will always use a certain styling pattern, it is
wide donor scar, for some reason, is often greater. The surgeon wise to assume that he may change his preferences over the
should be certain these patients are willing to maintain a hair- course of time. The great majority of men prefer one of five
style over the years in which the donor area hair is not trimmed hairstyles:
too short, in case such a scar should occur. To minimize wide
scars, the surgeon should be more conservative in harvesting 1. Swept from one side to the other: This is perhaps the
the width of donor tissue, should leave sutures in for 3 to 7 most common styling pattern. The hair is combed usu-
days longer than usual, and/or should use two-layer closures. ally left to right if the patient is right-handed and the
Also, because scars in hyperelastic patients have a tendency to opposite if he is left-handed.
be wider than usual, ARs are more problematic in these patients. 2. Swept straight back: In this hairstyle, the hair is simply
As indicated earlier, on close inspection, such patients, in addi- swept straight back, or, in some instances, back toward
tion, often tend to have a slightly unnatural appearance where one of the posterior vertex corners. Even if the patient
the grafts exit from the skin, even if they are one-hair or two- intends to comb his hair straight back, it usually angles
hair FUs. There is a tendency for the hairs to be compressed slightly toward the side of the hand doing the combing.
and to take on a slightly pitted appearance. In our experience, 3. Short, layered style: This style has many variations but
this is most pronounced in patients with intensely dark hair. generally features the hair trimmed short and brought
Leaving grafts slightly above the recipient area skin and trim- back obliquely in various directions in a layered fashion.
ming off all or most of the epidermis on the grafts help to 4. Short, curly, permed look: This works particularly well
minimize this problem. for those with naturally curly hair because it is easy to
accomplish by ‘‘messing’’ the wet hair after washing
Whisker Hair it; furthermore, this style appears thicker than it actually
is.
Whisker hair was first mentioned by Norwood in 1980 (10). 5. Parting the hair down the midline: This works best for
As noted earlier, a high percentage of men with whisker hair men or women with at least some persisting original
progress to an advanced type of MPB, and hair transplanting hair and/or minimal hair/skin color contrast and/or for
objectives must be altered accordingly (Fig. 5A-25). individuals treated primarily with FUs.
106 Chapter 5
Whenever possible, the surgeon should try to produce slightly

denser hair coverage in the portion of the recipient area from
which the hair will be combed to create an appearance of greater
density than is actually present. Of course, such a strategy as-
sumes that the patient will commit to a given hair styling pattern
for the rest of his life. It is, therefore, more likely to be a success-
ful long-term solution if the patient is middle-aged or older.
PLANNING THE HAIRLINE ZONE

Of all the decisions the hair restoration surgeon makes, the most
important is the creation of the frontal hairline. Regardless of
how well the remaining scalp is transplanted, it will go virtually
unnoticed if the hairline is unnatural in its location, shape, or Figure 5A-26 The hairlines of maturing men usually recede
composition. There are five considerations in planning the fron- in an inverted V or triangular pattern. This frontotemporal triangle
tal hairline zone: (1) At what height should the hairline be is formed by the more or less simultaneous recession of the tem-
placed; (2) which grafts should be used to create the most ante- poral hairline posteriorly and the frontal hairline superiorly. (WU)
rior aspect of the frontal hairline zone; (3) how ‘‘deep’’ or wide
the frontal hairline zone should be; (4) what shape or contour
the hairline should have; (5) how the periphery of the frontal
hairline zone will be micro-contoured. The manner in which the frontotemporal recessions enlarge and deepen, the apex of
these questions are handled constitutes a large part of the art- the triangle will, nonetheless, remain on the same vertical line
istry required to produce excellent hair transplant results and as it did previously (although at a more posterior position on
distinguishes the experienced hair restoration surgeon from the the head) (5). For many years, hairstylists have used the apex
novice. The actual construction of the hairline zone is covered of the frontotemporal triangle as the most anterior point of the
in more detail in Chapter 12, but some matters related to plan- part, and they recommend this guideline when styling, regard-
ning are summarized in the following section.
The Naturally Maturing Hairline

The hairlines of maturing men usually recede in an inverted V
or triangular pattern. This frontotemporal triangle is formed by
the essentially simultaneous recession of the temporal hairline
posteriorly and the frontal hairline superiorly (Fig. 5A-26). Al-
most all mature Caucasians and Asians who are not bald de-
velop frontotemporal triangles bilaterally to a greater or lesser
degree. Therefore, not only is bridging this frontotemporal trian-
gular recession with grafts technically demanding because of
the fine and sparse nature of temporal hair but also it is unusual
enough in Caucasians and Asians that it inevitably draws un-
wanted attention to the hairline. The older the patient, the more
likely it is that filling in this area will look unnatural (14).
Good cosmetic surgery does not usually draw attention to itself;
instead, it blends in easily with other features, making the indi-
vidual look better or more attractive but for no conspicuous
(and therefore artificial) reason.
Blacks, some Middle Easterners, and, to a lesser extent, peri-
Mediterranean dwellers and Latin Americans, often retain a
rounded, more feminine hairline that curves down at its lateral
margins and is flatter than the typical Caucasian hairline. The
reconstruction of a hairline in these patients, therefore, does not
necessarily involve the creation of an alopecic frontotemporal
triangle. Figure 5A-27 Dotted line A′B represents minimal temporal
recession. Solid line AB represents greater temporal recession. Dot-
The Mature Part ted line CA′ represents minimal frontal recession. Solid line CA
represents greater frontal recession. Although apex ‘‘A’’ obviously
The apex of any alopecic frontotemporal triangle is formed by represents a greater degree of baldness than apex A′, hair parted at
the intersection of the lines of the frontal and temporal reces- A still appears natural and balanced relative to other facial features
sions. When viewed from the front or full-face position, the because it falls on line DD′. (Figures 5A-26 and 27 are reproduced
apex is almost invariably found on a vertical line drawn superi- from the third edition of Hair Transplantation, published in 1995.)
orly from the lateral canthus of the eye (Fig. 5A-27a). Even as (WU)
less of the degree of recession. Styling the hair in this manner 2. Hair parted at the apex of a frontotemporal triangle vis-
appears most aesthetically pleasing for two reasons: ually divides the large, fleshy expanse of forehead, making the
1. With the part at the apex of the frontotemporal triangle face appear more elliptical and thereby balancing the superior
(even a large, deep one), both the frontal and temporal hair fall and inferior aspects of the head (Fig. 5A-27b). Hair parted infe-
away from the part in a gradual, smooth-rounded arc that is rior to the apex creates a long, straight line across the breadth
inherently pleasing to the eye because it is balanced by the soft of the forehead, serving only to accentuate and broaden it and
curves and arcs of the other facial features. As a man’s hair to make the head appear as more of an inverted triangle than
recedes with an expanding frontal triangle, there is always the an ellipse; therefore, the head seems unbalanced and unnatural.
temptation to comb the hair from where he has it over to where When the frontal recession proceeds to the point at which the
he does not. Attempts to part the hair inferior to this apex, apex falls significantly lateral to the outer canthus of the eye
however, create sharp, unnatural angles and lines that invariably or when the entire frontal forelock either recedes or involutes
draw the observer’s eye toward this area of the hairline. to a significant degree, baldness occurs.
Figure 5A-28 (a) This 57-year-old patient with type VI to type VII male pattern baldness (MPB) was clearly destined to evolve into
Type VII and had an unusual request. He wanted to preserve what was left of his temporary fringe hair and to raise it to a level where it
would look as if he had type V MPB. He was not interested in producing frontal hair to frame his face because, as he said, ‘‘People know
me as bald.’’ This photograph shows him in 1994, 4 months after 800 micrografts had been transplanted (400 hundred superior to each
temporoparietal area). The transplanted hair had barely started growing. He thus ‘‘invented’’ the important concept of restructuring a lateral
hump. (b)An intra-operative photo of the second session. Another 800 micrografts were transplanted to raise this superior temporoparietal
fringe a further 2.5 cm while at the same time thickening the previously treated fringe. (These photographs were reproduced from the third
edition of Hair Transplantation, published in 1995.) (WU) (c)This photograph shows the result in this patient after four sessions. It was
taken for this text 8 years after the patient’s first session. Once the humps had been created, the patient had agreed to two more sessions.
The first of these two was used to create a bridge of hair across the midscalp and the second to create a frontal tuft. Today, we can
accomplish the same or even better results in one or two sessions. In 1994, a session of 800 micrografts was generally considered a seriously
large undertaking. (See also Fig. 5A-38.)
108 Chapter 5
The aesthetic consequences of this normal process are that of hair and face. As seen in Fig. 5A-30, even small linear devia-
(1) in nearly all patients, the only appropriate reconstructive tions in a lateral direction from the outer canthus of the eye
option is the restoration of the frontal forelock and the temporal result in larger, inferior deviations of the part because the up-
fringe, and (2) the final depth of the reconstructed triangle must ward vertical projection of these lines falls on the perimeter of
always be determined by the intersection of a line drawn verti- an ellipse. Patients readily grasp these points when the surgeon
cally from the outer canthus of the eye with the anterior line draws a wider hairline and demonstrates the lower and more
of the temporal fringe. Therefore, the location of this apex is lateral part on their own heads. The surgeon can then advance
determined by the extent of the temporal recession or its recon- the temporal side of the triangle with a gentian violet marker
struction. Whether this point is more anterior or posterior de- to further demonstrate that this area has contributed, unsuspect-
pends on the degree of angulation of the anterior border of the ingly, to the baldness for which the patient seeks treatment.
persisting or transplanted temporal fringe, or hump (Fig. 5A- It follows from the foregoing discussion that a patient with
6). Shapiro has referred to a transplanted temporoparietal fringe more advanced alopecia and an anterior temporal fringe situated
as a hump and deserves the credit for realizing how aesthetically far posteriorly can only avoid an unnaturally wide or bizarrely
important its reconstruction is in a man with extensive MPB shaped hairline if he is willing: (1) to expend donor hair in
(14). It should be pointed out, however, that in the third edition recreating a new anterior-temporal zone or a new temporoparie-
of Hair Transplantation, Unger showed one of his patients who tal hump (Fig. 5A-6), or (2) to undergo scalp extension (see
featured such a transplanted hump. It was, in fact, suggested Chapter 20) or one or more ARs (Fig. 5A-29 and 30b). As shall
by the patient who was thus the first to ‘‘invent’’ it (15) (Fig. be discussed later; planning involves a decision-making process
5A-28). As noted earlier, the hump’s importance is not only based on a series of tradeoffs to accommodate patients’ current
related to its location, degree of angulation, and shape but also wishes and the future progression of their hair loss. If anything,
to the direction and angle of the hairs within it. Such humps the increase in the number of treatment modalities now avail-
are best created exclusively with FUs or a combination of FUs able has made the decision-making process more complicated.
and DFU grafts. Their reproduction is technically difficult and Ironically, it is this same increase in options that has allowed
consumes donor tissue that, at a later time, may be better used greater numbers of balding patients to consider and be consid-
in other areas affected by MPB. However, the ultimate decision ered suitable for hair transplanting.
to create a hump or an isolated frontal forelock primarily be-
longs to the educated patient, assuming enough donor hair exists Setting the Height of the Frontal Hairline
to pursue either plan. The surgeon can also alter the level of
the superior border of the temporal hair and the angulation of The ‘‘hairline,’’ of course, is not a ‘‘line’’ at all, but a zone
its anterior border with various patterns of ARs (Fig. 5A-29), whose characteristics Nusbaum has outlined as follows: it has
and this, too, should ideally be offered to such patients. (1) a somewhat wavy anterior border; (2) random hairs, singly
Attempts to obliterate a larger area of the frontotemporal (sentinel hairs) or in groups protruding anterior to the general
triangle by overcompensation with a broad frontal hairline be- mass of hairs in the hairline zone; (3) fine-textured hairs most
ginning more laterally, succeed only at the expense of the natu- anteriorly, gradually becoming progressively coarser as one
ral part and generally appear unnatural. This plan places the moves more posteriorly; (4) low density hair most anteriorly,
part further laterally and inferiorly, thus distorting the balance gradually becoming progressively denser as one moves more
posteriorly; and (5) irregular hair density within the general
change noted in (4). As mentioned earlier, Arnold has pointed
out that the hairline zone is also often wider laterally than anteri-
orly.
Where should the most anterior hairs of the hairline zone
be located and what overall shape should the hairline have?
Dow Stough has suggested a routine measurement of 8 cm to
9 cm superior to the glabella as a ‘‘reliable starting point’’
in designing a ‘‘mature hairline.’’ For many years, Unger has
suggested a more flexible approach. He recommends that sur-
geons begin by choosing the points that they think ultimately
will be the anterosuperior-most temporal points and joining
them either with an oval or bell-shaped line to the anterior-most
point of a proposed hairline so that the line runs more or less
horizontally when viewed laterally (16). By accentuating or
minimizing the bell shape, the anterior-most point of the hairline
can be raised or lowered, respectively, while a horizontal dispo-
sition is maintained. (A reconstructed hump allows more op-
Figure 5A-29 Alopecia reduction (AR) raises the anterosuper- tions.)
ior points of the temporal area—the starting-points and end-points Beehner has suggested that the anterior-most point of the
of the new hairline—so that the most anterior midline point of the hairline be located in a zone of transition where the forehead
hairline can also be placed more superiorly while maintaining a begins changing from a more or less vertical orientation to one
hairline that runs more or less parallel to the ground when viewed that slopes posteriorly to the more or less horizontal orientation
laterally. In addition, AR alters the level of the superior border of of the top of the head. We have already suggested earlier in
the entire temporal and parietal areas. (WU) this chapter that this recommendation should be combined with
Figure 5A-30 (a) This schematic demonstrates the importance of placing the transplanted hairline correctly so that the lateral point E
of the reconstructed hairline GE falls on line AA′, which is drawn vertically from the outer canthus of the eye (point C). Attempts to
decrease the exposed frontotemporal GEF by shifting the part to a more lateral position along the line JJ′ from point C to D demonstrate
the unexpectedly large inferior shift in the part (lines EH and FD) for relatively small lateral shifts (line CD). Compare line CD with lines
EH and FD. This occurs because small lateral shifts, when projected vertically on the lateral perimeter of an ellipse (the head), cause large
inferior shifts. (Figures 5A-29 and 30a were reproduced from the third edition of Hair Transplantation, published in 1995.) (b) (A), Side
view. (B), When viewed from above, only the anterior portion of temporal fringe permits a part to be placed through it. The rest of a
cosmetically appropriate part-line will pass through areas that must be transplanted. (C) Proposed inverted Y reduction outlined above.
Carrying out such an AR will elevate the posterior aspect of temporal fringe that contains original hair that is dispersed more evenly and
naturally than any hair restoration surgeon can create. (This schematic was reproduced from the third edition of Hair Transplantation,
published in 1995.) (WU)
Unger’s proposal during the decision process regarding the ap- to work better in men with somewhat elongated, more vertical
propriate degree of accentuation of the bell shape. Alt has fur- facial structures, because it produces the appearance of a lower
ther noted that although, as Da Vinci claims, the ideal division hairline at the cost of relatively few grafts. Whenever this design
of the face is the one of equal thirds shown in Fig. 5A-31, the is employed, the surgeon should try to create it with fine-tex-
superior border of the upper third is not actually the hairline tured donor hair and single follicle grafts and should try to raise
but the point to which the hair falls when it is styled in the way the height of the rest of the hairline to conserve grafts.
the patient intends to wear it (16). Obviously, if the patient As seen from the above discussion, arbitrary rules as to
plans to comb his hair somewhat anteriorly and to one side or where to locate the anterior-most point of the hairline—for
the other, the anterior-most point of the hairline can be placed example, a fixed number of finger widths above the eye-
somewhat more superiorly while the ideal ‘‘rule of thirds’’ is brows—are too simplistic. It should be enough to point out that
still maintained. Beehner, using the inferior reference point of some physicians have fat fingers and some have skinny ones.
the supraeyebrow line, places 95% of his hairlines 7 cm to 8 Choosing where to precisely place the hairline is impacted by
cm above the eyebrows, which results in essentially the same three important considerations:
location as Stough uses. Finally, many patients seem to prefer 1. Age of the patient: If the patient is in his early 20s, the
a widow’s peak to a rounded midline shape. This is a preference surgeon should most often draw the hairline somewhat higher
that has waxed and waned over the last 30 years but which within the previously described range. This protects the patient
seems to be growing in popularity. The widow’s peak seems from the cosmetic consequences that would later ensue should
110 Chapter 5
Figure 5A-31 Although the face should be divided into thirds

according to Leonardo Da Vinci, the hairline in the figure refers
to where the hair falls rather than to the actual hairline. In many
men, a higher hairline than that which produces the result shown
is also acceptable (see text). (This schematic was reproduced from
the third edition of Hair Transplantation, published in 1995.) (WU)
he develop a type VI or type VII MPB. In this age group, both

the height and the contour of the frontal hairline should ideally
be such that the patient’s transplanted hair can be converted
into an aesthetic, isolated frontal forelock pattern at some future
time, if necessary.
2. Position of the temporal hair: In the final analysis, there
should be a pleasing proportion between the temporal hair and
the frontal transplant zone of hair. The temporal hair aestheti-
cally serves the purpose of holding up this frontal hair. (Two
examples of the extremes of temporal hair position are demon-
strated in Fig. 5A-32). The patient’s age is essential in evaluat-
ing this hair because, as noted earlier, in a younger man the
anterior temporal border is likely to migrate posteriorly in future
years. If the temporal hair is already set fairly far posteriorly,
closer to the ears, a more superior frontal hairline height pro-
duces a more balanced and aesthetic appearance. On the other
hand, another option is to strengthen this temporal area with
FUs if the hair is sparse, or to transplant anteriorly to the existing
temporal hair. Adding grafts in this region assumes that ample
reserves of donor hair are present and that the surgeon and
the surgical team are capable of artistically transplanting small,
closely spaced, properly angled grafts there. If the patient’s hair
characteristics or estimated long-term donor/recipient area ratio
is less than ideal, this area is often best left untreated, unless
the objective is a relatively light coverage of only the frontal-
third to half of the evolving area of MPB. Beehner limits this
latter option to patients 35 years of age or older. Unger considers Figure 5A-32 (a) Two extremes of temporal hair positions are
it for those younger than 35 years of age as long as he is confi- demonstrated in this figure. Part a identifies the anterotemporal
dent that the patient fully understands its consequences (See hair set far posteriorly in a 65-year-old man. (b)The anterior temple
Chapter 17.) hair is in a very anterior position in this 32-year-old man. Occasion-
3. The patient’s input: At the consultation or on the day of ally, the surgeon adds grafts to a sparse temporal area or transplants
surgery, the surgeon should allow the patient to choose where anteriorly to the existing temporal hair so that a temporal area holds
he prefers the hairline to be placed, as long as it falls within up a more anterior location for the frontal hair. In this patient, the
the allowable normal range. Some men do not want their hair- anterior temporal border was anticipated to migrate posteriorly in fu-
line placed too inferiorly because it creates too jarring a change ture years unless it was transplanted with follicular units to reinforce
from their former appearance. However, if they request a hair- it and to create more permanent hair density at the site. (MB)
line that is too superior, then the face will not be framed properly pleasing to the eye. As implied earlier, most are drawn with
because too much hairless forehead is left exposed. In such one of two contours: Either they are smoothly rounded or are
cases, we usually try to persuade the patient to have the hairline rounded and flare outward as they approach the lateral temporal
placed no higher than 10.5 cm above the glabella. A much more areas.
frequent problem is the patient who wants the hairline placed
too low and has to be persuaded to accept a higher placement. Flared Hairline
This is usually because the patient is young, the temporal hair The flared or bell-shaped hairline, in our opinion, is the pre-
has receded too far posteriorly, or the patient requests that the ferred hairline for the great majority of transplant patients be-
surgeon place the hairline somewhere on the vertical plane of cause it most accurately mimics the natural hairline of the ma-
the forehead. jority of men in their 40s, 50s, and later decades who have not
lost much of their hair. Furthermore, the flared hairline can be
Summary styled in a variety of ways, even with its entire breadth exposed.
Our approach to setting the hairline height is first to ask the As noted earlier, accentuating the flare also allows the surgeon
patient how he would prefer to style his hair if the frontal region to raise the anterior-most midline point of the hairline, thereby
were filled in with hair. We then tell him that we will draw the conserving donor tissue without affecting the more or less hori-
hairline at a location we would choose if we had our ‘‘druthers.’’ zontal orientation of the hairline when it is viewed laterally.
For the great middle ground of patients, who are in their 30s Thus, flare accentuation also reduces the anterior to posterior
or 40s and possess an average amount of temporal hair, we set length of the alopecic area to be treated.
the hairline approximately 7.5 cm to 9 cm superior to the gla- The flared hairline is rounded frontally, and, as it heads
bella. The deciding factors for whether to place it more superi- posteriorly and then laterally, it gently curves outward to create
orly or inferiorly within this range are the patient’s age, his a bell-shape with a natural appearing frontal recession (Figs.
forehead anatomy, the adequacy of the donor supply, and the 5A-33 and 34). This most lateral aspect of the flared hairline
location of the anterior temporal hair. After we have drawn the is directed into the temporal hair. It is important, particularly
hairline, the patient has a chance to see it in the mirror and to in the younger patient, to take the precaution of joining the
give his reaction. Such an approach prevents the surgeon from lateral-most point of the hairline to where the surgeon expects
seeming too dictatorial or forceful, but, at the same time, it the anterosuperior-most point of the temporal hair will eventu-
gently nudges the patient in the correct direction. In consider- ally be. This is nearly always 1 cm to 2 cm posterior and inferior
ably more than 90% of cases, this initial hairline is accepted to where it is located on a younger patient being seen for the
by the patient, especially if we take the time to explain why it first time (Fig. 5A-33). Such a strategy allows for the natural
works well for him in terms of all the factors discussed earlier. posterior and inferior receding of the temporal hair and prevents
For many transplant surgeons, the placing of the hairline the possibility of later having a frontal hairline that curves infe-
height is actually only a starting point for the hairline. As subse- riorly into an abyss of alopecic skin.
quent sessions take place, there is a tendency for the hairline
to wander inferiorly beyond the initially placed line. This is
usually not so much a deliberate attempt to overextend the pre-
viously set hairline but rather the subconscious result of the
surgeon seeking to make the frontal hairline more natural and
fuzzy with sentinel hairs and other jutting groups of fine tex-
tured, one-haired grafts placed anterior to the original line. If
the surgeon has experienced a tendency to ‘‘wander’’ anteriorly,
this impulse should be borne in mind at the time the hairline
is first drawn and should result in a line drawn more posteriorly
than the surgeon actually intends it to ultimately be.
Type of Grafts Used at the Hairline

We favor a frontal transition zone that is approximately 1.5 cm
to 2 cm in depth. The coarser the hair and the greater the hair/
skin color contrasts, the wider the zone should be. We prefer
using a combination of one-hair to three-hair FUs in this area,
with all of the irregularly spaced anterior-most grafts containing
one hair each. The rest of the hairline is created with two-hair
and three-hair FUs. Some hair restoration surgeons, who use
FUs exclusively, employ only one-hair FUs throughout the en- Figure 5A-33 An example of a gently flared frontal hairline
tire width of the hairline zone and rely on various degrees of that is aesthetically pleasing in appearance. Note also that the lateral
graft densities/cm2 to effect the desired hair density gradation. ends of the proposed hairline are 1 cm to 2 cm posterior to where
they are currently. The patient is young, and the anterorsuperior-
Setting the Contour of the Frontal Hairline most points of the temporal hair will move to a more posterior
location with the passage of time. Ending the transplanted hairline
Over a period of years, most physicians acquire an innate knack where these points presently exist would cause the hairline to curve
for repeatedly drawing naturally contoured hairlines that are into an abyss of alopecic skin. (MB)
112 Chapter 5
Figure 5A-34 (a) A 38-year-old patient before transplanting. (b)In this man, the frontal hairline was gently flared to fill deep temporal
recessions and to leave a normal-appearing frontotemporal gulf. This photograph was taken after four sessions. The patient also requested
a widow’s peak, which was created with follicular units. In most men, however, it is wiser not to come as far down on the forehead as I
did here. (This patient’s abundant donor reserves and the contours of his face and head made it reasonable for him to have a widow’s peak
in the position shown). (MB) (c) A 56-year-old man before transplanting. (d)The patient is shown after four sessions of follicular units
(FUs)/small minigrafts (average 650 FUs and 350 small multi-FU grafts per session.) The frontal hairline shows gradation of one-hair FUs
into two-hair FUs and eventually into a small minigraft zone. The slightly flared hairline has been directed into the patient’s temporal hair.
(MB)
Rounded Hairline 1. Men who prefer a side-to-side hairstyle: For those patients
The other commonly used hairline contour is the rounded, who firmly intend to style their hair always from one side to
somewhat hemioval one, as drawn in Fig. 5A-35. Some hair the other, usually with the hair falling somewhat inferiorly onto
restoration surgeons employ this contour on most of their pa- the forehead, a rounded or more oval hair contour often serves
tients. With their expertise, good patient selection, a properly better than a flared one. Such a naturally occurring hairstyle
set hairline height, and creation of a ‘‘feathered,’’ irregular, can be seen on the American television personalities Tom Bro-
natural hairline, this rounded contour can produce highly ac- kaw and Bob Costas. Often, men who use this hairstyle who
ceptable results. In our own practices, this contour is used in are starting to lose their hair seek help because they want their
approximately 10% to 15% of patients. We primarily reserve frontotemporal recessions reduced in size. A more rounded hair-
it for the following groups: line accomplishes this reduction and gives them more hair to
Figure 5A-35 A relatively flat hairline proposed for transplant-

ing the frontal area in an Asian man with typically wide facies.
(MB)
sweep from one side to the other. Such patients should be told
that if they later opt to style their hair straight back, for example,
when they are in their 50s or 60s, this hairline might draw
attention because it lacks the indented recessions usually seen
in older men.
2. Ethnic groups that typically feature rounded hairlines:
As noted earlier, many ethnic groups, most notably Blacks,
Hispanics, some Asians (Fig. 5A-35), and some of Mediterra-
nean descent, feature more rounded, sometimes flatter hairlines.
Even older men, if they are not affected by MPB, often retain
these rounded hairline contours. They also usually have abun-
dant temporal hair that begins more anteriorly than in the aver-
age Caucasian. In addition, if the patient’s hair is naturally curly,
as in Black men, such hairlines are easy to conceal and have
a naturalness imparted to the hairline by the curly hair.
3. Men with a long frontal region: Some patients with MPB
possess a longer than average anteroposterior distance from the
anterior-most border of the midscalp to the ideal most anterior
point of the ideal frontal hairline (Fig. 5A-36). These men often
have a somewhat narrow, vertical head shape. If the surgeon
chooses the flared hairline for such a patient, the frontal zone
of hair may turn into a narrow, frontal column of hair rather
than a full frontal zone of hair that frames the face. For such
men, the hemioval contour allows more hair to be placed in the
frontal region and gives the patient the optimal appearance. Figure 5A-36 (a) A 43-year-old man with frontal baldness and
a larger-than-average distance from the anterior border of the mid-
scalp to the most anterior point of a residual isolated frontal forelock.
An Arbitrary, Step-by-Step Method for Creating a (b)The patient shown in Fig. 5A-36a after three sessions of trans-
Frontal Hairline planting in the frontal and midscalp areas, plus the placement of fol-
licular units to form a new temporal point and anterior temporal line
Most of us do not possess the artistry of Leonardo da Vinci and that hold up the new frontal area in an aesthetically pleasing way.
cannot draw freehand, natural looking, aesthetically pleasing, (c)A close-up of the patient shown in Fig. 5A-36b, showing the
contoured hairlines without the aid of some organized method. proper angle and direction of the frontal hairline hairs, and also the
The following is a step-by-step method used by Beehner for steep, acute angle of the transplanted anterotemporal hairs. (MB)
114 Chapter 5
drawing the slightly flared hairline that he uses for the majority is observed from the front. (WU) If there is any asymmetry,
of his male patients: the portion of the hairline that is asymmetrical is corrected,
Initially, three points are designated. The first of these is with a new line drawn anterior or posterior to the previous
the midpoint of the frontal hairline. The patient’s head is bent one. Only then is the previously drawn asymmetrical segment
downward, so that the midpoint is visible aligned with the tan- erased. This new hairline is again viewed from above to check
gential view of the nose’s position, and the surgeon can be that the correction is adequate.
certain of identifying the true midline. This point is then en- This is only one example of an organized system for creating
larged into a tiny curved arc (Fig. 5A-37a and b). a relatively natural but essentially symmetrical hairline. Despite
The two lateral points are then drawn as follows: Holding the foregoing discussion, as with other aspects of our body,
a pencil vertically and aligned with the lateral canthus, and slight asymmetry is more normal than perfect symmetry, so
with one eye shut, (the one that is not directly aligned with the slightly less than symmetrical perfection in drawing this frontal
patient’s corresponding eye), the surgeon moves one finger to line is a virtue.
a position along the temporal recession and aligns it with the
pencil (Fig. 5A-37a). Rather than marking this point precisely
at the frontotemporal corner, the surgeon deliberately places it MICROCONTOURING THE FRONTAL
approximately 1 cm to 2 cm (sometimes further) posterior to HAIRLINE
the existing corner but still in line with the lateral canthal line.
After marking the lateral points on each side, the surgeon Although Beehner prefers to create a natural, fuzzy hairline
next makes certain that they are aligned at equal lateral depths simply by randomly placing small grafts in the frontal hairline
and are truly opposite each other and equidistant from the midzone during each session, others have advocated a planned mi-
line. The surgeon does this by having the patient bend over crocontouring of the front hairline at the time of the first session.
once again so that the top of the patient’s head is facing the As Shapiro has proposed (14), such a plan may feature a pre
surgeon. Using the nasal tip as a midline reference point, the drawn, wavy line along which the transplant progresses at each
surgeon then visually extends a vertical line back between the session, or, as Parsley suggests (17), it may take the form of
two lateral marks, locating a point coronally aligned with the small ‘‘mounds,’’ which are placed at the midpoint and a few
lateral points, and marks that spot (Fig. 5A-37b). The surgeon centimeters lateral to the midpoint on each side. Parsley dis-
next takes a centimeter ruler and measures the distance from cusses his hairline construction in detail at the end of this chap-
this new midline mark to each lateral mark to ascertain that the ter. Unger describes his relatively organized approach to micro-
distances are equal. If the patient is to have a hemioval, more contouring the frontal hairline in Chapter 12. Whether the
rounded hairline, the surgeon then simply draws a curved free- unplanned or the planned microcontouring approach is used, it
hand line connecting each lateral mark with the tiny frontal is always valuable to include lone, one-haired sentinel hairs,
mid-line arc. which stand out in front of the hairline and help to create a
If, on the other hand, the surgeon plans to create a flared natural, visual blur along the hairline. Such grafts help greatly
hairline, as is most often the case, four more marks need to be to minimize the wall effect or the transplanted look.
drawn. On each side, the surgeon draws a slightly oblique, short
line approximately 0.5 cm to 1 cm. lateral to the lateral mark that Six Pitfalls in Creating the Contour of the Frontal
has already been made. The surgeon then marks an intermediate Hairline
point on each side, which is 1.5 cm to 3 cm anterior to this
new lateral point and 1 cm to 2 cm medial to it. Next this mark Much of the preceding can be summarized as the avoidance of
is visualized as medial to the point where a perfectly rounded the following six pitfalls:
hairline passes on its way from the midline frontal point to the 1. Too high: Some hair restoration surgeons are so worried
initial lateral point. A similar point is also drawn on the other about placing the hairline too low that they over compensate
side. by placing the hairline so superiorly that it provides little if any
With the small front-central arc as a starting point, a full, framing for the face. This is generally not a serious problem,
curved line is drawn from it to the intermediate point on each because it is easily correctable with additional grafting. In older
side, creating a medium-sized, smoothly rounded half circle patients, with donor/recipient area ratios that are more than
(Fig. 5A-37c). adequate, even the usually acceptable hairline levels might seem
Next, the surgeon arbitrarily proceeds to complete the right too high to the patient. Unger has had several patients who
side first (which seems easier, if the surgeon is right-handed). insisted on lowering their hairlines after he had completed trans-
Starting at the end of the half circle, the surgeon draws a gently planting the frontal area at a level he urged the patients to accept
curved line that flares out laterally and meets up with the lateral- by insisting that anything lower would look unnatural. He con-
most of the two lateral marks (Fig. 5A-37d). This is then re- siders himself fortunate that these patients were so pleased with
peated on the left side, creating the full, ‘‘flared’’ hairline. their initial results that they accepted the inconvenience of addi-
It remains extremely important to double-check the symme- tional surgeries to achieve the effect they had initially requested
try of the hairline. The best way to accomplish this is for the (Fig. 5A-38 and Chapter 17).
surgeon to stand behind and over the patient, looking down 2. Too low: Setting the hairline too low is probably the worst
on the hairline from above, with the nose tangentially visible. transplanting sin, because it is often impossible, or at least ex-
Standing behind the patient and looking in a mirror from the ceedingly difficult, to correct later. A hairline that is too high
patient’s perspective to see the frontal reflection is also useful. can always be lowered, but raising a hairline that is too low is
Frequently, the right side of the hairline appears higher than a challenging task. The error is most frequently committed in
the left, even though they look symmetrical when the patient younger patients, who often demand a low hairline in order
Figure 5A-37 (a) The small front-central arc has already been drawn. The physician is now holding a pen alongside the patient’s lateral
canthal line and using his finger to mark the spot where this line intersects deep in the frontotemporal gulf region. (b)A central mark
(aligned with the nasal tip) is made. (c) A half-circle is created from the anterior midline arc to an intermediate point along the proposed
hairline. (d)The intermediate point is connected with the far lateral point by a gently curved concave arc. (MB)
116 Chapter 5
patient, ‘‘I don’t want you throwing darts at my picture in 20

years because I created a hairline that I know will eventually
make you unhappy.’’
3. Too round: Except for some Blacks and the other ethnic
groups mentioned earlier, it is unnatural for a mature man to
have a round hairline that resembles the edge of a cereal bowl.
Such a hairline appears unnatural precisely because, for most
races, it does not usually exist in nature.
4. Too flat: An overly flat hairline is also unnatural in most
men, although again, in some ethnic groups, a flat hairline is
common and natural. In these individuals, it is usually accompa-
nied by a wide facial structure and full temporal hair that ex-
tends farther anteriorly than usual. The mistake of making the
hairline too flat often occurs when an inexperienced surgeon
sets the central hairline height at an appropriate location and
then connects this point with the frontotemporal corners, which
happen to be positioned more anteriorly than usual. This ap-
proach leads to an extremely short ‘‘front porch’’ to the frontal
area. In patients with especially anterior frontotemporal corners,
an overly flat curve can be avoided simply by aiming the lateral
ends of the hairline more posteriorly and inferiorly as discussed
earlier.
5. The V: It is extremely rare to see a natural hairline that
is in the shape of a sharply angled V. And yet this contour is
seen from time to time on men with hair transplants. It should
be avoided as a frontal hairline contour in transplanted patients
because it draws attention owing to its relative rarity in the
general population. This frontal V shape is to be distinguished
from a small V-shaped widow’s peak, which is naturally present
in some men and which is reasonable to reproduce with FUs
if the patient asks for it (Fig. 5A-34).
6. The frontal hairline that becomes unsupported laterally:
It is certainly acceptable to create a frontal forelock, even an
isolated one, in a young man whom the surgeon suspects will
Figure 5A-38 (a) A patient before transplanting in 1991. Note ultimately develop a Norwood type VI or type VII MPB. How-
the lateral triangle marked in black crayon. At that time I referred ever, as stressed earlier, it is unacceptable to flare the lateral
to this area that was always transplanted concomittantly with the aspects of the frontal hairline into the anterior-most temporal
frontal area medial to it as the ‘‘ledge.’’ Today we call it the ‘‘lateral hair of such men, only to see the natural balding process erode
hump.’’ (b)After three sessions of transplanting were completed, the temporal hair inferior to it. The latter hairline leaves the
the patient asked for his frontal hair to be moved more inferiorly transplanted hair sitting there awkwardly, with nothing to sup-
and his temporal hair more anteriorly. This had been his original port it. Because correcting this mistake is a difficult challenge,
request, and I persuaded him to proceed with a more conservative it is worth repeating that in young men it is best either to flare
plan. Several of my patients insisted on lowering their hairlines the lateral arms of the frontal hairline to end well posterior to
after I had completed transplanting the frontal area to a level that the present anterosuperior-most point of the temporal area or
I encouraged them to accept, insisting that anything lower would
simply to conduct the hairline directly into lateral transplanted
look unnatural. Fortunately, they were so pleased with their initial
areas of the midscalp without flaring it.
results that they accepted the inconvenience of additional surgeries
to achieve the effect that they had initially requested. This patient
demonstrates that the doctor is not always right and should listen Setting the Angle and Direction of the Frontal Hairs
carefully to intelligent and thoughtful patients. (WU)
For the man who still has some residual hair in the frontal
region, placing the recipient sites in this area with the proper
angle and direction is simply a task of following the existing
hairs’ angle and direction. The vast majority of patients have
to appear similar to their peers. It probably behooves all hair some discernible remaining hairs, however vellus or miniatur-
restoration surgeons to have some ‘‘line in the sand’’ beneath ized they are, at or near the hairline area, whose angle and
which they refuse to place a hairline, a patient who rigidly direction the surgeon should attempt to imitate exactly. This
demands a lower hairline will be rejected for hair transplanta- greatly simplifies the entire task of creating a new hairline. It
tion. In discussing this subject with such a patient, it is important is important to realize that normal hair direction varies enor-
to go to great lengths to explain how a low hairline carries with mously from patient to patient, and no single rule on this subject
it the later risk of appearing unnatural. Beehner often uses the is optimal for all patients. The individual shown in Fig. 5A-
tactic of injecting a little humor into the situation by telling the 39a–c is the son of Walter Unger. His short hairstyle enables
Figure 5A-39 (a) Hair direction in the temporal area is most commonly directed anteriorly and inferiorly as is shown in this patient.
At a level that would be the natural part-line, the direction is almost exactly anteroposterior to a point beginning at the lateral midvertex.
The hair gradually changes medial to the part-line, turning in a slightly medial or coronal direction. (b)A frontal view of the same patient
with the head tipped down. Note the slight rightward direction of the hair on this individual’s left side, which continues past the midline.
The hairline zone hair on his right side is directed more anteroposteriorly, but posterior to the hairline zone, it is directed slightly to his
right side. (c)Note the peculiar hair directions at the center of the whorl of the same patient’s head. This area should be treated only with
follicular units if damage to existing hairs is to be avoided. Note also that the hair on the right side of the patient’s midscalp is directed
sharply to the left, crossing the direction of the hair in the left midscalp. The author (WU) has frequently seen this pattern in other patients.
one to see clearly hair directions that are normal for him, but, than anteriorly. If these hairs are of reasonably good caliber, it
particularly in the vertex area, not normal for many others. is best to use FUs exclusively in this area and to ensure that
Hence comes the recommendation that surgeons generally the newly transplanted hairs follow the orientation of the hairs
should follow what they see on their patients’ heads instead of already present in this cowlick. However, if the cowlick consists
following some arbitrary general rule. It is sometimes difficult of fine, vellus hairs that are unlikely to be present in a few
to discern hair direction accurately when the hair is more than years, it is best to ‘‘march through’’ the cowlick area and to
2 cm to 3 cm long. Jerry Wong asks his patients with relatively prepare the recipient sites in such a way as to produce the usual
early MPB to cut their hair very short before surgery. This anterior and slightly coronal orientation of the hairs. This is the
makes it easier for him to decide accurately on hair directions lone exception to the rule of always following the direction of
in different areas. Although this makes postoperative camou- the existing hair.
flage of the surgery more difficult, it might be a worthwhile For the very small minority of men without any visible hair
trick to use if surgeons are relatively new to hair restoration in the recipient area, hairs should be directed anteriorly and
surgery or if they have noticed frequently that their treatment also slightly to the left or right or, occasionally, inferiorly in
appears to accelerate hair loss in early MPB. the lateral aspects of the frontal area (18). The slightly coronal
We often see men who still retain a frontal cowlick, in which direction of hair has advantages in producing the appearance
hairs may be directed in one or several different directions other of denser than actual hair density if multi-FU grafts are used
118 Chapter 5
and if the hair is combed from one side to the other or straight well as in a ‘‘frontal tuft’’ in the frontal area (22) (see Chapter
back (see Chapter 12F Hair Direction section). Within the com- 12D). This process is described more fully in Chapter 12 (Harris
mon denominator that the hair in most hairlines generally has discusses his method of increasing the number of three and four-
an anterior orientation, there are several different variations that hair ‘‘recombinant’’ FUs in the same chapter). In the majority of
are acceptable. We recommend asking a totally alopecic patient our patients, the authors use a combination of FUs in the frontal
whether he has a strong preference for parting the hair on one hairline and a mixture of slightly larger grafts in the central
side or the other. If the patient replies that he would part his frontal region posterior to the hairline. Fig. 5A-40a–40d illus-
hair from the left or that he would use any other hairstyle besides trates Beehner’s general approach to the frontal transplant zone
parting on the right, we would direct all of the hairs along the and midscalp. Unger’s general approach when employing FU/
left side of the hairline antero medially. We would then continue Multi-FU grafting is discussed in Chapter 12 and is schemati-
through the frontal apex of the hairline with the recipient sites cally shown in Fig. 5A-40e. Clinical examples of Unger’s re-
still directed anteriorly and still somewhat toward the right. sults with this grafting pattern are seen in Fig. 5A-16, 17, 18
As the hairline would complete this curve and start to head and 20), and in Chapter 12F and G.
posteriorly, then gradually, over the course of a 1 cm to 3 cm It is important to take into account the patient’s age and to
segment of the hairline, we would gradually reorient the sites project what is likely to occur as MPB progresses. If the patient
so that they would now head almost directly anteriorly (Fig. is young, there is always the chance that the temporo parietal
5A-39b). If the patient should part his hair on the right, we fringe will recede farther than the surgeon originally thought,
would make the recipient sites in a mirror-image fashion from leaving the transplanted frontal hair as an isolated forelock. It
that just described, starting on the right. We have found after is, therefore, important to use FUs and DFU grafts in the lateral
carefully observing hundreds of men with residual hair in this aspects of this region so that such a forelock has a more natural
region, that the pattern of orientation as described, with a pre- looking periphery.
dominantly left-to-right direction through the anterior-most
frontal curve, is the one most commonly seen. Variant Pattern of Hair Loss
The recipient sites at the hairline should also be made so
Approximately 15% of men who experience MPB have a var-
that the hair projects out at a 20 degree to 45 degree angle from
iant pattern of hair loss that usually affects only the frontal
the scalp—most often closer to 20 degrees than 45 degrees and
region (Fig. 5A-41a,b). For the variant pattern, it is fairly easy
never vertically. This normal range applies to the entire scalp,
for both the doctor and the patient to agree on a plan. The area
except for the temporal and vertex regions, where hair usually
to be transplanted is relatively small, and there is only one
grows at a more acute angle. A hair angle that is toward the
hairline with which to deal. A small amount of work in the
lower range of normal angling is sometimes useful in patients
limited frontal area of hair loss accomplishes a great deal by
with extremely thin scalps. Lucas advocated directing the hairs
simply framing the face.
of the frontal hairline anteromedially on the left and then contin-
uing this same rightward orientation all the way around to the
right temple, with all hair swept in one direction (19). Having Deep Temporal Gulf Pattern
the hair extend radially away from the curved hairline has also This is a relatively common pattern of hair loss that requires
been proposed in various texts in the past as a legitimate option transplanting only in the frontal area. The hair posterior to these
(20). Unfortunately, the latter configuration is not often seen large receded areas is often fairly dense, whereas the frontal
in the natural state, and thus we believe it carries some risk tuft of hair that projects out medially between these two gulfs
of appearing unnatural and of being difficult to style. This is can range anywhere from full density to thinning, partly vellus
especially true if the hair is angled acutely (less than 30 de- hair. A number of decisions have to be made before transplant-
grees). ing such a patient. The surgeon should closely examine the hair
in the frontal tuft, and if there is any suggestion of thinning
Transplanting the Frontal Region there, it is wise to transplant through the hair-bearing frontal
region in addition to transplanting the posterior aspect of the
The frontal transplant zone shown in Fig. 5A-1 is the area of recessions. Even when the hairs in the frontal tuft are full and
the scalp most commonly transplanted. As explained earlier, dense and the surgeon decides not to transplant through this
Unger has recommended that for a better understanding of the area, it is wise to at least ‘‘march through’’ the anterior part of
typical extent of this area when it is transplanted, the anatomical this frontal hair to a depth of approximately 1.5 cm to 2 cm.
frontal region is slightly expanded to include a narrow area of This creates a visual continuity across the breadth of the hairline
the anterior midscalp and takes on a concave posterior contour. that will endure even after the patient’s own frontal hairs have
The importance of the frontal transplant zone derives from the started to thin and fray at the edges. In our experience, omitting
fact that it principally provides the framing for the face. Starting this follow-through transplantion from one side to the other at
with a feathered frontal hairline zone, there should be a gradual the frontal rim often leads to a situation years later in which
transition to greater density posterior to the hairline zone. Sur- the central portion becomes thinner than the lateral areas that
geons who use combination grafting create this transition with were transplanted earlier.
a combination of multi-FU grafts and FUs and, in the densest One final comment about transplanting these temporal gulf
areas, with round grafts. When FUs are used exclusively, they areas: In transplanting a bald Norwood type VI patient, the
achieve the gradient by packing FUs more closely as the poste- surgeon sets the standard for what the density will appear to
rior aspect of the front hairline is laid down and/or by using be for the hair distribution on the top of the head. But in patients
FUs with two, three, or four hairs or Follicular Families (FF) with deep temporal gulfs, the hair in the adjacent areas is usually
in the zone just posterior to the most anterior hairline hairs as quite dense. Therefore, this is one instance in which maximum
Figure 5A-40 (a) This generic transplant pattern excludes the vertex, but it includes the entire frontal and midscalp regions. Narrow
zones for follicular units (FUs) are placed at all four borders; 1.5-mm round grafts are placed in the center of the frontal area (and, in this
patient, extended into the anterior midscalp region). The remaining intermediate areas of the recipient area are treated with smaller (1.3
mm), round grafts. Alternately, densely transplanted FUs that each contain three or more hairs or recombinant grafts can be used in the
central area, and a combination of FUs, slit or microslit grafts, and 1.3-mm round grafts can be transplanted into the intermediate zone.
(b) The same patient as is shown in Fig. 5A-40a; a frontal view six months after a third transplant session of micro-minigrafts. (c) A lateral
view of the patient taken at the same time as the photograph in Fig. 5A-40b. (d) A top view of the same patient 6 months after his third
session. (MB) (e) A schematic drawing of the different types of grafts that are generally used by Unger in different areas of the recipient
area. Note that Unger organizes his round grafts potentially to fill solidly specific zones in the recipient area, whereas Beehner scatters his
round grafts. (See also Chapter 12G).
120 Chapter 5
Figure 5A-40E Continued.
density is preferable so as to avoid a dramatic contrast in hair entire midscalp region can be transplanted along with the frontal
densities of these contiguous areas. Fig. 5A-34a,b shows a 38- region, thus transplanting back to the curved, anterior border
year-old patient with deep temporal gulfs who was densely of the vertex. Much of this zone resides on a relatively horizon-
transplanted in four sessions with FUs at the hairline and round tal plane in most men. For this reason, if a combination of FUs
grafts (four to seven hairs each) posterior to them, resulting in and multi-FU grafts is used in the overall transplant project,
an appearance of equal density in both the newly transplanted the portion of the midscalp that is truly on the horizontal plane
recession areas and the preexisting hair. is ideally suited for use of round grafts, which can contribute
significant density to the overall transplant result. Because of
Transplanting the Midscalp Region the horizontal plane and the natural angulation imparted to the
grafts, they nicely overlap one another in this region, creating
In the section that discussed an expanded frontal transplant zone an appearance of maximum density along with minimal detecta-
pattern, it was noted that a portion of the anterior midscalp was bility (Figs. 5A-16, 17, 18, 20, 40, 41, 42b–d). This last feature
included in the area to be transplanted. For many men, the is further enhanced by treating all of the lateral border zones
with FUs or a combination of FUs and DFU grafts.
Figure 5A-41 (a) A patient with a variant of male pattern baldness, with the outline of a proposed transplant pattern drawn in. (b)The
patient shown in Fig. 5A-41a 6 months after the fourth session of a combination of follicular units and various types of minigrafts. (c)A
variation of the generic transplant plan that was shown in Fig. 5A-40a. (MB)
The authors’ most common transplant plan is to treat both rate of hair loss. If there is dense, full hair in this bridge zone,
the frontal region and the midscalp as far posteriorly as the it is often adequate to transplant anterior and posterior to the
vertex transition point. Many men with early MPB, such as bridge, but donor area reserves must always be left, in case this
those with Norwood types III, IV, and V, possess residual hair area needs transplanting at some future time. If, on the other
in the midparietal bridge area. This hair should be carefully hand, the hair in this bridge area was already starting to thin,
evaluated in the context of both the patient’s age and his recent it would make sense to transplant through it and to treat this
122 Chapter 5
region along with the frontal transplant region. In patient’s density objectives for various areas that are or will be affected
whose residual hair in the midscalp is only starting to thin, and by MPB. In most patients, a decision to fill in the vertex means
whose hair still looks as if much of it will persist for at least that the surgeon has considered the following four factors: First,
another 5 years, the use of microslit grafts is preferable to the the patient may one day need the entire frontal area transplanted;
use of round or slot grafts, because microslit grafts do not re- second, the vertex will most certainly enlarge and will need
move hair and cause the least damage to the existing hair. If additional transplanting; third, there is ample projected perma-
the hair in this area is quite vellus in quality and likely to be nent donor hair to accomplish both of the first two eventualities;
gone within 5 years, Beehner prefers to fill in the area with or fourth, the patient actually prefers to treat the posterior aspect
randomly spaced round grafts ranging in size from 1.3 mm to of his fully developed MPB instead of the frontal aspect. It
1.5 mm. Unger, on the other hand, uses a mixture of microslit takes a great deal of careful explanation and establishment of
grafts, slot grafts, and random or highly organized round grafts a good doctor-patient relationship for such a patient to accept
from 1.5 mm to 2.0 mm in diameter, depending on hair charac- a decision not to transplant the current problem area.
teristics, how many prior transplant sessions have been done There are a number of ways that Beehner describes to pa-
in the same area, and the patient’s density objectives (see Fig. tients the consequences of transplanting the crown. He points
5A-40e and Chapter 12F and G). The curved posterior border out that the vertex is like a billboard because it is often oriented
of the midscalp is transplanted with FUs as in the frontal hairline straight up and down and is easily visible. He stresses that
so that a natural transitional border is created, which is undetect- because of its highly visible location, if the vertex is trans-
able from the posterior line of view. planted, it must be done to look absolutely natural and so that
it can always be maintained in a completed state. He emphasizes
Transplanting the Vertex that the cosmetically most important areas of the scalp to trans-
plant are always the frontal and midscalp regions of the head.
The complexity of transplanting the vertex is somewhat compa- If the patient is relatively young and the permanent donor supply
rable to that of transplanting the frontal hairline. If done poorly, is uncertain at this early time, it does not make sense to embark
the vertex at least equals the frontal hairline in calling attention on a project that may have to remain incomplete later because
to a poor hair transplant. For the majority of patients trans- of a lack of donor hair. He even offers to show patients ‘‘horror
planted, it is wise not to include this area in the initial hair pictures’’ of past patients who have come to him and other
transplant plan, especially for men in their 20s and 30s. As surgeons with exactly this predicament. (Usually the photo-
noted earlier, it is interesting that a small number of men seeking graphs are from the era of large grafts because of the time lag
hair transplantation, regardless of their age, point to their alope- it takes to develop such a state. Also, fortunately, the patient
cic crown area as bothering them more than their frontal loss. usually takes his word and does not choose to see the photo-
It is our experience that if these patients can be convinced to graphs).
limit the transplanting to the frontal and midscalp areas, they Unger, on the other hand, transplants the vertex at almost
will later view their hair loss in the vertex with much less con- any age if the patient accepts that he will not also treat the
cern. This is especially true for those who choose to style their frontal area until he is convinced that there is enough donor
hair straight back. tissue to join the proposed frontal area and the transplanted
For many men, especially those with Norwood types VI and vertex areas. The evidence that enough donor hairs exist and,
VII patterns, the total area of the alopecic vertex sometimes by extension, Unger’s conviction that he will succeed in joining
equals the combined area of the frontal and midscalp regions. the areas, usually does not occur until the patient is in his late
Because the vertex is on a different plane and is back there out 30s or early 40s. Unger, too, stresses the wisdom of waiting
of sight when viewed in a mirror, patients believe it is a smaller and treating the frontal half or two thirds of the developing area
area than it actually is, and, therefore, they assume it is readily of MPB instead of the posterior half or two thirds, but he leaves
amenable to being filled in. This notion needs to be dispelled the final decision to the patient if he is convinced that the patient
in many of our patients, and the cosmetic primacy of the frontal fully understands the consequences of his choice and still pre-
and midscalp regions needs to be emphasized. fers to treat the vertex. Often, he convinces his younger patients
to receive treatment of the thinning midscalp as far posterior
Transplanting the Vertex Before Middle-Age (‘‘The as the vertex transition point (or just posterior to it) instead of
Trap’’) trying to have the entire vertex treated. This new hair can be
Beehner has drawn a rigid line in the sand with regard to patient combed posteriorly to camouflage thinning in the rest of the
age and transplanting the vertex: He does not perform this pro- vertex. This compromise is made more acceptable in the eyes
cedure if the individual is younger than 38 years of age. Many of the patient because he is told that the frontal area will be
of the men who are ruled out by this cutoff point are displeased transplanted earlier than otherwise would have been elected,
with this age limitation, especially if they still have good hair and the density in the front half of the scalp will be much greater
density in the frontal and midscalp areas. Patients who seek if the surgeon does not have to use or conserve donor tissue to
treatment with such density are typically in their 30s or 40s and treat the vertex. Given these options, few patients decide to
have an alopecic or thinning vertex. Usually, there is also a have the entire vertex area treated at an early age.
gradation of thinning hair anterior to the vertex, which becomes The other exception that Unger makes with regard to trans-
denser as it approaches the frontal region (Fig. 5A-42a). The planting the vertex area in patients younger than 38 years of
patients make a simple enough request: Fill in this small area age relates to whether the patient is willing to undertake, and
in back. Again, as with so many decisions in hair transplanta- is a candidate for, various types of AR or scalp extension (Figs.
tion, the final strategy is affected primarily by the age of the 5A-43, 44, 45a and b). This variable should be added to the
patient, the amount of donor hair present, and the ultimate hair three noted earlier—age, donor/recipient area ratio, and density
Figure 5A-42 (a) ‘‘The trap’’: crown baldness in a middle-aged or younger man. (b) An anticipatory prospective forelock pattern
drawn on a 19-year-old man with early and (for his age) moderately severe male pattern baldness. (c) Six years after his transplant, the
patient’s male pattern baldness has progressed; however, the transplanted hair still looks natural. (d) A different view taken at the same
time as in Fig. 5A-42c. (MB)
124 Chapter 5
objectives—before the surgeon decides whether to try to treat he wanted to treat the entire developing area of MPB before
the vertex area. The decision to undergo AR or scalp extension transplanting was performed in the midscalp and vertex area.
is itself more easily made by a patient who already has signifi- He underwent scalp extension with Dr. Patrick Frechet. On
cant thinning in the midscalp and vertex areas. Naturally, the completion of the scalp extension, the remaining areas of thin-
physician feels more secure if the AR is carried out before any ning were transplanted.
transplanting in these areas. However, it is not necessary to If there is still a substantial amount of hair in the midscalp
carry out AR before transplanting as long as the surgeon is and vertex area, AR should be deferred until thinning is more
certain that the patient intends at some point to excise part of advanced. There are two reasons for this: (1) The surgeon
the developing area of MPB (see later). should not excise areas of scalp with good hair density before
The ideal situation is one in which a younger man with it is necessary to actually undertake an AR or to transplant such
moderate thinning of the midscalp and vertex area agrees to areas, in case the hair in these areas will be longer-lived than
AR (or scalp extension) before any transplanting is carried out anticipated; (2) paradoxically, even a fine scar passing through
in those zones. The AR may take the form either of a standard an area with fairly dense hair coverage is more likely to appear
AR, an AR in which prolonged acute tissue expansion is em- as a hairless line than if the hair density in that area is less,
ployed at the time of the AR to enhance the amount of scalp and, therefore, the contrast between the hairless scar and the
that can be excised (see Chapter 19A), or, in the most optimal surrounding sparse hair is less obvious. In such cases, Unger
situation, by scalp extension (see Chapter 20). The patient usually leaves an untransplanted area in the shape of a flattened
shown in Fig. 5A-43 is an individual in his early 30s who knew S for a future AR as shown in Fig. 5A-44a). The design of the
Figure 5A-43 (a) A 32-year-old man who knew that he wanted the entire developing area of male pattern baldness to be treated. The
above photograph shows him after two sessions of transplanting in the frontal area, but before transplanting was performed in the midscalp
and vertex areas. The outlines of two proposed alopecia reductions, which are to be carried out before any further transplanting, have been
drawn in. (b)Three months after the first scalp extension carried out by Dr. Patrick Frechet and 60 days after the second. (c)Patient shown
5 weeks after Dr. Frechet did his three-flap corrective procedure. The patient now has normal hair direction and a far smaller midscalp
and vertex area to treat with transplanting. (WU)
Figure 5A-44 (a) Pattern of proposed first alopecia reduction (AR). At an appropriate time, a second AR will also be carried out to
the right of, and posterior to, the first one. The design of the proposed AR will include a portion of the midline frontal area and the non-
part side of the midscalp and vertex, areas which often have reasonable hair density initially but whose hair can be expected to be lost.
(WU) (b) A 54-year-old gentleman with an outline of the proposed alopecia reduction that was, in fact, carried out 6 weeks before the
first transplant in this area. (c)One year after the first transplant session to the vertex and midscalp. A combination of micrografts and slit
grafts was used. The hair has been parted for critical evaluation. (d) A photograph taken at the same time as that shown in Fig. 5A-44c,
with the hair combed as normally worn. The frontal area had also been transplanted with three sessions of micro-minigrafts. (WU)
proposed AR includes a portion of the midline frontal area and planted with the objective of total coverage of the eventual area
the non-part side of the midscalp and vertex areas, where hair of MPB.
may still be present, but where hair can be expected to be lost Obviously, the foregoing discussion implies a certain faith
with the passage of time. The pattern of the AR also wraps on the part of the surgeon that the patient is determined to follow
around the posterior aspect of the vertex area, including areas through on the plan for AR. It is completely understandable that
that may have sufficient hair density but that the surgeon reason- other physicians may question a younger man’s determination
ably anticipates will be involved in the balding process. As time or may be less impressed with the results of AR, and, therefore,
passes and these areas become more and more alopecic, they they agree to treat the vertex areas only in middle-aged or older
can be excised at the appropriate moment. A second or (rarely) patients. In Unger’s practice, the consequences of not following
third AR may also be carried out laterally and posteriorly to through with this plan are made clear; they are emphasized and
the preceding one(s) if this is deemed advantageous. Because documented before any attempt to transplant the entire area of
the surgeon knows that these areas will be excised at some MPB. As a result, after more than 20 years of incorporating
future time, the remaining midscalp and vertex may be trans- AR into his practice, he has never had a patient not follow
126 Chapter 5
through on his agreement to incorporate AR into the transplant series of procedures. For most men in whom the vertex is trans-
planning as described earlier. Older patients or alopecic patients planted, it is best to lower expectations for the density that will
more often precede transplanting of the mid-scalp or vertex be achieved. Beehner uses only FUs in this region. He explains
area with an AR (Figs. 5A-44b–d and 45a & b). Regardless of to each patient that the density of hair in this area will be less
physician philosophy, however, the most important goal of a than what he could create in the two more anterior zones. In
lengthy discussion with the patient is for him to accept the fact addition to enlisting the billboard analogy mentioned earlier,
that his surgeon is his advocate who cares about his future and he also tells the patient that he wants him to be theoretically
believes it is important that nothing be done which the patient able to pass the ‘‘grocery line test’’ after the transplant is com-
will later regret. pleted. That is, if, after a patient has completed his course of
treatments, he were to stand in a grocery line for 5 or 10 minutes,
Graft Selection in Vertex Transplantation the person standing in line behind him should never notice that
All of the aforementioned cautious comments notwithstanding, surgical work was performed on the patient’s scalp. Beehner
there are many men, specifically those older than 38 years of also explains that the hair in this area is naturally arranged in
age, who possess generous stores of donor hair, for whom the a multidirectional whorl, and, because of this arrangement,
vertex can be transplanted without too much risk. Transplanting grafts at the center of the whorl are more visible. If the grafts
the vertex may be combined with transplanting the frontal and placed there have four or more hairs per graft, they can look
midscalp regions, or it may be performed later as a separate pluggy. After all of these considerations are explained in a rea-
Figure 5A-45 (a) A patient before transplanting of the vertex in 1989. Three AR had been carried out by Dr. Martin Unger before
transplantation and, hence, the unusual shape of the vertex area. (b)After two sessions of a combination of follicular units and slit grafts
with the hair parted for critical evaluation. The patient’s salt and pepper hair coloring was particularly advantageous. (WU) (c) A 52-year-
old man before transplanting of the vertex. (d)The same patient after three sessions of follicular unit transplantation. (MB)
soned, nonjudgmental manner, Beehner finds that the great ma- method for selecting this spot. A common one is to place the
jority of patients accept lower density expectations in return for whorl slightly to the right of, and just inferior to, the level of
having the transplant look completely natural (Fig. 5A-45c, d). the vertex’s true geometric center. In patients with an advanced
Unger, on the other hand, always uses FUT for the center Norwood type VI pattern, in whom the vertex lies mostly on
of the whorl and for at least one session. But if the hair color the vertical plane, we prefer to set the whorl center point slightly
contrasts minimally with the skin color, if the hair is fine-tex- to the right of the midline, but slightly superior to, or at the
tured, or if more than one session is planned for the vertex midpoint of the vertical height of the vertex (i.e., at the halfway
area, he often employs a combination of FUs and DFU grafts, point of a vertical line drawn from the midline occipital fringe
peripheral to the center of the whorl, for one or more sessions to the midline point of the anterior border of the vertex or the
in that area. If only one session is contemplated, or if the area vertex transition point [Fig. 5A-46]). If the whorl center is
is originally essentially alopecic, FUT is used for the first ses- placed at this level, a significant percentage of the grafts situated
sion. If the area still has hair when the first session is done, in the vertex will be directed inferiorly and will help cover the
then the last session is done exclusively with FUs (see also inferior half of the vertex. Even if hair loss in the vertex should
Chapter 12G). The one exception to this philosophy arises when progress further inferiorly, these hairs will continue to shingle
the patient is Caucasian and his hair is white. In these cases, downward over each other and camouflage this new alopecic
DFU, TFU, and even QFU grafts or slot grafts are often com- area. Another reason for not placing the center of the whorl too
bined with FUs, whether the area is totally alopecic or not and inferiorly is that styling the hair in an anterior direction from
whether one, two, or more sessions are contemplated (Fig. 5A- such a low position is sometimes difficult and does not look
13). Unger presents the same information in a similar fashion natural.
to his patients as Beehner does, but he finds that using grafts
larger than a single FU in combination with FUs produces better Vertex Hair as Tacking Hair
density and excellent cosmetic results without noticeable plugg- For the man who is committed to sweeping his hair straight
iness if the above approach is followed. This is especially so back or back but at a slight angle toward one of the posterior
if hair characteristics are good—for example, little hair/skin corners of the vertex area, the presence of FUs placed in an
color contrast as noted, or the presence of some curl, fine tex- alopecic vertex serve as tacking hairs that help anchor and hold
ture, frizz, and so forth (Figs. 5A-44b, c, & d). Beehner agrees the long hairs swept over them. Otherwise, with nothing but
with this approach (the use of microslit grafts and larger grafts) smooth, alopecic scalp underneath them, these long hairs have
only for creating density in the anterior portion of the vertex
that lies in a more horizontal plane.
The appearance of lower hair density in the vertex, of course,
should be expected, especially at the center of the whorl, be-
cause the whorl pattern minimizes the overlapping or shingling
effect that is so necessary in creating the illusion of hair density
with hair transplanting. Because of the limited shingling effect,
more hair has to be transplanted into the vertex to achieve the
same appearance of density as elsewhere on the scalp, where
shingling is greater. This is especially true for the center of the
whorl of the vertex, which often must be transplanted three or
four times to produce good density. Frequently, Unger trans-
plants the center of the whorl of the vertex with FUs at the
same time he transplants the frontal or midscalp areas in patients
who are acceptable candidates for transplanting the entire area
of MPB and wish to do so. Similarly, he commonly adds more
FUs to the hairline zone at the same time that he transplants
the vertex or midscalp, because the hairline zone also allows
for minimal overlapping and therefore receives minimal aid
from the illusion of density that overlapping provides.
Placement of the Whorl’s Center Point

If enough residual vertex hair is present, even if vellus, it is
usually best simply to adopt the patient’s natural whorl center
point as the epicenter for the transplanted vertex. Occasionally,
there are two or more separate whorls in this area. In patients
with multiple whorls, we generally select only one of the whorls Figure 5A-46 A schematic diagram of the vertex whorl pattern
and transplant the hair to spin off from it, unless there is still of hair direction. The center of the whorl has arbitrarily been placed
a moderate amount of hair present in the vertex. In the latter just to the right of center and at the mid-height of the vertex. In
case, all preexisting whorls must be reinforced. However, with addition, although the direction of hair on the right anterior section
regard to the man with total vertex baldness or extremely sparse is shown from above to continue the whorl pattern, in many individ-
hair, the previous center of that patient’s whorl may be ignored uals the hair in this section is directed more anteriorly (see Fig.
and a new one arbitrarily selected. There is no single right 5A-39c).
128 Chapter 5
a tendency, especially in the wind, to slide around and lose their unnatural and in whom this area is best left alone. Mayer and
originally styled orientation. These small grafts appear natural Shapiro discuss the creation of temporal points in detail in
owing to their even distribution and also because many men in Chapter 15.
the evolution of losing their hair possess similar hairs.
Transplanting the Crease (Lateral Alley) Area
The Combination Solution for a Full Density Vertex The crease areas are relatively narrow zones of scalp that lie
Given the limitations described earlier for transplanting the ver- superior to the temporoparietal areas and within the lateral as-
tex with significant density, it is worth mentioning to our pa- pects of the midscalp (Fig. 5A-5). As pointed out before, the
tients the possibility of transplanting the anterior alopecic scalp hairs located within this zone exhibit a transition in their hair
(e.g., the frontal and midscalp areas) and then obtaining a clip- direction. Although the hairs in the inferior aspect of the crease
on, nonsurgical hairpiece for the remaining posterior area of are directed inferiorly and slightly anteriorly for much of its
hair loss (Fig. 5A-17). With this combination, the patient can length, the hairs in the superior aspect are, for the most part;
have the naturalness of his own hair frontally and can achieve directed anteriorly or anteromedially. A surgeon looking care-
the appearance of full density in the vertex. Although some fully can note that the hairs in the exact centerline of the crease
patients are extremely pleased with this approach, our experi- are directed anteriorly (Fig. 5A-6). Thus, hair in the creases
ence has been that a number of individuals who begin late with gradually swings from an anteroinferior direction to an anterior
this combined plan abandon it once they see their own trans- and then an anteromedial one. To create this change in direction
planted hair growing. For this reason, it is important, at least of recipient sites (and hair) without damaging adjacent hairs,
initially, to create a feathered zone of hair at the posterior border the grafts and sites must be as small as possible. Thus, FUs
of the transplanted area, so that an unnatural, tufty border is not must dominate transplanting in the creases, where DFU grafts
visible posteriorly should the patient decide against obtaining a are the largest grafts employed, and then only if hair and skin
hairpiece. On the other hand, if the patient does follow through characteristics are suitable.
and use a hairpiece in this fashion, his surgeon may have to Most men undergoing transplantation, including those with
thicken the posterior border of the midscalp so there is not too Norwood types III, IV, and V patterns, usually still have hair
marked a difference in hair density where the transplanted hair in these creases. It is, however, wise to place FUs or a combina-
meets the hairpiece. tion of FUs and minislits in them. Doing so provides two bene-
fits: First, if larger grafts are used centrally, these small grafts
Transplanting the Temporal Region on each side provide visual blurring and camouflage of the
denser, potentially more detectable, centrally placed grafts. Sec-
The contour and position of hair in the temporal region varies ond, should the patient develop a wider than anticipated area
widely from one man to another. For most, as noted at the of MPB with alopecic alleys bilaterally, he will have a natural
beginning of this chapter, the anterior temporal hairline gradu- appearing cadre de cheveaux (large oval forelock pattern of
ally recedes posteriorly as the years pass, often with the loss hair) already in place and will not be cosmetically obligated to
of the temporal point. With the present capability for placing undergo additional transplanting.
large numbers of closely spaced FUs, this area is increasingly As discussed earlier in this chapter, Unger and Shapiro have
incorporated into the transplant plan (Fig. 5A-36). However, it proposed transplanting in selected patients what Shapiro has
is usually unwise to transplant into the temporal region of a termed the lateral hump (14,16). This hump is a hemioval area
young man in his 20s or early 30s, because the eventual balding that in many men is present superior to the natural lateral fringe
pattern and the extent of the permanent donor hair reserves are at some stage of the evolution of MPB (Figs. 5A-6 and 28a–c).
unknown. Doing so could disfigure him if, later in life, this area (The crease traverses its inferior border). When a lateral hump
recedes substantially and he develops a greater than expected is included in the transplanting plan, the lateral ends of the
severity of MPB. hairline can be placed more superiorly and still intersect the
In older patients, the best use of grafts in this region is simply hump. A deeper and more superior location of the apex of the
to add to the density of the thinning areas already present. frontotemporal triangle is thereby created, but it looks natural
Sometimes, the main body of temporal hair is reasonably strong, because of the hump. The chief drawback for regularly employ-
but the temporal point is starting to thin. Small grafts added ing this strategy in individuals with types VI and VII MPB is
there help restore a more natural, aesthetically pleasing appear- that they are the patients with the smallest donor areas from
ance. Some men have a sharply angulated anterior temporal the outset. Adding one more task that requires donor hair, in
hairline that recedes superiorly into the temporal gulf, creating addition to the creation of a forelock, can overtax the demands
a sharply angled frontotemporal area of alopecia (Fig. 5A-36). made on available hair. Thus, when the hump is used, it is
This acutely angled recess of alopecic skin may be blunted by nearly always created exclusively with FUs, which produce the
transplanting the portion that lies posterior to a line that extends most natural coverage with the least amount of donor tissue. It
gracefully downward from the frontal hairline, merging with is extremely useful to consider conceptually the possibility of
the existing temporal hair and its anterior point; but, as noted creating this hump as the surgeon elects a strategy for trans-
planting the man who has or will likely have types VI or VII
earlier, the surgeon should never aim to transplant the entirety
MPB.
of this recession. It goes without saying that a keen sense of
artistry, featuring the use of only FUs and fine-textured hair Hair Transplant Plan for the Generic or Typical
and an extremely acute angle of grafting, must be employed in Transplant Candidate
transplanting this highly visible area. Lastly, it should be noted
that there are some men with extremely coarse, dark, or frizzy When busy hair restoration surgeons look back on all of the
hair in whom even FUs in this region carry the risk of appearing men on whom they have performed initial sessions in the past
year, there is a certain prototype patient—the ‘‘generic’’ pa- slot grafts. More often, he employs scattered slot grafts rather
tient, if you will—who comprises approximately 40% to 50% than round grafts anterior to the solid round grafted zone—un-
of the surgeon’s patients. The following is a walk-through ap- less the transplanted hair is relatively fine and/or has little color
proach taken by Beehner to such a patient. (Unger discusses contrast between hair and skin and/or is frizzy, wavy, or curly.
his approach in Chapter 12G). This more organized approach in the latter zone, in which 2-mm
The patient is usually between 30 and 60 years of age. He round grafts are usually used, has advantages and disadvantages
is a reasonable sort of fellow and, for the most part, defers to relative to Beehner’s technique. The advantages are that it pro-
the plan the surgeon thinks will work best for him. He is healthy duces zones of maximum hair density—theoretically, 200 or
and the series of procedures is not a great financial burden more hairs/cm2 can be easily achieved—and, when solid graft-
for him. At the consultation he seems sufficiently motivated to ing is completed (after four sessions), no plugginess is detecta-
follow through with the sessions recommended. He has the ble. This is true even if hair characteristics are poor for trans-
usual caudal area of hair thinning or total alopecia, with perhaps planting; for example, high color contrast of hair and skin color,
a few residual hairs in the midparietal bridge and frontal fore- and even if the hair is wet and parted through the round grafted
lock areas. It is clear he will have Norwood type VI MPB by area. The negative consequences of Unger’s approach are often
the time he is 60 to 70 years of age. Fig. 5A-40a shows such the use of more donor tissue than required in Beehner’s ap-
a patient who is 35 years old. His transplant plan features narrow proach and the aforementioned potential for producing a stark
zones along the anterior, lateral, and posterior borders, which difference in hair density in different zones of the recipient area.
will be filled in with FUs (Fig. 5A-40a). At each session, he
receives approximately 240 FUs along the frontal hairline, 40 Approach to Common Hair-Loss Patterns
to 80 FUs in each crease zone, and 110 FUs along the posterior
curved border. The large alopecic area surrounded by these Norwood III-Vertex, Type IV or V Pattern
peripheral FU zones is divided into an encircling intermediate One of the most commonly presented patterns a hair restoration
zone and an oval or pear-shaped central zone (Fig. 5A-40a). surgeon sees is the young man between 25 and 40 years of age
On Trichoscope (Welch-Allen Instruments) examination of the with a Norwood type III-vertex, IV, or V pattern. By definition,
donor area, it is determined that the patient has a density of 26 the type IV patient has a relatively strong midparietal bridge
hairs per 4 mm diameter circle (slightly better than average of hair, so he can usually be treated in the same manner as a
density). In the intermediate zone, 310 small round grafts are man with a variant pattern of frontal loss by simply filling in
inserted into randomly placed 1.3-mm limited depth holes (av- the frontal transplant zone (Fig. 5A-41). In the patient who
erage of four to five hairs per graft). In the central zone, 60 to initially has a type V pattern in which the hair in the midparietal
70 slightly larger round grafts are placed into 1.5-mm diameter bridge is already thinning, transplanting both the frontal zone
recipient sites (average of six to seven hairs per graft). Because and part or all of the midscalp area is usually preferable (Figs.
the patient has light brown hair, he is told that three sessions 5A-40a, b, c, and d). Unger creates an anticipatory lateral hump
will probably achieve his goals, and that there is a 50% chance and transplants FUs and DFU grafts into areas of persisting hair
that a fourth session may be needed at some future date. The that he thinks will eventually be lost in the hump. We have
second session is performed 5 months later, and the third session already discussed the management of type III-vertex.
6 months after that. He is then told to wait a full year before
deciding whether or not he wants a fourth session. The photos in Norwood Type VI Pattern
Figs. 5A-40b–d, show his results 1 year after his third transplant
session. At the time of his second session, he is given a Derm The man with a Norwood type VI pattern of hair loss usually
Match sample that matches his hair color. He uses that until manifests a straightforward situation. The main variables are
the third session has grown out and his transplanted hair has the patient’s age (will the fringes migrate or thin out further
sufficient length and density. To create a look of central density, down the side of the head?) and the amount of donor hair avail-
the frontal hairline is a gradation from one-hair FUs to two- able. In some instances, where total coverage or near total cov-
hair FUs and finally to small and medium-sized round grafts. erage is the goal, an AR or scalp extension procedure can facili-
The patient states that he is pleased with the density achieved tate success, provided the scalp’s characteristics and donor area
in three sessions and does not want further work done at this hair density are suitable (see Chapters 19 and 20). Once again,
time. As noted in the photos, he prefers a short-cropped, layered Unger transplants an anticipatory lateral hump through any per-
hairstyle. Fig. 5A-41 demonstrates an alternate plan for the ge- sisting hair in the hump area. As with many of the younger
neric patient and its effect as well as depicting the generic pa- patients with pattern, types IV and V when the type VI patient
tient with a variant pattern of frontal hair loss. is younger than 40 years of age and the donor hair reserves are
It should be emphasized here that Beehner always uses round marginal, leaving the circular vertex area untreated is almost
grafts in a scattered fashion and generally employs a 1.3-mm always the wisest course. One exception is an individual who
to 1.8-mm trephine to create his recipient sites. Unger, on the wants total coverage in return for lower density objectives, espe-
other hand, only sometimes uses scattered round grafts anterior cially if hair characteristics are good.
to a zone of round grafts that are carefully organized to poten-
tially produce a solid zone of high-density hair in four sessions Norwood Type VII Pattern
(Fig. 5A-40e (See also Chapter 12G, Fig. 16). Unger’s scattered For the patient with a Norwood type VII pattern, some type of
1.3-mm to 1.8-mm graft sites are employed to blur what would isolated frontal forelock is usually the only possible option. As
otherwise be a sudden and marked difference in hair density mentioned earlier, the prospect of building a sparse, lateral
between the solid, round-grafted zone and the area anterior to hump should also be considered in these patients and is dis-
it that is created with a mixture of FUs, microslit grafts, and cussed later in more detail.
130 Chapter 5
Low-Lying Isolated Forelock psychiatric disease should also indicate that it is unwise to per-
Another difficult challenge is presented by the man with a low- form hair replacement surgery at this time.
lying isolated frontal forelock (Figs. 5A-34a, b). Should the A Prospective Forelock Approach
surgeon bring the hairline down to the anterior border of the
forelock? In a patient approximately 40 years of age or older In this plan, a younger patient has transplantion in the frontal
who has temporal hair situated well anteriorly, it is possible to and even midscalp regions, but, contrary to what is done in the
transplant down as far as the existing low hairline if donor majority of our patients, no attempt is made to transplant
reserves and the contour of the face and head are appropriate. through areas that we think will be lost in the future (Fig. 5A-
In the majority of men, it is wisest to create a hairline that 42). Thus fewer grafts are used, but the patient has the presently
intersects the forelock at the same height as if the forelock were thinning areas treated and, therefore, at least temporarily, has
not present. a full head of hair while he is young. The lateral and posterior
If surgeons choose to carry out hair transplanting using FUs borders are, per usual, treated exclusively with FUs or a combi-
exclusively, Bernstein and Rassman have published two tables nation of FUs and DFU grafts so that the transplanted hair will
to help them decide how many FUs are likely to be required later exist on its own and will appear natural as an isolated
for the different types of MPB (9,24). The total number of FUs forelock, or cadre de cheveaux, when the original hair in the
usually transplanted in the first session for specific Norwood creases gradually disappears. [The Isolated Frontal Forelock
classifications are listed. In general, the higher the donor hair (IFF) is discussed later in this chapter]. This approach, there-
density, the greater the number of hairs each FU contains. With fore, can be thought of as a prospective or anticipatory isolated
low donor hair density, little scalp laxity, or poor hair character- frontal forelock. Such a design is ideal for younger individuals
istics, the tables may be less satisfactory. with family histories of types VI and VII MPB or for those
who may develop types VI and VII MPB. It should also be
recalled that even when grafting extends into areas that are
Planning Hair Transplantation for the Younger expected to lose their hair, these areas are treated with FUs or
Patient a combination of FUs and DFU grafts. Thus, if the MPB eventu-
Young men in their 20s who desire surgical hair replacement ally progresses further than anticipated, the individual is left
represent the most difficult challenge for planning. The early with a still natural looking but larger than usual IFF or cadre
appearance of thinning hair is an abrupt and rude awakening de cheveaux.
for them. Their youthful, virile self-image may be seriously
Alternative Strategies for Buying Time
threatened by the loss of their hair. On the one hand, they are
usually the most demanding patients—expecting low hairlines For some of the young men with early hair loss, the wisest
similar to those of their peers and total, relatively dense cover- strategy is for the surgeon to suggest that they buy time by
age of the entire scalp, including the vertex. On the other hand, considering one of three temporary strategies.
from the viewpoint of the hair restoration surgeon, the crystal The first, and the one that the majority of hair restoration
ball for reading their future hair loss pattern is very cloudy surgeons most commonly use, is medical treatment with either
and unclear at their early age. A number of considerations are topical minoxidil or oral finasteride—or the two treatments
important when approaching such patients. combined. It is important to document with photographs the
baseline status of the patient’s hair at the start of treatment. If
Good Doctor-Patient Relationship and Counseling the patient accepts this approach and later recognizes some hair
growth, or at least a diminishment in the rate of hair loss, a
If the young man in his early 20s is summarily dismissed as a few years may pass before a decision for surgery needs to be
candidate without much accompanying explanation, it is likely made. At that later time, the patient will be older and perhaps
that he will keep looking until he finds a surgeon who will give more realistic and accepting of a more conservative plan than
him what he wants. It is important for the surgeon to make an he initially desired.
effort to win the patient’s trust and to convince him that the A conundrum presents itself later, however. The medical
advice he is being offered is based on his long-term welfare. treatment may, in fact, partly mask the true stage of hair loss
Many of these younger patients have great difficulty looking that exists in accordance with the patient’s hereditary plan were
ahead to when they will be 50 or 60 years old or older. he not being treated. We believe that the evolution of a man’s
hereditary program for hair loss is like a stampede of buffalo
Use of Clues from Examination and History that cannot be totally stopped but only slowed down, and that
There are a number of things which, if present in either the in a few years hints will emerge indicating the future states of
history or the examination of the scalp, should make the surgeon the patient’s MPB. If this is true, reasonable decisions can still
wary and more conservative than usual. Some have been noted be made after several years while the patient remains on medical
earlier but are worth repeating: The presence of whisker hair, treatment. On the other hand, if the surgeon believes that medi-
the lack of strongly demarcated lateral fringes, a family history cal treatment can virtually halt the advancement of hereditary
of type VII MPB, the presence of diffuse, nonpattern alopecia, hair loss, and if the patient is one of the lucky few who achieves
a rapidly evolving pattern of hair loss, or a poor donor/recipient impressive hair growth, it might be better to delay any surgical
area ratio at this early age. When one or more of these conditions decisions until after the patient has been off medical treatment
are present, it is wise to assume that the patient has the potential for approximately 6 months, when the natural or true state of
to evolve later into an advanced Norwood type VI or even a his degree of hair loss more clearly reveals itself.
type VII pattern. In addition, as discussed earlier, psychological The other two important strategies available for buying time
or behavioral signs such as hostility, immaturity, or obvious are the use of camouflage products (discussed elsewhere in this
text) or a nonsurgical hairpiece. Both of these modalities help imposition of arbitrary correct ages is wrong and medicolegally
to fill the void until the patient is older and the future hair loss hazardous to our colleagues when proposed by authoritative
pattern is more evident. surgeons or texts.
Should There Be a Minimum Age for Transplanting

Creating a Density Gradient Between Two Adjacent
We have already mentioned earlier in the chapter that it is often
best not to have a rigidly fixed minimum age but rather to Zones
consider each case individually on its merits. The following is The overwhelming majority of men older than 40 years of age,
an example of such a situation: who have retained some or most of their hair, feature natural
Suppose that a 16-year-old boy who is suicidal about his gradients of density in the various zones of the scalp. As they
hair loss comes to see you along with his father, who is a cos- gradually lose their hair, initial thinning occurs at the various
metic dental surgeon. Despite the fact that the father has had peripheral aspects of the evolving area of MPB, most notably
explained to him the pitfalls and the disadvantages of beginning in the frontotemporal recessions, in the lateral crease areas, and
his son’s treatment at such an early age, he begs the surgeon in the vertex. In hair transplantation, the creation of these same
to start treatment, making the following statement: ‘‘My son gradients of hair density at the juncture between the fringe and
was outgoing, happy, socially active, and an excellent student. the transplanted hair is both a desirable artistic goal and a way
Now, despite his taking Propecia and receiving psychiatric to conserve grafts or to employ them over a larger proportion
treatment, he is introverted, doesn’t want to go to of the area of MPB. This is especially so for a man with ad-
school—where he is presently failing—and is afraid to ap- vanced MPB. Creating transitional areas of graded density also
proach girls. I’m sure he will not be alive in 6 months if some- protects a man from looking peculiar at some future date, should
thing isn’t done done to successfully reverse his hair loss.’’ the adjacent fringe hair thin or become alopecic. If the adjacent
Such a patient came to Unger in 1996. The easy answer would hair does thin, the patient will not be left with thicker looking
have been to walk away from this potential ‘‘snake pit’’ and transplanted areas adjacent to sparser superior rim hair, which
to leave the problem to be tackled by the young man’s family produces an extremely unnatural appearance. If the adjacent
and psychiatrist. But if the surgeon could actually correct the rim hair is lost entirely, the patient is left with a natural looking,
problem—at least in the short run—in the hope that by the larger than usual, IFF or cadre de cheveaux. The polar opposite
time any possible problems might occur, the individual would approach is to transplant hair with a homogeneous density
be better able to handle them psychologically—with or without throughout the area of alopecia, using similar size grafts with
a hairpiece, what might happen? In Unger’s opinion, there is uniform spacing, and, therefore, to run the risk of later, disas-
no easy or absolutely ethical answer to this dilemma. Each trous consequences that can be surmised from the preceding
physician should answer the question—what age is the right discussion.
age to begin treatment—with a response that fits the patient’s There are four different ways to create a gradient between
likely long-term prognosis, and the surgeon’s own personal tol- two transplanted zones:
erance for stress combined with experiences and conscience.
Ethical surgeons are obligated to explain fully to their pa- 1. Graft spacing: Placing grafts closer to each other in one
tients the disadvantages of beginning treatment at an early age zone compared with the adjacent one.
and their past experiences with the consequences of doing so. 2. Graft size: Placing somewhat larger grafts (i.e., more
The individual surgeon’s experiences may be worse or better hairs per graft) in one zone compared with those placed
than those of other physicians, depending on the surgeon’s prog- in an adjacent zone, with each area occupying a similar
nostic and other skills. Later, for example, we discuss the debate amount of space. Using recombinant FU grafts is a
regarding whether transplanting into hair-bearing areas acceler- method of increasing the number of hairs/FU site in
ates MPB in those areas; we believe it does not, if the surgeon FUT when an insufficient number of three-hair to four-
is skilled. The physician should also encourage patients who hair FUs exist (see Chapter 12E).
are younger than 25 years of age and who have family histories 3. Caliber of hairs: Transplanting hairs with greater cali-
of severe forms of MPB to delay starting hair transplantation ber in one zone than in the other. The use of different
if they can psychologically tolerate their present hair loss. A caliber hairs is, for example, sometimes employed in
trial of medical treatment with minoxidil and/or finasteride is constructing the frontal hairline, where fine hairs har-
often helpful in convincing young patients that a delay may vested from temporal or inferior occipital areas are used.
prove to be beneficial rather than harmful. If surgery is under- Higher caliber hair from occipital and parietal areas is
taken, a cautious physician should use exclusive micrografting usually used to create more density in other areas (see
or microslit grafting, both of which can produce natural-looking Chapter 12).
results with only one or two treatments even in an alopecic 4. Selective transplanting of specific zones: Transplanting
area. The area to be treated should be limited to the regions one zone at a subsequent session and not transplanting
of developing MPB that the patient finds most offensive—for the adjacent zone. In other words, transplanting one area
example the frontal area—and/or employ a plan for an eventual more or fewer times than another.
Isolated Frontal Forelock or cadre de cheveaux. Unger’s patient
was treated in this way. Within months, he returned to his outgo- Types of Grafts Employed in Hair Transplantation
ing and happy character, and, 7 years later, he remains happy,
successful, and, he claims, psychologically capable of handling For the most part, the first 30 years of hair transplanting created
any future eventuality with his hair loss—including the possible a negative image of the surgery in the mind of the public. That
necessity of a hairpiece. Time will tell. It is our view that the image was one of clusters of hair appearing like a doll’s head
132 Chapter 5
of hair or like corn rows. During those years, hair was mostly Limmer, take a more doctrinaire view and state that FUT should
transplanted as 4 mm circular grafts containing 10 to 25 hairs not include such methods. They further narrow the definition
each, which were placed in slightly smaller recipient sites, ar- of this type of transplanting by stating that donor hair can be
ranged in parallel rows. The obvious and ultimate answer to harvested only by excising a donor area ellipse. Single-file
this negative pluggy image, according to several prominent and slices of FUs, aligned vertically, are then slivered away from
vocal hair restoration surgeons in the early 90s, was to restore the ellipse by means of a stereoscopic microscope. These thin
hair surgically using only individual FUs as they existed on the slivers are finally dissected into FUs (see Chapter 11B). These
scalp. This method was promoted for creating a totally natural authors stipulate that the use of the stereoscopic micro-
and undetectable hair transplant result. Similar to the old beer scopic—usually 10⳯ magnification, sometimes 6⳯ power
ad in which ‘‘tastes great’’ and ‘‘less filling’’ were endlessly (Mantis Microscope)—is mandatory. Thus, anyone using stan-
argued back and forth, this debate, which is likely to continue dard eye loupes, backlighting (without microscopes), or donor
for many years to come, features FU proponents as saying harvesting with multibladed knives is not, in their opinion, per-
‘‘more natural’’ and the advocates of a mixed approach (FUs forming FUT in its purest form.
and multi-FU grafts) saying ‘‘more density,’’ and ‘‘better sur- Micro-minigrafting and microslit grafting is criticized most
vival rates.’’ This topic is covered in great detail in Chapter notably for the fact that multi-FU grafts are more detectable
12, and, to avoid redundancy, it is dealt with here only briefly. than natural FU groupings. Multi-FU grafts have the potential
However, the type of grafts used is obviously an important to be more detectable during the early stages of transplan-
component of planning. For this reason, we suggest that the ting—especially if the recipient area is alopecic. The means of
reader review the discussions on graft types in Chapter 12 im- creating multi-FU grafts (e.g., harvesting with a multibladed
mediately after completing the reading of this chapter. A few knife) are also criticized by the advocates of elliptical harvesting
comments, however, are warranted here. for wasting and destroying follicles.
The advocates for using micro-minigrafting and microslit
The Big Debate: Exclusive Follicular Unit grafting in hair transplantation point to the fact that with their
Transplanting (FUT) vs. Micro-Minigrafting combination approach they can, on the one hand, create natural-
looking borders with the FUs and, at the same time, more easily
In the past few years, this issue has been at the heart of most and with more follicular safety, produce greater density in the
of the heated debates among hair restoration surgeons. This central areas with the multi-FU grafts. They believe that the
choice also represents one that the patient has to make, because follicles in the multi-FU graft are less subject to the effects of
the physician he chooses to perform his transplant is usually desiccation and trauma than those in FUs because of the physi-
wedded to one of these transplanting philosophies. The exclu- cal buffering provided by the greater amount of tissue surround-
sive use of very small grafts that resemble what we now call ing them. Furthermore, this approach is less labor-intensive,
FUs was first introduced by Uebel in the early 1990s (22). requiring fewer staff members—who may or may not be in top
Limmer was privately experimenting with similar grafts at ap- form on any given day—and takes less time for the cutting and
proximately the same time but soon started using stereoscopic placement of the grafts. Because of the reduced staff and time
microscopes in an effort to keep intact the small groupings of requirements, combination grafting is generally less expensive
hair he saw in the donor tissue. Although he did not call these for the patient. Also, with either a random or a regularly spaced
small groupings ‘‘follicular units,’’ he presented his technique pattern of multi-FU grafts, it is relatively safe and easy to go
at the annual meeting of the International Society of Hair Re- back for a third or fourth session in the same area, in order to
placement Surgery (ISHRS) in 1994 and published it that year place more grafts for additional density (see Chapter 12F and
(23). Seager visited with him in October of 1995 and was specif- G). Finally, if the recipient area still has some persisting original
ically told by Limmer that the basis of his approach was keeping hair, it is easier later to find previously transplanted microslit
the little groups of hair together and using them as the ‘‘building grafts, slot grafts, and round grafts in the midst of this hair
blocks’’ of the transplant. He, therefore, is clearly the father of than to locate previously transplanted FUs in the surrounding
FUT (see also Chapter 12). Bernstein, in 1995, after reading original hair. Thus, with multi-FU grafting, the grafts in each
Headington’s seminal article, named these groups ‘‘follicular subsequent session can be placed optimally between previously
units’’ and, together with Rassman, published his own report transplanted hairs before all the hair in such areas in lost.
on this technique in 1995 (24). Further refinements in this
method were added in the mid-1990s by Bernstein, Rassman, A Balanced View of the Controversy
Seager, and others. The most often cited attributes of this
method are the following: The exact units of hair that exist As with many controversies, there is often a lack of tolerance
naturally on the hair-bearing scalp are transplanted into the re- by members of both camps for each others’ methods and a
cipient area, thus eliminating any possibility of noticeable series of rigid postures regarding the absolute superiority of the
plugginess. Furthermore, if the FUs are transplanted densely respective methods. A good starting point for reconciliation is
enough, only one or two sessions are usually necessary to com- to realize that although one practitioner can create excellent
plete the hair restoration process in any area. Some of the lead- results by using a favorite method, another practitioner, using
ing proponents of this method, including Shapiro, Seager, Rose, a totally different method, can also achieve excellent results.
Norwood, Harris, and Parsley, now include the option of using Hair transplantation has evolved and become complicated
double FUs or follicular families (25) (i.e., small grafts contain- enough that physicians have to determine, over a period of time,
ing two FUs that are closer to each other than usual), or recombi- what works best in their hands and practice environments. Ide-
nant FUs (see Chapter 12) in a central area in the frontal region ally, each surgeon would master the various common ap-
to create added density (25). Others, including Bernstein and proaches in surgical hair replacement, including both of the
modes of transplanting discussed earlier. The ability to trans- typical approach to micro-minigrafting is less problematic than
plant with FUs exclusively or with a combination of grafts of it is in a practice where, for example, 90% of patients are totally
different sizes and shapes allows the surgeon to assess each alopecic—or nearly so—when they are first seen?
patient’s unique hair characteristics and goals, as well as their
donor and recipient area attributes, and to fashion a plan that The Need to Reassess (Not Being Locked in to Any
best accommodates each patient’s specific needs. That said, One Course of Action)
surgeons have a bias toward the particular method with which
they work best and which they employ on the majority of their When presenting a patient with a plan for transplanting, it is
patients. wise to talk in terms of the area to be transplanted and to give
In our two respective practices, the majority of, but not all, a general description of what type of grafts will be used. Giving
male patients receive a combination of microslit grafts, with or exact accounts of graft numbers and sizes at the start handicaps
without some slot grafts or round grafts, and FUs. These are the surgeon during the transplant process. It is extremely helpful
our preferences—the method works best in our hands. And yet, and adds greatly to the artistry of the final result if, at the
in our practices, there still exist a significant number of patients beginning of each session, the surgeon steps back and studies
for whom we recognize that the exclusive use of FUs is best. the visual impact of the work completed at that point. The trans-
Patients for whom this is true: (1) are totally alopecic (see also planted hair should be viewed frontally, laterally, posteriorly,
the discussion of creation of ‘‘fine cover’’ that follows); (2) and superiorly—the ‘‘top’’ view. After such an evaluation, the
have substantial hair-skin color contrast; (3) insist on absolute surgeon may decide to add a proportionally greater number of
undetectability, even after only one session; or (4) desire only FUs at one site or another for increased naturalness, or he may,
one or two sessions and are satisfied with less density than most for example, decide to increase the round graft size from four-
of our patients. The option of adding larger grafts to create hair grafts to six-hair grafts to produce the appearance of greater
more density in the same areas in later sessions is always avail- density in other areas.
able and is frequently used (see Chapter 12). In addition, in It is valuable also to combine the physician’s overview with
some patients, FUT may be used for the final session in specific the patient’s assessment of the work done up until that point.
areas to produce an even coverage of permanent background Patients’ objectives commonly change as they see new hair
hair for the slightly larger grafts. Exclusive use of FUs is also growing. They also often gain new insights regarding what to
desirable sometimes when a patient is not totally alopecic but expect from the surgery in general and can see the result of
has high hair caliber and high color contrast between skin and using specific types of grafts. It is not, for example, unusual for
hair. Another group for whom FUT should be used is one com- individuals to start with relatively modest goals that gradually
posed of patients with extremely low donor hair density. A large increase in terms of both density and proportion of the area of
proportion of their FUs typically consists of only one hair. It MPB they want treated. When deciding on a treatment plans
makes little sense in these individuals to use multi-FU grafts for individual patients, surgeons recall what actual visual effect
and thus to transplant the relatively large amount of hairless skin has been brought about in past, similar cases when various sizes
that exists between these single-haired FUs. As noted earlier, of grafts have been used with like degrees of hair caliber, curl,
Shapiro describes planning with FUT in more detail in Chapter and coloration, just as artists decide on what colors and tech-
12D. niques to use in a painting pictures each time they return to
At the other end of the spectrum, Unger continues to use 2- their easels. But as both hair restoration surgeons and artists
mm and larger round grafts in carefully selected patients to see their creations evolving adjustments in their plans are usu-
create the appearance of great density. He discusses this ap- ally made to accommodate changes in objectives that they think
proach completely in Chapter 12G. Suffice it to say that he uses may produce more satisfying ends. If the surgeon goes about
it in a small minority of individuals with specific characteristics, hair transplantation as a purely mechanical, homogeneous
and that he is one of very few practitioners who find the results placement of ‘‘x’’ number of grafts over a given area, there is
both practical and, in some respects, cosmetically superior to no artistry involved and optimal aesthetic results will never be
FUT as well as microslit grafting. Moreover, he has succeeded achieved. The metaphor of ‘‘painting all the rooms the same
in using DFU grafts, slot grafts, and round grafts without detect- color’’ has been used to describe this mechanical approach.
ability in most of his patients because they come for treatment
before they are totally alopecic. These grafts are far less notice- Special Strategy Considerations
able if they are transplanted into hair-bearing areas than if they
are transplanted into an essentially alopecic recipient area. Sub- Should the Surgeon Treat Areas of Evolving MPB
sequent sessions are routinely done in pace with the rate of hair As we have stated previously in this chapter, we believe that
loss so the grafts are never left with a background of total alope- treating areas of evolving MPB that are still bearing hair should
cia and are, therefore, unlikely to be noticed during the course be a standard feature of nearly all transplant sessions. Does
of treatment (Fig. 5A-12 and 19). Unger believes he attracts doing so cause acceleration in the rate of progression of MPB?
patients who are not yet alopecic in greater numbers than most Debate on this question has existed for almost as long as hair
hair restoration surgeons because he has advocated and used transplanting itself. Hair loss in MPB occurs in stages that begin
this approach successfully for many years. Doctors, hairstylists, at any time and last for periods that vary tremendously from
and his patients’ acquaintances know this and therefore refer person to person. The periods of loss are interrupted by periods
to him or consult with him earlier than is the case in most of relative stability. The length of stable periods also varies
practices. Approximately 90% of his patients are not totally from person to person. It is, therefore, impossible to know with
alopecic when their treatment begins, and a sizeable minority certainty if any increased loss is coincidental or the result of
has substantial amounts of hair. Is it any wonder, then, that his surgical intervention. The best the surgeon can do is to guess
134 Chapter 5
the relation between surgery and hair loss on the basis of numer-
ous and repeated experiences. What is clear, however, is that
if physicians have had one or two negative experiences, they,
no doubt, stop intervening early and, therefore, limit sampling;
whereas those who have more positive experiences continue to
operate on patients with early MPB and reach their conclusions
based on a far larger sampling. We belong to the latter group.
We are convinced that early skillful treatment does not signifi-
cantly accelerate MPB. Unger believes there is a small possibil-
ity that earlier transplanting can even retard or partially reverse
MPB if some recipient area tissue containing follicles that over-
produce dihydrotestosterone (DHT) is excised as a component
of treatment—specifically, if round or slot grafts are employed
or sites are prepared with a laser (26) (Fig. 5A-47). The surgeon,
however, must be deft. The more hair still present in the recipi-
ent area, the more important accurate angling and directing
of the cutting instrument becomes during the preparation of
recipient sites; such care prevents lethal injury to adjoining
follicles.
It is true that if some temporary loss of existing hair occurs
in the recipient area, the hairs falling out because of interruption
of their blood supply will be one hair cycle farther along toward
their eventual vellus state. For this limited number of hairs,
MPB is accelerated. Furthermore, if the persisting hairs are
particularly short, fine-textured, and near the end of their cos-
metic value, the surgeon may find that the transplanted hairs
produce only slightly more hair in that area. This might happen,
for example, if the original hairs go into telogen/anagen efflu-
vium and grow back as essentially invisible vellus hairs. In
such a circumstance, the surgeon has essentially traded light
coverage with original hair destined to be lost for light coverage
with permanent (transplanted) hair. Thus, even though this type
of patient may see only slight improvement after his first session
(especially if done exclusively with FUs), the new hair is perma- Figure 5A-47 (a) A patient before transplanting showing mod-
nent. On the other hand, whenever we use the term ‘‘early erate thinning in the frontal area. (b)The same patient 8 months
transplanting,’’ we are not referring to patients with only a light after a first session of standard grafts only. This individual was
coverage of original hair. In addition, in our experience, typi- treated approximately 17 years ago, before slit grafting and micro-
grafting were proposed. The increase of hair in the transplanted
cally only 5%, and at the most 20%, of existing hair is actually
area, with minimal or no plugginess, suggests that some of the
temporarily lost. If surgeons frequently see higher rates of
miniaturizing hairs in the thinning areas had reversed course and
telogen/anagen effluvium, they should reassess all aspects of
become coarser and longer rather than finer and shorter. I believe
their techniques. In our experience, transplanting hair into an that this change could not have been the result of only the hair that
area that is still bearing hair always increases apparent hair had been transplanted in the grafts. The results were too
density and bulk far more than any decrease in hair density that good—both in density and naturalness—in response to what had
may occur secondarily to the consequences of telogen/anagen been done. Perhaps early transplanting retards or partially reverses
effluvium of a relatively small proportion of existing hairs. In male pattern baldness provided some recipient area tissue that con-
addition, any hair still present in the recipient area provides: tains follicles that overproduce dihydrotestosterone (DHT) is ex-
(1) guidance for the surgeon to identify the natural hair angle cised as a component of the treatment—specifically, if round or
and direction in any given area, (2) postoperative camouflage, slot grafts are employed or sites are prepared with a laser. (WU)
and (3) the installation of permanent hair in the problem area;
thus, the patient never has to experience the embarrassment of
actually going bald or nearly bald before treatment begins. In
the latter respect, the debate is somewhat analogous to argu- not accelerate MPB, and because most men ultimately lose their
ments over what is the correct age at which to begin transplant- hair to a lateral fringe line that is parallel to the ground or that
ing. Should surgeons wait for baldness or near baldness to occur angles somewhat inferiorly as it moves posteriorly, we advocate
before interceding? Or should they ignore theoretical disadvan- the simultaneous treatment of (1) frontal corners or creases with
tages that urge them toward caution, because: (1) these disad- less obvious thinning and (2) more obvious areas of frontal
vantages are impossible to prove or disprove for any individual thinning and a portion of the fringe surrounding obvious thin-
patient and, (2) not ignoring them leads to other practical prob- ning in the midscalp and vertex. Such an approach helps avoid
lems? There is no absolute and correct answer to these ques- constantly chasing an enlarging balding area. There are few
tions. Physicians must act on the basis of their own experience things more frustrating than completing the correction of a thin-
and conscience. Because we believe early transplanting does ning area with transplanting, only to find a new thinning area
just beyond the borders of the treated site. If the surgeon at-
tempts to treat future areas of thinning at the same time as more
obvious problem areas are transplanted, such a catch-up game
can be avoided; for example, the frontal third to half of the
typical area of MPB may need to be treated no more than three
or four times over the course of the individual’s lifetime. As
noted earlier, such areas of future thinning can often be clarified
if the hair is wetted and examined closely and if a good family
history is taken.
Initial Creation of Fine Cover

Some men who seek hair transplantation are very sensitive to
the fact that others will notice the sudden growth of hair on
their normally bare scalps. Placing a relatively small number
of FUs—for example, 300 to 600—across the area of the antici-
pated frontal hairline and sparsely into the midfrontal region
and then waiting 10 to 12 months for that hair to gain sufficient
length is a strategy to diminish detectability. During this time,
the patient’s friends, family, and co-workers gradually grow
accustomed to the slight and relatively imperceptible change in
the patient’s appearance. Then the normal sequence of trans-
planting ensues. The chief disadvantage of such a tactic is that
it delays, by almost a year, the time required to actually achieve
the ultimate goal. Another far more common variation of this
strategy, to which we have already alluded, is to initially fill
in the entire area to be transplanted with FUs (1000 to 1500 or
more) and then, in subsequent sessions, to use a combination of
FUs and microslit grafts in the central regions to create greater
density. Round grafts and slot grafts are best avoided in such
a scenario, because previously transplanted hair can be damaged
or excised.
Use of Alternative Donor Sites

Figure 5A-48 (a) This photograph shows normal scalp hair
For some men, the donor reserves are so small that a minimal and beard hair from the same patient, which demonstrates the
plan to adequately frame the face is not possible. For such greater caliber of the beard hair. (b)The beard area scar 6 months
situations, it is possible to consider using beard hair as a donor postoperatively. (MB)
source. Such hairs are obviously coarser and curlier than the
usual scalp hairs and, for these reasons, need to be placed within
the central confines of the transplanted area. The hairs placed
in this location contribute to the visual fullness and bulk of the
transplanted result, and they do not detract from the naturalness do not justify the labor and potential morbidity involved with
of the exposed borders. such an undertaking.
Four things are important to consider before using beard
hair. First, the physician must carefully assess the density of Working from the Back Forward
hairs in the area beneath the chin and jaw-line. This density Sometimes, the patient requests that the transplanting begin in
varies greatly from one man to another. Second, the bony con- the posterior area of the scalp and then gradually be brought
tour of the jaw and mandible must be such that there is adequate forward in later sessions. The first reason for such a request is
protuberance of these structures to hide the resultant scar. Third, that it avoids a sudden appearance of hair that was not present
the patient must be willing to accept the presence of a scar on before in the frontal region; and second, the hair transplanted
the underside of his jaw. If the patient already has a beard in the posterior scalp may be styled forward and used as camou-
growing and is committed to keeping it, this last consideration flage for the sessions that follow. We think this is generally a
is far less important, because the scar will be well hidden by poorly conceived strategy for a number of reasons. It requires
the beard hair. And fourth, the patient must be informed that a larger than normal number of sessions, and, therefore, it neces-
beard hair is coarser and curlier than scalp hair and can only sarily becomes a more expensive strategy. It also delays begin-
be transplanted well within the borders of the recipient area. ning the chief objective of any hair transplant, namely, the fram-
Figure 5A-48a shows normal scalp hair and beard hair from ing of the face and the creation of the frontal hairline. What is
the same patient and demonstrates the greater caliber of the more, if a FU/multi-FU grafting approach is used, the surgeon
beard hair. Figure 5A-48b shows the beard area scar. Reports is not going to waste FUs at the anterior aspect of this posteriorly
on harvesting chest hair have been published by Brandy (27) located area. If the patient does not complete the later, more
and Beehner (28), but the graft numbers obtained in their reports anterior work, he is then left with larger than optimal grafts at
136 Chapter 5
the anterior border of the uncompleted work. For these reasons, than 800 men who wore hairpieces (approximately 40% of his
Beehner absolutely refuses to transplant with a start-at-the- patients fall into this group!), and he allows them to wear the
back-and-work-forward framework. When time is taken in the hairpiece the day after surgery and has never noted any impair-
consultation to explain these drawbacks, he finds that most pa- ment of hair growth or increase in infection rates (30). He also
tients change their minds and agree to a plan that includes ini- asks his patients to shave the recipient area preoperatively and
tially transplanting the frontal region and hairline. Unger agrees to use chlorhexidine gluconate (Hibiclens) the night before, and
with this sentiment but believes that after its drawbacks are the morning of, surgery. This facilitates keeping the area clean
strongly pointed out and understood by the patient, the patient after surgery.
is ultimately entitled to his preferences. There is also the added As a pragmatic matter in our practices, for the duration of
theoretical advantage that the grafts used in the initial area have the transplant process, the patient has to convert his hairpiece
a ‘‘virgin’’ anterior blood supply, which they might not other- attachment method to one that uses clips. He usually still re-
wise have if grafts are concomitantly transplanted anterior to quires two-sided tape to secure the hairpiece frontally. Most
them. Therefore, hair survival within grafts in the initial area hairpieces extend further down on the forehead than the trans-
can be better with the former approach. planted grafts, so the individual is usually able to secure his
hairpiece just inferior to the transplanted frontal hairline. If this
Patients Who Wear a Hairpiece is not the case, it is advisable to initially have the anterior por-
Doing a hair transplant on a man who wears a hairpiece is a tion of the hairpiece simply ‘‘sit on’’ the new grafts. Later,
mixed blessing. The positives are as follows: Usually, such a the newly growing hairs may be shaved down for a while to
patient condemns the unnaturalness of the hairpiece and all the accommodate a small tape attachment.
maintenance, visits, and cost involved. For these reasons, he is
often highly motivated to follow through with the transplant Timing of Intervals Between Transplant Sessions
process and to be rid of his ‘‘appliance.’’ Also, the hairpiece
provides a built-in cover for camouflaging the transplant pro- There are many different schedules that are followed by various
cess until sufficient hair is growing. On the negative side, the hair restoration surgeons. Most recommend having at least a 5-
hairpiece wearer usually has grown accustomed to having the month to 6-month interval between transplant sessions. This
appearance of thick hair covering his entire alopecic scalp. The time span allows the recently transplanted hair to begin growing
transition to a head of transplanted hair means that the trans- and permits the scalp’s vasculature to fully recover from the
planted hair possibly does not cover the entire alopecic area last surgery. Some surgeons who use large numbers of FUs in
and almost certainly appears less full than the hairpiece. Put their sessions recommend the patient wait a year before the
differently, many of these men have been ‘‘spoiled’’ by their next procedure is performed. As a general rule, the more work
‘‘full head of hair.’’ A few opt for dense transplanting frontally that has been done on a patient—whether it be ARs or transplant
and a hairpiece posterior to the transplant so that they do not sessions—the longer the interval should be between surgical
have to accept lower hair density (Fig. 5A-17), but for most sessions. There are a number of reasons for this recommended
practitioners, the first job in the consultation is to lower the delay First, in patients with multiple past procedures, the vascu-
patient’s expectations for hair coverage. Simply stated, most of lature usually needs more time to recover so that it can ade-
these men have to want to have their own natural hair so much, quately support the next group of grafts. Second, by waiting a
and dislike the hairpiece to such a degree, that they are willing longer interval, the patient’s hair will have time to grow longer,
to make the trade off and to proceed. Another unpleasant aspect thus making a visible difference that the patient can appreciate
concerning the nonsurgical hairpiece is that, as the first two or and providing valuable additional camouflage for the early heal-
three transplant sessions begin growing out, the hair is matted ing stages of the next surgery. Third, many physicians, includ-
down by the hairpiece and is unattractive. It is helpful at this ing both of us, believe that there may be a delay of as long as
stage to suggest that the patient have his hair groomed by a 12 months before essentially all of the transplanted hair begins
professional stylist, using a blow dryer and whatever other aids growing in patients who have undergone several past proce-
can make the hair look as full as possible. Then the decision dures, making it impossible to do proper evaluation earlier Mar-
whether or not to discard the hairpiece can be made more realist- tinick has done studies that indicate some hair regrowth can
ically. occur as late as 18 months after FUT (31). Fourth, spreading
A final yet important matter with regard to hair transplants sessions farther apart makes the change more gradual and less
on an individual who wears a hairpiece is whether the hairpiece noticeable to others—a goal of many patients. Fifth, for patients
itself causes poor growth of transplanted hair in some men. with a fair amount of residual hair, spacing sessions as far apart
Many hair restoration surgeons, including both of us, have seen as a year is sometimes beneficial because the surgeon can de-
scattered cases of what appear to be lower hair survival rates velop an accurate impression of the cosmetic impact of each
when hairpieces have begun being worn the day of, or the day session and can also more clearly discern the grafted hair against
after, surgery. The exact cause of this occasional phenomenon the background of the original hair in that area because the
is uncertain. A mechanical shearing stress on the newly growing regrowing, transplanted hair is initially both short and fine. As
grafts or the presence of a hot, humid environment conducive the hair grows, its length and caliber increase. Thus, older trans-
to the growth of bacteria are two possible theories that have planted hair has a greater caliber and is more likely to be dis-
been put forth to explain this occasional poor growth. Unger cernible against a background of miniaturizing and, therefore,
has long recommended that patients not wear a hairpiece for 1 finer textured, original hair. As a result, the surgeon can choose
full week after each procedure, and that they then wear it for and place the new grafts more optimally. Finally; the surgeon
an additional week only as necessary, such as during the work- can develop a better idea of the rate of loss of the patient’s
day (29). On the other hand, Vance Elliott has operated on more original hair.
In contrast, the man who wears a nonsurgical hairpiece or tive IFF discussed earlier in this chapter for the vast majority
who is completely alopecic may want the intervals to be as of them. In Beehner’s practice, approximately 15% of patients
short as possible so that he can complete his treatment as quickly who proceed to surgery are treated with a frontal forelock of
as possible. For such patients, sessions may theoretically be one type or another, the majority of which are also of the pro-
carried out as close as 6 weeks apart in the same areas or as spective or anticipatory variety. The candidates for this type of
early as 1 day apart in different areas—for example, the frontal transplant pattern can be divided into two major categories and
transplant region on day 1 and the midscalp on day 2. Some three minor ones. Ninety-five percent of these patients come
practitioners prefer to do both areas on the same day. Unger, from the first two major categories:
however, is concerned about physical stress on both patient and
1. The very bald: These are men who have a relatively
staff as well as the blood supply to central grafts in sessions
small amount of donor hair available and an extremely
of more than 2500 micrografts or 1500 micro-minigrafts; com-
large area of actual or potential alopecia.
bining the treatment of the entire frontal and midscalp areas
2. The very young: These are men in their 20s and possibly
also rarely produces good hair density after one session with
early 30s whose future balding pattern is unclear and
such relatively low numbers of grafts.
in whom there are signs pointing to later, extensive hair
Handling Various Scalp Lesions and Unattractive loss and/or a family history of types VI or VII MPB.
Markings 3. Patients who request an IFF: An occasional patient,
It is not unusual to find various lesions on the scalp at the time usually an older man, requests that only a limited area
the surgeon is planning the hair transplant project. If any appear in the frontal midline scalp be transplanted. Most com-
even remotely suspicious, it is our practice always to excise monly, this is a man who earlier in life had a similar
them before, or at the time of, the first transplant procedure and thatch of hair there but gradually lost it, and, with this
send the tissue for pathologic identification. This is especially hair loss, also lost the framing of the face that the hair
important for growths on the recipient scalp, where future had provided. Such a patient prefers a more modest IFF
growth of hair can hide progression of lesions. Occasionally, restoration rather than a return to the full head of hair
patients have unattractive lesions on the forehead near the hair- of his youth.
line, such as hemangiomas or benign nevi, which are likely to 4. Patient with limited finances: Some men can afford only
detract from the completed hairline’s aesthetic appearance. We a small amount of transplanted hair in a limited number
usually offer to treat patients with these at no cost during the of sessions; primarily, they just want their faces framed.
course of the transplant procedures. Likewise, lesions in the The forelock design fits their needs well.
donor area must be diagnosed to prevent any dissemination by 5. Rearrangement of old transplants: There are some pa-
means of the transplant process. When lesions that are almost tients who have had transplants in the past with large
certainly benign are encountered in the donor area, such as grafts that were scattered widely over a large area of
compound nevi, it is our policy to carry the donor harvesting thinning scalp. As the years passed, these patients lost
through the tissue if it happens to be in the line of normal all of their preexisting hair in the recipient area, which
harvesting. The affected tissue is then excised from the strip(s) caused their grafts to stand out against the newly alope-
and either discarded or sent to the pathology laboratory, if indi- cic areas. Some have also seen their fringe hair recede
cated. from the transplanted area, creating a halo of alopecia
that surrounds the old grafts (Fig. 5A-49). In other
The Frontal Forelock Concept words, too much was tried with too little. An ideal strat-
egy for rehabilitating the cosmetic appearance of these
In the early 1990s, Marritt first proposed that an IFF pattern men is to rearrange their existing hair into a centralized
be used more frequently in hair transplantation (32). Beehner IFF pattern. Usually, there remains a small amount of
and others have added to this concept with various design pro- residual donor hair that can be harvested, which, along
posals and techniques in the years since then (33,34). When the with the hair obtained from excision of grafts outside
grafts were larger and the number of grafts used per session the forelock area, can be used to create a forelock pattern
smaller, it was impossible to cover the entire area of alopecia in the anterior half of the scalp, with gradients of de-
in most transplant patients. Now that we have the ability to creasing hair density peripheral to a central zone. This
transplant a great number of very small grafts, we can more subject is covered in more detail in Chapter 17. Such
easily fill in the MPB in many men with a lower, but more a project requires a seriously motivated patient and an
even hair density, thereby creating a more natural appearance. imaginative surgeon. Unfortunately, many of these pa-
Marritt’s initial proposal, therefore, which was a reaction to the tients are bitter and distrustful of the entire hair trans-
large-graft era, is not as commonly needed today as at the time plant community. Finances can also be problematic. It
he proposed it. Yet there still remains significant numbers of takes much counseling and an unusually good doctor-
transplant candidates for whom a forelock design is the best, patient relationship before this type of patient will agree
and, occasionally, the only possible pattern. Because of our to such an undertaking.
present grafting capabilities—even in men with limited donor
resources—a number of design features are possible within this
Possible Forelock Designs
concept.
As noticed earlier, a forelock may be designed either as a frontal
Candidates for a Frontal Forelock forelock or a frontal-midscalp forelock, also referred to as a
Unger transplants true frontal forelocks, as described later, in cadre de cheveaux. A frontal forelock has the majority of its
only a very small percentage of patients, preferring the prospec- area anterior to a line drawn between the two frontotemporal
138 Chapter 5
Figure 5A-49 (a) A patient who 15 years earlier had had large grafts scattered all over his scalp and was donor depleted. (b)A small
to medium-sized forelock zone was created by removing grafts from outside the forelock area and reusing them as follicular units. (c)The
mirror-image effect of the forelock abutting the temporo parietal fringe can be seen in this lateral close-up of the final result. (d)The
‘‘mirror-image’’ effect is shown in the drawing superimposed on a photograph of the patient seen in Fig. 5A-49a–c. A light covering of
follicular units was used in the posteroparietal triangles to create the effect seen in Fig. 5A-49c. (MB)
corners. A frontal-midscalp forelock, as its name implies, is Detailed Comments Concerning the Four Forelock
somewhat larger, and the majority of its area lies posterior to Designs
this line. After 6 years of trying various configurations, Beehner
has settled on four design patterns that work best in his hands. 1. Small anterior oval forelock: This pattern is ideal for the
Each of these is described individually. patient who wishes to have a minimalist approach (Fig. 5A-7a
and b). Often, this patient is an older man who only wants a
Scatter Zones Before proceeding, it is necessary to define
little hair added to help frame the face and recapture what he
a scatter zone. It is an area adjacent to the main body of a
forelock design into which FUs are sparsely transplanted. This possessed 10 years earlier. Triangular scatter zones are usually
thinly transplanted zone helps connect the central body of the created bilaterally. The smaller forelocks are often constructed
forelock to the peripheral fringe at various points, thereby creat- with only two zones in the oval forelock itself. In the central
ing a visual blur in the intervening alopecic zone. In the follow- portion, randomly spaced four-hair to five-hair round grafts are
ing description of the four designs, the scatter zones in each typically placed into 1.3-mm recipient sites. In patients with
are designated as dotted areas, lateral to the main body of each low donor area hair density, 1.5-mm diameter punch recipient
forelock. To be effective, there should be a dropoff in density sites are required. If the hair is particularly dark and coarse,
from the forelock’s edge to the scatter zone. The scatter zone FUT often works best. In the peripheral zone surrounding the
also enables the surgeon to create a visual mirror image of the round grafts, FUs are placed with moderate density—approxi-
forelock in its relationship to the adjacent fringe (Fig. 5A-49). mately 15 to 20 FU/cm2 per session. The two lateral and triangu-
lar scatter zones are then sparsely filled in with FUs—approxi- these two posteroparietal triangles is the parietal fringe. The
mately 8 to 10 FU/cm2 per session. anterior border of these triangular areas is the posterior aspect
2. Large or medium-sized oval frontal-midscalp forelock: As of the forelock. From a posterior view, an observer is casually
has been mentioned several times previously, a design similar to aware of the appearance of a circular alopecic (or thinning)
this one was described in 1994 by B. Stough and elegantly vertex, demarcated by the concave, curved line created by these
termed a cadre de cheveaux (4). The scatter zone on each side two sparsely transplanted scatter zones in the posteroparietal
of this forelock pattern attempts to bridge the gap between a triangle (Fig. 5A-51e). But if the surgeon focuses instead on
portion of the lateral aspects of the forelock and the temporopa- the dominant pattern of density in the midscalp as viewed poste-
rietal fringes. Since then, Beehner has been using a medium- riorly, there is a detectable convex, curved outline of relatively
sized version of the large oval forelock, which is equally long dense hair that projects posteriorly to the vertex transition point.
in the antero-posterior axis but narrower and therefore incorpo- Thus, these transplanted triangular scatter zones create the vis-
rates wider scatter zones bilaterally (Fig. 5A-7c and 49a–d). ual impression of a concave line, whereas the more densely
This medium-sized version is particularly valuable for the pa- transplanted body of the forelock creates the impression of a
tient with extremely poor donor hair density. convex line.
3. Rounded arrowhead design: This design may be used for
the reasonably mature man whose temporal fringe is not too Conclusion
low (Fig. 5A-50). This hair pattern appears most aesthetic when In summary, the use of a forelock design allows the hair restora-
the forelock maintains contact with at least the sparse hair in tion surgeon to use a relatively small amount of donor hair to
the superior temporal fringe. Its use should be discouraged in create the impression of natural and acceptable hair coverage
the younger patient because it is less attractive if it becomes over a relatively large area. Furthermore, by using a central-
isolated in later years. Another candidate for this design is the density concept, the surgeon protects the patient’s future cos-
man who intends to sweep his hair from one side to the other. metic appearance, should his evolving pattern of alopecia be-
The rounded frontal contour of this pattern gives a full look to come larger than anticipated.
frontal hair styled this way.
4. Oval frontal-midscalp forelock with flared frontal hair-
line: This design comprises 70% to 75% of the forelock designs THE ROLE OF ALOPECIA REDUCTIONS
in Beehner’s practice. It is somewhat similar to the large oval
frontal-midscalp forelock but differs in that both lateral projec- Although ARs are still of value in carefully selected patients,
tions of the frontal hairline flare out laterally to approach the they are performed far less frequently now than 10 or 15 years
temporal fringe (Fig. 5A-51a). The posterior aspect of this de- ago. The reasons are many. Most importantly, they appear to
sign ends at the vertex transition point and is convex. The pa- be less necessary today because of: (1) our current ability to
rameters of this prototype forelock pattern are so designed be- easily place 1000 to 2000 grafts per session (depending on the
cause many men with a persistent, large forelock of hair often size and mix of grafts), creating a lower density, but more even,
possess this pattern. In its posterior aspect, the design features natural hair coverage over a larger area of the scalp, and (2),
what may be referred to as the paradox of the two curves. The improved donor area techniques leave less scarring than in the
visual illusion of two curves is created by the triangular scatter past. The latter allows more hair to be removed from the donor
zones, which lie lateral to the posterior aspect of the forelock area without overly depleting hair density at that site. AR was
(Fig. 5A-51b–e). The posterior limits of these scatter zones introduced during an era when it was possible to cover only a
curve inferiorly toward the lateral occipital area and together portion of the scalp with the large grafts then in use. When this
create the anterior border of the vertex. The lateral border of procedure arrived on the scene, it promised to reduce the size
of the alopecic area, thereby making it possible to transplant a
larger proportion of the remaining area with the original number
of harvested grafts.
Drawbacks
Over the years, a number of potential drawbacks concerning
AR have emerged. A phenomenon called stretch-back, in which
some of the initial gains of the procedure were later lost, was
detected. It occurred in the ensuing weeks and months after
transplanting, as the remaining bald scalp relaxed and widened
somewhat. This was especially true of thin, hyperelastic scalps
or in cases where closing tension was intentionally great. An-
other drawback was the unavoidable resultant scar. Although in
the great majority of well-performed ARs the scar is essentially
undetectable, in a small percentage of procedures, the scars are
wider than anticipated and difficult to camouflage. In addition,
it is not always possible to predict accurately which men will
have undetectable scars and which will have wide ones. The
Figure 5A-50 A ‘‘rounded arrowhead’’ isolated frontal fore- U-shaped and M-shaped reductions also have the disadvantage
lock has been designed for this patient. (MB) of cutting full thickness through a line that partially encloses
140 Chapter 5
Figure 5A-51 (a) This is a design of a frontal midscalp forelock with a flared front before transplanting. (b)The paradox of the two
curves is seen here in the same patient shown in Fig. 5A-51a. Denser minigrafts form the posterior convex line and follicular units have
been placed into the posteroparietal triangles to help form a relatively weak posterior concave line. (c)The same patient shown in Fig. 5A-
51a and b before transplanting, with a combination of micrografts and minigrafts. (d)The same patient shown in Fig. 5A-51c, after three
transplant sessions. (e)A posterior view of the two different curves created in the posterior aspect of a frontal midscalp forelock in a 30-
year-old man. (MB)
the area to be transplanted later (see Chapter 19). Thus such cient height of hair-bearing scalp on each side of the area of
ARs possibly compromise the scalp’s vascular support for grafts MPB. This vertical wall of hair-bearing scalp is ideally where
placed later in the area surrounded by the scar. Also, multiple the majority of the stretching should occur if the width of the
ARs thin and attenuate the scalp, again possibly impacting the alopecic skin is to be reduced. As an extreme example, an AR
vascular support therein. Finally, ARs always thin out the hair on a Norwood type VII patient is always a futile exercise be-
density in the donor area proportionate to the total amount of cause the bilateral 3-cm to 4-cm height of hair on each side is
alopecic skin that is excised. required to absorb the gains from excising a 3-cm to 4-cm width
of skin from the 18-cm to 20-cm wide area of alopecic scalp
Planning between them. Any later partial stretch-back, almost certainly
occurs primarily in the 15-cm to 17-cm wide area of remaining
Before a surgeon commits to performing an AR, the physics alopecic skin and does not preferentially select these narrow
of the situation must make sense. That is, there must be suffi- hairy fringes as a location in which to occur.
edge, which results in the creation of small, vertical

furrows at the occipital fringe. If hair is present in this
area, it becomes compressed in these furrows and ap-
pears unnatural.
Unger finds the concerns raised by Beehner to be considerably
less problematic than Beehner does. In particular, the degree
of stretch-back and scalp thinning is very technique dependent.
Unger’s views on the pros and cons of ARs are similar to those
of his brother, Martin Unger, who presents them in Chapter
19A. Walter differs from Martin only in the level of enthusiasm
expressed in proposing this option to patients; nonetheless, Wal-
ter’s enthusiasm is significantly greater than Beehner’s. He be-
lieves in presenting the pros and cons by advising the patient
that if he chooses not to undergo AR or scalp extension, he
is limiting the likelihood that the entire area of MPB can be
transplanted, and/or that whatever is transplanted will need to
be transplanted less densely than the patient might like. If the
Figure 5A-51 Continued.
individual elects not to undergo AR, Unger will, in almost all
cases, limit his objectives to treating the alopecic area only as
far posteriorly as the vertex transition point. He believes that
there can be a hidden ‘‘time bomb’’ ticking in patients who
have had relatively large areas of MPB transplanted relatively
Despite the potential negative effects mentioned, there are, lightly and who then choose the lower density objective in order
in our opinion, specific patients for whom AR is invaluable. It to avoid AR. As such patients grow older, they may note a
has the potential to reduce the alopecic scalp area, especially significant decrease in recipient area hair density, because, with
in men for whom the risks of stretch-back and scar visibility the passage of time, the transplanted hair becomes less dense
are minimal. in proportion to the decreasing hair density in the donor areas.
Beehner performs a single scalp reduction on carefully se- Thus, what was originally a satisfactory appearance of hair den-
lected men who fulfill the following criteria: sity may become almost alopecic after 15 to 25 years. The
sometimes remarkable decrease in hair density that has been
1. Patient age of 35 years or older
seen in some patients treated many years ago with standard
2. Thick, loose scalp
grafts may be an ominous forewarning of what we can expect
3. Little or no hair present on the skin to be excised
in today’s patients who have been treated more lightly in order
4. Degree of baldness not greater than Norwood type VI
to avoid AR (Fig. 5A-52). The role of AR, which is sometimes
5. Goal is to fill in the entire area of MPB (frontal, mids-
important in the improvement of cosmetically unsatisfactory
calp, and vertex areas)
hair transplanting, is also discussed by Unger in Chapter 17.
6. Highly motivated patient who has an aggressive attitude
John Cole offers one more way of looking at the question
for doing everything possible to eliminate alopecia and
of ‘‘to AR or not to AR.’’ Cole is a widely acknowledged expert
achieve maximal hair density
in FUT and donor area study (see Chapter 10). At the annual
Beehner’s preferred AR pattern is the lazy S pattern (See Chap- meeting of the ISHRS in 2002, he estimated that if, on average,
ters 19A and 19B). It starts in the midfrontal region (to narrow one could remove 42 cm2 of alopecic or future alopecic scalp,
the bitemporal width of alopecia) and curves gently toward the the approximately 1918 FUs—which would otherwise have
right-lateral parietal fringe and then just anterior to the occipital been required to transplant that area adequately (at 50% of its
fringe border. The excised segment is generally 3.5-cm to 4.5- original density)—would be liberated to treat the remaining
cm wide at its widest points in properly selected candidates. area of MPB. He calculated the 1918 FUs by assuming that 42
Stretch-back in Beehner’s practice has been measured in a series cm2 would contain an average of 42 ⳯ 210 hairs/cm2, or 8820
of 11 patients by means of tattoo dots and was found to average hairs, or 3835 FUs (if there were an average of 2.3 hairs in
37% (range of 24% to 55%) (35). All 11 patients had scalps each FU). It is important to note that a 42 cm2 area represents
that were 6 mm to 8 mm thick. a strip that, for example, is only 2 cm wide and 21 cm long.
Beehner proposes three reasons to perform only one lazy S Excising such a strip in a patient with average scalp laxity would
AR: be a very modest objective for most competent AR surgeons.
It should be achievable in most patients even after stretch-back.
1. Stretch-back is greater at the time of the second AR In the same lecture, Cole also stated that, in his opinion, the
(see Chapter 18A). average donor area could be expected to have approximately
2. More than one AR excessively thins the scalp, making only 7000 FUs available for moving via strip excision without
it possibly less ‘‘friendly’’ for transplants to thrive. running the risk of over depleting the supply. (Bernstein has
3. If a second AR is performed at the time of the second estimated that only 6000 FUs are available.) Saving approxi-
closure, the surgeon must bring into exact opposition mately 1918 FUs with one AR, or considerably more FUs with
the long posterior edge and the much shorter anterior two or three AR, clarifies the potential importance of this much-
curved edge. This requires bunching of the longer skin maligned procedure.
142 Chapter 5
Sequence Options for Combining Hair

Transplantation and Alopecia Reduction
The initial decision that must be made is whether to begin with
the AR and then follow with transplanting, or the other way
around. Beehner always prefers to perform the AR first, with
the initial transplant procedure scheduled no earlier than 6
weeks later. The advantage of performing the AR first is that
the surgeon can plan the hairline later with no risk that its
contour will be drawn in by the AR procedure. Unger, con-
versely, usually begins with transplanting, leaving a frontal mid-
line and a lateral posterior area untransplanted so that it may
later be excised surgically (Fig. 5A-44a). Most frequently, the
untransplanted areas have persisting hair that he anticipates will
ultimately be lost and that he will, otherwise, have to transplant.
This approach has several advantages: (1) Previously trans-
planted hair can be used to camouflage the postsurgical course
of the later AR; (2) the surgeon can far better assess the likeli-
hood of good AR scars if good scars have been previously
produced in the donor areas; (3) after several transplants, it
can become apparent that if sufficient donor tissue remains in
reserve, an AR may not be necessary after all—especially if
the patient is satisfied with lower than average hair density; in
other words, this approach allows the surgeon options for an
alteration in treatment; and 4) once a transplant has been per-
formed, the patient can more objectively consider the pros and
cons of AR, because he does not face the uncertainty of how
he will tolerate both a transplant and an AR—neither of which
he has previously undergone. This is especially important be-
cause of the extensively publicized negative commentary on
AR. Regardless of the preceding considerations, ARs are some-
times carried out before transplants for the same reason Beehner
has described, especially if the scalp is more lax than average
and/or the alopecic area is extremely large, requiring more than
Figure 5A-52 (a) A patient at the end of transplanting 20 years one AR, or if scalp extension is used (see Chapter 19), all of
ago with four sessions of standard grafts producing a thick growth which make the distortion of a previously transplanted frontal
of hair frontally. (b)The same patient 25 years after the photo shown area more likely.
in Fig. 5A-52a showing marked decrease in hair density that has In our opinion, including AR in the surgical plan makes little
kept pace with the decrease in hair density in the donor area. (This sense unless (1) it makes the difference in allowing the surgeon
patient’s result has, in fact, turned into an isolated frontal forelock.) to transplant completely the entire balding scalp, or (2) it is
The sometimes remarkable decrease in hair density that has been used for repairs of poor transplanting, in which alopecic areas
seen in some patients treated many years ago with standard grafts may be excised instead of transplanted if there is insufficient
may be a forewarning of what we can expect in some of today’s donor tissue. In both instances, ARs enable the surgeon to use
patients whose lesser hair density has been chosen to avoid process
the available donor resources in a more concentrated manner
detectability and/or alopecia reduction. (WU)
over the remaining alopecic scalp. With this strategy, the scar
is ultimately covered with transplanted hair, thus rendering it
undetectable, regardless of how well it heals or its ultimate size.
Cole also estimated that a maximum of approximately only
170 cm2 of an alopecic area could be reasonably covered with GENERAL COMMENTS ON THE PLANNING
7000 FUs (approximately 40 FU/cm2). The reader who has been OF HAIR TRANSPLANTATION IN WOMEN
attempting to cover large areas of MPB with FUT or even
micro-minigrafting, but who does not believe in AR, is referred Many physicians and organizations still advise that hair trans-
to Chapter 12D, Fig. 5. This figure is Ron Shapiro’s diagram- plantation should rarely, if ever, be performed on women. With
matic estimation of the square area of alopecia in the frontal, modern techniques, which use very small grafts, this viewpoint
midscalp, and vertex areas of an average patient with fully devel- is, in our opinion, no longer true and is covered in detail in
oped MPB. Surgeons can quibble about the preceding numbers, Chapter 12H. However, in discussing hair transplantation with
increasing or decreasing them according to their inclinat- women, we have to use a different approach from that taken
ion—especially if they are on record in the literature. However, with men for a number of reasons.
any numerical differences are highly unlikely to ever be large As is the case with men, the most important first question
enough to make a significant dent in the obvious potential im- to ask is whether a particular woman meeting with a surgeon
portance of AR when the objective is maximum coverage. for consultation is a candidate for hair transplanting. The single
most important factor that quickly disqualifies a woman for planting in this small frontal area posterior to the frontal hairline
surgical hair replacement is inadequate hair density in the oc- does wonders for their appearance and self-esteem, and creative
cipital donor area. For women with low donor area density, a styling can help with the more posterior thinning area (Fig. 5A-
nonsurgical hair replacement unit is often the only recourse 53).
available. The physician must show empathy for these patients In the majority of female patients (if patients have an ade-
and review with them some of the available medical therapies quate frontal hairline, as do most of these women), we plan a
and camouflage techniques. The surgeon should also make cer- 1 cm to 2 cm deep area just posterior to the hairline into which
tain that an adequate medical workup is carried out to rule FUs are placed. The temporal region is examined for thinning.
out nonhereditary causes of alopecia. The majority of female If hair coverage is too sparse, these areas may also be trans-
patients with hair loss who seek help from us do have adequate planted with FUs. The anterior temporal region should appear
density of donor hair in most of the parietal and occipital re- relatively full in women, because it serves an important aes-
gions, but usually their hair density lessens considerably in the thetic function, holding up the frontal hair and imparting a
anterior parietal and especially the temporal areas. fuller, more striking framing of the face. The surgeon asks each
As noted earlier in this chapter, most of these women also female patient her preference for hair styling. Does she part her
share certain other characteristics. They possess a well-defined, hair down the center? Or does she part it on the right or left side?
though sometimes sparse, 1-cm to 2-cm wide frontal hairline. Because there is usually not enough donor hair to transplant
They have thin hair evenly distributed throughout the frontal completely the full width of the sparse or thinning midscalp
and/or midscalp and/or vertex areas; and, although the temporal and frontal regions, we often limit transplanting to a moderately
triangles in most women are normally shallow and blunted, narrow zone, around 4 cm to 5 cm in width, which extends
with the hair forming a gentle, curved contour, many of these from the frontal region posteriorly to the anterior vertex. In
alopecic women have male like recessions with triangular zones the sparse, untransplanted lateral areas on both sides of the
of hair loss on each side of the scalp (see Chapter 3B). In transplanted corridor, the hair will later appear full because of
addition, in most females with androgenetic alopecia, the sur- overlapping between the newly transplanted hairs and the sparse
geon faces the dilemma of a poor recipient/donor area ratio. hairs. By limiting the ‘‘plan of attack’’ in such a manner, it is
Thus, goals have to be prioritized and expectations often have possible to create the illusion of a full head of hair in many
to be moderated from the patient’s initial objectives, which may women. We prefer very small, randomly spaced minislit grafts
be too ambitious. mixed with FUs in the posterior frontal hairline zone and in
Nevertheless, we find that approximately 60% to 70% of the relatively narrow zone through which the patient plans to
the women appearing in our offices are candidates for hair trans- part her hair. If the vertex area is sparse and there is adequate
plantation. In other words, there is some plan, however limited, donor hair to transplant it, Beehner transplants exclusively with
that will help to improve their appearance. For example, the FUs at that site, whereas Unger continues to use a mixture of
most common complaint presented by women in our practices DFU grafts and FUs as described more fully in Chapter 12.
is that from a frontal viewpoint—as they view themselves in In discussing the transplant procedure with women, we find
the mirror—they can see their scalp through their hair. Thus, it valuable to be as honest as possible and not to sugar-coat
for some women with a limited area of good donor hair, trans- things. They should know that the full density of a wig cannot
Figure 5A-53 (a) A close-up before photo of a 47-year-old female patient. (b)A close-up of the hairline after three sessions of a
combination of follicular units and small slit grafts. (MB)
144 Chapter 5
be achieved. The possibility of forehead edema and temporary willing to refer patients to other surgeons if they do not
hair loss in the recipient area should be stressed, as, typically, perform a procedure that best serves their needs.
these side effects occur more frequently, in women. In addition,
we find it valuable to ask that the patient be committed to com- In the third edition of this text, Martin Tessler offered a quota-
pleting two sessions. We emphasize that although a single ses- tion that we think is worth repeating:
sion shows some improvement, the cumulative impact of two The ability to develop a surgical plan based on the
or more sessions makes a marked difference in most individuals. patient’s present situation and balanced with the likely
prospect of further hair loss is an art that takes
TRANSPLANT PHILOSOPHY AND A FINAL considerable experience and an abiding concern for the
OVERVIEW patient’s appearance many years in the future.
Consider the following:
There are a number of reliable guidelines that we feel apply to
the planning and organization of hair transplantation in a prac- Having hair is great.
tice that seeks consistently to create excellent aesthetic results. Being bald is not as great, but at least it looks natural.
Having poor hair replacement surgery is much worse than
1. The frontal transplant zone is almost always the highest
being bald.
priority area for hair transplantation. If the donor re-
serves are limited and another area of the scalp is trans-
planted, the surgeon must always remember to leave ADDENDUM
aside enough donor hair to adequately transplant the
frontal area at a future time, if this should become neces- Michael L. Beehner
sary.
2. Less is almost always better in terms of deciding how In the time that has passed since I initially contributed my views
aggressive to be in transplanting a given individual. This on transplanting to this chapter I have had some new thoughts
is especially true regarding the younger male, whose and a few changes in my practice style that are worth sharing
future balding pattern is uncertain. with the reader.
3. In creating gradients of density in the transplanted area,
it is almost always best to make the hair densest in the
central area of the transplanted scalp zone and then to Incorporation of Limited Dense Packing into the
plan for this density to decrease as the four peripheral Hair Transplant Plan
borders are approached. Because of the results of my own research in comparing the
4. Having the patient’s hair look natural is always more growth of minigrafts and FUs after one, two, and three sessions,
important than creating density. If the surgeon creates with superior growth being found after the first session—and
maximum density for a patient, but everyone who sees because of some of the reports by David Seager on his ‘‘one-
him recognizes that his hair has been transplanted, the pass technique,’’ in many of my patients I now often transplant
surgeon has failed. a focused area of the scalp in a dense-packing fashion, using a
5. The surgeon should avoid making the transplant too stick-and-place technique. Because I am uncomfortable with
perfect. Hairlines should never appear too straight at an assistant determining the angle and location of the graft sites,
their edges or too symmetrical or rounded in their con- I do this part of the transplant myself. This is usually done
tours. The overall distribution of hair on the scalp should with all 2-hair and 3-hair FUs placed in 19-gauge and 20-gauge
not be too perfectly homogeneous. All of these perfec- needle sites. The commonest location in which I employ this
tions have the potential of creating unnatural looking technique is just behind the hairline zone on the side from which
results. the patient plans to part his hair. I believe combining this fo-
6. The lateral hump is an extremely important concept to cused type of dense-packing with the usual three-session type
incorporate into planning in younger males with a likeli- of graft spacing gives surgeons the best of both approaches,
hood of developing type V or greater MPB. allowing the creation of instant density in selected key areas,
7. Future areas of hair loss should ideally be transplanted but also allowing them to fill in a large area of the balding scalp
at the same time as more obvious areas are treated in with relative safety for the grafts placed. My main objections
order to minimize the likelihood of the never-ending to routinely transplanting all male patients with 3000 densely
chase of an enlarging area of MPB. packed FUs in the front third of the scalp are the following:
8. In our opinion, hair restoration surgeons best serve their
patients if they are familiar with using a variety of graft 1. I prefer in the great majority of my patients to transplant
sizes and types to suit individual needs and situations. the anterior two thirds or the entire balding area.
We recognize that all practitioners have a favorite 2. I am skeptical concerning what the hair growth percent-
modus operandi that works best in their own hands and age is with this technique because there are no studies
which they use on the majority of their patients; how- addressing this issue.
ever, surgeons should avoid being rigid in their views 3. I still am convinced that in men who have a finer caliber
and intolerant of other approaches. By remaining open of hair and in those who do not possess a large number
to new ideas and by being willing to adapt over the of two-hair to four-hair FUs, that all too often the final
years, they glean wisdom from others and ensure that transplant result is somewhat thin in appearance and not
they will always provide their transplant patients with as full as could be achieved by use of a combination
the best possible results. In addition, they should be graft approach over three to four sessions.
Combining Hair Transplantation with Oral often being harvested from ear to ear. I believe that reducing
Finasteride the alopecic area by pulling up and stretching the two hair-
bearing fringes does not make a lot of sense, if I then proceed
Finally, after seeing more of my own results in these past years in my donor harvesting to take a 1-cm wide strip from both
when I have placed patients on oral finasteride and also trans- sides of the donor area in three subsequent procedures for a
planted their hair, I am more convinced than ever that these total reduction of almost 6 cm of donor hair height. I believe
patients turn out looking much better. This is simply because these two tasks compete with one another and that performing
two positives have been set up: The rebirth of the newly trans- an AR makes the chances for incurring a wide donor scar later
planted hair and, in most cases, the stimulation of additional on more likely. I would certainly agree that the use of extenders
hair mass in the existing native hairs. And the best part of it (the Frechet extender) negates my argument concerning occur-
all, which makes this approach a ‘‘no-brainer,’’ is that the sur- rence of stretch-back and may even help to make the scars less
geon gets credit for both positive outcomes. Conversely, if a noticeable, but I still think the thinning of the scalp and the
patient undergoes transplanting and is not encouraged to take reduction in laxity of the bilateral donor areas are important
finasteride, the surgeon is left with one positive and one negative factors to keep in mind.
result. Thus, the ravages of hereditary MPB continue on their Having made these remarks, I firmly believe that the skills
merry way despite the newly transplanted hair, and the overall involved in performing ARs are very important ones for the
result over the next 5 to 10 years is not as spectacular as it transplant surgeon to master, especially in some corrective
otherwise could have been. I now make an extra effort to try cases, and that it would be a shame if surgeons who are currently
and get all of my male patients to take finasteride. using these skills should not try to pass them on to the next
generation of hair restoration surgeons. I also believe there are
The Use of Beard Donor Hair in the Transplant some ideal cases in which AR could still contribute to the overall
plan, specifically in the patient of mature age with a modestly
Plan
sized bald crown, in whom a lazy-S reduction could remove a
We have used the beard as a source for donor hair in seven large portion of the crown skin and allow the surgeon to create
procedures performed on five patients. After seeing these pa- a final result with a thickly haired crown. (MB)
tients come back and after examining the results of their hair
restoration and getting their feedback, I would like to stress the Dr. Walter Unger Comments on the Preceding
following two points: (1) It is probably unwise to use beard Discussion
hair, even within the central areas of the scalp, in individuals As noted previously in this chapter, I believe that one should
who possess a fine caliber of scalp hair, because the contrast never produce an AR scar in an area that cannot subsequently
is too jarring and unaesthetic; (2) It is highly desirable that be transplanted with hair. Nor should one carry out ARs in such
the patient whose beard donor hair is harvested be one who is a fashion as to thin the skin or to impair the creation of a normal
committed to wearing a beard for the rest of his life, because hair direction pattern with subsequent hair transplanting. I agree
a scar will necessarily be present and the beard will make it with Dr. Beehner that with current methods we have enough
totally undetectable. In the five patients we have harvested, two donor hair to produce very nice coverage of the anterior two
are committed to always having a beard, two thought their scar thirds of the MPB in the majority of our patients without resort-
was very acceptable, and one was unhappy with his scar. Ironi- ing to the use of ARs. If density objectives are lowered, there
cally, the patient who was unhappy had the best scar of all. is also a minority, of our patients—but not a small minor-
ity—whose entire area of MPB can be treated with a combina-
Alopecia Reductions tion of micrografts and microslit grafts or minigrafts without
resorting to ARs. As a result of the preceding discussion, as
In the 18 months since I helped co-author this chapter, my well as a very heavy anti-AR bias on the Internet and in the
thoughts on including AR in a hair restoration strategy have medical literature of the last decade, I found my patients so
changed. We have performed no ARs in our practice in that resistant to the concept of AR that I became increasingly reluc-
interim. There are three reasons I can give for this change in tant even to bring up the subject of AR. Instead, I began to
practice philosophy on my part: First, our stretch-back study encourage patients to have their scalps treated only as far poste-
on 10 patients with ideal scalps (thick and lax) showed there riorly as the vertex transition point or, as indicated earlier, to
was 37% stretch-back two months after the time of the first treat the entire area of MPB but with a lower hair density objec-
transplant procedure. Second, it has been my experience that tive.
in 80% of AR patients, the resultant scar is virtually undetecta- What concerns me about this turn of events is that I am not
ble after transplanting and after all of the hair has grown out. sure that this policy is wise with regard to long-term planning.
However, in about 20% of AR patients, the scar remains some- Having been involved in hair transplanting for more than 35
what detectable, often despite repeated vigorous attempts to years, I have often noted a marked decrease in hair density
transplant hairs around and into the scar. In the final analysis, occurring, with the passage of time, in areas that I had previ-
I am just not willing to subject myself and my patients to a ously transplanted. I have discussed this at various points in
procedure that has a 20% chance of making them unhappy, the textbook; one should always take this future thinning into
when simply transplanting with small grafts and not including account when choosing today’s recipient area densities. I worry
the AR has an almost 100% chance of making them happy. My that in the years to come, those patients whom other surgeons
third reason is that, because an overwhelming majority of my and I myself treated more lightly than we could have had we
patients seek coverage in either the anterior two-thirds or the included AR in our approach—patients whose hair looks very
entirety of the typical MPB area, the donor strips are necessarily good at present—might look extremely thin again in 20 to 30
146 Chapter 5
years. This thinning will evolve as they lose some of their trans- effects in both blocking further hair loss and producing signifi-
planted hair in pace with the rate at which hair is lost in the cant vertex hair regrowth over a 5-year period. Five-year results
donor area from which that transplanted hair came. In brief, by that were released in 2002 showed that by hair-count, 65% of
minimizing the use of AR to reduce the size of the recipient men with mild to moderately severe vertex AGA (II vertex, III
area, we may be satisfying both our fear and our patients’ fear vertex, IV, or V) were stable or improved (3). Assessment of
of AR at the cost of unsatisfactory future recipient area hair standardized clinical photographs by an expert panel demon-
density. As long as sufficient donor reserves are left, such future strated that 90% of patients were stable or improved, similar
thinning can always be corrected later, should it occur. Unfortu- to the investigator visual assessment of their patients, which
nately, many practitioners ‘save’ only a small amount of donor demonstrated that 93% were stable or improved. Some men
hair for future use, or none at all, because their patients want who have been taking finasteride for 9 years have demonstrated
to accomplish as much as possible while they are younger and continued maintenance of benefit (4). For many physicians,
at a point in their lives when their appearance is more important finasteride is now front-line therapy for male AGA. These
to them. Time will tell if we are really doing our patients a highly significant results suggest that we may expect prolonged
favor in not offering them ARs more frequently. benefit from this medication in some patients. In those individu-
Finally, although an AR may only slightly reduce the bi als, the progression of AGA may even turn out to be optional
temporal distance, this varies with the degree of scalp laxity rather than compulsory. Time will tell.
and surgical technique. Also, multiple ARs can consistently do If we accept that for some male and female AGA patients
more than that (see Chapter 19). Furthermore, scalp extension stabilization is achievable, does this allow surgeons to create
routinely and substantially reduces the bitemporal distance with new design rules when planning the surgical management of
absolutely no thinning of recipient area skin (see Chapter 20). AGA? Will patients who were previously considered marginal
Is it wise, in the long run, to not take advantage of scalp exten- candidates become more suitable for transplantation? Previ-
sion in properly selected individuals? Once again, time will tell. ously, surgical planning was predicated on conservative design
(WU) rules to take into account the probability (or inevitability) of
further hair loss progression. This had implications on both the
placement of the hairline and the advisability (and extent) of
5B. Effect of Medical Therapy on grafting to the crown. This was particularly true for patients
Surgical Planning with extensive male pattern AGA or those with moderately
severe AGA who were young. Potentially, new planning rules
Russell Knudsen might be based on acceptance of stabilization of hair loss, thus
offering theoretical advantages by allowing use of more donor
Despite many claims over thousands of years, effective treat-
hair resulting from better estimation of the ‘‘safe’’ donor area.
ment of male and female androgenetic alopecia (AGA) has
This would allow treatment of larger areas of AGA (e.g., the
proved elusive. Indeed, male AGA has demonstrated clearly
crown area of a Norwood type VI) and perhaps placement of
that it is a relentless, although intermittently progressive condi- lower and flatter frontal hairlines.
tion. Improvements in the medical treatment of AGA have In women, it is my current opinion that medical stabilization
shown considerable promise in modifying the progressiveness has no effect on surgical planning in most cases. Suitability for
of this condition, and, in some cases, demonstrated medium- transplantation in these patients depends more on the quality
term significant reversal of the hair loss. It is, therefore, possible and amount of donor hair than on stabilization of loss. However,
that we have now entered the era of pseudostabilization of AGA, the use of minoxidil may be advantageous in reducing the risk
and this may have some implications for its surgical manage- of postoperative anagen defluvium, which is very distressing
ment. when it occurs. In women with temporal recessions, the benefit
There are currently two Food and Drug Administration of stabilization is to prevent further need for surgery rather than
(FDA)-approved treatments for male AGA: minoxidil (Ro- alter the surgical planning.
gaine), and finasteride (Propecia). Minoxidil is the only FDA- The two most obvious problems of wholesale acceptance of
approved treatment for female AGA. Minoxidil, a topical appli- the concept of stabilization are first, patient compliance with
cation that is available in two strengths, 2% and 5%, has been lifelong need for medication, and, second, the definition of
shown to both reduce hair loss and promote hair growth in when stabilization has been achieved after initiation of medica-
patients with male and female AGA. Although claims that it tion.
slows or stops hair loss in more than 80% of cases are made
(1), strong placebo response rates have been demonstrated in
COMPLIANCE
numerous trials, indicating that evaluation techniques have
room for improvement. My personal experience and that of Compliance with ongoing medication is largely determined by
others, suggests that approximately 50% of men have their hair two issues: incidence of side effects and demonstrated mainte-
loss slowed, 35% continue to lose hair (i.e., no effect) and ap- nance of benefit. Minoxidil has a low incidence of skin irritation
proximately 15% show some signs of regrowth. In men, 5% as its main side effect, which is generally well tolerated. Results
minoxidil has been shown to be more effective than 2%, demon- of 5-year trials in men, published in 2002, have demonstrated
strating a dose-dependent response (2). It appears that minoxidil significant slowing, and, in some cases, stabilization of hair
acts as an anagen-prolonging agent that delays the inevitable loss (5). With minoxidil, ease of use is also an issue. Twice daily
further hair loss seen in AGA and can, in some cases, cause application, particularly of the more oily 5% version, presents
partial reversal, particularly in the crown area. styling problems (especially in women), and some patients find
Finasteride is a 1mg oral tablet taken daily, which acts as a the careful application technique burdensome. Men, in particu-
potent 5␣-reductase type-2 inhibitor. It has shown impressive lar, prefer simple routines for continuing medication.
Finasteride presents fewer problems with routine because it the hairline. Both minoxidil and finasteride are more effective
is a tablet. It also has a low side-effect profile, although any in producing hair regrowth at the crown than at the hairline.
possibility of sexual side effects is unsettling to a few men. The Minoxidil, in particular, has not been shown to produce in-
5-year trial results are particularly impressive for both stabiliza- creased hair in the frontal area in men, whereas finasteride’s
tion and maintenance of any improvement. Provided accurate benefits appear to be significantly better in the vertex than in
information is given about the timing of recognizable benefits, the frontal area (see later). The difference in response of the
compliance, in my experience, has not been a problem. Given vertex and frontal areas has implications that are discussed later.
the success of these results, it seems that compliance with medi-
cation is largely determined by the motivation of the patient.
THE CROWN
MOTIVATION The chance of significant improvement in crown hair growth
(36% with finasteride) (6) means that in cases of mild thinning
Motivation for therapy is generally high in younger patients;
(the best responders), there is a good argument for delaying
therefore, most accept the importance and benefit of stabiliza-
surgery in the crown (12 to 24 months until the full effect of
tion. This motivation may, however, decline with age. Physi-
the medication has been explored. Thus, frontal surgery may
cians need to be particularly aware of the young patient who
be initially performed, with deliberate delay of surgical inter-
manifests premature balding. These patients may exhibit overt
vention in the crown. If only stabilization or minimal improve-
(‘‘Balding wouldn’t worry me if I were older’’) or covert (the
ment is produced, surgery in the crown can be initiated at a
young patient who is acutely panicked by the first signs of
later time. This delay has the effect of potentially reducing the
hair loss) responses. These patients may not continue long-term
surgical intervention required. In larger areas of crown balding,
therapy after they have psychologically adjusted; moreover,
where no improvement is expected, stabilization protects
performing aggressive transplantation on them is risky. because
against further surgery by preventing the circumferential expan-
of the promise of medical stabilization.
sion of balding. This may prevent the commonly seen ring of
Older patients may also have high motivation, particularly
baldness from developing lateral to the grafts. In some cases
if they clearly understand the benefit of long-term stabilization
of larger crown-balding, patients who previously would have
for their mild to moderately severe male pattern balding. They
been advised against surgery may now be regarded as suitable
stand to benefit from reduction in the number of procedures
candidates who have an adequate donor area to achieve their
required, lower overall cost, and, probably, better visual out-
goals.
come if the grafting is added to their ‘‘stable’’ remaining hair.
Areas of thinning at the margins of the balding crown may
also escape the need for surgery. Working only in moderately
TIMING OF BENEFITS thin areas and avoiding areas of early miniaturization may re-
strict the size of the area that needs grafting. Previously, grafting
Another factor to be weighed when deciding the potential effect
the extensively balding crown was regarded as risky because
of stabilization on surgical planning is recognition of when sta-
of the large number of grafts required. The need for extensive
bilization has occurred. It is obviously risky to assume success-
grafting caused the crown to be regarded as the ‘‘black hole,’’
ful stabilization at initiation of medical therapy followed by
because it ‘‘sucked’’ all available grafts into the area. In patients
immediate surgical intervention. In my opinion, if the surgeon
who have achieved stabilization, some surgeons may be com-
wishes to be more aggressive with planning, it is preferable to
fortable in harvesting a donor area closer to the occipital balding
wait at least 6 months (in younger patients perhaps 12 months)
margin than normal conservative practice would suggest. In
before commencing surgery. In addition, this gives time to as-
such instances, more grafts would be available to the surgeon
sess the patient with regard to motivation for long-term therapy
because the defined ‘‘safe’’ donor area has become enlarged.
and to exclude the possibility of side effects.
The use of various patterns of alopecia reduction may be
enhanced also by the stabilization achieved with medication.
SHORT-TERM THERAPY Possible future balding lateral to the reduction scar significantly
inhibits surgeons and patients from choosing this option. The
There is one possible scenario in which deliberate short-term
ability to reduce the crown, to cover the remaining area with
therapy might be usefully employed. In patients with mild thin-
grafting, and to maintain the benefit, may make this option more
ning who have no long-term desire for therapy, use of medica-
viable to both the surgeon and the patient in selected cases.
tion to reduce the chance of postoperative anagen effluvium
might be applied during the course of the operative program.
This might involve medication for 12 to 18 months, with cessa- THE HAIRLINE
tion on completion of the final session of grafting and achieve-
ment of satisfactory growth. In my view, conservative planning The effect of medical therapy on surgical planning of the hair-
is required here; therefore, medical therapy has no real effect line may be regarded as more controversial than its effect on
on planning. the crown. The benefit of stabilization of hair loss is very easily
acknowledged because it may prevent the need for future sur-
EFFECT OF STABILIZATION ON SURGICAL gery. According to published data, the potential for significant
PLANNING regrowth of the hairline/forelock is low compared to that of the
crown. In the published reports on the cohort of 326 patients
Once stabilization has been achieved, the influence on surgical taking finasteride who were involved in the Frontal Hair Loss
planning is directed to the effect on two areas—the crown and study with Norwood/Hamilton stages II, IIv, IIa, III, or IIIv,
148 Chapter 5
only 4% showed moderate regrowth and none showed great Editors’ Comments
improvement at 1 year (6,7). On the other hand, for the larger
Dr. Knudsen gives an in-depth analysis of how surgical plan-
group of patients in the vertex studies (1553 men) with stage
ning may be affected by the use of medical therapy to stabilize
IIv, IIIv, IV, or V, many of whom also had frontal thinning,
the progression of hair loss. One must remember that Dr. Knud-
assessment of the same photographic views has been said to
sen started this chapter by saying, ‘‘If we accept the notion that
demonstrate that 15% were moderately or greatly improved at
some male and female stabilization is achievable,’’ it may allow
1 year, so perhaps the response might be better than previously
us to alter our surgical planning in some patients. This is a
published data would suggest (see editors’ comments on unpub-
major ‘‘if.’’ One of the primary concerns about altering our
lished material later). In my practice, the only benefit of delay-
surgical planning in patients on medical therapy is the uncer-
ing surgery to the hairline is to assess the success (or lack of
tainty of whether permanent stabilization is possible. Although
success) of stabilization. If the presence or absence of stabiliza-
published studies on finasteride, 1 mg daily, have shown stabili-
tion does not affect the decision to proceed with hairline recon-
zation for up to 5 years, there is still concern that hair loss may
struction, surgery may begin simultaneously with the com- resume at some time after 5 years. Hair counts, although far
mencement of medical therapy. The potential for controversy better than in the placebo group, showed a tendency to decrease
relates to whether medical stabilization allows surgeons to vary from a high at approximately 12 months to a lower level at the
the accepted rules of hairline design. 60-month point (Fig. 5B-1).
Traditionally, a conservative approach to hairline design has We are frankly alarmed by the frequency with which we
been almost universally accepted. This often incorporates a de- have heard that stabilization at 5 years is presumed to be perma-
gree of temporal recession that may conserve the donor area nent. This presumption has occurred more and more commonly
for future anticipated hair loss. In addition, very young patients at meetings and in the literature and is as yet unproved. It is,
are usually refused surgery because of uncertainty about future therefore, in our opinion, a cosmetically perilous method to
hair loss, and because of their frequently unrealistic expecta- incorporate into long-term planning. It is also worthwhile to
tions. Will the ability to provide medical stabilization tempt emphasize that finasteride appears to be more successful in the
surgeons (and patients) into producing lower, flatter hairlines crown area than in the frontal area (with regard to slowing
that incorporate significant rounding of the frontotemporal down or stopping hair loss, and regrowing hair). Furthermore,
angle? Will surgeons be tempted to operate on younger pa- it should be remembered that the patients in the 5-year studies
tients? on the crown were between 18 and 41 years of age and had a
The three hairline design factors most relevant to issues of modified Norwood/Hamilton classification of type II vertex,
medical stabilization are degree of balding, age of the patient, type III vertex, IV, or V (1), whereas those in the 1-year frontal
and the demonstrated success of medical therapy. area studies were between 18 and 40 years of age and had type
In my opinion, hairline design for mild recession (Norwood II, type II vertex, IIa, III, or III vertex pattern hair loss (2).
I, II, III) is unaffected by medical stabilization, as is severe Many of us would view type II or type III frontal loss as rela-
extensive balding (Norwood VII). Patients with moderate/se- tively early or mild; the results, therefore, might not be as good
vere balding (Norwood III, IV, V, VI) may be potentially af- for patients with more advanced loss. (Leyden and associates
fected by medical stabilization. Lower, flatter hairlines may be described the patients in the study as generally having ‘‘mild
offered in these patients with use of a rationale incorporating to moderate hair loss/thinning in the frontal area’’ (2).) Tables
the stabilization benefits of donor area protection, apparently 5B-1, 5B-2, and 5B-3 summarize the studies on finasteride.
increasing the safe donor area that can be used, and preventing They were supplied by Merck on March 21, 2002. Note that
progression of temporal baldness. The latter benefit would pre- there is a difference between what was found by hair count
vent the development of an isolated frontal forelock. and what was found by global photography assessments. The
Age is relevant, because younger patients generally want photography assessments were significantly better than the hair
lower hairlines, and older patients generally accept higher hair- counts would have suggested. Each physician must decide
lines unless some portion of the frontal forelock has been re- which assessment is more clinically meaningful.
tained. It may be preferable to consider only a less conservative Table 5B-3 tabulates observations about frontal thinning in
design in older patients, because it is more difficult to assume patients who were, in fact, being studied for the effect of finast-
compliance with medical therapy in younger patients. Offering eride on vertex alopecia. Hair counts were therefore not done
surgery to very young patients (i.e., those. younger than 22 in the frontal area, and we are left with only global photography.
years of age) is almost always risky, and aggressive planning The photographic evidence apparently has been judged to dem-
should be avoided. If surgery is performed in young patients, onstrate that 15% and 18% of the study subjects, respectively,
it might be wise to incorporate a fall-back position with no had moderate to great improvement of the frontal areas at 1
frontotemporal rounding and a central density concept in fore- year and 5 years.
lock design. This allows development of a natural-looking iso- With regard to topical minoxidil, it too is far more effective
lated frontal forelock if medical therapy is stopped or becomes in the vertex area than in the frontal area. The differences are,
less successful over time. in fact so great that for many years investigations have been
In my opinion, not many patients would be candidates for done exclusively on patients with vertex hair loss. One study
more aggressive hairline designs, even those with demonstrated included 393 men aged 18 to 49 years, with naturally dark hair
successful medical stabilization. The risks seem to outweigh and AGA characterized as vertex pattern 3, 4, 5, or 6, with a
the benefits in most cases. Patients, however, may possibly density rating of 4 to 7, according to the Savin Male Pattern
recognize the benefits of stabilization and their potential effect and Density scale (3). It revealed superior photographic changes
on hairline design. They may demand lower, flatter hairlines. and mean changes in nonvellus hair counts in the groups using
Figure 5B-1 Hair count comparison of men taking finasteride versus placebo over a 5-year period. The chart also shows cross-over
studies of men who started on placebo and switched to finasteride, as well as men who started on finasteride and switched to placebo.
Table 5B–1 Vertex Alopecia (Vertex Studies)
No further Slight Moderate Great

hair loss improvement improvement improvement
1 year
Hair count 86%
Global photography 51% 30% 16% 2%
2 years
Hair count 83%
5 years
Hair count 65%
Table 5B–2 Frontal Alopecia (Frontal Studies)

1 year
Hair count 70%
Global photography 62% 34% 4%
2 years
Hair count 71%
Global photography 53% 38% 4%
150 Chapter 5
Table 5B–3 Frontal Alopecia

1 year
2 years
5 years
Source: Vertex Studies; unpublished data courtesy of Merck.
minoxidil versus those on a placebo solution (4). It also showed therapy sometimes allows surgery to be delayed for a
that a 5% solution produced better results than a 2% solution year or longer while the individual awaits evaluation of
at week 48 (Fig. 5B-2 and Table 5B-4). The authors concluded, the effect of treatment. During this time, many of these
‘‘In men with AGA, 5% topical minoxidil was clearly superior patients develop a more realistic goal and accept a less
to 2% topical minoxidil and placebo in increasing hair regrowth, aggressive hairline.
and the magnitude of its effects was marked. (45% more hair ● Patients who have hair loss in both the frontal area and
regrowth than 2% topical minoxidil at week 48.) Men who used the crown often initially request that both areas be
5% topical minoxidil also had an earlier response to treatment treated. It is much easier to convince them to address
than those who used 2% topical minoxidil. Psychosocial percep- only the frontal area surgically, if, at the same time, they
tions of hair loss in men with AGA were also improved. Topical are assured that they are treating the crown medically.
minoxidil (5% and 2%) was well tolerated by the men in this During this period, the crown may respond well enough
trial without evidence of systemic effect, although an increased that the patient requires less work or no work at all in
occurrence of pruritus and local irritation was observed with that area. Even if the crown does not respond, the patient
5% topical minoxidil compared with 2% topical minoxidil’’ has had time to develop more realistic expectations and
(4). may no longer want to have a transplantation in that
We find that one of the major benefits of medical therapy area.
is that it allows us to be less aggressive surgically rather than ● If patients are started on medical treatment at the time
more aggressive. Some examples are the following: of their first transplant, and if they have a good response,
● Young patients or those just beginning to lose their hair the need for a second transplant may be delayed for an
often want to recreate a hairline that is too low. Medical extended period of time. Ideally, finasteride should be
Figure 5B-2 Change from baseline in non-vellus hair count; p values reflect statistically significant differences favoring 5% topical
minoxidil over 2% minoxidil. TMS ⳱ Topical minoxidil solution. (Reprinted from Olsen, E., et al. 2002. A randomized clinical trial of
5% topical minoxidil vs. 2% topical minoxidil and placebo in the treatment of androgenetic alopecia in men. J. Am. Acad. Dermatol. 47(3):
377–385.)
Table 5B–4 Retrospective Photographic Evaluation of Clinical Response at Week 48a
Reviewer No. 1 Patients [No. (%)] Reviewer No. 2
5% Minoxidil 2% Minoxidil Placebo 5% Minoxidil 2% Minoxidil Placebo

Variable (n ⫽ 139) (n ⫽ 142) (n ⫽ 71) (n ⫽ 139) (n ⫽ 142) (n ⫽ 71)
Dense growth 3 (2.2) 4 (2.8) 0 14 (10.1) 5 (3.5) 0

Moderate growth 52 (37.4) 28 (19.7) 5 (7.0) 28 (20.1) 17 (12.0) 5 (7.0)
Minimal growth 31 (22.3) 30 (21.1) 16 (22.5) 33 (23.7) 32 (22.5) 7 (9.9)
No change 44 (31.7) 71 (50.0) 43 (60.6) 40 (28.8) 67 (47.2) 43 (60.6)
Hair loss 7 (5.0) 4 (2.8) 7 (9.9) 9 (6.5) 2 (1.4) 10 (14.1)
Unable to 2 (1.4) 5 (3.5) 0 15 (10.8) 19 (13.4) 6 (8.5)
a
Comparison of baseline (week 0) with week 48; grading of week 48 results compared with baseline may not total 100% because of rounding.
started at least 6 months after hair transplant surgery still fall short of our goal of naturalness. Before this artistry
rather than around the same time as the surgery. This can be applied, however, the surgeon must have a thorough
enables both patient and surgeon to be clear as to which knowledge of natural balding patterns.
results are due to the surgery and which to the medical As opposed to natural hair in a balding individual, trans-
treatment. (Any positive hair growth effects of finaster- planted hair is permanent, and consideration must be given as
ide usually become noticeable only 6 to 12 months after to what will happen with the passage of time. It is advisable
it is started). to look at all patients as future 70-year-old individuals and guide
the transplant to be compatible with their appearance when they
In this way, medical therapy does alter the approach to surgical
will have reached that age. These goals should be considered
planning, despite the uncertainty of long-term results.
for hair transplantation:
Finally, a small amount of diffuse new hair growth may
provide a significant cosmetic benefit to some transplanted 1. Natural – To the degree that a transplant does not look
areas by providing a background of diffuse and colored hair, natural, to that same degree it is a failure. Naturalness
even if it is short. For example, if the recipient area was origi- is not for a point in time but is an ongoing goal for the
nally lighter colored than the hair, and was alopecic or had lost life of the patient.
its original hair since completion of the transplant, this new 2. Frame the face – If the face is not framed, the person’s
background hair would decrease the color contrast between the appearance is not improved, with the exception of the
transplanted hair and what was previously alopecic pale skin. slight improvement afforded to the crown. If the hairline
Unfortunately, studies to confirm this likelihood have never is placed too low, it may look unnatural later because
been done because of the difficulty of finding patients willing there is not enough donor reserve remaining to keep
to be in a placebo group. The concept remains an intriguing pace with future hair loss. But if it is placed too high,
one (WU and RS). the patient may still look bald or not have the optimum
result. Experience of the surgeon is vital here.
3. Density – If the above goals are met, denser hair will
5C. Hair Transplant Goals Based on look better than sparser hair if it matches the overall
Natural Hair Patterns hair pattern. Density should be created just posterior to
the hairline and not on it. Normally, density is most
William M. Parsley advantageous in the central region of the frontal scalp
(the forelock region), because this is an area that fre-
INTRODUCTION quently has good density, even in a balding person.
For the first 30 years of modern hair transplantation, the round To obtain these goals, close observation of the natural patterns
punch was the primary instrument, which limited creativity in of baldness is necessary. In particular, Norwood types II and
designing a natural pattern. It was usually necessary to create III patterns, along with frontal forelock patterns, need to be
a wall of hair at the frontal hairline to mask the plugginess of studied, because these patterns are usually the goals of most
these grafts. The advent of micrografts, minigrafts, slot grafts, surgeons in transplanting. However, every transplant surgeon
and follicular unit grafts (FUGs) made it possible to create a is confronted with unique problems that require unique solu-
naturalness that was not realized previously. Now, nearly all tions. For these cases, solutions that remain within the confines
surgeons use the smaller grafts, some for the entire procedure of natural patterns are vital.
and some in combination with various types of larger grafts. The hair zones of most concern are the frontal zone, temporal
With this new technology, there are numerous patterns and graft zone, midscalp, and vertex (crown) (Fig. 5C-1). Each of these
placement choices, making decisions more complicated and in- zones exhibits a myriad of alopecia patterns. These individual
volved than in the past. Technology has made these great areas can have recession or diffuse thinning along with a variety
strides, but now the artistry must keep pace or the results may of different shapes.
152 Chapter 5
pecia—DUPA). DPA refers to diffuse loss over the frontal

scalp, mid scalp, and/or vertex, whereas DUPA refers to diffuse
loss over the entire scalp and is discussed at greater length
elsewhere in this text. Hairs in the involved areas of these pat-
terns appear to be miniaturizing at roughly the same pace.
3. Isolated frontal forelock–The isolated frontal forelock
(IFF) has been described in a number of articles, and the varia-
tions of this pattern of hair loss are described in detail in Chapter
5A. In this pattern, there is retention of hair in the central part
of the frontal scalp and often the midscalp, whereas the sur-
rounding hair has receded, leaving it isolated (Fig. 5C-2). Dr.
Michael Beehner has done the most extensive work in describ-
ing and defining this pattern. The significance of the pattern is
that it is an excellent pattern to duplicate when a person already
has advanced alopecia or when it is anticipated that future hair
loss will be severe. The natural frontal forelock can take many
forms, ranging from a small patch of hair at the frontal hairline
to a much larger patch of hair extending back to the posterior
edge of the midscalp. The shapes can be round, oval, crescent,
Figure 5C-1 This diagram shows the regions of the hair-bear- or diamond. Although the frontal rim is usually convex, the
ing scalp that are of significance to hair transplantation. posterior border can be convex, flat, or concave. The frontal
forelock generally has its greatest density at the center, progres-
sively thinning toward the periphery. Future alopecia usually
NATURAL PATTERNS
Natural baldness patterns are extremely variable—some are at-
tractive and some are not. Our main concern is to be aware of
patterns that would be desirable to recreate and to know the
implications of these patterns for estimating future loss. The
following is a brief description of the basic natural patterns of
hair and hair loss.
FRONTAL SCALP
General Patterns
1. Recession patterns–Recession of the frontal hairline consists
of (1) posterior and/or medial retreating of the hairline with
complete or incomplete hair loss in the areas of recession; (2)
miniaturization of the hairs in the areas of recession, causing
them to be finer in diameter and shorter in length; (3) smaller
numbers of hairs per follicular unit (FU) in the area of recession;
and (4) a decrease in number of FUs/cm2 in the areas of reces-
sion. In male pattern baldness (MPB), more than 90% of FUs
on the frontal hairline are single hairs, with the others being
two-hair FUs. This is compared with only 20% to 30% of the
FUs of the occipital scalp, being single-hair units. Most, but
not all, of the hairs of the frontal hairline are miniaturized. The
hairs only vaguely define the hairline, rarely allowing an abrupt
line to delineate it. The single hairs at the border are randomly
spaced. Nearly all patients have some degree of gaps of little
or no hair and clusters of hairs scattered linearly along the
hairline, also with random spacing between them. These will
be discussed later in the chapter.
2. Diffuse patterns–In this pattern, miniaturization and thin-
ning of the frontal scalp is diffuse, with very little recession. The
number of FUs/cm2 often is reasonably high. Miniaturization is
the driving force behind the loss of hair volume. This can occur Figure 5C-2 This is a typical, natural, isolated frontal forelock
in the frontal zone alone or as part of a larger pattern (diffuse (IFF) with surrounding alopecia. Note that the frontal border is not
patterned alopecia—DPA, or diffuse unpatterned alo- greatly receded from its original position.
Figure 5C-4 Linear hairline. Fifty-five percent of hairlines do

Figure 5C-3 An isolated frontal forelock often consists of two not exhibit any significant mounds.
clusters of hair. This is possibly related to the persistence of two
lateral mounds.
linear appearance of the frontal hairline. Close inspection re-

veals that these clusters occur to some extent on nearly every
progresses from the periphery. The frontal border may or may
hairline. Clusters of up to four or more hairs (nearly all single-
not have associated mounds (mounds are described in more
hair units) are seen with 2-mm to 10-mm gaps of no hair be-
detail later in this chapter). Patterns of loss can be quite irregular
tween them. They occur at random anywhere along the frontal
(e.g., up to 90% of the hair loss can be on one side of the
hairline, including the area in front of the mounds. Also, along
frontal scalp). Another irregular pattern consists of two separate
the frontal hairline are randomly scattered hairs of which 90%
clusters of hair in the frontal zone, possibly corresponding to
to 95% are single-hair units. Another frequently seen pattern
residual natural mounds (Fig. 5C-3).
is composed of lines of three or more single hairs extending
4. Whorl patterns–Smaller, but similar to the crown, swirls
anterolaterally from the hairline. These small patterns are not
(whorls) are frequently seen at the frontal hairline. They gener-
as obvious as mounds but can be easily seen with close inspec-
ally occur only on one side and often present a dilemma to
tion or macrophotography.
the surgeon as to whether or not to follow that pattern when
transplanting.
VERTEX
HAIRLINE SHAPES The pattern of alopecia in the vertex is generally round or oval.
The center of the circle or oval has the least density, with the
1. Large patterns–There are very obvious mounds (protrusions) density gradually becoming greater as it moves toward the pe-
along the frontal hairline. Although most transplant surgeons
are aware of their existence, there has been little written about
them. Except for rare circumstances, there are a maximum of
three mounds, with patients having 0, 1, 2, or 3 of them (Fig.
5C-4) (5–7). There are two lateral mounds, one on each side
of a central mound (the widow’s peak). The distance of the
peaks of the lateral mounds from the peak of the frontal hairline
varies from 1.5 cm to 4.0 cm. The mounds are either rounded
or slightly triangular. The borders usually show recession and
miniaturizing of the hairs, but in most cases (not all), the
mounds seem to be less affected by recession. Hairs in the
middle mound (widow’s peak) may be angled forward, but often
they are angled acutely in a lateral or posterolateral direction.
Mounds are easily visible by pulling back the frontal hair. If
the patient has a widow’s peak and a single lateral mound on
one side, a concave area can be seen on that side. If the patient
has a widow’s peak and both lateral mounds, a typical ‘‘bat-
wing’’ appearance is seen at the midfrontal hairline.
2. Small patterns–Nearly all patients have some degree of
gaps and clusters of hairs at the hairline, with random spacing Figure 5C-5 One mound. This patient has a right lateral mound
between them (Fig. 5C-8) (9). Clusters are different from with the absence of the left lateral mound and the central mound
mounds in that they are smaller and do not detract from the (widow’s peak).
154 Chapter 5
Figure 5C-6 A, B, C Two mounds. These patients all have two out of three of the possible mounds. Parts A and B demonstrates a
left mound and a central (widow’s peak) mound, whereas part C has a right mound and a central mound. Note the prominent concave area
between the two mounds in part C.
Figure 5C-7 Three mounds. This patient has all three of the Figure 5C-8 Macrophotographic picture of a natural frontal
possible mounds along the border of the frontal hairline. hairline demonstrating clusters of hairs (arrows) and gaps with
little or no hair between them. On observation, the hairline still
appears linear.
As with all areas of natural alopecia, the single-hair FUs

predominate.
TEMPLE
Moving superiorly from the sideburn area (anterior to the ear),
the hairline moves in a superoanterior direction until it reaches
the temporal point (protrusion). The hairline then moves in a
superoposterior direction until it meets the frontal hairline. The
hairline from the temporal protrusion to the frontal hairline can
be slightly convex, straight, or slightly concave. The direction
of the hair growth along this line varies from almost directly
posterior to an anteroinferior direction (Fig. 5C-11a–c).
As alopecia develops, the tendency is for the line from the
temporal point to the frontal hairline to become more concave.
The temporal point may be affected only slightly or disappear
Figure 5C-9 Another photograph of a natural frontal hairline
completely with androgenetic alopecia. The alopecia progresses
showing clusters (arrows). Note the variation of size and morphol-
ogy of these clusters. from the periphery but can be irregular along this border. Like
the frontal hairline, the vast majority of hairs at the border are
single-hair FUs.
Temples become important when they recede to a degree
riphery. Somewhere within the vertex zone, there is a whorl greater than hair loss elsewhere would indicate. The trans-
pattern. The pattern emanating from the center of the whorl is
planted frontal hair can look like a ‘‘lid’’ because of the discrep-
radial and curvilinear. The pattern can whorl either clockwise
ancy in appearance of a strong frontal hairline with weak tem-
or counterclockwise. The curvilinear pattern generally straight-
ples. In such cases, transplanting the temples can be very
ens out within a few centimeters. Occasionally there can be a
rewarding. Great care must be taken to place the grafts at a
second whorl within the vertex region.
very acute angle and to use grafts containing only one and two
A figure 8 pattern can occur occasionally, in which, just
inferior to the larger pattern of alopecia, there is a smaller circu- hairs.
lar or oval pattern (Fig. 5C-10). There is a band of thinning
hair separating the two patterns; this band eventually disap-
pears, leaving one larger pattern. Dr. Jim Arnold, in a lecture MIDSCALP
at the meeting of the International Society of Hair Replacement
Surgery (ISHRS) in 2000, described this small area of alopecia This is the area between the parietal mounds or humps. Alope-
as the ‘‘coronet’’ to contrast with the larger ‘‘crown’’. This cia can develop here in a variety of patterns—either associated
name was given because a king would wear a crown, whereas with a progressing frontal or vertex pattern, or, sometimes, inde-
a prince would wear a coronet, which is smaller than a crown. pendent of these patterns. When a recession pattern occurs, it
can be from the midline toward the periphery or from the pari-
etal hump centrally (as in a large, isolated frontal forelock).
Occasionally, the midscalp can develop nearly complete alope-
cia while the frontal scalp retains most or all of its hair—a
pattern that would create an anteriorly located frontal forelock.
Conversely, frontal and vertex alopecia can develop while hair
is retained in the midscalp, which leaves a midparietal bridge
of hair between the parietal humps.
USING PATTERNS TO GUIDE HAIR

TRANSPLANTATION
FRONTAL SCALP
The use of mounds and clusters can be a valuable tool when
transplanting the frontal hairline (Fig. 5C-12a,b) (13). There
are several desired results that can be achieved by the use of
mounds:
Figure 5C-10 ‘‘Figure 8’’ pattern in the crown. The smaller 1. The ‘‘bowl’’ effect of transplanting can be broken up
balding area inferiorly in this photograph has been named the ‘‘co- with the use of one to three mounds.
ronet’’ as opposed to the larger area termed the ‘‘crown’’. 2. Asymmetry can be created in a natural form.
156 Chapter 5
Figure 5C-11 A, B, C–These photographs of natural temples demonstrate the different directions of hair growth that can occur in the
temple region.
Figure 5C-14 Created ‘‘clusters’’ can break up the abruptness

of a fronta 1 hairline while preserving the linear appearance.
3. The frontal peak of the hairline can be widened.

4. With the use of a widow’s peak, the distance between
the glabella and the frontal hairline peak can be short-
ened without lowering the entire hairline.
Martinick recognized these mounds in a technique she termed
‘‘snail tracking.’’ Instead of designing three mounds, however,
she designed five mounds (1). Other than this reference, little
has been written about the use of mounds.
With the use of clusters (Fig. 5C-14), the following can be
Figure 5C-12 A, B –Created mounds can be used to break up accomplished
the ‘‘bowl-like’’ appearance of the frontal hairline. Here the before
(A) picture is compared with the after (B) picture, which demon- 1. The abruptness of the hairline can be reduced.
strates the creation of three mounds (arrows). 2. Asymmetry along the frontal hairline can be accom-
plished.
Wolf, in a response to Martinick’s article, thought that a hairline
zone 4 mm to 5 mm in depth and consisting of triangles offers
a softer, less abrupt look (2). This technique would be more in
line with clustering as described earlier in the chapter. Shapiro
also has written about the use of triangles (3). He described a
series of triangles extending anteriorly from a more dense, de-
fined zone, to soften and add subtle irregularity to the frontal
hairline. He described the cluster as areas of ‘‘intermittent den-
sity.’’ Spacing from the glabella to the frontal peak can also
be guided by natural patterns. Natural hairlines of the desired
pattern generally vary between 7 cm and 9 cm superior to the
glabella but this can be altered by the judgment of the surgeon.
Isolated Frontal Forelocks

Norwood, Limmer, Marritt, Nusbaum, and Shiell have all writ-
ten about this concept (IFF) (4–9). Norwood recommended that
the frontal forelock be used in conjunction with a bridge across
the midscalp. Nusbaum recommended an anterior convex pat-
tern with a posterior concave pattern, believing that the design
would look natural even if he never did transplant the vertex
Figure 5C-13 Created mounds. This patient has had a right (crown). Shiell first started creating the frontal forelock in 1977,
and a central mound created along the transplanted frontal hairline. using quartered round grafts to give a softer appearance. At the
158 Chapter 5
lief from baldness for many people who are otherwise not good
candidates for hair transplantation (Fig. 5C-16a–d).
Whorl Patterns
As a general rule, if a patient has any significant hair in a frontal
whorl, it is best to follow the same angle and direction of the
hair. Significant damage can be done to existing hair by creating
a new angle. If, however, a patient has weak, insignificant hair
remaining, it may be acceptable to follow the standard anterior
direction of the hair. It is important to consult with the patient
about this. Some patients want to keep this whorl pattern be-
cause they identify it with themselves, whereas others are happy
to be rid of it.
VERTEX
Figure 5C-15 This patient with a ‘‘burr’’ haircut demonstrates Vertex transplanting has many pitfalls. This area can become
the developing frontal forelock pattern. The anterior ‘‘forelock’’ surprisingly large with progression of male pattern alopecia
zone is convex both anteriorly and posteriorly. However, the blur and can outstrip donor supplies. There is no natural pattern
zone of fringe hair can give the posterior border a concave appear- consisting of hair in the center of the vertex with a halo of
ance when viewed from behind the patient. surrounding alopecia. Additionally, it must be remembered that
the border is forever moving (as opposed to the frontal hairline,
where a stable border can be created). To further complicate
matters, the natural density of the vertex is greater at the periph-
time, only a few patients were willing to accept this limited ery, with the thinnest area being at its center. This means that
procedure. as the diameter of alopecia increases, the periphery must be
As noted earlier, Dr. Michael Beehner has written several transplanted with at least as much density as that transplanted
articles on the IFF (10–14). He has described a variety of natu- more centrally. Finally, the area increases exponentially with
rally occurring patterns that vary greatly in shape and size. Dr. the increasing diameter of alopecia. For example, compared
Beehner made an astute observation that the hairline anterior with a 2-inch diameter patch of alopecia, a 4-inch diameter
to the bald vertex often appears concave when viewed from patch has four times the area, and a 6-inch patch has nine times
behind the patient, but it appears convex when viewed from in the area. The area of a circle increases proportionally with the
front of the patient (with the patient’s head tipped down). This square of the radius. For these reasons, many surgeons do not
apparent contradiction is related to the heavier density of a large transplant the crown until the patient is 45 years in age or older.
forelock, which usually has a convex shape posteriorly. Viewed Transplanting the vertex can be rewarding if the surgeon is
from a posterior position, the weaker lateral fringes outside confident that the patient will always have enough donor hair
the forelock zone are more obvious and impart the concave to adequately treat the future hair loss. One must find the center
appearance. He emphasizes soft borders, which blend to the of the whorl and follow the directions and angle of the residual
bald scalp, and central density. Also recommended is a blur hair radiating from this area. The hair grows from the point of
zone of single-hair grafts, which creates a lateral fringe connect- the whorl in a radial curvilinear fashion before straightening
ing the forelock to the parietal hair (Fig. 5C-15), giving the hint out (Fig. 5C-17a–c).
of concavity along the posterior border, particularly when larger
patterns are used (see also Chapter 5A).
Judgment is crucial when designing any pattern, but it is TEMPORAL SCALP
especially important with IFFs. A few generally accepted prin- Temporal scalp transplanting has become much more popular
cipals are the following: with the advent of minigraft micrograft/FU grafting. There are
1. Use only naturally occurring patterns. several factors to consider:
2. Use a pattern that fits well with the individual’s face
1. The direction of the hair: As pointed out earlier, the
and hair pattern.
patient’s temporal hair direction is quite variable. In
3. Create the greatest density centrally.
general, it is best to follow the natural hair direction.
4. Use one-hair or two-hair grafts exclusively for the bor-
2. Whether or not to create the temporal point if it is absent
ders to keep them soft.
or diminished.
The glabellar-frontal peak distance is subjective, as is the shape 3. Whether or not there is enough donor area to support
of the posterior border. Also, mounds and clusters are useful a created temple in light of anticipated further recession
tools in the IFF if the surgeon determines they are appropriate in this area. It must be remembered that further needs
in a particular individual. must be doubled because there are two temples.
In general, the IFF, done properly, is one of the least risky 4. Whether or not the donor area has hair fine enough hair
hair transplant procedures for long-term results. It can give re- to match the naturally occurring temporal hair.
Figure 5C-16 A, B, C, D–Parts A and B show before and after pictures of one session in creating an isolated frontal forelock. Parts
C and D show the design of the frontal forelock with the subsequent growth. The created ‘‘blur’’ zone can give the illusion of a connection
to the tempoparietal region. (Fig. 5C-16C and D courtesy of Dr. Michael Beehner.)
160 Chapter 5
Figure 5C-17 A, B, C–Created vertex. Fig. 17A is before, 17B is the projected pattern, and 17C the growth after two sessions. Note
that the hair growth pattern is both radial and curvilinear.
5. Will the area running from the temporal point to the patient with Norwood type VI or VII, transplanting the midscalp
frontal hairline be straight, convex, or concave? creates a bridge between the parietal humps. This bridge can
then become a base for extending the transplant anteriorly into
These decisions require artistry and knowledge of natural pat-
the frontal scalp, whereas the posterior edge forms a natural
terns.
concave pattern as mentioned earlier.
MIDSCALP (and Parietal area)
The midscalp is an excellent area to transplant and gives
support to both the frontal region and the vertex region (Fig.
5C-18a–d). A common natural pattern of alopecia results in SUMMARY
hair in the midscalp with or without hair in the frontal or occipi-
tal region. The posterior border is generally concave if there The advanced techniques that allow more natural transplant
is vertex baldness. The anterolateral borders are also slightly results also require us to pay more attention to natural patterns.
concave as they extend from the parietal hump. Norwood re- Creating patterns that are natural leads to results that do not
ported on Dr. Ron Shapiro’s technique of building up the pari- draw attention to the fact that the patient has had a transplant.
etal ‘‘humps’’ if they are too low (15). Later, Dr. Shapiro further The patterns designed for each zone must be compatible with
explained this technique and described these creations as ‘‘lat- the design for the other scalp zones. Additionally, attention must
eral humps’’ (16). be paid to accommodate for aging so that the transplant design
This is an excellent technique and helps avoid chasing the will hold up to future loss and still remain natural. The study
parietal area and lowering the frontal hairline excessively. In a of patients and photographs of patients with androgenetic alope-
Figure 5C-18 A, B, C, D–Created midscalp. In parts A and B, the midscalp and frontal scalp are created without plans to transplant
the crown. This technique conserves grafts in a severely bald patient for use where they are most significant cosmetically. In parts C and
D, the midscalp and frontal scalp are created along with a raising of the parietal humps. (Fig. 5C-18C and D courtesy of Dr. Michael
Beehner.)
162 Chapter 5
Figure 5C-18 Continued.
cia are very important methods for learning the variations of only for the recreation of his humps. His photographs were
baldness and for guiding the transplant. shown in the 1995 edition of this textbook (Fig. 14 on page
806). He later asked for his humps to be expanded into a mids-
Editor’s Comment calp bridge, which I referred to as a ‘‘bridge over troubled
waters.’’ Still later, he asked me to create a frontal area anterior
If the devil is in the details, William Parsley has certainly done to the bridge. Thus, his concept of how to treat a large area of
a wonderful job of flushing him out. Hair restoration surgeons MPB predated the general recognition of it by the ‘‘experts.’’
would be well advised to look at and attempt and copy for (WU)
their patients the appropriate pattern of hair loss shown in the
schematic drawings of the Hamilton/Norwood types of male
pattern baldness (see Chapter 3). What is appropriate varies REFERENCES
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18. Unger W. The recipient area. In Hair Transplantation. 3rd ed 14. Bernstein R. Unified terminology for hair transplantation. H T
Unger W, ed. New York: Marcel Dekker, 1995:215–321. Forum Int 1999; 9(4):121.
19. Lucas M. Aspects of artistic craftsmanship when performing 15. Wolf B. Hairline placement: not Getting it wrong the first time.
small-graft hair transplantation. In Hair Replacement: Surgical H T Forum Int 1999; 9(5):155–157.
and Medical Stough D, ed. St. Louis: Mosby, 1996:162–166. 16. Pomerantz M. Creating a hairline. H T Forum Int 1999; 9(6):
20. Norwood OT. Angling and direction of grafts. In Hair Transplant 184–186.
Surgery. 2nd ed Thomas Charles, ed. Ill: Springfield, 1984:55. 17. Pomerantz M. Creating a hairline. Dermatol Clin 1999; 17(2):
21. Bernstein R. The future in hair transplantation. Aesthet Dermatol 271–275.
Cosm Dermatol 1999; 1(1):55–75. 18. Bernstein R, Rassman W. The logic of follicular unit transplanta-
22. Uebel CO. Punctiform technique: hair replacement procedure of
tion. Dermatol Clin 1999; 17(2):277–296.
over 1000 micrografts and minigrafts. In Hair Transplantation.
19. Martinick J. Hairline placement: getting it right the first time. H
2nd ed Unger W, Nordstrom R, eds. New York: Marcel Dekker,
T Forum Int 1999; 9(3):65–70.
1987:467–290.
23. Limmer BL. Elliptical donor stereoscopically assisted micrograft- 20. Nusbaum B. The recipient area: an organized approach for pre-
ing as an approach to further refinement in hair transplantation. venting complications. Cosm Dermatol 2000; 13(6):33–35.
J Derm Surg Oncol 1994; 20:789–793.
24. Bernstein R, Rassman W. Follicular transplantation. Int J Aesthet
Restorative Surg 1995; 3:119–132. Effect of Medical Therapy on Surgical Planning
25. Seager D. Dense hair transplantation from sparse donor area—in-
troducing the ‘‘follicular unit family’’. H T Int 1998; 8(1):21–22. 1. Rundgren T, Trancik RJ. Stabilization of Hair Loss with Minoxi-
26. Unger W. Hair transplanting in ‘‘early’’ androgenetic alopecia. dil Solution, Presented at the Ninth Annual Meeting of the Inter-
In Hair Transplantation. 2nd ed Unger W, Nordstrom R, eds. New national Society of Hair Restoration Surgery, Puerto Vallarta,
York: Marcel Dekker, 1988:285–290. October 18–22, Mexico, 2001.
27. Brandy D. Chest hair used as donor material in hair restoration 2. Price V, Menefee HE, Strauss PC. Changes in hair weight and
surgery. Dermatol Surg 1997; 23(9):841–845. hair count in men with androgenetic alopecia, after application
28. Beehner M. The use of beard and chest hair as donor sources. of 5 percent and 2 percent topical solution, placebo and no treat-
Am J Cosm Aesthet Surg 2001; 3(2):73–74. ment. J Am Acad Dermatol 1999; 41(5, pt 1):717–721.
29. Unger W. The interview. In Hair Transplantation. 3rd ed Unger
3. The Finasteride Male Pattern Hair Loss Study GroupLong-term
W, ed. New York: Marcel Dekker, 1995:95–96.
(5-year) multinational experience with finasteride 1 mg in the
30. Vance E- 2001, personal communication.
31. Martinick J. Hair Growth after 18 Months with Follicular Unit treatment of men with androgenetic alopecia. Eur J Dermatol
Transplantation, European Society Annual Meeting, Istanbul, 2002; 12:38–49.
2000. 4. Roberts J. 2002.
32. Marritt E, Dzubow L. The isolated frontal forelock. Dermatol 5. Avram MR, Cole JP, Gandelman M. The role of minoxidil in the
Surg 1995; 21:523–538. hair transplantation setting. Dermatol Surg 2002; 28(10):
33. Beehner M. The frontal forelock concept. Am J Cosm Surg 1997; 894–900.
14:125–32. 6. Kaufman KD, Olsen EA, Whiting DA. Finasteride in the treat-
34. Beehner M. The frontal forelock. H T Forum Int 1995; 5(1):1–5. ment of men with androgenetic alopecia. J Am Acad Dermatol
35. Beehner M. A Study of Stretchback in Alopecia Reductions, 1998; 39:578–89.
Ninth Annual Meeting of International Society of Hair Restora- 7. Leyden J. Finasteride in the treatment of men with frontal male
tion Surgery, Oct, Puerto Vallarta, Mexico, 2001. pattern hair loss. J Am Acad Dermatol. 1998; 40(6 pt 1):930–937.
164 Chapter 5
Editors’ Comments 4. Norwood OT, Taylor BJ. Hair transplant surgery: innovative de-
signs. J Dermatol Surg Oncol 1990; 16:50–54.
1. Kaufman KD, Olsen EA, Whiting DA. Finasteride in the treat- 5. Limmer B. Isolated Frontal Forelock. Hair Transplant Forum
ment of men with androgenetic alopecia. J Am Acad Dermatol 1993; 3(5):17–19.
1998; 39:578–89. 6. Marritt E, Dzubow L. The isolated frontal forelock. Dermatol
2. Leyden J. Finasteride in the treatment of men with frontal male Surg 1995; 21:523–538.
pattern hair loss. J Am Acad Dermatol 1999, 40:6, Part I, pp. 7. Nusbaum BP. Frontal forelock: overall design. H T Forum Int
930–937. 1995; 5(1):14.
3. Trancik RJ, Savin RC. Classification scale for male and female 8. Shiell RC. Front forelocks: a new idea again. H T Forum Int
androgenetic alopecia [Abstract]. Clin Pharmacol Ther 1996; 59: 1995; 5(3):5.
166. 9. Shiell R. A truly isolated front forelock. H T Forum Int 1995;
4. Olsen E. A randomized clinical trial of 5% topical minoxidil vs. 5(4):23.
2% topical minoxidil and placebo in the treatment of androgenetic 10. Beehner ML. The front forelock. H T Forum Int 1995; 5(1):1–5.
alopecia in men. J Am Acad Dermatol 2002; 47(3):377–385. 11. Beehner ML. Additional results of frontal forelock procedure. H
T Forum Int 1995; 5(2):23.
12. Beehner ML. A frontal forelock/ central density framework for
Hair Transplant Goals Based on Natural Hair hair transplantation. Dermatol Surg 1997; 23:807–815.
Patterns 13. Beehner ML. Where is thy crown, Your Majesty. H T Forum Int
1998; 8(1):18–19.
1. Martinick JH. Hairline placement: getting it right the first time. 14. Beehner ML. The vertex transition point revisited. H T Forum
H T Forum Int 1999; 9(3):65–71. Int 1998; 8(6):33.
2. Wolf BR. Hairline placement: not getting it wrong the first time. 15. Norwood OT. Guadalajara meeting. H T Forum Int 1999; 9(2):
H T Forum Int 1999; 9(5):155–157. 44.
3. Shapiro R. Creating a natural hairline in one session using a sys- 16. Shapiro R. Creating a natural hairline in one session using a sys-
tematic approach and modern principles of hairline design. Int J tematic approach and modern principles of hairline design. Int J
Cosm Surg Anesth Dermatol 2001; 3(2):89–99. Cosm Surg Anesth Dermatol 2001; 3(2):89–99.
6
The Initial Interview
6A. My Personal Approach to the third to set goals that are realistic and wise both in the short
term and, more importantly, in the long term.
Interview A written description of the principles on which hair trans-
Walter P. Unger planting is based, the various types of grafts that are available
and their purpose, and a review of the expected postoperative
Sometimes the only thing worse than not getting what you course and results are recommended. If such information is
want is getting what you want. clear and in layman’s language, the prospective patient will
have all the necessary and accurate information to review after
departing from the office. (Most patients cannot recall even one
INTRODUCTION major risk or complication within 24 hours of reading some-
I continue to personally conduct consultations with all pro- thing as simple as an information consent form) (1). Providing
spective patients, although, occasionally, if I am delayed, an such information also relieves the physician of laborious repeti-
associate physician in my practice may start to provide routine tion of the same information, sometimes several times a day.
information. I am concerned, as are other practitioners that In addition, clear-cut and complete information forms provide
nonmedical individuals may lack the professionalism and ethi- medicolegal protection—there should be no misunderstandings
cal standards that I believe my practice should have. Unfortu- or accidental omissions. Appendix 6a is the information booklet
nately, there is no method of being certain that your standards we use in our practice. It describes the procedure in lay terms
are always being met unless you yourself conduct each inter- and presents it in a more negative than positive way, an ap-
view. In addition, as will be described later, the purpose of a proach that tends to eliminate patients who are not well moti-
consultation is not just to provide information; although it is vated. It also minimizes recriminations from those few individu-
sometimes tedious and sometimes exhausting, the more time als who experience more than average problems or less than
you spend with a patient the better those other purposes are expected results. It is also available on my website (www.walt-
served. erunger.com). which has the advantage of including before and
Despite the foregoing, I understand that personal interviews after photographs of patients with varying degrees of male pat-
with all prospective patients may be impractical for some physi- tern baldness (MPB) treated with different types of grafts. Pa-
cians. This is especially likely for those whose advertisements tients who contact us for a consultation appointment or who
attract large numbers of people, only a small minority of whom are seen in consultation are encouraged to review this website
can be expected to proceed with surgery. They must, therefore, before and/or after their visit to the office.
find reasonable ways of managing the potential problems that There are numerous hair transplant sites available on the
would bother me if others would carry out the consultation. web; most of them are obvious ‘‘infomercials.’’ The patients I
There are, no doubt, ways to help ensure that high standards see occasionally mention that one of the reasons they came to
are maintained. These are discussed by Leavitt in this chapter. see me was that my website seemed to be confined to providing
In the following section, however, is a summary of my philoso- information. Photographs are used only to validate my stated
phy with regard to physician consultations. opinions. The lack of an obvious commercial intent is attractive
to many individuals and is an objective you might consider as
a way of distinguishing yourself from others.
PURPOSE
If spouses or close friends of the patients accompany them
There are three main purposes to the interview. The first is to to the office, I encourage their presence during the consultation.
provide information to the prospective patient; the second, to Patients are understandably nervous during a consultation for
establish the compatibility of the patient and doctor; and the surgery, and sometimes a close friend or spouse can not only
165
166 Chapter 6
help make the patient feel more relaxed but can also think of satisfied but also because they are far more likely to sue or
questions that the patient might think of only later. Inviting physically threaten, and they may actually carry out such
accompanying persons into the consultation also helps promote threats.
a friendly and cooperative atmosphere. All cosmetic surgeons see patients with BDD—the difficulty
Compatibility between the physician and the patient is par- they face is deciding whether an individual has BDD or is
ticularly important in any surgical procedure that is multistaged merely trying to look as good as possible for either professional
and that may extend over many years. Some patients feel more or personal reasons. Once again, experience and clinical judg-
reassured and prefer assertive physicians who allow very little ment play important roles in interpretation of the situation. For-
give and take between the parties. Other patients have a need tunately, a two-part screening questionnaire for BBD has been
to take part in all, or virtually all, decisions. The physician’s proposed by Dufresne and associates, which has been reported
mode of practice and the patient’s preference for input should as having ‘‘a sensitivity of 100% and a specificity of 93%’’
be compatible, and one of the main purposes of the interview (7). It is reproduced in Appendix 6B and Appendix 6C.
is to establish that such compatibility does, in fact, exist. I also use a questionnaire that elicits information about the
It is also important to establish realistic goals for each pa- patient’s general medical history and hair history These ques-
tient. Young patients, for example, may want to reproduce teen- tionnaires are reproduced in Appendix 6D and Appendix 6E.
age level and shaped hairlines, and it is obviously important to These forms are filled out by patients before they are seen.
advise them that what they should really be deciding on is a Questions pertaining to past personal and family health are self-
hairline that will be appropriate for them at any age, including explanatory. Those related to a family history of alopecia pro-
their 50s, 60s, and 70s. A compromise should be sought between vide information that, together with examination of the scalp,
what they would ideally like at their present age and what will enables the physician to make a more valid judgment on how
look appropriate when they are much older. In addition, they large the individual’s permanent donor area and eventual alope-
should be advised of the likely eventual extent of the area of cic area will be.
MPB and the corresponding size of the potential donor area, I usually sit on the same side of the desk as the patient to
as well as the probable ultimate hair density of the donor area help create a relaxed atmosphere. The questionnaire is reviewed
(especially in the temporal area). Objectives should be matched and the family history relative to alopecia, is filled out at that
to these inescapable factors and should be based on the worst time. In establishing the width of the potential donor area based
possible scenario that can be realistically foreseen in the long on a family history, I point with a pencil to various levels on
run for that individual. When advising a patient, it is wise to the side of my head, numbering them 1, 2, 3, and 4 as I move
remember that, although the individual may be relatively dis- superiorly. The patient is asked which number corresponds to
turbed by MPB at the time you are seeing him, most balding the relative in question. The questionnaire is then marked off
men do adjust to less than a full head of hair, and most will for whether that rim is narrow, average, or wide.
retain the functioning integrity of their personality (2). Heroic The hair is then examined, and the colour, texture, caliber,
solutions should be avoided. Alt has correctly advised that the curl, and density are noted in the chart If certain areas are rela-
surgeon is better off deferring treatment until the patient is older tively sparse (e.g., the temporal area), this is also recorded. The
(or refusing to treat a patient who has unrealistic or cosmetically eventual sizes of the donor and recipient areas are estimated
unwise goals) than to agree to an irreversible and improper after careful examination. Sometimes, the hair is wetted to aid
plan (3). The education of the patient is sometimes quite time- in this estimation, which is conducted under a bright light. The
consuming. In my office, consultations last for 30 to 60 minutes less experienced the physician, the wiser it is to wet the hair.
or more. Some physicians routinely spend 2 hours on a consulta- A copy of Norwood’s schematic classification of alopecia may
tion appointment (4). also be added to the chart and used to record the family history
and estimated ultimate prognosis in a male patient. For female
Body Dysmorphic Disorder (BBD) patients, Hamilton’s and Ludwig’s schematic drawings may
also be used (see Chapter 3A and B).
BBD, as it is defined in the Diagnostic and Statistical Manual All of the foregoing data are condensed into a number, from
of Mental Disorders of the American Psychiatric Association, 1 to 10, with 10 representing the best possible hair characteris-
can be summarized as (1) preoccupation with an imagined de- tics and 1 the worst. The estimated eventualdonor/recipient area
fect in appearance. With regard to the latter, the degree of con- ratio is also rated as a number on the same basis. Should patients
cern is markedly greater than usual for what most individuals have questions once they have left the office, they are invited
would consider a ‘‘slight physical anomaly.’’ The concern re- to telephone, and their ratings from 1 to 10 as well as notations
sults in (2) ‘‘clinically significant distress or impaired function- on hair characteristics and ultimate prognosis usually allow the
ing, and (3) there is no other mental disorder that would explain surgeon to answer their questions over the telephone, without
this pre-occupation with physical appearance. This condition the need for a second visit.
frequently results in withdrawal from family, work, and social Devine and Howard described a method of donor area classi-
activities and may be associated with depression, which can be fication based on hair density and texture (8). In their system,
severe enough to result in suicide (5,6). Because these patients type I refers to dense, coarse hair and approximately 20 hairs
are declined treatment by most ethical practitioners, they usu- in 4 mm2. Type II is less coarse hair with approximately 14
ally have a history of consulting many physicians. Because the hairs in 4 mm2. Type III is finer hair with approximately 10
defect is so small and the patient is so sensitive to even slight hairs in 4 mm.2 Type IV is very fine hair and approximately
imperfection, dissatisfaction with surgical treatment is also six hairs in 4 mm2. This classification proved to be inadequate
high. Obviously, it is wisest for the surgeon to avoid such indi- for several reasons and was not adopted by hair restoration
viduals, not only because of the likelihood that they cannot be surgeons; however, the idea was a good one. More detailed
The Initial Interview 167
evaluations of hair and follicular unit (FU) densities, as well patient but also helps establish that you are thinking of the long
as hair caliber, are described in the chapter devoted to the donor term, rather than the short term, and that the patient should do
area (Chapter 10). They are most useful for scientific studies likewise. The patient’s input is important, and any differences
and for those patients who are treated exclusively with follicular of opinion should be discussed and resolved. In the midscalp
units FUs, especially if accurate estimations of FUs are deemed and vertex areas, a similar approach is employed. The black
necessary because specific numbers of them are required per grease pencil delineates the estimated ultimate eventual extent
session for planning or financial reasons. Unless I am doing a of alopecia in the area and therefore includes currently hair-
study, I find that making these evaluations is too time-consum- bearing areas in most patients.
ing and constraining. I also suspect that although the method of After all of the foregoing data are combined with the pa-
evaluating the donor area described in Chapter 10A is obviously tient’s objectives for coverage and density, recommendations
more scientific than the one just described, it may well be less are made concerning the type and density of grafts to be used
accurate than we hope. Hair and FU density, as well as hair in various areas of the recipient area, and the reasons for these
caliber, can vary so much along any significant length of a donor suggestions are explained. It is at this point in the interview
strip, and at varying levels of the donor area, that examining a that photographs become very valuable. The wider the selection
few sites may well be inadequate for truly scientific purposes. of such photographs, the more likely it is that one will be able
I, therefore, prefer to use the 1out of 10 rating system described to find an example that approximates the type of hair and the
earlier. During the consultation, I provide only estimates of the eventual extent of MPB of the patient being interviewed. Photo-
number of grafts and costs per session and have found that this graphs, slides, or videotapes allow the patient to acquire a visual
approach is virtually always satisfactory for my patients. understanding of the procedure and what type of results can be
At this stage in the interview, I routinely use a black grease reasonably expected. Unfortunately, it is difficult to cover the
pencil to draw in a suggested hairline. The individual is advised entire spectrum of potential results and impossible to pinpoint
that this line must begin and end at the place where, in the exactly what any particular individual can anticipate. Patients
future, the most anterosuperior points of the temporal fringes may mistakenly visualize their own results as matching those
can reasonably be expected to recede. These two lateral points of one of the photographs when, in fact, they should expect
of the hairline must be joined to a third point, more anterior something rather different. It is especially for this last reason,
and in the midline, with a smooth oval or bell-shaped line, and particularly in offices where an extensive file of photo-
according to the preference of the patient and physician. As is graphs is not available, that it is best to supplement the available
noted elsewhere in the text, when drawing this line, one must supply with photographs from published articles or textbooks.
anticipate and discuss the effect that any proposed future alope- When photographs, are used, they should ideally include: (1)
cia reductions (AR) would have on it. (see Chapter 5A) The ones in which the hair is combed directly back from the hairline
patient is also told that the anterior midline point is ideally for critical evaluation, and (2) views of the top of the scalp with
chosen so that it lies somewhere in the zone of transition be- the hair combed as it is normally worn, as well as parted,
tween the more or less flat caudal aspect of the scalp and the through the transplanted areas.
essentially vertical forehead. When the individual is observed Photographs of patients who have been treated with various
laterally, the hairline should also usually run more or less paral- types of grafts should ideally be available so that the patient
lel to the ground. has a clear understanding of the advantages and disadvantages
In addition, it is important to point out that if the midline of each. I believe that an explanation of the reasons for the
point is chosen too far forward, an inordinately large number various combinations of types of grafts that were employed in
of grafts may be required to fill in the frontal area posterior to each of the demonstrated cases is an important component of
the resulting hairline, leaving fewer grafts in reserve to treat educating the patient, but, of course, this is based on my experi-
the midscalp or vertex area. An excessively anterior placement ence. If the physician employs only FUT, photographs showing
also makes it more difficult to successfully use existing and various colors and textures of hair and their effect in patients
potential comb-over hair. Alternatively, if one puts the midline with different degrees of MPB can be used instead. If the patient
anterior point too far posteriorly, the hairline will be either too has information from another source that conflicts with what I
flat or will have a ‘‘bowl-like’’ appearance. Variations of the say, I point out that different practitioners have honest differ-
original line are drawn, taking into account the patient’s input, ences of opinion based on their personal experiences. Denigrat-
until a decision is reached. The agreed-on hairline is then ing another physician’s ability is, more often than not, seen by
recorded in the chart. If it is somewhat unusual for any reason, the patient as self-serving and unprofessional.
I also take a Polaroid photograph to record it more graphically. Computer programs that allow the physician to use a com-
This decision will be referred to on the day of surgery, at which puter-projected photograph of the patient and to add varying
time a final line will be chosen just before the procedure is amounts of hair as well to demonstrate the results of different
begun. hairline designs and levels can be very helpful. One should be
The lateral boundaries of the anterior third to half of the careful, however, not to frighten or depress an already con-
scalp that will be treated are also drawn. These run more or cerned individual by projecting a worst-case scenario of future
less parallel to the ground, or, more often, tilt inferiorly as one balding; one must also guard against obviously suggesting re-
moves posteriorly (see Chapter 5A). Often there is still some sults that may be considerably better than one can actually
hair present above these lines. I point out to the patient that achieve.
unless this area is treated at the same time as more obvious The number of sessions that will likely be required in the
thinning areas are being transplanted, there will almost certainly short term, as well as in the long term, for the anterior third,
need to be a constant ‘‘chasing’’ of the progressing alopecia. two-thirds, and/or vertex area of MPB should be estimated. As
This discussion not only provides required information to the nobody has a magic crystal ball that will provide an unerringly
168 Chapter 6
accurate forecast of the future progression of MPB, these edu- If, in fact, the area of main concern is the posterior third to
cated estimates should be presented as such rather than as abso- half of the area of MPB, one should always stress the potential
lute guarantees. For patients who still have some hair present downside of beginning with the treatment of this area rather
in the potential recipient area, I emphasize that micrografting than with the anterior third, half, or two thirds. In particular, it
and micro-slit grafting will have a minimal initial thinning ef- should be stressed that if there is not enough hair or funds to
fect on the hair density in that area. On the other hand, if I think transplant the entire eventual area of MPB, most individuals
they are also appropriate candidates for slot or round grafts, I would prefer to transplant the anterior third, half, or two thirds
tell them that these types of grafts can, in my opinion, result rather than the posterior third, half, or two thirds. This is because
in greater ultimate hair density, but that they will cause a tempo- the anterior aspect provides the frame of the face and is far
rary decrease in hair density until the hair in those grafts begins more useful in making an individual look his age than transplan-
to grow (see Chapter 12F). I always point out that FUT will tation of the vertex.
result in the most natural, even, hair distribution, and that after Specific information that is provided during consultations
one session, even in a totally alopecic area, the hair will be for women who have androgenetic alopecia and for those who
able to ‘‘stand on its own’’ and look natural without further have cicatricial alopecia is found in other chapters in this text.
transplanting. Patients are also advised that, generally speaking, Although the patient may read the information booklet,
an area to be treated with FUs combined with micro-slit grafting which covers the negative aspects of the postoperative course
will look cosmetically acceptable with one to three sessions that can be expected with transplantation, I like to restate them.
(depending on the amount of persisting hair and hair characteris- Specifically, I emphasize the following points:
tics), whereas round grafting in any given area will usually 1. One of every 50 patients experiences edema severe
eventually require at least three sessions unless the hair is partic- enough to cause ecchymosis around the eyes, which will take
ularly fine-textured and light coloured and also depends on 10 to 14 days to resolve. Because edema is quite a common
whether 1-mm to 1.5-mm round minigrafts are employed. One problem and varies from minor to severe, patients are advised
should be sensitive to time as well as financial considerations to arrange to take a week off work after at least the first session,
that affect patients. For example, some individuals want to pro- in case they are one of the unfortunate ones to experience a
ceed as quickly as they can, whereas others want to proceed as more severe form. This is balanced by reiterating that physical
slowly as they can. At the time of the initial interview, patients incapacity rarely extends beyond the day of surgery and that
are informed about how quickly or slowly the procedures can swelling is usually mild and usually disappears in a few days.
be done as well as the attendant advantages and disadvantages They are told that edema usually begins on the second or third
day postoperatively and that it has no effect on ultimate hair
of the various options.
growth. They are also informed that, generally, a subsequent
I propose a conservative estimate of what portion of the
session, carried out within 6 months of the previous one, pro-
eventually fully developed MPB I feel it would be reasonable
duces less postoperative edema (and this effect continues for
to transplant. However, during the initial interview, I generally
each following session), and that the use of systemic corticoste-
try to discuss as little as possible the treatment of the vertex,
roids, ice compresses, and a semisupine sleep position all tend
unless the patient has come specifically for this purpose or indi-
to minimize the problem.
cates that his goal is definitely maximum coverage. A complete
2. A variable amount of crusting can be expected for 3 to
description of the treatment of the vertex almost always requires
14 days. Smaller grafts, such as micrografts and minislit grafts
an explanation of AR, the various shapes of AR available, the generally shed their crusts earlier than larger ones. Crusts fall
timing of the AR, and the pros and cons of this procedure. One off faster if they are kept moist, for example, with Aloe barba-
should consider how much information any given individual densis (vera) extract, vitamin E oil, or bacitracin ointment.
can reasonably be expected to comprehend during a single visit. Grafts may be pink, brown, somewhat purple, or perfectly skin-
Generally, all I will say during the first consultation is that if colored once the crusts have fallen off. Eventually, the colour
the posterior third of the scalp is to be treated, there should will blend in with the surrounding skin, but, once more, patients
usually be an attempt to make that area smaller with AR at should be advised at the time of the interview of the possibility
some point during the course of treatment. I assure the patient of temporary discoloration. To a large extent, this can be camou-
that AR will be discussed in a second consultation—ideally, flaged in many patients by combing fringe hair across the recipi-
after the first transplant has been done and many of the questions ent area. Ingrown hairs are only occasionally problematic, but
about that aspect of treatment have been answered. Exceptions patients should also be forewarned of this complication, espe-
to this general approach are made for patients who want to start cially if their hair is naturally curly and if FUT or micro-slit
with transplanting of the vertex and who should have AR before grafts are being used.
any hair transplanting (see Chapter 5A) or for those who want 3. The scalp will be less sensitive after transplanting as the
all the information, regardless of its complexity. I also like to result of severed nerves. Usually, sensitivity is back to normal
point out that it looks perfectly natural to transplant only the in 3 to 6 months, but, if a large nerve is cut, it may take as
anterior one third, one half, or two thirds of the MPB without long as 18 months for a return to normal. Also, in approximately
treating the posterior third or half. Many men go bald naturally 1 of 100 surgeries, a small area of permanent decreased sensitiv-
in the vertex area but not in the frontal area. Patients should ity can occur. I stress that such an area is not completely insensi-
not feel that transplanting only the anterior portion of MPB tive but only less sensitive than other areas, is not painful, and
would look unnatural. Individuals who, for example, cannot has no medical significance.
afford the time or money to transplant all of the MPB may 4. Postoperative pain is usually mild enough that acetamino-
forego treatment altogether if this mistaken belief is not cor- phen with codeine, 8–30 mg (Tylenol 噛l, 噛2, or 噛3), is nearly
rected. always adequate to completely control it. I also reassure patients
by telling them that analgesics are usually necessary only for occupation or hobby involves wearing a hard hat or a covering
the first night after surgery, and that we will provide three types of the scalp. Hats with air holes, which allow some air circula-
of them so that the control of essentially all postoperative dis- tion, can be used. In my practice, we provide such a hat on the
comfort is possible. Oxycodone-acetaminophen (Percocet), one day after surgery, thereby assuring a proper choice as well as
or two tablets every 4 to 6 hours, for example, may be taken for a clean one. Individuals who have jobs that expose them to
more than average discomfort, and meperidine hydrochloride considerable amounts of dirt and debris should be advised that
(Demerol), 50 mg to 100 mg every 4 to 6 hours, can be used for it is necessary to be away from work for at least 1 week after
severe pain. Nearly all of our patients are given an intramuscular each procedure. They are told that weight training is prohibited
injection of 30 mg of ketorolac tromethamine (Toradol) at the for the first week postoperatively and should not include maxi-
end of the procedure. This keeps all but those with the most mum exertion for an additional week thereafter. Sexual inter-
severe pain completely pain-free for a period of approximately course is not prohibited, but patients are warned to use modera-
6 hours. tion in frequency and exertion for 1 week.
5. If there is any hair in the recipient area, there may be a
temporary loss of some of it. Hair loss occurs in approximately
10% to 20% of men in my practice and usually involves no PATIENT SELECTION
more than 10% to 15% of the recipient area hair. However, the
more grafts transplanted per session, and/or the denser, and Although in the past I asked all patients who decided to under-
larger the grafts used, the more likely it is that some hair loss take hair transplanting to have a complete physical examination
will be seen. Women, however, experience this problem far carried out by their own physician before the procedure, I have
more frequently than men do, with 40% to 50% of them report- not required this for many years—unless I have reason to be
ing its occurrence (9). They are told that if they are not emotion- concerned about their general or mental health. However, pro-
ally prepared for hair loss to happen, they should forget about vided patients do not object, we continue to send a letter to
hair transplantation. Using a 3% or 3.5% solution of minoxidil their physician and dentist to inquire about any medical or psy-
twice daily, for 1 week before and 5 weeks after surgery, seems chological factors, past or present, that should be considered,
to decrease the frequency and severity of hair loss. The tempo- such as cardiopulmonary disease, idiosyncratic drug reactions,
rary nature of this hair loss is emphasized several times. allergies, bleeding diathesis, or psychiatric disorders. Although
6. The cost of the procedure and the terms of payment are some may consider this overly cautious, I have on several occa-
clearly outlined and repeated as they are being written into the sions interviewed patients who intentionally misinformed me
medical record so that there is no misunderstanding. The esti- about their past health because they feared they would be con-
mate of the number and types of treatments anticipated are also sidered unacceptable for the operation. There are also a few
repeated as they are entered into the chart. Although misunder- patients who forget significant items in their medical histories,
standings about these matters are uncommon in my practice, and a check with their doctors can reveal this. At the very least,
the best way to be sure that the information has been clearly a letter may provide some medicolegal protection. This letter
communicated, is to never write anything into the chart without also informs dentists and physicians that you practice hair resto-
saying it, and vice versa. Your own doubts about what you ration surgery. In my experience, the letter is sometimes helpful
have or have not told the patient are your worst problem if the in identifying patients with BDD, discussed earlier, because
patient subsequently tells you that something was not discussed. they usually have a history of consultations with many cosmetic
It is for this last reason that all of the disadvantages of trans- surgeons, and their family physician may be aware of that fact.
planting just discussed are also routinely pointed out to all pa- There are very few general physical disorders that entirely
tients in the order noted. I always end this negative list by adding preclude hair transplanting, provided they can be brought under
two positive points: (1) I have never had a ‘‘failure’’—there is reasonable medical control. Hypertension, for example, can
always a cosmetically significant improvement in all of my cause excessive bleeding during and after operations, resulting
patients; (2) I have never encountered a serious complication in poor graft ‘‘takes’’ (10), but once hypertension is under con-
that required a patient to be hospitalized during or after surgery. trol, these patients present no further difficulties. Even patients
The result of covering the transplanted area with a hairpiece, with moderate cardiac disease or previous cardiac bypass opera-
immediately or soon after sessions, is the subject of some de- tions can undergo the procedure if it is staged properly with
bate. Most practitioners do not object to the use of a hairpiece smaller than usual sessions and provided epinephrine is used
within 24 hours of the procedure; others allow it almost immedi- cautiously (see Chapter 8A). Diabetic patients should probably
ately afterward. On the other hand, some, including myself, have sessions spread at least 4 to 6 months apart because of
prefer that no hairpiece be worn for at least 1 week postopera- their impaired peripheral blood supply and the increased perme-
tively and as little as possible for another week. Warmth and ability of their peripheral vasculature (11). The latter causes
moisture under hairpieces are conducive to the development of increased postoperative tissue edema, resulting in further de-
infection, and, although this complication is uncommon, it creases in circulation.
would seem wise to avoid hairpieces whenever patients’ objec- Local cutaneous disorders that could prevent success, such
tions are not too strong. Marritt sometimes recommended a as active cutaneous lupus erythematosus, morphea, alopecia ar-
small hairpiece that is attached only to one side of the rim hair. eata, and severe folliculitis are contraindications for surgery.
The hair was then combed over the recipient area for camou- Transplanting should not be carried out until treatment has been
flage, but with no part of the hairpiece base coming in contact provided for these diseases, and until they have been quiescent
with the recipient area. He believed that such a device could for at least 6 to 12 months. Other factors that contribute to the
be worn immediately after removal of bandages. The same re- decision to accept or reject a patient are discussed in Chapters
strictions as described for hairpieces apply to any patient whose 5A and 6A.
170 Chapter 6
PATIENT QUESTIONS How do physicians evaluate patients’ expectations? They

must talk with their patients, even more importantly, they must
At the end of the interview, patients should be invited to ask listen carefully to their responses.
any questions that have come up during the course of the consul-
tation. In addition, anyone who has accompanied them to the
consultation is invited to ask questions. At this point, patients
have been given basically all of the information that they require REALISTIC EXPECTATIONS
to make a decision about proceeding with hair transplanting, The initial expectations of a person seeking the services of hair
but, because of the amount of information provided, they may replacement surgeons are frequently unrealistic for many rea-
be confused or undecided. Although we encourage patients to sons. The human psyche often desires that all be made exactly as
telephone if they think of questions once they have left the it once was. Patients want to recreate their youthful appearance.
office, seeing the patient in person for a second time obviously News reports about what can be achieved by medical science
allows the surgeon to answer questions more validly than by in the 21st century are in the patient’s mind. Patients have seen
referring to notes taken during the consultation. Patients are scientists clone an entire sheep or restore excellent visual acuity
therefore also invited to come back for a second meeting should to the nearly blind. They therefore sometimes presume that if
they have additional questions after they have left, or should modern medicine can accomplish these miracles, certainly it
they wish to bring an advisor, such as a spouse or a friend. should be able to restore a once thick head of hair to its previous
The less confusion there is going into the procedure, the less glory.
possibility exists for recriminations later. It is worth emphasiz- Clever marketing material, which the public sees in all ven-
ing that it is always wise to overestimate rather than underesti- ues of the media, has also played a role in creating unrealisti-
mate the numbers of grafts and sessions that will be required cally high expectations. We see advertisements that often claim,
and to indicate that the numbers are only educated approxima- ‘‘a full head of hair after only one transplant session’’, and
tions with, for example, a 10% margin of error, rather than ‘‘remove your bald spot forever with one reduction.’’ It is there-
definite figures. One should also overestimate, slightly, the time fore essential that the surgeon makes perfectly clear to a pro-
that will be required to produce a good cosmetic result. spective patient, the good, the bad, and the realistic results that
may be provided for before the individual comes in close prox-
imity to the scalpel.
Patients also may mistakenly believe that restoring their hair
6B. Patient Expectations and loss will make all the problems in their life disappear. People
Surgical Options Based on Age, sometimes attribute the cause of all that is wrong in their lives to
Ethnicity, and Sex their having been endowed with less than magnificent physical
attributes. It is, therefore, important to rule out for surgical
Robert T. Leonard intervention a patient who thinks cosmetic surgery will correct
inadequacies beyond the initial physical issue of hair loss.
INTRODUCTION A physician must be careful not to be seduced by unsuitable
candidates who are ready to jump right into surgery. Individuals
As discussed repeatedly in this text, proper assessment of pa- who expend the energy and summon the fortitude to come for
tient expectations before surgery is performed as a vital part of a consultation obviously have a greater than average concern
the evaluation process. One cannot have satisfied patients with- about their hair loss. To these individuals, hair loss is not a
out meeting their expectations. In my opinion, proper assess- minor concern, and they may be motivated to begin surgical
ment of those expectations is only secondary in importance to hair restoration immediately. Such a person may erroneously
knowledge of medical conditions such as allergies to medica- appear to be the surgeon’s dream patient. After all, the surgeon
tions or significant cardiac disease, which pose a risk to patients may very well have invested a great deal in marketing funds
who are undergoing surgery. In this chapter, we discuss expec- to attract patients. This patient is ready to move forward imme-
tations and the options available to meet them, based on age, diately. However, a patient whose expectations of results are
ethnicity, and gender. unrealistic could become the doctor’s worst nightmare.
The Greek word for physician, iatros, translates specifically
as teacher. During the consultative process, physicians must
PATIENT ASSESMENT AND EDUCATION learn from their patients as well as educate them about what
can realistically be achieved from the surgeries. I stress the
To meet a patient’s expectations, a physician needs to do the plural form of ‘‘surgery’’ because one of the most important
following: facts that the patients have to understand, remember, and be-
● Assess a patient’s initial expectations. lieve is that androgenetic alopecia will progress throughout their
● Determine the potential achievable surgical results for lifetime. Consequently, hair transplant procedures will most
this specific patient. likely be multiple in nature. Patients must know that they proba-
● Educate the patient about realistic expectations. bly will be back for future surgical sessions with the passage
of time and the continuation of hair loss.
After this process is finished, the physician has to answer the It is, of course, of the utmost importance to provide a great
question: Are the patient’s expectations and the achievable re- deal of information about the procedure and then to determine
sults compatible? If the answer is no, the procedure should not whether the patient is: a candidate at all, a candidate for medical
be performed. therapy only, a candidate for surgical intervention and/or medi-
cal therapy. Another consideration is choosing the time when and/or minoxidil (Rogaine) treatment, there may be a more
treatment should begin. static condition for transplantation. In other words, if they can
keep what they have in addition to what I can transplant, at the
end of the day (actually the year), they will have that much
AGE more hair on their heads. The idea of slowing down, stopping,
Common thoughts and expectations exist among patients in or reversing their hair loss is comforting to these patients, and,
various age groups. It is important for the doctor to recognize in my experience, they are often happy to take this advice.
these issues and to address them during the initial interview. Another issue for patients in this age range is divorce. Men
Remember that not everyone who seeks a consultation will be and women sometimes have been married or have been in long-
a surgical candidate. term relationships that have recently ended. They find them-
selves in the world of dating once more. Now, however, they
are older, and, more disturbingly, they look older. They are
Young Patients
convinced that if they could regain thicker hair, they would be
Young men between 18 and 25 years of age are among the in a better position to compete in the dating scene. I caution
most difficult patients to make happy. Sometimes, at the first physicians again to carefully evaluate expectations to be sure
sign of hairline recession, a patient will come to your office that patients do not think that more hair will guarantee happi-
wanting surgery and expressing his desire to ‘‘bring my hairline ness.
back to where it was when I was in high school.’’ He may
arrive for his consultation wearing a baseball cap that an accom- Patients Fifty Years of Age and Older
panying parent states is virtually never removed from his head.
The parent commonly offers that the patient has become with- In my experience, men in their fifth, sixth, seventh, and eighth
drawn from social and family events. A physical examination decades of life are the most realistic in their expectations. Often,
reveals matted, dirty hair and a scaling scalp. This patient indi- they have a great deal of hair loss. These patients most com-
cates that he washes his hair very infrequently because, when monly just want to get some of their hair back or at least enough
he does, a lot of hair falls out. He is terrified because he thinks so that they do not appear ‘‘very’’ bald. They typically are
that hair washing causes male pattern baldness (MPB). This satisfied with high, narrow hairlines. Physicians must be aware
type of patient needs to be taught about genetic hair loss and that potentially serious medical conditions are common in per-
proper scalp hygiene. The best approach to such a patient is to sons at this stage of life. The surgeon should always get medical
(1) initiate medical treatment for his hair loss; (2) refer him to clearance from the personal physicians of patients who may be
a psychologist or psychiatrist, if you think this is indicated; and, at risk. A fact never to be forgotten is that cosmetic surgery
(3) follow him conservatively for many months or years in case should not place a patient in harm’s way.
he may become a surgical patient. It is important for this patient
to know that the surgeon cares about his situation. Therefore, ETHNICITY
appointments for re-evaluation should be made for him on a 6-
month to 12-month basis. This situation warrants the passage The etiology of androgenetic alopecia is constant among mem-
of significant time to determine the patient’s response to that bers of the various ethnic groups; however, the surgeon’s ap-
treatment, to evaluate his maturity as he ages, and to give him proach can be somewhat different toward individuals within
more time to learn about possible surgical options in the future. these groups. Transplanting in specific ethnic groups is dis-
(A somewhat different view of the management of younger cussed in detail elsewhere in this text, but a brief summary of
patients is presented in the editors’ comments at the end of this my views on this subject follows.
chapter. Chapter 6.)
African Americans
Patients Between 30 and 40 Years of Age
The density of hair in the donor area of African-American pa-
Expectation issues common to older patients are somewhat less tients is less than in Caucasian and Asian patients. If one were
difficult to address. Patients in their 30s and 40s are often very to take into consideration only the number of hairs/cm2, vir-
busy building families and careers when they suddenly notice tually all African Americans would be considered poor candi-
one of the early signs of aging—hair loss. They often declare dates for hair restoration surgery. However, because of their
that their youthful head of hair has disappeared almost ‘‘over hair characteristics (curly, coarse, wiry, with minimal contrast
night’’. The truth, of course, is that this diminished density has between scalp and skin color), fewer hairs are needed to create
probably occurred over several years. The nature of these busy the same illusion of density than are needed in other races. Once
people is to disregard their hair loss until it is well established. the transplanted hair grows, its curliness and other characteris-
At this point, contemporaries may begin to tease them and they tics create the illusion of a greater density than hair with less
become more aware of younger colleagues with full crops of favorable characteristics.
hair. Another important fact to recognize in African-American
The potential for the progression of hair loss during the third patients is that their follicles curve significantly within the der-
and fourth decades of life must be fully discussed with these mis. This curvature may be dramatic and poses a potential prob-
patients. Again, early initiation of medical therapy is important lem with donor harvesting, because hair shaft transection could
because their hair loss may proceed rapidly. I tell my patients be increased with typical strip harvesting. Several alternatives to
that if the progression of androgenetic alopecia can at least be the usual method of harvesting have been suggested to minimize
decreased—and possibly stopped—with finasteride (Propecia) such transections:
172 Chapter 6
1. Infiltraton of the donor area with a large amount of saline seen, the surgeon can proceed with confidence. If a keloid
tumescent solution is one proposed method of addressing this forms, the patient is obviously not a surgical candidate.
problem. The pronounced turgor that is created in the tissue may
help straighten these follicles as well as increase the distance
between them, thereby decreasing the probability of transection. GENDER
2. When use of round graft punches was the standard harvest- Gender has an impact on the surgical needs and expectations
ing method, careful manual curving of the punch was done in of patients. Hair transplantation is currently much more com-
an attempt to follow the curve of the follicle as the punch gradu- mon in men than in women, but the number of women seeking
ally cut deeper into the dermis. Some practitioners have reverted hair restoration surgery is on the rise. The subject of female hair
to the use of the punch in African Americans for this reason. transplantation is discussed in detail in Chapter 12H. However,
3. With strip harvesting, it has been recommended to use a there are specific issues that are worthwhile reviewing here with
strip cut from a single blade to minimize the shaft transection respect to the expectations and needs of female patients’.
that multiple blades can create. Physically bending the surgical In our society, it is socially acceptable for a man to lose his
blade to approximate the curvature of the hair shaft has also hair. He may not like it, but at least male pattern hair loss is
been suggested. (J. Arnold, personal communication, 1999). considered a variation of ‘‘normal.’’ After all, a majority of
Once the strip is excised, careful separation into individual men have some degree of noticeable hair loss by the time they
grafts must be undertaken, with close attention paid to the follic- reach midlife. Hair loss in women is socially unacceptable be-
ular curving. In my own practice during the last 18 years, I have cause noticeable female hair loss is much less common. With
had a significant opportunity to work with African-American female pattern baldness, women feel ‘‘abnormal’’ and find
patients. I have had the best success in limiting transection and themselves in a position that makes them extraordinarily un-
increasing hair survival in these patients by using the punch comfortable. They attempt to find hairstylists who can hide this
harvesting technique, supporting the idea that, ‘‘all that is old embarrassing condition. If the problem is not addressed, these
is not bad.’’ women may remove themselves from family and public events.
Psychiatric and/or pharmaceutical intervention may be neces-
Asians sary. The purpose of restoring a man’s hair is primarily to make
him look better. The purpose of replacing hair in women is not
Asian patients also have particular skull and hair characteristics only an attempt to make them look better, but also to make
that are factors in determining the results. The forehead area them look and feel ‘‘more normal.’’
of Asian skulls tends to be larger and wider than that found in It is far more common for a woman with androgenetic alope-
Caucasians. In addition, in Asians, the donor area hair density cia to display a more diffuse pattern of hair loss than is seen
is usually low, whereas the color contrast between black hair in a man. What is often observed is a hairline zone approxi-
and light skin is high. All these factors make it more difficult mately one-quarter inch to one-half inch wide, followed by dif-
to create an illusion of density. On the other hand, the hair shaft fusely thinning hair throughout the remainder of the scalp. If
diameter in Asian men is usually significantly greater than in this thinly distributed hair is also present in the donor area, the
Caucasians. This largely counterbalances the lower donor den- surgeon must carefully assess whether the transplant will be
sity found in Asians. Cole has noted that increasing hair diame- able to provide a sufficient cosmetic improvement.
ter by only 0.01 mm increases hair bulk by 36% (1). This in I tell all of my female patients that my goal in transplanting
turn increases coverage. Therefore, Asians do not need as high their hair is not to create a truly thick head of hair; rather,
donor hair density as Caucasians to be acceptable candidates the goal is to provide additional hair that can be styled for
for hair replacement surgery. cosmetically satisfactory coverage. These women must also be
In performing hair transplanting on these individuals, it is made to understand that, like male pattern baldness, the female
important to remember that these large-caliber black hairs have pattern of hair loss is progressive. It is important for them to
a greater potential to create a pluggy look. Meticulous place- know that they will require more surgeries in the likely event
ment of single-follicle grafts at the hairline minimizes any po- that their hair loss progresses.
tential for a pluggy, compressed appearance. Behind the hairline
zone, slightly larger grafts can provide the necessary density
for a good aesthetic result. CONCLUSION
Innumerable issues need to be discussed and addressed with
Keloid Formation in African Americans and Asians people seeking professional services from hair restoration sur-
Post-traumatic keloid formation is more common in African geons. As in all areas of medicine, physicians should remember
Americans and in Asians than in Caucasians. A high index of that their first priority is to ‘‘do no harm.’’ The patient’s expec-
suspicion is therefore necessary when transplanting hair in these tation of results must be carefully assessed. If the surgeon is
individuals. One should check for the presence of keloids in convinced that his patient has unrealistic expectations, the pro-
areas of high flexibility (e.g., elbow, wrist, shoulder, knee) as cedure should be postponed until physician and patient are of
well as on the scapula area and the sternum. Performance of a one mind.
keloid test procedure should be done in patients whom you
suspect may form keloids. This is done by transplanting a single Editor’s Comment
2-mm round graft to an area at the border of the recipient area Leonard’s opinion concerning the effect of the patient’s age on
of hair-bearing skin. A period of 3 months should then pass, the acceptance or rejection of him for surgical treatment is
after which observation of the healing is made. If no keloid is widely accepted. However, the difference between humane
treatment and heartless analytical medicine lies in the ability programs and training in the more modern techniques of hair
of the physician to make exceptions to the rule. Such exceptions restoration. The lack of residency training may be partially re-
should be made only after much thought and discussion with sponsible for the small number of doctors whose primary spe-
the prospective patient (and sometimes with the patient’s par- cialty is hair restoration. Reinforcing this point is that although
ents). It is especially difficult when the patient is young to hair restoration began to receive recognition with publication
make a long-range prognosis, as to the type of MPB that will of Norman Orentreich’s article in 1959 (1), the International
eventually evolve. Generally, the more severe and the earlier Society of Hair Restoration Surgery (ISHRS)—the specialty’s
the onset of MPB, the worse the prognosis. Nevertheless, excep- largest society—currently has fewer than 900 members world-
tions are sometimes warranted. I can recall an extremely good- wide (2). This slow growth in critical mass made it more diffi-
looking 17-year-old patient who had been a model and was cult to establish organized hair restoration societies, to publish
suicidal about his hair loss despite his having received psychiat- journals dedicated to the specialty, and to form a hair restoration
ric intervention. His father (a cosmetic surgeon) and mother board.
pleaded with me to treat him, preferring to deal with the poten- The advent of specialty societies and of a certifying board
tial problems later, ‘‘when he was hopefully more mature and resulted in the establishment of guidelines for acceptable stan-
stable, than to have a dead son now.’’ After several visits and dards of practice. The use of non-physician consultants is an
prolonged discussions with the patient, his parents and his psy- area that was not publicly discussed among the practitioners
chiatrist, I carried out a session of micrografts and minislit grafts of the specialty until the 1998 annual meeting of ISHRS in
in a prospective isolated frontal forelock pattern (see Chapter Washington, D. C. The discussion at this meeting was prompted
5A). At the first sign of new hair growth, the effect on the boy’s by the appearance of reports in the media regarding the use of
psyche was immediate and profound. Two more such sessions consultants in the field. In my opinion, now is the appropriate
were done—each time with real trepidation but spurred on by time to establish guidelines for the ethical and beneficial role
the patient’s resumption of his usual outgoing and happy per- of non-physician, medical or nonmedical consultants in hair
sonality. He had gone back to school, his grades returned to restoration practices.
normal, and he was dating and modeling again. The end of this
story cannot yet be written, but 7 years have passed, his hair INTRODUCTION
looks wonderful and he now claims he will be satisfied with
an isolated frontal forelock if that should happen. He functions Hair restoration has been previously described as a new elective
field. Because hair restoration is a new, dynamic, and evolving
at a very high level academically, socially, and professionally.
area, many prospective patients do not enter a consultation with
He is, of course, using minoxidil, 5%, and finasteride, 1 mg
realistic expectations, knowledge of costs, or understanding of
per day. His frontal hair loss has stabilized, but it should be
the surgical procedure and the postoperative course. In addition,
remembered that both these preparations work significantly bet-
patients who desire cosmetic procedures in general, and hair
ter in the vertex area than in the frontal area—where hair loss
transplant patients in particular, may exhibit psychological pro-
most frequently begins. Thus, the effect of these drugs may or
files that require a substantial investment of time and education
may not be playing a role in the stabilization of this patient.
from the perspective of a physician’s practice.
Nevertheless, because I sense that he is more mature, I believe
Hair restoration is an expensive elective procedure that has
he is more realistic about both his future and the relative impor-
neither the urgency of most medical treatments nor the benefit
tance of hair in his life. (WU)
of insurance coverage. The decision-making process for the
patient should be as thorough as possible, which often necessi-
tates a lengthy consultation process. The consultation should
6C. Non-Physician Interviews: occur in a relaxed, unhurried environment. Questions should
be encouraged and as much education as possible should be
Advantages/Disadvantages and provided. The field of hair transplantation has incorporated
Ethical Control many new techniques in a relatively short time; therefore, an
enormous amount of basic information needs to be relayed to
Matthew L. Leavitt
the patient. Much of this information is generic and is equally
applicable to all patients.
HISTORY/OVERVIEW Use of a nonmedical or medical consultant to provide basic
information and education to patients, leaves the physician free
This chapter discusses the use of non-physicians as consultants to focus on the specific diagnosis and treatment plan. An edu-
for hair restoration patients. Before examining this subject, it cated patient can more easily understand the rationale behind
is important to understand the nature of this specialty. the treatment options offered by the physician. This education
Hair restoration is a unique medical specialty in many ways. process also saves a great deal of time, allowing the physician
Primarily, it is solely elective. Despite the fact that many pa- to spend more time in each surgery, to perform more surgeries,
tients believe that being bald is worse than many diseases, no and to have less pressure during the surgery, knowing that
one dies because of hair loss. Therefore, it is not surprising that prospective patients are being attended by a consultant. Benefits
hair restoration is not covered by insurance (although a few to the patient are numerous and are discussed later.
exceptions exist). In totally elective procedures, there is a
greater burden for physicians to follow the rule, ‘‘first do no THE RATIONALE FOR A CONSULTANT
harm.’’ To this end, creating realistic expectations and provid-
ing patient education are very important. Compounding the For the purpose of this chapter, the consultant is not the same
problem is absence at the university level of specific residency person as the hair restoration physician. As previously noted,
174 Chapter 6
the consultant may be a medical professional (e.g., registered sume some of these initial tasks, thereby enabling the physician
nurse, licensed practical nurse, medical assistant, physician’s to have more time for surgery.
assistant) or may have no medical background. The consultant’s The length of the appointment is often critical during the
function is not to diagnose or to render a specific treatment consulting process. Appointments can be scheduled every 1 to 2
plan but to provide education, education, and education. The hours to accommodate the patient’s needs. Flexible scheduling
consultant can also function as a patient-care coordinator. Ge- gives the patient more time to analyze and understand educa-
neric education for the patient is now readily available through tional materials such as CDI, photographs, videotapes, and so
many resources such as books, television shows, newspapers, forth. Additionally, a patient’s expectations may be unrealistic
brochures, videotapes, and the Internet. However, owing to the or nonexistent when at the first visit. A less rigid schedule
rapid introduction of many new techniques in the field, much provides a sufficient amount of time for the consultant to ex-
of this information can be conflicting and confusing to the layp- plain what can be reasonably expected during the transplanta-
erson. Information specific to an individual practice is best con- tion process and to decrease unrealistic expectations. These ser-
veyed personally during the consultation process. vices are invaluable to physicians, assisting them in formulating
A consultant’s responsiveness to a patient’s individual needs correct surgery plans for their patient while managing expected
will determine the comfort level offered by the practice, and, results.
ultimately, the selection of one particular practice from all avail- Consultants who have had experience as hair transplant pa-
able choices. This chapter’s description of the consultant’s du- tients have the added advantage of allowing prospective patients
ties provides a rationale for the argument that non-physicians to examine their results on a personal, first-hand basis. The
can competently perform this role. consultant can discuss personal experiences to illustrate the sur-
gical process step-by-step. Such consultants have a great deal
of empathy for patients. Consultants can arrange for prospective
HIRING THE RIGHT CONSULTANT patients who may wish to meet other patients in order to see
results and discuss the surgical experience. This is frequently
The consultant is often the first person in the office whom a a time-consuming process, which the consultant can handle
prospective patient meets and the person who actually spends without infringing on the physician’s surgery or patient time.
the greatest amount of consulting time with the patient. The One of the more valuable aspects of the consultant position
consultant must, therefore, be articulate and a ‘‘people person.’’ is that the prospective patient is welcomed into a nonthreatening
A good consultant is cognizant of the value of the patient’s and atmosphere. The third-party consult with a nonmedical staff
the physician’s time. Personality traits such as punctuality and member is often less intimidating for the patient than meeting
excellent organizational skills are mandatory. The combination only with the physician. There is a reduced risk of embarrass-
of knowledge and enthusiasm is contagious to a prospective ment or discomfort if the patient solicits information. The pa-
patient and helping to create a successful consultation. Patients tient may feel less inhibited about asking for information or
who have undergone hair restoration have sincere passion for may feel free to voice concerns without appearing either unedu-
what the procedure has done for them personally and they are cated or disrespectful to the physician. Many delicate issues
the best talent resource for the consulting position. The consult- such as licensure, training and education, problem patients, law-
ant must be an excellent listener who helps recognize the pa- suits, and cost issues can also be discussed candidly and com-
tient’s needs before the physician provides treatment. This fortably with the non-physician. The apprehensive patient is
groundwork in good communication enables the physician to less concerned about taking up a consultant’s time and may
interact more effectively with the patient and to respond to the call numerous times with additional questions.
patient’s concerns. Important as they are, however, consultants The essential ingredient for the success of the consultant is
must know their place—they are not physicians. the training process. Consultants must have a rigorous set of
standards guiding what they may or may not say and do. Well-
trained and educated consultants are a valuable resource in
ROLE OF THE CONSULTANT screening initial candidates, thereby leveraging the physician’s
time for patients who are serious candidates for surgery. Many
The consultant is responsible for scheduling the patient’s ap- prospective patients are not viable surgical candidates; for in-
pointments from the initial consultation through nonsurgical stance, an individual who is a class VII patient may want a
follow-up dates. The primary duty is to be available to the full head of hair another individual may have expectations of
patient when needed. The consultant does not have to juggle acquiring a full head of hair immediately. Patients who are
performance of surgery versus consultation time, allowing a unable to afford the procedure cannot be considered as candi-
more convenient and prompt dialogue for the patient. In addi- dates, but they can consume significant amounts of time. The
tion to a greater number of appointment times, the consultant consultant can tactfully present the facts to such patients,
is more likely to schedule weekend and evening appointments thereby performing a necessary function that could be distaste-
to accommodate the patient. More timely consults may result ful, uncomfortable, and inefficient for the surgeon to handle.
in scheduling of an earlier surgery date. When a prospective practices that feature consultants advertise this service and do
patient has decided to choose a surgical solution, it is best not not charge for the visit. This may attract more prospective pa-
to dampen enthusiasm by a prolonged wait for surgery. Con- tients to visit the office than the surgeon can handle. The skilled
versely, a busy hair restoration surgeon may not have time to consultant can manage the increased volume, taking the time
meet with a potential patient. Unfortunately, this limited avail- to wean out the possibly significant number of patients who
ability may open the door to competitive practices. This prob- are just curious or not yet prepared to make a commitment from
lem can potentially be alleviated by having the consultant as- the serious candidates.
The Preoperative Phase a significant amount of time. Consultant who are poorly trained
or badly chosen can damage the reputation of the practice.
Once a patient decides to have surgery, the consultant becomes Without exception, competitors use the presence of a con-
a valuable resource during the preoperative stages. A relation- sultant as a negative feature against another practice. Consult-
ship based on trust has already been established, and the con- ants are invariably depicted as sales people who add to the cost
sultant serves as a liaison to the nurse and physician for any of the surgery. The fact is that a consultant is an extra person
last-minute questions and concerns. As the provider of point-
on the physician’s payroll. To hire the right individual may be
of-contact service, the consultant ensures that all documents
rather expensive, not only with regard to salary but also with
and paperwork have been completed and submitted before being
regard to training.
reviewed by the medical personnel. Consultants are compas-
sionate and reassuring resources for nervous patients. They are
accessible to patients at all times, nights and weekends included,
which makes patients feel comfortable and secure. CONCLUSIONS
The benefits of consultant-based practices were underscored by
Surgical Phase an ad-hoc survey performed in 1999. (3) Patients indicated that
Consultants help to make the surgery experience more relaxed consultants greatly enhanced the experience of hair restoration.
and enjoyable. They are familiar figures whose presence is a They gave an approval rating of 90Ⳮ% for practices that in-
welcome sight on the day of surgery. Consultants provide conti- cluded consultants versus those that featured only physicians.
nuity to the experience and help to ‘‘walk’’ patients through Chief among the perceived benefits cited were the time consult-
the entire process. They are the customary contacts for patients’ ants devoted to patients and the education they provided.
families. They also coordinate nonsurgical details, such as trans-
portation, meals, and hotel arrangements.
Financial arrangements are handled by the consultant rather ACKNOWLEDGMENT
than by the surgical staff. Because a specific person is in charge
of these matters from the beginning, there is less chance of The author would like to give special thanks to Valarie Montal-
error and better compliance with patient confidentiality guide- bano for her assistance with helping to write and edit this
lines. The consultant’s function also ensures a more profes- chapter.
sional process for the patient and the surgical team. It is helpful
for the physician not to become distracted by these details, Editor’s Comment
and because such matters are out of the physician’s hands, the The use of nonmedical consultants is a controversial subject
potential for uneasiness about financial issues is eliminated because of its potential advantages and disadvantages. I have
from the physician-patient relationship. had experience both with and without the use of consultants
and would like to add a few of my comments.
Postoperative Phase Advantages Clearly, there are some advantages as previ-
ously elucidated by Dr. Leavitt. In summary, the main advan-
Consultant responsibilities in the postoperative phase are as
tages are as follows:
important as they were at the initial consultation. Consultants
help to provide continuity of care for patients, remaining acces- ● More time available to spend during the consultation.
sible as liaisons in arranging appointments with doctors and This is possible because the consultant, unlike the physi-
nurses. If reassurance is needed, they are significant members cian, does not have to juggle time between consulting
of the patient support team. Consultants arrange follow-up visits and performing surgical procedures.
and are the first office personnel whom patients see after sur- ● More flexibility in scheduling the time of consultations
gery. The benefit for the physician is the ability to spend more
(i.e., anytime during the day, after hours, weekends).
quality time with the patient during that visit.
● More availability to answer future questions after the
initial interview. This availability gives a sense of com-
fort to the patient.
DISADVANTAGES OF NONMEDICAL ● Much of the basic information and many of the principles
CONSULTANTS of hair transplantation that need to be presented to the
There are several disadvantages in having a non-physician con- patients are repetitive and time consuming. A consultant
sultant in a hair restoration practice. Chief among these is that can accomplish this time-consuming task. This enables
the physician has potential liability for the consultant’s actions the physician to spend more time presenting the actual
and words. Anything a consultant says to a patient may have treatment plan.
repercussions on the office staff. Significant liability is inherent ● It is easier for a physician to communicate with an edu-
in a practice with a poorly trained or poorly managed consultant. cated patient. Thus, when the treatment plan is presented,
A system of checks and balances must ensure that there are no it can be done in a more efficient and timely manner.
errors in financial transactions. Moreover, it is difficult to find ● More time made available for the physician to spend
consultants who are dedicated to their patients and who adhere in surgery also allows more surgical slots to be made
to ethical standards. To be truly effective as practice members, available. This can lead to a more efficiently run and
they require thorough training—something that can consume financially successful practice.
176 Chapter 6
Disadvantages and Potential Problems Dr. Leavitt Only the last two options are ethical, however. Both still result
briefly addressed some of the disadvantages earlier, including: in a patient who has lost a degree of confidence in the clinic
liability, negative image, extra cost, and the difficulty in finding and its staff.
and training consultants who are ethical and who will live up The use of consultants does not have to result in the scenario
to high standards of medical care. My experience with the use just described. If consultants are used properly, the advantages
of nonmedical consultants has made me aware of additional without the disadvantages can be enjoyed. In summary, we must
problems that can occur. do the following:
It was emphasized by Dr. Leavitt that the primary role ● Ensure that consultants are used primarily to educate
of the consultant is to ‘‘educate rather than to diagnose or rather than to sell
present a treatment plan.’’ Unfortunately, consultants have ● Discourage incentive-based reimbursement of consult-
sometimes been used primarily for sales rather than education. ants
In this role, consultants often end up selling a patient on a ● Ensure that the physician is involved in the treatment
specific treatment plan without the involvement of the physi- plan before the day of surgery. (RS)
cian. This matter is made worse if consultants are on a
Second Editor’s Comment
commission-based salary as they then have more of an incen-
tive to make a sale than to give proper advice to patients. In a private communication in December 2002, Mangubat told
This is even more of a problem in a new clinic or one that a group of hair restoration surgeons that, for several years, he
had used ‘‘consultants’’ to carry out the initial interviews with
is not doing well financially. Physicians are inundated with the
patients. ‘‘The idea was to place considerable value in the phy-
concept of following the ‘‘Hippocratic Oath.’’ Their ultimate
sician’s time and to pass on the basic information about hair
responsibility is to provide ethical medical care. Although
restoration surgery (HRS) to the patient but not to diagnose
this is their livelihood, they are taught that proper medical or recommend treatment.’’ Unfortunately, he found that the
care comes before financial gain. It is my experience that counselors tended to ‘‘feel the power and play doctor’’ often
laypersons, especially those with a sales or business back- enough that they required constant surveillance and he had to
ground, have a more difficult time truly implementing this ‘‘pull in the reigns on a regular basis’’ even after they had
concept. several years of experience. This occurred with three different
Another problem with the use of a consultant is the poten- counselors. As Shapiro has already noted in the preceding com-
tial for a patient’s first contact with a physician to be on mentary, if the employee is unsupervised daily and is commis-
the day of surgery. This is more likely to occur with the sioned on sales, the potential for abuse increases appreciably.
use of a remote consultation office and in situation where Today, after 3 years without a counselor, Mangubat has elected
procedures are scheduled by consultants for surgeons who not to use them again despite all the usual advantages that Lea-
do not live locally. vitt and Shapiro have enumerated. He offers as one of the most
The combination of a consultant functioning primarily as compelling reasons for his decision the following comment:
a salesperson and a physician who is not involved in the Even today, I occasionally have patients coming back
treatment plan until the day of surgery is a formula for with misconceptions or expectations that they can
disaster. The physician, on seeing the patient for the first blame on my counselor. Perhaps they are true or
time, may not agree with the proposed treatment plan. He simply justification for asking for free surgery. Now
may feel for example that: that I do all my consultations, communication is
unquestioned and patient expectations and satisfaction
● The patient is a poor candidate or not a candidate at all are at an all-time high. I waste considerably less time
● The patient was left with unrealistic expectations trying to backtrack on the ‘well I was told by John’
● The patient was promised too many or too few grafts banter that is so unproductive. (WU)
● The patient would have benefited from a 1-year trial of
finasteride and/or minoxidil APPENDIX 6A
● The patient has medical issues that could alter the treat-
ment plan The following is a patient handout that Dr. Unger uses in his
Therefore, at this point, the physician may be put under practice to help educate the patient before the consultation.
pressure to proceed. After all, the patient has been looking Using an informational handout such as this helps ensure that
forward to the procedure for months. He may have taken all—important points are covered and makes the actual in-
leave from work or traveled long distances. The physician person consultation flow more easily. The information in this
handout is specific to Dr. Unger’s practice, and although the
who works for a large group may, for financial reasons, be
information in these types of handouts may vary from practice
put under pressure not to cancel.
to practice, the principle of using them remains the same.
None of the options available to the physician at this point
are appealing. The physician can make one the following
choices: PATIENT GENERAL INFORMATION ABOUT
HAIR TRANSPLANTATION
● Proceed with a surgical plan without totally believe in it
THE PRINCIPLE
● Cancel the surgery
● Spend a great deal of time re-educating and convincing Hair transplantation depends on the now well-established prin-
the patient to proceed with a different surgical plan ciple that transplanted hair follicles (roots moved from their
original location to another area) will behave as they did in hairs. (Some physicians refer to micrografts simply
their original site. For example, even in the most advanced cases as ‘‘follicular units.’’) These are placed into tiny
of common male pattern baldness (MPB), a horseshoe-shaped holes made with an ordinary hypodermic needle in
fringe of hair persists. Hair follicles moved from this hairy front of any larger grafts that may also be used, or
fringe (the donor area) to a bald area on the same patient’s scalp to fill in any hairless gaps between larger grafts or
(the recipient area), will take root and grow. Continuing hair previously transplanted micrografts. If the recipient
growth in such transplants has been observed since 1958, and area is totally bald, the follicular unit may be the
it is believed that it will continue to grow for the individual’s only type of graft used. However, in many patients,
lifetime. Many less common types of hair loss, in addition to some original hair is still present in the recipient
ordinary male pattern baldness (MPB), can be helped by this area; therefore, micrografts are usually employed
procedure. These include thinning hair in many women, scar- exclusively only for the hairline and the center of
ring from prior injuries or surgery, and a number of diseases the whorl of the crown. Micrografts are therefore
that sometimes cause hair loss. used for at least part of every session. They enable
patients to wear their hair in virtually any style,
THE PROCEDURE even combed straight back.
b. Donor tissue may also be sliced into narrow sec-
1. At the beginning of each session, the patient is given a
tions, each of which contains two or three follicular
mild tranquilizer (Valium) either orally or intrave-
units (lined up one behind the other like a row of
nously. This minimizes anxiety, reduces discomfort,
soldiers) and approximately three to five or five to
and helps to prevent or decrease any side effects that
eight hairs. These hairs are placed into slits made
might be caused by the anesthetic.
with blades of various sizes. Such ‘‘microslit’’ or
2. Hair in the donor area is clipped to a 2-mm length in
‘‘slit grafts’’ may be used in combination with mi-
one or two zones that are less than 12 mm (1/2 inch)
crografts in a 3⁄4⬙-wide to 1⬙-wide zone in front of
wide, and 10 mm to 25 cm (4⬙–10⬙) long. If the hair
larger grafts (as described later), to produce a natu-
in the donor area is left 11⁄2⬙ to 2⬙ long, the hair above
ral-looking hairline with gradually increasing den-
the donor sites completely camouflages these areas im-
sity or, alternately, they may be used for the entire
mediately after the procedure.
recipient area behind the hairline zone. The slit
3. The donor area and the recipient area are anesthetized
grafts are also used in areas such as the crown,
by injection of a local anesthetic with a very small gauge
which usually does not need to be transplanted
needle that is about the size of an acupuncture needle.
densely. Slit grafts are particularly appropriate for e
To reduce the sting when the local anesthetic is injected,
patients who want only medium-density coverage,
in addition to using a small-gauge needle, we neutralize
who already have or who will have very large bald
the pH of the anesthetic, which is stored in an acidic
areas, or who have relatively little hair in the donor
form. (The acidity is the main cause of the stinging the
areas; a limited supply of donor tissue can cover a
patient usually feels). Nitrous oxide (laughing gas) may
greater surface area because these smaller grafts
also be used simultaneously for particularly sensitive
produce a sprinkled type of hair growth that is far
or nervous people. Anesthetizing the area is the only
more natural-looking than the ‘‘pluggy’’ or ‘‘Bar-
part of the session that may cause discomfort, and, al-
bie-doll’’ look that may be produced by larger
though it may be hard to believe, many patients have
grafts. The finer the texture of your hair, the less
told us that the above technique usually causes less dis-
contrast between the color of your hair and skin,
comfort than they experience during a visit to their den-
and the more frizz or curl in your hair, the less
tist.
difference there will be between the apparent natu-
4. After the anesthetic has taken effect, a scalpel is used
ralness of follicular units and slit grafts (or, for
to cut narrow ‘‘strips’’ or ‘‘ellipses’’ of hair-bearing
that matter, even larger grafts). Slit grafts are also
scalp from the donor areas. (A similar method can also
advantageous for patients who have (or who will
be used to remove scars). This tissue is then divided
have) sparse temple hair. In the latter type of indi-
into a variety of graft sizes. In subsequent sessions, the
vidual, densely transplanted frontal hair would look
scars from the preceding sessions are excised as part of
unnatural.
the new donor strip. At no time will there be more than
c. ‘‘Round’’ grafts are actually square grafts that con-
two fine scars in the donor area of virtually all patients.
tain an average of 8 to 20 or more hairs, but that
5. Many types of grafts are now used in the recipient area.
are inserted into round holes made in the recipient
In general, the smaller the size of the graft used, the
area with a round ‘‘punch’’ that has a diameter of
less noticeable treatment will be postoperatively and in
1.5 mm to 3.5 mm. The holes are placed approxi-
between sessions. On the other hand, the smaller the
mately one graft apart, in a ‘‘checkerboard’’ fash-
graft, the less hair density will ultimately be achieved.
ion, to leave a surrounding blood supply. Four ses-
The following is a description of the types of grafts we
sions can solidly fill any area (see figure later).
employ:
Round grafts produce dense coverage in the most
a. ‘‘Micrografts’’ are obtained by slicing the donor efficient way. After four sessions, one can approxi-
tissue under magnification into very small sections; mate the normal donor area density of approxi-
each of these sections is composed of a single ‘‘fol- mately 220 or more hairs per cm2 — as opposed
licular unit,’’ which usually contains one to three to a maximum density of approximately 150 hairs
178 Chapter 6
per cm2 after four sessions of exclusive follicular 6. Grafts are held in place by coagulated blood. To keep
units or micrografts. However, if round grafts are them secure and properly oriented, a turbanlike bandage
used, they are always placed behind a zone com- is usually applied after the operation and left in place
posed of one or more of the smaller graft types overnight. The following day, the bandage is removed
described earlier. Because most patients do not and the area is cleansed. If the front half of your scalp is
have a large enough donor area, or because they being transplanted, if there is no more than the average
may (or may not) look pluggy between transplant- amount of bleeding during surgery, and if you are willing
ing sessions, round grafts are currently used in less to remain in the office for 1 to 2 hours after the procedure
than 10% of our patients. is completed, you can go home without a bandage. (Most
d. ‘‘Slot grafts’’ are similar to slit grafts in that they patients seem to prefer the security of an overnight band-
contain follicular units lined up behind each other age). Patients who prefer no bandage must book their ap-
like a row of soldiers, but in the case of slot grafts, pointments for mornings only. You should still return the
there are two side-by-side rows rather than a single next day for follow-up cleansing, hair washing, and a
row of soldiers and twice as many follicular units check-up.
as are present in a slit graft of comparable length.
These ‘‘fat’’ slit grafts are placed into a linear slot NUMBER OF TRANSPLANT PROCEDURES
made by a special slot punch. They can produce NEEDED
almost the same hair density as round grafts, but,
because they have a linear shape, they are usually Generally, the front third to half of a totally bald area can be com-
less easy to detect than round grafts during a series pleted with a single session if only micrografts are being used.
of treatments. Additional sessions are optional because the result of a single ses-
e. In general, micrografts and slit grafts produce more sion of micrografts perfectly natural. Further treatment is re-
natural-looking results than an equivalent amount quired only if more density is wanted. The same area will usually
of donor tissue transplanted as slot grafts or round need two to three sessions if micrografts, minigrafts, and slit
grafts. However, because no bald skin is actually grafts or slot grafts are being used, or three to three and one-half
removed (hair is only added), and because mi- sessions if round grafts are also being employed. As notedearlier,
crografts can rarely be transplanted even half as these types of grafts will produce more hair density than sessions
close together as they exist naturally in donor tis- of exclusive micrografts, but once a graft contains more than a
sue, micrografts and slit grafts do not ultimately single follicular unit, at least two sessions, and sometimes three
produce as high hair density as slot grafts and round sessions, are usually necessary to produce sufficiently natural-
grafts. looking results. The finer your hair texture, the curlier or frizzier
f. As noted earlier, this is an important but seldom your hair, and the less contrast between the color of your hair
mentioned drawback of treating patients with mi- and skin, the fewer sessions are required to create natural-looking
crografts only or with single follicular units. On results. If round grafts are also being used, the fourth ‘‘half-ses-
the other hand, ‘‘all-micrograft’’ sessions are ideal sion’’ is used to solidly fill the area started with round grafts;
for creating hairline zones, for treating completely therefore, even if the hair is wet or wind-blown, no plugginess
bald areas in individuals who are willing to do extra will be noticed. Sometimes this half-session can be done at the
sessions to achieve the density they want in return same time the midscalp or crown is being treated rather than as
for possibly less noticeability during treatment, or a completely separate procedure, and, many times, patients do
for those who are genuinely not interested in high not consider it necessary by because of the high hair density cre-
density. Slit grafts and micrografts are very advan- ated by three sessions of round grafts.
tageous in treating areas that have persisting hair; Transplant sessions may be done as far apart as the patient
for example, in patients who have relatively early wishes; however, they are not done in any given area without
MPB or female thinning. Slit and needle holes can a 6-week interval between the first two sessions, and a 4-month
be placed between existing hair and no hair is actu- interval between the following sessions. If entirely separate
ally removed as occurs during the making of a slot areas are being transplanted (e.g., the front and the crown),
or a round hole for slot grafts, minigrafts, and stan- sessions can be as close as 1 day apart. Although the typical
dard grafts. session done in our offices will result in the transplantation of
g. Each case must be considered on an individual basis. 2500 to 3750 hairs, the number of grafts that should be trans-
There are a number of factors that influence the deci- planted at one session, and the frequency of transplant sessions,
sions regarding which types of grafts will be used depend on the size of the graft used and the characteristics of
and where they will be placed. These factors include each individual’s hair texture, caliber, wave, color, and density.
the texture, color, and density of hair; the size of the It is becoming more common for patients to have one or
donor area; the size of the site to be transplanted; and two ‘‘early’’ transplanting sessions before hair loss has reached
the patient’s goals. In many individuals, a combina- an advanced stage. The benefit of these early sessions is three-
tion of two or more of the graft types will be used, fold: (a) the remaining hair provides natural camouflage for the
whereas in others, only micrografts will be used. initial session—not only for the immediate postsurgical period
You will be shown photographs of what you can ex- but also for the timeframe when grafts larger than 1 micrograft
pect from each type of graft. Despite claims to the might be noticeable. As long as additional sessions are done in
contrary, no one type of graft can provide ‘‘the best pace with the loss of the original hair, grafts containing more
of all worlds’’ for all patients. than one follicular unit are no more noticeable than micrografts
and will ultimately produce more density. (b) The transplanted injured (as each hair is closer to the edge of the graft), and thou-
hair (once it has grown) will persist, providing additional cover- sands of incisions in the scalp obviously will cut more blood ves-
age for any later sessions. (c) sessions can be spaced farther sels than hundreds of incisions. Moreover, the longer the tissue
apart, thus spreading the inconvenience and cost over a longer is out of the body, the greater the chance the hair follicles will be
period of time. damaged by improper temperature, handling, and dehydration.
In 10% to 20% of male patients, there may be some mild thin- Although most megasessions produce what appear to be ade-
ning involving the preexisting hair of the recipient area within quate yields, a minority produces very little hair. It is likely that
the first 2 to 3 weeks after a transplant. In women, the incidence is, there are many patients between those two extremes, who will
unfortunately, closer to 40% to 50%. This thinning (if it occurs) is grow hair, but less than they would have if a more conventional
always temporary, and the hair will regrow at the same time as approach had been used. In the May-June 1997 issue of Hair
the transplanted hair begins to sprout, or, often, earlier. Transplant Forum International, (the official publication of the
International Society of Hair Restoration Surgery), a foreign
TRANSPLANTING WITH ONLY ‘‘FOLLICULAR physician working in a California clinic that specialized in meg-
UNITS,’’ ‘‘MEGASESSIONS,’’ AND ‘‘DENSE asessions and dense-packing, reported that in his experience only
PACKING’’ OF GRAFTS 75% of the grafts transplanted in 1500 graft sessions had good
growth, and that in sessions of 2000 or more grafts, the number
As implied earlier, if you feel you would be satisfied with light dropped to 50%! He did not give his name because he feared he
to moderate hair density, you may want to consider using only would be fired for reporting this information. In the same issue
micrografts or follicular units for your transplant. There are of that journal, an American hair transplant surgeon reported on
four advantages to such an approach: a case of infection subsequent to a megasession that he believed
was caused by the size of the session and dense-packing, ‘‘About
1. Micrograft recipient sites cause the least damage to any
30% to 50% of the grafts appeared to be lost.’’ Exclusive follicu-
existing hair in the recipient area.
lar unit transplanting has been significantly improved over the
2. Micrografting produces the least amount of postopera-
last few years and hair survival rates have improved. Some clinics
tive crusting.
achieve better hair survival rates than others. However, reports in
3. Micrografts generally grow somewhat faster than other
the medical literature and at medical meetings suggest that lower
types of grafts.
survival of hair is more likely when large numbers of follicular
4. Micrografts—even in a totally bald area—produce ab-
units are densely packed together.
solutely no clumping or plugginess.
Patients often want to have as much done as quickly as possi-
In fairness, it should be pointed out that if slightly larger slit ble and are therefore anxious to believe a physician who tells
grafts are also used, damage to existing hair could also be them that there is no intrinsic problem with megasessions or
avoided. With most hair types, unless you part the hair and look dense-packing. Unfortunately, the possibility of lesser hair yield,
very closely, you won’t notice any clumping. In addition, it permanently, should be weighed against the temporary conve-
takes twice as long, for example, to prepare and insert 1500 nience of a faster result.
micrografts as to prepare and insert 750 minigrafts and slit grafts
that contain approximately the same number of hairs. As a result LASER HAIR TRANSPLANTING
of the extra time required, the ‘‘all-micrograft’’ approach is
more costly. It is, therefore, not generally used unless: a) the The first surgeons to use a laser in hair transplanting were Dr.
patient is less concerned about cost than he is about even slight Walter Unger and Dr. Larry David, working together in Los An-
and temporary tuftiness that might occur with the addition of geles in September 1992. The first medical publication on laser
slit grafts containing two or three micrografts; b) the recipient transplanting was written by Dr. Unger in 1993. Despite adver-
area is totally bald—in which case, even slight tuftiness might tisements and media reports suggesting that laser transplanting
be temporarily noticeable; or c) the patient feels that a somewhat produces superior results with less bleeding and pain, there is, in
lesser hair density than most patients want is an acceptable goal fact, currently, no laser available that will consistently produce
in return for essentially complete naturalness, even under very superior cosmetic results. In addition, less hair may grow in some
close inspection. patients. Laser manufacturers are still working on producing an
Transplanting the front third or so of a bald head in one or entirely satisfactory machine. As a result, Dr. Unger has, for the
two ‘‘megasessions’’ of 3000 or more micrografts per session time being, stopped doing laser hair transplants.
is possible but will typically require sessions of 10 to 12 hours
or longer. Moreover, such sessions will usually produce rela- WHAT TO EXPECT AFTER EACH SESSION
tively low hair density unless the grafts are ‘‘dense-packed’’
or repeated one, or even two, additional times. These operations A crust or scab will form over each graft shortly after the proce-
are also more physically and emotionally stressful than standard dure and will remain attached for several to 14 days. When the
transplanting sessions and should not be undertaken by anyone area is healed, the crusts will then separate from the scalp and fall
who isn’t in excellent physical condition. Practically speaking, off, leaving a clean, pinkish area to indicate the site of each graft.
therefore, megasessions of micrografts are best used in rela- Although these crusts are visible during the 1-week to 2-week
tively young and/or very fit patients. healing period, many patients can camouflage them by combing
A more serious possible consequence of megasessions com- the adjacent hair over the transplanted site. If a hairpiece is nor-
bined with dense-packing of micrografts—in order to create mally worn, it may be used to conceal the crusts after the first
higher hair densities per session—is lower survival rates of the week, keeping in mind that it should be worn as little as possible
transplanted hair. The smaller the graft, the more easily it can be until all of the crusts or scabs are gone. Slit grafts, round mini-
180 Chapter 6
grafts, and slot grafts are usually virtually undetectable within 7 ‘‘resting phase’’ when they were originally counted. After more
to 10 days. The holes made for micrografts disappear within a than 25,000 hair transplant sessions, we have never encountered
few days to a week. a patient who failed to grow hair.
The hairs in the transplanted grafts are shed between the sec- Within 1 to 6 months, the skin surface of the grafts will usually
ond and eighth week after the procedure. Sometimes they fall out blend in perfectly with the surrounding scalp. In some patients,
attached to the separating crusts; occasionally, they persist however, the grafts may be a shade lighter in color until they are
longer. Rarely, one or two of the transplanted follicles do not shed ‘‘aged’’ by sun exposure. The grafts are usually level with the
their hair at all, but continue to grow immediately after the proce- surrounding scalp, but a few may be slightly elevated in less than
dure. With these exceptions, the grafts are usually bare for a pe- 1% of patients. Such grafts are flattened down with an electric
riod of 10 to 14 weeks after the operation, during which time the needle without interfering with hair growth. Occasionally, a few
follicles recuperate to produce new hair. A new generation of hair grafts may also be slightly depressed. Surrounding skin can be
is usually visible at the surface of the scalp by the 12th week after cauterized to correct this, or the graft can be replaced with another
transplanting, but this may occur slightly earlier, or up to 8 weeks one. The original graft can be divided and re-used elsewhere in
later in a few patients. These hairs grow at the same rate as they the recipient area as micrografts.
did in their original location (usually 1⁄2⬙ per month). Micrografts, The final appearance is that of ‘‘early thinning,’’ which is
round grafts, slit grafts, and slot grafts usually show regrowth 2 not meant to imply ‘‘thin’’ hair, but rather to convey the idea
to 4 weeks earlier than ‘‘standard’’ grafts. that you cannot expect to look like you did as a teenager.
When a large area is transplanted, swelling of the forehead As patients age, the rim hair from which the grafts were
frequently occurs. Although this swelling is usually mild and taken gradually becomes less dense. Thus, transplanted areas
lasts only 2 to 4 days, it occasionally can be severe enough to will also thin somewhat. However, they will never go bald
cause a large amount of puffiness around the eyes, and approxi- again. In addition, as the hair goes gray with aging, it will look
mately 1 of 50 patients has swelling bad enough to cause ‘‘black thicker; therefore, any decreased density may or may not be
eyes.’’ Generally, the swelling begins 2 to 3 days after the noticeable. Because of this gradual thinning effect, you may
procedure and is most noticeable after the first session. With want to transplant the area a little more thickly to begin with,
subsequent treatments, it usually occurs in a milder form or not or, alternately, you may want to conserve some grafts for use,
at all. In view of this, if possible, it is advisable to schedule a perhaps in 15 to 20 years.
holiday to coincide with the first session. The swelling is always
SUMMARY
temporary and has no harmful effect on the healing grafts. An
intramuscular injection of a cortisone-type drug can usually be In summary, with the new techniques of micrografting or follic-
given at the time of the operation to help minimize swelling. ular unit grafting, slit grafting, slot grafting, and minigrafting,
Contrary to what many patients have been told, the scalp the hairline no longer appears as abrupt or dense as was the case
(hairy or bald) has an excellent blood supply. A certain amount years ago when only larger grafts were being used. Micrografts
of bleeding during the transplant procedure is expected and is create a very natural-looking hairline, enabling patients to wear
simply controlled by applying pressure. The donor area is their hair in virtually any style, including combing the hair
stitched closed to produce better scars and to minimize bleeding. straight back. Slit grafts create a more feathered, less tufty ap-
The stitches are normally removed 7 to 10 days later. pearance, thereby avoiding the ‘‘Barbie-doll’’ look that has
The nurses will wash your hair the day after surgery. You often been thought of as the hallmark of hair transplants. Mi-
may gently shampoo on the second day after transplanting. crografts and slit grafts also do not result in the removal of any
Patients from out of town are required to stay in town over- existing hair in the recipient area and are therefore advantageous
night after the transplant procedure so that any bandage can be for transplanting in patients with ‘‘early’’ MPB or female thin-
removed and the areas of surgery can be properly cleaned. They ning. Most women, in fact, can now consistently expect cosmet-
should not drive home themselves on the day of surgery because ically significant improvement compared with results that were
of the lingering effects of medications. achieved 10 years ago, when most women were not considered
Ingrown hairs are occasionally a temporary problem, begin- acceptable candidates for transplantation. Current techniques
ning 8 to 12 weeks after surgery, especially when micrografts have increased the proportion of patients who can be helped
and slit grafts are used, and especially if the hair tends to be by transplanting while at the same time producing far more
naturally curly. It is easily controlled, does not cause any perma- natural-looking results than those of the past.
nent damage, and does not occur in a majority of patients.
A temporary decrease in scalp sensitivity is always noted ALOPECIA REDUCTION (AR)
after transplanting because nerves are cut as donor grafts are It is strongly recommended that if the patient wants to have the
taken and recipient sites are prepared. Usually, this will correct frontal, midscalp and crown areas transplanted, an attempt
itself completely in 3 to 18 months as the nerves regenerate. should be made to decrease the size of the bald area with one or
Rarely, there may be permanent decreased sensitivity in one more ‘‘alopecia reduction’’ (AR) operations. ARs increase the
area or another. probability of being able to transplant the whole (reduced) area
before the supply of available donor grafts has been completely
FINAL RESULTS depleted. Essentially, a portion of bald or balding scalp is re-
moved, and the normal laxity of the scalp is used to close the re-
It is impossible to predict precisely how many hairs will appear sulting gap. A narrow scar is usually all that remains after the
in any given graft, but at least 90%, and often 100%, of them procedure. Within a few weeks, the scalp will become loose again
will survive transplanting. Not uncommonly, more hairs will and, often, the bald area may be further reduced by additional
grow than were planted because some were in an invisible ARs.
Although AR may sound rather frightening and painful, it hair. Cells are removed from the patient’s hair, and millions
is, in fact, a relatively simple procedure; in most patients, AR of similar cells can be reproduced within several weeks.These
produces no more discomfort than a transplant session. Not- cells, when injected into immunocompromised mice, can pro-
withstanding these facts, some patients have enough donor tis- duce hair. The ultimate objective is to inject them back into
sue to cover the whole bald area without the need for AR. the human donor in order to grow unlimited amounts of hair.
Clearance for human testing by the University of Toronto
‘‘CLONING’’ HAIR Ethics Committee was obtained in October of 2000, and
studies began in late spring of 2001. It is likely that at least
Since 1998, Dr. Unger has co-directed studies at the Univer- 2 to 5 years of experimentation will be necessary to perfect
sity of Toronto on what is popularly called ‘‘cloning’’ of the technique.
182 Chapter 6
APPENDIX 6B
APPENDIX 6C
184 Chapter 6
APPENDIX 6D
186 Chapter 6
APPENDIX 6E
188 Chapter 6
REFERENCES 10. Vallis CP. Hair transplantation In:. Goldwyn RM, ed. The Unfa-
vorable Results in Plastic Surgery. Boston: Little, Brown, 1972:
My Personal Approach to the Interview 397.
11. Bolinger A. Patterns of diffusion through skin capillaries in pa-
1. Cassileth. Informed consent—why are its goals imperfectly real- tients with long-term diabetes. N Engl J Med 1982; 307:
ized. N Engl J Med 1980; 302:896–902. 1305–1314.
2. Cash T. The psychological effects of androgenetic alopecia. J Am 12. Knudsen R, Stough D. Editors’ message. Hair Transplant Forum
Acad Dermatol 1992; 2:926–931. International 2001; 11:99.
3. Alt T. Hair transplantation and scalp reduction. In:. Coleman III
W, Hanke CW, Alt T, eds. Cosmetic Surgery of the Skin:. Phila- Patient Expectations and Surgical Options Based on
delphia: BC Decker, 1991:102–146.
4. Coleman III W. A visit to the office of Dr. Emanuel Marritt. J
Age, Ethnicity, and Sex
Dermatol Surg Oncol 1993:664–668. 1. Cole J. A calculated look at the donor area. HT Forum Int 2001;
5. American Psychiatric Association. Diagnostic and Statistical 11:150–154.
Manual of Mental Disorders (DSM-IV). 4th ed.. Washington D
C: American Psychiatric Association, 1994.
6. Cotterill JA, Cunliffe WJ. Suicide in dermatological patients. Br Non-Physician Interviews: Advantages/
J Dermatol 1997; 137:246–250. Disadvantages and Ethical Control
7. Dufresne RB. A screening questionnaire for body dysmorphic
disorder. Cosmetic dermatologic surgery practice. Dermatol Surg 1. Orentreich N. Autografts in Alopecias and other selected derma-
2001; 27:5. tological conditions. Ann N Y Acad. Sci 1959; 83:463–479.
8. Devine J, Howard P. Classification of donor hair in MPB and 2. 1999–2000 Membership Directory of the International Society
operations for each type. Fac Plast Surg 1985; 2:189–191. of Hair Restoration Surgeons.
9. Unger WP. Surgical approach to hair loss In:. Olsen E, ed. Disor- 3. Leavitt M. Patient Services Survey (Postconsultation, conducted
ders of Hair Growth. New York: McGraw-Hill, 1994:353–374. nationally). Maitland. FL: Medical Hair Restoration, 1997–1999.
7
Preoperative Phase
7A. Preoperative Preparation and drug prescribing practices before, during, and after routine hair
transplantation surgery (HTS). Acetylsalicylic acid (ASA) and
Instructions nonsteroidal anti-inflammatory drugs (NSAIDs) were restricted
Walter P. Unger by all of them for 3 to 21 days (mean 10 days); alcohol was
restricted by 93% of them for 2 to 24 days (mean 7 days) and
anticoagulants for 3 to 14 days (mean 7 days). In addition, 79%
COORDINATION OF PREOPERATIVE EVENTS
of the surgeon’s restricted vitamin E intake for 4 to 21 days
AND DISSEMINATION OF INFORMATION (mean 10 days) and 29% of them restricted specific foods and
Preoperative Check List spices for 2 to 21 days (mean 7 days) before surgery.
The authors then reviewed the literature to see whether these
A number of preoperative events should occur to help ensure practices were based on reported scientific evidence and con-
a smooth and successful hair transplant procedure. It is helpful cluded that they were not. In a commentary on that article, I
to delegate a specific staff member to be a patient coordinator pointed out that anecdotal evidence accumulated for 30 years by
and to make sure no steps are overlooked. A preoperative check- practitioners of hair restoration surgery (HRS) did not constitute
list attached to the chart and reviewed by the patient coordinator scientific support for these practices. Nevertheless, good theo-
is a useful tool (Appendix 7A). retical reasons existed for many of these practices; therefore,
some or all of them might be worthwhile, even though they
Preoperative Package were not yet confirmed by proper studies. Such studies are
certainly needed and we can hope they will be done some day. A
Once the patient has been scheduled, many practices send out summary of the rationale and my views on some of the common
a preoperative package that includes: a written confirmation of current recommendations are discussed in the next sections of
the time and date of the procedure (Appendix 7B), a map with this chapter.
directions to the clinic, laboratory requisition forms, and preop-
erative instructions. The preoperative instructions I use in my
practice are provided at the end of the chapter (Appendix 7C). Acetylsalicylic Acid and Nonsteroidal Anti-
Some physicians also send the postoperative instructions and inflammatories
the preoperative consent form with this package so the patient
has time to review them adequately before surgery. We send ASA irreversibly inhibits cyclooxygenase, which in turn inhib-
this package to our patients 10 weeks before the date of surgery. its thromboxane synthesis (2). Thromboxane enhances platelet
Again, it is helpful to delegate a patient coordinator to make activation and the production of platelet products. Because
sure the patient receives all the preoperative materials and to ASA’s effect on platelet function is irreversible, its effect lasts
make sure laboratory tests are received and reviewed in a timely for the lifetime of the platelet or approximately 7 to 10 days.
manner. NSAIDS also inhibit cyclooxygenase, but their action is reversi-
ble and is dependent on the presence of the circulating drug
and therefore its half-life. For example, because ibuprofen has
PREOPERATIVE MEDICATIONS AND a short half-life, it need only be discontinued on the day of
SUBSTANCES TO BE AVOIDED surgery, whereas other NSAIDs with longer half lives must be
avoided for somewhat longer times. Has this theoretical basis
In 1995, Langtry and colleagues (1) reported on the preoperative for discontinuing ASA and NSAIDS been proved necessary in
instructions of 14 leading hair restoration surgeons from the clinical studies? The answer so far appears to be no for skin
United States and Canada with regard to dietary restrictions and surgery. Otley and associates (3) retrospectively studied the
189
190 Chapter 7
complication rate in 653 patients who were taking platelet inhib- fatty acids, garlic, and monosodium glutamate (often used in
itors at the time they underwent Moh’s micrographic surgery. Chinese food). It is hard to know where to start or end with
These investigators concluded that surgical complications were food and vitamin restrictions. At one time, I provided a list of
not significantly reduced by the brief perioperative discontinua- foods containing the aforementioned vitamins and substances
tion of the platelet inhibitors. However, it is difficult to compare and asked patients to avoid them for 3 weeks before surgery.
the usual skin excisions and Moh’s surgery with HTS, which The resulting diet proved to be very difficult to follow and
requires hundreds, if not thousands, of small incisions. In addi- seemed to be more effective in causing weight loss than in
tion, there is no doubt that ASA ingestion can cause increased achieving consistent reduction in bleeding. In addition, I noticed
bleeding for up to 10 days after it is discontinued (4). Very that after I started using a 1:50,000 epinephrine solution in the
small grafts and closely placed recipient sites increase the risk of recipient area (see Chapter 8), excessive bleeding was uncom-
excessive bleeding, which is dangerous to hair survival because mon whether or not the dietary restrictions had been followed.
‘‘popping’’ prolongs the surgery and the grafts may require As a result, I have eliminated instructions on diet and simply
extra handling. Thus, in my opinion, discontinuing ASA for 7 ask patients not to take vitamin supplements or herbal prepara-
to 10 days and NSAIDS for 12 to 24 hours before HTS seems tions for 3 weeks before surgery. I do not recommend vitamin-
justified until studies are available to prove otherwise. The sur- mineral supplements as a method of enhancing results. How-
geon and patient should also be aware of the ingredients in ever, patients who are inclined to take vitamins are advised that
over-the-counter medications the patient is taking, because on a theoretical basis, there may be some benefit from taking
these drugs may contain ASA or NSAIDS. Appendix 7C lists vitamin C and E postoperatively.
common over-the-counter preparations that contain ASA, ibu-
profen and naproxen—two of the most popular NSAIDS—as
well as some of the medications that contain them. This list Warfarin
can be sent to patients in the preoperative instruction package. Warfarin (Coumadin) interferes with the production of vitamin
K-dependent clotting factors II, VII, IX, and X by depleting
Alcohol the reduced form of vitamin K. It is widely used in North Amer-
ica and should not be discontinued without consulting the pre-
With the large number of elective surgeries performed today, scribing physician. (Duration of action is 2 to 5 days.) Surpris-
clinical studies are needed to compare the bleeding rates, during ingly, a number of practitioners have carried out hair transplants
and after surgery in patients who have consumed a moderate on patients who did not discontinue their warfarin and have
amount of alcohol and those who have practiced complete absti- reported acceptable levels of intraoperative and postoperative
nence preoperatively. On the other hand, chronic heavy con-
bleeding. My own experience (one patient) with this approach
sumption and acute alcohol intoxication have been shown to
was that there was less than the usual amount of bleeding. Both
prolong the bleeding time and impair platelet function. In one
donor and recipient areas were infiltrated intradermally with 1:
prospective study involving 30 patients undergoing elective sur-
50,000 epinephrine and I waited a full 15 minutes before incis-
gery of the colon or rectum, there was an increased frequency
ing in those areas. Alternativeely, if you and the patient’s gen-
of complications, including excessive bleeding, in the heavy
eral physician agree to discontinue warfarin, the patient can be
drinkers (5). Bleeding times returned to normal after 7 days.
switched to long-acting heparin (Lovenox) 6 days before sur-
Again, it seems wise to request the avoidance of alcohol for 7
gery. A typical dose is 1 mg/kg every 12 hours or 30 mg every
days preoperatively until this recommendation is proved to be
12 hours for more moderate anticoagulation—for example, as
unnecessary.
used for atrial fibrillation. The last dose of heparin is given on
the morning of the day before surgery and restarted as soon
Vitamins and Foods after surgery as you and the patient’s managing physician deem
appropriate. I usually try to wait for 36 hours after surgery.
Nelson’s section later in this chapter, (Conventional and Non-
The warfarin is restarted at the same time as the heparin is
conventional Medications in Hair Transplantation) discusses
discontinued. It is worth repeating that the doctor responsible
this topic in greater detail and contains tables listing conven-
for the individual’s general medical care should be the one to
tional medications as well as herbal supplements that may affect
bleeding times. decide whether the surgery is safe for the patient and what
Vitamin E and vitamin E quinone inhibit platelet aggregation anticoagulation management is appropriate.
as well as other coagulation factors for as long as 3 weeks
(5–7). Many surgeons therefore recommend that these vitamins Nicotine
be discontinued for 3 weeks before surgery, despite the absence
of clinical studies confirming the theoretical advantage of doing Because nicotine decreases circulation, McGillis and others
so. Vitamin B complex and niacin also appear to increase bleed- (10) recommend discontinuing smoking for several weeks be-
ing if they are ingested during the week before surgery, but, fore surgery, if at all possible. Unfortunately, patients who
again, clinical studies are lacking. Foods high in these vitamins smoke heavily rarely find this possible. To the contrary, we
include green leafy vegetables (e.g., lettuce, spinach, water- have learned to sometimes allow heavy smokers to ‘‘take a
cress), egg yolk, mayonnaise, margarine, peanut butter, corn cigarette break’’ in the middle of surgery. Many of these indi-
oil, and other vegetable oils. A variety of other foods and food viduals seem to bleed excessively if this is not done and show
additives have also been associated with postoperative bleeding a remarkable decrease in bleeding if they are given these
as a result of reductions in platelet counts or platelet inhibition. ‘‘smoking breaks’’. We and others do, however, ask all smokers
These include eicosapentanoic acid (8,9), fish rich in omega-3 to try to reduce their smoking as much as they can (11,12).
Preoperative Phase 191
Other Medications with Potential Adverse have none. The medication, however, usually is harmless (it
Interactions with Drugs Commonly Used in Hair may sometimes cause gastrointestinal upset, edema, and taste
Transplantation Surgery changes) and does seem to help many patients.
There are a number of medications that are commonly used

Antibiotics
during HTS. These include: epinephrine, prednisone, and local
anesthetics such as lidocaine or bupivacaine (Marcaine), antibi- The use of antibiotics prophylactically for elective surgery re-
otics such as cephalexin (Keflex) or erythromycin and analge- mains a subject of continuing debate. My views are presented
sics such as hydrocodone/acetominophen (Vicodin) or ibupro- here. Resolution of the issue is complicated because many of
fen (Motrin). There is the potential for these drugs to interact the studies reporting the effects of prophylactic antibiotics have
with medications the patient may be taking at home. Some of not been appropriately designed. One review, for example,
these interactions are mild, whereas others are potentially seri- noted that of 131 published articles surveyed, only 24 were
ous. Patients are asked to notify the surgeon of any medications thought to be designed satisfactorily (15).
they will be taking at the time of the procedure so that they It has been shown that antibiotics produce a maximum de-
may be discontinued, if necessary. In general, all tranquilizers, gree of suppression of infection if they are given before bacteria
antihistamines, monoamine oxidase (MAO) inhibitors such as gain access to tissue; that is, if they are administered before
tranylcypromine (Parnate), isocarboxazid (Marplan), and nia- surgery (16). In addition, prophylaxis for longer than 3 days
lamide (Niamid), and phenothiazines, such as chlorpromazine seems to be unnecessary and may also be counterproductive
(Thorazine), promazine, (Sparine), thioridazine (Mellaril), tri- (15). I began using perioperative prophylactic oral erythromy-
fluoperazine (Stelazine), promethazine (Phenergan), perphena- cin stearate (250 mg, four times daily, commencing 48 hours
zine (Trilafon), prochlorperazine (Compazine), trimeprazine before treatment and continued for 5 days afterward) 27 years
(Temaril), and propiomazine (Largon) should be discontinued ago. The incidence of infection in the recipient area decreased
1 week before surgery. It would be prudent for the patient to to 0.1% from a level of approximately 0.5%. Twelve years ago,
consult with the prescribing physician before discontinuing a the dosage was changed to 333 mg of erythromycin (PCE) three
routine medication to avoid a potential withdrawal effect. In times daily, starting either the night before surgery or 2 hours
particular, the combination of MAO inhibitors and lidocaine before surgery and continued for 3 days after the operation. For
has been responsible for fatalities (13). Inderal, which is a 13- the last 7 years, we have been using cefadroxil (Duricef), 1
adrenergic receptor blocking agent, and epinephrine together gm, and then, in the last year, cefdinir (Omnicef), 300 mg,
may also result in a life-threatening reaction and should not be preoperatively. The advisability of administering a second simi-
used for 1 week before surgery. A mixture of these two drugs lar dose 6 hours later is more controversial but may be appropri-
can ultimately lead to cardiac arrest or a hypertensive cerebral ate for the unique field of HTS. We have, therefore, adopted
vascular accident. This has not been reported in HTS; is it, this approach.
therefore, necessary to discontinue the antipsychotic? Such a It may be argued that infection after hair transplanting is
reaction did occur in a patient taking propranolol, 60 mg/day, extremely rare, even without prophylactic treatment. I suspect
in whom only 8 mL of lidocaine with 1:200,000 epinephrine it is higher than it is generally thought to be. One survey in the
was used (14). early 1980s reported that more than one third of physicians
Puig has created a table (Appendix 7D) containing a list of experienced infection rates of 1% or more (17). A later study
medications that may interact with drugs commonly employed involving 2375 cases of class I surgery showed a 1% infection
during HTS. In addition, the Internet and commonly used hand- rate (18). Class I types of surgery include all those with full-
held computers now have easily accessible programs that enable thickness penetration of skin and subcutaneous tissue, without
a physician to enter the medications patients are taking and any form of contamination from within the body. Procedures
check for potential adverse interactions. Examples include such as skin excisions, skin grafts, flaps, alopecia reductions,
PDR.net, ‘‘PDR for Palm’’, and Pocartes Rx for PDAs (per- and hair transplanting qualify for this designation. Also, a 1%
sonal digital assistants), which use PALM operating systems. to 16% infection rate was reported in patients with clean and
clean-contaminated wounds, depending on patient risk factors
(19). Finally, in a study of 47,054 patients undergoing so-called
PREOPERATIVE MEDICATIONS SOMETIMES clean procedures (no break in technique, no trauma, no infec-
USED IN HAIR RESTORATION SURGERY tion), a 1.5% infection rate has been reported (20). Hair trans-
Vitamin K planting would fall into this category of clean procedures, and
our infection rate of what currently appears to be zero suggests
Vitamin K is normally present in adequate amounts in healthy that perioperative prophylactic antibiotics, as described, are use-
individuals. In addition, no scientific study has yet proven its ful. Unfortunately, all of the previously noted studies (18–20)
effectiveness in decreasing surgical bleeding. Nevertheless, it also included patients with underlying health problems such as
is widely used prophylactically to minimize operative and post- diabetes mellitus, connective tissue disease, and malignancies
operative bleeding in plastic surgery and ophthalmological sur- and may not have fairly represented the infection rate of cuta-
gery as well as for liver biopsies. Some physicians have used neous surgery on healthy people. More importantly, however,
it routinely for hair transplanting (1,6). We recommend vitamin Bencini and colleagues (21), in a controlled prospective study
K, 5 mg, three times daily, beginning 1 week before surgery of 2165 outpatients, found a lower infection rate in those
only for persons in whom we encounter excessive bleeding undergoing excision of a variety of noninfected skin lesions
during the first session. Sometimes, vitamin K appears to have who were given prophylactic antibiotics. It appears that no blan-
a profound effect, whereas on other occasions, it appears to ket-rule will be forthcoming. Prophylactic antibiotics are almost
192 Chapter 7
certainly useful in certain types of surgery (e.g., abdominal and dizziness, nausea, gastrointestinal pain, and fluid reten-
vaginal hysterectomies). Prophylaxis may also be useful in pation—which may cause elevation of blood pressure. More in-
tients who are more highly susceptible to infection but not in formation should be available for patients from hemophilia so-
those who are generally healthy. As far as hair transplanting is cieties.
specifically concerned, however, the question is still unre-
solved. Shiell and most Australian hair restoration surgeons,
Systemic Corticosteroids
for example, have not used prophylactic antibiotics for many
years and claim infection rates as low as for those who do use Most hair restoration surgeons administer systemic corticoste-
them. On the other hand, those who have employed antibiotics roids to their patients, during or after surgery, in an effort to
remain reluctant to ‘‘argue with success’’ by discontinuing the decrease the possibility of severe postoperative facial edema.
practice. The effectiveness of this preventive measure varies with the
Patients who do not tolerate, or are allergic to, cefdinir may timing as well as the type and amounts of medication used; it
be given alternative medications such as trimethoprim-sulfa- also varies from patient to patient. Currently, I ask my patients
methoxazole (Septra DS), two tablets, 2 hours before surgery; to take 60 mg of prednisone orally on the morning of their
particle-coated erythromycin, 666 mg (with food), 2 hours be- surgery, or administer 8 mg of dexamethasone (Decadron) intra-
fore surgery; or clindamycin, 600 mg (with food), 2 hours venously at the beginning of surgery. I prescribe another 60
before surgery. It is worthwhile emphasizing that whichever mg of oral prednisone for the morning after surgery. Thereafter,
antibiotic is used, if it is begun after surgery rather than patients use a dose-pak of prednisone, starting with 30 mg the
preoperatively, it will be ineffective for the prevention of infec- second morning after surgery and tapering off at the rate of 5
tion and may, in fact, complicate the treatment of infection, if mg less each subsequent day. In the past, I used lower doses
it should occur. Whether or not antibiotics are used, all agree and started with 8 mg of intramuscular depo-medrol (22). I
that donor and recipient sites should be shampooed the night added preoperative prednisone or Decadron after listening to
before and the morning of surgery. Any shampoo product ap- Jerry Cooley at two meetings where he discussed the phenome-
pears to be satisfactory. non of ischemia reperfusion injury (IRI) (23,24). Hair follicles,
Patients with mitral valve prolapse who have a significant like other tissues, are subject to relative ischemia from the time
murmur should be treated like patients with other forms of car- they are excised from the donor area until at least the time they
diac valvular disease that require endocarditis prophylaxis. Dr. are implanted at their recipient sites. When ischemic tissue is
John Karl Randall discusses endocarditis prophylaxis and the reperfused with oxygenated blood, a biochemical cascade is
controversy surrounding use of preoperative antibiotics in more initiated that results in the formation of free radicals, which can
detail later in this chapter (see Prophylactic Antibiotics). cause cellular injury (25,26). Cooley has suggested that just as
in other instances of IRI, perioperative corticosteroids—that
is, corticosteroids before as well as after hair transplant sur-
Nocturnal Sedation gery—may reduce IRI. They are even more likely to reduce
If patients require nocturnal sedation, you should be familiar postoperative edema. Such edema is almost certainly caused,
with the drug and dosage used. Patients in my practice are given at least in part, by the same injurious free radicals.
diazepam orally for anxiety, 5 mg to 10 mg, the night before
surgery and are asked to get at least 8 hours of sleep.
LABORATORY TESTS
Von Willebrand’s Factor Deficiency Preoperative laboratory testing is also an area of controversy
in hair transplantation. Harris and Shapiro discuss this subject
If your patient has a history of excessive bleeding, during or in greater detail later in this chapter (Occupational Safety and
after prior surgeries with you or others, the possibility of a Health Administration [OSHA] and Laboratory Screening). I
bleeding disorder such as Von Willebrand’s disease or a factor discuss my views and practices here. We routinely order a com-
VIII deficiency should be considered. If investigation reveals plete hemogram, urinalysis with microscopic examination, Ve-
a deficiency of either of the latter two factors, the use of desmo- nereal Disease Research Laboratory (VDRL) screen, and hepa-
pressin preoperatively may prove very helpful. Desmopressin titis B and C profile. In addition, all patients are tested for human
is a drug that stimulates the release of factor VIII and Von immunodeficiency virus (HIV) infection. Patients’ results are
Willebrand factor from the body’s storage sites. It is used for identified by a number, and the results of their HIV tests remain
patients with mild or moderate hemophilia AA and for some confidential. If I or any of my assistants are accidentally injured
platelet disorders. It may prevent bleeding or help to control by a used instrument, prophylactic treatments can be started
ongoing bleeding. To confirm the effectiveness of desmopres- immediately, without waiting for the results of HIV testing or
sin, responsive testing is carried out before and after the first the patient’s permission to perform this test. The drugs used
time the drug is employed. Typically, desmopressin, 0.03 mg/ for treating HIV exposure have potentially serious side effects,
kg, is administered 30 to 60 minutes before the patient goes to and these drugs should be avoided if they are not absolutely
the dentist or has surgery, in one of three ways: intravenously necessary. Elective surgery in HIV-positive individuals is, in
over 20 to 30 minutes (DDAVP), subcutaneously (Octostim) my opinion, very unwise because it exposes immunocompro-
or via a nasal spray (Octostim Spray or Stimate). The latter mised patients to unnecessary risks. Any HIV patients who de-
two routes allow patient self-administration. Maximum effects cide to go ahead with transplanting, despite being given this
occur 1 hour after administration, with some benefit lasting for 8 advice, are asked to get a signed letter from their primary care
to 12 hours. Side effects include flushing of the face, headaches, physician. The letter should state that, in the physician’s opin-
ion, it is medically safe for these individuals to proceed with INFORMED CONSENT
hair transplanting.
We discontinued routine testing for bleeding time, prothrom- Most hair restoration surgeons have their patients sign an in-
bin time, and thromboplastin time approximately 6 years ago formed consent agreement before operating on them. Its pur-
because, in nearly 12 years of ordering such tests, abnormal pose is to confirm an agreement between the physician and
results were found in only one patient who had not forewarned patient that a full discussion of possible treatments and compli-
us of a tendency to increased bleeding or a bleeding diathesis. cations has taken place. Some would say that it also explicitly
(He had intentionally withheld a history of a minor type of confirms a discussion of a) the possible results of not having
hemophilia because he was afraid, correctly, that he would not treatment or certain types of treatments, for example, alopecia
be accepted for surgery). reductions or grafts larger than one follicular unit (defined in
Given the increasing incidence and serious consequences of Chapter 5) and b) all potential complications, even if they are
hepatitis B and C infection, it would be wise for all doctors and rare, if that complication could have serious consequences. Un-
medical staff who engage in surgery to immunize themselves fortunately, far more time than is normally devoted to a discus-
against hepatitis B, and, as indicated, routinely screen for hepa- sion of the procedure would be necessary to completely satisfy
titis C. Prompt identification of patients who test positively can all of the above objectives. Moreover, frequently the patient’s
be potentially life-saving. The medicolegal ramifications of the intelligence or language skills or emotional stability can com-
promise the legality of even a theoretically complete disclosure.
foregoing considerations vary from one locality to another, and
An informed consent signed by a patient with Body Dysmorphic
readers should familiarize themselves with the laws in their
Disorder (BDD), for example, may not be legally binding (see
area. The approach just described is not intended to represent
Chapter 6). Perhaps it is useful to decide what the purpose of
the standard of care in all geographic areas. If your patient is
an informed consent should not be. In my view, it should not
hepatitis C positive, over 70% will also be positive for hepatitis
be a list of all possibilities with the pros and cons elaborated
A or B or both—only 28.6% have neither—according to a
upon, but lacking any guidance as to what in your opinion is
study of 341 hepatitis-C patients, which was published in Janu-
the best, second best, and maybe third best options—and your
ary 2000 (27). Hepatitis C (like hepatitis B) is potentially a very
reasons for these recommendations. Furthermore, an informed
serious disease. Infection becomes chronic in 50% to 90% of consent should not be a list of all complications, whose purpose
cases and can lead to cirrhosis, hepatocellular cancer and death. is only a way of saying: ‘‘I told you everything, so if anything
The prognosis becomes worse if the patient also is or becomes goes wrong with the choices you made, it will be your fault,
infected with hepatitis A. In the latter situation, 41% develop not mine.’’
fulminant liver failure and 35% die. An excellent review of What I want from any physician—or any lawyer or accoun-
hepatitis C and its management has recently been published and tant for that matter—with whom I consult, is the answer to the
is recommended (28). questions: what would you do if you were in my place and
why? The latter should be in easy to understand language. It
should, however, be recognized that in a multi-racial, multi-
HAIR LENGTH AND STYLING cultural society, the interpretation of what you say to your pa-
tient may or may not be what you intended; not only may the
Patients should be advised to let their hair grow long enough words not be fully understood, the complexity of the concepts
(4 cm or longer) to fully cover the donor site with adjacent may not be fully understood either. Nevertheless, if you are
hair immediately after surgery. Some hairstylists disregard their knowledgeable and honestly convey to your patients what you
client’s request and, for that reason, patients should avoid get- would do if you were in their place, you will never question
ting their hair cut for two or three weeks before surgery. Because yourself as to why you did not recommend one course over
suturing of the donor area minimizes the potential effect of this another. Should you find yourself in a court of law some day,
problem dramatically, it is rare for any noticeable defect to be those who judge you will hopefully sense this.
present, even immediately postoperatively, and even in those One other thing an informed consent should not do is to
whose hair density is not optimal. Clearly, care should be taken provide you with an excuse for operating on someone because
to avoid trimming more of the donor area than will be harvested you have decided that if you don’t operate ‘‘someone else will’’.
to further minimize the risk of exposing the donor site postoper- This may, in fact, be part of the reason you decide to operate
atively. but it should never be the entire reason. You must always feel
Patients should also consider the possibility of combing their you are capable of achieving the patient’s goals even if they
hair from untreated areas over the recipient area if they are don’t want to follow your advice about what you would do in
particularly concerned about others knowing about their sur- their place. Elsewhere in this text, I will discuss patients who
gery. Hair must sometimes be allowed to grow quite long on were pressured by me into more conservative objectives than
one side of the scalp to accomplish this with any degree of they really had in mind, and who I subsequently felt obligated
success. Most men, of course, are reluctant to do this, as it to treat again because they were ‘‘pleased’’ but ‘‘not happy’’
might be considered as a very obvious and artificial effort to about not achieving their original objectives. I believe our re-
hide ‘‘something’’. It can, however, be used to great advantage sponsibility is to advise and give the reasons for that advice,
to partially or completely cover the recipient area during the but not to coerce patients into choosing what we want them to
somewhat unsightly immediate postoperative period. As a re- choose. This is not to say that if you feel the right course is no
sult, some men will, all the same, utilize this styling ‘‘trick’’ surgery, or no surgery at that time, that you operate all the same.
while women usually have no difficulty in adjusting hair styling It is simply recognition that different people have different
to accommodate such an objective (See Chapter 12H). goals. If you believe that your patient fully understands the
194 Chapter 7
consequences of his/her goals and that you can achieve them, prevent hair loss may be due to its vasodilatory effect. For this
then not operating or, for example, agreeing to transplant only very reason, many surgeons suggest that minoxidil be discontin-
a relatively high hairline with deep recessions, may not neces- ued before surgery to minimize intraoperative bleeding. (6,7)
sarily be the ethically superior course of action. On the other hand, because of its vasodilatory effect, minoxidil
Finally, unfortunately, there are some individuals who will should theoretically minimize the ‘‘shock’’ phenomenon that
sue a doctor simply because it costs them nothing to do so, and/ can affect the newly transplanted grafts. This so-called shock,
or because they feel the doctor or his insurance company will or postsurgical temporary loss of hair from the grafts, is thought
pay them something just to avoid the cost and aggravation of by some to result partially from surgical interruption of blood
going to court. It would be nice to reserve the right to counter- supply during graft preparation. This same shock phenomenon
sue patients who would engage in such frivolous lawsuits. One can also affect the preexisting hairs of a partially alopecic recipi-
mechanism that may give you the right to do so is to include ent area. If too many recipient site incisions are created between
in the consent agreement, a sentence that commits the patient these hairs, there is a theoretical compromise of their blood
to seek another expert opinion about what you have done, before supply as well.
consulting with an attorney about suing you for malpractice. One would assume the most logical approach would be to
Most patients do not consult with another expert before being minimize the duration of vascular compromise and maximize
instructed to do so by the lawyer they retain. If this is the case, the duration of vascular dilatation. If one follows this logic, a
and if you have included the above sentence in your consent patient should use minoxidil right up to the time of surgery and
form, you may be able to sue the patient for ‘‘breach of con- resume its use after surgery as soon as the skin can tolerate its
tract.’’ A frivolous suit may be dropped if the patient realizes application. The critical question then becomes, ‘‘Does preoper-
he has potentially something to lose instead of only possibly ative application of minoxidil cause significant intraoperative
something to gain. As laws change from time to time, and are bleeding?’’ More specifically, ‘‘Do the benefits of minoxidil
different in different localities, this suggestion may or may not outweigh its potential?’’ Although an actual paired comparison
be applicable to your situation and you may want to discuss it study has not been performed, it is my personal experience that
with an attorney. Appendix 7E contains the consent form I use adequate hemostasis is quite easy to produce using standard
in my office. accepted measures, in spite of using minoxidil right up the day
of surgery. In our practice, we use a 2% solution of minoxidil
and instruct patients to stop it 2 days before surgery and resume
it 4 to 5 days after surgery. There are many who would disagree
7B. Additional Comments on with this position, and, unfortunately, conclusive studies do not
Preoperative Preparation exist.
Bernard H. Cohen
PREOPERATIVE MEDICATION FOR PAIN AND

Preoperative preparation can be handled differently by various
physicians. Dr Cohen comments on some of the aspects of the ANXIETY CONTROL
preoperative preparation of his patients in this section, empha- How, and to what degree, patients are preoperatively sedated,
sizing and elaborating on some of the areas previously discussed varies widely from one practitioner to another. When patients
by Dr Unger as well as addressing new areas. have scheduled their surgery, it is our practice to provide both
preoperative and postoperative instructions along with prescrip-
tions for alprazolam (Xanax), 0.25 mg, and vitamin K (Mephy-
MEDICATIONS AND CHEMICALS TO BE ton), 5 mg. Alprazolam can help overcome sleeplessness stem-
AVOIDED ming from an unfamiliar hotel environment or anticipation of
I would like to reemphasize a few points with respect to poten- surgery. We order postoperative medications in the patient’s
tial drug interactions. Interaction of epinephrine with mono- name, several days before the surgery from a local pharmacy,
amine oxidase (MAO) inhibitors and beta blockers presents a and dispense them at the conclusion of the procedure.
potential life-threatening situation (1–4). Suffice it to say it is Immediately upon arrival at the office, approximately 30
worthy of mention more than once. Nicotine has a vasocons- minutes before, a topical anesthetic cream containing lidocaine
tricting effect, and, for this reason, McGillis and others recom- and prilocaine (EMLA) may be applied to the medial eyebrow
mend discontinuation of smoking for several weeks before sur- area in preparation for a supraorbital nerve block. Patients
gery (5). However, ironic as it sounds, smokers may be should be welcomed cheerfully, reassured, and fully informed
theoretically less likely to have intraoperative bleeding because as to what they can expect during the procedure. They are re-
of this effect. minded to ask for more local anesthesia should they feel any
Erythromycin has the potential for a life-threatening interac- sensation at the surgical site and to wait for actual pain sensa-
tion if taken with cisapride (Propulsid), terfenadine (Seldane), tions before advising the surgical team. Patients should also be
ketaconazole (Nizoral), or astemizole (Hismanal). reminded that they may use the bathroom, have a drink or snack,
request a blanket, and so forth, at just about any time during
the procedure. Only after appropriate consent forms are signed
THE MINOXIDIL PARADOX (Appendix 7E), should the patient be given oral sedation. Alpra-
zolam is often preferred over diazepam (Valium) because of its
Although the precise mechanism of action of topical minoxidil shorter duration of action. Oral oxycodone / acetaminophen
is unknown, it is speculated that its ability to grow hair and to (Percocet, 5mg) may be used in addition to alprazolam to mini-
mize needle pain, but the incidence of nausea and vomiting document that this practice is standard and consistent, they are
may be significant. Distraction techniques, topical anesthetics, on much firmer medicolegal ground.
ice compresses, slow injection, warmed lidocaine, and 30-gauge Some surgeons who do not perform infectious disease
needles are all helpful adjuncts in reducing pain. screening draw an extra tube of blood (with the patient’s permis-
In a particularly anxious patient, nitrous oxide analgesia may sion) and hold it in reserve until after the surgery. If there is
be used as per dental protocol. Patients hold the mask to their an accidental needle stick during the procedure, the surgeon is
own face and breathe nitrous oxide analgesia (not to be confused insured that blood is available for HIV and hepatitis testing.
with nitrous oxide anesthesia). The apparatus is designed to
deliver a mixture of nitrous oxide with no less than 3 liters of
oxygen at any time. The delivery system has a fail-safe auto-
HAIR CARE AND STYLING BEFORE SURGERY
matic shutoff valve should the oxygen tank become depleted.
Patients feel a pleasant ‘‘high,’’ the equivalent of that experi- Several years ago, I underwent a follicular unit transplant sur-
enced after three or four cocktails, and should they become too gery. I discovered unhappily that my most significant ‘‘compli-
sedated, their relaxed hand will cause the mask to fall from cation’’ was a conspicuous hairless patch in the donor area (an
their face. Nitrous oxide delivery machines are available from area that had been trimmed but not excised as part of the donor
dental supply dealers, and a weekend course for physicians and strip). I have since come to appreciate the significance of hair
assistants is the generally required prerequisite. length and its relation to the surgical technique. Therefore, if
the donor area hair is relatively short, care must be taken to
trim only that area that is to be excised. A minimum hair length
ANTIBIOTICS of 1.5 inches (3.75 cm.) in the donor area is usually adequate.
If patients arrive with longer hair in the donor area, the trimming
The pros and cons of perioperative antibiotics have previously may be less precise. If patients avoid getting a haircut for 3
been discussed by Unger. The arguments against their use have weeks before the procedure, an overzealous barber will not have
been bolstered by a relatively recent article that reported on a the opportunity to remove the necessary camouflage.
6-year study of 1400 patients who underwent plastic surgical Hair length and styling in the recipient area may be an impor-
procedures having received preoperative intravenous antibiotics tant consideration as well. At the time of the consultation, the
during the induction of anesthesia (8). The authors concluded patient should be made aware of how he will look during the
that this approach was not warranted. It should be pointed out, immediate postoperative period. If the patient feels that privacy
however, that these surgeries were carried out in sterile operat- is essential, hair in areas adjacent to the recipient area should
ing rooms and with sterile techniques that would rarely be avail- ideally be long enough to comb over and camouflage the opera-
able and would rarely be used in hair transplantation. Therefore, tive site during the postoperative days when crusting is apparent
these conclusions may not be applicable to hair transplant sur- and during the awkward days and months when the hair first
gery. begins to grow.
The postoperative appearance is somewhat influenced by
the size of the graft. If follicular unit grafts are used, the crusts
PREOPERATIVE BLOOD WORK usually persist for less than 7 days and the new growth is essen-
tially free of tufting. With larger grafts, crusting may persist
Preoperative blood work—how much is enough? A brief pre-
for up to 2 weeks, and the new growth (seen months later) can be
sentation of my viewpoint is given here. Many practitioners
quite conspicuous. Therefore, for those patients not exclusively
generally agree that a complete blood count and clotting profile
receiving follicular unit grafts, long hair adjacent to the recipient
assay (prothrombin time, partial thromboplastin time, platelets,
site (available for comb-over camouflage), is considerably more
and bleeding time) are a worthwhile, if not a minimally essen-
critical. If patients color their hair, they should be advised to
tial, battery. The controversy is often whether or not hepatitis
do so a few days before the procedure. Coloring should not be
B, C and HIV testing are appropriate or of value. If universal
precautions are practiced, an infectious screening profile should reapplied as long as crusts are present, sutures are still in place,
theoretically be irrelevant. If one considers the 6-month sero- or skin surface integrity is compromised. Patients are advised
negativity period in an HIV patient with an early stage of the to shampoo their hair the night before the procedure with regular
infection, the ‘‘negative’’ HIV test result becomes a meaning- shampoo, and the morning of the procedure with chlorhexidine
less piece of data. Nonetheless, some physicians still prefer to gluconate 4% soap solution (e.g., Hibiclens, Hibitane, Dyna-
screen their patients, especially those patients with high-risk Hex, Exidine). They are cautioned to keep the suds from con-
sexual activities. The medicolegal problem with this practice tacting the eyes. No mousse, gel, or conditioner, should be ap-
is twofold: If patients are screened for HIV, for no other reason plied after the morning shampoo on the day of the procedure.
than the surgeon’s peace of mind, the action is discriminatory
and subject to legal challenge. If the screening test is positive
for HIV or hepatitis, and the surgeon refuses to perform the CLOTHING AND OTHER COMFORT
procedure, a similar legal challenge may be entered by the pa- CONSIDERATIONS
tient.
Regardless of which screening tests are performed, the most The transplant procedure almost always lasts longer than 3
defensible position is to perform the same testing profile on hours and is sometimes 5 or 6 hours long. Patients should be
each and every patient regardless of the history or social impres- as comfortable as possible during the time spent in the operating
sion that one has obtained at the interview. If surgeons can room. Patients may be given the choice of sleep medication
196 Chapter 7
(oral alprazolam) during the procedure or they may be enter- and mess of poor intraoperative and postoperative hemostasis.
tained with movie videotapes and compact disks (CDs). They ‘‘Postoperative bleeding increases the risk of infection, flap
are encouraged to bring videotapes and CDs to the procedure. and graft necrosis, wound dehiscence, pain, and scar forma-
Earphones may be used if the patient’s selection proves to be tion’’ (1).
a distraction to the surgeon and staff. Patients who do not bring When assessing the risk of intraoperative bleeding, a thor-
their own entertainment material appreciate a video and music ough preoperative history should be taken. It should consist of
library. For some patients, boredom is more ‘‘painful’’ than a detailed personal and family medical history. Emphasis should
pain. be placed on any known bleeding diathesis in patients or mem-
In the preoperative instructions, it should be clearly stated bers of their immediate family. Any history of excessive bleed-
that a shirt with buttons, rather than a pullover, be worn to the ing after previous surgeries, including dental procedures, and
procedure. This is especially significant if the surgeon uses a the presence of cardiovascular, hepatic, or renal disease should
postoperative bandage. Patients should also be advised to bring be elicited. Last, but not least, a careful inventory of all medica-
a pair of soft, heavy socks to keep their feet warm if they should tions should be taken.
wish to take off their shoes. A cloth (rather than paper) examina-
tion gown is appreciated, and some patients may choose to wear
a pair of oversized surgical scrub pants as well. HEMOSTASIS
Many physicians who do not use a postoperative dressing
gown have the patient wear an oversized baseball hat or bandana Functionally, the coordinated process of hemostasis after surgi-
after surgery. Some physicians provide these items for patients, cal trauma can be divided into four basic interrelated steps:
whereas others instruct patients to bring their own but provide 1. Vasoconstriction
instructions on how to apply them after the surgery is finished. 2. Platelet aggregation
3. Clotting
4. Fibrinolysis
TRAVEL CONSIDERATIONS
Both quantitative and functional deficits in any one of these four
An essential part of preparation is to ensure that the patient steps can exist. The majority of clinically relevant ingestant-
arrives at your office in a timely manner, unaffected by frustrat- induced bleeding alterations that may affect the hair transplant
ing traffic problems or a sleepless night before the procedure. patient population typically exert some influence on either
The patient coordinator should be aware of patients’ travel ar- platelet number or function or on the clotting cascade. As a
rangements and guide them accordingly. Patients who are trav- result, our focus is on step 2 (platelet plug formation) and step
eling a long distance, should arrive the day before and spend 3 (clotting). A detailed discussion of each of the these factors
the night at a hotel near the office. A wakeup call is often and their interrelationships is beyond the scope of this text. For
helpful and a pickup at the hotel by one of the physician’s a more detailed discussion, any of a number of hematology
staff members ensures that no foulups will occur. Out-of-town texts can be consulted.
patients should be advised of rush hour traffic problems so that
they may adjust their travel routes. Some surgeons insist that
their patients not drive themselves on the day of the procedure. CONVENTIONAL MEDICATIONS
If this is the policy, arrangements must be made ahead of time
for transportation to return home or to a hotel after the surgery. Typically, a drug history consists of patients’ supplying a list
of their prescription medications and over-the-counter medica-
tions. A number of conventional medications may increase the
SUPPLIES FOR POSTOPERATIVE CARE risk of bleeding or have documented hemorrhagic complica-
If the clinic does not provide supplies for postoperative care, tions associated with their use. Table 7C-1 contains a list of
it is useful to include a ‘‘shopping list’’ of what is needed with medications that can increase the risk of bleeding. All of the
the preoperative instructions. Examples of items that might be medications listed could be encountered in the outpatient der-
needed include saline spray, gauze pads, ice packs, and a chlor- matologic surgery patient population. Many of these medica-
hexidine shampoo. tions are obtainable only by prescription.
NON-CONVENTIONAL MEDICATIONS
7C. Conventional and Non-
Conventional Medications in Unfortunately, in this day and age, a simple drug history of
conventional medications is no longer sufficient. The number
Hair Transplantation of Western consumers of vitamin and mineral supplements,
Jonathan L. Nelson ‘‘nutriceuticals,’’ herbal remedies, and herbal teas has been in-
creasing dramatically. The use of these products increased by
INTRODUCTION 380% between 1990 and 1997 and appears to be growing by
15% each year (2).
The importance of anticipating the risk of intraoperative bleed- More than 50% of adults aged 35 to 49 years use at least
ing cannot be overemphasized. Excessive bleeding can have one alternative therapy and nearly one in five individuals taking
several dire consequences besides the obvious inconvenience prescription medications was also taking herbs, high-dose vita-
Table 7C–1 Conventional Medications That Can Increase Bleedinga
Acenocoumarol Dexchlorpheniramine Isotretinoin Percodan

Acetylsalicylic Diclofenac Ketoprofen Piroxicam
Acid(aspirin) Dicumarol Ketorolac Propylthiouracil
Aggrenox Diflunisal Levodopa Reserpine
Alprostadil Digitoxin Levonorgestrel Reviparin
Amoxicillin Dipyridamole Lopinavir/ritonavir Robaxisal
Amtolmetin Donepezil Magnesium Salsalate
Anagrelide Empirin Meloxicam Sertraline
Anisindione Enoxaparin Methimazole Sodium Salicylate
Ardeparin Ethacrynic acid Methotrexate Soma
Ascriptin Etodolac Mofetil Sotalol
Auranofin Etretinate Mononitrate Sulindac
Carbenicillin Felbamate Mycophenolate Suprofen
Chlorphenesin Fenoprofen Nabumetone Tiaprofenic acid
Chlorpheniramine Fiorinal Naproxen Ticlopidine
Cholestyramine Fluoxetine Nelfinavir Tinzaparin
Choline salicylate Flurbiprofen Nimodipine Tolmetin
Ciprofloxacin Fluvoxamine Nitroglycerin Tranexamic acid
Clopidogrel Ibuprofen Norgesic Tretinoin
Dalteparin Indinavir Oxaprozin Trimethadione
Danaparoid Indomethacin Paramethadione Vicoprofen
Danazol Indoprofen Paroxetine Warfarin
Dantrolene Interferon beta – 1b Penicillin G
Darvon Isosorbide Pentoxifylline
a
Table compiled from MICROMEDEX Inc. database cross-referenced with the NLM MEDLINE plus database.
min supplements, or both (2,3). In one report, more than 70% Non-Conventional Products That Affect Platelet
of patients surveyed acknowledged using alternative therapies, Function
but, more ominously, they never mentioned their usage to their
physicians (4). Many of these preparations have untoward side Garlic
effects, which can include an increased tendency to bleed. Garlic (Allium sativum) has a vast array of positive health bene-
Therefore, it is not only important for the practitioner to ask fits that have been attributed to its use, including enhanced
about their use but also to be open-minded and not to sound immune function, antioxidant properties, and antibacterial and
judgmental with regard to nonconventional treatments. If pa- antifungal properties. It has been shown to lower both blood
tients perceive the physician as disapproving of alternative ther- pressure and serum cholesterol levels (7). However, its use,
apies, they may not divulge their use of them (5). especially in large quantities over long periods of time, has been
Given the increased prevalence of nonconventional remedies associated with abnormal bleeding. Three constituents have
used today, it is vital for the transplant surgeon to have a work- been identified as the culprits: adenosine, allicin, and paraffinic
ing knowledge of these formulations and their mechanisms of polysulfides (8). The antiplatelet effects of garlic can be clini-
action, particularly with regard to their effect on the cardiovas- cally significant and have been demonstrated by increased
cular system and hemostasis. Also, given the vast number of bleeding times lasting as long as 1 week, and altered platelet
prescription medications on the market today, some understand- aggregation studies lasting for as long as 4 weeks (9).
ing of ‘‘drug-herb’’ interactions is also increasingly important.
This task is a difficult one; indeed, it is made more difficult Ginger
because of the paucity of data available regarding herbal reme-
Ginger (Zingiber officinale) has long been known to possess
dies. As of this printing, in the United States, herbal medicines
antiemetic qualities. In small doses over short periods of time,
(phytomedicines) are not legally considered medicines at all.
ginger has not been shown to affect bleeding. However, in large
Rather, they are classified as dietary supplements, and as such,
doses or if used over long periods of time, ginger can exert
fall under the purview of the Federal Trade Commission. There-
clinically significant antiplatelet effects. It does so by inhibiting
fore, most of these products do not undergo the same extensive
thromboxane A2 and by promoting the synthesis of prostacyclin
testing and research as drugs, and they are not required to meet
(10).
the same stringent safety and efficacy standards that would be
required by the Food and Drug Administration. One unfortunate
result of this absence of regulation is the limited amount of data Ginkgo Biloba
available on dosage, mechanism of action, efficacy, safety, and Gingko biloba (derived from the leaves of the maidenhair tree)
interaction with other substances (6). is often used for its purported beneficial effect on memory func-
198 Chapter 7
Table 7C–2 Herbs, Supplements, and Vitamins That Can Potentially Increase Bleeding
Angelica root Co-enzyme Gingera Papain Sweet clover

Arnica flower Q10 Ginkgo bilobaa Papaw Turmeric
Anise Danshena Ginsenga Parsley Umbelliferae
Asafetida Devil’s claw Green tea Passion flower Vitamin Ea
Bogbean Dong quai Guggul Herb Willow bark
Borage seed oil Fenugreek Horse chestnut Poplar Szechuan pepper
Bromelain Feverfewa Licorice root Quassia Plant bark
Capsicum Flaxseeda Lovage root Quinine
Celery Lucid Magnesiuma Red clover
Chamomile Ganoderma Meadowsweet Rue
Clove Garlica Onion Saw palmetto
a
Primarily affect platelet adhesion or aggregation
tion. It is believed to act by improving circulation to the cerebral lactone and parthenolide. Sesquiterpine lactone inhibits phos-
cortex. Ginkgo extracts contain flavinoids and terpinoids, which pholipase activity, the first step in the arachidonic acid cascade;
are potent antagonists of platelet-activating factor (11). There parthenolide inhibits platelet aggregation by inhibiting seroto-
are several reports in the literature of spontaneous bleeding nin release by platelets (26,27).The increased risk of bleeding
and intraoperative hemorrhage accompanied by prolongation remains theoretical, because no clinically significant hemor-
of bleeding time, which are felt to be attributable to Ginkgo rhagic complications have as yet been reported.
biloba alone or in combination with other anticoagulant therapy
(12–14). Flaxseed
Flaxseed is said to be one of the richest food sources of Omega-
Ginseng 3 fatty acids (alpha linoleic acid). Omega-3 fatty acids in turn
Ginseng (variety of species of plants from the family Aralia- are claimed by some to reduce the rate of blood clot formation.
ceae, genus Panax) is believed by many to reduce fatigue and (Margaret Wittenberg, Good Foods).
increase the sense of well being. It has documented hypoglyce-
mic properties in animals and is sometimes taken by diabetic Vitamin E
patients because of this effect (15,16). Ginseng has been shown
to inhibit platelet aggregation and to enhance fibrinolysis (17), Vitamin E (tocopherol) is a lipid-soluble antioxidant. It is not
and has been linked to vaginal bleeding (18,19). only popular as a dietary supplement but is also found in many
common foods, including wheat germ, leafy green vegetables,
nuts, eggs, and vegetable oils. Vitamin E inhibits protein kinase
Saw Palmetto
C and leads to decreased platelet pseudopodia formation,
Saw palmetto (an extract of the saw palmetto berry) has been thereby reducing platelet adhesion (28). There are conflicting
shown in double-blinded trials to be more beneficial than pla- reports regarding vitamin E and its effect on bleeding in hu-
cebo in the treatment of benign prostatic hypertrophy (20,21). mans. Nevertheless, theoretical and anecdotal support for such
A single case report of severe intraoperative hemorrhage associ- an effect is strong enough that many ophthalmologists, hepatol-
ated with its use can be found in the literature. In that case, the ogists, and dermatologic surgeons ask their patients to refrain
prolongation of bleeding time was significant but returned to from ingesting vitamin E for several weeks before biopsies or
normal after a 1-week cessation of the oral supplement (22). other surgeries. Unger’s comments on this subject are found
Animal studies show that saw palmetto was found to inhibit earlier in this chapter.
cyclooxygenase and 5-lipoxygenase activity (23).
Magnesium
Danshen
Magnesium has been shown to increase bleeding time by 48%
Danshen (derived from Salvia miltiorrhiza) is popular in East- (29). It has been demonstrated that magnesium interferes with
ern medicine as a treatment for cardiovascular and cerebrovas- platelet adhesion and aggregation both in vitro and in vivo (30).
cular disease. Danshen inhibits platelet aggregation, interferes The clinical significance of these altered bleeding parameters
with extrinsic blood coagulation, possesses antithrombin–III- remains to be determined (31).
like activity, and promotes fibrinolysis (24).
Feverfew Non-Conventional Products That Affect the Clotting

Cascade
Feverfew (Tanacetium parthenium) has documented anti-in-
flammatory properties and has been useful in the prophylactic Most of the herbs and dietary supplements discussed thus far
treatment of migraine headaches and in the treatment of rheu- ultimately alter bleeding by inhibition of platelet adhesion and
matoid arthritis (25). Extracts of feverfew contain sesquiterpine aggregation. Others herbs may actually affect bleeding through
a different mechanism. Some herbs, such as umbelliferae (Coni- on an elective basis. This, combined with the flexibility in
oselinum univittatum) and herbal elixirs contain coumarins such scheduling an elective surgical procedure such as hair transplan-
as dicumerol. These function by antagonizing vitamin K, tation, should permit discontinuation of these therapies with
thereby altering the clotting cascade by reducing the levels of minimal disruption of a patient’s routine. Given the paucity of
vitamin-K-dependent procoagulant proteins (34,35). data regarding the duration of anticoagulant effect of most of
Although few hair restoration surgeons are willing to treat these agents, it would be wise to err on the side of caution. A
patients who are taking warfarin, some do, and, surprisingly, minimum ‘‘drug-holiday’’ of 1 week’s (preferably 2 to 4 weeks)
have not reported unmanageable bleeding (see Unger’s Com- duration from all nonessential supplements would seem to be
ments in Chapter 8). in order.
The list of herbs that can potentiate the effects of warfarin
or reinforce anticoagulant therapy by heterogeneous mecha- Editor’s Comment
nisms is long. However, many of these substances may them- Is the avoidance of ‘‘nutritional supplements’’ and nonconven-
selves act as anticoagulants by as yet poorly or altogether unde- tional medications, really important for hair restoration sur-
fined mechanisms. Some herbs and supplements that potentially gery—or, for that matter, any surgery? When I asked Jonathan
increase the risk of bleeding, potentiate the effects of anticoagu-
Nelson to write this submission, I thought that aside from vita-
lant therapy, or reinforce their action by heterogeneous mecha-
min E, and perhaps foods containing vitamin E, there would
nisms include angelica root, arnica flower, anise, asafetida, bog-
be only a few additional substances that we might have to ask
bean, borage seed oil, bromelain, capsicum, celery, chamomile,
our patients to avoid presurgically, just to be ‘‘on the safe side.’’
clove, coenzyme Q10, danshen, devil’s claw, dong quai, fenu-
greek, feverfew, lucid ganoderma, garlic, ginger, ginkgo, gin- I was surprised by the length of his lists but wondered whether
seng, green tea, guggul, horse chestnut, licorice root, lovage the theoretical concerns he raised really had any negative clini-
root, meadowsweet, onion, papain, papaw, parsley, passion cal consequences. After all, scientific studies with regard to
flower herb, poplar, quassia, quinine, red clover, rue, sweet their effect on surgical and postsurgical bleeding have never
clover, turmeric, vitamin E, willow bark, and the bark of the been done on any of them.
szechuan pepper plant (36, 37). I have relayed elsewhere the anecdotally based precautions
It is worth noting that many of the items on this list can also of hepatologists before liver biopsies, ophthalmologists before
be found in herbal tea formulations. Patients who drink herbal eye surgery, and many physicians who do liposuction and who
tea on a regular basis should be encouraged to read the ingredi- have learned to routinely ask their patients to avoid all nutri-
ents on the label and compare them with this list. Consideration tional supplements for up to one month before surgery. To this
should be given to reducing or eliminating consumption of pos- must now be added a report at the annual meeting of the Ameri-
sible offenders before surgery, as mentioned elsewhere in this can Academy of Cardiology in Atlanta in 2002 on a study in-
chapter. volving 145 patients. The presenters found that 71% of the
cardiac patients in their sampling were using alternative thera-
Alcohol pies ranging from multivitamins to ‘‘energy healing,’’ prayer,
Ethanol is not typically considered an herbal remedy; however, yoga, and reiki (healing by touch). Moreover, 25% of this group
it is a nonconventional ‘‘herbal’’ substance that has been shown did not report their practices to their cardiologists. The authors
to increase the risk of bleeding by affecting both platelet func- were not so concerned with small doses of alternative sub-
tion and the clotting cascade. Long-term alcohol use can impair stances but noted that large doses appeared to be more problem-
bleeding through multiple mechanisms including decreasing vi- atic. In particular, some of them could potentiate the effects
tamin–K-dependent clotting factors produced in the liver. It has of anticoagulants leading to unexpected disastrous bleeding. If
also been shown to have an immediate detrimental effect on in physicians are aware of these ingestants, they can adjust and
vitro and in vivo platelet aggregation. Significant prolongation monitor their anticoagulant medications more carefully, just as
of bleeding time, accompanied by an impairment of platelet they do when their patients are also using acetylsalicylic acid.
response to both collagen and ADP, was demonstrated in But, as noted, too frequently they are not told about them. The
healthy human volunteers 1 and 2 hours after they consumed problem is compounded because the doses of different ingredi-
moderate amounts of alcohol (32, 33). ents vary from one supplement to another and there is lack of
legal oversight to ensure accurate labeling, such as occurs with
prescription drugs. Incidentally, the paper also noted that nutri-
CONCLUSION tional supplements can interact with many other medications
Determining whether a patient taking prescribed medication is in as yet unquantified ways. The following examples were
a safe candidate for hair restoration surgery can be complicated. given: St. John’s wort interferes with the action of some drugs
The issue is further compounded by the fact that the list of to treat AIDS; echinacea can offset the actions of immune-
both conventional and nonconventional medications that can suppressants such as prednisone and cyclosporine. Obviously,
increase the propensity to bleed is so extensive. When it comes this is an area where more strict enforcement of proper labeling
to conventional medications, a decision regarding whether to and studies on interactions are needed. In the meanwhile, each
discontinue or change a drug, to wait until the patient no longer of us must decide whether we want to advise our patients of
requires that drug, or to defer a procedure altogether, must be this fact, as well as of the possibility that the listed agents may
made. In the case of nonconventional remedies, the choice is have unknown effects on their other medications and may also
usually much simpler. Most patients use alternative medications increase bleeding. (WU)
200 Chapter 7
7D. OSHA and Laboratory Screening the United States is 0.2% to 0.5% of the general population. In
subpopulations, such as intravenous drug abusers and homosex-
James A. Harris and Ron Shapiro ual men, the prevalence may be five to ten times higher. The
incidence of HBV infection in the United States is declining
INTRODUCTION with the effective use of vaccination against HBV. The antibody
to HBV (anti-HBs) confers immunity to hepatitis B.
The Occupational Safety and Health Administration (OSHA)
directs and enforces the Occupational Safety and Health Act, Hepatitis C Virus (2,3)
which went into effect in 1971. The purpose of this law is to
protect employees and reduce workplace injuries and illnesses Currently, HVC virus is the most common of all blood-borne
by mandating certain safety and health standards. OSHA has infections in the United States. It is estimated that there are
promulgated the blood-borne pathogens standard, which is ap- about 30,000 to 180,000 new cases of acute HCV infections
plicable in any workplace environment where the employees each year. Of these, about 85% develop chronic HCV infection.
are at some risk for exposure to blood-borne pathogens. This This higher rate of conversion to a chronic disease that occurs
standard applies to all ‘‘occupational exposure’’ to blood and/ with HCV rather than HBV makes chronic HCV infection more
or ‘‘other potentially infectious materials.’’ A typical hair trans- prevalent in the general population than HBV (1.8% versus.
plant practice certainly falls into the purview of OSHA stan- 0.2% to 0.5%). Chronic HCV infection is the second most com-
dards because any employee involved in the surgical portion mon cause of chronic liver disease (alcohol is the first). Before
of the procedure is at risk for exposure (1). the advent of tests capable of screening for HCV and thus help-
There are numerous record-keeping, vaccination, hazard ing to eliminate this virus from the blood supply, HCV was
communication, information, and training requirements man- the most common cause of posttransfusion hepatitis. Since the
dated by OSHA. Familiarity and compliance with these require- introduction of second-generation immunoassays for the virus
ments are important because there are penalties imposed for not in 1992, the risk of posttransfusion hepatitis C has declined and
following them. A detailed presentation of these requirements is is estimated to be about .01% to 0.001% per unit transfused.
beyond the scope of this chapter. However, there are numerous The risk of inoculation from a single needle stick accident from
private and government organizations that provide OSHA edu- a known positive patient is estimated to be approximately 1.8%
cation and training to employees of medical practices and that in prospective studies (range 0% to 7%).
help ensure that a practice is compliant with OSHA regulations.
It is difficult for a busy practicing physician to stay up to date Human Immunodeficiency Virus (2,3)
with these various rules and regulations. Therefore, it is helpful
to use one of these resources and to have a delegated staff The first reported cases of AIDS were described in 1981 when
member who is specifically trained in OSHA standards. The previously healthy homosexual men were diagnosed with Pneu-
first part of this chapter briefly addresses the very basic require- moscystis carinii pneumonia and Karposi’s sarcoma. By 1997,
ments and standards put forth by OSHA with respect to blood- there were an estimated 1.1 million people infected with HIV
borne pathogens. The second topic addressed in this chapter (a prevalence of 0.4% or 1 in 250). Most of these cases are
relates to the laboratory screening for diseases that are life confined to high-risk groups (e.g., homosexual males, intrave-
threatening or those that can cause a serious illness as a result nous drug abusers, hemophiliac patients). The prevalence in
of exposure in the workplace environment. As an extension of low-risk groups is much less. The estimated risk of sexual trans-
this topic, there is a brief discussion concerning the controversy mission of HIV from a known positive source is 1 in 300 for
of obtaining screening laboratory tests for routine hair transplant male-to-male transmission, 1 in 500 for male-to-female trans-
patients. mission, and 1 in 1000 for female-to-male transmission. The
estimated risk of acquiring HIV after a percutaneous encounter
Epidemiology with a sharp instrument contaminated with HIV is estimated at
being 1 in 300 (0.32%). The risk is increased when the injury
The three potentially most dangerous blood-borne pathogens involves a hollow-bore needle that has been inside an artery or
are the human immunodeficiency virus (HIV), hepatitis B virus vein and when it is more severe than a simple needlestick. In
(HBV), and hepatitis C virus (HCV). The following is a brief a retrospective case-control study, the use of zidovudine after
overview of the epidemiology of these entities. percutaneous exposure was associated with an 80% reduction
of HIV transmission. As of June 2000, the Centers for Disease
Hepatitis B Virus (2,3) Control had documented 56 cases of confirmed seroconversion
after occupational exposure and an additional 138 of possible
Chronic hepatitis B is a major global health care problem. Five seroconversion after occupational exposure.
percent of the world’s population, or approximately 300 million
persons, are estimated to be carriers worldwide. In the United OSHA Blood-Borne Pathogens Standards
States, about 120,000 to 300,000 new cases of acute HBV are
reported to the Centers for Disease Control each year. Of these, The OSHA requirements for blood-borne pathogens can be
about 5% develop chronic hepatitis B (patients remain positive summarized as follows. OSHA requires that the regulations for
for hepatitis B surface antigen [HBeAg]). This is significantly safety be posted for all employees to see. The employer has
less than the rate of development of chronic hepatitis after expo- the responsibility to provide masks, safety gloves, gowns, and
sure to HCV, which occurs in about 85% of people infected protective eye wear when there is a ‘‘reasonable’’ risk of expo-
with the HCV virus. The prevalence of chronic hepatitis B in sure to blood-borne pathogens. The employee must be offered
hepatitis B vaccinations at no cost. The proper handling and a positive test and the high incidence of false-positive tests in
disposal of sharp materials contaminated with blood and other groups with low prevalence. It has also been argued that it is
body fluids is required. The adoption of universal precautions more efficient to screen only those patients who appear to be
is required. It is this last requirement that is discussed in this in a high-risk category as revealed by their medical history.
chapter at some depth. There are well-known medicolegal problems associated with
Certainly, there are no disputes surrounding the requirement such a policy of ‘‘profiling.’’
that physicians provide their surgical staffs with items that give
adequate physical protection in the form of barriers. What has Arguments for Testing
emerged as a topic of debate centers on the need to presume
that all patients are potential carriers of a blood-borne pathogen. Proponents of routine testing counter with the point that, unlike
The goal of universal precautions is to treat any particular general surgery, hair transplantation is a totally elective proce-
patient, regardless of the individual’s true infection status, as dure, and there is no need to accept any risk, no matter how
an actual threat. Ideally, the strategy will minimize the risk of small, of exposure to blood-borne pathogens. They argue that
infection from exposure to infected patients who test negatively routine screening for a totally elective procedure in a small,
because they have not yet undergone seroconversion. Such pa- select group such as this should not be looked at in the same
tients must be treated with the same caution as those with a light as routine screening for the general public.
proven disease state. Another argument supporting preoperative hepatitis and
HIV screening has to do with the clinical and medicolegal situa-
tion that exists after an accidental occupational exposure. That
Preoperative Testing for HIV and Hepatitis is, if the disease status of a patient is unknown, and there is an
Controversy exists over the practice of obtaining routine preop- exposure incident, in all likelihood a request will be made to
erative screening tests for HIV and hepatitis. The arguments test the source patient. A problem may occur if the source pa-
for testing, relating to universal precautions are that if it can tient refuses to undergo testing by virtue of the right to privacy,
be shown that a patient is positive for HIV or hepatitis, ‘‘extra which must be balanced with the exposed health care worker’s
special’’ universal precautions and more careful protection can right to know. Some state and federal laws may address this
be afforded to the employees who in turn can take ‘‘extra’’ care issue (4). In addition, although studies of preoperative testing
to avoid contamination. do not support this practice, and the probability of finding a
significant surgical risk not picked up by history is low, for the
one patient who does turn out to be positive, statistics do not
Arguments Against Testing
matter. A preoperative test would have resolved the issue before
Detractors cite several flaws in this logic. They contend that if there was an exposure incident. In some offices, physicians get
universal precautions are in place and if all patients are treated around this by asking patients to give permission for an extra
as if they pose risk for exposure, the epitome of caution has tube of blood to be drawn and held until after surgery for testing
been reached . If, in fact, a patient with a positive result is in the event of an accidental needlestick.
treated differently, routine universal precautions are not being OSHA does not stipulate whether preoperative laboratory
followed. Moreover there is the dilemma of the patient who has tests for blood-borne pathogens should be ordered. This is a
been exposed to the HIV virus but who has not yet undergone medical decision and if, in fact, strict universal precautions are
seroconversion. If this patient is treated with less regard or as being followed, the operating-room staff is protected regardless
a low risk, the staff will be at a higher risk for exposure if of the status of the patient. A small survey of 30 physicians
anything less than standard universal precautions are followed. who perform hair transplants around the United States revealed
There are other arguments made by opponents to routine preop- that currently both practices are about equally common (5). The
erative testing for HIV and hepatitis. The incidence of a positive question of whether to perform an elective, cosmetic procedure
test in a preselected low-risk group, such as hair transplant pa- on a patient who is HIV-positive or hepatitis-positive is outside
tients is low, and the cost of testing is high. It is not considered the scope of this chapter. There are no general guidelines or
cost-effective to do routine screening. It is interesting to look consensus. It is a decision to be based upon the judgment of
at the statistical probability of an employee’s contracting HIV the individual physician, the level of competence of the staff,
if stuck by a needle from an unknown source during a single- and status of the individual patient. The arguments against per-
hair transplant procedure. Statistical analysis states that the total forming surgery are the risk to the staff and the potential harm to
probability for an event to occur is the product (or multiplica- the patient from undue surgical stress. Physicians who perform
tion) of the probability of the individual factors that need to surgery on these patients present these arguments. All patients
occur for the event to take place. This means that the probability have a right to cosmetic surgery regardless of their infectious
of an employee’s contracting HIV from a needlestick during a disease status. Modern medications contribute to successful
procedure is the product of the probability of a patient’s being management of patients with hepatitis and HIV; therefore, a
HIV positive times the probability of a needlestick causing sero- hair transplant may not present a grave risk to their health.
conversion. [Formula: ‘‘Prevalence of HIV in normal popula-
tion’’ (.4%) x ‘‘Incidence of seroconversion from a single
needlestick (.33%)] The math shows this to be as follows: Dealing with Accidental Exposures
4% ⳯ .33% ⳱ .001%, or a 1 in 75,000 probability An accidental exposure is defined as a percutaneous injury, a

needle stick, or a cut with a sharp object, for example, combined
Other considerations against testing are the obligation to pro- with contact of the injured site with blood, tissue, or other poten-
vide proper counseling and disposition for patients who have tially infectious material. Once this occurs, decisions must be
202 Chapter 7
made regarding postexposure management and postexposure Consensus Conference in 1988 stated that the available evi-
prophylaxis (PEP). dence did not support this rule. The literature is somewhat
The U.S. Public Health Service has published guidelines for mixed on whether preoperative anemia increases the risk of
the management and PEP of exposure to HBV, HCV, and HIV postoperative complications. Exceptions to this rule are patients
(6). In addition, a National Clinicians’ Postexposure Hotline who have reached the ninth decade of life and those who are
([PEP line] 1-888-448-4911) can be used to consult with an in high-risk categories owing to concurrent medical problems
expert. These sources can provide details of the protocols and (7).
the decision process for the severity of the exposure; however, Screening for coagulopathies usually includes a PT/PTT lev-
a brief description of the protocol for each exposure is presented els and a platelet count. A bleeding time test is needed to screen
here. for platelet abnormalities. Multiple studies have given evidence
The risk of HBV infection from an occupational exposure that these tests are not usually predictive of postoperative bleed-
is related to the hepatitis B e-antigen (HBeAg) status of the ing, nor do the results predict intraoperative bleeding (7).
source person. The risk of developing clinical hepatitis when A preoperative urinalysis in hair transplant patients is proba-
the source is positive for both HBeAg and hepatitis surface bly of limited value. It is undertaken to identify patients with
antigen is between 22% and 31%. An HBV exposure requires occult renal disease or urinary tract infections. Abnormalities
the administration of hepatitis B vaccine, if the person has not in this test are common, ranging from 5% to 39%, yet only 0%
been vaccinated previously, as well as hepatitis B immune glob- to 6% of abnormalities require further testing or treatment. The
ulin (HBIG). Employees who have been immunized with hepa- chance of a wound infection from a urinary tract infection in
titis B vaccine and who have a positive HBV antibody are pro- this setting approaches 0% (7).
tected against HBV exposure. Because of lack of correlation between any ‘‘routine’’ preop-
Studies have shown that HCV is not transmitted to any great erative laboratory studies and postoperative morbidity, our of-
degree through occupational exposures to blood. The risk of fices have adopted a protocol of using clinical indicators and
seroconversion after exposure is 1.8%. There have been no stud- a medical history to determine the need for laboratory tests. In
ies to assess use of antiviral agents to prevent HCV infection and addition, with the state of managed care and frequent routine
therefore there is no PEP for HCV. Postexposure management physician examinations, many laboratory tests are obtained for
involves early detection of chronic disease and referral for treat- routine health maintenance. Often laboratory tests have been
ment options. done within a year of the proposed hair transplant, and, there-
HIV transmission after an exposure has been estimated to fore, use of these results should be adequate. A study by Mc-
be approximately 0.3%. PEP for this exposure consists of a 4- Pherson and colleagues (8). noted that tests repeated within a
week regimen of either zidovudine (ZDV) and lamivudine year showed a 0.4% abnormality rate on retest. Most of these
(3TC), 3TC and stavudine (d4T), or d4T and didanosine (ddl). abnormalities could have been found by means of a medical
When there is an increased risk of transmission, such as an history and physical examination. Therefore, laboratory tests
exposure to a larger quantity of blood, a third drug may be obtained within a year can be reasonably accepted as valid un-
added to the regimen. In cases of occupational exposure, strict less there has been a change in the patient’s medical history.
adherence to OSHA guidelines and prompt (within 2 to 3 hours) In Dr. Harris’s office, a medical questionnaire is given to
evaluation by qualified personnel is recommended. the patient that looks for risk factors that suggest the need for
testing. Risk factors for HIV, hepatitis B, and hepatitis C (such
General Preoperative Laboratory Testing as a history of blood transfusion, intravenous drug use, and
hypersexual activity), and a history of diabetes mellitus, hyper-
The need to perform general preoperative laboratory testing tension, renal or cardiac disease, and current medications are
and screening is another area of controversy. OSHA’s standards elicited by direct questioning. Dr. Harris has had more than 7
play no role in this debate. To evaluate the status of a patient’s years of experience as a head and neck and facial plastic surgeon
health, physicians obtain these tests. In this field, some of the in private practice, performing both elective and nonelective
routine tests ordered are complete blood count (or hematocrit procedures. His use of the history and physical examination as a
and hemoglobin), electrolyte panel, prothrombin time (PT)/par- screen has eliminated the need for ‘‘routine’’ laboratory testing.
tial thromboplastin time (PTT), and urinalysis. Presumably, After thousands of cases, not a single incident has occurred
these tests evaluate the patient’s ‘‘fitness’’ to undergo the proce- when use of this protocol led to an untoward event.
dure in terms of the ability to withstand anesthesia, achieve
homeostasis, and withstand the surgical insult. In general, stud-
ies evaluating the necessity and value of preoperative testing 7E. Antibiotic Use in Scalp Surgery
support the adage that one should not order a laboratory test
John Karl Randall
unless the results of the test will change the course of action.
Studies on electrolyte testing reveal that abnormalities are INTRODUCTION
rare in otherwise healthy individuals, and that the rate of abnor-
mal results increases with increasing age and/or history of hy- This chapter explores the rational administration of antibiotics
pertension. The effect of abnormal electrolytes on postoperative in the prophylaxis of surgery of the scalp using evidence-based
recovery does not generally seem to increase the risk of postop- medicine. Evidence-based medicine (Tables 7E-4 and 7E-5)
erative dysrhythmias (7). empowers practitioners to make rational, scientifically based
Adequate hemoglobin and hematocrit levels have tradition- decisions about the care of individual patients.
ally been set at 10 g and 30%, but the rationale for these values Evidence based medicine is used for grading treatment, diag-
is not explicit in the literature. The National Institutes of Health nosis, prognosis, and other aspects of medical care. The best
Table 7E–1 Recommended Antibiotic Prophylaxis for Endocarditis
Reference Drug/Dosage/Timing Alternative/Special
Wagner 1986 (2) Dicloxacillin 2 g PO 1 hr preop and 1 g 6 hr postop For PCN allergic: Erythromycin 1 g PO
1 hr preop and 0.5 g 6 hr postop
Sabetta, 1987 (3) Dicloxacillin sodium 2 g PO 1 hr preop and 500 mg 6 hr Vancomycin IV for recent prosthetic valves
postop
Halpern, 1988 (9) 1st-generation cephalosporin PO 1–2 g 1 hr preop and
500 mg 6 hr post-op
Terracina, 1993 (27) Dicloxacillin 2 g 1 hr preop and 1 g 6 hr postop For PCN allergic Erythromycin 1 g 1 hr
preop and 500 mg 6 hr postop
Spelman, 1993 (13) Flucloxacillin 1 g 1 hr preop (abnormal native valves) For PCN allergic: Vancomycin 500 mg
Flucloxacillin ⫹ IV or IM gentamicin (prosthetic valves)
Hobbs, 1994 (28) Dicloxacillin 2 g 1 hr preop and 1 g 6 hr postop For PCN allergic: Erythromycin 1 g 1 hr
preop and 500 mg 6 hr postop
Haas, 1994 (29) (Contaminated skin, Staphylococcus aureus) 1st-generation
Cephalosporin, 1 g PO 1 hr preop and 500 mg 6 hr postop
(Contaminated skin, S. epidermidis) Vancomycin, 500 mg
IV 1 hr preop and 250 mg IV 6 hr postop
(If methicillin-resistant, Staphylococcus or prosthetic
valves) Vancomycin, 500 mg IV 1 hr preop and 250 mg
IV 6 hr postop
PCN ⫽ penicillin; IM ⫽ Intramuscular; IV ⫽ intravenous.
decisions are always grounded in fact. For further information antibiotic prophylaxis because no specific data exist. The litera-
on evidence-based medicine, I highly recommend that the ture on cutaneous surgery and chemoprophylaxis is generally
reader review reference’s at the end of the chapter (46–48 and classified as levels III to V (1–17, 36, 38–40, 49–51). Literature
56–57). of much higher quality (levels I and II), is available, but gener-
ally contains information that is applicable only to general sur-
gery and chemoprophylaxis (18–21, 52–54). Furthermore, tra-
BACKGROUND ditional surgical wound classification systems are not easily
Unfortunately, levels of evidence and grades of recommenda- applied to hair restoration owing to a number of factors astutely
pointed out by Dr. Walter Unger.
tion cannot be directly applied to hair restoration surgery and
A critical review of the use of antibiotics in cutaneous sur-
gery leaves numerous unanswered questions. Areas of concern
include antibiotic prophylaxis for treatment of patients with
Table 7E–2 Conditions for Which Endocarditis Prophylaxis Is endocarditis and for prevention of postoperative infection and
and Is Not Recommended prosthetic device infection. Despite the fact that 200 or more
articles on antibiotic prophylaxis are published per year (1) few
Recommended for: have applicability to cutaneous surgery (2), and an even smaller
Prosthetic valves percentage meet criteria that results in grading the validity of
Rheumatic valvular diseases, most other acquired valvular evidence as 1a, 1b, or 1c, as described by multiple authors on
dysfunctions evidence-based medicine (2–8). Articles that meet grades of
Congenital cardiac anomalies (some exceptions) recommendation of 2, 3, 4 or 5, usually fail to provide conclu-
Previous episodes of endocarditis sive evidence on which to base medical decisions.
Mitral valve prolapse associated with mitral regurgitation A less scholarly but more practical approach to use of antibi-
Hypertrophic cardiomyopathy/idiopathic subaortic stenosis otics for patients with postoperative wound infections is to
Surgical systemic—pulmonary shunts evaluate risk factors such as preexisting medical status, clean
Not recommended for: versus dirty wounds, length of procedures, sterility, and so forth
Kawasaki disease, rheumatic fever without cardiac valvular (18, 22–26). A study by Campbell and colleagues (26) noted
disease a 15.4% surgical site infection rate for diabetic patients versus a
Coronary artery bypass procedures 7.6% rate for nondiabetic patients in clean procedures. Problems
Nonpathologic murmurs
with traditional wound classification systems and the very low
Mitral valve prolapse without insufficiency (isolated)
surgical site infection rates (usually less than 1%) for healthy
Secundum atrial septal defect (isolated)
patients undergoing clean procedures have led many authors to
Six months after post repair of atrial septal defect, ventricular
septal defect
discourage prophylactic antibiotics for patients who are
Patent ductus arteriosus (if no residual defect) undergoing most clean cutaneous procedures (21, 27, 29, 45).
Pacemakers or implanted defibrillators The lack of high-quality medically based evidence support-
ing prophylactic antibiotic use for hair restoration surgery, com-
204 Chapter 7
bined with the known risks of taking antibiotics: (1) allergic to significant amounts of anesthetic fluid and placement of au-
reactions (some fatal), (2) drug interactions (some fatal), (3) tologous tissue.
intolerance, (4) superinfections, (5) cost, (6) inducing resistant Therefore, if a practitioner is going to use prophylactic anti-
bacteria, and (7) inappropriate use (timing), lead me to not rec- biotics despite lack of evidence to justify their use, cefadroxil
ommend routine prophylactic antibiotic use for patients is recommended. Available oral first-generation cephalosporins
undergoing hair restoration surgery. It should be pointed out include cefalexin, cefradine, and cefadroxil. Cefadroxil is well
that the percentage of patients who take prophylactic antibiotics absorbed and is the only first-generation cephalosporin that can
and experience a significant adverse reaction is greater than the be taken without intake of food delaying or decreasing peak
percentage who would develop a postoperative wound infection serum levels (33, 35). Cefadroxil (Duracef) achieves rapid (1.5
from a clean cutaneous surgical procedure (58–60). hour) and high minimum inhibitory concentrations (28 ␮g/mL)
after a single 1000 mg dose, and it’s half-life (t1⁄2) is twice that
of cefalexin or cefradine (33, 35). To ensure therapeutic drug
ROUTINE PROPHYLAXIS levels with most oral antibiotics, one and a half-times to two
times the standard dose should be given 11⁄2 hours before the
The rate of dermatological reactions to cephalosporins is 2.8%, procedure (2 g of cefadroxil).
with hypersensitivity reactions occurring in 5% to 10% (59).
A study of fatal anaphylactic reactions to antibiotics noted that
ENDOCARDITIS PROPHYLAXIS
of the six deaths attributed to cephalosporins, three patients had
no history of allergy to penicillin (61). It should be noted that Endocarditis prophylaxis in hair restoration surgery should be
the risk of reactions to cephalosporins in a penicillin-allergic guided by existing recommendation (21,36). This does not
patient is increased by fourfold, or about 8% (62), but this esti- imply that adhering to the recommendations will prevent endo-
mate still cannot predict severe, even fatal, reactions to cephalo- carditis, but if they are not followed, medicolegal difficulties
sporins (beta-lactam antibiotics account for a large percentage may be the result. Despite what most physicians may believe,
of all drug reactions, including approximately 300 deaths per few data (no medically based evidence of at least grade I or II
year). [Tables 7E-5 and 7E-6] exist that show efficacy of antibiotics
Cephalosporins are used to illustrate the difficulties in deter- in preventing bacterial endocarditis.
mining the appropriate prophylactic use, because first-genera- Table 7E-1 is a review of all current literature on endocardi-
tion cephalosporins are still the antibiotic of choice (18, 21, 30). tis prophylaxis and cutaneous surgery. Table 7E-2 is a listing
First-generation cephalosporins have an excellent antimicrobial of cardiac lesions that require or do not require preoperative
spectrum against organisms encountered in scalp-related sur- antibiotic coverage. Table 7E-3 includes my recommendations.
gery. Groups B, C, and G-Streptococcus viridans, S. pyogenes It should be noted that antibiotics in dental procedures or most
(group A beta-hemolytic), Staphylococcus aureus, and Staph. general surgery are not appropriate for endocarditis prophylaxis
epidermidis (both penicillinase and non-penicillinase produc- in cutaneous surgery (2, 3, 9, 13, 27–29, 36).
ing, but not methicillin resistant), are susceptible to first-genera- Physicians who are not comfortable managing a patient with
tion cephalosporins (18, 31, 32). Propionibacterium acnes and cardiac lesions should not hesitate to contact the patient’s car-
other scalp diphtheroids are also sensitive to first-generation diologist, internist, or local infectious disease specialist for
cephalosporins (31, 32). treatment recommendations.
Despite my illustration of the high risk to low benefit rela-
tionship of prophylactic antibiotics, Dr. Unger has pointed out
that hair transplantation may be unique among surgical and 7F. Emergency Intervention in Hair
dermatologic procedures. Hair transplantation, which by its na- Restoration Surgery
ture and, to some degree, by the habit and training of its practi-
tioners, is carried out by many in less than optimally sterile Carlos Puig and Ron Shapiro
settings. Nevertheless, hair transplantation involves hundreds INTRODUCTION
to thousands of wound sites, requires the operative field to be
open to the environment for extended time periods, and causes Rare though they may be, life-threatening emergencies can be
the operative field to be kept edematous for hours to days owing associated with hair replacement surgery. Seldom is hair resto-
Table 7E–3 Endocarditis Prophylaxis in Hair Restoration Surgery
Individuals with high-risk cardiac Antibiotic/dose/timing Cefadroxil 2 g

lesions (see Table 7E–2) 1 hr preop and 500 mg 6 hr postop
Individuals with cardiac pathology but None
not high risk (see Table 7E–2)
Special note:
1. For prosthetic valves ⬍ 60 days after transplantation, use vancomyacin, 500 mg IV
over 1 hr preop and 250 mg IV 6 hours postop
2. For penicillin-allergic patients, clindamycin, 300 mg PO 1 hr preop and 150 mg PO
postop, or erythromyacin 1 g 1 hr preop and 500 mg 6 hr postop can be used
Table 7E–4 Evidence-Based Medicine—Levels of Evidencea support (ACLS) care. One can see that such a health care deliv-
Level Recommendation/Grade ery system places an enormous responsibility on the diagnostic
and intervention skills of the physician.
I Strong recommendation, or grade of A How can the surgeon be ready to deal with this problem? It
a systematic review of random controlled trials is the intent of this chapter to do the following:
an individual review of a random controlled trial
an all-or-none case series
● Describe how a facility and its staff can prepare itself
II Strong recommendation, or grade of ‘B’ for an emergency should one occur. This includes a brief
a systematic review of cohort studies discussion of basic life support (airway, breathing, and
an individual review of a cohort study, or a circulation [ABC], and cardiopulmonary resuscitation
low-quality random controlled trial [CPR], as well as ACLS).
a review of outcomes ● Discuss briefly the priorities and approaches to specific
III Good recommendation or grade of B emergency situations that may arise in a hair restoration
a systematic review of case control studies surgeon’s office.
an individual review of a case control study
IV Poor recommendation, or grade of C
a case study, also poor-quality cohort studies BEING PREPARED
V Poor recommendation, or grade of C
an expert opinion without contemporary rhetoric
Successful resuscitation of any unstable patient is facilitated by
early recognition and intervention. Neither of these actions can
a
This table is a stratification of criteria for the validity of medical research. take place without preparation. Proper preparation includes
training and rehearsing the staff as well as conducting a proper
equipment inventory, including supplies and pharmaceuticals. It
is also helpful to be in communication with the local emergency
medical services systems (EMSS).
ration surgery performed with the aid of an anesthetist. The
It is not the intent of this chapter to reiterate the American
responsible hair restoration surgeon must be alert to the early
Heart Association’s Advanced Cardiac Life Support course.
signs of an evolving emergency situation. Often a prompt, ap-
However, the intervention protocols of basic life support (BLS)
propriate response to an evolving emergency can minimize or
and ACLS are a good platform from which the surgeon may
even prevent a patient catastrophe.
develop an approach to the management of any deteriorating
Preparedness is an important aspect of dealing with a medi-
patient. Surgeons and staff who are trained in current BLS and
cal emergency. The office environment in which hair restoration
ACLS are better prepared for dealing with life-threatening
surgery is performed seldom lends itself to a rapid response.
emergencies.
There is usually only one physician and several medical techni-
It should be noted, however, that the actual risk of emer-
cians. Not all offices have the luxury of registered nurses. Not
gency events occurring during a hair transplant procedure is
all offices are equipped to perform full advanced cardiac life
low. Although it would be ideal for all practices to be totally
prepared for all emergency situations, in actual clinical practice,
total preparation is often not practical. The information in this
Table 7E–5 Evidence-Based Medicine Grading System for chapter discusses suggested methods of preparing for, and deal-
Reviewing Medical Informationa ing with, emergency situations, but it is not meant to be con-
strued as policy or dogma.
Evidence for Tx, Rx, and Prevention
Level I A randomized controlled trial showing a Basic Life Support (ABCs and CPR) and Advanced
significant difference
Life Support (ACLS)
Level II A randomized controlled trial not showing a
significant difference The thought of dealing with an unresponsive or deteriorating
Level III A nonrandomized case-control trial, or an patient is very intimidating to the average cosmetic surgeon.
analysis of a subgroup of a randomized Every unstable patient should be approached with priorities
controlled trial given to those things that are most likely to cause immediate
Level IV A before-and-after study, or a comparison permanent loss of cerebral function. Brain anoxia, caused either
study with at least 10 patients having by lack of respiration or lack of circulation are the most immedi-
similar histories
ate concerns. All emergencies should be approached with the
Level V A case series of at least 10 patients not
same methodical examination and treatment priorities. Perform-
having similar history
ing the ABC’s and initiating CPR, if indicated, are the first
Level VI A case report of less than 10 patients
Grading System for Recommendations systematic steps in dealing with any deteriorating patient. It is
Grade A Recommendation based on level I my intent to provide a somewhat succinct approach to this com-
Grade B Best evidence available at level II plex area.
Grade C Best evidence available at level III Patients with an altered level of consciousness must have
Grade D Best evidence available lower than level III immediate attention given to their airway by the person who
and including expert opinion discovers the altered level of consciousness. The opening exam-
ination and clearing of the airway is always the first intervention
a
Data from Carruthers. Can Med Assoc J 1993; 149: 289–293. of emergency care. There are several techniques for accom-
206 Chapter 7
plishing this. The simplest and most often effective is the jaw One must also recognize that the sequence of steps is imaginary,
thrust (Fig. 7F-1). Supplemental oxygen should be given to the and the best-case scenario during such an event would be to
patient as soon as possible. have many of these activities proceeding simultaneously. One
Verification that the patient is indeed breathing, ventilating person clears and secures the airway while another checks for
the lungs, is the next important step in basic emergency care. a pulse and starts CPR and yet another introduces an intravenous
If that is not happening, ventilation must be assisted. Breathing line. This team approach is very helpful in bringing order to a
may be confirmed by watching the patient’s chest expand and potentially chaotic situation. The physician is the team leader
listening for breath sounds in both lung fields. If breath sounds and must know priorities of diagnosis and intervention.
are absent, or if the chest does not rise with ventilation, one A finely tuned office staff, acting as a team, can stabilize a
must immediately recheck the airway for missed obstructions patient in a matter of seconds and move on to advanced life
and assist the patient’s ventilation. support systems. ACLS protocols consist of more advanced life
After airway and breathing have been stabilized and proved support interventions such as bag-valve-mask assisted ventila-
to be functional, the patient’s circulation status is assessed. The tion, synchronized cardioversion, intravenous medications,
patient’s circulatory system perfusion capabilities are assessed monitoring, and patient evacuation to a higher level of care.
by feeling a pulse, observing the patient’s skin color and temper-
ature, and noting the level of consciousness. Pulses present in
peripheral circulatory system locations are a very reliable esti- Preparing Equipment and Supplies
mate of blood pressure; therefore, the use of a sphygmomanom-
eter in an unstable situation is unnecessary. If the patient has A properly prepared surgical facility should have a properly
a carotid pulse, the systolic blood pressure (SPB) is at least 60. equipped emergency cart. This device, often referred to as the
If there is a femoral pulse, the SBP is at least 70, and if there crash cart, is a mobile platform that can carry the instruments,
is a radial pulse, the SBP is at least 80. Peripheral capillary monitoring devices, and pharmaceuticals necessary to manage
refill time in the extremities correlates well with perfusion in a cardiovascular emergency. The cart should be mobile because
a warm patient. A nailbed capillary refill time in excess of a patient’s emergency may arise anywhere within the facility.
2 seconds indicates that the patient’s peripheral circulation is It is possible that the patient’s heart attack may not occur until
compromised. he sees his bill in the discharge office.
If the pulse is absent, CPR should commence. A peripheral The crash cart itself must be carefully monitored. It is best
vein intravenous access should be obtained and intravenous to keep a log to document the functionality of the equipment.
fluids should be given to the patient. If a defibrillator is present, The log should also verify that all of the pharmaceuticals are
the use of the quick-check paddles can provide information present and within their expiration dates. This may seem like
about the cardiac rhythm. If indicated, three quick defibrill- overkill; however, these tools are used so infrequently that the
ations, at 200, 300, and 360 joules should be immediately ad- logging requirement is helpful in keeping the staff aware of
ministered. their location and functionality. Nothing is more frustrating in
It is important to note that these ABCs involve very little an emergency situation than a laryngoscope with dead, crusted
equipment, and carefully trained office staff with little formal batteries or a nonfunctional cardiac monitor.
medical education can take the most important basic steps. In- I am trained in emergency medicine and personally believe
deed the most important steps in airway management have been in keeping a fully equipped crash cart that enables me to deliver
taught to the general public in CPR courses for the last 30 years. ACLS. This is not meant to be taken as dogma. In actual prac-
tice, many offices are not so fully equipped and do not have
monitoring devices, defibrillators, or intubation equipment.
They are, therefore, limited in their ability to deliver full ACLS
in a cardiac arrest situation and must rely on BLS and CPR
until help arrives from local EMSS.
A fully equipped crash cart contains the following:
● Basic monitoring tools: A cardiac monitor, pulse oxi-

meter, a blood pressure cuff, and a stethoscope.
● Emergency airway and oxygen delivery devices: Endo-
tracheal tubes of various sizes, a laryngoscope, suction
equipment and tubing, and a portable oxygen tank.
● Intravenous access access supplies: Intravenous fluids
and the equipment necessary to start a large-bore (14-
gauge or 16-gauge) peripheral line.
● Cardiac defibrillator: A device with synchronized cardi-
oversion capability and a rhythm strip printer.
● Medications: Drugs that are essential to the care of the
patient in cardiac arrest as developed in the pharmaco-
poeia listing of the American Heart Association.
Figure 7F-1 Opening the airway. Top view, airway obstruction
produced by tongue and epiglottis. Bottom view, relief by head tilt These and medications used in other emergency situations
and chin lift. should be kept on the cart (Tables 7F-1 and 7F-2).
Table 7F–1 Emergency Cart Equipment Once the staff is trained, rehearsal and retraining help main-
Defibrillator monitor Oxygen tank tain a higher level of performance. Mock emergency situations
Stethoscope Ambu-bags and drills—some announced and some unannounced—can be
Sphygmomanometer Oxygen (non-breathing) masks integrated into the surgery schedule. This gives the staff oppor-
Electrocardiographic electrode Nasopharyngeal airways tunities to practice their skills. Time should be allotted immedi-
packs ately after the drill to review the team’s performance. Open
Electrocardiographic paper Tracheal tubes discussion from the entire team will generate ideas that will
Microdrip intravenous tubing Endotracheal tube make its operation more efficient.
Macrodrip intravenous tubing Mini-tracheotomy kit
Intravenous start kits Intubation stylet Preparing for Patient Transfer to Another Facility
Intravenous catheter Yankauer suction tube
Tourniquets Laryngoscope Transfer protocols and agreements so that a surgery in progress
Small vein infusion set Magill forceps may be properly completed in a nearby hospital or another col-
Safety spectacles Size C batteries league’s office are important components of the plan. An emer-
Irrigation syringe Nasogastric tubes gency evacuation tray containing those instruments unique to
Seizure sticks Toomey syringe hair restoration surgery may be kept sterile in the office to be
taken with the patient to the prearranged alternative site where
the procedure will be completed. Temporary emergency closure
of the patient’s wounds, which can be effected with staples and/
or dressings, should be used to ensure the safe, rapid evacuation
of the patient. Donor tissue must be treated carefully, trans-
Preparing the Staff: A Team Approach ported on cooling trays, and kept with the patient.
Emergencies are best handled by a team approach. Thorough Prearranged agreements between a hospital facility and, pos-
and frequent team training reinforces each team members’ re- sibly, a colleague’s facility will ensure continuity of care for
sponsibilities and creates a level of confidence that prevents the patient.
panic and encourages the cool, methodical response necessary Additionally, it is most helpful to communicate with the
to handle any situation. local EMSS about the facility. It is best to invite the EMSS
It is valuable for multiple members of the staff, including into the facility for a site visit. During that time, they will be-
business office staff, to be familiar with the techniques of airway come aware of the facility’s exact location, the type of services
management and CPR. Each can be trained to recognize a com- provided, the level of emergency care that the facility can pro-
promised airway and to deal with it. Each can learn how to vide, and the best evacuation and access routes of both the
assess the ABC’s and know how to intervene at the BLS level. facility and planned destinations.
Paramedical and nursing assistant staff members should each
be given a specific task assignment in the event of an emer- Preparing for Environmental Emergencies
gency. Who gets the crash cart? Who activates the EMSS to Given that resuscitation situations are so rare in hair restoration
evacuate the patient to a facility that can provide a higher level surgeries, one may assume that an environmental emergency
of care? Who scribes the record of events? Who gets the intrave- may be more likely. The development of an emergency response
nous equipment ready, and who helps with CPR and airway plan to an environmental emergency is very office specific.
management? Specific task assignment and cross training are How does the team respond to a fire, earthquake, or loss of
important in building a team that can respond promptly and power in the operating room facility? What plans have been
efficiently. made for emergency lighting? How does the surgeon plan to
protect the patient and unset donor tissue under these extreme
circumstances?
Fire exits must be clearly marked and illuminated with bat-
Table 7F–2 Emergency Pharmacology tery lights that can operate when the power grid is off in the
facility. Similar lighting should be available in the operating
Cardiac and anti-arrhythmic Miscellaneous emergency agents rooms so that emergency closures can be completed before pa-
agents • Diazepam (Valium) (for tient evacuation. The physical characteristics of each facility
• Lidocaine seizure) are different; therefore, every emergency evacuation plan will
• Procainamide (for • Phenytoin (Dilantin) (for have different requirements for lighting, exits, and transfer
ventricular arrhythmias) seizure) plans. It is not hard to make such contingency plans; however,
• Bretylium • Prednisolone (Solu-Medrol) trying to do so during a disaster is next to impossible. These
• Verapamil (for anaphylaxis) plans should be documented so that the current staff can refer
• Diltiazem • Nifedipine(gel caps)
to them, new staff can familiarize themselves with them, and
• Adenosine • Pseudoephedrine(Benadryl)
they can be rehearsed. Once again, specific staff assignments
• Epinephrine 1 : 10 : 000 (for anaphylaxis)
should be made.
• Atropine • Naloxone(Narcan) (narcotic
• Magnesium antidote)
• Sodium bicarbonate • Flucosanol (diazepam antidote) SPECIFIC EMERGENCY SITUATIONS
• Morphine calcium chloride • Prochlorperazine (Compazine)
• Nitroglycerine spray (for nausea and vomiting) In this section, some of the specific situations that a physician
may face in a hair transplant practice are discussed.
208 Chapter 7
Cardiac Arrhythmias (Cardiac Arrest and Other of a patient having chest pain. Obviously, a higher index of
Arrhythmias) suspicion should be present for patients who have a history of
cardiac disease or who have risk factors (e.g., high blood pres-
The most common cause of sudden death is cardiac arrhythmia. sure, diabetes, smoking, obesity). Although patients with active
Defining the appropriate emergency intervention is dependent cardiac disease should not be accepted for a surgical procedure,
on the correct analysis of two variables: (1) is the patient hemo- patients with a history of stable disease are often accepted after
dynamically stable, and (2) what is the cardiac rhythm? The being ‘‘cleared’’ medically by their cardiologist or primary phy-
American Heart Association has developed algorithms for deal- sician. This does not guarantee that a cardiac event will not
ing with specific cardiac arrest arrhythmias, be they: (a) ventric- occur, as first-time cardiac events can occur in previously
ular fibrillation, (b) ventricular tachycardias, (c) supraventricu- healthy patients. Some patients, especially those with diabetes,
lar tachycardias, (d) bradycardias, (e) asystole, or (f) pulseless can have myocardial ischemia without pain. They can manifest
electrical activity. There are four rhythms that are considered what is called an ‘‘angina equivalent’’ (e.g., severe weakness,
the most deadly: ventricular fibrillation (Vfib), ventricular sob, diaphoresis, nausea). The take-home message is that if a
tachycardia (Vtach), asystole, and third-degree heart block. patient, especially a high risk patient, has chest pain or one of
Electricity (e.g., defibrillation) is the cornerstone treatment of these angina equivalents, the physician should err on the side
Vfib and Vtach in the unstable patient. The physician is referred of safety and proceed as if the cause is potentially myocardial
to the ACLS manual for further details of these protocols. Peri- until proved otherwise. There should be a low threshold for
odic review of these protocols is wise, because the hair restora- transferring a patient with chest pain to an emergency room for
tion surgeon seldom has a need to refer to them. I recommend a more thorough evaluation. If a patient has associated hyperten-
keeping laminated copies of the protocols attached to the office sion, hypotension, or cardiac arrhythmias during an ischemic
emergency cart. event, these symptoms will need to be addressed and treated
Knowing which cardiac rhythm exists, as well as having the appropriately. Initial treatment for stable coronary ischemia in-
proper interventional equipment and medications, is necessary cludes oxygen, 2 liters, by nasal prong; sublingual nitroglycer-
for the application of the advanced ACLS protocols. As men- ine, 4mg over 5 minutes three times if needed; morphine sulfate
tioned earlier, many offices do not have monitoring devices, 2mg to 5 mg intravenously every 5 minutes for pain, and aspirin,
defibrillators, or intubation equipment. They are therefore lim- 150mg orally (see Appendix 7F).
ited in their ability to deliver full ACLS in a cardiac arrest
situation. In addition, simply being certified in ACLS and hav-
Hypovolemia
ing the appropriate equipment does not make one proficient in
the advanced treatment of varying life-threatening emergencies. Hypovolemia is caused by a true decrease in intravascular fluid
Time can be wasted and mistakes can be made when a practi- volume. It can be due to blood loss or dehydration. Serious
tioner inexperienced in dealing with emergencies on a frequent bleeding is usually not a problem in hair restoration but can
basis attempts to administer complicated medical therapy. If potentially occur during more extensive scalp reduction or flap
this is the case, it is important for the office staff and the practi- procedures. Patients who have lower baseline blood pressures
tioner to realize their limitations. They should follow the ABCs, and who then undergo long 6-hour to 8-hour surgeries are more
start CPR, if indicated, and call for EMSS backup immediately. susceptible to symptomatic hypovolemia.
EMSS will start ACLS protocols when they arrive. Until the Table 7F-3 classifies increasing degrees of hypovolemia and
EMSS arrive, the patient should be ventilated with a bag and hypovolemic shock. It is important to note that the blood pres-
mask, and consideration should be given to starting a line for sure and pulse do not change until the patient has lost 30% to
intravenous access and administration of medications and 40% of their intravascular volume (1500 to 2000 mL of fluid
fluids. More advanced therapy should be attempted only if the depletion). Indeed, the earliest sign of hypovolemia is a narrow
physician has the proper equipment and is comfortable using pulse pressure (systolic pressure minus diastolic pressure). The
it. pulse pressure narrows to less than 15 mm Hg when 15% to
30% of circulating intravascular volume has been lost (750 mL
Myocardial Ischemia (Angina, Myocardial to 1500 mL of fluid loss). The treatment of hypovolemia in a
Infarction) hair restoration practice is to control bleeding and initiate fluid
replacement. (see Appendix 7F)
Angina refers to an episode of myocardial ischemia that is short
lived and does not cause myocardial damage. Myocardial in- Incidental Asymptomatic Hypertension
farction refers to an episode of myocardial ischemia that lasts
long enough to cause myocardial muscle damage. Myocardial It is possible for patients, especially those with a history of
ischemia occurs when the oxygen demands of the myocardium hypertension, to arrive the morning of surgery with an elevated,
become greater than the supply. The most common cause of initial blood pressure (diastolic pressure greater than 95 to 100).
myocardial ischemia is coronary atherosclerosis, although other In general, asymptomatic hypertension is not an emergency, but
causes exist. The classic symptom of myocardial ischemia is the presence of an elevated blood pressure may cause increased
chest pain that is characterized as tightness in the chest that bleeding during surgery. Most of the time this is called white
radiates to the neck or left arm. It can be associated with diapho- coat hypertension and will resolve after the patient gets comfort-
resis, pallor, weakness, palpitations, and dizziness. If a patient able or is given preoperative diazepam (Valium). If the blood
develops chest pain during a procedure, it may be difficult to pressure remains elevated, it is worthwhile to see if a dose of
be certain whether it is cardiac in origin. It is beyond the scope routine blood pressure medication was missed. If this is the case,
of this text to review the differential diagnosis and evaluation giving the patient the missed dose may resolve the situation. If
Table 7F–3 Estimated Fluid Lossesa Based on Patient’s Clinical Presentation
Class I Class II Class III Class IV
Blood loss (ml) Up to 750 750–1500 1500–2000 ⬎2000

Blood loss (%BV) Up to 15% 15%–30% 30%–40% ⬎40%
Pulse rate ⬍100 ⬎100 ⬎120 ⬎140
Blood pressure Normal Normal Decreased Decreased
Pulse pressure Normal or increased Decreased Decreased Decreased
a
For a 70-Kg male.
the blood pressure remains elevated, it is prudent to reschedule other inflammatory mediators from mast cells. In its milder
the case after the patient’s primary care physician has brought forms, this results in an urticarial, pruritic rash. More severe
the blood pressure under control. forms can cause bronchospasm, wheezing, and shortness of
breath. The most severe manifestation of allergic reactions is
Vasovagal Reactions (Fainting, Syncope, Near anaphylactic shock. Anaphylactic shock can include the afore-
Syncope mentioned symptoms but also results in vasodilatation of the
peripheral vascular system and shock. It is a form of distributive
Vasovagal reactions are probably the most common emergency shock.
event that occurs in the hair restoration practice. A vasovagal Anaphylactoid shock is the same clinical syndrome as ana-
reaction is a reflex stimulation of the autonomous nervous sys- phylaxis, except that it is not IGE-mediated, and it does not
tem causing bradycardia and vasodilatation. This leads to a drop require previous sensitization to the offending agent. Studies
in blood pressure and resultant syncope or near syncope. Early have shown that the final pathway in both syndromes is the
symptoms may include generalized weakness, diaphoresis, pal- same. Although rare, antibiotics, local anesthetics, and nonste-
lor, and nausea. This rapidly progresses to full syncope. In se- roidal anti-inflammatory drugs (NSAIDs) can all cause allergic,
vere reactions, some tonic-clonic muscle contractions may anaphylactic, or anaphylactoid reactions in susceptible patients.
occur, which should not be mistaken for seizures. Vasovagal These are all used in a hair restoration practice, so it is important
reactions can be triggered by a variety of factors including: to try and elicit any history of previous allergic reactions to
pain, fear, emotional stress, sight of blood, and so forth. In a these agents. Epinephrine is the drug of choice for the treatment
hair restoration practice, this reaction most commonly occurs of systemic anaphylaxis because of its ability to inhibit the
during anesthesia or donor removal. Patients who have a past release of mast cell mediators and to counteract mediator-in-
history of this reaction are more likely to have it during surgery. duced vasodilatation and bronchoconstriction. Epinephrine is
In these patients, the intramuscular injection of .5 mg of atropine administered subcutaneously as an injection, 0.3 mL to 0.5 mL,
may be useful as a preventive measure. Preoperative diazepam of a 1:1000 dilution (0.3 to 0.5 mg). This dose is repeated every
may also limit the incidence of this reaction by decreasing the 10 to 20 minutes as needed. In the setting of severe hypotension,
anxiety and fear that surround receiving injections. Treatment epinephrine can be administered intravenously as a continuous
consists of placing the patient in the supine, or Trendelenburg, drip (1 mL of a 1:1,000 dilution in 500 m: of 5% dextrose in
position with legs raised. This nearly always results in a rapid water at a rate of 0.5 to 5.0 mg/minute [0.25 to 2.5 mL/minute]).
reversal of symptoms and signs. Patients who have their anes- Other secondary pharmacological measures include both an H1
thesia and donor removal performed in a sitting position are receptor blocker (diphenhydramine, 50 mg, administered intra-
particularly prone to become symptomatic during a vasovagal venously, intramuscularly, or orally), and an H2 receptor
episode. Physicians should instruct patients to notify the staff blocker (cimetidine, 300 mg, administered intravenously or or-
if they begin to feel nauseated or light headed. If this is done, ally), and corticosteroids (methylprednisolone, 50 mg, adminis-
the staff can immediately place the patient in the Trendlenburg tered intravenously). For persistent bronchospasm, an inhaled
position and avert a more severe episode. The head should be beta-adrenergic agonist bronchodilator and aminophylline may
turned so that the tongue does not fall back into the throat, be added to the regimen. Supplemental oxygen is administered
blocking the airway. Peripheral irritation, such as sprinkling or for the treatment of hypoxemia. Hypotension requires the ad-
dashing cold water on the face and neck, or applying cold, moist ministration of intravenous normal saline (1 liter every 20 to
towels is helpful. If available, aromatic spirit of ammonia may 30 minutes) and sometimes dopamine, 5 to 20 mg/kg/minute
be given cautiously by inhalation. If a patient does not respond (Appendix 7F).
fairly quickly to these measures, other causes of decreased level Hypoglycemia
of consciousness should be considered.
Hypoglycemia is usually defined as serum glucose of less than
Allergic, Anaphylactic, and Anaphalactoid 50mg/dL with associated symptoms. The neurological symp-
Reactions toms of hypoglycemia include confusion, agitation, lethargy,
seizures, and coma. Early physical signs and symptoms can
Typical allergic reactions are usually caused by a substance include hunger, nausea, diaphoresis, palpitations, and tremor.
(allergen) triggering the production of immune globulin E Hypoglycemia can mimic many other causes of altered mental
(IGE), which subsequently causes the release of histamine and status and decreased level consciousness. In the hair transplant
210 Chapter 7
practice, diabetic patients who take an oral hypoglycemic agent tract. When this disease causes laryngeal edema, it may be life
or insulin are at greatest risk. During longer procedures, these threatening. The cause of this disorder is either a dysfunctional,
patients may have a drop in serum glucose because of inade- or decreased, level of C1 inhibitor protein. Head and neck sur-
quate oral intake. It is important for the hair transplant surgeon gery has been shown to precipitate attacks of laryngeal edema,
to be aware of this history before surgery begins; this way, long and for this reason, the hair transplant surgeon should be aware
periods without food intake can be avoided. The treatment for of this entity. In general, an affected patient has a history of
hypoglycemia is either oral or intravenous glucose replacement this disorder; however, less severe forms of the disorder may
(Appendix 7F). be previously unsuspected. Assays for C1 inhibitor protein can
be used to make this diagnosis. Patients with this disorder can
Seizures be prophylactically treated preoperatively with , (Sanozol),
aminocaproic acid (Amicar), and fresh frozen plaza (Appendix
Grand mal seizures occur as a result of electrical activity of the 7F).
brain causing generalized repetitive tonic-clonic muscle con- Treatment of an active episode includes airway protection,
tractions. Typically, a seizure is short lived, lasting 1to 3 min- subcutaneous epinephrine, and/or racemic epinephrine by nebu-
utes and followed by a postictal stage during which the patient is lizer. In general, hereditary angioedema does not respond well
lethargic and confused but gradually returns to a normal mental to the usual methods of treating allergic reactions.
status. If the seizures become repetitive or last longer, the condi-
tion is called status epilepticus, which is a life-threatening situa-
tion. The most common cause of a seizure would be for a patient PHARMACOLOGICALLY RELATED
who has an idiopathic seizure disorder to not have a therapeutic EMERGENCIES
level of antiepileptic medication. In a hair restoration practice,
secondary seizures can be caused by hypoglycemia and lido- Medications are ubiquitous in a medical practice. Many patients
caine toxicity. The use of preoperative diazepam in a hair resto- are taking medications when they come to us, and we often add
ration practice is protective against seizures. Patients should be more for our treatment. A hair restoration surgeon should be
protected from injuring themselves during active seizures. After aware of the potential problems that can occur with these medi-
seizure activity ends and patients are in a postictal state, they cations as well as the appropriate treatment. In a broader sense,
should be given oxygen and ventalory support. An intravenous the patient’s pharmacological history provides the hair restora-
line can be inserted for the administration of diazepam to pre- tion surgeon with insights as to other potential problems the
vent recurrence. Hypoglycemia or lidocaine toxicity should be patient may have. For instance; those on psychotropic drugs
considered. The patient can be given oral or intravenous glucose may have unrealistic expectations of the planned surgery; iso-
empirically. The patient should be transferred to a higher level tretinoin (Accutane) is known to induce hypertrophic scarring;
facility for further evaluation. and those on cimetidine (Tagamet) may be at greater risk for
bleeding from stress ulcers.
Potential problems with pharmaceuticals can be divided into
Malignant Hyperthermia
three major categories: allergic reactions, toxic reactions, and
This is a very rare autosomal dominant disorder of metabolism interactions with other medications. The treatment of allergic
and skeletal muscle that can result in death. In susceptible pa- reactions has been discussed earlier. Toxic reactions to local
tients, it can be precipitated by volatile inhalation agents used anesthetics and epinephrine are discussed in detail in Chapter
in general anesthesia, muscle depolarizing agents (succinylcho- 8 (An Overview of Anesthesia), and are not repeated here.
line), or neuroleptic agents (e.g., haloperidol [Haldol]). The in-
cidence of this reaction occurring in patients receiving general Interactions with Other Medications
anesthesia is low, at a rate of less than1: 250,000. As these
agents are seldom used in hair restoration practices, the true In a hair restoration practice, there are a number of medications
risk during a transplant procedure is even lower. Most anesthetic that are commonly used, including: antibiotics, NSAIDs, nar-
agents used in hair restoration surgery (e.g., narcotics, local cotic analgesics, local anesthetics, and benzodiazepines, and
anesthetics, benzodiazepines, nitrous oxide), are not considered epinephrine.
a risk for malignant hyperthermia. The routine use of high levels of epinephrine and lidocaine
The major symptoms of malignant hyperthermia include necessitates that the surgeon carefully screen patients who are at
muscle rigidity, high fever-induced tachycardia, arrhythmias, risk of potential drug interactions or pharmacologically lowered
and elevated end tidal carbon dioxide. The primary treatment toxic thresholds. Rarely does this mean these patients are not
includes discontinuation of any inciting anesthetic agents, hy- candidates for hair restoration surgery; rather, their treatment
perventilation, control of hyperthermia with cooling techniques, plan must be modified to accommodate or eliminate the risks.
and rehydration. Muscle rigidity can be controlled with dantro- Appendix 7C contains a list of medications that potentially in-
lene (a nonspecific skeletal muscle relaxer), and benzodiazipnes teract with drugs commonly used in hair restoration. In addition,
(Appendix 7F). the Internet and a number of commonly used hand-held com-
puters now have programs that enable a physician to check
Hereditary Angioedema easily for drug interactions (i.e., PDR.net, Palm PDR). A few
of the more notable drug interactions are discussed here.
Hereditary angioedema is a rare autosomal dominant disease Non-selective beta-blockers have been recognized as inter-
with incomplete penetrance. It is manifested by recurrent edema acting with epinephrine and other sympathomimetic drugs to
of the extremities, face, gastrointestinal tract, and respiratory produce hypertensive crises. The beta-blockers allow an unop-
posed alpha response to the epinephrine, often accompanied by MAO inhibitors (MAOIs) may prolong and potentiate the ef-
reflex bradycardia. The cardioselective beta blockers have not fects of epinephrine. Patients using this class of drugs should
been shown to have this effect. One should consider weaning have treatment plan modifications as well.
patients taking nonselective beta blockers off these drugs before Macrolide antibiotics, especially erythromycin, clarithro-
their elective hair restoration surgery. mycin (Biaxin), and azithromycin (Zithromax) are often used
Additionally, all beta blockers have been shown to elevate in place of penicillin or cefalexin (Keflex) in those patients with
plasma lidocaine levels. Plasma clearance of lidocaine is re- a history of allergy to penicillin. These antibiotics can cause
duced by 15% to 45% in patients taking beta blockers. This lethal arrhythmias when used with the prescribed antihistamines
increases the risk of developing lidocaine toxicity. terfenadine (Seldane), and asetemizole (Hismanal). Macrolides
Monoamine oxidase (MAO) is one of the enzymes that me- can also cause life-threatening arrhythmias when taken with
tabolizes catecholamines, and it is fairly well documented that ketaconazole (Nizoral) or cisapride (Propulsid).
212 Chapter 7
APPENDIX 7A
APPENDIX 7B
214 Chapter 7
Patients Scheduled for Morning Surgery:

APPENDIX 7C Please make sure that you have a full breakfast.
Below are the pre-operative instructions that Dr. Unger sends
to patients 10 weeks before surgery EXCEPTION:
If you are having intravenous sedation by the anesthetist,
you are not to eat anything after midnight on the evening
PRE-OPERATIVE INSTRUCTIONS before surgery. You are permitted to have a small amount
IMPORTANT: YOU MUST STRICTLY FOLLOW THESE of clear liquids when you awaken on the morning of surgery.
INSTRUCTIONS TO AVOID COMPLICATIONS (i.e., excess Patients Scheduled for Afternoon Surgery:
bleeding and/or longer healing process) AND ENSURE THE Please eat a full breakfast and lunch.
BEST POSSIBLE RESULTS
EXCEPTION:
THREE (3) WEEKS BEFORE SURGERY: IF YOU ARE HAVING INTRAVENOUS SEDATION BY
THE ANESTHETIST, YOU MAY HAVE A LIGHT
ELIMINATE intake of vitamin E capsules or vitamin pills con- BREAKFAST BEFORE 7:00 A.M.
taining vitamin E. Notify office now re: any medications you All other patients are to eat a good breakfast and a good
will be taking at time of surgery. Some have to be discontinued, lunch.
or an alternate drug may have to be substituted.
SEE the attached list of conventional medicines that may
cause bleeding (page 6). OTHER IMPORTANT INSTRUCTIONS
SEE the attached list of herbs, minerals, and supplements
MEDICATIONS: At least three (3) weeks before the date of
that may cause bleeding (page 6).
your surgery, you must contact our office if you are using any
If you live out of town, make arrangements to stay over-
medications (prescription or over the counter).
nightbecause traffic and/or weather could delay your arrival at
DO NOT TAKE: (1) Any monoamine oxidase (MAO) in-
our office. If you arrive late, your appointment may have to be
hibitor (e.g., Parnate, Marplan, Niamid), etc.
postponed. The day after surgery, do not book flights until after
(2) SELDANE (antiallergy medication) or NIZORAL
12:00 noon. If you want to be seen very early the day after
(antifungal medication) when you are taking our prescribed an-
surgery, please arrange this with the appointment secretary 1
tibiotic: ERYTHROMYCIN or P.C.E. (Polymer-Coated
to 3 weeks before your appointment.
Erythromycin) OR CEFADROXIL (Duricef).
ANTIBIOTIC: If you are allergic to erythromycin or P.C.E.
ONE (1) WEEK BEFORE SURGERY: (Polymer-Coated Erythromycin), cefadroxil or penicillin, con-
DO NOT take any ASPIRIN (ASA) or any drugs containing firm with our office that you have notified us of the allergy and
aspirin. (Read the label of your over-the-counter cold remedies you will receive a different antibiotic.
to make sure they do not contain aspirin. A list of some of them ICE PACKS: Two (2) reusable cold packs will be given to
can be found on page 7.) Note: You may use Tylenol. you to be used starting the day after surgery.
DO NOT drink any alcohol (wine, beer, liquors). CLOTHING: On day of surgery, do not wear any shirt or
DO NOT use marijuana or any nonapproved drugs. other clothing that needs to be pulled over your head to be
removed. Wear a shirt/sweater/jacket with buttons or zipper that
opens completely. We suggest that on the day of surgery women
DAY BEFORE SURGERY: patients bring a scarf to cover the bandage. The same scarf may
PLEASE drink one quart (1-liter) of fluids the day before sur- be used the next day, after bandage removal and hair washing.
gery. TRAVEL/ACCOMMODATIONS: If you live outside the
Ibuprofen and Naproxen should be discontinued. Trade area, please make arrangements to stay overnight in town for
names of products containing these medications can be found 2 nights (the evening before your surgery and the evening after
on page 7. your surgery).
Evening Before Surgery: Because it is crucial that you
arrive for your appointment on time, and traffic and/or weather
NIGHT BEFORE SURGERY:
conditions may delay your arrival, it is important that you stay
Shampoo/rinse hair well with any shampoo. in the area for the evening before your surgery. If you arrive
If you have long hair, please use a cream rinse. late, your surgery may have to be rescheduled to a different
Get a full night’s sleep. date (subject to availability).
Day of Surgery: The drugs administered during the proce-
DAY OF SURGERY: dure will significantly impair your driving ability; conse-
quently, you will not be able to drive after your surgery. Ideally,
PLEASE DO NOT be late for your appointment. Allow for you should therefore plan to take a taxi or arrange to have
unusual traffic delays. someone pick you up and remain with you overnight. If you
Take first dosage of antibiotics 2 hours before scheduled are unable to have someone stay with you overnight, you can
time of surgery–unless otherwise directed. stay at one of several nearby hotels that offer our patients special
Shampoo your hair well with any shampoo. rates.
Conventional Medications That Can Cause Bleeding
Acetaminophen Dexchlorpheniramine Mononitrate Piroxicam

Acenocoumarol Diclofenac Isotretinoin Propylthiouracil
Acetylsalicylic acid(aspirin) Dicumarol Ketoprofen Reserpine
Aggrenox Diffunisal Ketorolac Reviparin
Alprostadil Digitoxin Levodopa Robaxisal
Amoxicillin Dipyridamole Levonorgestrel Salsalate
Amtolmetin Donepezil Lopinavir/ritonavir Sertraline
Anagrelide Emperin Magnesium Sodium
Anisindione Enoxaparin Meloxicam Salicylate
Ardeparin Ethacrynic acid Methimazole Soma
Ascriptin Etodolac Methotrexate Sotalol
Auranofin Etretinate Mycophenolate Mofetil Sulindac
Carbenicillin Felbamate Nabumetone Suprofen
Chlorphenesin Fenoprofen Naproxen Tiaprofenic Acid
Chlorpheniramine Fiorinal Nelfinavir Ticlopidine
Cholestyramine Fluoxetine Nimodipine Tinzaparin
Choline salicylate Flurbiprofen Nitroglycerin Tolmetin
Ciprofloxacin Fluvoxamine Norgesic Tranexamic Acid
Clopidogrel Ibuprofen Oxaprozin Tretinoin
Dalteparin Indinavir Paramethadione Trimethadione
Danaparoid Indomethacin Paroxetine Vicoprofen
Danazol Indoprofen Penicillin G Warfarin
Dantrolene Interferon beta-1b Pentoxifylline
Darvon Isosorbide Percodan
Evening of Surgery Date: You will need to return to our can be found in drugstores, beauty supply shops, and health
office the morning after surgery for hair washing and a check food shops):
of the donor and recipient areas. Therefore, you must plan to Redken, Nexxus, Neutrogena
stay in the area the evening of your surgery and to depart no Light hair sprays, gels, and mousses may be used when you
earlier than 12:00 noon the day after surgery. begin shampooing your hair, (the second morning after surgery)
HAIR LENGTH, PERMANENTS, AND COLORING: but preferably as little as possible for the first week, and they
You should let your hair grow to a length of 2 1/2 to 3 inches must be washed off daily. Any hair spray that has a nonalcohol
in the back and on the sides of your head (this allows for easy base may be used.
coverage of donor areas after surgery). Permanents and/or hair CAMOUFLAGE: You may have an important meeting or
coloring may be done up to days before surgery. After surgery, function you must attend after your surgery and you might like
it should not be done until all of the crusts have fallen off—gen- to be able to use a cover-up makeup to camouflage the recipient
erally within 1 to 3 weeks. area grafts for a few hours. Two suggestions: (1) Lancome:
HAIR PRODUCTS: Recommended shampoos and condi- ‘‘Maquicontrole’’, an oil-free, water-based makeup available
tioners include most products under the following labels (these at large department stores), or (2) any other water-based makeup
Herbs, Vitamins And Minerals That Can Cause Bleeding
Angelica root Devil’s claw Horse chestnut Red clover

Arnica flower Dong quai Licorice root Rue
Anise Fenugreek Lovage root Saw palmetto
Asafetida Feverfew Magnesium Sweet clover
Bogbean Flaxseed Meadowsweet Turmeric
Borage seed oil Lucid Onion Umbelliferae
Bromelain Ganoderma Papain Vitamin E
Capsicum Garlic Papaw Willow bark
Celery Ginger Parsley Szechuan pepper
Chamomile Ginkgo biloba Passionflower herb Plant bark
Clove Ginseng Poplar
Co-enzyme Q 10 Green tea Quassia
Danshen Guggul Quinine
216 Chapter 7
SOME OVER THE COUNTER MEDICATIONS TO AVOID BEFORE SURGERY WHICH CONTAIN ASPIRIN
(ACETYLSALICYLIC ACID) OR IBUPROFEN
CONTAINS APIRIN • Bayer Aspirin & • Empirin (Pu mo uglis • St. Joseph Aspirin for children
Children’s Chewable lveilcome) • St. Joseph Cold Tablets for
• Alka-Seltzer Pain Reliever & Aspirin • En Tab-650 Tablets children
Antacid • Bayer Children’s Cold • Excedrin • Sine-Off Sinus Medicine
• Alka-Seltzer Plus Cold Tablets • Extra-Strength Bufferin Tablets-Aspirin
Medicine • Bufferin Capsules & Tablets • Triaminic Tablets
• Anacin Analgesic Capsules • Cama Inlay-Tabs • 4-Way Cold Tablets • Vanquish
and Tablets • Congespirin • Goody’s headache powders
• Arthritis Bayer Timed-Release • Coricidin D Decongestant • Medipren
Aspirin Tablets • Momentum Muscular
• Arthritis Pain Formula by the • Coricidin Demilets & Backache Formula CONTAINS IBUPROFEN
Makers of Anacin Medilets for Children • Midol
• Arthritis Strength Bufferin • Coricidin Tablets for • Norwich Aspirin & • Advil
• Ascriptin Adults extra-strength aspirin • Motrin
• Aspergum • Ecotrin Tablets • Panalgesic (poythress)
SOME TRADE NAMES OF PRODUCTS CONTAINING IBUPROFEN AND NAPROXEN

IBUPROFEN: Advil, Vicoprofen, Dristan-Sinus, PseudoFed, Sinus Advance
NAPROXEN: Advil, Motrin, Anaprox, Naproxyn, Naprox, Synflex, Naxen
you can obtain more easily. Whichever cover-up method you vessels, increasing the blood supply to the area, and minimizes
use, shampoo and remove it as soon as possible after the func- the chance of some existing hair falling out temporarily. It also
tion. accelerates the healing of the grafts. A prescription for minoxi-
COMPACT DISKS/TAPES: Our operating rooms are dil is enclosed. The cost is approximately $65.00. Your pharma-
equipped with stereo equipment, so please feel free to bring the cist should make up a 3% solution. The hair will grow and any
kind of music you would like to hear. lost hair will regrow, even if minoxidil is not used, so filling
OPTIONAL: MINOXIDIL (Rogaine): We recommend a the prescription is optional.
twice-daily application of 3% minoxidil (Rogaine) to the recipi- You will be given separate and more detailed oral
ent area for 5 weeks, postoperatively. (Female patients should and written Post-operative Instructions on the day of sur-
also use this for 1 week before surgery.) Minoxidil dilates blood gery.
APPENDIX 7D
This appendix contains a list of medications that may interact with drugs commonly employed during hair transplantation surgery. In
addition, the internet and commonly used hand-held computers now have easily accessible programs that enable a physician to type in the
medications patients are taking and check for potential adverse interactions. (i.e.: PDR.net, “PDR Software for Palm Pilot) Drugs that
Potentially Interact with Hair Restoration Surgical Medications.)
Documentation
Generic name Druga Severity levels Half-life Type of adverse effects
ACEBUTOLOL HCL epi Not specified Not specified 13 h Bradycardia, hypertension, resistance to
epinephrine in anaphylaxis
AMIODARONE lido Major Poor 10–55d Lidocaine toxicity (cardiac, seizures, -coma
BUCINIDOLOL epi Major Fair ? Bradycardia,- hypertension, resistance to
CARTEOLOL epi Major Fair 6h Bradycardia, hypertension, resistance to
CARVEDILOL epi Major Fair 10 h Bradycardia, hypertension, resistance to
CHLORPROMAZINE epi Moderate Fair 48 h tachycardia, hypotension
CIMETIDINE lido Moderate Good 24 h Lidocaine toxicity (neurotoxicity, cardiac
arrhythmias, seizures)
CISATRACURIUM lido Moderate Poor 1/2 h Neuromuscular blocking action is enhanced
CLONIDINE lido Minor Good 24 h Lidocaine absorption is reduced after
combined epidural administration
CLORGYLINE epi Moderate Fair 5d hypertensive effects are increased
CLORGYLINE epi Major Fair 9h Extreme elevation of blood pressure
DILEVALOL epi Major Fair ? Bradycardia, hypertension, resistance to
ENTACAPONE epi Major Poor ? Increased chronotropic and arrhythmogenic
effects of epinephrine
FURAZOLIDONE epi Not specified Not specified 5d Alpha-adrenergic effects are increased
GUANETHIDINE epi Moderate Excellent 17 h Guanethidine effectiveness is decreased
HALOPERIDOL epi Moderate Fair 8h Vascular response is reduced
HALOTHANE epi Major Fair 5 min Ventricular toxicity (ventricular arrhythmia)
HYALURONIDASE lido Major Fair ? An increased incidence of a systemic
reaction to the anesthetic
ISOTRETINON lasers Major 25 h Thinning hair, hypertrophic scalp, eruptive
xanthomas
LABETALOL epi Moderate Fair 24 h Bradycardia, hypertension, resistance to
LEVOBUNOLOL epi Major Fair ? Bradycardia, hypertension, resistance to
METOPROLOL epi Major Fair 7h Bradycardia, hypertension,
lido Major Good 7h Lidocaine toxicity
MOCLOBEMIDE epi Moderate Fair ? Hypertension
NADOLOL epi Major Fair 7h Bradycardia, hypertension, resistance to
lido Moderate Good 7h Lidocaine toxicity
NITROUS OXIDE lido Moderate Poor 1 min Nitrous oxide toxicity (asphyxia)
PENBUTOLOL epi Major Fair 20 h Bradycardia, hypertension, resistance to
lido Moderate Poor 20 h Prolongation of the elimination half-life of
lidocaine
PHENELZINE epi Moderate Fair 10 d Hypertensive effects are increased
PHENYTOIN lido Major Fair 30 h Additive cardiac depressive effects;
depressive lidocaine serum concentration
PILOCARPINE epi Minor Fair 2h Increased myopia
(Continued)
218 Chapter 7
Continued
Documentation
Generic name Druga Severity levels Half-life Type of adverse effects
PINDOLOL epi Major Fair ? Bradycardia, hypertension, resistance to

PROPRANOLOL epi Major Excellent 4h Bradycardia, hypertension, resistance to
PROPOFOL lido Major Fair 15 min An increased hypnotic effect of propofol
PROCURONIUM epi Major Poor 20 m An increased risk of post-operative
reparalysis
SELEGILINE epi Moderate Fair 7d Hypertensive effects are increased
SOTALOL epi Major Fair 12 h bradycardia, hypertension, resistance to
SPIRONOLACTONE epi Moderate Fair 16 h Vascular response to epi is reduced
SUCCINYLCHOLINE lido Major Poor 4 min Succinylcholine toxicity (respiratory
depression, apnea)
TIMOLOL epi Major Good 4h Bradycardia, hypertension, resistance to
TRANYLCYPROMINE epi Moderate Fair 24 h Hypertensive effects is increased
TRICYCLIC epi Major Good 24h Cardiac arrhythmias, hypertension,
ANTIDEPRESSANTS tachycardia
TOCAINIDE lido Moderate Fair 15 h Cns toxicity (seizures)
a
This is the hair transplantation medication with which the offending drug may interact. (CNS ⫽ central nervous system) (epi ⫽ epinephrine) (lido ⫽ lido-
caine)
Note: Although the information contained in this table is current at the time of publication, the reader is advised to consult updated references when making
decisions concerning patient care.
APPENDIX 7E
220 Chapter 7
APPENDIX 7F
Emergency Situations in Hair Restoration Surgery
Problem Signs or symptoms Treatment
Cardiac Arrest Arrhythmias • Unresponsiveness • Airway, breathing, and circulation (ABC’-s)

• V-tach., V-Fib, asystole, 3 ° • No pulse • Cardiopulmonary resuscitation (CPR)
block • No respiration • Advanced cardiac life support (ACLS)
• These are immediate, life- ➢ Increased respiratory support with oxygen and
threatening “ ‘deadly’ bag/mask
arrhythmias ➢ Establish intravenous (IV) access
➢ ACLS arrhythmia protocols
• Call 911 and transfer immediately
“Stable” cardiac arrhythmias • Decrease LOC • ABC’s
• Stable V-tach, 1° & 2° block, • Abnormal pulse • CPR if indicated
supraventricular • Hypertension or hypotension • (ACLS)
tachyarrhythmia’-s ➢ Increased respiratory support with oxygen and
• “Stable” is a relative term … bag/mask
they can become unstable at ➢ Establish IV access
any time ➢ ACLS arrhythmia protocols
• Call 911 and transfer immediately
Myocardial ischemia • Chest “pain” or tightness radiating • ABC’s
• Angina, myocardial infarction to the arm or neck • Oxygen 2 L nasal prong
• Pallor, diaphoresisis, nausea, • Establish IV access
• Respiratory distress • Nitroglycerine (s1 or spray). 4 mg q 5 min times 3, if
• Cardiac arrhythmia needed
• Hypertension or hypotension • Morphine sulfate 2–5 mg IV q 5 min for paint
• Some patients, can be without • Aspirin–150 mg PO
pain and only manifest the • Cardiac arrhythmias as per ACLS protocols
associated symptom. This is • Call 911 and transfer
called and anginal equivalent. It
is more frequent in diabetics
patients
Dehydration and hypovolemia Narrow pulse pressure, tachycardia, • Make sure patient is hydrated before surgery and is
weakness, and hypotension able to take fluid during long surgeries
• Supine or reverse Trendelenburg position
• Control bleeding if present
• Replenish intravascular volume with IV normal saline
Asymptomatic stable Asymptomatic • If the patient has a history of HBP and is on daily
hypertension medication make sure they have taken their daily
• On the day of surgery, a patient medication has been taken
may manifest unsuspected • Maintain calm and relaxed atmosphere
asymptomatic high blood • Give usual preoperative benzodiazipines
pressure (HBP). This is not an • Observe and repeat blood pressure (BP) check
emergency, but it may cause • If HBP persists, consider canceling the case until BP
increased bleeding during can be controlled
surgery or pose an increased
risk to the administration of
epinephrine.
Hypoglycemia Altered mental status, weakness, • Carbohydrates PO
seizure, tremor, diaphoresis, • 50 mL D5W IV
tachycardia
Seizure Grand-mal seizure followed by • Prevent injury during active seizure
• Seizures may occur with decreased level of consciousness • Diazepam (Valium), 5–10 mg IV
hypoglycemia, anesthetic and confusion • Post-ictal stage
toxicity, and in patients with a ➢ Oxygen and respiratory support
past history of seizure • Call 911 and transfer
(Continued)
Continued
Problem Signs or symptoms Treatment
Vasovagal reactions (Most Altered mental status, diaphoresis, • Preventive measures (diazepam, 5–10 mg PO,
common event in a hair pallor, nausea rapidly followed atropine IM,.5 mg
restoration practice) by loss of consciousness • Supine or Reverse TrendelenbUrg
• Cold compresses, inhaled aromatic ammonia
• Atropine, 5 mg IV for persistent bradycardia
Simple allergic reactions Urticarial or erythematous rash • Epinephrine 1 : 1000 subcutaneously,
0.3 mL–0.5 mLq 20 min as needed
• Benadryl, 50 mg PO
Anaphylaxis and anaphylactoid Urticarial rash, bronchospasm, • Epinephrine 1 : 1000 subcutaneously, 0.3 mL–5mL q
reactions hypotension 20 min as needed
• (Benadryl), 50 mg IV
• Cimetidine, 300 mg IV
• Solu Medrol, 50 mg IV
• For bronchospasm
➢ Inhaled beta adrenergics
➢ Aminophyilline, 6 mg/kg IV loading dose
• For hypotension
➢ IV normal saline
• Call 911 and transfer
Local anesthetic toxicity Altered mental status, copper- 1. ABC’s
penny taste, seizures 2. Medications to control seizures:
hypotension, arrhythmias a. intravenous diazepam—5–10 mg bolus or
10–20 mg given slowly over 1–5 min
3. Hypotension
a. intravenous fluids
b. vasopressors to enhance myocardial contractile
force-ephedrine, 50 mg IM or 10–25 mg IV, or
epinephrine 1–2 mL (1 : 10,000) IV
c. for bradycardia—atropine, 0.6–1.2 mg IV
d. follow (ACLS) protocol
4. Asystole or unresponsive severe hypotension should
be managed with CPR.
Narcotic toxicity Decreased level of consciousness, (Nalaxone (Narcan), 0.1 mg–2 mg IV q 2–3 min until a
respiratory depression response is seen (up to 10 mg)
Benzodiazepine toxicity Decreased level of consciousness, Flumazenil, .2 mg IV q 2–3 min until a response is seen
respiratory depression (up to 3 mg)
Malignant hyperthermia (rare) Masseter muscle rigidity, high • Terminate anesthesia
fever, tachycardia, arrhythmias, • Hyperventilation
hypotension, tachypnea, • Control hyperthermia (ice packs and cooling
cutaneous mottling techniques
• Dantrolene, 2.5 mg/kg IV up to 10 mg
• Diazepam (Valium) 5–10 g IV
Hereditary angioedema (rare) Brawny nonpitting edema, urticaria, • Prophylactic
laryngeal edema respiratory ➢ Sanazol, 2 mg 3 times a day for 3 weeks before
distress, abdominal pain surgery
➢ (Aminocaproric acid) (Amicar) one unit the night
before surgery, 1 unit the morning of surgery and one
unit after surgery
➢ Fresh frozen plasma 1 unit the morning of surgery
• Active episode
➢ Subcutaneous and/or nebulized racemic epinephrine
➢ Airway protection
222 Chapter 7
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8
Anesthesia
8A. Overview of Anesthesia have increased. Anesthesia and hemostasis must be maintained
to perform these longer and more technically demanding surger-
Bradley R. Wolf ies. Adequate anesthesia improves hemostasis by limiting
bleeding caused by the cardiovascular effects of pain and anx-
INTRODUCTION iety.
The cardiovascular effects of pain are initiated by the release
There was a time when a shot of whiskey and a bite on a bullet of catecholamines from the sympathetic nerve endings and ad-
were the standard armamentarium for surgical pain control. renal medulla. The sympatho adrenal release of catecholamines
There has been a lot of progress since then. However, achieving and the effects of angiotensin II may result in hypertension,
both safe and effective anesthesia is often a challenge for the tachycardia, and, ultimately, increased bleeding. Bleeding de-
hair transplant surgeon. The proper selection and administration creases visibility during site creation and graft placement and
of an anesthetic agent is one of the most important components can lead to iatrogenic trauma, poor graft survival, and poor
of hair transplantation surgery. Patients should be physically results. H-factor is defined as subtle iatrogenic trauma to the
and psychologically as comfortable as possible, and this can be follicular growth center during the operative process and occurs
achieved only by minimizing pain and anxiety (1). The impor- when the surgeon or assistant directly traumatizes the follicle
tance of pain control in all aspects of hair transplantation cannot by overhandling or improper handling (3). Effective anesthesia
be overestimated (2). Toward this end, physicians must be controls pain and decreases bleeding, which facilitates site crea-
aware of the action, duration, dosages, potential toxicity, and tion and graft placement and leads to increased graft survival
treatment of toxic reactions for all medications used to provide and improved results.
anesthesia during hair transplantation surgery.
Improved Patient Safety
BENEFITS OF OPTIMAL ANESTHESIA
Allergic and/or toxic reactions to anesthetic medications are
Patient Comfort and Practice Growth potentially lethal complications of hair transplant surgery. With
longer procedures, more anesthetic is used over a longer time
Prospective patients provide evidence that fear of pain is one period. Knowledge of proper dosages, toxic dosages, and treat-
of the most frequently cited reasons for avoidance of hair trans- ment for allergic and toxic reactions increases the safety of the
plantation surgery. The amount of pain a patient expects plays procedure.
an important role in the decision to proceed from consultation
to surgery. The severity of pain that actually occurs during
surgery may also affect whether or not the patient returns for NONPHARMACOLOGICAL ADJUNCTS TO
needed subsequent surgical procedures. Thus, controlling pain ANESTHESIA
and anxiety before and during the procedure may have a signifi-
cant effect on the growth of a physician’s practice. In this chapter, the major pharmacological agents used for anes-
thesia are discussed; however, there are a number of nonphar-
Improved Hemostasis, Visibility, and Results macological adjuncts that can help reduce pain and anxiety.
The surgeon should explain anticipated events and proposed
Modern hair transplanting involves the transfer of smaller, and anesthetic management to allay the patient’s apprehension.
many more grafts per session than in the past. Because of these Other factors that can help reduce anxiety include friendly staff,
changes, the procedures require far more time to carry out. In relaxing music, pleasant and warm office decor, isolation of
addition, the technical skills needed to prevent graft trauma the reception area from the odors and noises of the operating
225
226 Chapter 8
rooms, and absence of instruments and blood from the patient’s mainstay of cutaneous anesthesia in hair transplantation
view. Operating rooms can be equipped with radio, television, surgery.
and/or videocassette recorders to distract the patient’s attention 3. Intramuscular administration: Uptake of drugs after in-
during the anesthetic administration and the surgical procedure. tramuscular (IM) injection is more rapid than after sub-
Providing the patient with Internet access during surgery is now cutaneous (SC) administration because of greater blood
a possibility. Any effective nonpharmaceutical method the phy- flow (4).
sician employs to reduce anxiety will help to create a relaxed, 4. Intravenous administration: Intravenous injection by-
confident patient and contribute to a successful surgical out- passes absorption processes so that therapeutic blood
come. concentrations can be rapidly attained. This is especially
advantageous when rapid onset of drug action is desired.
It also facilitates titration of dosage to individual pa-
LOCAL ANESTHETICS VERSUS SYSTEMIC tients’ responses, which, in the hands of physicians ex-
SEDATIVES AND ANALGESICS perienced with this technique, adds a level of safety and
control. If the IV line that is used to administer the
In general, medications used for outpatient anesthesia in hair
anesthetic remains in place during surgery, ongoing and
transplantation can be divided into two broad categories de-
immediate access is available to treat potentially ad-
pending on whether the primary effect desired is local or sys-
verse reactions with therapeutic medication. Unfortu-
temic.
nately, rapidity of onset also has its hazards, especially
in the hands of physicians who are less experienced
Locally Active Agents with the use of IV medications. Should an adverse drug
True local anesthetic agents such as lidocaine or bupivacaine reaction or overdose occur, the effects are immediate
(Marcaine) are used for nerve blocks or field blocks. Solutions and potentially severe. A relatively small number of
containing various concentrations of epinephrine are used for physicians performing hair transplantation surgery rou-
local hemostasis and tumescence. Although the primary pur- tinely use IV preoperative sedatives and narcotic anal-
pose of these agents is their local effect, we must be aware of gesics, but, as implied, this is less safe for most sur-
their incidental and potentially serious systemic side effects. geons.
5. Inhalation administration: Uptake of inhalation anes-
thetics from pulmonary alveoli to the blood is exceed-
Systemically Active Agents
ingly rapid because of the large total surface area of the
Sedative-hypnotics, anxiolytics, synthetic narcotic analgesics, alveoli and the fact that alveolar blood flow is almost
and nitrous oxide are among the most common systemically equal to cardiac output. Nitrous oxide anesthesia is of-
active agents used in outpatient hair transplant surgery. They fered by some physicians performing hair transplanta-
are used in various ways to reduce anxiety, decrease pain, and tion surgery to minimize the pain associated with the
create a state of conscious sedation. Conscious sedation is dis- initial injection of local anesthetics. The anesthetic
cussed later in the chapter. Other agents used for general anes- should be given only by trained anesthetists, unless pre-
thesia (intravenous (IV) or general anesthetic inhalation agents) viously prepared mixtures of nitrous oxide and oxygen
are usually not employed in outpatient hair transplant surgery. are self-administered by the patient.
6. Transcutaneous Administration: There are now several
topical anesthetics that are being used before dermato-
ROUTES OF ADMINISTRATION logic procedures. There is, however, some controversy
concerning the efficacy of transcutaneous anesthesia in
Systemically active agents can be delivered orally, subcutane-
hair restoration surgery. Cutaneous application of
ously, intramuscularly, intravenously, or by inhalation. Local
EMLA (eutectic mixture of local anesthetics) cream, a
anesthetic agents are usually administered subcutaneously or
mixture of lidocaine and prilocaine, reduces the pa-
transdermally.
tient’s perception of pain and temperature. After 60
1. Oral Administration: This is a common route of admin- minutes of cutaneous application under occlusion, the
istration. The advantages of oral administration are con- local effect of EMLA is sufficient for virtually painless
venience, economy, and safety. Disadvantages are re- needle insertion and minor superficial skin surgery. The
quirement of patient’s cooperation, incomplete analgesic efficacy increases with longer application
absorption, and metabolism of the drug in the gastroin- times. EMLA cream has, for example, induced suffi-
testinal (GI) tract or liver before it reaches the systemic cient analgesia for the cutting of split-skin grafts with
circulation. In hair transplantation surgery, sedatives, a dermatome after 120 minutes of application (5).
anxiolytics, synthetic narcotics, and nonsteroidal anti- Nevertheless, hair transplant surgeons have found the
inflammatory medications are commonly administered timing and untidiness of the application inconvenient
orally. and have been reluctant to adopt the use of EMLA.
2. Subcutaneous administration: Absorption of drugs from
the subcutaneous tissue is relatively slow, which per-
mits a sustained effect. The rate of absorption can be MEDICATIONS USED FOR ANESTHESIA
altered by changes in the drug formulation such as the
addition of vasoconstrictors to local anesthetic solu- General anesthesia is rarely employed, not only because local
tions. Subcutaneous injection of local anesthetics is the anesthesia is safer, but also because most patients are more
Anesthesia 227
comfortable knowing they will be awake during surgery. In amide type of local anesthetics such as lidocaine, mepivicaine,
addition, local anesthesia is less costly and the vasodilatation bupivacaine, prilocaine, and ropivacaine, are less allergenic,
that can occur with general anesthesia can result in more bleed- have greater potency, longer duration of action, and are consid-
ing. Local anesthetics, epinephrine, opioids (narcotics), benzo- erably more rapid acting. The amide class is primarily cleared
diazepines, barbiturates, propofol, and nitrous oxide are re- from the bloodstream by metabolism in the liver, with only
viewed in the next section. prilocaine having any significant extrahepatic metabolism.
Thus, patients with liver disease are more prone to toxicity from
the amide class. When choosing a local anesthetic, one must
LOCAL ANESTHETICS (TABLE 8A-1) take into consideration the duration of surgery, surgical anes-
thetic requirements, the potential for local or systemic toxicity,
Local anesthetics may be defined as drugs that block the genera-
and any other metabolic constraints.
tion and conduction of nerve impulses, presumably by increas-
ing the threshold for electrical excitation in the nerve. This
slows the propagation of the nerve impulse by reducing the rate Lidocaine
of rise of the action potential. In general, the progression of
anesthesia is related to the diameter, myelination, and conduc- Lidocaine (Fig. 8A-2) mixed with epinephrine is the most com-
tion velocity of the affected nerve fiber. mon short-acting local anesthetic used in hair transplantation
surgery. The amide local anesthetic class, including lidocaine,
has no cross reactivity with the ester group and therefore, for
Amide Versus Ester Local Anesthetics
example, can be used in patients who are allergic to procaine
The typical clinically employed local anesthetic molecule is (Novocain). The onset of action of lidocaine is 2 to 4 minutes;
weakly basic in nature, containing an amine residue that contrib- the duration of action is 1 to 2 hours when used alone and 2
utes water solubility in its quaternary form and that is separated to 4 hours when combined with epinephrine at a 1:200,000
from a lipophilic domain by an intermediate alkyl chain. These concentration. The recommended maximum total dose of lido-
molecules can be divided into two general chemical classifica- caine is 4.5 mg/kg (a maximum of 300 mg) when used alone
tions based on the structure of their intermediate chain: those and 7 mg/kg (a maximum of 500 mg) when combined with
containing an ester linkage and those containing an amide link- epinephrine at a 1:200,000 concentration. The manufacturer
age (Fig. 8A-1). The ester type of local anesthetics, which in- does not recommend exceeding a total of 50 mL of a 1% solu-
clude procaine, tetracaine, and chlorprocaine, are more aller- tion of lidocaine with epinephrine 1:200,000. However, this
genic, more easily metabolized, and produce less systemic total dose is frequently exceeded in many types of dermatologi-
toxicity. This ester class is primarily cleared from the blood cal surgery, sometimes substantially, without occurrence of ad-
by plasma and liver cholinesterases. Persons with abnormal or verse effects. This is possible if its administration is done in a
deficient forms of plasma cholinesterases can therefore exhibit staged fashion with intervals of, for example, 30 minutes be-
signs of toxicity from usual doses of chlorprocaine (6). The tween doses.
Table 8A–1 Local Anesthetics Useful in Hair Transplantation
Average Average analgesic Max dose

Name Usual onset duration without and without and
generic conc. time with epinephrine with epinephrine
(trade) (%) (min) (min) (mg) Metabolism Type
Lidocaine 1 2–4 75 (30–120) 225 (120–280) 300 500e Liver Amide

(Xylocaine)
Prilocaine 1 2–4 75 (30–120) 250 (60–400) 400 900 Liver Amide
(Citanest)
Mepivacaine 1 2–4 135 (90–180) 240 (150–330) 400a Liver Amide (May
(Carbocaine) cross-react
w/ester)
Bupivacaine 0.25 5–10 200 (120–240) 360 (240–480) 175 225b Liver Amide
(Marcaine)
Ropivacaine 0.5–1.0 2–15 200 (120–360) NAc 375d NA Liver Amide
(Naropin)
a
Combined with levonordefin (1 : 20,00), which is a sympathomimetic amine used as a vasoconstrictor instead of epinephrine. Compared with epinephrine,
levonordefin has similar activity, is more stable, and less potent in raising blood pressure and as a vasoconstrictor.
b
Number refers to maximum single dose and can be repeated every 3 hours, not to exceed a daily dose of 400 mg.
c
Epinephrine has no significant effect in time of onset, duration of action, or in limiting systemic absorption of ropivacaine.
d
Not to exceed total dose of 770 mg over a 24-hour period.
e
No historical or clinical basis for this parameter exists via studies on human subjects.
228 Chapter 8
Figure 8A-1 Local anesthetic molecule.
Higher concentrations of epinephrine also increase the safety are areas that are relatively avascular and heavily adipose. Lido-
doses of lidocaine by slowing its absorption. Several studies caine is extremely lipophilic and is largely absorbed into the
have also suggested that the recommended maximum total dose underlying adipose tissue, much of which is ultimately re-
is quite probably too conservative. For example, 52 consecutive moved. Studies of lidocaine doses in suction lipectomy ob-
patients who had facial-cervical plasty performed were anesthe- viously cannot be applied to hair transplantation surgery be-
tized with lidocaine combined with epinephrine 1:400,000. Rec- cause scalp tissue, on the other hand, is highly vascular and
ommended total dosage of lidocaine was exceeded by 52.8% large volumes of adipose tissue are not removed during the
to 100%. Minimal therapeutic blood levels of lidocaine were procedure. Finally, the length of surgery and the concomitant
never achieved, raising questions about the generally accepted use of other local anesthetics, such as bupivacaine, influence
pharmacokinetics of lidocaine (7). the toxic dosage of lidocaine. The absolute toxic dose of lido-
Higher than recommended doses of lidocaine are also rou- caine has not been established and can be influenced by the
tinely used in suction lipectomy, with up to 55 mg/kg being factors noted earlier. The minimum lethal dose (MLD) for lido-
infiltrated. In suction lipectomy, however, the sites of injection caine is based on a patient’s body weight (in kg). There is no
historical or clinical basis for this parameter via studies in
human subjects (7).
The author as well as other hair transplant surgeons have
exceeded this recommended lidocaine dosage without patient
side effects. Unger, in his commentary at the end of this chapter,
notes that he almost always uses far larger doses of lidocaine
without having any clinically significant patient toxicity after
thousands of procedures, because staged administration and the
use of 1:100,000 to 1:50,000 concentrations of epinephrine are
employed. Seager has likewise described the same experience
(Seager, private communication). I myself retrospectively stud-
ied 48 consecutive patients who were undergoing follicular unit
hair transplantation (FUHT) surgery. An average of 1056 grafts
was performed over 8.46 hours. Twenty-five percent of patients
received more than 500 mg of lidocaine with no symptoms of
toxicity.
Until definitive studies on human subjects are performed to
Figure 8A-2 Lidocaine molecule. establish absolute criteria for the MLD of lidocaine, physicians
Anesthesia 229
must take into account multiple factors when determining the Ropivacaine
maximum lidocaine dosage including body weight, interval of
dosing, epinephrine concentration, general health status of the Ropivacaine, a new long, acting local anesthetic in the amide
patient, concomitant use of other local anesthetics, concomitant class, has the advantage of being less cardiotoxic than bupiva-
use of neuro protective medications (e.g., benzodiazepines), and caine. However, both ropivacaine and bupivacaine are consider-
total length of surgery. ably more cardiotoxic than lidocaine. Although ropivacaine is
structurally similar to bupivacaine, it displays different charac-
teristics. Statistically, the onset of anesthesia with ropivacaine
Prilocaine was nearly as rapid as that of lidocaine, but the anesthetic effect
lasted significantly longer. The depth and duration of sensory
Prilocaine is a lidocaine homologue and the only secondary block are, in general, similar to those of bupivacaine. The maxi-
amine local anesthetic that remains in clinical use. Unfortu- mum safe dosage has been documented at 375 mg (9). Ropiva-
nately, it can cause methemoglobinemia if (1) more than 500 caine mixed with epinephrine is not commercially available.
mg is used or (2) if the patient has an inborn deficiency of Ropivacaine controlled postsurgical pain when infiltrated di-
glucose-6-phosphate dehydrogenase. Prilocaine has a fast rate rectly into wound sites and was as effective as bupivacaine (10).
of clearance, increasing its margin of safety compared with that Ropivacaine has not gained popularity in the hair transplanta-
of other amide class local anesthetics. Personal experience has tion specialty because: (1) the anesthesia produced by bupiva-
shown prilocaine to cause less pain on injection than lidocaine caine and ropivacaine are similar, (2) surgeons have become
or bupivacaine. Should methemoglobinemia occur, it is treated accustomed to, and are therefore comfortable with, using bupi-
with intravenous methylene blue and administration of oxygen. vacaine in small nontoxic amounts for long-acting anesthesia,
and (3) ropivacaine is new, more expensive, and currently must
Bupivacaine be obtained by special order.
Bupivacaine (Fig. 8A-3) is the most commonly used long-acting Mixtures of Local Anesthetics
local anesthetic. Combined with epinephrine, it has a duration
of action that can be as long as 8 hours. Long-acting local Mixtures of local anesthetics are commonly used in hair trans-
anesthetics have proved to be effective for the suppression of plantation. For example, mixing lidocaine with bupivacaine has
both intraoperative and postoperative pain. These, anesthetics been reported to produce a block with rapid onset and long
are useful for lengthy procedures and prevent severe pain after duration. Yet, despite the potential theoretical benefits of com-
many types of surgical procedures. The recommended concen- bining local anesthetics, clinical and laboratory evidence sug-
tration for field blocks is 0.25%, whereas 0.5% is used for nerve gests that neural blockade produced by mixtures of local anes-
blocks. The maximum dosage is 225 mg when combined with thetics is unpredictable and may differ from blockade produced
epinephrine 1:200,000. Its disadvantage is increased toxicity by the individual agents (6). The results of a study comparing
that results from both direct actions on the heart and depressant lidocaine 1%, a 50/50 mixture of lidocaine and bupivacaine,
effects on the central nervous system (CNS). An intraoperative and bupivacaine alone, for example, indicated that with respect
injection of bupivacaine into the incision site of patients to onset and duration of anesthesia, there was no significant
undergoing cholecystectomy was shown in one study not only advantage to using a 50/50 mixture compared with using the
to decrease the use of narcotics postoperatively but also to im- two solutions independently (11). Furthermore, the use of the
prove pulmonary function after surgery (8). I use approximately mixture did not prove to have the advantage of early onset and
5 mL of bupivacaine, 0.25%, without epinephrine, in the donor prolonged duration as had been hypothesized.
area after it has been sutured. A ‘‘touch-up’’ injection of bupi-
vacaine can be administered in longer procedures after approxi-
mately 3 to 4 hours to prevent the recurrence of pain. EPINEPHRINE
Epinephrine is a vasoconstrictive agent that is used in hair trans-
plantation to prolong the duration of anesthesia, minimize the
peak level of local anesthetic in the blood, increase the intensity
of the blockade, and reduce surgical bleeding. These benefits
are particularly useful for longer procedures. Specifically, epi-
nephrine 1:100,000 increases the duration of action of lidocaine
from 2 to 42⁄3 hours and bupivacaine from 4 to 8 hours (12).
As noted earlier, by limiting systemic absorption, epinephrine
also increases the maximum safe dose of local anesthetics
(Table 8A-1).
Epinephrine acts directly on alpha, beta1, and beta2 adrener-
gic receptors. Cardiovascular responses to epinephrine are both
receptor site and dose dependent. Stimulation of alpha-adrener-
gic receptors located in blood vessels causes vasoconstriction,
whereas stimulation of beta2 adrenergic receptors causes vaso-
dilatation. In the heart, stimulation of beta1 receptors induces
tachycardia. With very low concentrations of epinephrine, the
Figure 8A-3 Bupivacaine molecule. beta-adrenergic effects predominate, producing vasodilatation
230 Chapter 8
and increased heart rate. At higher concentrations of epineph- ● Shiell defines super juice as a 1:80,000 or greater con-
rine, the alpha-adrenergic effects predominate, causing vaso- centration of epinephrine and uses a concentration up to
constriction and, in some cases, elevated blood pressure. In 1:40,000.
the lungs stimulation of beta2 receptors causes relaxation of ● Bernstein and Rassman define super juice as an epineph-
bronchial smooth muscle and therefore epinephrine is useful for rine concentration in the range of 1:25,000.
the treatment of bronchospasm. The concentrations commonly ● Cole and Shapiro use concentrations of up to 1:30,000.
used in local anesthetics (1:100,000 and 1: 200,000) primarily ● Beehner uses concentrations of 1:83,000 in the donor
induce local vasoconstriction, although an inadvertent general- region, 1:65,000 in the recipient area, and 1:25,000 when
ized systemic reaction can occur (13). necessary for dense packing of micrografts.
● Limmer routinely uses a concentration of 1:25,000 in
the recipient area using no more than 1 cc at a time and
The Issue of Safe Doses and Concentrations of a total of 10 mL to 20 mL over 4 to 6 hours.
Epinephrine ● I use a maximum concentration of 1:10,000 in the recipi-
Controversy exists with regard to the maximum concentration ent area, no more than one-half mL at a time, and I do
and dose of epinephrine that is considered both safe and effec- not exceed 5 mL in a 4-hour period.
tive to control bleeding in hair transplantation surgery. Potential No clinical or scientific studies have been performed to evaluate
systemic toxic effects of epinephrine include fear, anxiety, rest- the results and side effects of super juice. However, it is worth
lessness, pounding headaches, tremors, hypertension, and car- mentioning that the aforementioned physicians have done thou-
diac arrhythmias. Potential local toxic effects include delayed sands of cases without serious side effect when proper caution
healing, reduced wound tensile strength, skin necrosis, and in- is employed. Most physicians who use these higher concentra-
creased infection rates. These complications are dose related. tions limit the volume (and thus the dose) of solution given at
A multitude of factors influence the safe dose of epinephrine one time. They also make sure the interval between doses (at
including the site of injection, the concentration of local anes- least 15 to 30 minutes or more) is long enough for any systemic
thetic, the concentration of epinephrine solution, the duration effect to have worn off.
of surgical procedure, the intervals between infiltration of addi- Some perspective on the safety of epinephrine may be gained
tional epinephrine and the presence of underlying medical con- by looking at the recommended doses of epinephrine used in
ditions. The existence of so many factors has made it difficult other situations. The American Heart Association believes that
to create a single hard and fast rule, and medical judgment is 0.2 mg of epinephrine given subcutaneously is safe even in
required. cardiac patients. For the treatment of asthma, the drug insert
Several authors have attempted to quantify the optimal con- for epinephrine (American Reagent Laboratories) recommends
centration of epinephrine for vasoconstriction, but there is little a dose of 0.2 mg to 0.5 mg to be given subcutaneously or
agreement. In one study of 63 subjects undergoing head and intramuscularly, starting with a small dose and increasing if
neck surgical procedures, a 1:100,000 concentration of epineph- required The maximum dosage of epinephrine in a healthy adult
rine appeared to provide the maximal reduction in cutaneous patient varies from .01 mg/kg to .1 mg/kg, with no more than
blood flow. There was no statistically significant difference 0.1 mg to 0.5 mg given in any 10-minute period (15).
when lower concentrations of 1:200,000 and 1:400,000 were Table 8A-2 shows the actual dose of epinephrine that is
used. However, epinephrine solutions at very low concentra- administered with various volumes and concentrations of
tions of 1:800,000 provided significantly less vasoconstriction superjuice. Notice that the actual dose of epinephrine with these
than the aforementioned concentrations (14). The usual concen- higher concentrations and at the volumes used by the physicians
trations of commercially available epinephrine premixed with is well below the recommended safe and maximum doses men-
local anesthetic are between 1:50,000 and 1:200,000; therefore, tioned in the previous paragraph. (i.e., 1 mL of 1:25:000 solu-
it is clear that stronger concentrations of epinephrine have some tion of epinephrine is equal to .04 mg, which is much less than
benefits in some tissues and some procedures. Nevertheless, the recommended maximum single dose of 0.5 mg).
the results of that study are intriguing. The foregoing discussion is meant to apply to healthy pa-
Despite the foregoing, many hair transplant surgeons use tients. Patients should obviously be screened for preexisting
higher concentrations of epinephrine, so-called super juice, be- conditions that may be exacerbated by epinephrine administra-
lieving empirically that they, in fact, get better vasoconstriction tion. Epinephrine should not be used in situations in which its
and homeostasis. The exact concentration and method of use undesirable systemic side effects would be particularly danger-
of these higher concentrations varies from practice to practice. ous, such as in patients with unstable angina, a history of dan-
A survey of the individual practices of various hair transplant gerous arrhythmias, and poorly controlled or uncontrolled hy-
surgeons who were experienced in the use of higher concentra- pertension. However, it is unlikely such unstable patients would
tions of epinephrine was conducted, and the results were as be accepted for hair transplantation. In patients with a history
follows: of stable cardiovascular disease, it would be prudent to discuss
the patient’s status with the primary care physician or cardiolo-
● Seager defines super juice as epinephrine in a concentra-
gist and use epinephrine in an even more cautious manner.
tion of between 1:25,000 and 1:50,000. He routinely uses
a 1:50,000 concentration with lidocaine in the recipient
area. In some cases, the 1:50,000 concentration does not OPIOIDS
prevent profuse bleeding, and 1:25,000 concentration of
epinephrine with lidocaine are intermittently and spar- The term opioids, is an all-inclusive term that distinguishes
ingly infiltrated with a 30-gauge needle (15). those drugs, both natural or synthetic, that have morphine-like
Anesthesia 231
Table 8A–2 Actual doses of Epinephrine Administered with Different Concentrations and Volumes of Solutions
Total milligrams administered

Volume
(mL) mg (1 : 10,000) mg (1 : 20,000) mg (1 : 30,000) mg (1 : 50,000) mg (1 : 80,000) mg (1 : 100,000)
1 0.10 0.05 0.03 0.02 0.01 0.01

2 0.20 0.10 0.07 0.04 0.03 0.02
3 0.30 0.15 0.10 0.06 0.04 0.03
4 0.40 0.20 0.13 0.08 0.05 0.04
5 0.50 0.25 0.17 0.10 0.06 0.05
10 1.00 0.50 0.33 0.20 0.13 0.10
15 1.50 0.75 0.50 0.30 0.19 0.15
20 2.00 1.00 0.67 0.40 0.25 0.20
qualities from drugs that bind at morphine receptor sites (16). tient, after administering IV midazolam (2.5 mg) or diazepam
Analgesia is generally the primary reason for administration (8 mg), he routinely and slowly (over 20 to 30 seconds) injects
of opioids. The opioids are more selective for painful stimuli, 35 mg of meperidine.
leaving other sensory and motor modalities relatively less af-
fected. This can facilitate injection with local anesthetics be- Fentanyl
cause opioids decrease sensitivity to pinprick. Because opioids
are not complete anesthetics, they have to be used in combina- Fentanyl is a potent opioid commonly used for conscious seda-
tion with other drugs for the induction of conscious sedation. tion because of its rapid onset and short duration. Fentanyl is
Opioid agonists induce sedation, euphoria, and analgesia but 100 times more potent than morphine (18). Fentanyl is titrated
not amnesia. Drugs in this group that are used for ambulatory at a dose of 0.5 ␮g/kg to 1.0 ␮g/kg given slowly. This dose
surgery include morphine, meperidine, and fentanyl. The use can be repeated after 20 to 30 minutes. Further doses should
of opioids poses a few problems. Opioid agonists can induce not exceed 0.5 ␮g/kg (17). Larger doses are not recommended
respiratory depression as well as nausea and vomiting. In addi- for office sedation because of the potent respiratory depressant
tion, storing opioids in an office requires a high level of surveil- effect of fentanyl, unless it is given by trained anesthetists in
lance to prevent theft and abuse. These are some of the reasons offices equipped with proper resuscitative/ventilatory equip-
that use of opioids for anesthesia is not as common as use of ment.
other modalities such as benzodiazepines.
Morphine BENZODIAZEPINES
Morphine is the opioid narcotic with which other analgesics Benzodiazepines are among the most popular drugs used for
are compared. It provides effective analgesia for 3 to 4 hours, preoperative medication in hair transplanting. They are used
has low CNS toxicity, and is preferable for painful procedures for preoperative anxiolysis, amnesia, and sedation. Importantly,
lasting longer than 30 minutes. Morphine has a slow onset and for those using high total doses of lidocaine, these drugs also
provides a comforting combination of anxiolysis, analgesia, se- have anticonvulsive activity. They facilitate the inhibitory neu-
dation, and tranquillization when combined with benzodiaze- rotransmitter gamma-aminobutyric acid (GABA) producing a
pines. The preferred route of administration is IV, at 0.1 mg/ calm, sedated state. Owing to the specific action on the GABA
kg or less, with diazepam or midazolam, the most commonly receptors in the CNS, there is relatively little depression of
given benzodiazepines. Caution must be exercised because the ventilation or of the cardiovascular system with usual premedi-
respiratory depressant effects of morphine and other opioids cant doses. The drugs most commonly employed for sedation
are markedly potentiated by benzodiazepines. in hair transplantation are midazolam and diazepam. Less com-
monly used benzodiazepines include lorazepam and oxazepam.
Meperidine The combination of usual doses of benzodiazepines with nar-
cotic-opioids, such as fentanyl, markedly potentiates the venti-
Meperidine causes less smooth muscle contraction, constipa- latory-depressant effect of the opioids.
tion, and cough suppression than morphine. In hair transplant-
ing, it is usually administered orally 30 minutes before surgery, Diazepam
at a dose of 25 to 50 mg, with or without other medications
such as diazepam. Some operators, however, prefer to use the The calming, amnestic, and sedative effects of diazepam make
IM or IV route. Given intravenously in doses of approximately it a very popular choice for premedication. It is the usual stan-
1 mg/kg, meperidine has an onset of 5 to 10 minutes and 2 to dard of comparison for other benzodiazepines. Because diaze-
3 hours’ duration of action (17). Unfortunately, a significant pam is insoluble in water and must be dissolved in organic
minority of patients experience nausea, and too rapid IV admin- solvents, pain may occur on IM or IV injection. Phlebitis is
istration can result in hypotension. Beehner has extensive expe- often a sequel of IV injection unless it is diluted with blood
rience using meperidine. In a monitored, normal, healthy pa- before injection (see later). Because absorption is unpredictable
232 Chapter 8
after IM injection and because of pain with parenteral adminis- Short-Acting Barbiturates
tration, many prefer to administer diazepam orally (19). The
usual oral dose is 5 mg to 20 mg. The peak action occurs after Secobarbital usually is administered to adults in oral doses of
60 to 90 minutes, whereas the elimination half-life may be as 50 mg to 200 mg when used for preoperative medication. Onset
high as 36 hours. Oral diazepam often produces an equivalent occurs 60 to 90 minutes after administration and sedative effects
blood level faster than the same IM dose. Dilution of diazepam last 4 hours or longer. Although considered a short-acting barbi-
by mixing, after venipuncture, 3 mL of blood with 2 mL of turate, it may impair performance for as long as 10 to 22 hours
diazepam (10 mg) in a 5-mL syringe decreases venous irritation (20). Pentobarbital may be administered orally or parenterally.
when it is injected. The oral dose used for adults is 50 mg to 200 mg.
Long-Acting Barbiturates
Midazolam
Pentobarbital has a biotransformation half-life of about 50 hours
Midazolam is a water-soluble, short-acting benzodiazepine. It making it unsuitable for shorter procedures.
has sedative, anxiolytic, and amnestic actions and is two to four
times more potent than diazepam. A significant advantage of Propofol
midazolam is that it is highly selective for amnesia, having an
amnestic dose that is one tenth that of its hypnotic dose. This Propofol is an ultra–short-acting IV sedative-hypnotic agent of
is beneficial in conscious sedation, as patients typically do not the alkyl phenol category. It is formulated as an aqueous emul-
remember the pain associated with the administration of local sion in soybean oil and sometimes referred to as ‘‘milk of amne-
anesthesia. Sedation after intravenous injection is achieved sia.’’ It has the advantages of rapid onset, fast emergence and
within three to five minutes. Peak sedation occurs in 30 to 60 return to baseline, and antiemetic effect. Like the barbiturates,
minutes. Given in recommended doses, it has the advantage of propofol can produce greater dose-related respiratory depres-
sion, apnea, and hypotension. Hair restoration surgeons should
not significantly affecting the gag reflex. The usual intramuscu-
not use propofol without a fully trained anesthesiologist or
lar dose is 0.05 mg/kg to 0.1 mg/kg. It is titrated 1.0 mg to 2.5
emergency physician present and facilities for positive-pressure
mg at a time when given intravenously.
ventilation immediately at hand (17). A high incidence of pain
The elimination half-life of midazolam is approximately 1
on injection occurs with propofol; however, pain depends on
to 4 hours and may be extended in the elderly. Tests show that
the site of administration and is minimized if the forearm or
mental function usually returns to normal within 4 hours after larger antecubital veins are used. The addition of 1 mL of 1%
administration (20). Intravenous midazolam is generally con- lidocaine (10 mg) to 19 mL of propofol significantly reduces
sidered superior to diazepam owing to its rapid onset of action, the incidence and severity of pain on injection. Propofol may
shorter half-life, faster patient recovery time, more profound be used for sedation during the 10 to 15 minutes required to
amnestic effect, and less frequent venous irritation. However, produce local or regional anesthesia; after this it can be discon-
it has less of an anticonvulsant effect than diazepam and some tinued.
patients dislike midazolam’s amnestic effect.
ADVERSE REACTIONS AND THEIR

TREATMENT
BARBITURATES AND PROPOFOL
Hair transplant procedures are usually performed in an outpa-
Barbiturates have been used in hospitals for many years as part
tient setting, with use of a combination of local anesthesia and
of the general anesthetic and preanesthetic regime. These drugs
oral or intravenous sedation. If an anesthesiologist is not present
are used primarily for their sedative effects. The barbiturates
to oversee patient sedation, the surgeon and staff must be famil-
may be given orally as well as parenterally and are relatively iar with the potential dangers of the drugs used and be able to
inexpensive. Adverse effects are dose related and, although they manage dangerous complications. The precise requirements
are fairly safe at therapeutic doses, at higher doses, respiratory vary according to local regulations but certainly include a range
depression and hypotension can occur. In addition, barbiturates of drugs for resuscitation, means of oxygen administration,
are unlikely to produce sedation in the presence of pain. For equipment for airway management and suction, and appropriate
these reasons, preoperative barbiturate administration for hair monitors. There should ideally also be a plan for hospital backup
restoration surgery is seldom used and has been replaced in in case of unforeseen complications. The safety and effective-
most instances by the use of benzodiazepines. ness of anesthetics depend on proper dosage, correct technique,
adequate precautions, and readiness for emergencies. The
smallest dose and concentration required to produce the desired
Ultra–Short-Acting Barbiturates
result should be administered. Optimally, surgeon and staff
The ultra–short-acting barbiturates, thiopental (Pentothal) and should be certified in basic and/or advanced cardiac life support.
methohexital (Brevital) can be used for conscious sedation.
Methohexital is twice as potent and half as long acting as thio-
LOCAL ANESTHETICS: ADVERSE REACTIONS
pental. The induction dose of thiopental is 3 mg to 5 mg/kg IV
and for methohexital, 1 mg/kg to 2 mg/kg. Respiratory depres- Common adverse reactions that can occur during the use of
sion may occur. Facilities for positive-pressure ventilation local anesthetics are vasovagal reactions, true allergic reactions
should be immediately available. (rare), and systemic toxicity.
Anesthesia 233
Table 8A–3 Treatment of True Allergic Reaction to Local

Vasovagal Reaction
Anesthetic
Vasovagal reactions during the administration of local anesthe-
1. Oxygen by mask
sia can lead to faintness and syncope. Faintness refers to lack of
2. Epinephrine 0.2–1 mg subcutaneously (0.2–1 mL of 1 : 1000
strength, with the sensation of impending loss of consciousness.
solution)—start with small dose and increase if required
Syncope comprises a generalized weakness of muscles, with 3. For severe anaphylactic reactions, intravenous (IV) epinephrine,
inability to stand upright and loss of consciousness. At the be- 1 : 100,000 should be administered (0.1 mg over 5–10 min or
ginning of the attack, the individual is nearly always in the 1 ␮g/min–4 ␮g/min IV drip)
upright position, either sitting or standing. The patient becomes 4. Diphenhydramine, 25–50 mg IV
confused, yawns, has ‘‘spots’’ before the eyes, and, possibly, 5. Hydrocortisone 100–200 mg IV
dimming vision and ringing in the ears. There is also a striking 6. Cimetidine 300 mg IV
pallor or ashen-gray color of the face, and very often the face
and body are bathed in cold perspiration. Nausea and sometimes
vomiting accompany these symptoms. The patient may remain
in this state for seconds to minutes or even as long as 30 minutes.
Usually the patient lies motionless with skeletal muscles re- examination (6). (Table 8A-3 lists treatment of allergic reac-
laxed, but a few clonic jerks of the limbs and face may occur tions.)
in exceptional cases shortly after the beginning of unconscious-
ness. Generalized tonic-clonic seizures are never a part of syn- Systemic Toxicity
cope. If seizures occur, other causes must be sought. If the
patient assumes the supine or Trendelenburg position, the attack Systemic blood levels of local anesthetic produce a concentra-
may be averted without complete loss of consciousness (21). tion-dependent continuum of effects ranging from therapeutic
Vasovagal syncope is a neurovascular reaction characterized to toxic (Fig. 8A-4). Systemic toxicity most frequently results
by hypotension and bradycardia. Patients at risk often have a from either accidental intravascular injection or administration
history of fainting at the sight of blood, when pain has been of an excessive dose of local anesthetic. The toxic effects are
inflicted, or at times of stress or anxiety. Syncope is common primarily directed at the CNS and the cardiovascular system
in physically fit patients who often have accentuated vagal tone. (CVS). The effects on the CNS are seen initially. The CVS is
Administering 5 mg to 20 mg of diazepam (Valium) 30 to 60 considerably more resistant; therefore, effects in the CVS occur
minutes before surgery can often prevent this reaction. For those after those seen in the CNS. To produce CVS collapse, four to
with a history of syncope during surgical and dental procedures, seven times the dose of local anesthetic must be given compared
the intramuscular injection of 0.6 mg of atropine sulfate is even with the dose that causes seizures (6).
more effective as a preventive measure. Treatment consists of The classic signs of neurotoxicity from local anesthetics are
placing the patient in the supine or Trendelenburg position with divided into early and late toxic reactions. The early signs in-
legs raised. This nearly always results in a rapid reversal of clude perioral numbness, a ‘‘copper penny’’ taste in the mouth,
symptoms and signs. The head should be turned so that the muscle twitching, tremors, shivering, and visual disturbances,
tongue does not fall back into the throat, blocking the airway. whereas later, more serious toxic complications include sei-
Peripheral irritation is helpful, such as sprinkling or dashing zures, coma, respiratory arrest, and cardiovascular collapse. Be-
cold water on the face and neck or applying cold, moist towels. cause the excitatory manifestations may be very brief or may
If available, aromatic spirit of ammonia may be given cautiously not occur at all, the first manifestation of toxicity may be drow-
by inhalation. If a patient does not respond fairly quickly to siness merging directly into unconsciousness and respiratory
these measures, other causes of decreased level of conscious- arrest (22). Local anesthetic-induced seizures can rapidly cause
ness should be considered. hypoxia, hypercarbia, and metabolic acidosis. At the first sign of
True Allergic Reactions

Unlike most adverse reactions, true allergic reactions are poten-
tially fatal. Fortunately, reactions to local anesthetics are rare.
Allergy to the commonly used amide class of local anesthetics
is exceedingly rare. Adverse reactions such as vasovagal syn-
cope and local anesthetic overdose are more common and may
be confused with a true allergic reaction.
Provocative skin testing can be used to differentiate between
adverse and true allergic reactions to local anesthetics. There
has not been a reported case of fatal allergy to amide anesthetics
in hair transplanting, therefore, such testing is rarely, if ever,
performed. Paraben derivatives, widely used in multidose local
anesthetic preparations, have excellent bacteriostatic and fungi-
static properties. The incidence of allergic reactions to parenter-
ally administered parabens is rare; however, some patients
thought to be allergic to local anesthetics were found to be
allergic to the preservative methylparaben after more careful Figure 8A-4 Lidocaine toxicity graph.
234 Chapter 8
neurotoxicity, the patient should be placed in the Trendelenburg Table 8A–4 Treatment of CNS and Cardiovascular Symptoms
of Local Anesthetic Toxicity
position, given supplemental oxygen, and administered 5 mg
to 10 mg of intravenous diazepam. Diazepam has been reported 1. Put patient in supine or Trendelenburg position
to be an effective anticonvulsant, with minimal side effects, 2. Secure, protect, and maintain open airway and administer
exerting its anticonvulsant properties by raising the seizure supplemental oxygen; intubate if unconscious, then hyperventi-
threshold of susceptible foci within the CNS. However, diaze- late; ask patient to hyperventilate if conscious. This may prevent
pam is relatively slow acting and may not stop seizures for 2 seizures. If not, call 911.
to 3 minutes after administration. It is therefore useful to give 3. Medications to control seizures:
oral diazepam preoperatively before convulsions occur and, as a. intravenous diazepam—5 mg–10 mg bolus or 10 mg–20 mg
noted earlier, intravenously at the earliest signs of neurotoxicity. given slowly over 1 to 5 min
Cardiovascular system toxicity is manifested by decreases 4. Medications for cardiovascular toxicity
in myocardial contractility and cardiac conduction. Low con- a. intravenous fluids
centrations may produce beneficial therapeutic effects such as b. vasopressors to enhance myocardial contractile force
prevention or treatment of arrhythmias, but higher concentra- (ephedrine—50 mg IM or 10 mg to 25 mg IV or epinephrine
tions may produce refractory arrhythmias and cardiovascular 1 mL to 2 mL (1 : 10,000) IV)
collapse. Bupivacaine is approximately 70 times more potent c. for bradycardia—atropine 0.6 mg to 1.2 mg IV
than lidocaine in blocking cardiac conduction; therefore, car- d. Follow advanced cardiac life support (ACLS) protocol
diac toxicity is seen more often with bupivacaine than with 5. Asystole or unresponsive severe hypotension should be managed
with cardiopulmonary resuscitation (CPR)
lidocaine, and the toxicity is more resistant to treatment (6).
Ropivacaine, similar to bupivacaine in onset and duration of
action, has been shown to be less cardiotoxic than bupivacaine
(9).
Cardiovascular system toxicity can be severe and difficult with the following exceptions: (1) beta blockers should not be
to treat. There is little information regarding the treatment of used as a single agent in epinephrine-induced hypertension be-
cardiovascular toxicity of local anesthetics in humans. Variable cause they may produce unopposed alpha-adrenergic stimula-
results have been described with use of epinephrine, amrinone, tion and paradoxically worsen hypertension; (2) phentolamine,
lidocaine, phenytoin, magnesium, bretylium, amiodarone, and an alpha-adrenergic antagonist, is higher on the list of possible
calcium channel blockers in the treatment of bupivacaine-in- therapeutic options. The dosage of phentolamine is 2 mg to 5
duced arrhythmias (23–25). Although lidocaine competes with mg IV every 5 to 15 minutes. Other therapeutic options used
bupivacaine for sodium channels, its use is generally avoided for a hypertensive crisis include nitroprusside (IV), nitroglycer-
owing to the risk of increased CNS toxicity (26). Animal data ine (IV, SL, or topical), hydralazine (IV), or Nifedipine (orally
suggest that high doses of epinephrine may be necessary to [PO]).
support the heart rate and blood pressure; atropine may be useful
for bradycardia; DC cardioversion may be often successful; Epinephrine/Beta-Blocker Reaction
and ventricular arrhythmias are probably better treated with
amiodarone than with lidocaine. Procainamide should be If a patient is taking a nonselective beta blocker (propranolol
avoided to prevent further sodium channel blockade. The ad- or nadolol) and receives local anesthetic with epinephrine, the
ministration of magnesium sulfate and/or sodium bicarbonate blockade of the beta–receptor-mediated vasodilatation effect
should also be considered in the presence of refractory ventricu- may result in unopposed alpha–receptor-mediated vasocon-
lar arrhythmias secondary to local anesthetic administration striction. This can, theoretically, produce serious drug-induced
(27). (see Table 8A-4 for the treatment of CNS and CVS symp- hypertension and bradycardia and can lead to cardiac arrest
toms of local anesthetic toxicity). (13). The proposed mechanism of this epinephrine/beta-blocker
reaction is as follows: Unopposed alpha-receptor vasoconstric-
tion of the peripheral nervous system causes severe drug-in-
EPINEPHRINE: ADVERSE REACTIONS duced hypertension. The reflex response to this hypertension
is stimulation of carotid artery baroreceptors, which in turn
It is my experience that preoperative oral diazepam (10 mg) activate the parasympathetic nervous system to slow the heart
prevents or lessens the milder side effects of epinephrine. Treat- through the release of acetylcholine from the vagus nerve. Be-
ment includes cessation of epinephrine use, reassurance, and cause the beta receptors in the heart are blocked, the sympathetic
observation with appropriate monitoring of blood pressure and nervous system is unable to counter act this vagal response and
heart rates. Serious side effects include elevated blood pressure, restore a normal heart rate. Thus, if the vagal response is strong
tachycardia (heat rate greater than 140 beats per minute), and enough, bradycardia can progress to full cardiac arrest. There
premature ventricular contractions with a frequency greater than is little risk for this reaction with cardioselective (B1) beta
six per minute or closely coupled (R on T phenomenon), mul- blockers for the following reason. The cardiac selective (B1)
tifocal premature ventricular contractions and ventricular tachy- beta blockers do not interact with the vasodilating (B2) adrener-
cardia. Treatment of ventricular arrhythmias includes adminis- gic receptors; thus, administration of epinephrine in the pres-
tration of lidocaine IV bolus, 1 mg/kg to 1.5 mg/kg, repeated ence of cardiac selective (B1) blockade does not cause unop-
with 0.5 mg/kg to 0.75 mg/kg every 5 to 10 minutes as needed posed vasoconstriction. If a vasoconstrictor in the local
to a maximum of 3 mg/kg. anesthetic is desirable, the patient’s primary physician or car-
Treatment options for severe epinephrine-induced hyperten- diologist should be consulted concerning the temporary discon-
sion are similar to those used in other hypertensive emergencies, tinuance of the nonselective beta blocker before surgery.
Anesthesia 235
Discontinuance could be unacceptable owing to the possibil- available as an emergency drug in the event of oversedation.
ity of withdrawal-rebound syndrome, which can have serious The onset of action of flumazenil after IV administration is 1
consequences. When clinically appropriate, a cardioselective to 2 minutes and the duration of reversal effect is 45 to 90
beta blocker can be used to replace the nonselective beta minutes. If the effect of the benzodiazepine continues longer
blocker. Only the patient’s primary physician or cardiologist than 90 minutes, flumazenil administration should be repeated.
should make this decision (28). For the sake of perspective, Side effects of flumazenil include anxiety, nausea, tremor, and,
this reaction is very rare with very few case reports in the litera- rarely, seizure (in patients with benzodiazepine dependency).
ture. The treatment of epinephrine/beta-blocker reaction is The use of flumazenil is not recommended to hasten recovery
based on the predominant symptoms. If severe hypertension from the normal effects of benzodiazepines.
exists, the treatment is similar to that described earlier for epi-
nephrine-induced hypertension (see previous paragraph). Atro-
pine, 0.5 mg to 1mg IV, may be useful if bradycardia exists.
Glucagon has been shown to stimulate the myocardium by in- BARBITURATES AND PROPOFOL: ADVERSE
creasing cAMP concentrations in a manner identical to that of REACTIONS
catecholamines but is thought to act via its own receptor. Thus,
glucagon is able to bypass the blocked beta receptor and is Barbiturates and propofol have more depressant effects on the
therefore useful for the treatment of bradycardia and hypoten- respiratory and cardiovascular systems than benzodiazepines.
sion seen with beta-blocker toxicity and overdose. Glucagon It is strongly recommended that these agents be used only by
may, however, be useful for the treatment of the epinephrine/ someone absolutely familiar with them and skilled in resuscita-
beta-blocker reaction. tion techniques and airway management. They should not be
used by surgeons who are overseeing both surgery and sedation.
These are potent agents, capable of producing profound anes-
OPIOIDS: ADVERSE REACTIONS thesia, potentiated by the concomitant use of other sedatives
and opioids. Potentially life-threatening reactions include: (1)
In general, the opioid agonists are very safe drugs with high
respiratory depression leading to apnea, (2) cardiovascular col-
margins of safety. The less dangerous side effects of opioids
lapse, (3) aspiration of gastric contents, (3) anaphylaxis, (4)
include nausea, vomiting, pruritis, and dysphoria. More serious
side effects include decreased respiratory drive leading to acute porphyria, and (5) malignant hyperthermia (29).
apnea, severe cardiovascular depression, bradycardia, broncho- The effects of IV anesthetics on the cardiovascular system
spasm (due to histamine release), and anaphylaxis (29). are more important than their effects on the respiratory system
Treatment is based on support of failing systems. Initial because there is no simple maneuver to counteract temporary
treatment is support of ventilation and the administration of IV cardiovascular depression in the way that artificial ventilation
doses of naloxone (Narcan), 0.1 mg to 0.2 mg, repeated every of the lungs is used to reverse temporary respiratory depression.
2 to 3 minutes until the patient is breathing and responsive or to
a total of 10 mg. Allergic reactions are uncommon and usually
consist of urticaria or skin rashes. Meperidine appears to be a CONSCIOUS SEDATION
more potent histamine releaser than morphine (16).
Conscious sedation is defined as ‘‘a minimally depressed level
of consciousness that retains the patient’s ability to indepen-
BENZODIAZEPINES: ADVERSE REACTIONS dently and continuously maintain an airway and respond appro-
Respiratory depression is the most common side effect of ben- priately to physical stimulation and verbal commands (19).’’
zodiazepine administration. Decreased respiratory drive and Conscious sedation is most commonly used before, or in con-
tidal volume occur and are associated with decreased respiratory junction with, local anesthesia during hair transplantation sur-
rate. Patients with preexisting respiratory disease are more at gery, to limit the pain of anesthetic injection. Although this
risk. Diazepam and midazolam rarely produce significant cardi- method is less common, some physicians like to keep their
ovascular changes when used in low doses for premedication patients in a light state of conscious sedation throughout the
or IV sedation, provided that precautions are taken against ven- surgery and not just during the administration of local anes-
tilatory depression. Small reductions in blood pressure, cardiac thetic. The challenge lies in selecting appropriate drugs and
output, and systemic vascular resistance can occur and, in the titrating their dosages. The objectives are as follows:
presence of preexisting cardiovascular disease, can cause severe
hypotension. 1. Reduce or eliminate the pain associated with injection
Other sedatives and narcotics potentiate the effects of benzo- of local anesthesia.
diazepines, and dosages must be reduced accordingly. Treat- 2. Reduce or eliminate patient apprehension.
ment includes supplemental oxygen, protection of the airway, 3. Reduce or eliminate recall of the operation or at least
and respiratory support. the period of anesthetic injection.
Flumazenil is a specific benzodiazepine antagonist that can
reverse all effects, including sedative-hypnotic, amnestic, mus- The preoperative history is extremely important and must in-
cle relaxant, and respiratory depression. Flumazenil competi- clude the patient’s current state of health, recent illnesses, medi-
tively inhibits the binding of the benzodiazepine to the GABA cal problems and medications, prior surgical and anesthesia
receptor site, effectively reversing the respiratory depression encounters, and family history. Patients should have no
induced by benzodiazepines. Flumazenil should be readily unevaluated medical problems and generally should be classi-
236 Chapter 8
fied as having physical status 1 or 2 by the American Society additional 10 mg orally after they arrive. Beehner, just before
of Anesthesiologists (ASA) (Table 8A-5). local anesthesia, gives most patients 2.5 mg of IV midazolam
Medications used for conscious sedation must be selected slowly, followed by 35 mg of meperidine IV slowly. If the
carefully. The use of small, incremental doses of sedative agents patient’s speech is not slurred, Beehner gives an additional 1.5
allows maintenance of the conscious state. As mentioned ear- mg to 2 mg of midazolam. After donor harvesting, he adminis-
lier, benzodiazepines are most commonly used for conscious ters an additional 1.5 mg IV push of midazolam. Shiell has used
sedation in hair transplantation surgery. In a survey conducted midazolam for 14 years, 5 mg to 10 mg IV or subcutaneously,
in 1996 at the International Society for Hair Replacement Sur- without ever encountering serious side effects. Seager prefers
gery, (ISHRS) meeting in Nashville, with 444 physicians in IV midazolam to diazepam, having used it thousands of times
attendance, 16% used no premedication, 47% used diazepam, with no problems. Mangubut, Cole, Parsley, and I prefer to give
and 25% used midazolam (30). Midazolam is an excellent seda- 10 mg of oral diazepam 1 hour prior to surgery. Avram uses oral
tive for the moderately anxious patient; it is better than diaze- diazepam in half of his cases and no preoperative medication in
pam because of its shorter duration of action and lack of venous the other half. He sedates 15% of his patients with propofol.
irritation. Limmer uses no preoperative medication.
The advantages of using diazepam are its ability to be given Most sedatives, given in sufficient doses, can produce gen-
orally and a greater anti convulsive effect than midazolam. The eral anesthesia and cardio respiratory compromise, rendering
use of oral premedication 1 hour pre operatively is helpful in the patient unconscious with an unprotected airway. The chal-
eliminating anxiety before surgery; however, oral premedica- lenge facing the surgeon is to select the agent that will achieve
tion is significantly associated with increased recovery time. the desired end-point while minimizing the potential adverse
The opioids meperidine and fentanyl provide both analgesic and effects that every sedative medication possesses. A complete
sedative effects. The ultra–short-acting barbiturates, thiopental written record requires documentation in the anesthesia log at
and methohexital, can be used to induce sedation. Propofol infu- regular intervals of the patient’s vital signs (respiratory rate,
sion appears to be an excellent alternative to midazolam for blood pressure, temperature, cardiac rhythm), oximetry read-
sedation but, as noted earlier, should not be employed without ings, and significant events from the initiation of sedation to
an anesthesiologist present. When intra operative amnesia is recovery. High-flow oxygen with positive-pressure delivery and
desired in addition to rapid recovery, administration of a small a suction apparatus should be immediately available. Any nec-
dose of midazolam (1 mg to 3 mg IV), before propofol infusion, essary material or instruments should be prearranged and ready
may offer advantages over either drug alone (31). Opiates, bar- on an emergency cart in the operating room.
biturates, and propofol are not commonly used by hair trans- Appropriate airway equipment, resuscitation drugs (includ-
plantation surgeons. A number of physicians use nitrous oxide ing opiate and benzodiazepine reversal agents), pulse oximeter,
during local anesthesia. and, ideally, a cardiac monitor-defibrillator should also be im-
Individual physician preferences vary with respect to medi- mediately available. The incidence of complications from am-
cations used for conscious sedation during hair transplantation bulatory surgery and anesthesia varies in the literature. In a
surgery. Unger prefers the use of 15 mg to 20 mg of oral diaze- prospective outcome survey of 38,598 patients who underwent
pam 45 minutes before surgery, or, if the patient is particularly ambulatory procedures with administration of anesthetics, there
anxious, 10 mg is given intravenously immediately before local were no deaths within the 1-week period after 45,090 surgical
anesthesia is started. Unger often uses higher total doses of procedures (32).
lidocaine and epinephrine than are given by the majority of hair The degree of physiological monitoring is directly propor-
restoration surgeons; he therefore likes the superior anticonvul- tional to the level of sedation employed. The level of monitoring
sive property of diazepam, which provides an added margin of must ensure that the sedation process does not compromise the
safety to his technique. He also is very familiar with the drug patient’s cardiorespiratory functions. Monitoring is best per-
and prefers that his patients remember the procedure. Nitrous formed by a qualified and dedicated patient observer, (not inti-
oxide may also be added for pain-sensitive or anxious patients. mately involved in the procedure at hand), who can directly
Propofol is administered by an anesthesiologist for particularly appraise the patient’s appearance and visually inspect the respi-
apprehensive individuals for the 10 to 15 minutes necessary to ratory effort. Once sedated, patients are never left unattended.
produce field blocks in both donor and recipient areas at the The use of pulse oximetry has become the monitoring stan-
beginning of surgery. Stough uses diazepam, 10 mg, 1 hour dard for most forms of sedation. Pulse oximeters are excellent
before patients arrive at the clinic and, in many cases, gives an for the early detection of hypoxia, usually well before it mani-
fests clinically. Patients undergoing deeper sedation with intra-
venous drugs or multiple agents should also be placed on a
cardiac rhythm monitor. Physicians who intend to use any seda-
Table 8A–5 Physical Status Classification of American Society tive-analgesic agent should be well versed in the pharmacoki-
of Anesthesiologists netics, pharmacodynamics, and adverse-effect profile of the
1. Healthy patient chosen medication. This knowledge allows the physician to an-
2. Mild systemic disease ticipate complications and be prepared to intervene expedi-
3. Severe systemic disease, not incapacitating tiously. Ideally, all physicians and nurses involved with patient
4. Severe systemic disease that is a constant threat to life care during conscious sedation should be certified in advanced
5. Moribund, not expected to live 24 hours irrespective of operation cardiac life support.
Minimum criteria for patient discharge include stabilization
Data from Tintinalli J, Kelen G. Emergency Medicine, 6th ed. New York, of vital signs, an acceptable level of consciousness, and lack
McGraw-Hill, 2003: 401–406, 1144. of evidence of complications. Patients should be instructed not
Anesthesia 237
to drive, operate potentially harmful machinery, or make legally ception of pain (35). Pain resulting from tissue injury begins
binding decisions for 5 to 12 hours after the procedure. Written with activation of peripheral small-fiber terminals that keep
instructions on discharge for patient and caretaker are necessary the gate in a slightly open position. Stimulation of large-fiber
because the amnestic period is variable. A phone call from the terminals tends to close the gate.
physician’s office the evening of surgery or the day after the When hair transplantation surgery is performed, the greatest
procedure is advisable and appreciated by the patient. cause of pain is the injection of local anesthesia. It is necessary
Regardless of the surgical setting—physician’s office, free- to anesthetize large surface areas of skin before surgery is per-
standing clinic, or operating room—the Standards of the Joint formed that consists of excising the donor area and creating
Commission on Accreditation of Healthcare Organizations recipients sites by incision or removal of tissue by punches.
should ideally be considered for professional staffing/training, Local anesthesia is accomplished by injection with small hypo-
emergency drugs/equipment, development of protocols, docu- dermic needles or needleless injectors. It has been empirically
mentation of care, and monitoring of outcomes. Awareness of recognized for many years that the pain of injecting local anes-
existing guidelines helps physicians to avoid situations that thetics can be reduced by concurrently applying stimulation of
could lead to patient injury (33). It should be noted however, the nearby skin. This can be accomplished by applying pressure,
that many of the recommendations listed have never been em- pinching, vibrating, and/or movement. Medical personnel who
ployed by many hair restoration surgeons, and despite this, over administer local anesthesia in the emergency department to chil-
the past 30 years, a lethal complication during hair transplanta- dren and those who give it before elective surgery have long
tion has never been reported in the medical literature. (A single known that the perception of pain can be attenuated by the
case of severe neurological damage due to the accidental IV noninvasive means listed.
injection of a bolus of anesthetic by a nurse did result in a Vibration and movement, consistent with the gate control
successful lawsuit on behalf of a patient.) theory, confirm the presence of pain relief during pure pain
stimulation by a CO2 laser beam (36). Repetitive, rapid pinching
and shaking of the skin significantly reduces the level of dis-
LIMITING THE PAIN OF LOCAL ANESTHETIC comfort during lidocaine infiltration. The reduction of pain by
INJECTION THROUGH LOCAL AND application of pressure to the site for 10 seconds before an IM
MECHANICAL METHODS injection supports the beneficial effect of pressure treatment
(37). A handheld mini-massager/vibrator (produced by
In the search to reduce the pain of administration of local anes- Brookstone) is used at the site by Gandelman and Parsley during
thesia, numerous methods have been suggested, including use local anesthesia injection with reported decrease in pain (Gan-
of the gate theory, buffering, warming, small needle gauge, and delman, and Parsley, personal communication,) These methods
slow rate of administration. have been proven to reduce pain, and in my view, should be
The perception of pain is not only a reflex that occurs in used during the administration of local anesthesia during hair
the brain and/or spinal cord but also a complicated response transplantation surgery.
mediated by numerous factors. There is no single pain center
in the CNS; rather, there are multiple areas. The interpretation
of pain takes place in the mind; the information is thus entirely
Buffering
personal and cannot be shared with anyone else or easily de- Local anesthetics are weak bases that are commercially avail-
scribed in terms that convey the same meaning to another per- able as hydrochloride salts and marketed at a pH between 4
son. The pain sensation disrupts a person’s behavior and and 6 to increase their shelf life and solubility. Buffering with
thoughts, motivating the person to stop the unpleasantness as sodium bicarbonate increases pH, decreases shelf life, and ren-
soon as possible. The patient’s experience of pain is greatly ders the local anesthetics chemically unstable and subject to
influenced by expectations, suggestions, level of anxiety, and photodegradation. Buffered lidocaine remains active for only
other psychological factors. Moreover, the central control from 1 week when stored at room temperature and a few weeks when
the cortex can act as an overriding regulator of pain. The indi- refrigerated. Studies and experience have shown that buffering
vidual’s emotions and previous experiences are some of the of acidic local anesthetics with sterile sodium bicarbonate de-
factors that induce the brain to intervene and change the balance creases the discomfort associated with local anesthetic infiltra-
of control of the ‘‘gate’’ (34). In addition, the pain associated tion (38). Buffering does not adversely affect the anesthetic
with the administration of local anesthesia can be decreased by efficacy of lidocaine. The mixtures of sodium bicarbonate and
use of either concomitant conscious sedation and/or various local anesthetic used in studies include the following:
mechanical methods.
1% lidocaine Ⳮ 7.5% NaHCO3 at a 9:1 ratio
Gate Theory 1% lidocaine Ⳮ 8.4% NaHCO3 at a 9:1 ratio (most common
mixture used)
The gate control hypothesis of Melzack and Wall suggests that
the ascending transmission of nociceptive (pain) information 2% lidocaine (4mL) Ⳮ 8.4% NaHCO3 (1mL) pH ⳱ 7.26
carried by slow, thin A-delta and C-fibers can be modified, or
gated, at the spinal level by afferent signals carried by fast, The disadvantages of using buffered local anesthetics include
thick, low-threshold A-alpha/A-beta fibers emanating from the increased bleeding and an increased incidence of post-transplant
same dermatome. Thus, when the low-threshold fibers are acti- facial edema (1). Straub studied postoperative edema in hair
vated by touch, pressure, and/or vibration, this stimuli transmis- transplant patients when lidocaine was and was not buffered
sion gates, or diminishes, the pain stimulus, reducing the per- with NaHCO3. He found the incidence of edema, in 305 cases
238 Chapter 8
to be 3.27% with nonbuffered lidocaine. When lidocaine was thetic with epinephrine is used. The Prestyl is powered by com-
buffered, the incidence of postoperative edema was 12.8% in pressed air and fired with foot pedals like a machine gun.
328 cases (39). Because of facial swelling associated with the The popularity of these injectors has decreased, possibly
use of buffered lidocaine, it is not often used in the recipient owing to the potential transmission of infectious disease. The
area. Of eight hair transplant physicians polled, (Beehner, Cole, entire instrument must be sterilized after each patient use. Wip-
Parsley, Epstein E, Seager, Marzola, Limmer, and me), one ing the tip of the instrument with disinfectant or changing the
(Limmer) uses buffered lidocaine in the donor area only, and disposable tip that contacts the patient’s skin is not adequate
none use buffered lidocaine in the recipient area. sterilization and can lead to transmission of infectious disease
between patients. The Wand is an instrument supplied by Mile-
Warming stone Scientific, which mechanically injects anesthetic solutions
at a very slow and steady rate. Although it is not truly a
Multiple studies have determined that warming the local anes- needleless injector, it is also considered to limit the pain of
thetic solution to body temperature reduces the pain on infiltra- injection.
tion. Harris reviewed the literature (40) and found that the con-
sensus was that the combination of warming and buffering had Topical Local Anesthetics
the greatest effect on reducing discomfort. Buffering had a
greater impact than warming, but warming the solution always As discussed earlier in this chapter, the topical application of
reduced pain on injection compared to use of anesthetic at room EMLA cream under occlusion with plastic for 1 to 2 hours
temperature. provides superficial anesthesia to the skin. Subsequent injec-
tions of anesthesia in these areas are thereby made less painful.
Needle Size If used, EMLA lends itself better to the recipient area because
it can be applied while donor harvesting is taking place. It is
It is my experience that a smaller needle size causes less pain inconvenient, if not impossible, for the patient to apply EMLA
during the injection of local anesthetic. Although a smaller to the donor area 1 to 2 hours before surgery. If EMLA is
needle gauge can decrease the pain of injection, the buffering applied at the physician’s office, a 1-hour to 2-hour wait is
of the lidocaine is more important than needle size in decreasing necessary before surgery can commence, which is inconvenient
the pain of intradermal injection (41). A 30-gauge needle pro- for both patient and physician.
duces the least amount of pain.
Rate of Administration TECHNIQUE OF LOCAL ANESTHESIA
It is my experience that reducing the rate of administration of The techniques of administering local anesthetics vary from
local anesthetic injections reduces pain. In the largest blinded physician to physician and depend on the site being anesthe-
study that has been conducted to assess administration rate and tized. With experience, physicians develop their own approach.
pain of local anesthetic, it was found that administration rate An overview of general principles is included under the follow-
had a greater impact on the perceived pain of infiltration than ing headings and subheadings:
buffering. This study demonstrated that rate of infiltration is 1. Peripheral Nerve Block (supraorbital/trochlear)
strongly predictive of perceived pain, whereas buffering was
modestly predictive of perceived pain for subcutaneous injec- A. Supraorbital notch injection
tions of lidocaine through intact skin (43). B. ‘‘Three-finger rule’’
In light of the foregoing information on reducing the pain 2. Field Block
of injection of local anesthetic, the most effective methods in-
clude (1) non invasive distraction technique (gate theory) such
as pressure, vibration, pinching, or shaking associated with in-
jection; (2) buffering the local anesthetic solution when anesthe-
tizing the donor area; (3) warming the anesthetic mixture to
body temperature; (4) using a small needle gauge (30 gauge);
and (5) slowing the rate of administration of the local anesthetic.
Needleless Injectors
A number of mechanical instruments are available for the deliv-
ery of local anesthetic. These include the Dermojet (Robbins
Instruments, Chatham, NJ), (Fig. 8A-5), Syrijet (Mizzy, Inc.,
Cherry Hill, NJ), and Prestyl (B. M. A. Technologies, Paris).
The Dermojet, the most commonly used needleless injector,
holds a volume of local anesthetic in a reservoir or cartridge.
After a lever is cocked to create high pressure in the mechanism,
a trigger is pressed, and as this pressure is released, the anes-
thetic is ejected, superficially penetrating the skin of the patient.
A circular wheal of skin blanching is produced when local anes- Figure 8A-5 Dermojet.
Anesthesia 239
A. Multiple wheal technique

B. Spinal needle-drawback technique
C. Continuous wheal technique
PERIPHERAL NERVE BLOCK

A nerve block involves the infiltration of a small volume of
anesthetic around the trunk of a nerve that has a specific and
defined anatomical distribution to provide anesthesia to the en-
tire region. Nerve blocks are sometimes useful in patients who
are difficult to anesthetize with only a field block (47). Periph-
eral nerve blockades in hair transplanting are most commonly
accomplished with lidocaine (0.5% to 1%) or bupivacaine
(0.25% to 0.5%). The addition of epinephrine 1:100,000 to 1:
200,000 is advantageous in prolonging the duration of the
blockade and in reducing the systemic blood levels of the local
anesthetic (see Local Anesthetics earlier for complete descrip-
tion). The distribution of sensory nerves in the scalp and the
corresponding regions of anesthesia are shown in Fig. 8A-6. A
star in the figure indicates the point of injection for an area of
regional anesthesia. Many surgeons prefer regional nerve
blocks followed by field blocks for hair transplantation and
alopecia reduction. The postauricular and lesser auriculotemp-
oral nerve can be blocked with a subcutaneous injection at the Figure 8A-7 Postauricular, lesser occipital block.
hairline just behind the ear (Fig. 8A-7), and the zygomatic and
auriculotemporal nerves can be blocked by injections just in
front of the ear (see Fig. 8A-6). It is important not to try to
inject directly into the foramen where a nerve exists. Doing so along the medial superior rim of the orbit, usually approxi-
increases the chance of accidental intravascular injection as well mately 2.5 cm from the midline or in the midpupillary line. The
as lacerates the nerve and permanently damages it (1). medial aspect of the forehead is innervated by the supratrochlear
nerve, which is the lateral aspect by the supraorbital nerve.
Supraorbital/Supratrochlear Nerve Block There is, however, anatomical variation in the emergence and
course of these nerves (see Seager’s and Simmons’ discussion
Sensory innervation of the forehead and frontal scalp is supplied in Chapter 8D). Haber and associates, during a large series of
by the supraorbital and supratrochlear nerves (see Fig. 8A-6), cadaver dissections, found the nerves sometimes emerged from
which are branches of the frontal nerve, a branch of the ophthal- two foramina but more often emerged from one foramen (and
mic division of the trigeminal nerve. The anterior aspect of the one notch); however, often, no foramen was found at all (43).
frontal hairline, especially near the midline, is most sensitive
during administration of local anesthesia. Nerve blockade of Notch Injection
the supraorbital and supratrochlear nerves is extremely useful
in minimizing the pain associated with anesthetizing this region, Supraorbital/supratrochlear nerve blockade can be accom-
because a single injection used to create the block can substitute plished by injection of local anesthetic at the supraorbital notch
for a larger number of injections. Also, a larger area can be of the superior or inferior aspect of the eyebrow. Unger recom-
anesthetized with a small amount of anesthetic. mends the superior approach, preferably with use of a 30-gauge,
These nerves classically emerge through a foramen that cor- 1 inch needle attached to a 5-mL syringe (Fig. 8A-8) (1). A
responds to the supraorbital notch, which is easily palpated needleless injector may be used to initiate local anesthesia at
each of the points where the nerves will be blocked. The needle
is introduced just lateral to the supraorbital notch and threaded
along subcutaneously just superior to the orbital ridge as far as
the midline. One should draw back on the syringe to make sure
that one is not accidentally intravascular; then the needle is
withdrawn moderately quickly, with the anesthetic solution in-
jected during withdrawal, thereby producing a wall of anesthetic
solution across the frontal bone on one side. The process is
repeated on the contralateral side.
Haber, Khan, and Stough recommend the inferior approach
noting that suboptimal anesthesia may be achieved via the supe-
rior approach owing to the wide separation of the two nerves
above the orbital rim and the variability in depth of the two
nerves (43). The approach of these physicians involves palpa-
Figure 8A-6 Regional anesthesia. tion of the supraorbital notch and insertion of a 1⁄2-inch, 30-
240 Chapter 8
infiltrate the inferior margin of the donor area anterior to the

proposed or existing hairline. Superficial injection into the
upper dermis results in rapid onset and longer duration of anes-
thetic compared with results of deeper injections. Injecting into
the superficial dermis creates a peau d’orange effect. Deeper
or subcutaneous injection can be accomplished faster and with
less strain on the physician’s fingers and wrists, but usually
more anesthetic is administered with slower onset of action and
shorter duration of anesthetic effect. Most physicians use one
of the following methods, or a variation of the methods, for
infiltration of local anesthetic for field blockade.
Multiple-Wheal Technique (Fig. 8A-10)

With a 30-gauge needle, 1% to 2% lidocaine with epinephrine
(1:100,000 to 200,000) is injected, raising isolated wheals 4 cm
to 6 cm apart along the border of the area to be blocked. A
needleless injector can be used instead to make the isolated
wheals. After waiting 1 to 2 minutes, the block is completed
by injection of the remaining anesthetic through these wheals,
connecting the line to complete the block. A syringe filled with
local anesthetic and attached to a 1-inch, 30-gauge needle is
inserted completely through one of the wheals in the direction
Figure 8A-8 Supraorbital nerve block.
of the line of the field block. The plunger of the syringe is
withdrawn slightly and aspiration is performed to avoid intra-
vascular injection. The anesthetic is injected slowly as the
needle of the syringe is pulled backward toward its insertion
point at the wheal. This procedure is repeated at the isolated
gauge needle just under the eyebrow until it rests on the bone wheals until local anesthetic has been injected across the entire
superior to the notch. They do not attempt to enter the notch perimeter of the area.
or elicit paresthesias. After aspiration, 2 mL of 0.5% lidocaine
with 1:100,000 epinephrine is infiltrated into the periosteum at Continuous-Wheal Technique (Fig. 8A-11)
this spot. The needle is then partially withdrawn and redirected
0.5 cm medially without exiting the skin, and an additional 0.5 Using a 30-gauge needle, 1% to 2% lidocaine with epinephrine
mL of anesthetic is again injected into the periosteum. They (1:100,000–200,000) is injected in the superficial dermis rais-
believe that with the needle in contact with the periosteum, the ing a wheal. Every 2–3 mm the needle is inserted into the wheal
anesthetic is forced along this tissue plane, effectively envelop- and anesthetic injected into the superficial dermis in an adjacent
ing the nerves as they emerge from the foramen. Maintaining area previously not anesthetized to gradually create a solid line
contact of the needle on bone is therefore an important aspect of anesthesia that will produce a field block. Essentially a line
of the technique. of continuous wheals is slowly created at the perimeter of the
area. The patient only feels discomfort during creation of the
first wheal. At the time of each injection less than 1 ml is
Three-Finger Rule infiltrated. This technique may take longer than other methods
There is absence of a palpable supraorbital notch in a small but is the one the author prefers. In the donor area the line of
percentage of patients. Both major nerve branches are noted by wheals is created using an average of 15–18 cc of 1% lidocaine
Khan to emerge just lateral to the outer fingers when three with epinephrine (1:200,000). In a typical hairline 10 ml or less
fingers are placed vertically over the inferior forehead and cen- of 1% lidocaine with epinephrine (1:200,000) is used to create
tered over the glabella (Fig. 8A-9). Khan refers to this finding the field block.
as the ‘‘three-finger rule,’’ and it can be used to help guide
the administration of the nerve block (43). Local anesthetic is Spinal-Needle Technique (Fig. 8A-12)
administered as previously described after the dual nerve loca-
Using a 30-gauge needle, 1% to 2% lidocaine with 1:100,000
tion is ascertained by use of the three-finger rule.
epinephrine is used to produce a wheal of anesthesia at the
Seager’s and Simmons’ technique of producing nerve blocks
midpoint of the donor or recipient area. A spinal needle (18-
is described in detail later in this chapter (see 8E).
gauge, 3 1/2 inches) is inserted through the wheal. Injection of
the anesthetic solution can be accomplished by injecting in the
FIELD BLOCKS subcutaneous plane while proceeding or by inserting the needle
its entire length and injecting as the needle is drawn backward.
Field, or ring, block involves total blockade of the approaching Unger prefers the latter method, which he describes later in this
nerve supply by anesthetic injection of the skin proximal to the chapter.
operative field. In the donor and recipient areas, the nerve sup- To avoid the possibility of accidental IV or intra-arterial
ply approaches from the inferior aspect, making it necessary to injection of local anesthetic, one should withdraw the barrel of
Anesthesia 241
Figure 8A-9 Three-finger rule
the syringe each time before injecting the solution. In practice, In most patients, 2% lidocaine solution is sufficient for com-
this is rarely done by most surgeons because many dozens of plete anesthesia even if the patient is somewhat more resistant
injections are made and it is quite time consuming and awkward than average to lidocaine. A minority of patients are not com-
with many types of syringes. An alternative approach is to keep pletely anesthetized with 2% lidocaine. Those patients can be
a finger just ahead of the entry of the needle into the skin. As treated with a solution of 2% lidocaine with 1:25,000 epineph-
the local anesthetic is injected, if the solution is not felt to be rine diluted in equal parts with 4% lidocaine made for IV use
going into a blood vessel, the injection should be immediately in patients with cardiac arrhythmias. The result is a 3% solution
terminated. If anesthetic is accidentally injected into a blood with 1:50,000 epinephrine. Some patients require 4% lidocaine
vessel, very little of the solution is actually injected before the with 1:50,000 epinephrine for complete anesthesia, even after
physician is aware of it. the 3% solution is injected. Patients who require more than 2%
242 Chapter 8
Figure 8A-10 Multiple-wheal technique.
lidocaine for the recipient area and 1% in the donor area are
usually quite uncommon, but one should know that these alter- Figure 8A-12 Spinal needle technique.
native strengths and agents are available. The use of nerve
blocks before field blocks greatly reduces the likelihood that
anything stronger than a 2% solution of lidocaine will be neces-
sary in either the recipient or donor area. local anesthesia or whether the anesthesia lasted a shorter time
Any patient can, for unknown reasons, require higher con- than usual. Patients of Celtic background and those who have
centrations of local anesthetic. When taking the patient’s medi- a history of excessive alcohol or drug use seem to be especially
cal history it is useful to ask whether, in the past, during dental prone to require unusually high concentrations of anesthesia
or other procedures, the patient required repeated injections of (1).
Differences in Donor and Recipient Areas

The occipital donor area is usually less sensitive than the hair-
line area, therefore, a lower concentration of local anesthetic
can be used. Commonly, 1% lidocaine is used in the donor area,
whereas 2% lidocaine is used in the hairline region or other
recipient areas. Buffered lidocaine, which is more likely to
cause postoperative edema, can be used in the donor area as
swelling will not be noticeable. When used in the hairline area,
buffered lidocaine more frequently causes noticeable postopera-
tive forehead and periorbital edema. If larger numbers of grafts
are transplanted, surgical procedures take longer. For this rea-
son, the donor area is nearly always anesthetized first, and the
recipient area is not anesthetized until after the donor strip is
harvested and the wound sutured. With shorter procedures, the
recipient areas can be anesthetized immediately after the donor
area. After the donor tissue is harvested, bupivacaine (Mar-
caine), 0.25%, is commonly injected below the incision to ex-
tend the duration of the nerve blockade. Similarly, bupivacaine
can be injected proximal to the hairline or other recipient area
during or after administration of a short-acting local anesthetic.
Some physicians choose to mix a short-acting and a long-acting
Figure 8A-11 Continuous, wheal technique. local anesthetic for simultaneous injection (see section on local
Anesthesia 243
anesthetics earlier in this chapter for discussion of anesthetic 30 mL to 80 mL) of a solution of 0.05% lidocaine. Parsley,
mixtures) in both the donor and recipient areas. The author Marzola, and many others use plain saline tumescence in the
injects bupivacaine, 0.25%, immediately after suturing the donor area. Beehner uses tumescence in the recipient area. In
donor area, and again at a later time, when the patient begins a typical case, he uses 100 mL to 160 mL of normal saline with
to detect even slight pain in the donor area. epinephrine concentration ranging from 1:85,000 to 1:125,000
in the frontal and miscall areas. Uebel infiltrates the recipient
area extensively (200 mL to 250 mL) with a saline solution
TUMESCENCE containing 0.025% lidocaine with 1:160,000 epinephrine to pro-
duce vasoconstriction and edema (47). It is important to note
Saline tumescence with or without anesthetic agents is often also that if large volumes of any fluid are used in the recipient
used in hair transplant surgery. area, incisions or holes made in the recipient area will move
closer as the solution later dissipates. Conversely, large volumes
Tumescent Anesthesia of fluid in the donor area decrease the number of follicles by
spreading them apart.
Saline tumescence should not be confused with tumescent anes-
thesia. Since its introduction by Klein in 1987, the tumescent Saline Tumescence
technique has become the standard approach to local anesthesia
for liposuction surgery (44). The tumescent anesthesia tech- In hair transplantation, it has become common practice to inject
nique is based on the concept that large volumes of very dilute large amounts (up to 100 mL) of saline in the donor area before
local anesthetics are less toxic than the same total milligrams harvesting. The advantages of tumescence include (1) creating
in more concentrated preparations. In liposuction, the tumescent a firmer cutting surface, fixing the hair follicles and allowing
technique results in better local anesthesia, decreased bleeding, the incision to follow the angle of the exiting hair follicles;
and low potential for toxicity (45). It is important to note the (2) increasing distance between follicular units and facilitating
differences between liposuction and hair transplantation sur- microscopic dissection, and (3) separating the superficial der-
gery. mis from the larger underlying blood vessels, which are less
With liposuction, the sites of injection are relatively avascu- likely to be severed, and thereby decreasing bleeding during
lar and of heavy adiposity. Because lidocaine is extremely lipo- donor harvesting.
philic, it is largely absorbed into the underlying adipose tissue.
Up to 25% of the injected lidocaine is ultimately removed dur- WOLF’S SPECIFIC TECHNIQUE OF
ing the extraction of fatty tissue. As noted earlier in this chapter, ANESTHESIA
studies of lidocaine doses in liposuction cannot be applied to
Given the large amount of sometimes confusing data in this
hair transplantation surgery because scalp tissue is highly vascu-
chapter, I thought it might be useful to distill the information
lar and large volumes of adipose tissue are not removed during
into a ‘‘working model’’ of anesthesia for novice hair restora-
hair transplantation surgery. Nonetheless, some physicians use
tion surgeons. To this end, my technique is summarized here.
the tumescent technique for anesthesia during hair transplant
Unger then presents another option.
surgery without adverse effects because far smaller volumes
are employed than required for liposuction. Technique for Donor Area (Table 8A-6)
The standard anesthetic solution for tumescent injection dur-
ing liposuction consists of normal saline with lidocaine, 0.025% Preoperatively, 1 half hour before anesthesia, 5mg of hydroco-
to 0.1%, epinephrine, 1:1,000,000 to 2,000,000, and sodium done and 10 mg of diazepam are given orally. With the patient in
bicarbonate, 12.5 mEq/L. Hunstad has reported using a solution the sitting position, the donor area is cleaned with an antiseptic
of lidocaine, 0.05%, with epinephrine, 1:1,000,000, in the donor solution. All anesthetics are administered slowly with use of
and recipient regions of 50 consecutive patients undergoing hair vibratory stimuli (digital or with plastic needle cover) proximal
transplant surgery. He used a CO2 pressurized infusion device to the area anesthetized. The donor area is anesthetized with a
(Cabot Medical, Langhorn, PA, and Byron, Tuscon, AZ), large- field block administered over 15 minutes to 20 minutes using
bore connecting tubing (Byron), flow-control handle, and 15 mL of 1% lidocaine with 1:200,000 epinephrine (average,
stepped awl device (Entrease) to limit penetration depth (46). 155 mg) the continuous wheal technique. Tumescence is ac-
Klein and Coleman use the following solutions for donor and complished by first injecting small amounts (approximately 5
recipient area tumescence: mL) of epinephrine, 1:20,000, in saline solution to provide vaso-
constriction. This is followed by plain saline (average, 40 mL).
1. Lidocaine, 0.1%, with epinephrine, 1:320,000 (30 mL The total amount of tumescent fluid averages 45 mL. After
NaCl, 0.9%, 2% plain lidocaine, 2mL, NaHCO3, 0.2 donor harvesting and suturing, bupivacaine, 0.25% (average, 5
mEq, 0.1 mL epinephrine, 1:1000) mL) is injected inferior to the suture line but in the zone of
2. Lidocaine, 0.5%, with epinephrine, 1:420,000 NaCl prior lidocaine anesthesia. Bupivacaine (Marcaine) injection (5
0.9%, 30 mL, 2% plain lidocaine, 11 mL 1.1 mEq mL) may be repeated later in the procedure before any pain
NaHCO3, epinephrine 1:1000, 0.1mL (45). returns (see Table 8A-6).
A field block using lidocaine (1% to 2%) with epinephrine (1: Technique for Recipient Area (Table 8A-7 and Fig.
50,000 to 200,000) is generally employed before tumescence 8A-13)
is induced in the donor region area. Cole, after a field block
with 2% lidocaine with 1:200,000 epinephrine, achieves tumes- Anesthesia of the recipient area is then performed. Lidocaine,
cence of the donor area by using, on average, 40 mL (range of 2%, with epinephrine, 1:100,000, is used with the continuous-
244 Chapter 8
Table 8A–6 Medications and Solutions Used by Author for Donor Areaa
Donor
b
Color Medication Syringe size Needle gauge mg amount mg amount
No dot 1% lidocaine with epinephrine 1 : 200,000 3 mL (6 drawn 30 180 (lidocaine) 0.09 (epinephrine)
up—18 mL)
Green 0.25% bupivacaine (avoid 0.5% 10 mL (5 cc 30 12.5
bupivacaine for sensory nerve block) drawn up)
Yellow epinephrine 1 : 20,00(2,4)c (9.5 mL saline 10 mL 30 0.5
with 0.5 mL epinephrine 1 : 1000)
No dot 0.9% saline 10 mL (5 drawn 25
up—50 mL)
a
All average values are drawn from a study of 60 consecutive surgical patients from 1/17/01–7/26/01. Follicular unit transplantation (FUT) using microscopic
dissection averaged 1056 grafts per surgery. The average time of operation was 8.5 hours.
b
The syringes are color coded to facilitate use and minimize confusion. Solutions are prepared on the day of surgery.
c
Avoid or lessen dose if patient has history of coronary artery disease or advanced age.
wheal technique. A ring block is then carried out proximal to

the recipient area of transplantation. On average, 10 mL of
lidocaine, 2%, with epinephrine, 1:100,00, (200 mg) is injected
over a 10-minute to 15-minute period. In the latter stages of
the procedure, additional lidocaine, 2%, with epinephrine, 1:
100,000, are required. The average amount of lidocaine used
in the recipient area over the course of the surgery is 294 mg. If
problematic bleeding is encountered that hinders vision during
creation of incisions and/or placement of grafts, small amounts
of epinephrine, 1:10,000 in saline solution are injected (0.5 mL
maximum per injection). The average total amount of saline/
epinephrine, 1:10,000, over the course of the incision creation
and graft placement is 3.7 mL (0.37mg). If pain occurs before
the end of surgery, oral hydrocodone (5 mg) is administered.
With these medications and this technique, an average of
lidocaine, 449 mg, bupivacaine, 12 mg, and epinephrine, 0.85
mg, was administered per surgical procedure.
It is important to be aware of the milligram amount of all
Figure 8A-13 Syringes for technique of Bradley R. Wolf. Pho- medications given at all times during the procedure. Reevalua-
tograph of color-coded syringes. tion of medication amounts given after donor area and recipient
area anesthesia is helpful in keeping track of the milligram
amounts given. I generally do not start an IV drip on my pa-
Table 8A–7 Medications and Solutions Used by Author for Recipient Areaa
Recipient
Colorb Medication Syringe size Needle gauge mg amount mg amount
Blue 2% lidocaine with epinephrine 10 mL (15mL 30 300 (lidocaine) 0.15 (epinephrine)

1 : 100,000 drawn up)
Red epi 1 : 10,000c (9cc saline with 10 mL (5mL 30 0.5
1 mL epinephrine 1 : 1000) drawn up)
a
All average values are drawn from a study of 60 consecutive surgical patients from 1/17/01–7/26/01. Follicular unit transplantation (FUT) using microscopic
dissection averaged 1056 grafts per surgery. The average time of operation was 8.5 hours.
b
The syringes are color coded to facilitate use and minimize confusion. Solutions are prepared on the day of surgery.
c
Avoid or lessen dose if patient has history of coronary artery disease or advanced age.
Anesthesia 245
tients, nor do I use nerve blocks. The amounts of medications

prepared before surgery also do not exceed the toxic dose.
8B. Techniques for Limiting the

Amount of Epinephrine in Large
Hair Restoration Surgeries
Robert M. Bernstein and William R. Rassman
INTRODUCTION
Epinephrine (adrenaline) is the body’s most potent stimulant
of the sympathetic nervous system. Through its action on alpha-
adrenergic and beta-adrenergic receptors, its effects include in-
creased heart rate and force of contraction, elevation of blood
pressure, relaxation of bronchiolar and intestinal smooth mus-
cle, glycogenolysis, lipolysis, and increased oxygen demand.
When used as a drug, epinephrine can cause fear, anxiety, rest-
lessness, pounding headaches, tremors, weakness, respiratory
difficulty, and palpitations. More serious reactions, including
cardiac arrhythmias, have been reported (1). In addition, adrena-
line can cause drug interactions with a number of commonly
used medications, most notably beta blockers.
Figure 8B-1 Epinephrine used in making ‘‘super juice.’’
A TREND
Epinephrine is extremely useful in hair restoration surgery, es-
pecially for lengthy hair transplant sessions. When combined the skin before the previous dose wears off, has also been em-
with local anesthetics, its vasoconstrictive properties signifi- ployed to maximize the vasoconstrictive effects.
cantly increase the duration of action of the anesthetic, decrease
the total amount needed, and increase the maximum amount
that can safely be used. Specifically, routine concentrations of
adrenaline have been reported to increase the duration of action THE PROBLEM
of lidocaine from 2 hours to 6 hours and bupivacaine from 4 In contrast to its exquisite ability to enhance the anesthetic prop-
hours to 8 hours (2). By limiting the systemic absorption of the erties of local anesthetics, the usefulness of epinephrine in pro-
local anesthetic, epinephrine increases the maximum safe dose viding hemostasis in lengthy transplant sessions is more lim-
of lidocaine from 300 mg to 500 mg and bupivacaine from 175 ited. One reason is that effects of epinephrine are short lived.
mg to 225 mg (2). In addition, there are times, especially toward the end of a
The vasoconstrictive properties of adrenaline also allow it to long procedure, when epinephrine alone seems to become
significantly decrease intraoperative bleeding. With large hair less affective in maintaining hemostasis. Both of these factors
transplant sessions that use tiny grafts placed at densities of 20 can lead to multiple re-injections in an attempt to maintain
follicular units/cm2 to 40/FUs/cm (dense packing), hemostasis hemostasis.
is particularly important because bleeding decreases visibility There are other hypothetical problems with using epineph-
during site creation and graft placement. This in turn contributes rine in large transplant sessions. One is that when the drug is
to graft popping, missed sites, multiple failed attempts at inser- infiltrated into the scalp over large areas, it may predispose to
tion, and, possibly, lower hair survival rates. Because of the postoperative telogen effluvium (shedding). Another, poten-
convenience of epinephrine as an effective hemostatic agent, tially more serious problem is that when adrenalin is added to
hair transplant surgeons performing large sessions and/or dense an area whose blood supply is already compromised by a large
packing have resorted to using increasingly higher concentra- number of recipient sites, the tissue may not receive enough
tions in increasingly greater volumes. oxygen. This problem may be magnified when the cutaneous
This trend can be exemplified by ‘‘super juice,’’ a term vasculature is altered from actinic damage or prior surgery (such
coined to describe concentrations of epinephrine in the range as scalp reductions). Although not proven, it is plausible that
of 1:25,000, which are infiltrated directly into the recipient area epinephrine infiltration into the recipient area is a contributing
to control bleeding (Fig. 8B-1). This is 800% greater than the factor in the development of the central necrosis that has occa-
concentration of epinephrine generally used to enhance the ac- sionally been reported during hair transplantation. It is also pos-
tion of local anesthetics. Piggybacking of injections, a technique sible that the intense vasoconstrictive action of epinephrine may
whereby additional quantities of epinephrine are injected into contribute to decreased graft survival.
246 Chapter 8
THE SOLUTION pain and anxiety are also important. These may include a com-
fortable chair, stretch breaks, repositioning of the patient, relax-
There is great value in adding modest amounts of epinephrine ing music, movies, and a caring and attentive attitude on the
to the anesthetic mixture; however, considering its limitations part of the staff.
in providing hemostasis during lengthy transplant sessions and
its toxic potential, it would seem prudent to use it to establish
Use Gravity to Advantage
anesthesia for the transplant but other modalities to control in-
traoperative bleeding. The simple techniques described in the Placing patients in a sitting position during surgery markedly
following sections can be used to achieve this goal: decreases blood flow to the scalp and is probably the single most
important (and easiest) way to control bleeding. Occasionally,
Perform a Thorough Preoperative Evaluation patients have a vaso-vagal reaction during the initial administra-
tion of local anesthetics, and this may sometimes lead to severe
An adequate preoperative evaluation is essential in ensuring hypotension and syncope with associated tonic-clonic contrac-
that there will be no unwelcome surprises during or after the tions. Therefore, caution should be exercised during this time.
procedure. Bleeding tendencies are best elicited by supplement- In most cases, the recipient ring-block can be administered with
ing the patient’s verbal history with a printed questionnaire. the patient in a slightly reclining position. We avoid having the
Unlike hemophilia, which is obvious during childhood, more patient lie totally flat because this position may cause more
subtle coagulopathies, such as von Willebrand’s disease, may discomfort from the injection owing to the increased vascularity
have no manifestations other than easy bruising and may go of the forehead (personal observation by the authors). However,
undiagnosed well into adult life. A comprehensive laboratory for a patient predisposed to fainting, the donor ring-block should
evaluation (complete blood count, platelet count, chemistry be administered with the patient lying in a flat, lateral position.
screen, prothrombin time test, partial thromboplastin time test, Once the patient is fully anesthetized, a more upright position
and, possibly, a bleeding time test) should be considered for can be used.
those patients with a positive personal or family history as well When recipient sites are being made, an attempt should be
as those that are at a higher risk of bleeding, such as heavy made to position the patient so that gravity moves blood away
drinkers. When von Willebrand’s disease is suspected, tests for from the operator’s visual field. When the frontal hairline is
factor VIII and von Willebrand’s factor should be carried out. designed, sites should be created from back-to-front, with the
If these tests are positive, patients can be treated with dessmo- patient tilted slightly backward (in the sitting position). The
pressin (DDAVP, Octostem, or Stimate) 30 minutes before sur- remainder of the sites in the front, midscalp, and crown can be
gery. made front-to back, with the head tilted slightly forward.
Discontinue Predisposing Agents in Advance Avoid High-Intensity Operating Room Lights
It is well known that certain commonly used drugs such as Incandescent or halogen lighting generates a significant amount
nonsteroidal anti–inflammatory agents as well as ingestion of of heat, which, in turn, causes the grafts awaiting placement to
alcohol and of certain vitamins may predispose to bleeding. warm and dry out. The lighting also increases blood flow to
Patients should be told to discontinue these agents far enough the scalp, resulting in excessive bleeding, decreased visibility,
in advance of their procedure for an effect to take place. For and more rapid metabolism of the local anesthetic.
example, acetylsalicylic acid causes acetylation of platelet Fluorescent ceiling lights generate very little heat. If spaced
cyclooxygenase, resulting in decreased aggregation and prolon- approximately, with one 2-foot bulb per 6 square feet (four
gation of the bleeding time, even at very low doses. Because panels of four 2-foot long bulbs in a 100-square. foot operating
this effect is irreversible, time must pass for a new population room), they provide enough light so that supplemental operating
of platelets to be produced by the bone marrow. As such, salicy- room lights are not necessary once the donor strip is removed.
lates should be discontinued at least 10 days before the trans-
plant to minimize their effects on hemostasis (see Chapter 7). Administer Ring Block Anesthesia (Table 8B-1)
The most efficient way to anesthetize the scalp for a hair trans-
Control Blood Pressure plant is through a ring block or a combination of ring blocks
and nerve blocks. Using local infiltration of throughout an area
Markedly elevated blood pressure is a relative contraindication
for hair transplant surgery, but a seemingly normotensive pa-
tient may become hypertensive during a transplant for a host
of reasons including, pain, anxiety, fluid overload, and sensitiv- Table 8B–1 Ring Block Mixture
ity to epinephrine and drug interactions. Increased bleeding dur-
ing the course of the procedure should alert the physician to MIXTURE
elevated blood pressure. Preferably, periodic blood pressure • lidocaine 0.5% 60%
readings with a sphygmomanometer or continuous monitoring • bupivicaine 0.025% 40%
with a pulse oximeter should be conducted to identify this prob- • epinephrine 1 : 200,000
lem and allow for early intervention. Proper and careful use of
VOLUME
local anesthetics and anxiolytics is a pharmacological method of Donor area 10–15 mL
decreasing anxiety and pain and thereby indirectly controlling Recipient area 15–20 mL
blood pressure. Non-pharmacological methods of controlling
Anesthesia 247
is a waste of time and anesthetic. When used as a block, we find pop from the puncture pressure, because grafts are not intro-
the following mixture to be adequate for most hair transplant duced until all (or the majority) of the sites are made.
sessions. More importantly, these doses fall within the maxi- With experience, it is relatively easy to estimate final graft
mum safe dose of lidocaine and bupivacaine by only a fraction. counts within 5% (3).
When administering the recipient ring block, it is important
to achieve the effect of peau-d’orange in the frontal area (the Scatter Sites to Initiate Coagulation (Fig. 8B-2)
region between the pupils) because the sensory nerves run very
superficially in this location. By using superficial injections in When recipient sites are created in a contiguous fashion, each
this site, both local anesthetic and epinephrine may be con- needlestick creates a fresh bleed that decreases visibility in adja-
served. cent areas. If the initial sites are made further apart, each site
can be made in a blood-free zone. The initial sites tend to cause
Use Tumescence (Table 8B-2) the cutaneous vasculature of the scalp to ‘‘clamp down’’, creat-
ing improved visibility for subsequent passes and allowing the
Donor Area Tumescence skipped areas to be filled in easily. Scattering sites initiates
Tumescence provides hemostasis; moreover, if used in the coagulation and significantly decreases bleeding, but without
donor area, just before harvest, it is useful in stabilizing the the intense vasoconstriction (manifested by blanching) that oc-
donor tissue and increasing the distance from the base of the curs when epinephrine is used.
hair follicles to the nerves and blood vessels lying in the deep
fat (i.e., providing a superficial plane of dissection). Tumescent Take a Break When Visibility Decreases
solutions that contain very low concentrations of lidocaine (i.e.,
.01%) are useful in ensuring that the previous ring-block anes- There is a temptation to rush making sites in order to ‘‘get on
thesia is complete (especially when there is donor scarring from with the next case.’’ However, taking short breaks after making
previous procedures). A simple tumescent mixture can be every 100- to 200 sites allows the coagulation pathways to work
achieved by diluting a bottle of lidocaine, 0.05%, and epineph- and gives time for the staff to clean the recipient area. These
rine, 1:200,000, with normal saline, either 3:1 or 5:1. breaks permit site placement to be made far more accurately
and eliminate the risk that one will merge with another (and
Recipient Area Tumescence result in a slit large enough to leave a scar). When the staff is
Tumescence in the recipient area can be useful in helping to of sufficient size and the physical facilities permit, it may be
limit the depth of the donor sites, as well as, provide hemostasis. advantageous to transplant two patients simultaneously, so that
Effective recipient tumescence can be achieved with epineph- the surgeon can alternate between patients and be literally
rine, 1:1,000,000, in normal saline without the addition of anes- forced to slow down and to let the staff and Mother Nature help
thetic. Recipient tumescence is more useful when all the sites out.
are premade, because the volume of fluid is less likely to cause
popping of grafts and the tumescence is needed for only a lim- Apply Bimanual Traction
ited amount of time.
Stretching the skin in the area where sites are being made (Fig.
8B-3) can easily control bleeding. If extra staff members are
Use Premade Recipient Sites
available, the surgeon can stretch the skin toward him with the
With the ‘‘stick-and-place’’ method, epinephrine is used to de- hand that is free-while the assistant uses one hand to stretch
crease bleeding, decrease graft- popping, and increase visibility. the skin in the opposite direction and the other to perform bal-
Premaking all the recipient sites before graft insertion (rather lottement. When the surgeon works alone, the sites can be made
than using a stick-and-place technique) provides solutions to in the skin stretched between the third or fourth fingers and the
these problems without the use of epinephrine. First, it initiates thumb. Stretching also decreases bleeding by helping control
the extrinsic pathway so that coagulation can begin well before incision depth. When the skin is held taut, the needle readily
the grafts are introduced. Second, it allows easy cleaning of pierces the skin and the depth of the puncture wound is very
any blood or coagulum from the recipient area, without the risk controllable. However, when the skin is loose, the needle tends
of dislodging grafts. Third, the close placement of sites can be to first depress the skin, giving greater depth to the resultant
achieved without concern that grafts adjacent to the site may wound. Deeper vessels are therefore more likely to be severed.
Keep Recipient Sites Small and Superficial

Table 8B–2 Tumescent Mixture It goes without saying that small recipient sites cause less injury
to blood vessels and therefore less bleeding. The importance
MIXTURE FOR DONOR AREA
of limiting the depth of incision has been emphasized by Dr.
• lidocaine (Xylocaine) 0.01%–0.017%
James Arnold (4). The Mindi Knife is one type of blade that
• epinephrine 1 : 600,000–1 : 1,000,000
was specifically designed to accomplish this goal. This and
VOLUME FOR DONOR AREA other instruments that minimize wounding permit the use of
Donor area 20–30 mL less epinephrine (Fig. 8B-4).
MIXTURE FOR RECIPIENT AREA
Slow, deliberate site creation at an acute angle also allows
• epinephrine 1 : 600,000–1 : 1,000,000 without anesthetic the surgeon to minimize the depth of the wounds, because, with
experience, one can feel the needle, or bladepassing through the
248 Chapter 8
Figure 8B-2 Scattered site pattern used to initiate coagulation. Note that the initial sites form a perimeter around the area to be
transplantedand also divide it into organized subsections.
Figure 8B-3 Bimanual traction applied with the help of an assistant.

Anesthesia 249
Figure 8B-4 Comparison of an 18-gauge NoKor needle with a Mindi Knife that minimizes incision depth.
dermis into the subcutaneous space. The technique of rapidly with nicotine deprivation. Rather than attempting to control the
bouncing the needle or blade off the skull while making sites bleeding with additional epinephrine, we occasionally have the
should be avoided. patient smoke part of a cigarette at the, midpoint of the surgery;
often, this tactic solves the problem. The patient is encouraged
Creating a Snug Fit to avoid smoking postoperatively so that healing may be facili-
tated. For all smokers, it should be stressed that after a hair
Choosing an instrument that makes a recipient site no larger transplant is an ideal time to give up smoking permanently.
than necessary allows a precut graft to fit securely into the
recipient site, where it may efficiently stanch bleeding. In addi- Keep Cool
tion, by eliminating the formation of a micro-coagulum and by
promoting contact between the wall of the recipient site and Last but not least, keep cool! Decreasing the temperature of
the graft, oxygenation is most likely facilitated. We find that the operating room to the lowest comfortable level appears to
site sizes ranging from 1.1 mm to 1.75 mm are ideal to produce decrease bleeding in the scalp (although the blood vessels in
a ‘‘snug fit’’ around FUs of one to four hairs, even for African the scalp do not actively undergo vasoconstriction in response
hair types. to cold as much as other acral areas of the body). We have
occasionally applied cold compresses to the scalp to promote
vasoconstriction, but now we rarely find this necessary.
Keep the Patient’s Headband Loose
Besides being uncomfortable for the patient, a tight headband CONCLUSION
decreases venous return and increases venous engorgement of
the scalp. Attention to this problem can easily eliminate it as The use of large amounts of epinephrine to establish hemostasis
a source of increased bleeding. in extensive hair transplant sessions is neither necessary, nor
desirable. Because intraoperative bleeding in the recipient area
Smoke Just This One Time during site creation and graft placement can be controlled by
simple methods that are easy to administer and free from ad-
Nicotine is a potent vasoconstrictor. Chronic smokers who stop verse effects, the reliance on epinephrine in these phases of the
smoking completely pre-operatively are often found to bleed procedure should be reconsidered.
excessively during the procedure, possibly due to reactive vaso-
dilatation. The increased bleeding associated with the cessation Editor’s Comments
of cigarette smoking may also be due to increased blood pres- There are many ‘‘pearls’’ in the discussion by Bernstein and
sure caused by the anxiety and hyper-adrenergic state associated Rassman. It is, however, important to emphasize that there is
250 Chapter 8
no clinical evidence to support some of the more ominous theo- dentally intravascularly. This helps to avoid a systemic
retical disadvantages that they describe as resulting from use bolus of anesthetic and/or epinephrine with accompany-
of higher doses of lidocaine and epinephrine. In particular, as ing unwanted effects.
Wolf has observed, the manufacturer’s guidelines for maximum 6. A small-bore, 30-gauge needle is used for all injections
safe doses of lidocaine and epinephrine are extraordinarily con- other than those for tumescence, and small amounts are
servative if they are used as described by Wolf, Seager, and given with each injection just in case intravascular injec-
many other hair restoration surgeons, including me. On the tion occurs despite the preceding precautions.
other hand, if Bernstein and Rassman’s suggestions result in 7. An intravenous line is inserted if unusually large
use of smaller amounts of lidocaine and epinephrine, so much amounts of either lidocaine or epinephrine are found to
the better. (WU) be necessary. (For the vast majority of patients, I have
not found an intravenous line necessary, and in 37 years
of hair transplanting I have never experienced a danger-
8C. Unger’s Technique for ous consequence of this policy).
Anesthesia Using the prophylactic measures as described, I have commonly
exceeded—over a period of 3 to 6 hours—the recommended
Walter P. Unger maximum dose of lidocaine (sometimes substantially) without
producing toxic side effects. Of course, an attempt should be
Numerous approaches to anesthesia for hair transplanting are made to keep under the recommended maximum dose whenever
described in this chapter, all of which work well in the hands this can be done without causing pain to the patient but if the
of the physicians describing them. Dr. Bradley Wolf has de- maximum dose must be exceeded to control pain, it appears
tailed his technique, and Bernstein as well as Seager and Sim- that this can be done safely by using the approach described
mons provide additional advice. This section presents another earlier.
anesthetic approach for consideration. It cannot be over-empha- The anesthetizing process is begun with the patients lying
sized, however, that whatever technique is selected after review on their stomach, with the face in a prone pillow (Fig. 8C-1).
of all of these methods of anesthesia, safety and minimizing As noted in Chapter 10, we sometimes employ two donor areas.
the patient’s pain are extraordinarily important aspects of hair One is obtained from the left or right side of the inferior occipital
restoration surgery. It continues to surprise me—and even to area to obtain fine-textured hair for the anterior hairline zone.
depress me—that so many of my surgical patients who have Another is excised from the contralateral side more superiorly,
been previously treated by sometimes well-experienced trans- from the midline across the occipital and parietal areas and
plant surgeons remark on how much more painful the experi- extending into a portion of the temporal area. The superior strip
ence was with those surgeons. There is no good reason for this usually contains (1) hair of higher caliber to provide better cov-
to be the case; such practitioners must have placed a relatively erage than fine hair, and (2) hair that will gray earlier (temporal
low priority on reducing the pain of the procedure. This position hairs), which can be used in the frontal recipient area so that
is not only ethically wrong but also, from a public relations when the temples gray, a sprinkling of gray hair will also appear
viewpoint, extremely shortsighted. There are few things that in the transplanted frontal area. The strips are removed from
provide better public relations than patients who tell their physi- contralateral sides to minimize tension on closure of the sites.
cians, friends, colleagues, and hairstylists that the procedure We initially produce a field block inferior to donor areas by
was painless, or nearly so. ‘‘A word to the wise...’’ using a 30-gauge needle, and Ph-neutralized lidocaine, 2%, with
My colleagues and I try to maximize the safety of the lido- epinephrine, 1:100,000, warmed to body temperature. This lat-
caine anesthetic we employ in a number of ways: ter solution is prepared in two parts:
1. Premedication with oral diazepam (Valium), 20 mg, is
administered 30 minutes preoperatively. This not only
relaxes the patient but, as Dr. Wolf has already noted,
also increases the minimal convulsive dose of lidocaine
by one third (1).
2. Anesthetic administration is staged, leaving intervals of
15 to 30 minutes or more between deliveries of signifi-
cant amounts of anesthetic solutions and epinephrine so
that the body can deal with such doses before more of
these drugs are infiltrated.
3. Usually the anesthetic and always the epinephrine are
injected very superficially to maximize their effects
while slowing their systemic absorption (exceptions are
noted later).
4. Relatively high concentrations of epinephrine are used,
such as 1:50,000 with most lidocaine injections, again
to slow the systemic absorption of anesthetic.
5. A finger is placed just in front of the needle each time
solutions are being injected allowing the surgeon to feel Figure 8C-1 Patients are placed on their stomach with the head
the solution going interstitially rather than going acci- in a prone pillow for anesthetizing and harvesting of donor areas.
Anesthesia 251
1. A sodium bicarbonate solution is obtained by mixing the donor area entered midway along its length and the needle
2 mL of sodium bicarbonate, 8.4%, and bacteriostatic inserted its full length anteriorly or laterally before being slowly
sodium chloride, 18 mL thus producing a sodium bicar- withdrawn while it concomitantly infiltrates the tumescent solu-
bonate solution of 100 ␮g per liter, which is stable for tion. The balance of the prepared tumescent solution is saved
only 8 hours. and later injected—intradermally—into each donor area imme-
2. A lidocaine and epinephrine solution is prepared by diately before each strip is excised. Sufficient tumescence must
combining of 4% lidocaine, 5 mL, without epinephrine be used to create a rock-hard donor site with FUs spread apart
with 1:1000 epinephrine, 0.1 mL, and the sodium bicar- maximally and standing as straight as possible so as to minimize
bonate solution, 5 mL, described in 1 above. The result their transection by the cutting blade (see exceptions later). The
is 10 mL containing 2% lidocaine with 1:100,000 epi- initial tumescence also balloons the subcutaneous tissue and
nephrine and sodium bicarbonate, 50 ␮g/liter, or stated therefore minimizes the likelihood of transection of the deeper
differently, 0.5 mL of sodium bicarbonate 8.4%, 4.5 mL and larger blood vessels and nerves during harvesting of the
of sodium chloride solution, and 5 mL of lidocaine 4% donor tissue.
with 0.1 mL epinephrine 1:1000. After the donor area is anesthetized, if the recipient area is
the frontal one third of the area of male pattern baldness (MPB),
This pH-neutral anesthetic solution is injected slowly, with care an intradermal wheal is raised at each of the lateral ends of the
taken to insert the needle into the skin as deep as high subcuta- proposed anterior hairline with approximately 0.3 mL of 4%
neous tissue for these initial injections, and at the same angle lidocaine with 1:50,000 epinephrine at each site. The latter mix-
as the hair that grows in the area. For some reason, doing this ture is created by adding 0.05 mL of epinephrine 1:1000 to 5
appears to cause less pain than when the needle is inserted mL of 4% lidocaine without epinephrine. These injections sting
without regard to hair direction. A wheal is initially raised at slightly but are over quickly—usually in less than 10 sec-
the midline, approximately 4 mm inferior to the clipped donor onds—and occur at the height of blood levels of diazepam.
strip hair. Other wheals are produced at the same level intermit- Two such injections are easily tolerated, and often forgotten
tently for the entire length of the prepared donor areas, each by virtually all patients. I have watched practitioners who use
wheal set approximately 3 cm apart from its neighbor. If two intravenous Midazolam (versed) with or without Meperidine
donor areas are being used, after the inferior donor area has (demerol) pre-operatively and have been impressed with how
been prepared this way, the superior donor area is prepared in well this approach works in relaxing the patient and making
the same fashion. On return to the inferior donor area, the needle the procedure more comfortable. I have been tempted to switch
is inserted through the now anesthetized wheals, and the skin from oral diazepam to intravenous midazolam on many occasi-
between them is anesthetized to produce a solid line of anesthe- ons—especially because of the latter drug’s superior amnestic
sia inferior to the donor site. The superior donor area field block effect. Thus far, I have not done so because of the following
is then completed in the same way. This approach, although considerations:
slow, still takes only 10 to 15 minutes and produces almost
painless field blocks with approximately half the number of 1. My current anesthetic technique seems to be virtually
needles being felt. Moreover, the ph-neutralized anesthetic painless and well tolerated so that the extra amnestic
causes far less sting than stock acidified anesthetic. It is rare effect of midazolam is probably unnecessary and even
that the full 10 mL of the blocking anesthetic is used. negative in the opinion of some of my patients, who
For those who do not want to prepare a neutral-ph anesthetic prefer to know what is going on all the time.
solution as described above, Koay and Orengo have suggested 2. Diazepam has a superior ability of to act as an antineu-
an alternate mixture that is almost as good (2). Lidocaine with rotoxic agent—and I believe I use higher total doses of
epinephrine has a pH of 3.5 to 4.5, whereas plain lidocaine has lidocaine than most hair restoration surgeons.
a pH of 6.5 to 6.8 (tissue fluid has a pH of 7.3 to 7.4). If 10 3. A higher margin of safety is enjoyed by oral rather than
mL of plain lidocaine are mixed with 0.1 mL of epinephrine intravenous medications—although intravenous mida-
1:1000, the result is a lidocaine solution with 1:100,000 epi- zolam is extremely safe when used by knowledgeable
nephrine but with the same pH as plain lidocaine. practitioners in small incremental doses.
The actual donor strips are then expanded painlessly with My preference for diazepam is, however, frequently re-as-
50 mL to 60 mL of a tumescent solution prepared by adding sessed. At one time, I combined diazepam with 50 mg of meper-
5 mL of 2% lidocaine without epinephrine to a 100-mL bag of idine or oxycodone (Percocet), but I discontinued use of this
0.9% sodium chloride to which 0.4 mL of epinephrine 1:1000 mixture because of an increased incidence of intra operative
have been added: nausea and/or syncope. I am currently trying a combination of
100 mL 0.9% sodium chloride Ⳮ 5 mL of licodaine without 20 mg of diazepam and 600 mg of ibuprofen.
epinephrine Ⳮ 0.4 mL of 1:1000 epinephrine The donor area field block is always reinforced toward the
end of the procedure with the infiltration of Marcaine, 0.05%,
(As noted by Wolf, many practitioners simply use a saline solu- with 1:100,000 epinephrine to theoretically control postopera-
tion for producing tumescence. In my experience, it is often as tive pain for 6 to 8 hours postoperatively. I say ‘‘theoretically’’
effective as the one just described—but not always). because the anesthetic effect rarely lasts for more than 3 to 4
The tumescent solution is injected using a 11⁄2-inch, 21- hours, probably because it is diluted by fluid already present
gauge needle that is inserted into the subcutaneous tissue just in the donor area. The field blocks may also be reinforced dur-
superior to the medial end of the field block, and for its full ing the procedure at the first sign of even the slightest discom-
length along the proposed donor areas. It is then withdrawn fort or if the procedure looks as if it will last more than the
slowly as the solution is being infiltrated. This is repeated, with typical 4 to 5 hours, or if there has been has been more than
252 Chapter 8
average difficulty in anesthetizizing the patient. In all such in- If the recipient area is the vertex or crown area of MPB, the
stances, 5 mL to 10 mL of anesthetic solutions are employed. field block is produced in the same staged manner, but the
It is well to remember these few ‘‘pearls’’ for local anesthe- patient remains lying on the stomach with the face in the prone
sia. First, an ounce of prevention is worth a pound of cure. Try pillow. For treatment of this area, more grafts are generally
to anticipate when the anesthetic will wear off and reinforce required than for the frontal or midscalp areas; therefore, I
the field block before this begins to occur. Second, a chain is nearly always use a donor area extending from the left to right
only as strong as its weakest link. If a small area of the anesthetic ear, passing through an area near the occipital protuberance and
line is accidentally insufficiently anesthetized, the field block ending approximately 2.5 cm to 3 cm superior to both ears (see
fails despite the adequacy of the entire remaining line. Finally, Chapter 10). The donor area field block and incision often create
once the anesthetic effect begins to wear off, it does so rapidly, a field block for the midscalp and vertex recipient areas, and
not slowly. Respond quickly. 2% or 3% lidocaine with 1:50,000 epinephrine are virtually
For patients who are more difficult than average to anesthe- always sufficient. Few, if any, injections are felt except, possi-
tize, stronger anesthetics such as lidocaine, 3% or even 4%, bly as the frontal border of this recipient area is anesthetized.
with 1:50,000 epinephrine may be used, in which case the total However, slow creation of the border, beginning at the anterior
amount administered at any given time is nearly always less lateral points and each time inserting the needle through previ-
than 5 mL. They are prepared as follows: ously anesthetized areas, prevents any significant pain as this
portion of the field block is produced.
3% solution— three 1.8 mL injection cartidges (carpules) A period of at least, 20 to 30 minutes elapses after creation
of lidocaine, 2%, with 1:50,000 epinephrine Ⳮ 5 mL of of the recipient area field block before a 1:50,000 epinephrine
4% lidocaine without epinephrine solution (without lidocaine) is injected intradermally and evenly
4% solution— 5 mL ampules of 4% lidocaine plus 0.05 mL throughout the recipient area. It is uncommon to require more
of epinephrine 1:1,000 than 10 mL of solution. The goal is to complete the infiltration
at least 20 (preferably 30) minutes before any incisions are
After the donor area has been sutured, if one is dealing with a made in the recipient area. This solution is prepared by adding
frontal or midscalp recipient area, the patient rolls over onto 0.6 mL of epinephrine 1:1000 to 30 mL of normal saline (0.6
the back, and three additional injections of lidocaine, 4%, with mL of epinephrine 1:1000 plus 30 mL normal saline ⳱ 1:50,000
1:50,000 epinephrine are administered. The first is in the mid- epinephrine). Immediately before beginning preparation of the
line anteriorly and just anterior to the proposed hairline. The recipient sites, another 10 mL may be injected, or this may be
others are on the left and on the right side midway between the done just before insertion of grafts into the recipient sites. Small
midline wheal just produced and the wheals raised approxi- amounts may also be intermittently injected during the course
mately 30 minutes earlier at the lateral ends of the anterior of graft insertion. With one exception, that is to be discussed
hairline (on completion of anesthetization of the donor area). later, I have not found it necessary to use higher concentrations
The infiltration of these three wheals, each with approximately of epinephrine in the recipient area, although Wolf has noted
0.2 mL or 0.3 mL of anesthetic, requires no more than a total that other practitioners routinely use 1:25,000 or 1:10,000 epi-
of 10 to 15 seconds and is easily tolerated by virtually all pa- nephrine, especially for dense packing of FUs
tients—in my experience, more easily than frontal and trigemi- I also use a 1:50,000 epinephrine solution instead of produc-
nal nerve blocks. ing tumescence in the donor area if a patient is receiving Cou-
The process of anesthetizing the rest of the frontal field block madin therapy, has a relatively tight scalp, and/or has low donor
is started approximately 20 to 30 minutes later. At intervals hair density. One such patient I treated was on Coumadin ther-
of 5 to 10 minutes, the needle is inserted through previously apy to prevent recurrence of a prior incident of pulmonary em-
anesthetized wheals (or areas), and the anesthetic is injected bolus. I created the donor area field blocks in this patient with
slightly to the left and then to the right of such areas until a solid non buffered lidocaine, 2%, with 1:100,000 epinephrine.
line of anesthetic is completed frontally and laterally. These Twenty minutes later, instead of the usual tumescent solution,
injections are essentially painless if the approach is not overly I injected a 1:50,000 epinephrine solution superior to the blocks.
aggressive (extending the anesthetized line too quickly), even if Then I excised the donor strip, and the patient had less than
they are aimed intradermally instead of at the high subcutaneous the typical amount of bleeding. In the recipient area, after pro-
tissue. It is rare that more than 5 mL are required for these ducing my field block in the usual manner, I used a 1:25,000
injections, which are spread over a 20-minute to 30-minute pe- epinephrine solution injected at a rate of 1 mL to 2 mL every
riod. Thus, a completed frontal area block is accomplished with 15 minutes. I waited 20 minutes before creating minimal depth
the patient having felt only two quick injections requiring 5 recipient sites for FUs and was surprised by the small amount
seconds to 10 seconds at the end of the anesthetizing procedure of bleeding that occurred— also less than usual. The patient’s
in the donor area and three more injections requiring 10 to 15 postoperative course was similarly unmarred by excessive
seconds approximately 30 minutes later. The slow administra- bleeding.
tion of the 4% solution allows for safe monitoring of any signs I am aware that using 3% and 4% concentrations of lidocaine
of toxicity as well as systemic absorption over a longer period is highly unusual for most practitioners, and I have no explana-
of time. In addition, the 1:50,000 epinephrine reinforces the tion for why they are required for total anesthesia in some of
slow systemic absorption. My colleagues and I no longer em- my patients. Perhaps this is because we initially aim for high
ploy pH-neutralized anesthetic solutions for frontal area field subcutaneous infiltration, rather than intradermal infiltration,
blocks or tumescent solutions in the frontal area. When we which is more painful. Once the area is initially anesthetized,
tried this, the incidence of severe periorbital edema increased subsequent injections are made intradermally. One group of
dramatically. patients who require higher concentrations of lidocaine are usu-
Anesthesia 253
ally those with reddish hair on scalp or beard, and/or green or

hazel eyes, and/or large body freckles, and a history of being
prone to sun burn—in other words, those with suspected or
known Celtic background. The other group of patients, in my
experience, who seem to require higher concentrations of lido-
caine are individuals with a past history of substance abuse.
Moreover, whenever such a patient is encountered, an intrave-
nous line is always established so that if intravenous diazepam
is required for any signs of lidocaine toxicity—such as
tremors—it can be immediately and easily administered. More
often, if large amounts are being used, I prophylactically admin-
ister 10 mg of intravenous diazepam (approximately 1 hour to
11⁄2 hours after the oral diazepam) before injecting high concen-
trations of lidocaine and/or epinephrine, and therefore before
any toxic symptoms or signs might emerge. As noted earlier
in reference to using this approach, I have not had a significant
Figure 8C-2 The Wand.
toxic reaction in 36 years of practice. The purpose of discussing
these doses and strengths of lidocaine is not to encourage their
use by others but rather to point out the difference between
theory and practical experience, so that if these dosages are
a constant flow of anesthetic without the need to push
found to be necessary to control pain in some patients, physi-
the foot pedal. Visual and audible monitoring of the
cians will not be afraid to employ them with, of course, the
volume of anesthetic being injected helps to prevent an
precautions noted earlier.
overdose. Although this instrument is slower to use than
My colleagues and I have self-administered nitrous oxide
conventional techniques, it provides effortless infiltra-
available for patients who find this modality helpful for the
tion. The Wand has two other benefits. First, because
initial injections. For particularly anxious individuals or those
only small amounts are injected slowly, tissue distention
with unusually low pain thresholds, we also offer the option of
is minimized and the process is a good deal less painful
an anesthesiologist who uses propofol (as well as fentanyl), than with conventional methods, even when the anes-
which allows the patient to sleep painlessly through the first thetic is infiltrated superficially. Second, the instrument
10 to 15 minutes of the procedure, during which all field blocks automatically performs an aspiration before each injec-
are produced (3). The anesthesiologist administers whatever is tion, thereby preventing accidental intravascular injec-
necessary to counteract any toxicity caused by the high doses tion. A 30-gauge Luer-Lok needle and 1.8-mL injection
of lidocaine and epinephrine, which are present owing to their cartridges containing lidocaine, 2%, with 1:50,000 epi-
relatively rapid administration. An anesthesiologist is always nephrine, are used with the instrument. True and Elliott
present for patients with a family or personal history of malig- have recently described their experience with The
nant hypothermia; for those with any past history of significant Wand. They found it superior to conventional methods.
cardiovascular disease; or for those who have required unu- Sixty-eight percent of the patients they studied reported
sually large amounts of lidocaine or epinephrine in preceding no pain or very little pain. Wand anesthesia was not
hair transplants. I believe that much of the success of my per- only associated with superior comfort during the admin-
sonal practice is related to the fact that throughout my career istration of anesthesia but ‘‘throughout the treatment
I have been constantly and acutely sensitive to the pain that my session and during the first 48 postoperative hours’’ (5).
patients feel. (The Wand Plus is manufactured by Milestone Scien-
The superficial injection of solutions with 30-gauge needles, tific, 151 South Pfingsten Rd., Deerfield, IL 60015. Tel:
in many patients per week, over many weeks, can cause debili- 1–847–272–3207, email milestone@milesci.com.)
tating wrist, hand, or finger pain to the administrator. The ac-
tions required may even cause carpal tunnel syndrome. Several Another instrument, first used by dentists, is a hand-held, spe-
methods have helped the members of my practice to avoid or cially designed Paroject syringe, (Fig. 8C-3). With this instru-
minimize these problems: ment, disposable, 30-gauge dental needles are used as well 1.8-
mL injection cartridges that contain articaine, 4%, with 1:
1. Small syringes (e.g., 3-mL syringes) rather than larger 100,000 epinephrine. Very little effort is required to press on
ones should be used. The narrower the barrel of the the activator (see arrow in Fig. 8C-3), which results in injec-
syringe, the less effort is required to depress the plunger. tion of 0.3 mL of anesthetic. (The Paroject syringe is available
2. A computed injection system called The Wand is used from Clinicians Research Dental Supplies & smp; Research
to inject anesthetic solutions (4) (Fig. 8C-2). This instru- Services, P.O. Box 1706, New Milford, CT 06776. Tel:
ment employs a computed flow-rate control for anes- 1–800–265–3444, Fax: 1–800–719–3292. Canadian distribu-
thetic infiltrations. It is activated by a foot pedal and tor P.O. Box 28040, London, ON N6H 5E1. tel:
there are three administration modalities to choose 1–800–265–3444, fax: 1–519–641–3083, email for both:
from: (1) a slow rate, which injects one drop of anes- info@clinicianschoice.com)
thetic solution per 2 seconds; (2) a fast rate, which is There is a very short learning curve for both the Wand and
usually used only after some anesthesia has been the Paroject syringe. Because the anesthetic is consistently in-
achieved; and (3) a ‘‘cruise-control,’’ which provides jected very superficially without any effort when these instru-
254 Chapter 8
solution whenever I think the advantages of tumescence might

be worthwhile. I have made this change primarily because I
was so impressed with the control of bleeding I noted in the
patient on Coumadin therapy whose case, was described earlier.
8D. Supraorbital and Supratrochlear

Nerve Blocks in Hair
Transplantation
David J. Seager and Cam Simmons
INTRODUCTION
Figure 8C-3 Paroject syringe.
Hair transplant surgeons anesthetize the recipient area by using
ring blocks, tumescent local anesthesia, nerve blocks, or a com-
bination of methods. A large portion of the recipient area can
be anesthetized with a small amount of local anaesthetic for a
ments are used, there is virtually always a concomitant reduc- long period of time with bilateral supraorbital and supratroch-
tion in the total amount of anesthetic necessary to produce total lear nerve blocks (1). The method described in this chapter
anesthesia. requires virtually no learning curve and is easy to perform; it
has a 98% success rate on the first attempt.
SUMMARY
Anatomy
It is worthwhile to emphasize that the pain experienced by the
patient during infiltration of an anesthetic solution is owed to The supraorbital and supratrochlear nerves are branches of the
(1) the needle puncture, (2) tissue irritation caused by the solu- frontal nerve, which is, in turn, a branch of the ophthalmic
tion, (3) tissue and fluid temperature differences, and (4) tissue division of the trigeminal nerve. Each nerve has a corresponding
distention by the fluid. The approach described earlier deals artery in close proximity. The supraorbital and supratrochlear
with these factors because of the following: nerves have been classically described and illustrated as having
consistent anatomical relationships and as providing sensation
1. A 30-gauge needle is used, which is especially advanta- from the supraorbital rim back toward the lambdoid suture (2,3)
geous if the angle and direction of the needle and hair (see Chapter 2B). Cosmetic, endoscopic, and brow surgeons,
in the area are similar. however, have studied and redefined the anatomy of the nerves.
2. The anesthetic donor area field block is produced with Their studies were motivated by their desire to avoid causing
a pH-neutral or near-neutral solution. nerve damage during cosmetic surgery.
3. The anesthetic is warmed to body temperature.
4. The anesthetic is initially injected subcutaneously and
Supratrochlear Nerve
there is greater distensibility of the subcutaneous tissue
compared with the dermis. Subsequent reinforcing anes- The supratrochlear branch of the frontal nerve is usually much
thetic injections can be done painlessly into the dermis, smaller than the common trunk of the supraorbital nerve. The
where they are more effective and longer lasting than supratrochlear nerve lies in the medial third of the orbit between
the subcutaneous injections. the periosteum of the orbital roof and the intraorbital fat. Al-
Of course, the less the volume of anesthetic necessary to pro- though it was classically described as exiting through a supra-
duce anesthesia, the less tissue distention and pain will be pro- trochlear notch or supratrochlear foramen, it has been noted
duced. Thus, the Wand and the Paroject syringes, which are that the supratrochlear nerve usually leaves the orbit without
used to almost effortlessly inject very small amounts of solution forming any significant impression on the supraorbital rim (4).
intradermally, can result in very little tissue distention and pain The supratrochlear nerve supplies sensation to the medial infe-
while producing a maximum level of anesthesia and longevity rior brow. It rarely reaches or supplies sensation to the area of
of anesthesia with minimal total doses of anesthetic. Finally, if the hairline.
the anesthetic solutions are judiciously administered in a staged
fashion over prolonged periods, the published maximum safe Supraorbital Nerve
doses of anesthesia do not appear to be applicable.
The supraorbital nerve also lies between the periosteum and
the intraorbital fat in the orbit, but regularly exits the skull
ADDENDUM through either a supraorbital notch or supraorbital foramen. Ap-
proximately 15% of the time, the supraorbital nerve forms two
Since I originally wrote this chapter, I have begun to use, instead branches before leaving the orbit (4). In this situation, the me-
of a tumescent solution, a 1:50,000 epinephrine solution, supe- dial branch exits the skull through a frontal notch or foramen
rior to the donor area field block. I use the solution as described and the lateral branch leaves through the supraorbital notch or
by Dr. Wolf. In such cases, I also infiltrate a simple saline foramen. Alternatively, both branches exit through a common
Anesthesia 255
broad notch or foramen. Although there may be multiple dial notch is likely to be a frontal notch, which contains the
branches of the supraorbital nerve, Knize has stated that there medial division of the supraorbital nerve, whereas the more
are two consistent divisions (5). The medial (superficial) divi- lateral notch is likely to be the supraorbital notch, which con-
sion quickly forms multiple small branches that perforate the tains the lateral division of the supraorbital nerve. The supra-
frontalis muscle to reach the skin of the forehead. The medial trochlear nerve is likely to be medial to the frontal notch. If a
division supplies the sensation to the forehead and the anterior single notch is palpable, one must take into account how broad
hairline. Most often, it supplies sensation only to the level of the or narrow the notch is and the distance from the midline. A
coronal suture. When the medial division does supply sensation single narrow notch near the midpupillary line is likely to con-
more posteriorly, there is usually overlap with the lateral divi- tain the common trunk of the supraorbital nerve. A single nar-
sion. row notch, located 2 cm from the midline, is likely to contain
The lateral (deep) division courses laterally and superiorly only the medial division of the supraorbital nerve (the lateral
deep to the frontalis muscle and then runs between the galea division may be contained in a supraorbital foramen). A broad
and the periosteum 1 cm to 1.5 cm medial and parallel to the notch lying near the junction of the medial third and lateral two
superotemporal line of the skull at the rim of the temporal fossa thirds of the orbit may contain both branches of the supraorbital
(5). It then curves to a more medial direction and bifurcates nerve. Consideration should be given to the palpable surface
before reaching the coronal suture. This lateral division of the anatomy, the usual locations of the nerves, the possible branch-
supraorbital nerve supplies the area of the scalp from 1 cm to ing patterns and the possible existence of accessory branches
3.5 cm behind the hairline to at least a coronal plane parallel to anywhere from 1.6 cm to 5.5 cm from the midline; thus, one
the posterior ear and, in some, supplies the scalp to the occiput. can be more certain of blocking all necessary branches when
the nerve block is performed.
Additional Innervation
The lateral part of the frontal recipient area may have additional Technique
innervation through branches of the zygomaticotemporal nerves
The goal in performing a nerve block is to infiltrate sufficient
and auriculotemporal nerves. Employing a nerve block to the
local anesthetic near the nerve trunk to anesthetize it as it exits
common supraorbital trunk blocks both medial and lateral divi-
the skull. An additional goal is to ensure that any early branches
sions, enabling a large portion of the ipsilateral recipient area
or nerves in a variant pattern are anesthetized as well.
to be anaesthetized, but the lateral recipient area may require
With anatomical variations in mind, some surgeons use a
additional anesthesia.
shotgun approach in which they blanket the periosteum with a
local anesthetic—along the length of the eyebrow (see Chapter
Surface Anatomy 8A). This ensures blockage of all potential patterns of nerve
As implied in the previous discussion, there are reasonably reli- branching. Unfortunately, this approach also requires more
able landmarks to assist in blocking these nerves. The supraor- local anesthetic than a more targeted nerve block. Others elicit
bital nerve often emerges in a notch on the superior orbital rim, paresthesias to ensure that they are injecting the local anesthetic
which has been described by some as being in the midpupillary near the nerve trunks. This technique increases the risk of dam-
line and by others as being at the junction between the medial aging the nerves with the needles; as a result of this possibility,
third of the orbit and the lateral two thirds of the orbit. In prac- the approach has generally fallen out of favour.
tice, it is often palpated anywhere between these two points. If Our preferred technique involves locating the supraorbital
a notch is palpable in a more medial position, it is more likely notch (Fig. 8D-1a) and holding the thumb of the noninjecting
to be a frontal notch for the medial division of the supraorbital hand on the notch (Fig. 8D-1b). A visual check to ensure that
nerve rather than a true supratrochlear notch. A notch is easily this location is near the midpupillary line is required. If the
palpable from the surface, whereas a foramen is not. There can notch is not palpable, the block can still be performed by starting
be considerable variation in patterns of notches and foramina, it at a point just above the eyebrow and just medial to the
collectively known as exit points. Thus, the surface anatomy midpupillary line. Some physicians recommend the ‘‘three-fin-
must be interpreted carefully. Examining the raw data from ger rule’’ (8), but, with this approach, we prefer that the block
three different studies of 577 skulls, 20% to 35% of orbits had be initiated about two finger widths (3.5 cm), rather than three
no notches, 71% to 80% had one notch with or without an finger widths, away from the midline. A half–inch, 30-gauge
associated foramen, and 3% had two notches (4,6,7). Extrapo- needle is used, which should penetrate to the level of the perios-
lating from the raw data, an isolated supratrochlear notch (with teum (Fig. 8D-1c). Whether the skin is penetrated above the
no supraorbital notch) was present in 5% of orbits (6). The eyebrow or below the eyebrow, the tip of the needle should
minimum distance to the first exit point of a branch of the contact the periosteum just superior to the notch/supraorbital
frontal nerve from the midline (nasion) was 1.6 cm, whereas rim. The surgeon should feel constant contact with the bone
the maximum distance to the last exit point was 5.5 cm (4). while aspirating and then while injecting 1 mL of local anes-
Miller also noted no exit points closer than 1.6 cm from the thetic. (If paresthesias are elicited or blood is aspirated at any
midline (6). time, the needle should be removed and repositioned.) The
needle is withdrawn until the tip is just under the skin and is
Practical Anatomical Considerations then reinserted medially and angled at least 45⬚ (Fig. 8D-1d).
With the tip of the needle at skin level, the skin can be stretched
In performing nerve blocks, one must visualize the underlying medially with the thumb and index finger of the noninjecting
anatomy. If two notches are palpable in an orbit, the more me- hand to ensure that the advancing needle will reach the approxi-
256 Chapter 8
a b c
d e f
g h i
Figure 8D-1 Figs. 8D-1a through 8D-1i illustrate the sequence of events described in the text for performing a supraorbital nerve
block. The supra orbital notch is found and marked. The needle is inserted and advanced to the periosteum at this site and approx. 1 ml
of anesthetic is injected. The needle is withdrawn until the tip is just under the skin and redirected medially at about a 45⬚ angle and
advanced to the periosteum again, where another 1 ml of anesthetic is injected. This is the approximate location of the supratrochlear nerve.
The needle is than withdrawn again until it is just under the skin and redirected laterally and advanced to the periosteum again, where a
final 1 ml of anesthetic is injected. The area is vigorously massaged.
mate location of the supratrochlear nerve. The needle should tion of the area above the eyebrow should be obvious (Fig. 8D-
then be advanced again until it is in contact with the periosteum 1i). The whole procedure is repeated on the contralateral side.
(Fig. 8D-1e). After aspiration, another 1 mL of local anesthetic Bupivacaine, 0.25%, with 1:100,000 epinephrine is our
is injected in the approximate location of the supratrochlear choice of anesthetic agent because only a small volume is re-
nerve. The needle is withdrawn until the tip remains just under quired to produce anesthesia and the duration of action is
the skin, and the angle is then changed to 45⬚ laterally (Fig. lengthy. However, lidocaine, 0.5%, 1%, or 2% with or without
8D-1f), the skin is stretched laterally, and the needle is advanced 1:100,000 epinephrine or bupivacaine, 0.50%, with or without
again until the bone is felt (Fig. 8D-1g). After aspiration, the 1:100,000 epinephrine may also be used.
final 1 mL of local anesthetic is injected. The next step is to It is important that an assistant hold the patient’s head se-
vigorously massage the area above the eyebrow while keeping curely to prevent movement during the blocks. Communication
the thumb on the notch (Fig. 8D-1h). This allows the local with the patient is also recommended to ensure that the patient
anesthetic to spread along the supraperiosteal plane. Edematiza- keeps the forehead relaxed throughout the procedure.
Anesthesia 257
Complications
As with any needle puncture, there is a risk of bleeding or
ecchymosis. Fewer than 5% of patients experience some ecchy-
mosis on the day of surgery and the following day. It is rarely
cosmetically distressing for patients.
Nerve blocks themselves can be more uncomfortable than
ring blocks. Techniques to minimize the discomfort of local
anesthesia can be employed (1).
The fine sensory nerves are blocked preferentially, but a
temporary block of the fine motor nerves to the eyelid can result
in ptosis that usually lasts 2 to 3 hours. In our practice, this
occurs in less than 1% of patients.
If the surgeon does not withdraw the needle before changing
the angle, there is a risk of lacerating nerves or vessels with
the needle tip. This can also occur if the patient suddenly moves
during the nerve block.
Finally, if thumb pressure is maintained over the supraorbital
notch to prevent the local anesthetic from tracking down into
the eyelid and causing ptosis, the surgeon must guard against
puncture of the thumb as a result of patient movement.
Results
In our experience, the initial nerve blocks are effective in pro-
ducing total anesthesia approximately 98% of the time. If they
are ineffective, it is usually because the medial superficial
branch or the supratrochlear nerve was not reached. If the initial Figure 8D-2 Diagram showing approximate areas anesthetized
block does not ‘‘take,’’ the nerve blocks can be reinforced suc- by bilateral supraorbital nerve blocks.
cessfully in the vast majority of cases.
Occasionally, a separate medial puncture is required. This
can be initiated over a palpable frontal/supratrochlear notch or
one finger width (1.7 cm) from the midline or above the medial area nerve blocks, combined with field blocks, to be extremely
canthus of the eye. The needle tip is advanced to the periosteum effective for long-term avoidance of intraoperative pain. The
just above the supraorbital rim. After aspiration, 1 mL of local addition of nerve blocks not only provides better pain relief but
anesthetic is injected. also requires the use of far smaller amounts of local anesthetics.
Although nerve blocks are said to take 5 to 10 minutes to In a letter to the editor of Dermatologic Surgery, James
be effective, in practice, they seem to be effective within 10 Swinehart, passed on two ‘‘pearls’’ with regard to nerve blocks
seconds of administration. Employing nerve blocks provides (1):
recipient anesthesia for 6 to 8 hours for the target area with 1. The occipital nerve almost always lies exactly 6.75
each block if a mixture of %bupivacaine, 0.25%, with 1:100,000 cm posterior to the insertion of the concha of the ear
epinephrine is used. into the scalp above the mastoid. If you measure this
yourself with a ruler, you will nearly always palpate a
depression in the skull—this is the area occupied by
CONCLUSIONS the occipital artery, vein and nerve. Injections into these
areas bilaterally will provide a nerve block of the poste-
Supraorbital and supratrochlear nerve blocks are easy to learn rior scalp 90% of the time.
and easy to perform. They provide quick and long-lasting local 2. For recipient sites in areas that tend to bleed, I have
anesthesia to a large part of the recipient area. The approximate borrowed a trick learned from ENT surgeons, who fre-
area anesthetized by this type of block is illustrated in Fig. 8D- quently deal with extremely vascular nasal surgery. One
2. These nerve blocks are, ultimately, more comfortable for the simply takes a full 30 cc bottle of 1% Xylocaine with
patient than repeated ring blocks and require much less local epinephrine and dumps it into a Petri dish containing
anesthesia ; therefore, the risk of anesthetic toxicity is reduced. several gauze sponges. Prior to insertion of the grafts,
Significant complications are few and can be avoided with good one may rub the anesthetic-containing sponge over the
technique. Infrequent minor complications resolve quickly. areas to be transplanted. The local anesthetic soaks
down into the ‘‘needle holes’’ or ‘‘slits’’ and therefore
Editor’s Comment
directly impacts the exposed ends of the bleeding ves-
Since he wrote his contribution to this chapter, Brad Wolf has sels. This is preferable to injection, as injection of local
been using nerve blocks with increasing frequency. He, like anesthetic into a recipient area containing slits is not
Seager and Simmons, has found both recipient area and donor very efficient, due to escape of the local anesthetic
258 Chapter 8
through one or two larger slits. With this method, we 24. Matsuda F, Kinney W, Wright W, Kamburn J. Nicardipine re-
are able to consistently obtain a near-bloodless field duces the cardio-respiratory toxicity of intravenously adminis-
prior to transplantation of the follicular units that we tered bupivacaine in rats. Can J Anaesth 1990; 37:920–923.
25. Maxwell I, Martin I, Yaster M. Bupivacaine-induced cardiac tox-
use.
icity in neonates: successful treatment with intravenous pheny-
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Anesthesia 259
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9
Graft Survival, Growth, and Healing Studies
9A. Studies of Hair Survival in graft (see Terminology Table 5A-1). The minigraft usually con-
tains three to eight hairs. Minigrafts may be variously placed
Grafts of Different Sizes into recipient sites that are created as round holes, slits, or slots.
Michael L. Beehner For the most part, these sites are made with cold steel instru-
ments (punches, blades, needles, etc.), but they have also been
made with various lasers, which vaporize the tissue at the recipi-
INTRODUCTION
ent site.
Considering the fact that hair transplantation has existed for The third type of graft is the FU, which usually consists of
more than 40 years, it is surprising that relatively few detailed a small group of hairs in a configuration that naturally exists
studies have been carried out measuring survival percentages on the scalp. Most patients average 1.8 hairs to 2.5 hairs per
of hairs in the various graft sizes. Over the past 10 to 13 years FU.
our specialty has undergone quantum-leap changes, first from
the sole use of large, 4-mm diameter standard grafts to the Criteria for Hair Growth Studies
additional use of smaller, three-hair to eight-hair minigrafts and It is important, when comparing studies of the same type of
one-hair to two-hair micrografts, and now, at present, when graft by various researchers that one is comparing apples with
some hair surgeons believe that all transplanting should be done apples and that the variables concerning graft trimming and
exclusively with follicular unit (FU) grafts handling are the same. In fact, a few of the studies that are
And yet, amid these changes, and despite righteous claims by reviewed in this chapter were primarily designed to look at
various authors that one method is superior to another, definitive something other than simple hair growth of that particular size
data documenting superior hair growth to back up their claims of graft. For instance, Limmer’s study on FU survival was pri-
are notably missing or scanty. There are essentially only two marily focused on survival of grafts after various time spans
criteria that are important in comparing two different methods that the hair was out of the body after donor harvesting (1).
of hair transplantation: (1) The aesthetic, natural effect created, Seager and Beehner’s studies on ‘‘skinny vs. chubby’’ FUs
and (2) the percentage of hairs taken from the donor area that (2, 3) were designed to look at the extremes of FU preparation.
survive and grow as new hair. This latter point is especially They did not include grafts trimmed moderately close, which
important because the donor supply is at present not only a represents the way most hair surgeons prepare them.
limited resource but also a diminishing one over the lifetime Other important criteria to know in evaluating an individual
of most men with male pattern baldness (MPB). study are whether or not the procedure was performed on a
‘‘virgin’’ scalp or during a later session; whether or not grafts
Definition of Terms were kept cool; whether the assistants who placed the grafts
were experienced; what instrument was used to place the grafts;
Various classification systems have been put forth to delineate whether or not the dissection of the donor material yielded any
the different types of grafts used in hair transplant surgery. wastage or whether all tissue was placed as grafts; the duration
These are covered in greater detail elsewhere in this text. For of the procedure; and the time period the grafts were out of the
the purposes of this chapter, it is probably best to oversimplify body.
them into three types of grafts:
The first is the round, 4-mm diameter, standard graft, which HAIR GROWTH STUDIES IN LARGE
was the mainstay of hair transplant surgery for 25 to 30 years. STANDARD GRAFTS
The second type of graft is the minigraft, which encompasses
a large variety of different species. Basically, it is any graft that There are five studies in the literature that measure hair growth
contains more than one FU but is smaller than a 4-mm standard in the older, 4-mm diameter grafts. The first three of these
261
262 Chapter 9
studies were directed at the ‘‘end product’’ only, counting the HAIR GROWTH STUDIES IN MINIGRAFTS
number of hairs in each graft after it grew in its newly created
recipient site. The number of hairs in the graft at the time of Minigraft Hair Growth Study (Beehner)
implanting was not recorded. In the first of these reports, in In 1999, Beehner reported on a study of 13 male patients in
1969, Adamsen found a range of 8 to 15 hairs per graft (4). In which he sought to determine hair survival percentages of round
1970, Mulbauer, a German surgeon, reported a count of 11 to minigrafts inserted into recipient sites prepared with punches
14 hairs per transplanted graft (5). In 1973, Norwood reported that had diameters of 1.8 mm to 2.0 mm (9). These grafts were
an average finding of 8 to 10 hairs per large graft (6). Only placed at the time of the third transplant session for each patient
two studies on record compared both pre-implantation and post- and were located in the central-most area in what were then
implantation hair growth in standard grafts. These were the ‘‘large’’ cases of at least 600 micro-minigrafts, each of which
studies done by Unger in 1979 (7) and by Nordstrom in 1989 encompassed at least the entire frontal and midscalp areas.
(8). Unger’s findings are reprinted from the first edition (1979) Tattoo marks were used to mark a 2 cm ⳯ 2 cm square area
of this text and can be found at the end of his commentary on in the center of each man’s scalp. At each visit, a grid was
this section (Appendix 9A-A). Unger’s results are historically drawn with a fine red marker, which mapped out four 1 cm ⳯
interesting because he studied many of the variables that were 1 cm squares (Fig. 9A-1). At each patient’s third session the
later examined for their effect on various types of minigrafts grafts from the first two sessions were photographed and
and micrografts. How many grafts can be transplanted safely mapped out on a drawing, and the location of the new grafts
per session? How closely should they be placed? What effects that were placed during the third session were drawn in for later
do time out of the body and cooling of the grafts have? How precise follow-up (Fig. 9A-2). These minigrafts averaged eight
big should the recipient site be in relation to the graft size? hairs per graft when placed. At the time of the study, the author
Unger’s standard grafts, obtained with a 4-mm punch, contained was using full-depth recipient sites, with no special care taken
6 to 32 hairs per graft (after transected hairs had been removed to limit the recipient site to the upper subcutaneous level. Ap-
from them during graft preparation). His hair survival rates at proximately 9 to 12 minigrafts were placed at the third session
4 months were almost always 90% to 100%. In Nordstrom’s in each of these patients. Five of these grafts for each patient
carefully controlled study using magnification, he found an av- were labeled as marker grafts on the map and followed for exact
erage of 22.6 hairs present in the large grafts before placement. hair counts before and after. Thus, a total of 65 grafts, five for
They ranged from 13 to 30 hairs per graft, with an average each patient, were followed.
survival of 20 hairs per graft, and a survival rate of 90% (8). A total of 521 hairs were counted in these 65 grafts at place-
Knowing what we do today about delayed growth of some folli- ment, and 493 were found to be present 6 months later, for a
cles, both Unger’s and Nordstrom’s survival rates would have growth rate of 94.6% of all hairs placed. Beehner thought that
most likely been better if the study period had been lengthened
to include a 12 month to 18-month follow-up (see Martinick’s
observations later).
Many factors account for the wide disparity in results among
these studies and for the fact that so few of such studies were
even carried out. The technical challenge of counting hairs in
such a densely packed graft is obviously greater than that of
counting hairs in the smaller minigraft or FU graft. Most observ-
ers note that the two principal obstacles to good hair growth in
large grafts are vascular and mechanical factors. The vascular
obstacle relates to the need for the innermost area of the graft
to receive vascular nourishment soon after being implanted in
the recipient site. A mismatch of size between graft and recipi-
ent site is also thought to play a negative role in hair survival.
If the graft fits too snugly, it is compressed, perhaps inhibiting
perfusion of the graft tissue. If it fits too loosely, there is a space
between the graft and the adjoining wall, which theoretically has
to be bridged for perfusion and nutrition to take place. The
result of this vascular embarrassment of large grafts has usually
been ‘‘donutting,’’ in which a circular pattern of growing hairs
is seen around a bare central area where hair failed to grow.
The mechanical obstacles during the first few decades of
large-graft transplantation related mainly to the difficulties of
harvesting the circular grafts from the donor bed without dam-
aging hairs. If the donor skin was not sufficiently tumescent, the
hairs, as they were encountered by the circular cutting surface of
the punch, would ‘‘buckle,’’ and the outer hairs would end up Figure 9A-1 Beehner’s minigraft study: 1.8-mm recipient
being transected. Also, if the cutting surfaces of the punches holes are made in tattooed 2 cm ⳯ 2 cm area in midscalp. These
were not extremely sharp and perfectly round, damage to the new graft sites were then plotted out on a drawing, along with all
most peripheral hairs within the graft could occur, again result- of the preexisting grafts that were previously transplanted during
ing in poor growth. the first two sessions.
Graft Survival, Growth, and Healing Studies 263
HAIR GROWTH STUDIES IN FOLLICULAR

UNITS/MICROGRAFTS
Studies of a Possible Relationship Between Perigraft
Tissue and Higher Hair Counts (Seager and
Beehner)
The following two studies seem to suggest that when grafts are
trimmed in such a fashion that more tissue is left surrounding
the graft, the hair survival counts may indeed be higher than
when the grafts are trimmed extremely closely.
In 1997, Seager found a 113% growth rate of hairs placed
as ‘‘chubby’’ FUs in the recipient area (2). In contrast, he found
that FU grafts trimmed in a very ‘‘skinny’’ fashion, with mini-
mal tissue left around the follicular structures, yielded only an
89% survival of the hairs originally placed. His study compared
the growth of 88 hairs from the skinny grafts with 163 hairs
from chubby grafts 6 months after they were planted (Figs. 9A-
3 and (9A–4). He noted that the ‘‘dermal papillae were left
almost completely exposed’’ in the skinny grafts.
A year later, Beehner repeated Seager’s study, but with a
Figure 9A-2 Seven months later, at the time of the hair count. small difference: Equal numbers of hairs were placed in each
Red-pen outline of the study area has been made with reference to of the two groups (3). Each group was made up of 30 one-hair
the four tattoo dots. Using the previous ‘‘map,’’ hair growth within grafts and 30 two-hair grafts. In addition, the dissection was
the new recipient sites is determined. carried out in both groups such that a small margin of fatty
subcutaneous tissue was left surrounding the dermal papillae.
Six months after the grafts were transplanted, Beehner found
a 103% survival rate from the hair planted in skinny grafts,
this study showed that minigraft hair yield is excellent, espe-
compared with a 133% yield from the chubby grafts. These
cially because it was obtained in the context of the two previous
percentages were obtained from counting 94 hairs in the skinny
transplant sessions which had been performed in the same area
box (which had 90 hairs placed in it) and 120 in the chubby
and which had healed before the study. It was presumed that
box, where 90 hairs had been placed.
there was some micro scarring in the scalp tissues that had to
What the two studies do have in common is a very similar
be traversed for the blood supply to reach the central-most study
increase in growth percentage in the chubby FU compared with
minigrafts.
the lesser growth the skinny ones. Seager found a difference
of 24% between the two groups, and Beehner found a difference
Minigraft Hair Growth Study (Unger) of 30%.
In 2000, Unger conducted a hair growth study of square mini- If the same amount of donor tissue was used to create the
grafts placed into recipient sites prepared by a punch with a 2- skinny and the chubby grafts, the question arises as to whether
mm diameter in a virgin scalp (10). The study was carried out the difference in the hairs that did not grow in the skinny grafts
on three men, none of whom had previously undergone trans- was the result of hairs that were physically present in the dis-
plantation. The area of the scalp in which the study was con- carded tissue from the dissection process but that were not seen
ducted was totally alopecic. The grafts were 2 mm apart and (hidden telogen follicles), or, instead, the result of the protective
were located in an approximately 1-cm wide band just posterior buffering of the extra surrounding tissue in the chubby grafts.
to, as well as anterior to, areas treated with a combination of Or, was the result a combination of these possibilities? The
FUs and slit grafts (Figs to 5A-40E). answer to those questions has yet to be established.
In counting the hairs within the grafts before transplanting,
Unger noted that the counts were lower when the usual magnify- Limmer’s 1992 Study of Micrograft Survival over
ing eye loupes were used compared with results using the Man- Time
tis 6⳯ microscope. Obviously, loupes were used in counting
the hairs after they grew out. The preplacement counts con- In 1992, Limmer set up a study to determine the survival of
ducted for the purposes of the study were the higher ones ob- micrografts implanted into the recipient scalp at intervals of 2,
tained with the Mantis scope. As an example, in the case of the 4, 6, 8, 24, and 48 hours after removal from the donor site (1).
first study patient, 73 hairs were counted in the six grafts with The study was carried out on each of two male patients (Figs.
the loupes versus 77 with the Mantis scope. Overall, combining 9A-5 to 9A-7). Donor hair was harvested as an ellipse and kept
the grafts from all three study patients, a total of 229 hairs were in chilled isotonic saline before and after the dissection process
counted with the Mantis before the grafts were transplanted. and until the time of planting. Hair counts were carried out 51⁄2
Eight to nine months later, 241 hairs were found to be growing, months later. The final growth rates for the six groups were as
for an overall survival rate of 105.2%. (If the loupe-counted follows: 95% survival in the hairs left out of the body at 2
figures had been used instead of the Mantis-counted ones, the hours, 90% at 4 hours, 86% at 6 hours, 88% at 8 hours, 79%
survival rate would have been 111%). at 24 hours, and 54% at 48 hours. These grafts were cut as intact
264 Chapter 9
Figure 9A-3 Seager’s chubby vs. skinny follicular unit (FU) study. Grafts on the left represent the excessively trimmed (skinny) grafts,
and the three grafts on the right represent the ‘chubby’ ones.
FUs, even though Limmer used the micrograft terminology at three-hair grafts. The intact grafts were FUs comprised of either
the time and noted that the grafts were ‘‘trimmed close’’ (Table two or three hairs, trimmed moderately closely. The non-intact
9A-1). grafts, with which the intact grafts were compared, were pro-
A number of valuable conclusions can be gained from Lim- duced by cutting through adjacent FUs, with the two-hair ‘non-
mer’s study. First of all, getting grafts placed in their recipient intact’ graft composed of a single hair cut off vertically from
sites in as timely a manner as possible ensures the best possible each of two adjacent FUs along with the intervening tissue
survival rate. In large 2000Ⳮ FU megasessions, these data (Figs. 9A-8 and 9A–9). The three-hair non-intact graft was
would support the practice of removing the donor hair in seg- produced in the same way, but with two of the hairs having
ments over time rather than as one large ellipse at the beginning been cut away from a three-hair FU (see Fig. 9A-3).
of the procedure. Seager has proposed such a staggered donor In each patient, 60 intact FUs were compared with 60 non-
harvest approach. Another conclusion is that within an 8-hour intact counterparts (Fig. 9A-10). Both graft types were com-
window of time, there is a very good (statistically around 89%) posed of equal parts two-hair grafts and three-hair grafts, for a
growth survival of the planted FU grafts. This relatively good total of 150 hairs implanted of each type in each patient. Overall,
survival may also suggest some value to the chilling of grafts the study of these three men compared 450 hairs that were
rather than letting them sit at room temperature, although a planted in the intact grafts with 450 hairs from the non-intact
comparison of chilled vs. nonchilled grafts was not done. And, ones. The grafts were kept in chilled saline dishes until implan-
finally, the fact that 79% and 54% of the grafts, respectively, tation. There was an approximately 2 1/2-hour to 3-hour interval
grew at 24 and 48 hours supports the practice of implanting between the time of donor harvesting and the placement of the
grafts after such intervals should some emergency intervene to grafts. The hair counts were conducted at 6 months for all three
delay their placement. patients, and at 10 months for two of the three patients.
The results at 6 months on the three patients showed an
Beehner’s Intact vs. Nonintact Follicular Unit Graft 85.1% growth yield in the intact FUs compared with a much
Studies higher 98.6% yield in the non-intact graft hairs (Fig. 9A-11).
However, the results of the two patients who returned for follow
From 1998 to 1999, Beehner studied three patients to try and up at 9 to 10 months were compared, there was an 82.3% sur-
determine whether there was any inherent quality in the intact vival rate in the intact grafts and a statistically similar 86%
FU that conferred on it an advantage for hair growth (11). In survival in the non-intact group (Fig. 9A-12). This difference
each patient, he compared equal numbers of two-hair grafts and at 10 months was not due to the fact that the third patient (who
Figure 9A-6 Limmer’s study: The six zones are labeled for
hair counts at 6 months.
Figure 9A-4 Chubby follicular unit graft from Seager’s study;
Note that there are two strong hairs and one fine hair, which is
much shorter than the others. Determining whether or not such
small hairs are telogen hairs or miniaturized hairs on one of their
last life cycles makes hair survival research somewhat difficult. was not followed at this later time) had a much higher yield of
hairs in his non-intact group, because at 6 months all three
patients had fairly similar survival rates.
One fascinating finding in this study was that the comparison
at 4 months showed a larger advantage in survival for the hairs
in the non-intact grafts (111% for non-intact vs. 88% for intact).
This advantage diminished somewhat at the 6-month count
(99% for non-intact vs. 85% for intact). And, in the two patients
followed at 9 to 10 months, the survival percentages approached
each other closely enough that there was no statistical difference
(86% for the non-intact vs. 82.3% for the intact). It can be
readily seen that the survival in the intact grafts remained rela-
tively constant as the three counts were done, coming in respec-
tively at 88.2%, 85.1%, and 82.3% at 4, 6, and 10 months.
However, in the non-intact group, for some reason, there was
what appeared to be an initial ‘‘flowering’’ of extra hairs not
accounted for at the baseline at implantation, which then dimin-
ished over time. This group showed a lusty 110.8% survival at
4 months, which decreased to 98.6% at 6 months, and then
ended up at 86% at 9 to 10 months in the two patients studied
at that time.
This study suggested a number of conclusions and also raised
some intriguing questions. First of all, it appears that there is
no inherent advantage for survival in the intact FU graft.
Whether hairs are kept together as a FU or carefully cut in such
a way that the intact FU is broken up longitudinally, the hairs
Figure 9A-5 Limmer’s study of FUs out of the body over dif- appear to have an equal chance of surviving. One practical point
ferent lengths of time. This view shows all six study areas a week that I, a proponent of the preparation of intact FUs, gained
after planting. during this study is that it is much more time-consuming and
266 Chapter 9
Figure 9A-7 Limmer’s study: The six zones are shown at the
6-month part with no markings present. Zones correspond to their
arrangement in Figure 9A–6. Figure 9A-8 Beehner’s intact follicular units vs. non intact
graft study. This schematic drawing shows how the various sizes
of grafts in the study were dissected to create intact and nonintact
grafts.
difficult to precisely cut vertically through an FU than to simply

cut around it.
As in the chubby vs. skinny study, the intact vs. non-intact
study also raises the question of whether the apparently hairless that went into an early telogen phase for some reason? Would
tissue that surrounds the FU does, in fact, include some invisible these hairs have resurfaced later and produced higher hair
follicles in the telogen phase, which results in a lowered hair counts if the study had been carried out up to 18 months as in
survival count when the tissue is discarded. Martinick’s study that is discussed later?
The intriguing aspect of the higher-than-baseline hair counts One final note in regard to this study bears mentioning. One
in the non-intact grafts at 4 months does not yield to any obvious of these three patients, a smoker, had consistently lower hair
explanation. Was this early extra growth caused by weaker hairs counts at each checkpoint than the other two men.
that grew initially but did not survive over the longer haul, or
Table 9A–1 Hair Survival in Micrografts (Two Cases)—Limmer
Number of Number of Hairs

Hours Between Number of Surviving at
Harvest and Transplanted 51/2 Months
Transplantation Hairs Post-Transplantation (%)
2 257 244 (95%)

4 200 180 (90%)
6 200 173 (86%)
8 227 219 (88%) Figure 9A-9 Beehner’s study: On the left are three-hair and
24 200 158 (79%) two-hair intact follicular unit (FU) grafts. On the near right is a
48 200 109 (54%) nonintact three-hair graft and on the far right is a nonintact two-
hair graft from the study.
Figure 9A-10 Beehner’s study: Tattoo dots are present, deline-

ating the two rectangular study zones. Each zone has 60 recipient
sites made with an 18-gauge NoKor needle. Figure 9A-12 Beehner’s study showing ‘nonintact’ hair grow-
ing at 9 months in patient 噛1 on the left and growth from ‘intact’
follicular unit grafts on the right.
Mayer’s Study Comparing FU Growth with

Different Planting Densities
40 two-hair FU per square centimeter. The recipient sites were
Mayer presented a case study of a 60-year-old Norwood class made with an 18-gauge needle and the dissecting microscope
VI patient on whose hair survival percentages for two-hair FUs was used to dissect the grafts. Hair counts were made and photo-
planted at four different densities he had set out to determine graphs were taken at 8 months (Fig. 9A-6 and Table 9A-2).
(12). An identical study was carried out on a second patient The hair counts performed at 8 months revealed a combined
with ‘‘very similar results.’’ It was presented at the 10th annual survival rate of 97.5% for the grafts placed at 10/cm2, 92.5%
meeting of the International Society of Hair Restoration Surgery for those at 20/cm2, 72.5% for those at 30/cm2, and 78.1% for
(ISHRS) in Chicago in 2002. those at 40/cm2 (Figs. 9A–15 to (9A–17).
In the anterior area of the vertex, he tattooed two symmetri- On the basis of this one study, Mayer concluded that perhaps
cal rows of four 1 cm2 boxes each, leaving a distance of 0.5 crowding of recipient sites leads to decreased hair survival. He
cm between the adjacent boxes (Figs. 9A-13 and 9A–14). On emphasized the need for further corroborative studies on this
each side he planted the recipient boxes with 10, 20, 30, and issue but conjectured that perhaps somewhere between 20 to
30 FUs per cm2 may be the ideal spacing for recipient sites.
Figure 9A-11 Beehner’s study showing hair growth at 6

months in patient 噛3 (patient had clipped all of his hair short). Figure 9A-13 Mayer’s study: The four ‘boxes’ (tattooed at the
Intact follicular units are shown growing on the left and ‘nonintact’ corners) are shown on both sides of the anterior vertex with their
grafts are shown on the right. respective planting densities marked.
268 Chapter 9
Figure 9A-14 Mayer’s study: Grafts have been planted in the Figure 9A-15 Mayer’s study: Hair growth at 8 months is
eight boxes. Approximate density can be visually noted by distribu- shown in the four boxes on the left side of the vertex. The box on
tion of grafts in surgical recipient sites. the left side of the figure received 10 follicular units grafts, and
furthest right of the four boxes in that row received 40 grafts.
The 9 month results of a 2003 study that Mayer and Sharon

Keene carried out to determine the effect of FU densities on found that if hairs were split at the level of the bulge, more
hair survival, can be found in Chapter 23I-1. than 100% of the original number of hairs grew out when the
upper and lower portions were all implanted in separate sites
Martinick’s Study of Intact FU vs. Vertically and at the hairline. This means that at least half of the fragments
Horizontally Cut Grafts thus placed resulted in a recognizable hair growth.
Martinick’s study included only three-hair FUs. She chose
In this study, Martinick attempted over a significant time span this size because she thought the shape of the three-hair FU
of 18 months to assess the growth of intact FU grafts compared was most susceptible to transection during graft preparation.
with FUs that had been traumatized by either partial horizontal Her overall aim was to investigate whether intact three-hair FUs
or vertical transection (13). The grafts in her study have been resulted in superior or earlier growth compared with similar
followed longer than any others reported in the literature to such minimally traumatized grafts.
date, and they bring into question the results in studies of These three-hair FUs were treated in four different ways.
shorter duration. The first group was left intact and untraumatized. The second
In her presentation, Martinick cited three earlier reports in group had one hair vertically cut off from the other two, with
which growth of horizontally transected grafts was studied. the two fragments implanted one alongside each other. The third
They are summarized briefly here. In 1993, Kim found that group had the lower half of one of the three hairs removed after
40% of the hairs grew when the upper half was implanted, and transection at the bulge. The fourth group featured a missing
20% grew when only the lower half was implanted. In 1994, upper half of one of the three hairs after transection at the bulge
Limmer found that only 7% (50 of 697) hairs grew when only (see Fig. 9A-6).
the upper half was transplanted, and 21% (152 of 694) grew The seven patients studied all had a totally bald 6 cm ⳯ 2
when only the lower half was similarly placed. In 1998, Mayer cm scalp area in the midscalp/vertex. They ranged in age from
Table 9A–2 Mayer: FU Survival Rates for Different Recipient Spacing
10 FUs/cm2 20 FUs/cm2 30 FUs/cm2 40 FUs/cm2
# hairs planted left box 12. 20 40 60 80

# hairs planted right box 20 40 60 80
hair survival numbers (left) 21/20 38/40 43/60 64/80
hair survival numbers (right) 18/20 36/40 44/60 61/80
% hair survival (left) 105% 95% 71.70% 80%
% hair survival (right) 90% 90% 73.30% 76.50%
hair survival numbers (combined) 39/40 74/80 87/120 125/160
hair survival % (combined) 97.50% 92.50% 72.50% 78.10%
At 6 to 10 months, the transplanted hair was coarser than

the donor hair. At 15 to 18 months, the hair had returned to the
diameter of the donor hair.
A search was conducted for four-hair grafts at 10 months
and at 18 months. At 10 months, five four-hair grafts were
observed among the 390 studied. These were found in the con-
trol and in the vertically split groups. At 18 months, four four-
hair FUs were seen, and were seen in the control, vertically
split, and two and a half were with top intact groups. Only one
of these four-hair grafts was found in the same patient and in
the same group on both occasions.
Regrowth rates for the four graft groups were measured at
4 to 5 months, 6 to 10 months, and 18 months. The best survival
rates were in the control (intact) group, which improved over
time from 52% at the 4-month to 5-month mark to 82% at
18 months. The vertically split grafts grew only slightly less,
improving from 50% survival at 4 to 5 months to 78% at 18
months. Table 9A-3 shows the survival percentages at each
Figure 9A-16 Mayer’s study: Hair growth at 8 months in the time point for the four groups.
four boxes on the right side of vertex is shown. The box at the top In studying the results of Martinick with the two groups, in
of the row of four boxes received 10 grafts, and the lowermost one which either the top half or the bottom half of one of the three
received 40 grafts. hairs in each graft was removed, it would appear that there was
only a small difference between survival in the hairs with only
the top left intact vs. those with only the bottom left in place
(74% vs. 65%). But if one assumes that two thirds of the hairs
32 to 64 years. All grafts were prepared with the use of stereo- are the intact ones that were not not bisected and that they
scopic microscopic dissection. The donor material and grafts survived at the average of the first two groups, (the intact and
were stored in lactated Ringer solution on ice. All grafts were vertically split ones), namely 80%, then one can calculate what
implanted within 4 hours after donor harvesting and were placed theoretically happened to the partial hairs themselves. When
at a depth of a 4 mm in holes created by 18-gauge, solid-core the intact hairs are subtracted and accounted for as described, it
needles. In each patient, 80 FU grafts were placed into the test appears that 62.6% of the hairs with only the top half remaining
area, with 20 being allocated to each type of graft (control, survived at 18 months, and that 34.5% of the hairs with only
vertically split, etc.). the bottom half remaining survived. If this were true, these
At 4 to 5 months the control (intact) and the vertically split results would then be somewhat more in line with what Kim
grafts were 4 mm longer than the other two groups with two found in his earlier study than with what Limmer had observed.
and a half hairs present. However, another way to look at these results is that, if both
the upper and the lower halves of a hair transected at the bulge
are transplanted separately, 97.1% of the original number of
hairs from which these halves originated are represented by a
growing hair. This figure is obtained by adding the 62.6%
growth rate for the upper segment with the 34.5% rate of the
lower segment. This would suggest that transection, at least at
this level of hair, does not hurt survival percentages for trans-
planted hairs.
Martinick’s conclusions from this 18-month study were as
follows: She believes that strong evidence exists that intact
three-hair FUs grew more hair at an earlier stage than follicles
with one hair traumatized. At 4 months, the traumatized FU
grafts were disproportionately delayed in their growth com-
pared with the control grafts, but by 18 months these differences
had narrowed considerably. This trend suggests that the trauma-
tized FUs were functional and that they had not suffered from
overhandling as much as would have been suggested by the
early growth rates.
Martinick has raised a number of fascinating questions with
her study. She wondered if these results could perhaps explain
the delayed growth that other doctors have reported. She has
also raised the consideration that the follicles might have under-
gone some sort of repair to the internal trauma incurred before
Figure 9A-17 Mayer’s study: Close-up magnified view of four they started growing. When all the hair does not grow at the
of the boxes at 8 months. same time point, does that mean that all the others are dead, or
270 Chapter 9
Table 9A–3 Martinick Study—Survival Percentages of Hairs in Four Graft Groups
Months after Intact Vert. 21/2 Top 21/2 Bottom

Transplanting (MO) Grafts (%) Split (%) Intact (%) Intact (%)
4–5 52 50 43 40
6–10 75 70 65 63
18 82 78 74 65
are all the hairs simply developing at asynchronous cycles? One

piece of supportive evidence for the asynchronous cycle theory
is the fact that four of the four-hair FUs that were observed at
10 months were not present at 18 months. Many questions re-
main to be answered, but this study opens the window for in-
quiry and raises doubts regarding some long-held suppositions
concerning hair counts and hair growth.
HAIR GROWTH STUDIES COMPARING

FOLLICULAR UNITS AND MICRO-
MINIGRAFTING
Reed’s Study of FU vs. One to Three-Hair Micro-
Minigrafts
In 2000, Reed presented data comparing survival of hairs of
FUs dissected under the microscope compared with the survival
of hairs from within micro-minigrafts cut with 4⳯ loupes (14)
(see also Chapter 12). At 4 1⁄2 months, he found a survival rate
of 73% in the FUs and of 77% in the micro-minigrafts. None
of the micro-minigrafts contained more than three hairs each.
In the same study, Reed sought to compare the impact of Figure 9A-18 Four study zones with recipient sites completed
hair volume in these two types of grafts cut in the different at first session.
manners described above. Using micrometers, he found that at
4 1/2 months there was a 28% loss of hair volume for mini-
micrografting, measured by hair-shaft caliber, as hair was with hair counts 6 months after each of the three sessions (Fig.
moved from the donor site to the recipient site. For FU trans- 9A-19). The hair survival percentages list included all of the
planting (including dissection by microscopes), there was a 34% grafts transplanted in the study square up to that point. Photo-
loss of hair volume at this time point of 4 1/2 months. Reed graphic analysis of the four quadrants, biopsies, and temperature
combined his data on survival and hair-caliber changes between studies were done in addition to the hair counts.
micro-minigrafting and FU transplanting to come up with the
following data. 73% of FU hairs surviving and growing at 66%
of their original diameter equals 48% of the theoretically opti-
mal hair volume being achievable. Correspondingly, micro/
minigrafts (of three hairs or less) cut under 4⳯ loupes resulted
in 77% of the hairs therein surviving and growing at 72% of
their original diameter, thus being equal to 55% of the theoreti-
cally optimal hair volume being realized. In Chapter 12, Reed
reviews this study as well as follow-up results.
Beehner’s Study of FU vs. 1.3-mm Minigrafts After

One to Three Sessions
From 1999 to 2001, Beehner studied a 42-year-old Norwood
type VI patient who had had three large transplant sessions, in
which the entire scalp was divided into quadrants. Beehner
looked at both FUs and small minigrafts that were packed
densely, using both limited-depth recipient sites and full-depth
(i.e., through the galea) ones (Fig. 9A-18). A 1 cm ⳯ 1 cm Figure 9A-19 Close-up showing minigraft spacing and the 1
tattooed square, or box, in the center of each zone was studied cm ⳯ 1 cm study-box with follicular units.
Table 9A–4 Comparison of Hair Survival in FUs and Minigrafts
Graft/Recipient Site Type After one session (%) After two sessions (%) After three sessions (%)
Minigrafts (full depth) 111 86.40 85.50

Minigrafts (limited depth) 102 81.80 69.40
FUs (full depth 108 71 56.90
FUs (limited depth) 94 76 57.60
The hair count survival percentages are listed in Table 9A- The biopsies showed a moderate amount of dermal fibrosis
4 above. Each tattooed FU study box received a total of 72 in both the full-depth FU sites and minigraft sites, and no fibro-
two-haired FUs (25, 25, and 22, respectively, over three ses- sis to minimal fibrosis in the limited-depth sites. There was also
sions) and each minigraft box received 31, 1.3-mm round grafts an increased number of inflammatory cells around the vessels
of four hairs each. The highest hair survival, at 6 months after in the full-depth sites compared with the limited-depth ones,
the third procedure, was in the full-depth minigraft zone where no such cells were seen.
(85.5%), and the lowest was in the two FU zones (56.9% and Subcutaneous temperature studies performed initially and
57.6% in the full-depth sites and limited-depth sites, respec- again at 6 months after each session showed no trend toward
tively). reduced vascularity in any of the zones compared with the virgin
Photographic analysis showed superior density but in- scalp control in the upper forehead. At the time of the final
creased detectability of tuftiness in the minigraft zones after photograph session and evaluation 1 year after the small fourth
sessions one and two, but after the third session of minigrafts makeup FU session, I placed the temperature needle probe at
had grown in, the detectability and density in both the FU zones three different depths in seven different locations (upper bare
and the minigraft zones looked remarkably similar (Figs. 9A- forehead, center point of the entire transplanted areas, center
20 to 9A–22). Because some one-hair FUs had to be used in of each of the four zones, and in the bare vertex behind the
the quadrants, the number of hairs planted after three sessions transplants). The probe depths were located just beneath the
was 2005 per minigraft zone and 1661 per FU zone. In order epidermis superficially, in the mid-subcutaneous layer (where
to equalize the number of hairs in each quadrant, 343 hairs were all of the previous temperature checks were carried out), and
added to each of the two FU zones in a session performed 6 deep, just above the galea. A fascinating finding was that the
months after the third procedure. The final photographs of the temperature went up in the deep zone compared with both the
four transplanted zones are presented in Figs. 9A-21 and superifical and midlevel probe measurements in all but three
9A–22. zones. It failed to rise in both of the full-depth quadrants and
in the bald vertex. This finding may be evidence that full-depth
sites do, in fact, have an effect on the circulation of the scalp.
As to the vertex, the question arises in my mind as to whether
the repeated donor harvests inferior to the vertex somehow im-
pacted the vascularity there.
I went into this study fully expecting to find superior hair
growth and survival in the limited-depth sites, but the opposite
was seen in this study, with the full-depth minigrafts growing
better after each of the three sessions, and the FUs growing
better in full-depth sites after the first session (growth became
similar for FUs after sessions two and three). Likewise, I fully
expected to see clear differences in temperature (vascularity)
between the full-depth zones and the limited-depth zones, with
the limited-depth ones showing higher temperatures. This also
was not the case in almost all of the probe measurements taken,
except for the final check at the three different depths, which
did hint that perhaps there was a vascular-sparing effect con-
ferred by using limited-depth recipient sites. Finally, I had ex-
pected that the minigrafted zones would appear denser than the
FU ones, but the final photographs show that the relative visual
density of the four zones is very similar. Considering that one
can remove less than 50% of the hairs in an area without the
loss being noticeable, it is obvious that there can be a large
variation in the actual number of hairs present in two zones,
and yet there may be similar visible density.
Figure 9A-20 Hair growth in the four zones 18 months after The fairly low survival of FU hairs when they have been
third session (and 12 months after a fourth small session in the repeatedly dense-packed in the same area contrasts with the
areas treated with follicular units). other studies reported in this chapter, in which the FUs studied
272 Chapter 9
Figure 9A-21 a, left: Minigrafts in full-depth recipient sites 18 months after the third session. b, Right: Minigrafts in limited-depth
recipient sites 18 months after the third session.
were set off in an area by themselves, transplanted into a virgin performed, this study would suggest dense packing all FUs,
area, and planted only once. It is to be noted that after one which, as Seager has suggested, would be the better method to
session, both types of grafts planted in both full-depth and lim- use, especially since detectability is greater after one session
ited-depth sites, grew in very good percentages close to 100% with minigrafts.
or greater.
Because both the minigraft zones and the FU zones showed
very similar density and lack of detectability after three ses- CONCLUSIONS OF HAIR GROWTH STUDIES
sions, and because 85.5% of the full-depth minigraft hairs sur-
vived compared with 56.9% of the FU ones, if three sessions It is a difficult to come up with absolute, irrefutable conclusions
were considered, using minigrafts in the central-most regions as to which type of graft survives best because there have been
would seem closer to the ideal and safe for the hairs thus trans- so few studies to examine this matter. In addition, each study,
planted. On the other hand, if only a single session were to be even when evaluating the same type of graft, differs in various
Figure 9A-22 a, Left: Follicular units in full-depth recipient sites 18 months after the third session. b, Right: Follicular units in limited:
depth recipient sites 18 months after the third session.
respects as to how the grafts were managed, especially with grafts, which is at the heart of everything to do with hair trans-
regard to the smallest grafts—the micrografts and FU. plantation. Part of the reason more progress has not been made
Despite the paucity of studies and the other variables that in this area of knowledge is that hair counts are difficult to
are present, a number of conclusions do seem reasonable at this carry out. They require tattoo markers and painstaking counting
time: of hairs in very close quarters at multiple time points in patients
willing to forego further transplanting while the grafts grow,
1. In regard to FUs, how closely the grafts are trimmed unencumbered by additional transplants during that time.
is an important factor, because a number of the studies
mentioned suggest that leaving surrounding connec-
tive tissue around the grafts seems to result in higher ADDITIONAL HAIR SURVIVAL STUDIES AND
hair counts. CONCLUSIONS (WALTER UNGER)
2. There is great variability in the hair growth percentage
of FU grafts and micrografts in these studies, espe- Beehner has summarized some of the more important studies
cially at 4 and 6 months after transplanting. They vary that have been done to date on hair survival with different types
from a low of 52% survival rate of closely trimmed of grafts and different types of FU transections. A brief descrip-
FUs at 4 months as reported by Martinick (a rate that tion of five other studies is a worthwhile addition to this discus-
rose to 82% at 18 months) to a high of 133% noted sion.
by Beehner when he studied growth of chubby FUs
at 6 months.
Reed’s Study on Grafts Obtained with Multibladed
3. The minigraft of five to eight hairs appears to have
the highest and most consistent survival rate of hairs Harvesting
after transplanting. Reed described 50 patients in whom transection rates of mini-
4. Martinick’s study suggests that researchers in the fu- grafts were assessed when a multibladed knife was used and
ture probably need to follow hair counts out to 18 when the 2-mm strips thus produced were cut into grafts with
months, especially if they are studying FUs. the assistance of loupes (magnification, ⳯4) (15). He found
5. There does not appear to be any inherent advantage total transection rates (during donor area harvesting and graft
for hair survival in the intact FU compared with sur- preparation) of 12% but an overall survival rate of 98.4% at 8
vival when the hairs in these intact units are broken months, when survival rates of intact graft hairs and transected
up. graft hairs were combined. His transection rates were in line
6. The sooner FU grafts are implanted into the recipient with those reported by Limmer (1) and survival rates of tran-
area after donor harvesting, the higher is the percent- sected follicles reported by Kim (16). The overall 98.4% sur-
age of grafts that survive. vival rate is also similar to that reported by Limmer in previous
7. If transection occurs at the level of the bulge, and if publications. (Limmer uses only elliptical excisions and stereo-
both upper and lower segments are transplanted, the scopic dissection of donor tissue). However, the use of a mul-
overall survival of hairs per recipient site made is dra- tibladed knife presented fewer problems with regard to techni-
matically lowered, but the representation of hairs cian quality control and person hours.
growing as a percentage of the original intact hairs Reed’s conclusion from his 50-patient study was that ‘‘it
that were transected, is considerably higher. is unclear that elliptical excision and microscopic dissection
8. Hair shaft diameter, or hair volume, seems to increase (EEMD) is superior to multibladed harvesting (MBH) for in-
over time after transplantation. creasing hair yield.’’ He further stated that ‘‘in view of the
9. Mayer’s study suggests that increasing the density of above noted conclusion, and the increased difficulty in main-
FU recipient sites may be related to somewhat lower taining quality control, as well as the increased effort of produc-
survival rates. ing grafts with EEMD (twice as many person hours and a longer
10. When FUs are dense-packed in sessions after the ini- technician learning curve), it would appear that MBH is supe-
tial one, there is possibly a dropsoff in survival of the rior to EEMD’’ (italics are mine). Finally, he concluded,
hairs contained therein. ‘‘Therefore, the hair transplant surgeon serves both quality con-
11. Small minigrafts planted in full-depth recipient sites trol and efficiency by focusing efforts on his/her MPB technique
appear to offer the best visible density and the highest rather than on training and supervising technicians to perform
hair survival yield. dissection with the microscope.’’
12. After one session, small, round minigrafts appear den-
ser than FUs, but they are more detectable. After three
Mayer’s Studies Comparing Hair Growth After
sessions, the relative appearance of density and detect-
Transection Through the Bulge Area to Produce
ability is very similar, with both small round minigrafts
and dense-packed FUs. Approximately Two Equal Halves
Melvin Mayer presented the previously noted study at the 1998
The aforementioned studies suggest certain fascinating conclu-
annual meeting of the ISHRS in Washington, DC (17). In that
sions as to hair growth in the various sizes of grafts. Most
study, 200 FUs were prepared with 5⳯ power magnification
importantly, however, they point to the need for more studies
and were divided into three groups:
to further corroborate and elucidate the conclusions noted ear-
lier and to answer the questions they raise. Certainly, not all Group A—Controls, consisting of 100 intact FUs and 181
of the answers are known about the growth of transplanted hairs
274 Chapter 9
Group B—The lower segment of 100 FUs (161 hairs) tran-

sected horizontally at the bulge
Group C—The upper segment of the transected 100 FUs
(161 hairs) in Group B
Each group of 100 FUs was inserted into holes made by sharp,
18-gauge, tri-beveled dilators at a density of 25 FUs/cm2, into
a recipient area that was 1 cm ⳯ 4 cm. Hair counts were done
with the Scalor Video-Loupe VL–7A Video Microscope.
Mayer reported that 63% of the upper half of the transected
hairs grew, and that 70% of the lower half of the transected
hairs were growing at 9 months, resulting in a total regrowth
rate of 133%.
At the 1999 Orlando Live Surgery Workshop, Mayer took
part in a similar study in which 108% regrowth was seen. In
this study, he noted that the caliber of the hairs was decreased,
and he suggested this technique would, therefore, be particularly Figure 9A-23 A figure showing round grafts in patient 噛1, 5
useful for creating fine hairs for hairlines (12). months after surgery at the time of the hair counts. Note vigorous
growth of hairs in these grafts.
Swinehart’s Study on Hairs Transected Through

the Bulge Area to Produce Approximately Two
Equal Halves segments that were approximately 2 mm2. The 2 mm2 grafts
were inserted into the recipient sites prepared with a 2-mm
In 2001, Swinehart published the results of his own studies on
punch. Thus, the 2-mm round grafts were actually ‘‘square
hairs sectioned through the bulge and made the same suggestion
pegs’’ that were used to fill the oval ‘‘holes’’ produced by the
as Mayer had made in 1999—that because the hair tends to
angled punch. Human skin pliability is such that, in fact, these
regrow with a reduced caliber, it was ideal for softening the
square grafts actually do completely fill oval holes without leav-
appearance of the hairline zone. He was less specific than Mayer
ing empty gaps around them. The number of hairs in each study
about instrumentation and graft density but reported that 46%
graft were counted with direct vision and also with the aid of
of the upper half and 47% of the lower half of his bisected hairs
regrew, for a total of 93% regrowth (18).
Unger’s and Seager’s Comparative Study on the

Growth of Follicular Units and 2-mm Grafts in the
Same Patient
With regard to hair survival in 2-mm2 grafts, it seems worth-
while to elaborate on the description of my first study, which
Beehner summarized earlier, as well as describing the study I
later carried out with David Seager. The first study involved
three patients who were treated in my office (10). The second
study, approximately a year later, involved two of Seager’s
patients, treated in his office, who also had a similar number
of hairs transplanted as FUs in a contralateral but otherwise
similar location to the 2-mm grafts (19).
In study 噛1, round recipient sites, made with a 2-mm punch,
were prepared in three rows, sandwiched between (1) a hairline
zone composed of a combination of FU, DFU and TFU grafts,
and (2) the rest of the recipient area, which was treated with a
combination of TFU grafts with FUs scattered between them
(see Table 5A-1 for definition of terminology).
A schematic drawing of the distribution of various types of
grafts that I have used and recommended for many years is
shown in Fig. 5A-40E. Fig. 9A-23 illustrates the recipient area
showing the round grafts in patient 噛1, 5 months after surgery
(at the time of the hair counts). Fig. 9A-24 is a schematic draw-
ing that was made at the time of surgery on patient 噛1 and that Figure 9A-24 A schematic drawing made for one of the pa-
was used to identify the study grafts at a later date. A similar tients in Unger’s study on 2-mm2 grafts. The six study grafts were
approach was used for patients 噛2 and 噛3. pinpointed on the line of round grafts, and their exact placement
A multibladed knife was employed to prepare 3-mm wide on this line was noted. The grafts could, therefore, be accurately
strips of donor tissue. These strips were then sectioned into found for hair counts at four and eight or nine months.
Table 9A–6 Patient #2 (Brown Hair)
Original # of hairs
# of hairs at
Grafts Loupes Mantis Microscope 9 months
1) 11 11 12
2) 11 12 14
3) 12 13 13
4) 10 12 14
5) 12 13 14
6) 11 11 10
Total 67 72 77
Tabulated results of patient #2 in Unger’s study of 2 mm2 grafts.
Figure 9A-25 Pattern of grafting in test subject showing nine office and two from Seager’s office. Photographs were taken
2-mm grafts in a 1 cm2 box on the left and 45 follicular units (FUs) to record the location of the test sites (see Fig. 9A-25). Hair
in another 1 cm2 box on the right. The test sites had an untreated counts were carried out on the test site grafts after 5 months
zone around them, but several hundred FUs were concomitantly and 11 months, by the same four technicians.
transplanted in the general vicinity as shown previously. The results of the three patients in study 噛1 are shown in
Tables 9A–5, 9A–6, and 9A–7. The results for the two patients
in study 噛2 are shown in Tables 9A–7 and 9A–8. As Beehner
has noted, in study 噛1 a total of 229 hairs were transplanted
a 6⳯ Mantis stereomicroscope. The locations of the holes into (Mantis count) and after 8 or 9 months, a total of 241 hairs
which the study grafts were inserted were noted in the patient’s were counted. (Each patient grew more hairs than were initially
chart, as shown in Fig. 9A-24. After 4 months, and, again, after transplanted.) This represents a 105.1% apparent hair survival
8 or 9 months, the hairs in the grafts were counted. rate. All three patients’ study areas were alopecic; therefore,
In study 噛2, I went to Dr. David Seager’s office, and two confusion of previous hair in the recipient area with transplanted
patients he had selected were the subjects. Both patients had hair was not possible.
less dense hair in their persisting rim than the typical patient I In study 噛2, one patient (see Table 9A-8) had 119 hairs
would treat with round grafts. In addition, to more fairly com- transplanted as 2-mm grafts; 109 of these hairs were strong,
pare rates of hair survival in round grafts and FUs containing terminal-type hairs. After 91⁄2 months, only 42 hairs were grow-
a similar number of hairs (which was one of the purposes of ing, as reported by Seager (I was not present at that time). But
the study), the two types of grafts were located in contralateral at 11 months, the four technicians who counted the hairs present
sites near the midline, in approximately the center of the recipi- found 117 to 136 hairs, representing a yield of 98% to 114%,
ent area that was concomitantly being treated with FUs (Fig. depending on which technician’s count you use. The other study
9A-25). Both patients had also previously had prior FU trans- patient (Table 9A-9) had 92 hairs transplanted in the 2-mm2
planting (FUT). The number of hairs in all the grafts was round grafts, and at 83⁄4 months, and 11 months, had 67 and 73
counted with 10⳯ magnification by two technicians from my or 74 hairs growing, respectively. This represents a yield of
Table 9A–5 Patient #1 (Black Hair)
1) Grafts placed laterally in the second row.
Original # of hairs
Loupes Mantis Microscope # of hairs at 4 months # of hairs at 8 months
1) 12 12 12 14
2) 13 13 11 14
II) Grafts placed laterally in the third row
3) 14 15 12 16
4) 13 15 12 14
III) Grafts placed near the midline on third row
5) 11 12 9 12
6) 10 10 12 12
Total 73 77 68 82
Tabulated results of patient #1 in Unger’s study of 2 mm2 grafts.
276 Chapter 9
Table 9A–7 Patients #3 (Light Brown Hair) (see Beehner’s observation earlier), I was surprised at that time
Original # of hairs to see how many more hairs were present in Nordstrom’s grafts
# of hairs at than I had found in mine. I assumed this was because (1) The
Grafts Loupes Mantis Microscope 9 months hairs in my grafts, before insertion in the recipient area, were
counted only after all the hairs that did not have complete folli-
1) 11 12 12 cles were removed. (Nordstrom’s graft preparation might not
2) 13 14 15 have been as obsessive as mine.) (2) He used sophisticated
3) 12 12 10
photography and magnification to count the hairs in his grafts,
4) 11 13 14
whereas my counts were done by a relatively less accurate direct
5) 10 12 13
visual counting technique. I could have easily missed some finer
6) 10 11 13
Total 76 74 77
hairs or some of the hairs in tight bunches.
It is even more surprising to read of Cole’s hair counts in
Tabulated results of patient #3 in Unger’s study of 2 mm2 grafts. round grafts obtained with a 4-mm punch. They far exceed
both Nordstrom’s and mine (see Chapter 10A). There are, once
again, several explanations for how this could happen: (1) Cole
used a power punch and high tumescence, whereas Nordstrom
and I used hand punches and had not appreciated as fully as
79% or 80% at 11 months. Once again, I was not present at the most practitioners do now, the importance of rock-hard tissue
first postoperative counting. This patient was also a particularly turgor when we did our studies. Both of these factors would
poor candidate for 2-mm2 grafts because of his low hair density result in considerably more intact hairs per graft. (2) Cole used
and unusual graft friability. I immediately pointed this out at even more sophisticated photographic techniques than Nords-
the time the grafts were obtained. He did, however, represent trom and 25⳯ to 50⳯ magnification.
one of only two samplings; therefore, he was included in the Cole’s hair counts suggest that our results of more than 25
study. A third patient was studied in a similar fashion by Seager, years ago were almost certainly not valid. On the other hand,
without Unger’s assistance, and is therefore not included here my more recent studies on hair survival in 2-mm2 grafts, as
as representative of what someone who is experienced with this noted earlier, support Cole’s numbers and vice versa. Given
technique can expect. Cole’s findings, 12 to 15 hairs in a 2-mm2 graft is not as peculiar
Although in study 噛2 the hairs in the FUs, grew earlier and as it might first seem to be from our old 4-mm graft hair counts.
better than in the 2-mm2 grafts (see Tables 9A–8 and 9A–9),
it is important to point out that they were planted in a central Jerzy Kolasinski’s Study on Hairless Grafts
area of the recipient area that is atypical of the location in which
I usually use them. In addition, they were surrounded by Jerzy Kolasinski recently reported on an unusual study he car-
hundreds of incisions for FUs, and posterior to an area trans- ried out on a 44-year-old patient with type VI MPB, on whom
planted at an earlier time with thousands of FUs. All of the he was concurrently doing a transplant (20). Posterior to the
preceding factors would result in a less satisfactory blood sup- area into which he had placed 1200 hair-bearing micrografts
ply to these larger grafts. The results are therefore not necessar- and multi-FU grafts, he transplanted 15 apparently hairless sec-
ily representative of what can be expected with the usual pattern tions of skin from the donor strip. These hairless grafts had
of mixed grafting that I recommend, whereas those of the first been examined under 3⳯ magnification and no follicles were
study are. seen in them. Seven months later, where the 15 empty grafts
With regard to the hair survival studies in grafts with a 4- had been inserted, he found 35 hairs growing with an average
mm diameter that Nordstrom and I did more than 25 years ago of 2.33 hairs/graft and a regrowth density that was 80% of that
Table 9A–8 The Tabulated Results Seen in Patient #1 in the Seager/Unger Study
Punch Grafts versus Follicular units Patient 1 – Tom

September 28, 2000
Follicular Units Punch Grafts
2 punch grafts ⫻ 9
Total units: not counted
Total # of hairs: 117 Total # of hairs: 119
Total # of good hairs: 109
June 14, 2001 (9.5 months later)
Total # of hairs: 109 Total # of hairs: 42
Percent growing: 93% Percent growing: 35%
August 29, 2001 (11 months later)
Total # of hairs: 156 Total # of Hairs: 117 to 136 (26)
Percent growing: 133% Percent growing: 98% to 114%
Table 9A–9 The Tabulated Results Seen in Patient #2 in the Seager/Unger

Study
Punch grafts versus follicular units patient 2 – Mehdi

September 28, 2000
Follicular units Punch grafts
2 Punch Grafts ⫻ 9
Total Number of Units: 40 Total Units: Not counted
Total # of Hairs: 92 Total # of Hairs: 92
June 21, 2001 (8.75 months later)
Total # of Hairs: 80 Total # of Hairs: 67
Percent growing: 84% Percent growing: 73%
August 29, 2001 (11 months later)
Total # of Hairs: 90 to 79 Total # of Hairs: 74 to 73
Percent growing: 98% to 86% Percent growing: 80% to 79%
present in the area transplanted with hair-bearing grafts! This hairs are relatively fine textured or curly, have little color con-
was a ‘‘study’’ on a single patient, but the results were, needless trast with the patient’s skin, or include a significant number of
to say, astounding. It suggested, amongst other possibilities, miniaturizing or vellus hairs.
that 3⳯ magnification is not great enough magnification to In Tables 9A–5, 9A–6, and 9A–7, it is also clear that the
reveal small segments of follicles that, amazingly, may be capa- initial hair counts, when done with the assistance of 2⳯ loupes,
ble of producing hairs. It also suggested that unseen telogen were sometimes different from counts established when the
follicles may be present in donor tissue and that they may be grafts were examined with a 6⳯ Mantis stereomicroscope.
accidentally trimmed away and discarded if only visible FUs Once again, the lighter the hair color, the more likely that such
are being left. A second similar study, but with substantially differences will occur. Moreover, one of the problems with all
different results, can be found in Chapter 23I-2. the clinical hair count studies done thus far is that (1) initial
graft-hair counts could be done with 6⳯ or 10⳯ magnification
as the grafts were separate from all hair that could confuse hair
CONCLUSION counts done later on the scalp and (2) the later hair counts on
In concluding this discussion, it is important to point out, as I the scalp were not done with 6⳯ or 10⳯ magnification; there-
have for a number of studies on FU hair survival, that studies fore, some finer and/or shorter hairs that might have been pres-
involving only one or a few patients are not scientifically valid. ent were more likely to be missed by the person doing the
This is equally true for studies on minigrafts. The results of counting. In addition, some hairs tend to cling together; this
such studies may result in (1) comfortable or uncomfortable may result in lower hair counts. Or, if hairs are counted more
impressions of likely hair survival rates, (2) in the hands of than once because they have sprung back to their initial location,
that particular investigator and (3) given all of the clinical they may produce higher counts. These factors are probably the
parameters in the study. Beehner has also already listed some main causes of different hair counts by the same and different
of the variables that can affect results when study grafts are hair counters.
being placed as part of a usual transplant session. This type of Most studies on hair survival with various types of grafts
study is more clinically meaningful than a study in which a also have not included examinations of hair caliber before and
group of grafts is studied in an otherwise untreated area. To after transplanting. Hair mass or bulk is what we are really
Beehner’s list must be added the total number of grafts trans- seeking. If even the same number of hairs that are transplanted
planted in the session, the density of the graft dispersion, the survive, but with reduced caliber if one or another type of graft-
location of the grafts within the recipient area, and numerous ing is used, the numbers of hairs present may be considerably
other variables. In brief, for a variety of reasons, the studies to less important than implied. A .01-mm decrease of hair caliber,
date do not provide absolute proof of what can be routinely for example, can result in a 36% decrease in hair mass. Hair-
expected in all patients and by all surgeons whose techniques caliber alteration is, in fact, considerably more important than
of transplanting and skills are different. numbers of hairs (see Chapter 10A) and makes most of the
In addition, what becomes immediately obvious when hair hair survival studies that have been done almost meaningless
count studies are being done, and as Beehner has also pointed because hair caliber, or hair mass, was not included in the obser-
out, is that accurate hair counts are extraordinarily difficult to vations.
do. It is common to have the same technician count the hairs We must also deal with the reports of more hairs growing
in the same graft or grafts several times and get slightly different than were initially transplanted. The ostensible explanations for
numbers each time. Moreover, different technicians have great this are the following:
difficulty in agreeing on the numbers of hairs in the same graft 1. ‘‘Invisible’’ (at 10⳯ magnification) and therefore un-
or grafts even after multiple counts. This is especially true if counted telogen follicles that have lost their hairs and are in an
278 Chapter 9
Table 9A–10 Hair Growth After Transection of Hair Through the “Bulge” Area to Produce Approximately Two Equal Halves
Kim Limmer Mayera Mayer et alb Swinehart Martinick
Upper half 40% 7.1% 63% n/a 46% 62.5%

Lower half 20% 21.9% 70% n/a 47% 34.5%
TOTAL 60% 29.0% 113% 108% 93% 97.0%
(↓diam) (↓diam) (↓diam)
diam ⫽ Diameter.
Data from Kim JC. 1st annual meeting of the International Society of Hair Restoration Surgery; Dallas; 1993; Limmer BL. Relating hair growth theory and
experimental evidence to practical hair transplantation. J Cosmet Surg 1994; 2.
a
Mayer MA. Follicular regeneration. 6th annual meeting of the International Society of Hair Restoration Surgery; Washington; DC, Sept 17; 1998; bMayer M.
Follicular regeneration—use of bisected hairs in a frontal hairline. Orlando Live Surgery Workshop; Orlando; FL, 1999; Swinehart J. Cloned hairlines: the use
of bisected hair follices to creates finer hairlines. Dermatol Surg 2001; 27: 868–872; Martinick J. The results at 18 months of the longitudinal clinical
research into the importance of transplanting intact follicular units vs. Follicular units that have been traumatized using a variety of methods including tran-
section at the “bulge.” 8th annual meeting of the International Society of Hair Restoration Surgery, Dec 2000, Hawaii.
exogen or kenogen phase. These follicles eventually produce Martinick intentionally divide all of the hairs? Whose results
hairs that will not have originally been counted and will there- are correct? Would they be Martinick’s, or Kim’s (60%), or
fore, invalidate the results. If, for example, one counts 100 hairs Limmer’s (29.0%), or others? (Tables 9A–10 and 9A–11).
but there are also 10-hair follicles in an invisible kenogen phase, What would happen if follicles were not transected at exactly
the later growth of 100 hairs does not represent 100% hair the bulge, or at a one third point, or at a two thirds point, but
survival. How many hairs are in an exogen or kenogen phase somewhere in between these points—where the use of mul-
at any given time? Nobody really knows because the number tibladed knives in donor areas could be expected to have divided
probably varies from time to time. Rebora and Guarrera, how- different follicles?
ever, reported on 12 men followed for 14 years. They studied It is also important to take special note of Martinick’s 82%
a specific delineated area of scalp hair and found that 80% of rate. She is an expert FUT practitioner, who carefully and mi-
the follicles in that area experienced a kenogen phase that lasted croscopically prepares grafts herself. She inserts only 20 intact
4 to 7 months. Two female patients, studied in the same way three-haired FUs into 18-gauge needle sites in a 1-cm2 area,
but for only 2 years, showed that 22% of the follicles went within 4 hours of being removed from the donor area. These are
through this phase that lasted 3 to 12 months. The more severe ideal parameters for 100% hair survival. They are far superior to
the androgenetic alopecia, the higher the frequency and the what could be expected in everyday practice from the average
longer the duration of kenogen appeared to be (21). Thus, stud- FUT practitioner’s multiple technicians during the average FUT
ies in which hair counts are based only on visible hairs do session of 1000 to 3000 FUs. Nevertheless, in this study, only
seem to be inevitably and seriously flawed (see also following 82% of the hairs were growing at 18 months. What better dem-
discussion in this chapter and Chapter 12C.) onstrates the demanding survival requirements of FUs than this
2. Synchronous loss and regrowth of all hair in the graft 82% rate? Limmer, Mayer, Seager, Beehner and others have,
occurs; therefore, counts are at least initially higher than in of course, had far better results in ‘‘study patients’’; therefore,
the original donor tissue, when follicle growth and loss were I do not mean to imply that this is a typical FU study survival
asynchronous. (The asynchronous hair growth eventually rees- rate; I believe it is not even typical for Dr. Martinick. Yet Mayer
tablishes itself in the grafts, and the initial visible hair counts and Keene had 76% survival with ‘‘stick and place’’ at 30 FU/
in them can therefore be expected to diminish with time). cm2 density, and both of these practitioners are acknowledged
3. Some small hairs may not have been originally counted. FU experts. Moreover, none of the studies on FUs have been
Kim, for example, using 40⳯ magnification found 20% more done on grafts in the middle of a typical session of FUT, where
telogen follicles in 100 ‘‘single-hair grafts’’ after Beehner and the effect of vascular supply would be an important factor in
Martinick had earlier found an additional 20 extra telogen folli- hair survival. (There is more about this topic in my commentary
cles in these same supposed ‘‘single-hair grafts.’’ (They had in Chapter 12B.)
used 10⳯ magnification) at one of the joint World Hair Resto-
ration Society/ISHRS meetings (22). Furthermore, if 100 hairs
can sometimes produce 133 hairs (3), what is one to make of
supposedly 90% hair survival (90 out of 100 hairs)? Is it really Table 9A–11 Regrowth of Upper and Lower Two Thirds of
68% hair survival (90 out of 133 hairs) or some other per- Follicles
centage?
Finally, as Martinick and others have shown, the numbers Kim1 Reed2
of hairs present and their calibers are different at different times Upper half 60% 51% (↓diam) Kim also upper 1/3 0%
and do not always increase with the passage of additional time. Lower half 80% 64% (n diam) lower 1/3 0%
And what does it mean when 62.6% of the upper segment of
Martinick’s horizontally sectioned follicles regrow, and 34.5% diam ⫽ Diameter.
of the lower segments grow, with the result that hairs sprout Data from Kim JC. ???. 1st annual meeting of the International Society of
in a total of 97.1% of the number of originally divided hairs? Hair Restoration Surgery, Dallas, 1993; Reed W. ???. 6th annual meeting of
On the other hand, only 82% of the intact hairs grow! Should the International Society of Hair Restoration Surgery, Washington, DC, 1998.
Given all of the above considerations, the results of all graft (12). This study focused on factors that could result in physical
studies to date are far from conclusive. When those results con- damage to the micrografts during a standard surgical procedure.
flict with common sense, they are all the more suspect. On the The sources of damage during this stage were considered to be
other hand, we tend to believe intuitively that intact FUs will of two classes:
produce greater hair survival rates than transected FUs. To this 1. Damage produced by handling with scissors, blades, or
end, we spend a great deal of time, effort, and money keeping forceps during dissection of specimens
the FUs intact; however, the evidence that this is true is not at 2. Damage produced by drying on gloves or elsewhere
all clear. Practitioners should ideally do their own studies on while grafts are waiting to be inserted into recipient
their own patients, using their own typical approach to trans- sites. For this study, patients donated 120 micrografts
planting. They should record both numbers and calibers of during sessions of hair transplantation. Crushing,
transplanted hairs or hair mass (see Chapter 22H). They should stretching, or bending the micrografts with forceps re-
not assume that the results of studies done by others on small produced damage caused by surgical instruments. Dur-
numbers of patients would be the same if done by them or that ing these manipulations, we employed forces normally
they are scientifically valid. Unfortunately, such studies only used during hair transplant sessions. Letting the speci-
suggest what those investigators might expect in their patients, mens stay on our surgical gloves, for 3 minutes in an
and we would all be well advised to remember this before we air-conditioned room induced drying of micrografts, re-
become dogmatic about factors that are, in our opinion, ‘‘essen- producing a scenario for what might occur during a
tial’’ for hair survival. surgical procedure performed by a thoughtless or tired
operator or a procedure in which grafts were difficult
to insert because of excessive bleeding, dense-packing,
9B. Light and Electron Microscopy or other factors (13).
of Follicular Unit Grafting: We analyzed the morphology of treated specimens with light
Studying Iatrogenic Injury of and electron microscopy to evaluate possible damage. For this
Follicles part of the study, the treated specimens as well as untreated
ones that served as controls were initially immersed for 24 hours
Marcelo Gandelman and Paulo Alexandre Abrahamsohn in a solution of fixative consisting of 2% glutaraldehyde and
2% paraformaldehyde in 0.1M sodium cacodylate buffer (pH
INTRODUCTION 7.2). After fixation, the tissues were washed in the same buffer
and fixed for 2 hours with 2% osmium tetroxide and washed
Poor growth is not a rare occurrence in hair transplantation.
with phosphate-buffered saline. Tissues to be analyzed by trans-
Patients and doctors have been demanding results that approach
mission electron microscopy were thereafter embedded with
or exceed a 100% survival rate (1). This is understandable be-
plastic resin and sectioned with an ultramicrotome, initially at
cause, for the patient, poor growth means less than desirable
a thickness of 1 to 2 ␮m. These sections were stained with
aesthetic results and increased procedure costs. For doctors,
toluidine blue and were evaluated under a light microscope.
poor growth results in frustration because it raises doubts re-
For electron microscopy, the tissues were sectioned at 0.4 ␮m,
garding quality of service, wasted time, and diminished profes-
collected on copper grids, stained with lead citrate and uranyl
sional pride (2, 3).
acetate, and examined with a JEOL 100 CX II transmission
In 1979, Unger pointed to several causes of sparse growth. electron microscope. Tissues to be analyzed by scanning elec-
These include improper cutting, improper handling, drying out tron microscopy were submitted to critical point drying in a
of the grafts because of insufficient saline in the cleaning and Balzers CPD-30 device. The micrografts were then glued to
‘‘holding’’ dishes, and excessively long transplant sessions (4, metal stubs and covered with a layer of gold, with use of a
5). In 1984, Norwood and Shiell introduced the term X-factor Balzers SCD 050 sputtering unit. The specimens were examined
as ‘‘unexpected, unexplained reduced hair growth’’ (6, 7). The with a JEOL 6100 scanning electron microscope.
standard of excellence in hair transplantation has grown with The treated micrografts were initially examined with a light
the refinements of the follicular harvesting technique, but mis- microscope and compared with intact, untreated micrografts.
handling and overzealous cleaning of grafts before their reinser- This analysis showed that stretching, crushing, and bending did
tion apparently decreases the yield (8, 9). Improvement of hair not cause evident damage to the micrografts. In fact, it was
transplantation procedures, such as the use of micrografts (sin- even difficult to recognize the places on the micrografts where
gle-hair follicular units [FUs]) instead of standard grafts, al- bending, stretching or crushing had occurred. For these reasons,
though they improved aesthetic results, brought forth other these specimens were not further analyzed with electron micro-
problems (10). One such problem is the need for better under- scopes. Light microscope sections of micrografts that were left
standing of the handling of the tissues. With the use of large drying for 3 minutes, on the other hand, showed unmistakable
hair grafts, mistreatment of one specimen would probably cause signs of damage. This damage was observed in the nucleus and
restricted damage (11). Depending on the kind of mistreatment, cytoplasm of the epithelial cells that formed the hair shaft. Many
some or (only rarely) all hairs of larger specimens would proba- nuclei of epithelial cells were darkly stained in comparison with
bly be damaged. However, in the case of a mistreated mi- the nuclei of cells of untreated control tissues. Besides the nu-
crograft, damage signifies total failure of the take of that particu- clear changes, the cytoplasm of epithelial cells of treated tissues
lar specimen. often had many vacuoles that were present only in few numbers
To identify factors contributing to poor growth with the aim in the cytoplasm of control epithelial cells. Cells of the connec-
of increasing the yield of micrografts, we searched for a com- tive tissue that surrounded the hair shafts were likewise dam-
mon denominator among the different forms of graft injury aged.
280 Chapter 9
Figure 9B-3 Low magnification of a follicular unit seen with

Figure 9B-1 Section of a normal follicular unit seen under a a scanning electron microscope. This is a nondamaged control spec-
transmission electron microscope. There are several epithelial cells imen in which the following components can be seen: the surface
in the figure. The cell at the center shows a nucleus (N) whose of the epidermis (E), a protruding hair (H), and the lateral surface
condensed chromatin (arrows) is concentrated under the nuclear of the dissected tissue (L) showing the exposed connective tissue.
envelope and has a normal appearance. Magnification: 8,800x. Magnification: 37x.
The tissues of dried and control micrografts were then ana- Intact and dried micrografts were also analyzed with scan-
lyzed with a transmission electron microscope. The nuclei of ning electron microscopy. Unlike the transmission microscope,
many epithelial cells contained large collections of very dark which, like the light microscope, uses thin sections, the scanning
and homogeneous chromatin (heterochromatin) as opposed to microscope analyzes the micrografts in their entirety and allows
the nuclei of control epithelial cells, which had a thin layer of the study of their surfaces at high magnifications (Fig. 9B-3).
dark chromatin under the nuclear membrane, as most other cell Control micrografts showed details of the skin surface and of
types do (Figs. 9B-1 and 9B-2). Vacuoles of several sizes were the protruding hair (Figs. 9B-4 and 9B-5). The cut surface of
also present in the cytoplasm of many cells of tissues submitted the connective tissue that surrounded the hair shaft showed the
to drying (Fig. 9B-2). Nuclei with very condensed chromatin arrangement of dermal collagen fibrils (Fig. 9B-6). Dried mi-
were also present in cells of the surrounding connective tissue. crografts did not show evident alterations of the protruding hairs
or of the skin surface. There were, however, gross alterations
of the connective tissue. The arrangement of collagen fibrils
was not visible anymore because the lateral surfaces of the
Figure 9B-2 Section of a dried follicular unit seen under a

transmission electron microscope. The nucleus of an epithelial cell
contains a great amount of condensed dark-staining chromatin (ar- Figure 9B-4 Higher magnification of a follicular unit under a
rows) disposed in a bizarre arrangement. Several vacuoles are seen scanning electron microscope showing details of Fig. 9B-3. Fig.
in the cytoplasm (E). Magnification: 8,800x. 9B-4–shows the surface of the epidermis. Magnification: 100x.
Figure 9B-5 Protruding hair. Magnification: 600 x. Figure 9B-7 Scanning electron microscopy of a dried FU. The
lateral surface of this unit is amorphous and no details can be
observed. Magnification: 180x.
micrografts seemed to be constituted of an amorphous material

(Fig. 9B-7). tures such as cells and their constituents as well as fibers and
The chromatin, which fills the cell nuclei, is usually seen other components of the extracellular matrix. For this reason,
under the microscope in two forms: condensed (or heterochro- the surfaces of living beings are usually provided with special
matin) and uncondensed (or euchromatin). The balance between protection at the interface between their tissues and air (e.g.,
the dark staining heterochromatin and the light staining euchro- cornified skin in the case of humans). Air-drying is in fact one
matin, although depending on the functional state of the cell, the worst treatments one can do to a biological material. In
is usually characteristic for each cell type. The abnormal accu- the case of dried micrografts, even internal cells, supposedly
mulation of heterochromatin, which results in darker staining protected by connective tissue, were damaged.
nuclei, is usually a sign of severe cell damage. The results of this study lead us to at least two main conclu-
All these data indicate that many cells of the micrografts sions:
that had been submitted to controlled drying were dying in 1. Reasonable handling of the FUs with surgical instru-
response to an external injury. Likewise, exposure to air caused ments does not produce damage to the specimens that
the collagen fibrils to collapse and transform into an amorphous could be observed with a light microscope. The han-
tissue. Water is the most widespread and most important solvent dling of micrografts, even accompanied by inadvertent
for ions, sugars, proteins, DNA, and most other important bio- (although reasonable) crushing, bending, or stretching
logical molecules. In fact, life on earth depends on water and its of the specimens, probably does not affect their take.
properties. Water has, however, a high surface tension. Drying a 2. Letting FUs dry causes serious damage, even to the
biological structure leads to an abrupt decrease of the surface point of inducing necrosis to their cells.
tension and, consequently, to the collapse of biological struc-
We thus recommend that FUs always be immersed in liquid or
at least covered by a thin layer of liquid to avoid damage to
them. Surgical techniques should also be tailor-made for each
individual patient so as to minimize the time the graft is out of
its holding dish before it is in place in its recipient sites. In this
regard, the number of grafts on an implanter’s gloved-finger
should be strictly controlled to avoid graft drying, especially if
grafts are densely packed, if the operator is relatively unskilled
at inserting grafts, or if there is more than usual bleeding.
9C. Hair Survival of Partial

Follicles: Implications for
Pluripotent Stem Cells and
Melanocyte Reservoir
Jung-Chul Kim and Yung-Chul Choi
INTRODUCTION
Figure 9B-6 Collagen fibrils on the lateral surface of the speci- The growth of the hair follicle, sebaceous gland, and epidermis
men. Magnification: 1500x. are known to be intimately related. Chase (1) postulated in 1954
282 Chapter 9
that the upper outer root sheath of the follicle contains a popula- 3. The upper two-thirds and lower one-third of the follicle
tion of pluripotent stem cells capable of forming not only the were obtained from the transection of the follicle at the
follicle but also the epidermis and the sebaceous gland. Other lower one-third of the follicle (Fig. 9C-2).
observations have supported this hypothesis (2). Both upper and lower follicle grafts were transplanted onto the
Particularly insightful work on this problem by Cotsarelis forehead or leg. Histological examinations were performed for
and colleagues (3) led to the discovery that follicular cells re- each successive biopsy after grafting. Biopsy samples were
taining 3H-thymidine were located in the bulge region close to fixed in buffered formalin (paraffin-embedded), and sections
the insertion of the arrector pili muscle. This information, along were stained with hematoxylin-eosin.
with previous histological findings (4), makes the bulge a tempt-
ing candidate as a site of the follicular stem cells (Fig. 9C-1). RESULTS
Kobayashi and coworkers (5) also reported that in the rat vi-
brissa, keratinocyte colony-forming cells are highly clustered Eight months after grafting:
in the bulge. On examination of the human scalp hair follicle, 1. Thirteen of the 20 (65%) grafted upper two-thirds re-
Yang and associates (6) reported that keratinocytes from the generated complete hair follicles.
bulge area indeed have a longer in vitro life span than cells of 2. Twenty-five of the 30 (83%) grafted lower two-thirds
the lower follicle, the sebaceous gland, and even the epidermis. regenerated complete hair follicles.
This supports the hypothesis that in humans, as in rodents, a 3. Ten of the 25 (40%) grafted upper-half and 4 of the
population of stem cells resides in the bulge. However, Rochat 15 (27%) lower-half follicles regenerated complete hair
and coworkers (7) have demonstrated that a large number of follicles.
keratinocyte colony-forming cells are clustered at a region 4. No hair follicle was regenerated from either the grafted
below the midpoint of the human scalp hair follicle. This region lower one-third follicle or the upper one-third follicle.
lies inferior to the site of insertion of the arrector pili muscle. 5. The regenerated hairs from upper follicle implants were
This raises the question of the existence of stem cells below thinner than those from lower follicle implants (Fig. 9C-
the bulge. The exact distribution of the stem cells within the 3a).
human scalp hair follicle is not known with certainty. We have A histological examination, 8 months after grafting, showed
performed transplantation experiments of human scalp hair fol- that the regenerated hair follicle from the upper half follicle
licles after horizontal sectioning in an attempt to locate the implant revealed the presence of a reformed dermal papilla, a
follicular stem cells. matrix, and active melanocytes. The reformed dermal papilla
had a pyramidal shape. The lower-half follicle implants recon-
stituted the complete hair follicle. The sebaceous gland was not
STUDY DESIGN
regenerated, but there was an outgrowth in the sebaceous gland
Regeneration of Hair Follicles After Horizontal region.
Sectioning Two years after grafting, the histological examination of the
regenerated bulb from the upper-half implant showed that the
We removed human hair follicles from the occipital scalp by shape of dermal papilla was the same as the control dermal
microdissection to study their regenerative activity. Implants papilla (Fig. 9C-3b). The regenerated follicle from the lower-
were prepared from follicles as follows: half implant showed that the sebaceous gland was completely
regenerated (Fig. 9C-3c).
1. The upper one-third and lower two-thirds of the follicle
were obtained by horizontal section just below the pilo-
DISCUSSION
sebaceous junction.
2. The upper and lower halves of the follicle were obtained Location of Stem Cells in Human Hair Follicle
from a transverse cut at the middle portion of the fol-
licle. Evidence has indicated that most stem cells may actually reside
in the bulge, which, when given the proper stimulus, generates
the new inferior, cycling portion of the follicle.
Figure 9C-2 Horizontal sectioning. The solid lines show the

Figure 9C-1 Bulge hypothesis. levels of the cuts LF ⳱ Lower follicle; UP ⳱ upper follicle.
Figure 9C-3 A, Surface view of the leg, 8 months after grafting

upper-half and lower-half grafts B, Longitudinal section of a regen-
erated follicle from an upper-half graft, 2 years after grafting. Mag-
nification: 10⳯. C, Light micrograph of the sebaceous gland Figure 9C-4 Hypothetical schema showing the location of fol-
regenerated from a lower-half graft, 2 years after grafting. licular epithelial stem cells and connective tissue sheath cells,
Magnification 100⳯. UF ⳱ regrown hairs from upper-half grafts; which can reconstitute a new papilla..
LF ⳱ regrown hairs from lower-half grafts. (Adapted from Cotsar-
elis G, Sun TT, Lavker RM. Label-retaining cells reside in the
bulge area of pilosebaceoue unit: implications for follicular stem
cells, hair cycle, and skin carcinogenesis. Cell 1990; 61:
1329–1337; and from Rochat A, Kobayashi K, Barrandon Y. Loca- Regeneration of the Pilosebaceous Unit
tion of stem cells of human hair folllicles by clonal analysis. Cell
1994; 78:1063–1073.) Our experiments indicate that a papilla and outer root sheath
from the middle one-third of the follicle must be present if the
hair is to grow. The connective tissue sheath cells that surround
the middle third of the follicle can be the source of new papillae
needed for the complete regeneration of a hair follicle.
First, a population of slow–cycling, label-retaining cells is Thus, when a hair follicle is cut below the lower one-third,
localized in the bulge, when mouse follicular cells are labeled only the remaining upper portion of this follicle can regenerate
with 3H-thymidine in vivo (3). Second, more than 95% of the a complete hair follicle. In the upper-follicle implant, the re-
keratinocyte colony-forming cells isolated from rat vibrissa are maining connective tissue sheath cells are reorganized to form
located in the bulge, and the remainder are mainly present in a new papilla. Then, the remaining keratinocytes, in concert
the bulb (5). Yang and associates (6) reported that the upper with the regenerated dermal papilla, can form a complete folli-
human hair follicle contains keratinocytes with superior in vitro cle. In the lower one-third follicle implant, the hair shaft of the
proliferative potential, supporting the hypothesis that, as in ro- lower portion is pushed up by subsequent regression of the
dents, the stem cells reside in the bulge. lower portion, but a new hair follicle cannot regenerate in the
However, designating the bulge as the only location of follic- next hair cycle because of the absence of hair follicular stem
cells that are located in the middle one-third of the hair follicle
ular stem cells posed problems for the interpretation of our
(Fig. 9C-5). This finding contrasts with the results obtained with
transection experiments, which showed that the lower-half folli-
implants of vibrissa bulbs, which always provide hair fibers (9).
cle implants (below the bulge-equivalent region) regenerated
When a hair follicle is cut near its middle portion where
the hair follicle. Because we could not identify a well-defined
follicular epithelial stem cells and connective tissue sheath cells
bulge in most dissected follicles, we localized the site of inser-
overlap, both upper-follicle and lower-follicle implants are able
tion of the arrector pili muscle by immunostaining of smooth to regenerate a complete hair follicle. In the case of the upper-
muscle-alpha-actin (8), which we found was always located in follicle implant, the remaining connective tissue sheath cells
the upper-half follicle in the adult human. migrate to form the new papilla, which is small and associated
Rochat and colleagues (7) demonstrated that most keratino- with the production of a fine hair. In the lower-follicle implant,
cyte colony-forming cells are located below the midpoint of the the lower portion undergoes catagen and telogen by pro-
human hair follicle, at a significant distance from the sebaceous grammed cell death. The hair shaft is then shed 2 weeks after
gland, the bulge region, and the site of insertion of the arrector implantation. The remaining follicular stem cells regenerate a
pili muscle on one hand, and from the hair bulb on the other. new epithelial column and make a new hair follicle through
However, our experiment showed that although 40% of the interaction with the dermal papilla. The diameter of the regener-
implanted upper-half follicles regenerated, the same was true ated hair from the lower follicular implant is the same as the
for only 27% of the grafted lower-half follicles. This may indi- original hair (Fig. 9C-6).
cate that more stem cells are located in the upper portion of the When a hair follicle is cut at the upper two-thirds level,
middle one-third (Fig. 9C-4). It is possible that the bulge con- only the remaining lower-follicle implant can form a new hair
tains most of the stem cells in rodent hair follicles, but in human follicle. The upper one-third follicle implant cannot form a new
hair follicles, the stem cells are widely distributed in the middle follicle because there are no connective tissue sheath cells in
one-third of the follicle. the upper portion (Fig. 9C-7).
284 Chapter 9
Figure 9C-7 Hair follicle regeneration after upper two-thirds

transection.
Figure 9C-5 Hair follicle regeneration after lower one-third

transection.
in the bulbs of regenerated hair follicles may come from the

proliferation and migration of inactive melanocytes in the outer
Our data also indicate that the sebaceous gland can be regen- root sheaths of the middle one-third of the follicle.
erated even in the lower half of the follicle implant; this raises We have grafted the lower two-thirds of the scalp hair folli-
the possibility that the follicular stem cells ascend through the cle onto skin with vitiligo and found that the grafted hair follicle
isthmus, giving rise to sebaceous glands. Our observation at induced the repigmentation of vitiligo. This observation also
present argues against the possibility that the sebaceous gland indicates that there is a melanocyte reservoir in human hair
may itself contain stem cells (10). follicles, and the repigmentation of vitiligo may begin with the
reproduction of melanocytes in the middle part of the hair folli-
cles. Thus, amelanotic melanocytes, which are located in the
Melanocyte Reservoir in Human Hair Follicle middle portion of the hair follicle, may migrate upward or
Active melanocytes located in the matrix of hair follicles syn- downward to become active melanocytes in the epidermis or
thesize melanin and produce pigmented fiber (11). Our results in the matrix.
show that surgical removal of the lower half, including the
matrix, which contains active melanocytes, cannot prevent the
regeneration of new black hair follicles. Thus, the melanocytes CONCLUSION
We have examined the regenerative capabilities of the human
scalp hair follicle after grafting the follicle, which was horizon-
tally sectioned. Our results showed:
● The lower two-thirds follicle implants and lower one-
half follicle implants were able to produce a complete
hair follicle. The caliber of this hair was normal
● The upper two-thirds follicle implants and upper one-
half follicle implants were able to produce a complete
hair follicle and did so by first regenerating their bulb
and then producing a complete new hair. The upper-half
implants produced a finer hair.
● None of the upper one-third follicle implants or lower
one-third follicle implants regenerated a hair follicle.
● The sebaceous gland was regenerated from the lower-
half follicle implant 2 years after grafting.
● The regenerated matrix from the upper-half follicle im-
plant contained active melanocytes.
These results provide evidence that the middle portion of the
hair follicle contains not only pluripotent stem cells, which can
give rise to hair follicles, sebaceous gland, and epidermis, but
Figure 9C-6 Hair follicle regeneration after one-half transec- also a melanocyte reservoir for pigmentation of the epidermis
tion. and hair matrix (Fig. 9C-8).
Figure 9C-8 Follicular epithelial stem cells and melanocyte reservoir.
9D. The Effects of Dehydration, sebaceous gland. After exposure to the traumatic factor being
studied, they were placed in organ-culture media for 7 days.
Preservation Temperature and The length of each follicle was measured microscopically at a
Time, and Hydrogen Peroxide on magnification of 20x, immediately, and at the end of a 7-day
Hair Grafts culture period. Follicles that continued to elongate and grow
were considered to ‘‘survive.’’ Follicles that did not show elon-
Jung-Chul Kim and Sungjoo Hwang gation or that had lost normal follicular architecture, owing to
degeneration late in the culture period, were regarded as not
INTRODUCTION surviving.
The advent of the follicular unit graft (one hair to four hairs per
graft) has allowed hair transplant surgeons to create extremely
DEHYDRATION
natural-appearing transplanted hair for men and women. How-
ever, this technique, with a long operating time, reliance on a Excessive dehydration is now considered one of the main causes
large surgical team, and use of delicate grafts, introduces a new of poor graft survival. Gandelman showed major changes in
set of problems, all potentially manifesting as poor growth. cell structure when follicles were left to dry for more than 5
Shiell and Norwood (1) first described the X-factor in 1984 as minutes (3). The changes in cell structure in his study were
something producing unexpected and unexplained poor growth greater for dehydration than for physical trauma. Our study
in 4-mm grafts. Greco, in 1994, greatly increased our awareness design was different from Gandelman’s in that it measured the
of the problems in dealing with small grafts with his introduc- effects of dehydration on in vitro hair shaft growth as opposed
tion of the term ‘‘H-factor’’ to describe iatrogenic contributions to changes in cell structure.
to poor growth (2). He focused on mechanical trauma as a major A total of 500 single-hair follicles were used for the dehydra-
culprit and offered the logical explanation that as grafts became tion study. The 500 follicles were separated into five groups of
smaller they would be more subject to a host of insults. The 100. Each group of follicles was left on dry gauze for a varying
latter included crushing, squeezing, bending, drying, and length of time (0, 5, 10, 20, and 30 minutes) at room tempera-
warming. ture.
The purpose of this study was to further examine some of Elongation of hair follicles was seen in 96%, 94%, 94%,
the factors potentially responsible for poor growth. Using organ 83%, and 68% for the 0-minute, 5-minute, 10-minute, 20-min-
culture methodology, we examined the effects of (1) dehydra- ute, and 30-minute air-exposed groups, respectively (Table 9D-
tion, (2) preservation time and temperature, and (3) hydrogen 1). Grafts exposed to air for 10 minutes or less all had survival
peroxide on follicular growth. rates of 94% or greater. On the other hand, survival rates signifi-
cantly decreased in follicles dehydrated for 20 minutes or more
ORGAN CULTURE METHODOLOGY (see Table 9D-1).
These findings lend further evidence to the detrimental effect
In vitro organ-culture methodology was used to evaluate hair of dehydration on graft survival. In Gandleman’s study, cell
growth. The hairs to be studied were transected just below the changes owing to dehydration appeared at 5 minutes. In our
286 Chapter 9
Table 9D-1 Effect of Dehydration on Hair Grafts 24 hours or more at room temperature and those preserved at
Duration of air-exposure (min) Survival rate (%) 4⬚C (Table 9D-2). This may indicate that temperature is not a
major factor in survival for the first 5 to 6 hours, but after this
0 (No exposure to air) 96 time period, it becomes increasingly important.
5 94 This study is consistent with the findings of Raposio and
10 94 associates (5), showing 87% survival rate and 88% survival rate
20 83* of grafts preserved for five hours at room temperature and at
30 68* 4⬚C, respectively. Our findings are also consistent with the in
* p ⬍ 0.05. vivo study reported by Limmer (6), who investigated the effect
on survival of grafts stored in saline at 4⬚C for various lengths
of time, ranging from 2 hours to 72 hours.
study, hair elongation in vitro decreased significantly after 10

minutes of dehydration. This should not be taken to mean that HYDROGEN PEROXIDE
it is safe to let grafts dehydrate for up to 10 minutes because
Many of us have been using hydrogen peroxide for years. The
the ability for a hair follicle to survive in the clinical situation
main reason for using hydrogen peroxide is to remove blood
(in vivo) may be less than its ability to survive (elongate) in a
during and after surgery. There has been concern expressed
cell culture (in vitro). The main lesson is that the effects of
dehydration are significant, and care must be taken to prevent about the potential toxic effect of hydrogen peroxide on grafts.
its occurrence. The purpose of this study was to observe the effect of different
concentrations of hydrogen peroxide on graft survival. Isolated
single-hair grafts were treated with hydrogen peroxide, 1%,
PRESERVATION TIME AND TEMPERATURE 1.5%, 3%, and 5%, for 1, 2, 5, and 10 minutes. Once again,
viability of treated grafts was judged by organ culture. Hair
When isolating hair grafts in hair transplantation procedures, growth was adversely affected even at 1 minute with the stan-
it is generally recommended to preserve the grafts at a low dard commercially available 3% solution of hydrogen peroxide.
temperature to enhance the survival rate of the grafted hairs (4).
However, hair growth was not affected by the 1.5% solution
Knowing the best way to preserve hair grafts may be important,
of hydrogen peroxide (Table 9D-3).
because with the advent of megasessions, a significant period
A nontoxic concentration of hydrogen peroxide has been
of time may elapse between graft harvesting and implantation.
shown to stimulate angiogenesis through (ets-1 and protease)
A total of 800 single-hair follicles were used for the preser-
induction of transcription factor ets-1 (7). Ets-1 has been shown
vation time and temperature study. To evaluate the effect of
preservation temperature and time on the hair graft, follicles to control angiogenesis by the regulation of the gene expression
were divided into two groups. Group 1 was preserved at room of proteases such as collagenase and stromelysin (8). Interest-
temperature and Group 2 was preserved at 4⬚C. Each group ingly, hydrogen peroxide increased the ets-1 mRNA level in
was further subdivided into smaller groups that were preserved dermal papilla cells compared with the basal level (Fig. 9D-1).
for varying lengths of time. The times were 5 minutes (used as In our study, hair growth was not affected by hydrogen perox-
a control) and then 6 hours, 24 hours, and 48 hours at both ide, 1.5%. In theory, a relatively low concentration of hydrogen
temperatures. Hair follicles preserved in petri dishes with saline peroxide can speed wound healing and induce early hair growth
for 6 hours showed a 92% survival rate at room temperature, by stimulation of angiogenesis. Therefore, in our opinion; solu-
compared with a 94% survival rate at 4⬚C. Thus, there appeared tions of hydrogen peroxide, 1.5% (or less), may be beneficial
to be no significant difference in the survival rates within 6 when used for scalp cleansing during hair transplantation.
hours regardless of whether hair follicles are preserved at room
temperature or 4⬚C. In contrast, there was a significant differ-
ence between the survival rate of hair follicles preserved for CONCLUSIONS
● We found a decrease in follicular survival (in vitro) after
10 minutes of dehydration
Table 9D-2 Effect of Preservation Temperature and Time on ● We found no difference in follicular survival (in vitro)
Hair Grafts
follicles stored at room temperature and those stored at
Survival rate (%) 4⬚C for the first 6 hours
Duration of ● Preserving grafts at 4⬚C appeared to be beneficial if the
preservation (hrs) Room temperature 4°C follicles were required to be preserved for more than 6
hours.
Control 95 96
6 92 94
● Follicular survival decreased after 6 hours whether or
24 40* 76-*§ not the follicles were preserved at 4⬚C.
48 34* 50§ ● Hydrogen peroxide at concentrations of 1.5% or less did
not appear to be harmful to follicles and, theoretically,
*, § p ⬍ 0.05 might be beneficial.
Table 9D-3 Effect of Hydrogen Peroxide on Hair Grafts
Survival rate (%)

Duration of
exposure (min) 1% H2O2 1.5% H2O2 3% H2O2 5% H2O2
Control 90 89 86 97
1 89 81 66 58
2 83 88 46 29
5 85 79 40 23
10 80 71 35 17
grafts on days: 0 (surgery day, baseline), 1, 3, 7, 14, 21, and

28, and at 3-months and 6 months (Fig. 9E-1).
Histological Stains and Tissue Markers

The graft biopsies were evaluated with the following histologi-
cal stains: Hematoxylin and eosin, factor VIII, CD 31, collagen
III, collagen IV, platelet-derived growth factor (PDGF), trans-
Figure 9D-1 Induction of ets-1 mRNA in dermal papilla cell forming alpha growth factor (TGF-alpha), transforming beta
by H2O2 growth factor (TGF-beta), epidermal growth factor (EGF), and
vascular endothelial growth factor (VEGF) (Table 9E-1).
CD 31 is an intercellular adhesion molecule believed to me-
diate endothelial cell-to-cell contact promoting interactions be-
tween leukocytes and endothelial cells. It labels platelets and
9E. Wound Healing and megakaryocytes. CD 31 and PDGF are useful for evaluating
Revascularization of the Hair neovascularization. Factor VIII reacts with fibroblasts, connec-
Transplant Graft: The Role of
Growth Factors
David Perez-Meza
INTRODUCTION
In general, wound healing has three specific phases: inflamma-
tory, proliferative, and remodeling (1–4). These phases require
a series of coordinated physiological events, which involve
white blood cells (neutrophils, eosinophils, macrophages),
platelets, fibroblasts, polypeptide growth factors, proteinase in-
hibitors, and nutritional elements (5–15).
A hair graft is a tiny free graft that has been detached from
its original blood supply and placed in a premade wound. As
in other grafting procedures, survival, or ‘‘take,’’ depends on
revascularization from the recipient site in the process of wound
healing (16–21). Very few studies had specifically explored
the process of graft healing, and no studies had investigated
revascularization of the hair graft. We decided, therefore, to
conduct a study for these purposes.
EVALUATION METHODOLOGY
Our study spanned a 6-month period and involved three healthy
men (Norwood types IV to VI) who had not undergone previous
surgery. Each patient received 700 to 800 small grafts. Using
photographic and histological methods, our study followed the
patients for 6 months. Digital pictures, videomicroscope photo- Figure 9E-1 Schematic drawing of different biopsy sites done
graphs, and 2-mm punch biopsies were taken of transplanted at different times.
288 Chapter 9
Table 9E-1 Description of Growth Factor Location and Activity
Growth factor Found in Activity
TGF-alpha Platelets, macrophages, Stimulates angiogenesis, fibroblast mitogen, and granulation tissue
keratinocytes formation. Associated with anagen inhibition and/or catagen
induction or hair follicle arrest in telogen-inhibitor.
TGF-beta Platelets, neutrophils, lymphocytes, Fibroblast proliferation, chemotaxis, collagen metabolism,
macrophages angiogenesis. Anagen induction. Promotion or catagen-promoter.
PDGF Endothelial cells, platelets, Vascularization (neovascularization), chemotaxis to evaluate the
macrophages, fibroblast healing process (inflammation and repair). Fibroblast proliferation.
EGF Almost all body fluids, platelets Granulation tissue formation, mitogen for keratinocytes, endothelial
cells, and fibroblasts.
VEGF Pituitary cells Mitogenic for endothelial cells, but no keratinocytes, smooth
muscles, or fibroblasts.
tive tissue cell, dermal dendrocytes, monocytes, and macro- Shedding of grafted hair is usually believed to result from
phages. It is useful to evaluate inflammation and tissue remodel- an anagen effluvium occurring typically 2 to 4 weeks after a
ing. Collagen III labels connective tissue in the extracellular traumatic insult. Our time frame for graft hair shedding is con-
matrix, and collagen IV labels collagen on the basal lamina. sistent with this explanation. Nongrafted hair (existing native
With these stains and tissue markers, we can evaluate various hair) can shed at 2 to 4 weeks (anagen loss), as well as 2 to 3
aspects of wound healing including: cytometry (cell counts), months after the transplant. The latter occurrence is usually
growth factor activity, collagen activity, and neovasculariza- considered a telogen effluvium, in which the existing anagen
tion. hair shaft that goes into telogen can remain in the follicle until
a new anagen hair pushes it out. In fact, a telogen hair can be
shed long before it is pushed out. The exogen phase of the
PHOTOGRAPHIC OBSERVATIONS hair cycle refers to this hairless stage of a telogen follicle (see
Chapters 2 and 3). There have been reports of patients who did
The recipient area was observed for subjective clinical impres- not shed all of their grafted hair after a transplant, and some
sions of erythema, recipient site edema, shedding of graft hair, transplanted hairs continue to grow. It may be that these hairs
and new growth of graft hair. Erythema was present immedi- do not reach the threshold of anagen effluvium.
ately after surgery but decreased gradually over time. In some
patients, erythema persisted for up to 28 days. Recipient site HISTOLOGICAL OBSERVATIONS
edema (swelling localized to the area directly surrounding the
recipient incisions) appeared immediately after surgery but usu- Cytometry (Cell Counts)
ally resolved after 14 days. Scabbing occurred immediately and
On day 1, we did not find inflammatory cells because of the
usually resolved by 7 to 14 days. Grafted hair began to shed
edema. By day 3, there was an influx of neutrophils and occa-
by 10 to 14 days and continued shedding up to day 28, by which
sional eosinophils. On day 7, neutrophils were still the dominant
time some graft sites contained no visible grafted hairs. Some
cell type but macrophages were also seen. By day 14, the pre-
percentage of the graft sites, however, still contained visible
dominant cell types seen were macrophages, fibroblasts, lym-
hairs at this time, and growth continued until the study was
phocytes, and occasional histiocytes. From day 21 to day 28
finished. By the next evaluation, at 3 months, many of the
the presence of inflammatory cells decreased until the cells were
sites showed evidence of new hair growth. By 6 months,
finally absent.
most graft sites showed aesthetically significant hair growth.
These findings appear in Table 9E-2 as well as in Figs. Growth Factor Activity
9E-2 to 9E-6. It should be noted that the time frame of the
observed events varies somewhat from practice to practice Only TGF-A was found on day 1. By day 3 all growth factors
and technique to technique. were observed.
Table 9E-2 Clinical Observations of the Recipient Graft Sites. (⫺ Absent, ⫹ Present)
Recipient site edema ⫹ ⫹ ⫹ ⫹ ⫺ ⫺ ⫺ ⫺

Recipient site erythema ⫹ ⫹ ⫹ ⫹ ⫹ ⫺ ⫺ ⫺
Recipient site scabbing ⫺ ⫹ ⫹ ⫹ ⫺ ⫺ ⫺ ⫺
Graft hair shedding ⫺ ⫺ ⫺ ⫹ ⫺ ⫺ ⫺ ⫺
Transplanted hair growing ⫹ ⫹ ⫹ ⫹ ⫹ ⫹ ⫹ ⫹
New hair seen at recipient sites ⫺ ⫺ ⫺ ⫺ ⫺ ⫹ ⫹ ⫹
Day 1 Day 3 Day 7 Day 14 Day 21 Day 28 Month 3 Month 6
a b
Figure 9E-2 (a), Digital image, day 3, shows erythema, edema, and scab formation. (b) Videomicroscope image of graft shows the
same with unshed, grafted hair still present.
(TGF-A, TGF-B, PDGF, EGF, and VEGF). By day 28, only growth factor and CD 31 helped to identify neovascularization.
EGF was found. Table 9E-3 summarizes growth factor activity The grafts placed in the recipient site followed the wound-heal-
from day 1 through day 28. ing model observed after the other forms of injury (1–4). A
general inflammatory phase took place from day 1 through day
Collagen Activity 7. During this time, an infiltration of neutrophils, lymphocytes,
macrophages, and monocytes accompanied edema. A prolifera-
Collagen activity was present by day 1 and persisted throughout
tive phase occurred from day 3 through day 28, and macro-
the study. Table 9E-4 summarizes the collagen activity. (Scale
phages and monocytes increased in number. Evidence of angio-
– through ⳭⳭⳭⳭ).
genesis, wound contracture, and epithelialization was also
Biopsy Observations observed during this interval. Growth factor activity appeared in
the inflammatory phase and was highest during the proliferative
The hair grafts and recipient sites were observed by routine phase. During this phase, cytokines and growth factors were
histological methods (Figs. 9E-7 to 9E-13). Platelet derived believed to modulate the wound-healing process. In the remod-
Figure 9E-3 (a) Digital photography, day 14, shows less erythema and edema. Scab has been released. Unshed hairs are still present.
(b) Video microscope image of graft shows the same patient with unshed grafted hair still present.
290 Chapter 9
Figure 9E-4 (a), Digital image, day 28, shows no scabs or edema. Slight erythema is still present. Most graft hairs have shed. (b),
Videomicroscope image of graft shows the same view. In this particular site, there is still a graft hair present at day 28.
eling phase, wound remodeling followed wound repair. Pro- Acute Healing Phases
gressive organization and maturation of the tissues occurred
and led to reported increases in wound strength for up to 2 The acute phase of wound healing consists of an inflammatory
years (1,2). phase, a proliferative phase, and a remodeling phase. These
phases overlap (Fig. 9E-14). After making the sites in the recipi-
ent area, wound repair starts with an inflammatory phase, char-
DISCUSSION acterized by clot formation, deposition of fibrin, and influx of
inflammatory cells into the wound. A proliferative phase fol-
Surgeons have used autologous hair-bearing scalp grafts suc- lows in which fibroblasts and epithelial cells migrate to repopu-
cessfully for many years as a method of hair restoration surgery late the wound. Wound contracture and epithelialization occur
(22–26). The literature documents the activities of the healing during this interval. Multiple cytokine growth factors (fibro-
process in many types of wounds and injuries (1–4). Our study blast, epidermal, platelet derived, TGA-alpha, TGA-beta and
identified similar and new observations of the healing process vascular endothelial) increase in the wound during the inflam-
at the site of hair transplant grafts (27). matory and proliferative phases. These growth factors appear
Figure 9E-5 (a), Digital image at 3 months shows new hair growth. (b), Videomicroscope image of a graft site shows two hairs
protruding from the site; one hair shaft looks more mature (of greater caliber) than the other.
a b
Figure 9E-6 (a), Digital image at 6 months shows much more hair growth, with a significant aesthetic effect. (b) Videomicroscope
image of a graft site shows two hairs both of which look mature, protruding from the site.
Table 9E-3 Summary of Growth Factors Activity (Scale ⫺ through ⫹⫹⫹⫹)
TGF – alpha ⫺ ⫹ ⫹⫹ ⫹⫹ ⫹⫹⫹ ⫺ ⫺ ⫺

TGF-beta ⫺ ⫹ ⫹ ⫹ ⫺ ⫺ ⫺ ⫺
PDGF ⫺ ⫹ ⫹⫹ ⫹ ⫹ ⫺ ⫺ ⫺
EGF ⫺ ⫹ ⫹⫹ ⫹⫹ ⫹⫹ ⫹⫹ ⫺ ⫺
VEGF ⫺ ⫹ ⫹⫹ ⫹⫹⫹ ⫹⫹⫹ ⫹⫹ ⫹
to play key roles in initiating and sustaining the phases of tissue graft and recipient site (primary inosculation). By day 7, neo-
repair (5–15). The growth factors ultimately diffuse from the vascularization further changes in the vessels (including lym-
wound site and are degraded by inhibitory proteases (10). phatics), with coiled vessels extending deeply into the dermal
Other studies have suggested that specialized fibroblasts and papilla and with budding around the follicular implant. These
growth factors from the dermal papilla play a key role in the changes take place simultaneously with the increase in inflam-
control and induction of the normal follicular growth cycle (28). matory cells and growth factors.
The increase in growth factors seen during tissue repair may
theoretically play a role in modulating hair growth during the CONCLUSION
healing phase of graft transplantation as well.
These observations initiate our exploration and understanding
Revascularization of the wound-healing process of the hair graft. From the time
the blade touches the skin and produces hundreds or thousands
Revascularization of the hair graft must also take place. We of wounds, a coordinated series of events begins that involves
identified three phases of revascularization: serum imbibition inflammatory cells, fibroblasts, growth factors (platelet, epider-
(⬃1 to 3 days), primary inosculation (⬃3 to 7 days) and second- mal, transforming alpha beta, vascular endothelial), proteinases,
ary inosculation (⬃7 to 21 days) (Fig. 9E-15). During the first etc. The exact mechanism by which these cells and growth
72 hours, nutrition and graft survival depend on diffusion of factors modulate wound healing and the revascularization of
serum from the recipient site (imbibition). By day 3, early re- the hair graft deserves further study. A schematic rendition of
vascularization occurs and connections form between the hair these events is shown in Figs. 9E-16 to 9E 21.
Table 9E-4 Summary of Collagen and CD 31 activity
COLLAGEN III ⫺ ⫹⫹ ⫹⫹⫹ ⫹⫹⫹ ⫹⫹ ⫹⫹ ⫹⫹ ⫹⫹

COLLAGEN IV ⫹ ⫹ ⫹⫹ ⫹⫹⫹ ⫹⫹⫹ ⫹⫹⫹ ⫹⫹ ⫹⫹
CD 31 ⫹ ⫹ ⫹⫹ ⫹⫹ ⫹ ⫹ ⫺ ⫺
292 Chapter 9
Figure 9E-9 Day 7 biopsy shows decreased edema (x), abun-

dantly present neutrophils (y), some macrophages, and no eosino-
phils.
Figure 9E-7 Day 3 biopsy shows severe edema on both sides

of the outer root sheath (x) (staining for TGF-a).
Figure 9E-10 Day 14 biopsy shows epidermal growth factor,

staining sebaceous glands (x), and inflammatory cells (y).
Figure 9E-8 Day 3 biopsy shows early revascularization (x). Figure 9E-11 Day 14 biopsy shows TGF-B staining of stroma
Normal preexisting dermal papilla vessels are also visible (y). (x).
Figure 9E-14 The different phases in the wound-healing pro-

cess: inflammatory phase, proliferative phase, and tissue-remodel-
ing phase.
Figure 9E-12 Day 14 biopsy with CD 31 stain shows intense

perifollicular vascular proliferation (x) and ductal hyperplasia
around eccrine glands.
Figure 9E-15 The phases of graft revascularization are shown:

serum imbibition, primary inosculation, and secondary inoscula-
tion.
Figure 9E-16 Immediately after recipient site incision has

Figure 9E-13 Day 14 biopsy shows collagen IV staining (x) been made with a punch graft.
to the level of the arrector pili muscle insertion (y).
294 Chapter 9
Figure 9E-17 Immediately after placement of a graft. Notice

the surrounding blood clot. Nutrition occurs through serum imbibi- Figure 9E-20 Secondary inosculation—showing further neo-
tion. vascularization with vessels budding around the follicular implant
and extending toward the dermal papilla.
Figure 9E-18 Primary inosculation— at approximately 3 days,

with surrounding early influx of inflammatory cells (x) and early Figure 9E-21 Normal vascularization at 6 months.
vascular connections (y).
APPENDIX 9A—HAIR COUNTS: A SCIENTIFIC

APPROACH TO THE EVALUATION OF
VARIOUS FACTORS IN SURVIVAL OF HAIR
TRANSPLANTS*
INTRODUCTION
Many variations in transplanting techniques are used by various
physicians viz graft sizes, patterns, intervals between sessions,
*
This report was presented by Dr. Walter P. Unger at the Annual Meeting
of the American Academy of Dermatology, Dallas, Texas, December
Figure 9E-19 Primary inosculation continued —at approxi- 1977, and the Annual Meeting of the American Society for Dermatological
mately 7 days, with (x) increase in inflammatory and (y) increase Surgery, Hilton Head, March 1977. (Reprinted from Hair Transplantation,
in vascular connections. 1st edition, 1979)
‘‘differential’’ between the size of grafts and recipient sites, Study 2 Effect of Different-Sized Recipient Sites
etc. Individual approaches have been based on the impressions
of each operator as to which is the most productive. A more Table 2a records the hair yields in 4.5-mm grafts inserted into
objective evaluation, however, is possible: If the number of 4.5-mm, 4.0-mm, and 3.5-mm recipient sites, and Table 2b the
hairs in donor grafts are counted, and the grafts are placed into hair yields in 4-mm grafts inserted into 4.0-mm, 3.5-mm, and
recorded sites in the recipient areas, the efficiency of any given 3.0-mm recipient sites. Study grafts were located at similar sites
technique can be assessed by counting the number of hairs that within any given pattern in an attempt to minimize the effect
regrow. In addition to investigating a group of specified vari- of differences in blood supply and were inserted at approxi-
ables, ‘‘hair counts’’ were used to study several currently ac- mately 30 minutes.
cepted concepts in hair transplanting. Hair yields in both 4-mm and 4.5-mm grafts appeared to be
This is a report of my findings. In some cases, the numbers better when a 0.5-mm differential was used compared with the
of patients studied were sufficient to yield what are probably yield when no differential or a 1 mm differential was used. Not
valid conclusions. In other cases, the studies did not include enough patients were included in this study nor were results
enough patients for this, and it is hoped that this report will different enough to draw valid conclusions. Further investiga-
stimulate some of the readers to do similar studies. Their results tion is needed.
can then be added to mine and, ultimately, a sufficient number Cosmetic factors, other than hair yields, must be considered.
of patients will have been studied to yield valid conclusions. Most operators have found it necessary to use 0.5-mm to 1-
mm differentials (depending on the patients) in order to avoid
empty rings of scar tissue around each plug. I find that a 0.75-
Study 1 Effect of Rapid Transfer of Grafts from the mm to 1-mm differential best avoids these hairless rings in most
Donor Area to the Recipient Area patients. Although such differentials are used in cosmetically
Table 1 shows hair counts seen in 4.0-mm grafts that were strategic areas, such as the first two rows of the hairline and
transferred almost immediately from the donor area to 3-mm the center of the whorl at the vertex, a 0.5-mm differential is
sites in the recipient area; 30 minutes after their removal from used elsewhere.
the donor area; and 1 hour after their removal from the donor
area. The grafts that were transferred ‘‘immediately’’ actually Study 3 Using Donors from a Nevus Flammeus
were transferred approximately 2 minutes after their removal,
(i.e.), after they had been properly cleaned. Table 3 records the hair counts in grafts taken from a nevus
Essentially no difference was noted in hair yields, regardless flammeus. The hair yield appears to be the same whether the
of whether they were transferred ‘‘immediately,’’ after 30 mingraft is obtained from a nevus flammeus or normal skin. The
utes, or after 1 hour. depth of color of the grafts tended to decrease after their transfer.
Table 1 Effect of Speed of Transfer of Grafts from the Donor Area to the Recipient Area
No. of hairs No. of hairs No. of hairs

Original that grew in that grew in that grew in
hair count grafts transferred grafts transferred grafts transferred
Patient in each immediately after 30 minutes 60 minutes
No. graft removal and cleaning after removal after removal
1 16 12 16 16
2 14 12 14 15
3 16 16 17 18
4 14 12 6 8
5 12 13 12 12
6 16 8 16 13
7 12 11 14 15
8 20 20 19 15 (read at 3 months)
9 14 9 14 12
10 12 8 14 16
11 16 12 15 18
12 16 16 12 13
13 14 15 18 14
14 14 9 14 12
15 12 11 14 15
Four-millimeter grafts were inserted into 3-mm recipient holes; read at 4 months except where indicated.
Comments: Ten 60-minute delays produce a better yield than immediate transfer. Five 60-minute delays produced a worse yield.
Conclusion: Essentially no difference was noted in hair yields, regardless of whether they were transferred “immediately” after cleaning, after 30
minutes, or after 1 hour.
296 Chapter 9
Table 2a Effect on Hair Yield of 4.5-mm Grafts Being Placed in Different-Sized Recipient Sites
Recipient hole size

Patient Original No. of hairs
No. in each graft 4.5 mm 4.0 mm 3.5 mm
1 20 23 25 20
2 16 15 7 8
3 16 14 16 15
4 19 13 19 16
5 25 28 24 25
6 21 20 22 20
7 24 12 16 19
8 16 14 16 15
9 21 19 19 19
10 16 15 7 8
11 18 9 24 20
12 14 20 13 12
13 24 25 20 22
14 9 10 11 9
15 14 11 9 8
16 12 13 15 11
Grafts were inserted 30 minutes after removal from donor area; read at 4 months. Comments: 0 differential between size
of donor punch and recipient punch best in 6, worst in 5; 0.5-mm differential between size of donor punch and recipient
punch best in 8, worst in 3; 1.0-mm differential between size of donor punch and recipient punch best in 1, worst in 4.
Conclusion: The 0.5-mm differential best; 0 differential second best.
Erythematous grafts became pink and pink grafts often became were 4 mm in diameter and were inserted into 3-mm sites at
skin-colored. approximately 30 minutes.
In seven patients who had those in three row patterns, yields
Study 4 Insertion of Grafts on Different Rows in the third row were as good or better than those in the first
Within a Given Pattern row in three patients (46%). In the four row patterns, yields in
the fourth row were as good or better than those in the first
Table 4 records the number of hairs per graft on different rows row in one patient (10%). Although hair growth was still quite
within a ‘‘U’’-shaped pattern (see Fig. 24, 1979 text). Grafts good in the fourth row, these results suggest a diminishing re-
Table 2b Effect on Hair Yield of 4.0-mm Grafts Being Placed in Different-Sized Recipient Sites
Recipient hole size

Patient Original No. of hairs
No. in each graft 4.0 mm 3.5 mm 3.0 mm
1 16 15 12 15
2 20 21 25 18
3 14 15 15 10
4 14 15 17 15
5 14 13 19 16
6 18 18 20 16
7 10 10 12 10
8 13 15 14 9
9 16 18 16 16
10 14 15 17 15
11 14 11 14 15
12 14 15 15 10
13 14 10 15 11
14 18 22 21 17
Grafts were inserted 30 minutes after removal from donor area; read at 4 months. Comments: The 0 differential best in
3, worst in 3; 0.5 differential best in 5, worst in 1; 1.0 differential best in 1, worst in 6.
Additional comments: Study grafts were located at similar sites within any given pattern in an attempt to minimize the
effect of differences in blood supply.
Conclusion: The 0.5-mm differential best; 0 differential second best.
Table 3 Hair Growth in Donor Grafts Taken from a Nevus Flammeus
No. of hairs in
Original No. transplanted grafts
Patient of hairs in 4 months after
No. graft transplant Color of healed graft
1 14 14 Normal color
2 14 15 Erythema (less than original)
3 8 7 Normal color
4 8 7 Normal color
5 10 11 Erythema (less than original)
6 12 11 Erythema (less than original) (4 into 3.5)
7 14 14 Normal color
Four-millimeter grafts were inserted into 3.0-mm recipient sites 30 minutes after removal from donor area.
Comments: Hair growth in donors from a nevus flammeus is good. Color appears to become paler and often normal if the original color
was not markedly erythematous.
turn as the number of rows increases. I have begun an additional excellent regardless of whether 4-mm or 4.5-mm grafts are
study in order to test this result. In addition, it would be worth- used, although more of the 4.5-mm grafts had less than 100%
while to see some figures from one of our colleagues who does survival than did the 4-mm grafts.
five rows or more per session. Four-row patterns may sound
limiting to some operators, but, in fact, rather large areas can
still be transplanted in a reasonable length of time if sessions COMMENTS
are properly planned (see Plate, 8A, B, page 41, 1979 text).
Hair count studies should be conducted using careful direct
Study 5 The Use of Different-Sized Grafts visual counts, preferably with the aid of magnifying equipment,
and/or by photographic means described by Rolf Nordstrom
Table 5 records the hair counts in 4-mm and 4.5-mm grafts, (1976).
transplanted at 30 minutes, using 1-mm differentials between There are some disadvantages of both direct and photo-
donor plugs and recipient sites. Hair survival appears to be graphic techniques. Photographs do not provide three-dimen-
Table 4 Effect of Insertion of Grafts on Different Rows within a Given Pattern
Original No. No. of hairs in No. of hairs in No. of hairs in No. of hairs in
Patient of hairs in graft in graft in graft in graft in
No. each graft first row second row third row fourth row
Four-row pattern:
1 16 16 16 21 14
2 14 13 15 15 18
3 18 21 18 17 20
4 16 13 12 12 12
5 16 18 12 19 17
6 15 19 14 14 15
7 16 13 12 12 12
8 16 17 15 17 16
9 16 16 16 18 14
10 24 22 16 25 21
Three-row pattern:
1 20 20 19 20
2 20 21 18 20
3 14 14 16 15
4 19 19 19 17
5 16 20 16 12
6 16 23 15 17
7 18 20 19 20
Four-millimeter grafts were inserted into 3-mm recipient sites 30 minutes after removal from the donor area; read at 4 months.
298 Chapter 9
Table 5 The Use of Different-Sized Grafts
4.0-mm grafts inserted into 4.5-mm grafts inserted into

3.0-mm recipient sites (at 30 minutes) 3.5-mm recipient sites (at 30 minutes)
Original No. No. of hairs in Original No. No. of hairs in

Patient of hairs graft 4 months % of hairs graft 4 months %
No. per graft after transplant Yield per graft after transplant Yield
1 16 16 100 14 17 100⫹
2 16 7 43.8 14 15 100⫹
3 13 14 100⫹ 21 22 100⫹
4 10 12 100⫹ 14 13 92.8
5 18 20 100⫹ 25 24 96
6 14 15 100⫹ 18 24 100⫹
7 26 32 100⫹ 30 39 100⫹
8 16 16 100⫹ 24 20 91.7
9 12 15 100⫹ 9 11 100⫹
10 14 9 65 12 11 91.7
11 14 16 100⫹ 19 19 100⫹
Comments: The 4-mm and 4.5-mm grafts give excellent yields, although more of the 4.5-mm grafts gave less than 100% yields than did 4.0-mm grafts.
sional pictures, and hairs that are behind other hairs at any given though from an aesthetic point of view, 1-mm differen-
angle may not be caught by the camera. In addition, wet hairs tials may be better at some sites).
stick together and, for example, if two or three hairs emerge 3. Grafts from a nevus flammeus produced good hair
from a single follicle, photographs may suggest a single hair growth and tended to become paler in their new site.
where more than one exists. On the positive side, there are no 4. U-shaped patterns of up to four rows produced adequate
other potential areas of error. hair yields in all grafts, although there was a suggestion
The hair counting is very tedious when using the ‘‘bare eye.’’ of a diminishing return on hair from three-row to four-
It is easy to get impatient and sloppy. The problem of wet row patterns.
hair clinging together is still difficult to surmount, although an 5. Percentage hair survival was excellent in 4-mm and 4.5-
accurate count is at least more possible than may be obtained mm grafts using 1-mm differentials, although more of
with photographs. Even so, the frequent occurrence in this re- the 4-mm grafts had 100% survival than did 4.5-mm
port of larger yields than original counts is, I believe, to a signifi- grafts.
cant extent due to this phenomena. In addition, the growth of
more hairs in some grafts than were originally counted, can be
explained by the presence of one or two hairs per graft that
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10
Donor Harvesting
10A. The Donor Area Bernstein introduced the important concept of hair volume (3).
Collectively, their work laid the foundation for the scientific
Walter P. Unger and John Cole assessment of the donor area and more accurate predictions of
anticipated coverage. Unfortunately, despite the efforts of these
INTRODUCTION pioneers, few physicians seem to recognize the importance of
accurate donor area measurements.
This chapter was cowritten by Walter Unger and John Cole.
Donor area management may be broken into the following
Both authors refer to themselves in the third person at various
components: delineation of the SDA, physical examination of
points in the chapter because their views and practices are not
the safe donor and recipient areas, method of harvesting and
always the same. References to ‘‘Unger’’ and ‘‘Cole’’ should be
closure, subsequent procedures, efficiency of technique, and
understood to represent the views of only that coauthor unless
complications. The current knowledge about each component
otherwise indicated. In addition, both authors contacted many
is presented in this chapter, but it must be emphasized that each
practitioners privately, and their opinions have been presented
component requires further study.
as private communications after their approval was obtained.
Perhaps the most important factors in predicting successful
hair restoration surgery are appropriate selection of the patient THE SAFE, OR PERMANENT, DONOR AREA
by the physician and of the physician by the patient. There are
four elements to this selection process: understanding of the This subject was presented in the third edition of Hair Trans-
patient’s goals, physical examination of the patient, ability of plantation, edited by Unger, and is reproduced here with slight
the physician to meet the patient’s goals, and acceptance of the alterations. It retains its importance without need of significant
physician’s abilities by the patient. Three of these elements change:
involve communication skills and a psychological or personal The objective in all patients is obviously to use only donor
assessment, but they are meaningless without a physical exami- hair that would have been permanent in its original site. What
nation of the patient’s recipient and potential donor areas; this is less obvious is how one can be certain of this likelihood. In
examination is, in fact, the basis of a scientific approach to hair the second edition of this textbook, Alt suggested that a line
restoration surgery. This chapter deals with the examination drawn perpendicularly from the external auditory canal should
and management of the donor area. Every donor region has define the anterior border of this safe area. The superior border
specific characteristics that allow the informed hair restoration was a more complicated affair, however. In most patients, the
surgeon to customize an approach to the individual patient. SDA began on the anterior border, which was 6.5 cm to 7.0
Failure to recognize these individual characteristics does not cm wide, with steady narrowing in the posterior direction. Alt
always doom the hair restoration process, but it does limit the believed that the ultimate donor area was substantially narrower
physician’s ability to control it precisely. in the midline of the occipital area than in the area superior to
At one time, few truly objective findings were included in the external ear. (This is contrary to the findings of Unger,
the assessment of the donor area. This is no longer the case. Alt, which are discussed later.) Alt suggested that a horizontal line
Unger, Rassman, and Bernstein can be considered the fathers of be drawn from a point 2 cm superior to the reflection of the
modern donor area assessment. Alt and Unger researched the skin of the external ear and the scalp. He chose the point at
limits of the safe donor area (SDA) (1), whereas Unger, in which this horizontal line intersects the midline of the occiput
addition, championed the concept of multiple donor sites for as the superior border of the SDA at that location (Fig. 10A-
variations of hair caliber and color. Rassman introduced physi- 1). He noted that it was obvious in some patients that the donor
cians to the need for accurate measurement of donor hair density area might be wider or narrower at various points, but he be-
and an accurate quantification of the available donor area (2). lieved that the foregoing perimeters would be valid for most
301
302 Chapter 10
Figure 10A-1 Alt’s safe donor area.
individuals. In addition, he counseled—and we agree—that at how much of the temporal area (or other areas) can be used.
least 2.5 cm of unharvested permanent hair should be left supe- The older the patient, the more confident one can be. However,
rior to the most superior donor areas to provide adequate long- Unger and others are grateful that many other surgeons appear
term camouflage of scar lines. to have agreed with Alt’s advice. The temporal areas are often
When deciding on the inferior border of the donor area, it a largely untouched reserve of donor tissue in patients seen for
is wise to remember that male pattern baldness (MPB) also repair of transplanting done by others.
affects the inferior aspects of the rim hair; therefore, an unhar- In 1995, Unger reported on a study of 328 men aged 65 years
vested margin of safety should be left at this level as well as or older (1). The patients were subdivided into the following age
superiorly. Inferior thinning occurs later and less markedly than groups: 65 to 69 years, 70 to 74 years, 75 to 79 years, and older
thinning elsewhere, but it is generally accepted that it usually than 80 years. The degree of alopecia (types I to VII Hamilton/
does not occur to a cosmetically significant degree inferior to Norwood) was noted for each patient (Table 10A-1). Accept-
a line drawn horizontally from the inferior reflection of the skin able donor sites in these individuals included only areas contain-
of the external ear and the scalp to the midline of the occipital ing eight hairs or more per 4-mm diameter circle. The widest
area. A decision should be made about the inferior border after inferior-to-superior measurements of zones containing this hair
the patient’s age, family history, and findings on physical exam- density were recorded in temporal and parietal areas as well as
ination (see later) are taken into account, but if Alt’s superior in the midline of the occipital area. In individuals with type I
border is accepted as the SDA, what remains in many cases is
or type II alopecia, the height of the donor area was arbitrarily
only a 20-mm width of usable donor tissue as the ultimate safe
limited to that of the individual with the greatest height in type
area.
III MPB. In addition, acceptable density found in the area ante-
There are no substitutes for taking a careful history of the
rior to Alt’s safe anterior border was noted and recorded under
extent of baldness in family members and for carefully examin-
ing a prospective patient’s scalp for evidence of areas of future the title ‘‘anterior.’’
thinning. Wetting the hair is especially useful in delineating The findings of Unger’s study can be viewed from the van-
areas that may be affected by MPB in the future. Bernstein and tage point (1) of all men in the sample or (2) focussing on the
Rassman have also recommended densitometry to identify the majority, who would most likely have been treated by a trans-
early changes associated with genetic balding. More is said plant surgeon. The latter group might reasonably have excluded
about this later. The younger the patient, the wiser it is to keep those with type I and type II MPB (although there are occasional
within the borders suggested by Alt. Later in this chapter, how- exceptions), and, if meaningful results were to be produced for
ever, we discuss how such a course represents ultimate safety most of the patients, this group might have excluded all type
but is overcautious to a substantial degree for a large majority VII candidates also. Why? If Table 10A-1 is analyzed and pa-
of patients. In particular, for more than 33 years, Unger has tients with type I and type II MPB are excluded from the sample,
often gone farther anteriorly in the temporal area than Alt’s 57 of the remaining 69 patients (82.6%) in the age group be-
safe anterior margin (1). Age is an important factor in deciding tween 70 and 74 years of age, have type III to type VI MPB,
Donor Harvesting 303
Table 10A–1 Unger’s Study
Age (years)
Type 65–69 70–74 75–79 80
I 2 (3.6%) 5 (6.2%) 4 (5.5%) 2 (1.7%)

II 9 (16.4%) 7 (8.6%) 7 (9.6%) 12 (10.1%)
III 4 (7.3%) 15 (18.5%) 18 (24.7%) 11 (9.2%)
IV 10 (18.2%) 16 (19.8%) 8 (11.0%) 10 (8.4%)
V 6 (10.9%) 7 (8.6%) 10 (13.7%) 16 (13.4%)
VI 13 (23.6%) 19 (23.5%) 16 (21.9%) 37 (31.1%)
VII 11 (20.0%) 12 (14.8%) 10 (13.7%) 31 (26.1%)
Total 55 (100%) 81 (100%) 73 (100%) 119 (100%)
Note:
• In age group 65–69 years, if one excludes type I and type II, 33 of the remaining 44 (75%) have types III to type VI (83.3%
Norwood);
• In age group 70–74 years, if one excludes type I and type II, 57 of the remaining 69 (82.6%) have type III to type VI (82.8%
Norwood);
• In age group 75–79 years, if one excludes type I and type II, 52 of the remaining 62 (83.9%) have type III to type VI;
• In age group 80 years, if one excludes type I and type II, 74 of the remaining 105 (70.5%) have type III to type VI (74.0%
Norwood).
and 52 of the remaining 62 patients (83.9%) in the age group also give an extremely reliable SDA for more than 80% of
between 75 and 79 years of age, have type III to type VI MPB. patients (younger than age 80 years). This donor area would
It is noteworthy that (1) the average life span of a man in more or less resemble a parallelogram (1) in the parietal-occipi-
most parts of the world is less than 80 years of age; (2) more tal area, whose inferior border might be chosen by the surgeon
than 80% of the men between 70 and 79 years of age who based on such factors as 10 or more hairs per 4-mm diameter
would likely be treated by transplant surgeons have type III to circle, patient age, and family history. (A density of 10 hairs per
type VI MPB (the percentage drops to 70.5% in the group aged 4 mm would provide a ‘‘cushion,’’ allowing for a subsequent
80 years or older but still represents a substantial majority); decrease in density with aging to eight hairs per 4-mm diameter
and (3) if patients with type I and type II MPB were included, circle). The number of hairs per 4-mm diameter circle could
the percentage of patients with less than type VII MPB would be increased to approach the entire donor area in an even more
be even higher. These figures should provide some comfort to conservative fashion. The superior border of the parallelogram
many practitioners who have feared that a majority of their would similarly contain at least 10 hairs per 4-mm diameter
patients would progress to type VII MPB before they died. Al- circle and would angle somewhat inferiorly, parallel to the post-
though there is no way to accurately predict every individual auricular superior hair margin, in the direction from the anterior
who will fall into the type VII group—no matter how small it to the midoccipital borders. A narrower delineation, shaped
is—it therefore appears inaccurate to make this assumption for more or less like a parallelogram, would sit on the inferior one,
more than 80% of MPB patients. If all of them were treated as with its posterior border beginning in the midparietal area. Its
if their MPB were going to evolve to type VII, this would be anterior border might be 28.6 mm anterior to a line drawn verti-
patently unfair. There is no doubt that MPB is progressive over cally from the tragus and would be parallel to the anterior tem-
the lifetime of any patient. What should be reassuring is that a poral hairline unless there were good reason to suspect that the
smaller than expected minority live to reach type VII MPB. area anterior to the tragus would not remain sufficiently dense
Table 10A-1 outlines the findings from the vantage point of over the long term (1). This superior parallelogram would be
all 328 subjects in the study: 55 aged 65 to 69 years; 81 aged
70 to 74 years; 73 aged 75 to 79 years, and 119 aged 80 years
or older. Table 10A-2 outlines the findings from the vantage
point of those with type III to type VI MPB, who make up Table 10A–2 Average Height (mm) of Acceptable Donor
approximately 80% of the patients. A total of 216 patients were Area (the 216 Patients with Types III, IV, V, VI MPB)
in these categories: 33 were aged 65 to 69 years, 57 were aged
70 to 74 years, 52 were aged 75 to 79 years, and 74 were aged Age (yr) 65–69 70–74 75–79 80
80 years or older.
Anterior 32.99 23.76 29.13 21.57
There are many ways to use the figures shown in the tables Temporal 79.71 54.76 62.47 58.70
as delineators of an SDA. For example, the lowest numbers for Parietal 96.72 75.84 79.32 80.55
each parameter could be selected, regardless of the age group Occipital 85.66 60.00 69.39 62.41
in which they occur. These numbers would designate the safest
SDA but would also be far more restrictive than the large major- Average figures for ages 65–79 years: anterior 28.6; temporal 65.6;
ity of patients would require. The findings in patients aged 65 parietal 84.0; occipital 71.7.
to 79 years could also be averaged (Table 10A-2). This would MPB male pattern baldness.
304 Chapter 10
Table 10A–3 Incidence of Male Pattern Baldness in 1000 Men by Type and Age (Norwood)
Age (yr)
Type 18–29 30–39 40–49 50–59 60–69 70–79 80
Type I 110 (60%) 60 (36%) 55 (33%) 45 (28%) 29 (19%) 18 (17%) 12 (16%)

Type II 52 (28%) 43 (26%) 38 (22%) 32 (20%) 24 (16%) 20 (19%) 11 (14%)
Type IIIa 14 (6%) 30 (18%) 37 (20%) 34 (23%) 22 (15%) 16 (16%) 12 (16%)
(3V) (15V) (15V) (10V) (7V) (8V)
Type IV 4 (3%) 16 (10%) 15 (10%) 21 (9%) 17 (12%) 13 (13%) 9 (12%)
Type V 3 (2%) 10 (6%) 13 (8%) 15 (10%) 22 (15%) 13 (13%) 9 (12%)
Type VI 2 (1%) 4 (3%) 7 (4%) 10 (7%) 19 (13%) 11 (11%) 10 (13%)
Type VII 0 2 (1%) 5 (3%) 4 (3%) 16 (10%) 11 (11%) 14 (17%)
Total 185 (100%) 165 (100%) 165 (100%) 156 (100%) 149 (100%) 102 (100%) 77 (100%)
a
Numbers in parentheses under type III represent type III vertex individuals.
10 mm high—also subject to clinical findings and family his- donor material if necessary. Although eight hairs per 4-mm
tory. Its superior border would drop somewhat inferiorly as it diameter circle might be a wise minimum if standard grafts
progressed posteriorly to meet the midline point of the occipital were being harvested, transplanting with standard grafts has
SDA. A third way of using Table 10A-2 would be to use the essentially ceased to exist. A minimum requirement of eight
figures for patients aged 75 to 79 years and the dimensions hairs per 4-mm diameter circle is probably too high a minimum
shown in Fig. 10A-2. This is the SDA that we prefer, because density if one is using strip harvesting for follicular unit trans-
it seems to be a good compromise between caution and over- planting (FUT) and micro-minigrafting. In such cases, one is
caution. As is shown later in this chapter, the SDA shown in usually looking for grafts containing only one to six hairs, and
Fig. 10A-2 is more than sufficient to provide for as many as the physician can simply increase the width of the strips to
six sessions, if donor strip widths are 10 mm or less. Sur- produce the desired number of follicular units (FUs) or mini-
geons, however, must be free to choose their own balance and grafts. Thus, the acceptable donor area for strip harvesting for
their own SDA, using the figures provided in Tables 10A-1 to FUT and micro-minigrafting is almost always larger than that
10A-3. suggested by the figures noted.
It is important to point out that this design incorporates per- Unger believes that if (1) alopecia reductions (ARs) or scalp
manent hair whose long-term density would be eight or more extensions, (2) total excision techniques in donor area harvest-
hairs per 4-mm diameter circle. However, according to this ing as described in this chapter, and (3) FUT or micro-minigraft-
study, less dense permanent hair would persist superior and ing (to produce less dense coverage that looks natural) are com-
inferior to these boundaries in virtually all patients. Some of bined, that with appropriate planning, there can be a reasonable
this less dense hair, in some patients, could be used as additional expectation for satisfactory treatment of the entire area of MPB
in a majority of patients. This is a remarkable advance from
the treatment options available in the early 1990s. Unger’s posi-
tion is intentionally provocative and will, no doubt, lead to much
debate. Key requirements are AR, reasonable patient density
objectives, a well-experienced surgeon, and a staged treatment
of the recipient area, with use of no more donor tissue in any
region than is absolutely necessary to satisfy the patient.
It is also important to emphasize that a family history and
clinical examination are necessary to confirm that the bounda-
ries of the proposed SDA are likely to apply to the individual
being treated. One should always err on the side of caution.
For example, 14 of Unger study patients did not have acceptable
donor area density anterior to the tragus. In a very few cases,
narrower parallelograms would be more appropriate, or the pa-
tient might not have an acceptable donor area. On the other
hand, in many more patients, wider parallelograms would be
warranted. The boundaries noted earlier are not intended as
perfectly safe for all patients but represent the implications of
the only objective scientific evaluation ever made in this area.
Based on that investigation, these boundaries would be very
Figure 10A-2 Unger’s safe donor site for 80% of patients under safe in approximately 80% of patients younger than 80 years
the age of 80 years, as determined from studies of 328 men aged of age. More restrictive areas can be chosen, for example, if
65 years or older. one prefers to plan for patients who might live to be 80 years
old or more, or if the patient has a father or maternal grandfather examination of the recipient area must also be conducted. This
with type VII MPB. It bears repeating that the older the patient, examination, like that of the donor area, should include an as-
the more certain one can be of the SDA. sessment of such things as the shape, size, and asymmetry of
the recipient areas as well as the degree of hair loss and the
state of any previous hair restoration surgery. In this regard, it
PHYSICAL EXAMINATION is important also to note that a circle and a square with the
same circumference have markedly different surface areas. The
There are several functions of the physical examination: (1) It surface area of the circle is much larger. Therefore, as the cir-
should support the diagnosis of androgenetic alopecia. (2) It cumference of a more or less round or oval alopecic area in-
should qualify the patient for hair restoration surgery. (3) It creases, it has an exponential effect on its surface area. Although
should allow the surgeon to estimate the total amount of mova- predicting coverage with 100% accuracy is not currently possi-
ble hair, the maximum width of excision for any particular pro- ble, a thorough examination establishes realistic expectations.
cedure, and the amount of donor tissue required for a particular Future work should, therefore, focus on improving methods of
procedure. (4) Finally, the physical examination gives the sur- objective evaluation and calculation of both donor and recipient
geon the opportunity to assess the impact of prior hair restora- areas.
tion surgery. The evaluations should ideally include donor hair
density (one or more areas), hair shaft diameter (one or more
areas), scalp laxity, thickness of the scalp, degree of hair loss, DONOR AREA HAIR DENSITY
hair color, skin color, hair wave, curl or ‘‘frizz,’’ appearance
of existing grafts, and results from any previous ARs, percent- There are three different densities that should be considered in
age of miniaturized hairs, and percentage of telogen hairs. (The donor area assessments. The first, hair density, is the number
percentage of telogen and miniaturized hairs is obtained when of hairs in a given surface area of scalp. The second is the
a strip of hair-bearing scalp is excised from the scalp and exam- number of hairs per FU, or the calculated density (see Chapter
ined with 6x to 10x magnification). According to Bernstein and 11 for a description of the FU). This is not measured directly,
Rassman, measuring the percentage of miniaturized hair in the but is an average of the number of hairs per FU as calculated
donor region has great practical value. In their opinion, the in a manner that is described later. The third is the number of
measurement can provide early identification for those patients FUs in a given surface area, known as follicular unit density
who are at risk of having their conditions evolve into diffuse (FUD). Each parameter reveals specific information and assists
unpatterned alopecia (DUPA) and therefore can identify those in customizing the procedure to the individual patient.
persons who would not be good candidates for hair transplanta-
tion. Bernstein and Rassman believe that miniaturization in the Hair Density
donor area greater than 20%, in a person younger than age of
30 years portends a significant risk for DUPA and extensive Many physicians subjectively assess the amount of donor area
hair loss in both the donor and recipient areas (2,3). Bernstein hair by simply combing the hair apart at various points in the
had had a more than 6-year follow-up record of a group of proposed donor area and making an estimate based on previous
patients younger than the age of 23 years, all of whom had experience. However, it obviously is much more accurate and
experienced 30% or more of miniaturization and all of whom meaningful to objectively measure the previously noted hair
had had rapid loss of large amounts of their hair when we last densities. There are several commercially available instruments
contacted him. Bernstein thinks that the recognition of a high to measure hair density. These include the Rassman densitome-
miniaturization rate as a reliable indicator of a poor prognosis ter (Fig. 10A-3), the Welch Allyn trichoscope, and the Kahn
is one of the most important contributions he and Rassman have densitometer. The viewing surface area of the Rassman densi-
made to the theory of hair transplantation practice. Time will tometer is approximately 10 mm2, whereas the Welch Allyn
tell how high the percentages must be to be as reliable as they and Kahn instruments are 12.56 mm2. It is, therefore, easier to
judge them to be. Keeping track of all of the parameters men- convert the density to hairs per mm2 with the Rassman densi-
tioned allows for the development of the most scientific evalua- tometer. The number of visible hairs in the 10 mm2 surface
tion of donor tissue potential but, unfortunately, at present, few area is simply divided by 10. For instance, if 21 terminal hairs
practitioners carry out this type of record keeping in its entirety. are counted, the density is 2.1 hair/mm2. The Rassman densi-
Each element of the record is discussed separately in this tometer also contains a light source and magnification, making
chapter. it easier to count hairs. This instrument is available at Radio
The size and symmetry of the head can also impact the proce- Shack (30x Microscope, Cat No. 63–851). The Kahn densitom-
dure significantly. Asymmetry, for example, may have a posi- eter has the same magnification as the Rassman densitometer.
tive, negative, or neutral impact. A head that is large in the However, it has no light source, and because the viewing area
donor area relative to the recipient area may positively affect is larger, there are more hairs to count. The latter two factors
the donor-to-recipient area ratio, whereas a broad forehead reduce the probability of an accurate hair count. It should be
without a correspondingly large donor area would have a nega- noted that all densitometers are commercially produced and not
tive influence on this ratio. It should be clear from the preceding subject to strict scientific standards of manufacturing. There-
information that although this chapter focuses on the donor area, fore, it is possible that the viewing orifice is slightly different
examination of the donor area alone without examination of than presumed. Physicians should verify the surface areas of
the recipient area at the same time does not provide sufficient their densitometers before incorporating them into their prac-
information. Therefore, if one wants to accurately predict what tice. More recently, a number of other dermatological instru-
can be accomplished with hair restoration surgery, a careful ments have been developed that can be used to measure density.
306 Chapter 10
Figure 10A-3 The Rassman Densitometer.
The most expensive and technically advanced instruments use Franklin plane, they are located in the (1) midsagittal plane at
electromagnetic waves and advanced computer programming the occipital protuberance, (2) 3 cm superior to the reflection
to count surface structures. of the helix on a line drawn superiorly from the external auditory
Over the years, many physicians have attempted to deter- meatus, and (3) at a point halfway along the line connecting
mine the average hair density in the donor area (4–8). Unfortu- points 1 and 2 over the ipsilateral mastoid. This line is generally
nately, there is wide variation in their findings. The difference in between 14 cm and 15 cm long, putting the midpoint between
values results from the difficulty in counting hairs, the extreme 7 cm and 7.5 cm from either end-point. The three reference
difficulty in measuring a defined surface area, and a lack of points serve as sites for all density measurements reported in
standardization in the method—for example, how many sites this chapter and are an attempt to standardize the examination
are examined and their locations. Table 10A-4 notes the differ- of the donor area.
ences in hair densities reported by various investigators: Using a Rassman densitometer, Cole measured hair density
Hair density usually decreases toward the ear and increases and diameter and FU density in the aforementioned three refer-
toward the occipital area in most individuals (see later). Theo- ence points in 40 patients. He then calculated the hairs per FU
retically, therefore, an excision of a donor area from the occipi- and calculated density in each region. Table 10A-5a summa-
tal area exclusively would contain much more hair than would rizes his findings, which confirm that hair density and FU den-
be harvested from the usual donor area. Bernstein recommends sity in virgin donor areas are generally highest in the midoccipi-
measurement of density 5 cm lateral to the midoccipital region tal region and least in the supra-auricular area. The density in
(8). Cole recommends measurement of density over the mid- the midmastoid area is usually somewhere between these two
mastoid area if a single site is assessed. This region is roughly measurements. He also studied round grafts obtained with a 4-
halfway between the occipital protuberance and the auricle. The mm punch. His findings are summarized in Table 10A-5b. The
measurement assumes that the surgeon will remove a donor surface area of round grafts varies with the angle of hair growth
strip extending from near the ear to a line drawn vertically in the area from which it is taken, because the punch should be
through the occipital protuberance (either unilaterally or bilater- angled to match it and therefore minimize follicle transection.
ally). However, because hair density varies from the midoccipi-
tal region to the supra-auricular area, it is more accurate to Rassman and Bernstein suggest that the SDA in an indi-
measure density in more than one location along the proposed vidual with straight hair of average diameter and average
strip; a minimum of three locations is recommended. These density corresponds to approximately 25% of the scalp
three points are called reference points. With the head in the and that only half the donor area can be removed without
excessive depletion (2,3). They also contend that the hair-
bearing scalp is 80 inches2, or 51,613 mm2, and that the
average scalp contains approximately two hairs per mm2.
Table 10A–4 Hair Densities According to Different Thus, the average scalp contains approximately 100,000
Physicians hairs (51,613 mm2 ⳯ hairs per mm2). Based on these
measurements, they have proposed Table 10A-6 for
• Wilson: 1.54 hairs per mm quantifying the effect of donor area hair density on the
• Pecoraro et al: 1.75 to 3.0 (occiput 2.4 hairs per mm2) number of hairs that are available for transplanting. This
• Cottington et al: 2.11 hairs per mm2 in the left temporal area table is useful in helping physicians and patients to un-
• Nordstrom: 1 to 2.4 hairs per mm2 (average 1.8 hairs per mm 2) derstand the limitations of donor areas and to the impor-
• Stough and Haber: 1.44 to 1.76 hairs per mm2 (average) tance of customizing the approach for each individual.
• Rassman and Carson: 2.0 hairs per mm2 (average density) Range The information provided in this table should not, how-
1 to 4 hairs per mm
ever, be construed as absolutely accurate or obligatory
• Jimenez and Ruifernandez: 1.24 to 2.00 hairs per mm2
for any single individuals because it is based on several
• Cole: 1.9 to 2.1 hairs per mm2 (average mastoid density)
assumptions and averages. In addition, as discussed pre-
Table 10A–5a Hair Density, Hair Diameter and FUD at the “Reference Points” Noted in the Text
Left supra-auricular Right supra-auricular

point Left mastoid Inion Right mastoid point
Density in mm2 1.8 2.1 2.4 2.1 1.8

Follicular 8.2 8.7 9.9 8.6 8.1
groups/10 mm2
Diameter in m 73.5 78.5 72 76.6 73.5
FUD Follicular unit density.
Table 10A–5b Findings in Round Grafts Obtained from 40 Patients with a

Trephine That Has a 4-mm diameter (Cole)
Average densities of hair in donor area
Terminal hairs/FU (hair/FU) 1.56–2.34 hairs/FU

Follicular Unit Density (FUs/mm2) .76–1.14 FU/mm2
Terminal hair density (hairs/mm2)a 1.55–2.66 hairs/mm2
Total hair density (hair/mm2)b 1.79–3.09 hairs/mm2
Average Densities of Hair in 4-mm Punch Graft
Area of 4-mm punch graft (mm2)c 13.23–15.64 mm2
FUs/4-mm punch graft (FU/graft) 11.8–16.35 FUs/graft
Total hairs/4-mm punch graft (hairs/graft) 24.2–35.05 hairs/graft
Terminal hairs/4-mm graft (hairs/graft) 27.85–40.65 hairs/graft
a
Total terminal hair refers to only terminal hairs that are greater than 30 microns
b
Total hair includes both terminal hair ( 30 ) vellus hair ( 30 )
c
All mean surface areas of elliptical plugs are greater than the 12.57 mm2 of a 4 mm circle.
The more acute the angle of hair growth, the larger the surface area of the excised plug.
viously, great variations exist with regard to the size and or calculating, it is described later. This number represents the
shape of the scalp, the size of the permanent donor area, mean number of hairs a person will receive with each FU, with
and even the number of hairs/mm2. each graft containing multiple FUs and, therefore, the mean
number to be obtained with each procedure. For instance, if a
Calculated Density person averages 2.3 terminal hairs per FU and 1000 FUs are
transplanted, the patient will receive approximately 2300 hairs.
The average number of hairs in each FU, or calculated density The typical 2-mm2 graft (one that is placed into a hole made
(CD), is an important quotient. The method used in obtaining, with a 2-mm punch) contains between four and six FUs or
Table 10A–6 Donor Density: The Effect of Changes in Donor Area Hair Density on Movable Hair
Donor density Total hair in Hair must remain Moveable % Change in % Change in
hairs/mm2 permanent zone in permanent zone hair density moveable hair
1.0 12,500 12,500 0 50% 100%

1.3 16,250 12,500 3750 35% 70%
1.5 18,750 12,500 6250 25% 50%
1.8 22,500 12,500 10,000 10% 20%
2.0 25,000 12,500 12,500 0 0
2.2 27,500 12,500 15,000 10% 20%
2.5 31,250 12,500 18,750 25% 50%
2.7 33,750 12,500 21,250 35% 70%
3.0 37,500 12,500 25,000 50% 100%
Data from Bernstein R, Rassman W. 1999. The logic of Follicular Unit Transplantation. Dermatol Clin 17; 277–295.
308 Chapter 10
partial FUs, and 11 to 15 hairs (see Chapter 12). Hence, 100 Follicular Unit Density
grafts that are 2 mm2, averaging 2.3 hairs per FU and an average
of five FUs would transfer 1150 hairs. The CD also helps to The FUD is important because it helps to predict the number
define the size of each graft. As the number of hairs in each of FUs that will be transferred from a given amount of excised
FU increases, the size of the FU graft increases, whereas if donor tissue. To determine the FUD, count the number of FUs
grafts containing multiple FUs are being used to transplant a in the surface area of the densitometer. Extrapolate these num-
specific number of hairs per graft, this type of graft can require bers to a square centimeter. This value gives an estimate of the
fewer FUs to reach that number, and can, therefore, be smaller. number of FUs per square centimeter at that specific reference
Grafts containing more than one FU can also be smaller than point.
average if they are ‘‘cherry-picked’’ to include only sections If the strip is limited to the midoccipital area, it is necessary
of skin in which FUs are closer together than average (see Chap- to know only the FUD in the midoccipital area. Should the strip
ters 11 and 12). Furthermore, in FUT, this type of selection extend from the midoccipital region to the supra-auricular area,
allows the surgeon to customize the transplant by using FUs the average of the three FU densities at the three reference
containing different numbers of hairs in different locations (9). points referred to earlier should be taken. This number gives
The CD combined with a determination of the FUD (see later) a reasonably safe estimate of the number of FUs per square
also assists the surgeon in predicting the amount of tissue re- centimeter in the donor strip. The number of FUs in the tissue
quired from the donor area. proposed for excision can now be calculated. Suppose that the
The calculated density also predicts the ratio of FUs with a donor strip extends from a point 3 cm superior to the right
particular hair count. Table 10A-7a outlines how the percentage auricle at the external auditory meatus to the occipital protuber-
of natural FUs containing one to six hairs changes as the CD ance (with the head in the Franklin position) and suppose that
changes (10). Knowledge of the CD allows the surgeon to cus- the length of your the strip is 15 cm (see later). The density of
tomize the size of the receptor sites based on the anticipated hair in the midoccipital, midmastoid, and supra-auricular re-
number of natural FUs of a particular size. A low calculated gions is measured as 260 hairs per square cm, 210 hairs per
density predicts fewer grafts containing four or more hairs. In square cm, and 140 hairs per square cm, respectively. The FU
this case, the surgeon needs to cut grafts containing multiple density at each reference point is 100 FU/cm2 in the midoccipi-
FUs if a larger number of denser grafts are desired. Conversely, tal region, 80 FU/cm2 in the midmastoid region, and 60 FU/
the surgeon might consider individual FUs more appropriate cm2 in the supra-auricular region. The calculated densities in
when the calculated density is higher. the midoccipital, mid-mastoid, and supra-auricular areas are 2.6
Cole’s study found a distinct regional variation in the number hairs (H) per FU, 2.63 hairs (H) per FU, and 2.33 hairs (H) per
of natural follicular groups containing one, two, three, four, FU, respectively.
five, six, and seven hairs. The lowest percentage of natural The average number of FUs, or groups, in this 15-cm area
single hairs was found in the midoccipital area, whereas the is the average of the three FU densities (100 Ⳮ 80 Ⳮ 60)/3 or
highest percentage of natural singles was found in the supra- 80 FUs per square cm; a 15 cm strip yields approximately 80
auricular area. The majority of natural FUs containing three, FUs per square cm. A 15-cm strip excised with a two-bladed
four, or five hairs were found in the midmastoid and midoccipi- scalpel set at 1 cm between the blades therefore yields approxi-
tal regions. Cole’s findings in his 40 patients, on this matter mately 1200 FUs. If the average of the three calculated densities
and others, are summarized in Tables 10A-7b, 10A-7c, and (2.6 hairs per follicular unit [H/FU] Ⳮ 2.63 H/FU Ⳮ 2.33 H/
10A-7d. FU/3), or 2.52 H/FU, is taken, the number of hairs to be moved
Table 10A–7a Calculated Density and the Percentage of FUs Containing One to Six Hairs (Cole)
Number of hairs/FU
(Calculated density) One Two Three Four Five Six
1.4 59 41 0 0 0 0
1.5 47 52 8 0.2 0 0
1.6 45 47 1 0.2 0 0
1.7 38 53 9 0.3 0 0
1.8 34 53 13 1 0 0
1.9 30 52 16 2 0.02 0
2.0 26 51 20 3 0.1 0
2.1 22 51 22 5 0.1 0.02
2.3 18 47 25 10 1 0.06
2.4 15 44 29 10 1 0.2
2.5 14 41 29 14 2 0.4
2.6 11 38 31 18 1 0.5
2.7 11 36 32 14 4 2
2.8 9 32 33 19 6 1
Table 10A–7b Percentage of FUs with Different Numbers of Hairs/FU in

Different Areas of the Scalp
Percentage of Total Number of FU
No. of hairs/FU
Table 10A–7c Mean Terminal Hair Diameter in Different Areas of the Scalp
Table 10A–7d Mean Total Number of Hairs Compared to the Mean

Number of Terminal Hairs/FU
can be estimated. This formula involves multiplying the average obtain the number of FUs required to produce this number of
number of H/FU by the total number of FUs in the donor strip. single-hair grafts if all FUs are divided into single follicles.
In this case, the number of hairs is safely estimated at 2.52 H/ The number of FUs must be subtracted from the predicted total
FU ⳯ 1200 FUs or 3024 hairs. and the number of single-hair grafts must be added to determine
Suppose 300 single hairs are required from this tissue. If all the total number of grafts in the donor strips. In this case, 1200
single hairs are removed from the most medial region of the FUs ⳮ 115 FUs Ⳮ 300 single-hair grafts, or 1385 grafts, can
scalp, and the average number of H/FU in that area is 2.6 H/ be expected from the excised donor tissue. To this number must
FU, the number of desired single hairs may be divided by also be added the number of grafts and hairs from the tapered
midoccipital area calculated density (300/2.6 H/FU ⳱ 115) to ends. Generally, there are approximately 30 to 50 additional
310 Chapter 10
FUs in each tapered end, and these ends are usually mirror SUMMARY
images of each other. The length needed to optimally taper the
ends of the strip depends on the width of the strip. Bernstein In summary, hair density quantifies the number of hairs per
recommends that the length of the taper should be at least 1.5 unit of area. It suggests how many hairs and grafts are available
times the strip width to ensure that the ends of the closure lie from part or all of the donor area. A high CD suggests that FU
perfectly flat. If the trapezoid closure (described later in this grafts may be larger simply because they have more hairs as
chapter) is used, the two triangular ends can be combined to well as their associated perifollicular tissue, whereas grafts con-
form a rectangle. In the example we have used, the average taining multiple FUs may be smaller if a fixed number of hairs/
number of FUs from the two ends is (100 FU Ⳮ 60 FU)/2, or 80 grafts is desired or if such grafts are cherry-picked. Calculated
FUs. Therefore, approximately 1465 grafts (1385 Ⳮ 80 FUs), or density also suggests how many hairs are present in any size
3226 hairs, (1200 FUs ⳯ 2.52 hairs/FU Ⳮ 80 FUs ⳯ 2.52 graft. As noted earlier, despite all this potentially useful infor-
hairs/FU) can be anticipated. mation, few physicians currently measure hair density during
The following formulas are useful in understanding the three the donor area examination. The previous discussion is intended
types of density and estimating the total number of hairs trans- to provide a template for maximum accuracy for investigators,
ferred: but many clinicians would find such measurements and calcula-
tions cumbersome and too time-consuming (although they
Density ⳱ D ⳱ total number of a given surface area or could be assigned to a trusted assistant). An easier method for
(Hair/cm2) estimating the total number of hairs moved is to simplify the
equation by taking the average of the three densities and multi-
FUD ⳱ FD ⳱ total number of FUs in a given surface area
plying this by the surface area removed from the donor region.
or (FU)/(cm2)
In our example case, the surface area is 15 cm2 (plus the tapered
Calculated Density ⳱ CD ⳱ 兵(D)/(FD)其 ⳱ Hairs/FU ends), and the average density is 2.033 hairs/mm2. This corre-
sponds to 203.3 hairs per square cm. Hence, the surface area
Total Hairs Transferred ⳱ THT ⳱ (Mean CD) (Mean FD) would yield an estimated 3253 hairs (15 cm2 Ⳮ 1 cm2 for the
(cm2 excised) tapered ends) (2.03 hairs/cm2), or only 27 more hairs than the
more accurate calculations. Finally, it is very useful to record
Which simplifies to: (1) the number of hairs, FUs, and grafts obtained after comple-
tion of graft preparation; and (2) the length and width of the
Total Hairs Transferred ⳱ THT ⳱ (mean density) (cm2 excised strip. In subsequent sessions, the surgeon can maintain
excised)
or alter these numbers by taking the new donor strip directly
adjacent to the scar from the earlier harvest(s), and by excising
Counting hairs is much more difficult with the Rassman densi-
a strip that has the same, less, or more length and/or width,
tometer and other types of densitometers than with a micro-
depending on whether the same number, fewer, or more grafts
scope. Therefore, it is more accurate to count the number of
hairs/FU (CD) after excising the tissue from the donor area. are wanted. There is another reason for estimating very accu-
Counting larger entities such as follicular clusters or FUs is a rately the number of FUs a given size of donor tissue contains.
precise exercise with the use of a densitometer. It follows that Such an estimation provides a mechanism for calculating the
the most accurate means of estimating the total number of hairs skill of the surgeon and the technicians in producing the hoped-
transferred would result from noting the FU density with a den- for 100% yield of FUs from the strip—both before preparation
sitometer and the calculated density with a microscope. and insertion of the FUs and after the FUs have been given the
The CD is noted for up to three reference points along the opportunity to regrow in the recipient area. In other words, a
strip. Density of FUs and hair density estimates after donor very accurate estimate of the number of FUs in the donor strip is
excision are not accurate because the donor tissue shrinks an the best way of furthering the scientific basis of hair restoration
estimated 5% to 10% after its removal from the donor area. A surgery.
5% reduction in the surface area of the aforementioned strip It is also worth remembering that although an FU density
would increase the density of the 1200 FUs to 89 Fus/cm2 from of 1/mm2 is relatively constant when measured in Caucasians
80 FUs/cm2 (an 11% increase). A 10% reduction in surface in the midportion of the SDA (3,11), there is considerable vari-
area would increase the FU density to 99 FUs/cm2 (a 24% ability of FU density in different parts of the scalp and in differ-
increase). Therefore, density increases proportionately (11% to ent races. For example, Cole has reported that FU density in
24%, and sometimes more) after donor tissue removal. the mastoid and temporal regions is often less than the 1 FU/
In this instance, the mean FD is noted in the three reference mm2 measurement that is often found in the vertex and midoc-
points with a densitometer whose surface area is known. The cipital regions (10,12,13). Thus, what is required in some areas
reference points are then circled with a marker. Once the strip to produce an appearance of ‘‘normal’’ density may be greater
is excised, the reference points are noted. Within each reference or less than the often quoted 50% of original density, or 50%
point, the total number of hairs of a given number of FUs is of 1 FU/mm2. In addition, depending on hair characteristics,
counted with the aid of a microscope set at 10x to 20x magnifi- 50% of original density may or may not be necessary to create
cation. The total number of hairs is divided by the sum of the this effect. Once these variables are recognized, however, the
FUs investigated. The quotient is the CD. This FD and CD are relative constancy of density of one FU/mm2 in Caucasians
plugged into the formula for THT to arrive at a more accurate simplifies the surgical planning and donor size estimation for
estimate. FUT. It therefore remains a useful concept.
METHODS OF ESTIMATING THE REQUIRED

DONOR TISSUE
The evolution of FUT and mass marketing in medicine has led
most physicians to quote costs for hair transplanting as being
determined, at least partially, by the number of grafts trans-
planted. In addition, patients are better informed about the pro-
cedure via advertisements and the Internet. These sources may
or may not be misleading, and individuals should arrive at the
consultation with specific questions and some level of skepti-
cism. The result of the foregoing is that one of the most common
questions asked is, How many grafts will I need to have trans-
planted? This of course is one of the most important questions
a hair restoration surgeon needs to answer to be able to estimate Figure 10A-4 Place the transparent sheet (plastic food-wrap)
how much donor tissue must be excised to create the desired over the specially designed graphic paper to count the number of
effect. Unfortunately, this number is dependent on numerous small squares. (Photograph courtesy Steven C. Chang.)
factors that include the patient’s objectives, hair/skin color con-
trast, hair caliber, wave, curl, etc.—and the types of grafts the
physician intends to use. To establish some type of concrete
and consistent way of making this estimate, some operators for the average patient, an attempt is made to reproduce the
have arrived at different techniques (described later) for estimat- 50% density in two sessions. In an alopecic patient, for example,
ing (1) the size of the recipient area and, (2) at least, the number the attempt to create this 50% density is made in two sessions
of FUs they must harvest to treat that area. As a by-product of of 25% density each. Thus, if the bald area is 100 cm2, 25 cm2
that estimate, physicians also have a way of conveying the likely of donor area must be harvested in each session in order to
cost of the treatments and the coverage that number of FUs will produce 25% of the donor area hair. The number of grafts that
produce. It is important to re-emphasize that even very careful can be obtained from this amount of donor tissue is easily calcu-
estimations of the number of FUs required are subject to the lated. Based on the assumption that there is one FU per mm2
aforementioned variables as well as to changes in the patient’s (as noted earlier, this is not entirely accurate), 1 cm2 can there-
density or coverage objectives while a number of sessions are fore be expected to produce 100 grafts and 25 cm2 2500 grafts.
carried out. Thus, calculations for the previously noted purposes Chang is careful not to tell patients how many grafts are con-
should always be clearly conveyed to the patient as estimates tained in 1 cm2 of their donor strip. They are told only that he
only. will deliver 25% of their own density per session. Using the
Estimates of the size of the recipient area and the number previously noted example, in order to cover 100 cm2 of alopecia,
of FUs necessary to produce a desired effect in that area, which he harvests 25 cm2 of donor tissue. This should produce 25%
are described below by Farjo and Chang, are useful for convey- density, and there is no need to count how many hairs are pres-
ing general concepts to patients and physicians. Moreover, they ent in the donor strip to reach 25% of the donor strip density.
are easy to carry out. The advantages of this approach are listed in an article published
in Hair Transplant Forum in July/August 2001 (14).
The Chang Method
The Farjo Method
Chang begins his method of estimating the number of grafts
necessary to treat a recipient area by marking the proposed Farjo has described a different method of estimating the size
recipient area on the scalp of his patient with a china marker of the recipient area and therefore the number of FUs necessary
(14). He then applies a transparent sheet (plastic food-wrap) to treat it (15). His method is based on picturing the recipient
over the scalp and traces the area to be covered onto the trans- area as simple geometric shapes—essentially, triangles, rectan-
parent sheet. Cole had earlier described assessment of the recipi- gles, squares, or circles. For example, the frontal forelock
ent area for purposes of donor area assessment by tracing its shown in Fig. 10A-5a can be seen as a triangle. As shown in
outline on a transparent sheet (12,13). This transparent sheet is Fig. 10A-5b, the area of the bold-line triangle provides a good
then placed over a specially designed graphic paper that has estimation of the area of the forelock. The area of the triangle
been divided into large and small squares (Fig. 10A-4). Each ⳱ A ⳯ B, where A is the distance between the anterior point
small square is 1 cm2 and each large square is 4 cm2. By doing and the most posterior point of the base of the triangle in the
this, one can estimate the approximate recipient area size in midline (not the base of the forelock) and B is equal to half of
square centimeters. A digital photograph of the scalp with the the base of the triangle. For example, if A⳱10 cm and B⳱5
recipient area marked in by china marker is taken and kept on cm, the area of the triangle and the isolated frontal forelock is
file in the patient’s chart, as is the photocopy of the transparent 10 ⳯ 5 ⳱ 50 cm2. (Cole first described the triangular method
sheet. A copy of the graphic paper that Chang uses can be of assessing the surface area for moustache hair restoration at
downloaded from the website: http://www.hairtransplant.com/ the live surgery workshop at Orlando, Florida, in 1999) (16).
Spencer.pbf. Chang states that 90% of his patients are satisfied In the vertex area, the shape is conceived as a circle (Fig. 10A-
with 50% of the donor site density; although he also notes that 6a), with the area equal to radius2 ⳯ ␲. For example, if the
this, of course, depends on the patient’s hair color/texture, skin diameter of the circle is 10 cm, the area ⳱ 5 ⳯ 5 ⳯ 3.14 ⳱
color, contrast between skin and hair color and age. However, 78.5 cm2. In estimating a total recipient area that includes both
312 Chapter 10
advent of strips of various sizes and ellipses made accurate

estimates more difficult to achieve. To complicate matters fur-
ther, the size of grafts decreased and the number of grafts in-
creased.
Although Cole no longer employs the multiple-strip tech-
nique, he has used it successfully in the past for what is now
commonly referred to as micro-minigrafting and total FUT. His
multi-FU grafts consisted of up to six hairs (rarely seven hairs),
a b whereas his FU consisted of predominantly one to three hairs,
with an occasional four-hair graft. Unger routinely records the
number of different types of grafts produced from the strips
Figure 10A-5 (a), A typical forelock pattern in the shaped of obtained during the first session of transplanting (the details
a wide boomerang. (b), The area shown in Fig. 10-5a can be imag- are described later in this chapter). This record, which is kept
ines as a triangle that is overlaid on the area as shown previously.
in the patient’s file, serves as a guide to what sizes of strips,
The area of the triangle is equal to a ⳯ b, where ‘‘a’’ is the distance
both lengthwise and widthwise, are needed to achieve the objec-
between the furthest point forward and the base of the triangle and
tives of later sessions. Most of Unger’s patients are treated with
‘‘b’’ is equal to half of the base of the triangle as shown previously.
FU and Multi-FU grafts, and neither he nor they are as con-
cerned with a very accurate anticipation of the number of grafts
created and transplanted per session. This is in contrast to the
concern shown by most physicians who employ FUs exclu-
the frontal midscalp and crown area, Farjo accepts Cole’s sug- sively. If too few grafts are obtained from the initial harvest,
gestion to envision the recipient area as a long oval (Fig. Unger simply goes back and excises a small extra donor area
10A–6b). The surface area of a long oval is equal to (A/2) ⳯ or makes up for the ‘‘shortfall’’ in a subsequent session. If
(B/2) ⳯ ␲. If only half of the recipient area is to be treated more than the desired number of grafts are obtained, he treats
(e.g., anterior or posterior half), the total area is simply divided a slightly larger area of the present or anticipated areas of hair
by 2. loss. With experience, neither a shortfall nor an excess occurs
very often. There are, in Unger’s opinion, too many variables in
techniques and staff skills to provide any consistently accurate
ESTIMATING DONOR TISSUE FOR GRAFTS estimating mechanism for different numbers of different types
LARGER THAN FOLLICULAR UNITS of grafts.
Although the foregoing discussion addresses methods of calcu- Finally, the preceding discussion has dealt with various con-
lating the number of FUs required, many practitioners employ cepts of estimating the number of hairs that are being trans-
a combination of graft types. When round trephines were used planted, but hair bulk, or mass, and, therefore, the apparent
to remove grafts, it was easy to predict graft counts. If 50 4- fullness of hair, is due not only to the number of hairs trans-
mm standard sized round grafts were removed, this resulted in planted but also the diameters of the hair shafts. This is dis-
50 4-mm grafts, 100 hemigrafts, or 200 quarter grafts. The cussed in the following section.
HAIR SHAFT DIAMETER

The importance of the hair shaft diameter cannot be overstated.
It is the most important predictor of coverage in hair restoration
surgery. To understand its effect, we must first define coverage.
Full coverage may be defined as reflection of light waves corre-
sponding to the wavelength of the hair. Thinning may be defined
as reflection of light waves corresponding to the wavelength
of both the scalp and the hair. Alopecia is defined as reflection
of light waves corresponding predominantly to the color of the
skin. The greater the surface area of the transplanted hair, the
greater the coverage resulting from the transfer of a specific
amount of hair.
Surface area of a hair is defined by the following formula:
a b Area = 2 πr 2 + 2πrh,
where r is the radius of the hair shaft and h is the length of the
Figure 10A-6 (a), The crown or vertex of the scalp is essen- hair.
tially a circle shape whose area can be measured in a similar fashion Because approximately only one half of the hair shaft reflects
to that of a circle. The diameter of a circle is the radius2 ⳯ ␲,
light, the formula may be simplified to the following:
where the radius is equal to half of the diameter as shown earlier.
(b), Another way of measuring the size of a combined frontal and Area = πr 2 + πrh
vertex recipient area is to conceive of it as the oval shown earlier.
It can be calculated with the formula (a/2 ⳯ b/2) ⳯ ␲. Variations in surface area are smaller than variations in volume.
For this reason, it is easier mathematically to appreciate the ␮. In a study of 40 patients, Cole, using 45x magnification,
significant changes in volume from slight changes in hair diam- examined the regional variation in hair diameter at the three
eter. Volume (V) of a hair is defined by the following formula: reference points described in the section on hair density in this
chapter (Table 10A-5a). He found the following mean diame-
V = π r2 h ters: left supra-auricular area 69.8 ␮, left mastoid area 73.6
␮, and midoccipital area 66.7 ␮ (Table 10A-7). This regional
In this formula, r is the radius of the hair shaft and h is the variation suggests that there is a predominance of finer textured
length of the hair. hairs in the midoccipital and supra-auricular regions, and a
The total hair volume resulting from a specific amount of predominance of coarser hairs in the midmastoid area. Unfor-
hair transferred would be defined by the following formula: tunately, the midoccipital area often contains not only the finest
hairs but also the highest number of hairs per FU and the highest
−
V = (THT) π r 2 h, FU density. It therefore becomes more difficult to isolate fine-
textured single hair FU for the hairline from donor strips that
In this formula, THT is the total hair transferred and r 2 is the do not extend into the supra-auricular area, because the only
mean radius squared. source left for the finer hairs is the occipital area, where the
Notice that by doubling the mean diameter the hair volume FUD and CD are higher. Fortunately, hair caliber also tends to
is quadrupled. By doubling the length or the number of hairs decrease inferiorly in both parietal and occipital areas. Hair in
transferred, only the hair volume transferred is doubled. There- these more inferior levels may become finer with the passage
fore, diameter is far more important than any other factor in of time, but, usually, there are some finer textured hairs in both
predicting coverage from any given amount of hair transferred. sites that will probably not change significantly. Unger has for
Hair length, however, is a variable controlled by the patient, many years recommended using such hairs, to transplant the
unlike hair diameter and total donor hair ‘‘bank.’’ Hair length frontal hairline (17). In the days before micrografting, excellent
can be hextupled or grown even longer, which offers the patient hairlines could be constructed with grafts taken from such sites
a means of significantly increasing hair volume. Hair length is because of their somewhat sparser and finer hair (Fig. 10A-
the second most important factor in predicting coverage, but 7a–d). These hairlines only improved with age. If the hairs in
only if the added length is within the bald surface area (see these areas became progressively finer, and/or some were lost
later in this chapter). entirely, the hairline became more ragged and natural looking.
Hair shaft diameter can be measured with a number of com-
From the preceding discussion, it should be obvious that
mercially available micrometers. The Starret digital micrometer
mean hair diameter cannot be determined by observation of a
(Sears and Roebuck Catalog), which Cole began using in 1996,
single hair. A minimum of 10 hairs, and preferably 20 or more
is useful for rough estimates, and the Mitutoyo digital microme-
hairs, must be observed in making this determination. (The
ter is appropriate for more accurate measurements (Micro Enter-
more hairs, the more accurate the figure.) In determining mean
prises, Norcross, GA). It is also possible to use a micrometer
diameter, Cole also does not include any hairs that are less than
attached to a microscope. Fine-textured hairs generally allow
50 ␮ in diameter unless they are the predominant types of hair
for more dense packing and smaller recipient sites. As a result,
in the group. If, for example, he were looking at 20 hairs, he
they may or may not result in less coverage. Coarser hairs usu-
ally require larger recipient sites but possibly fewer grafts in a would not include a single hair measuring 42 ␮. Furthermore,
given recipient area; they produce better coverage per hair but, he disregards hairs that are well over the prevailing measured
if planted more sparsely than fine hair, may not produce better diameter unless there are a significant number of them (for
overall coverage. In addition, scalp ‘‘compliance’’ plays a role instance more than 25% of the sample). If the majority of hairs
in the choice of how closely grafts can be placed. Inserting measured were between 55 ␮ and 72 ␮, he would, for example,
grafts into the scalp always increases the tissue volume. If the discard a measurement of 95 ␮. In this way, the predominant
scalp has minimal compliance, the increased volume of each width of hairs is measured and a measurement closer to the true
graft exerts pressure laterally, thereby decreasing circulation mean is determined.
somewhat and also making the insertion of grafts into adjacent Cohen argues that the variability in hair diameters makes it
recipient sites more difficult. As scalp compliance increases, difficult if not impossible to determine an average or mean
the size of the graft or the number of grafts a given recipient diameter. (Personal communication by email on or after March
site will accept increases. Scalp compliance is subjective, and 21, 2001.) Cole disagrees with this assessment and believes that
understanding of it comes only with experience. A clue to scalp if the sampling of hairs is large enough, it is possible to arrive
compliance is derived at the time the donor strip is excised. If at a representative mean hair diameter for that individual. Fur-
the skin has a tough, leathery nature during excision and/or the thermore, although it is impossible to identify a person by a
donor area closure seems surprisingly tighter than expected, it single hair, it is often possible to rule out a person if sufficient
is important to perform test sites and insert some grafts before hairs are sampled. Some people, for example, have generally
making all the recipient sites. If the donor strip is undermined fine hair, whereas other people have generally coarse hair.
with a scalpel blade and the blade becomes relatively dull during Therefore, mean hair diameter assessments must have some
the excision, this is also a good indicator that the tissue is predictive value. Seager, on the other hand, believes that the
‘‘harder’’ than average and the scalp may have a lower compli- mean diameter is the same regardless of the donor area location.
ance. (Personal communication by email on or after March 21, 2001.)
Cole has found a wide range of scalp hair diameters: 20 ␮ Cole firmly disagrees, but the measurement of multiple hair
to 128 ␮. He rarely sees scalp hairs greater than 110 ␮, and samples is necessary to determine most accurately the mean
the largest mean diameter of donor hair he measured was 105 hair diameter. Furthermore, he claims that the variability in
314 Chapter 10
a b
c d
Figure 10A-7 (a), A patient before transplantation more than 20 years ago. (b), After four sessions of standard grafts to the frontal
area. (One additional session had also been carried out in the midscalp and anterior crown area). (c), Side view showing hair as normally
worn. Photograph taken at the same time as that shown in Fig. 10A-7b. (d), Hair combed up to expose completed hairline. This patient
had very good results with standard round grafts only because he had fine-textured and light-to-medium brown hair. In the days before
micrografting, cosmetically acceptable hairlines such as that shown here, could often be constructed in such patients with grafts taken from
donor areas with the finest textured hairs and lower hair density. Most frequently, this type of donor tissue was found in the inferior
occipital and parietal areas.
diameter is so striking that it is possible to visualize the differ- transplanting to either the frontal area only or the frontal and
ences between individuals with only a Rassman densitometer. midscalp areas because they have less total hair mass to move
Vellus hairs have been defined as being less than 30 ␮m in and, therefore, the illusion of greater coverage is often impossi-
diameter, of limited length, and of reduced color (12). The effect ble to achieve. A number of variables can affect this generaliza-
of these hairs on total hair surface area and volume is so limited tion: (1) a high FUD and calculated density improve the poten-
that it seems to make little sense to include them in calculations tial coverage; (2) wavy, curly, or kinky hair can improve the
of mean hair diameter. For the same reasons noted earlier, hairs illusion of coverage; (3) a smaller color contrast between hair
that are less than 50 ␮m in diameter should probably not be and skin can create the illusion of denser hair (see later); and (4)
routinely included. Generally, the proportion of these hairs is hairs sometimes change their characteristics after transplanting
small in the overall number of hairs moved. It would be useful (e.g., becoming more wavy) and may thus increase the impres-
to quantify these hairs to reinforce or modify these suggested sion of greater than actual hair density.
principles of calculation, because their exclusion does not mean Despite the foregoing, Unger has pointed out at several med-
that they have no impact on the illusion of coverage. Rather, ical meeting, that a very remarkable phenomenon in hair trans-
the finer hairs have more limited impact on volume, whereas planting is that a very small amount of hair is usually transferred
the larger ones have a more marked impact. In addition, because per session; nevertheless, the appearance of full or nearly full
of their size and lesser pigmentation, the smaller hairs are much coverage is often achieved over a relatively large portion of the
more difficult to count during the graft production phase. As a area of MPB. The reasons for this are discussed later in this
result, they are often not included in the final hair count. This chapter. Figure 10A-8 demonstrates the amount of hair clipped
is particularly true when the epithelium is removed from the from a typical donor area by Unger (approximately 1.2 cm ⳯
grafts. 24 cm), before excision of most but not all of the area. (Usually,
David Whiting has estimated that there are approximately the tissue actually excised is only 8 mm to 10 mm wide). After
seven terminal hairs for every one vellus hair in the normal two or three sessions, this relatively small amount of hair is
crown. This represents 14.3% of hair at that site, or 143 vellus typically expected to produce acceptable coverage to the frontal
hairs for every 1000 terminal hairs. If this trend held true in area of a man who might have type V or even type VI MPB.
the donor area, it is likely that most technicians would not see As noted in Chapter 5, this hair is used to treat not only evidently
or count 14.3% of the hairs present in the donor tissue. There thinning areas but also areas with hair that are expected to be
are, of course, other hairs with diameters greater than 30 ␮m lost in the future.
and less than 50 ␮m that also are less than averagely pigmented. As an extreme example of the foregoing, the patient shown
These hairs would have a reduced probability of being included in Figs. 10A-9a and 10A-9b had type VI MPB and a donor
in a technician’s hair count. In studies Cole has performed in area with dense hair that was approximately only 5 cm wide
his office, technicians did not include as much as 20% of the before transplanting. A wide zone of very sparse hair was pres-
hairs that he had originally counted in the donor area. Some of
ent inferior to the area with dense hair, but this area was unusa-
the missed hairs may not have been counted owing to transec-
ble for transplanting because of its sparseness and the fine tex-
tion; however, Cole believes that the majority were not counted
ture of hair within it. A single donor area was used, and the
because of their limited size and pigmentation. Of course, it is
scar from previous sessions was excised as part of each new
more difficult to count miniaturized hairs in Cole’s office be-
harvest. The patient is shown in Fig. 10A-9c through 10A-9f
cause he prefers to remove the epithelium from his grafts. Thus,
after five sessions (and two ARs), with light but effective cover-
in a patient with nonpigmented hair, the disparity in true hair
age over the anterior three quarters of the original area of MPB
count and technician count would almost certainly widen.
(his chosen objective). How was it possible to create this illusion
with so little hair? For that matter, how is it possible to achieve
Classification of Hair Diameter much better results in most patients who have better donor/
Hair diameters may be conveniently grouped into the categories recipient area ratios but who have transplanted per session only
of very fine, fine, medium-fine, medium, medium-coarse, and the hair shown in Fig. 10A-8? A small amount of hair somehow
coarse. Table 10A-8 attempts to define them numerically ac- goes a long way. As noted in Chapter 5, part of the reason so
cording to mean hair diameters. much apparent coverage is possible is because the hair in the
As noted earlier, it is possible to calculate hair surface area recipient area is usually longer than the hair that is clipped in
and hair volume and to predict coverage based on these calcula- a typical donor area. This extra length results in more hair vol-
tions. Patients with mean hair diameters greater than 70 ␮m ume, and, because of the length, it can be layered hair over hair
and a Norwood classification less than or equal to V are gener- in the same way as a roof is shingled. If such layering is not
ally much better candidates for the illusion of full coverage present (e.g., at the part or center of the whorl of the vertex),
after hair restoration surgery. When treating patients with a the illusion falls apart and the area must be treated more times
mean hair diameter less than 70 ␮m, it is often better to limit to create an appearance of coverage equal to that of adjacent
Table 10A–8 Classification of Hair Diameters
Very fine Fine Medium-fine Medium Medium-coarse Coarse
60 m 60–65 m 65–70 m 70–75 m 75–80 m 80 m

316 Chapter 10
nor are the physical components of the carpet altered).

Scalp surgery that utilizes the scalp’s facility to glide is
highly effective and minimally traumatic to tissues. The
relatively restricted width of donor strip excision in the
temporal area is the result of the lateral extremity of the
subgaleal space not extending that far laterally (i.e., the
galea blends with the temporalis fascia and results in
only three layers of tissue being present in the temporal
area).
The second property of scalp laxity is its extensibility or
ability to stretch. It is reiterated that this is independent
of the sliding phenomenon. Some scalps are highly elasti-
cized, and reasonably wide strips can be removed by
undermining and stretching, but this is relatively much
more detrimental to tissue viability and, often, the forma-
tion of fine scars than sliding.
The net consequence of the above is that notably wider
horizontal strips can be taken from the superior donor
area (because the subgaleal fibroareolar layer allows the
gliding described above) than in the lower area. As much
as a 2-cm width or more may be taken in the higher
Figure 10A-8 This photograph demonstrates the amount of regions of the occipital scalp and closure effected without
hair clipped from a typical donor area by Unger (approximately difficulty. In the inferior donor area, where there is no
1.2 cm ⳯ 24 cm) before excising most but not all of the area. subgaleal fibroareolar layer, the width of the strip taken
This relatively small amount of hair is expected, after two or three is determined by the skin extensibility (loosely termed
sessions, to produce acceptable coverage to the frontal area of a elasticity) and subcutaneous tissue. Here, a horizontal
man with type V or even type VI MPB, and usually does that. (See strip as narrow as 1 cm may result in difficulty with
photos in Chapters 5A, 12F, and 12G as well as Fig. 10A-9). closure. It must also be remembered that some scalps
have relatively poorly developed fibroareolar layers (i.e.,
are ‘‘tight scalps’’) in which the gliding phenomenon is
minimal. This is easily determined by simply placing the
pulps of the examining fingers on the scalp and moving
areas that are layered. Patients who complain of being able to them on the underlying pericranium. The orientation of
see the scalp at such sites must be reminded of this fact, but the lines of minimum tension (Langer’s lines) also plays
they should be forewarned during the initial consultation. a part in determining the width of the strip that can be
taken. At the midscalp, crown, and going down into the
scalp’s upper donor area, Langer’s lines are largely ver-
SCALP LAXITY
tical and allow generous excision of tissue taken in a
The terms scalp laxity and elasticity are not synonymous al- vertical axis (Fig. 10A-10). Conversely, there is an asso-
though they are frequently misused in that fashion. Gerard Seery ciated relative limitation in excision widths in the hori-
has described scalp laxity as being composed of two distinct zontal axis (because here Langer’s lines are cross-cut),
components. His description of these components and their im- but this is more than compensated by the tissue laxity
plications follows (18): provided by the fibroareolar layer in the upper donor
region. As Langer’s lines proceed inferiorly into the mid
The first component of scalp laxity is the ability of the donor area, they increasingly assume a more horizontal
scalp to slide or glide on the underlying pericranium. orientation and, in the inferior part of the donor area,
This is possible because the loose fibroareolar tissue in are entirely horizontal. This facilitates a relatively wider
the subgaleal compartment allows the scalp to be moved donor strip excision in the inferior donor area than would
on the cranium. This has nothing to do with the stretching otherwise be the case, but this does not nearly compen-
or the elastin content of the skin and is simply a mechani- sate for the absence of the ‘‘gliding’’ subgaleal fibroare-
cal movement of the scalp on the pericranium. In a scalp olar layer present in the upper donor area.
with a high capacity to slide/glide, an excision of 4 cm
or more (if made parallel to Langer’s lines) may be possi- Bosley outlined a method of objectively assessing scalp
ble and closure easily effected. Operations that take ad- laxity for AR. He quantified the decrease in distance be-
vantage of the scalp’s capacity to glide, rather than tween two dots on either side of the alopecic area follow-
stretch, are virtually complication-free and result in neg- ing manual compression between both thumbs and index
ligible topographical distortion of tissues. (The analogy fingers (19). Norwood proposed a somewhat similar
of pulling a carpet over a polished floor comes to mind. means of evaluating scalp laxity. He counted the number
The carpet and the furniture are moved, but their topo- of folds created on the alopecic scalp as a result of man-
graphical relationships to each other are not changed, ually compressing the temporal regions of the scalp to-
a b
c d
Figure 10A-9 (a), The patient shown earlier had type VI MPB with a sparse residual frontal forelock and a donor area that was only
about 5 cm wide before transplanting. (b), A view of the patient’s donor area showing a wide zone of very sparse hair inferior to a relatively
narrow potential donor zone of denser hair. (c), After three sessions of micro-minigrafting to the frontal area and two sessions to the
midscalp. (d), A side-view photograph, taken at the same time as that shown in Figure 10A-9c. How was it possible to create this illusion
with so little hair? (e), A posterior view. (f) The only donor scar present in this patient after five sessions. The hair has been clipped in
preparation for a sixth session, which was to be used for a session of follicle unit transplantation to the crown area.
318 Chapter 10
e f
ward one another. Scalp laxity of the donor area, unfortu-

nately, still remains entirely subjective. One can estimate
scalp laxity at that site by manually compressing two
anatomically different regions toward one another, or
the skin can be moved up and down to get a sense of
laxity, but a standard and objective method of assessing
laxity in the donor area is still required. Until one has
evolved, we can, at least, suggest grading scalp laxity as
‘‘tight, moderately tight, slightly tight, average, slightly
loose, moderately loose, or loose’’.
In general, a tight scalp requires a longer, narrower incision
to move a given amount of hair than a lax scalp, because the
donor wound should ideally be closed with minimum tension.
Limitations in the width of donor area excisions are reduced
further with multiple excisions in the same donor region as part
of subsequent sessions (see later). Failure to recognize a tighter
than average scalp may compromise the surgeon’s ability to
close the donor area without significant tension. If the excision
width exceeds the combined laxity and elasticity of the donor
region, it may even be impossible to approximate the margins
of the wound. Such instances may require undermining of one
or both wound flaps and/or the use of mechanical creep by
approximating the wound edges as closely as possible with
towel clips or staples for 30 to 60 minutes or longer before final
closure is attempted. In the worst scenario, even with undermin-
ing and the use of mechanical creep, it may not be possible to Figure 10A-10 Schematic representation of lines of minimum
approximate the margins with reasonable tension. Galeal su- tension. (Langer’s lines). (Photograph courtesy of Gerard Seery,
tures or ‘‘deep plane fixation,’’ as described by Seery, at the MD.)
end of this chapter, should then be used. If necessary, the edges in the respective wavelengths of reflected light. Therefore,
may be left with a slight gap at one or more points along the transfer of more hair mass to the bald or thinning area is gener-
course of the wound closure. The gap(s) will fill in by secondary ally required to produce the illusion of full coverage when the
intention, and the resulting scar(s) may be cosmetically im- color contrast between the hair and skin is greater. Darker pig-
proved at a later time. It is wise to err on the side of a conserva- mented skin can work either to the advantage or disadvantage
tive assessment of what is a reasonable maximum width for the of a patient. Dark hair and dark skin result in a lower color
donor strip and to avoid such situations. contrast, improving the ability to achieve the illusion of cover-
It follows from the preceding discussion, that a tight donor age, whereas light hair and dark skin result in a more negative
scalp limits the amount of donor area that may safely be moved color contrast.
to the recipient region during each session. In a patient who It is also important to note that as the contrast between hair
also has a more severe type of hair loss, it may not be possible and skin color increases, each hair has more visual impact. In
to achieve the coverage desired by both patient and physician, areas with fewer hairs, such as the hairline, the visual impact
or such coverage may require an unacceptable number of of each hair has a greater potential to detract from the illusion
smaller than usual sessions. Thus, to prevent unrealistic expec- of density and naturalness. This effect becomes more marked
tations, it is imperative that the patient and physician understand as the calculated density increases or as the hair shaft diameter
the consequences of limited scalp laxity before hair restoration increases. Therefore, one might strongly consider cherry-pick-
surgery is begun. Scalp laxity nearly always varies from area ing more finely textured single hairs for the hairline and frac-
to area and frequently is greater on one side of the head than tionating FUs (to reduce the average number of hairs per graft)
the other. Thus, the maximum width of any donor strip can immediately posterior to the single hairs), especially when the
be greater or smaller at various points along its length. Most patient has high color contrast, calculated density, and greater
commonly, from the point of view of scalp laxity, the donor hair shaft diameter.
strips can be wider in the temporal and occipital areas. However, There is a wide variation in color of scalp hairs in any indi-
because the permanent donor hair zones in the occipital and vidual. There also may be variations in hue depending on
temporal areas are not as wide as those in the parietal area (Fig. whether the hair is medullated or not. Hair with absence of
10A-2), it may be advisable not to excise maximum widths at pigment, or white hair, is particularly important to the graft
those sites despite adequate laxity to do so. One of the disadvan- production phase of the transplant. White hairs reflect or trans-
tages of the elliptical donor strips used by many hair replace- mit all light waves and have no color. It is difficult to see
ment surgeons is that they are typically widest in the occipital white hairs in yellow adipose tissue and technically much more
area, whereas the permanent rim hair is approximately 10 mm difficult to dissect them into grafts. The risk to these white hairs
narrower than in the parietal areas. Most of the parietal area increases as the size of the graft decreases. Gray hairs, on the
is usually lax enough for quite wide donor strips; however, the other hand, although not particularly common, have color and
postauricular areas nearly always are the least lax, and donor are easily seen against the yellow adipose background.
strips should accordingly be narrowed—sometimes substan- As a patient ages, the hair often begins to lose its pigment.
tially—in that region. Both scalp laxity and the varying widths This is because tyrosinase activity decreases in the follicular
of the SDA must be taken into account. (1) If elliptical donor melanocytes. As this metamorphosis occurs, the contrast be-
strips are employed, it would seem wisest to use ellipses whose tween hair and skin changes. This can work in favor of the
widest points are in the midparietal region, with narrowing as individual with prior high contrast but may be a slight disadvan-
they approach the postauricular and occipital areas. The tapered tage for the individual who previously benefited from having
ends should also ideally overlap each other in the midline, where darker skin. Scalp hairs typically begin to lose their pigmenta-
hair density is usually highest, and where transection of follicles tion first in the temporal areas. Individuals with predominantly
could otherwise be expected to be very high. (2) If the strip white hair also often retain a larger percentage of pigmented
extends from ear to ear, a single-bladed knife can be used to hairs in the occipital region. This has significance because, as
excise the strip in an undulating pattern that is wider at some noted earlier, it is technically easier to dissect small grafts such
points than others. Alternately, two-bladed knives of various as FUs and single-hair grafts, when hair pigment is present.
widths (according to scalp laxity) can be used along the length Because harvests from the temporal areas in individuals with
of the donor area, with gaps of intact skin between them. The predominantly white hair often contain a greater percentage of
gaps can then be incised with a single-bladed knife to join the white hair, the graft production phase can be technically more
sections (Fig. 10A-11). This approach is discussed later in the challenging from this harvest if only FUs are used. Keene has
chapter. suggested immersing donor tissue containing white hair in a
0.2% methylene blue solution before grafts are prepared (20).
The methylene blue stains the follicles and surrounding tissue
HAIR COLOR to different degrees and allows better visualization of the FUs
(Fig. 10A-12). Unfortunately, this technique works well only
The combination of light hair on fair skin results in a lower with slivers of donor tissue that are one FU wide, so it is not
contrast between hair and skin colors. Because hair and skin helpful with the initial slivering (see Chapter 11). In addition,
are close in color, the reflected light waves are more similar in although methylene blue has apparently been previously used
length, and the alopecic spaces between the hairs are therefore safely in vivo, all stains may have potential but unrecognized
less noticeable. As a result, when the contrast between hair and toxic effects on the stained hairs or on the patient. There are,
skin color is lower, transfer of less hair mass is generally re- therefore, significant hurdles to overcome in order to achieve
quired for the illusion of coverage. Conversely, the greater the U.S. Food and Drug Administration approval for this purpose
contrast between hair and skin color, the greater the difference (21,22). Cole has described a technique that uses monochro-
320 Chapter 10
Figure 10A-11 The strip on the left was cut with a two-bladed scalpel with the blades spread 7 mm apart. The strip on the right was
incised with a two-bladed knife with an 8-mm spacer (more laxity on the right side) and was removed before the strip on the left was cut.
A no.15 scalpel was used to join the inferior incisions and is likewise used to join the superior ones before the second strip is removed.
matic wavelengths of light, refraction, and color subtraction to ⳱ mx, results in much less surface area coverage than the
create contrast between white hairs and surrounding tissue (23). equation for a curly hair, which becomes more sinusoidal (such
However, harvests from the temporal area as well as the occipi- as y ⳱ sin t [wavy hair] or y ⳱ 2 sin t Ⳮ cos 2t [kinky hair]).
tal region result in a nice mixture of future hair color for the To understand these concepts more clearly, additional straight
frontal recipient region. Harvests limited to the occipital region lines may be added to the graph of straight hairs and additional
may result in cosmetically inappropriate amounts of darker hair sinusoidal lines may be added to the graph of curly hair or
in the recipient area at a time when the majority of the adjacent kinky hair. The addition of these lines, corresponding to the
temporal hairs are gray or white. A harvest from both the occipi- equation of curly and kinky hair with varying points of origin,
tal region and the temporal area produces a potentially more results in considerably more coverage of the surface of the paper
natural mix of hair color in the frontal areas as the patient ages. than a similar number of straight lines with varied points of
origin. Alternatively, just the amount of shaded surface on the
graph, which is covered by the corresponding lines, can be
WAVE OR HAIR BODY considered.
Straight hair follows a straight-line path along the scalp. It re-
flects light along this path. The reflected light of this particular SCALP DEPTH
wavelength results in the illusion of coverage along the line.
As the amount of wave or curl increases, the hair begins to As a general rule, the matrices of finer hairs are closer to the
undulate and to reflect more light waves over a greater surface skin surface than those of coarser hairs. Conversely, as the mean
area of alopecic or thinning scalp. This principle explains why diameter of the hairs increases, their depth of penetration into
the illusion of body, or coverage, increases as the amount of the subcutaneous tissue increases. Thus, the depth of incision
hair wave or curl increases. Kinky hair, which is common in required for donor areas with coarser hair must be greater, as
African Americans, is capable of producing massive quantities must the depth of recipient sites for the resulting grafts. There-
of reflective power. It is noteworthy that the reflective power fore, it is more likely that arteries and veins in the deeper layers
of any hair is beneficial to the illusion of coverage only as long of the subcutaneous tissue will be inadvertently cut when the
as it is covering the alopecic or thinning scalp. If the length of hair is coarser. In addition, generally, individuals with a higher
the hair extends beyond the thinning or alopecic area, it main- percentage of body fat have this fat deposited deep to the bulbs
tains reflective power, but its benefit to the illusion of coverage of the hair follicles. The additional fat adds a greater cushion
ceases. between the hair follicles and the vessels in the deep subcutane-
It is possible to clarify these principles in a graph form (Fig. ous tissue. By contrast, individuals with a lower percentage of
10A-13). It can be seen that the equation for a straight hair, y body fat have a smaller distance between their hair bulbs and
Figure 10A-12 The donor tissue of this white-haired patient was immersed in a 0.2% solution of methylene blue before dissection.
The methylene blue stains the follicles and tissues differently, resulting in better visibility of the follicles.
vessels. This reduced distance increases the probability that one TECHNIQUE
of the larger vessels will be incised during donor incisions or
during undermining of the donor wound edges, which may neg- Donor area harvesting is much more than a simple excision
atively impact healing of the wound. In a 40-patient study, Cole of tissue from the permanently hair-bearing scalp. There are
also found that scalp depth was greater in the midoccipital donor numerous factors to contemplate, including the location of the
region than in the virgin midsagittal superior aspect of the scalp donor strip, whether one or multiple blades will be used,
at the level of the external auditory meatus. The mean scalp whether one or two layers will be used to close the donor region,
depth at the inion was 8.7 mm, whereas the mean scalp depth whether staples or sutures will be used (and, if the latter, which
on the top of the scalp was 4.8 mm. An additional finding was type of sutures), and whether one or multiple donor area scars
that the acute mean angle of hair growth to the scalp at the will be created. In addition, many physicians, though not all,
inion was 52 degrees and 39 degrees on the top of the scalp. introduce tumescence in the donor region to different degrees.
All of these are discussed in the following section.
DONOR SITE PREPARATION

Most physicians have patients wash their hair and scalp the
night before and the morning of surgery with an antiseptic such
as Betadine, Hibiclens, Technicare, or a regular shampoo. As
noted in Chapter 5, it is helpful to wet the hair to clarify the
SDA and to make visible any signs of future loss such as shorter,
finer, or lighter-colored hair. The hair immediately superior to
the area that will be excised should be combed superiorly, re-
ducing its obtuse angle to the scalp. This better exposes the
area to be excised. Wetting the hair also often helps to do this.
The hair that is combed superiorly is held in place with hair
clips, rubber bands, or tape. The hair in the proposed donor
area is then trimmed to a 1-mm to 3-mm length with either
small electric clippers such as those used for the beard and
sideburns or large clippers or curved Metzenbaum scissors. The
Figure 10A-13 A graph of straight (y ⳱ mx), curly (y ⳱ sin t), width of the clipped area should be 1 mm or 2 mm wider,
and kinky hair (y ⳱ 2 sin t Ⳮ cos 2t). both inferiorly and superiorly, than the width of the strip to be
322 Chapter 10
excised. It should be borne in mind that the wider the extra than 1000 patients, with no adverse effects noted at that site.
width of the trimmed area, the more difficulty the patient may This injection results in excellent hemostasis; however, tumes-
have in concealing the donor region in the immediate postopera- cent infiltration with lower concentrations of epinephrine is su-
tive phase. Some practitioners leave the hair in the donor strip perior in all respects, including hemostasis. There is also no
slightly longer than 2mm to 3 mm. They believe the longer scientific evidence to support the suggestion of reduced hair
length aids in maintaining the scalpel blade parallel to the angle survival in the recipient area if epinephrine is used in the donor
of hair growth. Once the donor region is trimmed, the cut hair area. To the contrary, excellent hair survival rates have been
is combed away. The inferior aspect of the donor region can reported by numerous practitioners who routinely use epineph-
be covered with a gauze wrap, a surgical towel, an absorbent rine in the donor areas (see Chapters 9, 11, and 12).
sponge, a Chux pad, or a feminine hygiene pad. These assist It seems logical to assume that because the follicles are
in absorbing blood as it runs inferiorly from the donor wound. spread farther apart by tumescence, that the same surface area
of skin will contain fewer follicles and, therefore, the yield of
follicles will decrease with tumescence if the same width of
TUMESCENCE OF THE DONOR AREA tissue is excised. Unger uses large amounts of tumescent fluid
immediately before he places blade to skin, and he accepts the
This subject is fully covered in Chapter 8. Donor tumescence concept of perhaps obtaining slightly fewer follicles in return
has been used since the days of punch grafting. The amount of for less follicle transection. Important exceptions to his general
tumescence and the method of infiltration have changed as the rule of maximum tumescence before incising are: (1) patients
methods of donor area extraction have changed. Saline tumes- with unusually tight scalps, (2) patients who are taking certain
cence results in vasoconstriction through the vascular compres- anticoagulants (see Chapter 8) and (3) lower than average donor
sion produced by the high volume of infiltrate in the extracellu- hair density. In such instances, he instead injects small amounts
lar space. In addition to this tamponade effect, tumescence lifts of a 1:50,000 solution of epinephrine superior to the field-block
the hair follicles off the underlying vascular bed and reduces and employs no tumescent fluid. Cole believes that maximum
the risk of transection of deeper and larger arteries and nerves, tumescence in the average office expands the donor region by
provided the depth of incision is controlled. Some practitioners, only 0.5 mm, and that this is generally partly compensated for
including Unger and Cole, add lidocaine and epinephrine to the by the point-to-point distance of the surgical blades. The point-
saline solution when preparing their tumescent solution (see to-point distance of the Arnold knife, for example, is 0.2 mm
Chapter 8). The lidocaine increases anesthesia and the epineph- greater than the distance between the two blades. This relation-
rine helps to improve hemostasis. Follicle transection is also ship partially negates the effect of saline infiltration on reducing
decreased by tumescence as a result of its spreading the follicles the follicular yield. Infrequently, maximum tumescence can ex-
within the donor tissue farther apart, stabilizing the tissue, and pand the donor area by up to 5 mm, but Cole thinks the dynamic
making the angle of hair growth more consistent. The impor- properties, which are especially characteristic of this type of
tance of rigidity of the tissue in preventing transection is more elastic skin, reduce this effect to a very short duration as the
significant with scalpels containing more than one or two skin rapidly returns to normal. Obviously, how much fluid is
blades. The depth of the incision should be 4 mm to 7 mm or infiltrated by any given practitioner, and how rapidly the strip
just below the depth of the hair follicles. As noted earlier, fine- is thereafter incised, affect the degree of any potential lower
textured hairs typically do not extend as deeply into the subcuta- FU yields. The amount of tumescence used has increased signif-
neous tissue as coarser hairs. icantly over the years. It is common to employ 75 mL or sub-
There are different planes to consider in the donor area: the stantially more to infiltrate the typical donor region. Arnold has
epidermis; the dermis; the subcutaneous fat, which contains the recommended that infiltration should result in a ‘‘plateau’’ in
follicular bulbs; and the subcutaneous fat deep to the bulbs; as the donor area rather than merely a raised area resembling a
well as the region between the galea and the skull. Tumescence ‘‘hill,’’ and Unger strongly agrees with this advice for most
in each of these planes has a different effect on the hair follicles. patients (see exceptions noted earlier). Blugerman goes further
Tumescence in the subgaleal plane alone may act to compress and advises that this plateau should extend at least 1 cm beyond
and distort hair follicle exit angles. Infiltration in the subcutane- the proposed area of incision (25). Beehner’s technique is to
ous plane alone increases the distance between the hair follicles infiltrate 10 mL to 15 mL into the subcutaneous tissue using a
and the neurovascular bundles but does not create the degree 10-mL Disposajet syringe (Byron). He then injects additional
of rigidity that is optimal for donor area excision. Tumescence fluid into the more superficial dermal layer every 3 cm, using
in the upper dermis alone creates a firm, flat surface, reduces two 5-mL syringes with 22-gauge needles. On average, he in-
follicle density, and perhaps decreases follicle transection rates duces tumescence in the donor area with a total of 70 mL to
but does little to lift the follicles away from the underlying 80 mL of normal saline containing 1:85,000 epinephrine. After
nerves and vessels. It is, therefore, beneficial to infiltrate both incising the parallel edges of the strip, he induces tumescence
the subcutaneous tissue and the dermis to a maximum or near in both extremities of the strip for a third time and incises its
maximum degree to produce the ideal level of rigidity. There tapered ends. (Personal communication by email or fax on or
are those who believe that infiltration of epinephrine into the after March 21, 2001.)
donor region may increase the risk of necrosis in the donor The optimal amount of fluid infiltration varies from one
area. Both Unger and Cole disagree—unless the wound has donor region to another. Some donor areas require very little,
been closed with too much tension—in which case it may play whereas others accept much larger volumes. In a substantial
some role in increasing the risk of donor area necrosis. Cole majority of instances, it is possible to achieve a firm plateaulike
has injected 5 mL of solutions containing concentrations of surface, but in some areas it is impossible to accomplish this.
epinephrine as high as 1:30,000 into the donor area of more The elasticity and reabsorbing capacity of the tissue are so great
that the effects of large fluid volumes are lost almost immedi- blade (with or without a depth guard) to excise an ellipse from
ately and the benefits are minimized. It is important to recognize the donor area is the method of harvesting demanded by those
such situations because the risk of transection with a mul- who tend to use FUT exclusively and who wish to define this
tibladed knife increases, and, therefore, only single-bladed or technique strictly. It is the approach preferred by Bernstein,
double-bladed knives should be used in such areas. Cole, Gandelman, Hugeneck, Limmer, Rassman, Sandavol,
Seager, Swinehart, Ramos, Uebel, and others. Their rationale
is that a single blade decreases the number of surgical margins,
EXCISION OF THE DONOR STRIP but this applies only to knives with more than two blades. Per-
haps a more important reason to employ a single blade is the
Coiffman was the first to propose the advantages of a block variation in hair growth angles on two different planes of the
excision of the donor area. Initially, he described a technique curved skull. The farther apart the most superior and most infe-
that left no hairs between excised round grafts. Later, he pro- rior blades are, the greater the difference in the angle of growth
posed a block excision of a solid donor area, leaving a single at the incision lines (see also later).
donor scar (26). In retrospect, it is both remarkable and sad that Griffin suggested that the transection rate for one strip sur-
it took as long as it did for this concept to become widely face should be multiplied by the number of blades on the knife
adopted, but in the 1990s, the scalpel essentially replaced the to obtain the total transection rate for any multistrip harvest. In
punch for donor area harvesting. fact, the transection rate is almost always greater than this be-
As discussed later, either a single-bladed or multibladed cause of the previously noted different hair growth angles in
knife may be employed. The first physician to describe the use different planes of the scalp. The mean transection rate for a
of a double-bladed knife was Vallis (27), but there are now single-bladed knife, in Cole’s ongoing studies, is 2%. Interest-
various knife handles available from a host of vendors (e.g., ingly, the transection rate for the first incision line is much
Ellis Instruments, A-Z Instruments, George Tiemann and Com- lower than that for the second. The mean transection rate for
pany, Robbins Instruments, Mediquip), which can incorporate a two-bladed knife set at 1 cm to 1.2 cm between the blades is
three or many more blades (see Chapter 22). In these handles, 2.6% of all the hairs in the strip. Pathomvanich’s transection
no.15 or no.10 blades are generally used and those produced rate, with his approach to elliptical excision, is 1.9% (29) and
by Persona are preferred by most operators because of their is described later. Reed projected the transection rate from har-
excellent degree of sharpness. The single-bladed or multi- vesting five 2-mm wide strips at 8% (see Chapter 12). Unfortu-
bladed knife is inserted into the donor region parallel to the nately, he determined this rate by taking a section of each strip
angle of hair growth and then drawn along the length of the containing approximately 200 hairs each, and counting the num-
proposed donor strip. To decrease the risk of follicle transection, ber of transected hairs on only one side of the strip. In this way,
it is advantageous to check the incision periodically and to mod- transections were not counted twice, but, as noted earlier, it is
ify the angle of the blade to conform to the continuously chang- very likely the transection rate on the uncounted side would
ing hair angles as the strip is cut. have been different from that on the counted side. Limmer re-
There are two incision surfaces that can be evaluated during ported that the transection rate with his method of elliptical
these assessments—the superior one and the inferior one. On harvesting and donor area dissection was between 2% and 5%
close inspection of the inferior surface, if the follicular bulb is and was usually between 2% and 4% (30). On the other hand, he
not found, the angle of the incision should be modified so that found the transection rate for strip excision and graft production
it becomes less acute by moving the handle of the scalpel cepha- from two 3-mm strips (using 3 scalpel blades) to be 8% to
lad. Should transection of the upper fractions of the hair follicle 16% when all transected hairs were actually counted instead of
be seen, the scalpel handle should be moved more acutely or estimated. (Personal communication by email or fax on or after
caudally. This technique led Kadach to propose the following March 21, 2001.)
pneumonic formula: ‘‘roots angle up, no roots angle down.’’ Bernstein reported that he can produce 17% more hair from
(28). Novices should ideally begin with a one-bladed or a two- the same amount of donor tissue because he has switched from
bladed knife spaced 4 mm or 5 mm apart. This is because when multibladed knives to double-bladed harvesting and stereomi-
the angle of the blades is not parallel to the hair shafts, the croscopic dissection (31). He also more recently reported that
percentage of follicle transection increases as the number of each FU obtained with the latter technique contained 2.26 hairs,
blades increases. The various effects of strip widths are dis- indicating almost no follicle transection (32). He also noted the
cussed later, but a wider strip and only two blades keep the production of 35% of FUs with three and four hairs, and 10
hairs in the middle of the strip out of harm’s way and thereby times the number of four-haired FUs than were obtained with
ensure, a higher yield of intact follicles. In addition, the more multiblade harvesting. His transection rate for a four-bladed
blades in the knife, the more resistance one can expect to en- scalpel with three 3-mm wide spacers ranged from 12% to 16%
counter. Therefore, the more blades in the knife, the more im- (33). Unger and Reed questioned the size of the 17% figure in
portant it is that they be extremely sharp. Laying the cutting view of the fact that (1) perfectly matched original sections of
edge of a five-bladed scalpel down forcefully on a hard surface, donor tissue are impossible to find for comparison purposes
for example, may be all that is necessary to dull the edges and were therefore not used, and (2) the skill of technicians not
sufficiently that the incision is made substantially more diffi- only varies from person to person but also in the same individual
cult. Mangubat noted that downward pressure on a multibladed with the passage of time. Bernstein worked with the same tech-
knife makes the movement of the instrument across the donor nicians in the earlier studies of multiblade harvests whom he
area easier. Practitioners have developed quite different prefer- worked with for studies of double-bladed and single-bladed
ences for the types of instrument they prefer to use for excision harvests carried out a year or more later, when they were more
as well as for different widths of donor strips. Using a single experienced. The study on which Bernstein based his 17% fig-
324 Chapter 10
ure was also flawed in several other important respects, which Excision in sections allows the remainder of the staff to begin
are discussed in articles in Hair Transplant Forum (34,35). dissecting the ellipse into smaller pieces that are 1 mm to 3
More importantly, all of the transection rates reported by mm wide. The procedure is more time-consuming than current
the previously mentioned practitioners were also dependent on methods, but with experience he has learned to perform the
other aspects of their harvesting techniques. For example, if the entire excision of the donor area within 10 to 15 minutes. In
amount of fluid used to induce tumescence in the donor area his opinion, the additional time required for this technique is
is altered, the transection rates of one practitioner compared warranted because it maximizes the reduction of follicle tran-
with those of another (or with those of the same physician at section as the ellipse is excised and minimizes injury to neuro-
a different career stage), may vary as much as or more than the vascular bundles. Dow Stough and Parsley observed this tech-
rates reported as the result of decreasing the numbers of blades nique at the Live Surgery Workshop held in Orlando, Florida,
used. in 2001. They found that the field of vision was substantially
Beehner, Mangubat, Khan, Unger, and Shapiro use mul- impaired by bleeding but that the transection rate seemed lower
tibladed knives for the production of minigrafts. Unger and than with other techniques (36,37). The procedure took approxi-
Shapiro obtain most of their FUs from donor strips excised with mately 30 minutes rather than 10 to 15 minutes to accomplish,
double-bladed knives, but some FUs are also easily produced but most practitioners work better in their own offices, so this
from the strips created by multibladed knives. The method of was probably not representative of the usual time required.
donor harvesting used is dependent on the type of graft they Stough believes that individuals with dark hair are the best
are producing. In their view, it is acceptable to use a multibladed candidates for this method, and, for obvious reasons, excellent
knife if minigrafts are being produced, as long as all of the tumescence and vasoconstriction are more necessary than with
transected follicles are transplanted with the intact ones. It is faster techniques. Parsley questioned an increased risk of desic-
easier to consistently make minigrafts of a specific size, for cation because the procedure is so time-consuming. (Personal
example 2 mm2 grafts, from narrow strips of consistent widths, communication by email or fax on or after March 21, 2001.)
such as those obtained with a multibladed excision than from Because there is little margin of error allowed for the cutting
an ellipse. A consistent minigraft size, in turn, makes the crea- angle with a horizontal incision of the donor area when a multi-
tion of the appropriate size of recipient site for each minigraft bladed knife is employed, Blugerman proposed what he called
possible. These practitioners also believe that an ellipse coupled the ‘‘vertical strip harvest (36).’’ In performing this technique,
with microscopic dissection is more appropriate when mostly he uses a nonangled, multibladed knife with no. 15 blades to
FUs, DFUs, TFUs, and QFUs are being produced. In this regard, initially incise the donor area vertically. The blades in this knife
they are in agreement with Cole, Gandelman, Hugenek, Lim- are 1.5 mm to 2.0 mm apart. He limits the depth of incision to
mer, etc. 7 mm or 8 mm to minimize nerve and vascular damage. He
Transplanting all transected, as well as intact, hairs in the then uses a no. 10 blade to remove this presectioned area as an
donor tissue may produce fewer hairs, the same number of hairs, ellipse. The thin strips are separated by the assistants and further
or more growing hairs depending on the study that is reviewed. dissected. Alkek has described a similar harvesting technique
This has been referred to previously in this chapter and is dis- (37), as have Al-Ghamdi and Kohn (38). We have found that
cussed in more detail in Chapters 9 and 12. Therefore, the im- these approaches are considerably more time-consuming and
portance of minimizing transection rates, although instinctively produce more follicle transection than we see with our usual
attractive, is not clear. All the same, the hairs that grow from method of strip harvesting. Nevertheless, the previously noted
transected follicles often have reduced caliber, and transected authors claim lower rates of follicle transection.
hairs are also more likely to be discarded by technicians. For
these reasons, it is important to know how many hairs are actu-
ally transplanted into the recipient area when hair survival stud- HOW WIDE SHOULD DONOR STRIPS BE?
ies are carried out—as they periodically should be—in all of-
fices. The decision regarding length and width of donor strips is based
Pathomvanich believes that all the current methods of donor on multiple factors that are discussed elsewhere in this chapter.
harvesting are ‘‘blind’’ in at least one dimension with regard The number of FUs desired and scalp laxity, however, are two
to hair angle. Therefore, he developed a new technique based of the most important ones. Rassman and Seager frequently
on the principle: ‘‘Cut what you see, and see what you cut (29).’’ excise strips that extend from ear-to-ear (or sometimes further
First, he marks the area he plans to excise. After a tumescent anteriorly) and are 12 mm to 15 mm across at their widest
anesthetic is infiltrated, he makes a superficial horizontal inci- points. (Personal communication by email or fax on or after
sion between several follicles with a no. 15 blade. This incision, March 21, 2001.) In the postauricular areas, however, where
which is approximately 1 cm long, is then opened with skin the scalp is tighter than elsewhere, the strip may be made con-
hooks, exposing the path of the hair follicles toward the subcuta- siderably narrower. Seager, for example, when trying to obtain
neous fat. He then continues the incision with the no. 15 blade, 2500 to 3000 or more FUs, commonly removes a strip that is
first to the left, then to the right, and eventually deeper, until 8 mm wide superior to the auricle but usually 1.2 cm wide in
the entire marked area is incised. Hemostasis is paramount to his the occipital area (although it may occasionally be 1.5 cm wide
technique, so that visibility of hair follicle angle and direction is or even wider) and approximately 7 mm wide in the postauricu-
optimized. Cotton swabs and a small roll of damp gauze are lar area. In trying to produce such large numbers of FUs in a
also used to keep the field clear of blood. As he dissects, Pa- single session, he generally excises the maximum width of tis-
thomvanich alters his course around the irregularly spaced FUs sue that allows closure with reasonable tension in each area.
and individual follicles in an effort to minimize transection. The effect of the preceding excision is that the shape of the
The ellipse may be removed in several sections or as a block. donor strip is often like that of a wave rather than a long rectan-
gle or an ellipse. This wave pattern is most frequently achieved resulting in a somewhat curved hair. Because the hair
by scoring the skin with double-bladed knives of various widths is shaped like a parabola, it is impossible not to transect
at various points along the proposed strips,—with a single blade it if it is excised with a straight scalpel blade. Hairs
joining the scored lines as the strip is excised. In subsequent superior to the scar are generally distorted only margin-
sessions, the initial widths may be decreased because of scarring ally (if at all), most likely because the preponderance
from previous harvests that has decreased scalp laxity. Alterna- of stretch comes from the neck. In brief, hair transection
tively, Seager may increase these widths to compensate for the is more likely to occur when a scar is excised, especially
presence of the hairless scar line within the donor strip and the on the inferior side.
decreased hair density on either side of the scar if scalp laxity 3. The texture of the scar is significantly harder than that
allows for this. Towel clamps are used in most patients to assist of the nontraumatized adjacent skin; therefore, greater
in donor area closure during each session, and staples are pre- force is required to dissect through the tougher scar
ferred to sutures. As implied by the foregoing, Seager usually tissue when grafts are being created from it. Greater
includes previous donor scars in new harvests from the same force requires more manual dexterity during the dissec-
general area and rarely leaves more than two scars in the donor tion process to minimize damage to the hair follicles.
area regardless of the number of sessions undertaken. During In other words, the margin for error is reduced.
the course of any patient’s series of treatments, extra separate 4. Scar tissue is less translucent than non-scar tissue,
and smaller excisions may sometimes be taken later from the which increases the technical difficulty of preparing un-
least lax but still usable portions of the parietal areas. These transected hairs.
are the areas where the previous strips were narrowest because 5. Skin stretch also reduces donor area compliance around
of low scalp laxity but where the SDA was wider than in the the scar. This means that the maximum width of donor
temporal or occipital areas. area excision will be reduced in subsequent procedures
Most practitioners use shorter and/or narrower donor strips that incorporate the scar, and the new scar will likely
than Seager. Avram, Shiell, Stough, and Beehner, for example, be somewhat wider.
usually limit their strips to a width of 8 mm to 10 mm, and 6. The scar contains no hair. If a scar is 1 mm wide, future
Mangubat limits his to 8 mm to 12 mm. (Personal communica- harvests that include it may result in a reduction of po-
tion by email or fax on or after March 21, 2001.) Although in tentially 10 FU/cm2 owing to the presence of the scar
the past Bernstein often excised 12 mm to 15 mm strips, for alone. Because the scar width varies significantly along
several years the maximum blade width he has used is 12 mm its path, FU estimation is also made more complex.
(and a blade width this large is used only in patients with good Moreover, when scars form in the donor region, they
scalp laxity). Because of the stretching from tumescence, the may be larger deep to the hair papillae than they are on
actual maximum strip width is close to 1 cm and usually mea- the surface of the skin. This can result from leaving a
sures 9 mm immediately after removal. Bernstein finds that this space below the hair papillae that heals by secondary
width is more than adequate for the largest procedures (2400 intention.
FUs in a single session) that he routinely performs. Unger’s
In reply to the preceding arguments, the following points should
and Cole’s approaches are described in detail at the end of this
be noted:
chapter.
1. Both decreased hair density and follicle angle distortion
are significantly affected by the closing tension of the
Should Old Scars Be Excised Within New Donor donor site. Minimal tension produces minimal change
Strips? in each. In the past, Bernstein routinely excised wider
Should scars from previous donor strips be included in subse- strips that were 12 mm to 15 mm wide; Rassman and
quent harvests, or should strips always include only unscarred Seager still employ this practice. Such excisions often
tissue? Unger and Cole prefer the former choice. Bernstein has result in greater wound closing tension, which has a far
discussed multiple potential problems that may result from a greater effect on adjacent hair density and angle than
donor excision that includes previous scars (39). These prob- that seen with the 8-mm-wide to 10-mm wide strips
lems are summarized later, along with additional comments by typically used by Avram, Shiell, Beehner, and others.
Cole (notwithstanding Cole’s preference for excising scars as Moreover, in Unger’s experience, once wound tension
part of new harvests): starts to increase, it does so exponentially. A mere 1-mm
increase in donor strip width can make the difference
1. When the donor area is excised, the defect is closed by between no tension on closing and substantial tension,
stretching the edges of the wound and suturing them which is remarkably disproportionate to the small in-
together. This skin stretch decreases the follicular den- crease in strip width.
sity of the skin adjacent to the scar. 2. If previous donor scars are not excised as part of the
2. Scar formation distorts hair growth direction or angle donor strip(s) in subsequent sessions, each session will
immediately adjacent to it. This directional distortion add an extra scar to the donor area. Six sessions will,
tends to be greater on the inferior side of the scar than for example, leave six scars instead of one or two scars,
on the superior side, creating a potential problem in which can result in an unnatural, zebralike pattern of
future donor area excisions, which incorporate the scarring in the patient’s donor area.
preexisting scar. The bulbar region of hairs inferior to 3. Multiple scars may well reduce scalp mobility and the
the scar generally appears to be pulled more inferiorly width of future harvests.
than the infundibular segment of the same hair shaft, 4. Each scar interrupts the blood supply superior to it. This
326 Chapter 10
is true whether the scar is wide or fine. Taking a strip IF VIRGIN MIDLINE ELLIPTICAL DONOR
from an area superior to a previous scar results in a AREAS ARE HARVESTED WITH EACH
reduced blood supply to the inferior flap of the new SESSION, SHOULD THEY BE INFERIOR OR
wound. It also results in inferior and superior cut-off of SUPERIOR TO PREVIOUS HARVESTS?
blood supply to the area between the old and new donor
areas and increases the risk of telogen effluvium or ne- Midline elliptical donor harvests may begin (1) at the most
crosis in that section of the donor area. Each additional superior aspect of what is judged to be the SDA, with new
donor strip superior to the preceding ones increases the strips taken more inferiorly in each subsequent session (2) in
risk of poor healing of the new wound and the donor the middle of the SDA, with subsequent harvests taken superior
area tissue between all old and new harvests and scars. or inferior to previous ones or (3) at the most inferior aspect
On the other hand, if subsequent donor strips are taken of the SDA, with subsequent sessions taken more superiorly.
inferior to each prior one, the inferior flap of the new The blood supply consequences of these options have already
donor wound always has an intact blood supply. The been touched upon, but others are discussed here:
superior wound flap blood supply, however, is more Working from the inferior aspect toward the superior aspect
profoundly affected than the inferior wound flap in the has certain advantages. (1) As noted earlier, hair angle on the
first example. The rationale is that if the scar is superior inferior side of the scar is distorted to a variable degree, whereas
to the wound, the blood supply comes to the superior the hair superior to the scar maintains a more natural angle.
flap area primarily from an inferior location, and the There is, therefore, less risk of follicle transection when a strip
new incision cuts off this source. Thus, the superior is removed from the superior side of the scar. (2) Working from
wound flap has its blood supply reduced superiorly (by an inferior to a superior location may also improve the patient’s
the old scar) and completely cut off by the new incision ability to conceal the scar. Should MPB progress inferiorly with
from the more important inferior source of blood the passage of time, there is less likelihood that it will impair
supply. camouflage of the donor site scar or advance into previously
5. Scars inferior to new donor strips impede diffusion of harvested areas. (3) Going from an inferior to a superior location
postoperative edema in the donor area and therefore results in progressive pulling of the mobile neck skin into the
may not only result in more tension at the wound but donor region rather than pulling of the alopecic (or future alope-
may also prolong this tension. Both of these factors may cic) crown into the donor region (with possible enlargement of
result in wider scars. the alopecic crown), such as occurs when harvesting goes from
a superior to an inferior location. On the other hand, superior
Unger minimizes follicle damage, wound tension, and other donor strips can be considerably longer than the most inferior
potentially negative sequelae that have concerned Cole and ones, which may yield more grafts. Superior strips can also be
Bernstein with the following procedures. (1) He keeps old scars wider, resulting in lower wound tension, as Seery pointed out
well away from the blades and never uses scalpels with more earlier in this chapter.
than two-blades if there are significant hair angle differences Harvests extending from one to the other supra-auricular
inferior and/or superior to an old scar. (2) He harvests narrower region require a curved incision over the occipital protuberance.
strips in the few instances when more than average donor wound This is not problematic with use of a single blade. When more
tension is anticipated. The instances are few because Unger than one blade is used, the inferior blade must travel faster than
rarely tries to transplant more than 1500 to 2000 FUs (or their the superior blade at this curve, or ‘‘turn’’. For this reason, Cole
equivalent in other types of grafting) per session. Moreover, terms this movement the critical turn of the occipital protuber-
he usually uses two contralateral donor strips instead of one. ance. It is similar to the action of running around a track that
Therefore, Unger generally harvests significantly narrower is 440 meters long. As the racer approaches each turn, the runner
strips than Cole, Seager, and Bernstein; Finally, (3) he begins in the outside lane has a greater distance to travel around the
with narrower donor strips and takes slightly wider donor strips, turn. Therefore, the outside runner must go faster or be given
if necessary, in subsequent sessions. This approach increases a head start so that all runners race equal distances. The speed
the likelihood that wound tension will be acceptable even after of the inferior blades must increase as the distance between the
multiple sessions in the same area. It can also compensate for blades increases. It is almost impossible for three or more blades
to each engage this turn at their respective ideal speeds. Hence,
any decreased hair density adjacent to old scars as well as for the
the risk of follicle damage is greater at the critical turn and
absence of hair in the scar, which is usually very fine because of
increases significantly as the number of blades increases.
low closing tension of prior harvests. If only two or three ses-
Harvests beginning in the middle of the SDA offer an impor-
sions are anticipated for an individual, the approach of Seager tant advantage over the other two options.As the patient ages,
and Bernstein is not problematic, but Unger prefers a more hair becomes progressively finer and sparser in the most inferior
measured use of donor tissue in four to six (or even more) and superior aspects of the donor area. Every effort should be
sessions, The rationale is given in Chapter 5, and later in this made to not harvest from areas in which future thinning can be
chapter. Cole is able to obtain five or more large sessions with anticipated to be cosmetically significant. Harvests beginning
his technique, with an average of 1500 FU grafts per session in the middle of the donor area offer the advantage that donor
and more than 2000 grafts in some individual sessions. Cole strips will be able to be removed from the inferior side of the
believes the average donor region contains at least 7000 mova- scar in the next procedure and on the superior side of the scar
ble FUs, whereas Bernstein believes that 6000 FUs is a more in a subsequent procedure, thus minimizing the chance of en-
reasonable figure. croachment on areas that are ultimately destined to lose their
hair or become excessively sparse. The safest approach is not white, obtaining grafts that contain more than one FU may be
only to begin with a single donor strip in the middle of the advantageous.
SDA, where the hair is the safest and most dense over the long-
term, but to excise in the center of the new strip any scar that
remains from any preceding session. Unger recommends this HARVESTING CURLY HAIR
approach whenever there is concern that the patient may de-
Markedly curly hair, such as Negroid hair, presents a different
velop type VI or type VII MPB. Cole recognizes the rationale
problem (see also Chapters 5, 6, and 15D). The incision must
for this approach, but points out that the follicular density is
follow the curvature of the hair shaft to prevent transection.
always lowest on both sides of the scar, particularly the inferior Arnold has described a technique of incising the donor area
side. Therefore, excising the strip with the scar in its center with a hand-made curved scalpel blade. Cole prefers Arnold’s
may lead to a reduction in follicular yield, unless the surgeon technique with Negroid hair. The resulting strip may also be
starts with strip widths that allow wider strips to be taken in pre-slivered in the donor area, with incisions made perpendicu-
subsequent sessions. lar to the long axis of the strip as described earlier in this chapter
and also by Blugerman, Alkek, Al Ghamdi, and Kohn. Unfortu-
nately, in our admittedly limited experience, this latter type of
SHOULD TEMPORAL HAIR BE INCLUDED IN dissection is likely to produce more transection than if the donor
DONOR STRIPS? tissue is directly visible during its dissection into grafts.
Using a multibladed knife in individuals with tightly curling
Some practitioners excise a relatively wide donor strip that ex- hair is almost certain to results in a higher follicle transection
tends through the left and right occipital and parietal areas but rate than if a single strip or elliptical harvest is employed; there-
that avoids the region superior to the auricles. The primary fore, a multibladed knife is contraindicated. On the other hand,
advantages of such a harvest are an increased hair yield and a harvesting of Negroid hair is one of the few instances in which
higher proportion of pigmented hairs. If the patient prefers a the use of the ‘‘old’’ power punch may be advantageous. Power
short hairstyle in the temporal areas, this may also be the most punches can be moved in a gentle arc that follows the curvature
appropriate pattern to conceal the donor scar. However, al- of the follicle as the individual grafts are being drilled out (see
though FUD and hair density are greatest in the mid-occipital Chapters 5 and 15D). Round grafts that are 4 mm to 5 mm in
region and the area superior to the mastoids, they decrease in diameter can be removed and divided into whatever size graft
the area superior to the auricles, the highest preponderance of is required. Cole sometimes uses a power punch at the end of
natural single hairs is in the area superior to the auricles (Table a case of FUT in which 20 or more empty FU-sized recipient
10A-7e) (40). This midline excision pattern is also potentially sites remain after all the FUs have been used. He is better able
the most inefficient means of donor harvesting when multiple to get the number of FUs he wants by calculating how many
procedures are carried out. Scars inevitably decrease the ulti- of these grafts will be necessary to produce them.
mate donor yield, and this technique has the greatest potential
for the most and/or widest scars, because the length of the strips
is shorter than that of strips extending into the temporal areas. DONOR STRIP REMOVAL
Therefore, the width or number of excisions must be increased Regardless of the number of blades in the scalpel, the objective
to produce the same number of hairs. In addition, the tapered of incision harvesting is to remove a donor area with a minimum
ends of the donor strip(s) often contain the most follicular tran- of follicle wastage. Such wastage results from transection of
section, which occurs in an area with high FUD and hair density hair shafts during scalpel incision or damage to hair bulbs as
if the donor strip stops before entering the sparser supra-auricu- the strip is being excised from its bed. Inserting the blade(s)
lar regions. Furthermore, the virgin supra-auricular area has a parallel to the angle of the hair shafts minimizes the former
far lower hair yield capacity when treated as a separate entity, problem, whereas careful separation of the strip from its bed,
because its length relative to the length of its tapered ends is just deep to the bulbs, minimizes the latter. A deeper excision
less advantageous. leaves more adipose tissue on the strip and increases the amount
This pattern also fails to take advantage of the natural ten- of work of the surgical staff at the time of graft preparation,
dency of the temporal hairs to lose pigmentation first. As noted but such an excision is also more likely to avoid accidental
earlier, hairs chronologically programmed to maintain pigmen- damage to the bulbs. Deeper excision also results in transection
tation longer may, later in life, lead to a cosmetically noticeable of the larger and deeper vessels and nerves. To separate the
disparity between the hair color of the grafted frontal region strip from its bed Cole prefers to use a scalpel with a no. 10
and the adjacent temporal areas, which have more of a ‘‘salt- Persona blade. He excises the strip up to and touching the der-
and-pepper’’ appearance. It has been noted that nonpigmented mal papillae but is very careful to avoid trauma to the papillae
hair is much more difficult to dissect into FUs. Even with use and matrices. He performs this process slowly with 5x magnifi-
of microscopes, it can be very hard to achieve a high hair yield cation, removing only as much adipose tissue on the underside
from nonpigmented donor regions. Therefore, although a har- of the strip as necessary to safeguard the dermal papillae.
vest limited to the occipital and parietal areas has the capacity Unger, on the other hand, prefers a deeper separation of the
to improve FU yield if surgery is performed on someone whose strip because he is more fearful of accidental bulb injury and
temporal hair is already less pigmented, it would seem to be believes that the time added to the technician’s work to remove
wise to excise and use these temporal hairs before they lose the excess subcutaneous tissue is relatively small. Trimming
their pigment. As has already been noted, if the hair is already fat away from the bulbs can also be done more accurately by
328 Chapter 10
technicians working at tables than during the process of strip leagues as they were enjoying coffee in the surgeon’s lounge
separation, when less magnification is employed, tissue is often between cases). For any vessel that bleeds excessively and that
further from the physician’s eyes, and varying amounts of fails to stop bleeding within approximately 5 minutes, Unger
bleeding may also be present. Unger is less concerned with uses a Birtcher hyfrecator set at unipolar delivery and at 12
severing the occasional deeper vessel than Cole and others who watts to 15 watts. He notes that the plumes should be removed
use shorter, wider excision patterns, because Unger’s generally with an efficient smoke evacuator system because they contain
narrower excision patterns are closed with essentially no ten- benzenes, aldehydes, hydrocarbons, carcinogenic carbonized
sion, which eliminates the most important cause of wide donor particles, virus, and even bacteria (42–44). Unger also points
area scars and other potentially negative sequelae. Unger ex- out that the decrease of blood supply and the incidence of post-
cises the incised strip with small, curved iris scissors held with operative pain are greater with cauterization, which should,
its concave side adjacent to the donor area bed. Multiple strips therefore, be kept to a minimum (45). For these reasons, Cole
can be removed collectively or, less often, separately. The tissue prefers to place a small hemostat or a temporary skin staple
is lifted externally with forceps or a tissue hook, which offer on vessels that experience significant bleeding; this approach
direct visibility of the hair bulbs. prevents all cautery in almost all cases. Beehner prefers an
Because the tapered ends of ellipses often have the highest infrared coagulator that was tried and discarded by Unger as
incidence of follicle transection, Seery has described trapezoi- inconsistently effective.
dally tapered ends to minimize the problem (Fig. 10A-14) (41). Many surgeons, including Dow Stough, Griffin, Arnold,
This method does appear to decrease transection but may result Mangubat, and Seager, prefer staples for skin closure. Most
in ‘‘dog-ears’’ if not done perfectly and may leave a potentially practitioners, however, continue to prefer sutures. There is no
less than ideal scar because it ‘‘violates’’ Langer’s lines. doubt that staple closure is faster, causes very little tissue reac-
tion, and, in most instances, results in scars comparable to those
produced by suturing, but the degree of patient discomfort con-
CLOSING THE DONOR AREA tinues to be debated. In our experience, sutures produce less
discomfort post-operatively, and at the time of suture or staple
Before donor wound closure, some physicians cauterize vessels removal. Mangubat has studied staples vs. sutures on contralat-
that bleed excessively. The so-called ‘‘end vessel of Arsenault’’ eral sides of the donor area. He has had no complaints regarding
is particularly vexing. This vessel can be defined as the arteriole discomfort from the staples noted on a post-operative question-
that nearly always gets severed and that bleeds excessively at naire he has had his patients complete at their follow-up visits.
one or both ends of the incision, no matter how long or short Interestingly, Mangubat’s patients have said that the staples
it is or where it is located. (This incision is named after the were more uncomfortable, but that they accepted them because
surgical resident who first pointed it out to Unger and his col- of his belief in them and because of his observation that ‘‘the
results are worth it.’’ The staples are removed after 10 to 14
days. (Mangubat does not undermine his wound edges if there
is excessive closing tension. Instead, he places towel clamps
on the edges to produce mechanical creep, removing the clamps
as he comes to them with the advancing staples). (Personal
communication by email or fax on or after March 21, 2001.)
Cole and Unger have both tried similar studies but did not com-
plete them because there was so much patient complaint about
the stapled side. Shiell has twice performed a 10-patient study
comparing 4-0 Nylon sutures with staples in closing 8-mm wide
donor wounds on contralateral sides. (Personal communication
by email or fax on or after March 21, 2001.) He found no
difference in cosmetic results between staples and sutures, but
almost all his patients claimed that the staples were much more
painful when they were removed after 7 days. Bernstein per-
formed a 22-patient study in which he compared staples with
Monocryl sutures (48). In this study, 14 of 22 patients preferred
the Monocryl side, one patient preferred the staple side, and 7
of 22 patients had no preference. The most common complaints
about staples were inconvenience, postoperative discomfort,
and occasional pain associated with removal. The average scar
width on the stapled side measured 1.78 mm compared with
1.42 mm on the suture side. It is hard to explain the differences
in patient acceptance of staples except in the context of the
power of suggestion by the surgeon.
The need for galeal, subcutaneous, or dermal sutures in
donor wound closure is another area of controversy. Dow
Stough, Shiell, Bernstein, Unger, and most hair restoration sur-
Figure 10A-14 A schematic drawing of a trapezoidal donor geons generally find no benefit in using double-layer closures
area. (Shaded areas). (Photograph courtesy of Gerard Seery, MD.) if there is no undue closing tension. (Personal communication
by email or fax on or after March 21, 2001.) Scars that are a simple running 3-0 Prolene suture that is removed 6 to 7 days
wider than 1 mm occur, for example, in less than 2% of Unger’s later. The resulting donor scar is rarely greater than 1 mm to
patients; the majority have scars that are 0.2 mm to—0.5 mm 1.5 mm, and Beehner says he rarely excises the old scars in
wide or less and are difficult to find unless one knows where subsequent procedures because of the narrowness achieved with
to look for them. Thus, two-layer closures, at least in wounds this method.
that close with minimal or no tension, appear to be superfluous Limmer and Parsley have a different method of using inter-
unless there is a prior history of unexpectedly wide scars with- rupted 3-0 Vicryl sutures. (Personal communication by email
out tension. In addition, buried sutures may cause a tissue reac- or fax on or after March 21, 2001.) They first place 4-0 catgut
tion that resembles an infection, which frightens patients, is vertical mattress sutures every 3 cm while using a towel clamp
annoying to treat, and usually produces worse than normal to approximate the skin edges. Between each of these sutures
scars. Such suture reactions are uncommon and generally occur they tie a 3-0 Vicryl suture in a manner similar to that of
only at the point of a buried knot, but if they are unnecessary Beehner, with the knot tied in the subcutaneous tissue or deep
in the first place, it seems unwise to add another possible com- dermis. Parsley does not believe that the subcutaneous tissue
plication to the surgery. At postoperative check-ups, Shiell has is of value for placement of donor area sutures. He too prefers
found there is rarely any difference between the patients who the holding strength of the deep reticular dermis. Moreover, he
were closed with two-layers and those who were closed with is careful to keep the Vicryl sutures at 1 mm to 2 mm below
one-layer. He believes that wide donor scars are more a result the epidermis to minimize the possibility that the suture will
of ‘‘genetic predisposition’’ than of tight closure and that they ‘‘spit.’’ He closes the epidermis with a 4-0 plain catgut suture
occur more frequently in individuals of Mediterranean and Afri- in a running lock stitch. The suture dissolves within 10 to 14
can origin. We agree that there is a genetic predisposition to days.
wide donor scars. Cole finds that they are more common in Cole also believes that subcutaneous sutures help to mini-
individuals with darkly pigmented, coarse, often wavy hair. He mize the width of the donor scar. His two-layer technique is
also generally finds that wide scars in those genetically predis- different from those of Beehner, Limmer, and Parsley. Cole
posed to them tend to recur, regardless of the method of closure uses either 3-0 Vicryl or 4-0 Monocryl in the subcutaneous
(staples, two layers, one-layer, or alteration in suture material), plane just deep to the papillae. He believes that some patients
and are widest when incisions are made in the inferior occipital produce wider scars regardless of technique and that even his
area and, rarely, superior to the ears. Both Unger and Cole also two-layer closure is minimally effective in such individuals. To
find, paradoxically, that wide scars are most likely to occur in eliminate the suture reaction, the initial knot is tied on the sur-
individuals with extremely lax scalps. Unger postulates that face 1 cm lateral to the incision margin. The needle is then
maturation of the scar is somehow delayed in such individuals; passed into the subcutaneous tissue from the surface of the skin,
therefore, he leaves sutures in place for a minimum of 14 days where it remains until he reaches the other end of the wound-
instead of the usual 7 to 10 days. This frequently but not always margin or another desired point along the suture line. He has
leads to more usual scar widths. In addition, he sometimes em- never seen spitting when Monocryl sutures and this technique
ploys galeal as well as superficial sutures in these patients. Cole are employed. Cole prefers, however, to bury the first knot of
recommends that the patient be evaluated for hyper-extensibil- his two-layer closure, because the amount of tension on that
ity of the joints when the scalp is significantly more lax than knot is greatest. The second knot is buried or passed outside
average and the patient has dark, coarse hair. the wound.
Beehner, Limmer, and Parsley use interrupted deep Vicryl As for what type of suture is best, Cole generally closes
sutures in their routine two-layer closure of the donor area. wounds that are 6 mm or less in width with a running 4-0
(Personal communication by email or fax on or after March 21, Supramid suture. He leaves these sutures in place for 7 days.
2001.) Beehner’s technique is to initially infiltrate 10 to 15 mL For wider wounds, he uses a 3-0 Nylon or Supramid suture, or
into the subcutaneous tissue of the entire anticipated donor area, a 2-0 Chromic suture. He may leave these sutures in place for
using a 10-mL Disposajet syringe (Byron). He then injects addi- 12 to 14 days. Placing the suture superficially in the upper
tional fluid into the subcutaneous and dermal layers every 3 dermis causes the least impairment of blood supply to the
cm, using a 5-mL syringe with a 22-gauge needle. On average, wound. However, superficial suture placement may result in a
he induces tumescence into the donor area with a total of 50 greater incidence of post-operative bleeding and wider scars in
mL to 70 mL of normal saline containing 1:85,000 epinephrine. the subcutaneous fat because of the open space that must fill
After removing either a triple or double strip, he induces tumes- with scar tissue. Cole, therefore, runs his sutures into the subcu-
cence into both ends of the strip before incising the tapered ends. taneous fat deep to the bulbs. Unger, after trying numerous
(Personal communication by email or fax on or after March 21, types of suturing techniques and sutures, has also settled on
2001.) For his longer incisions, he uses five to six sutures, and a relatively deep but single-layer closure—similar to that of
for the shorter ones (7 cm to 9 cm) he employs three sutures. Cole—and usually uses 2-0 Supramid on a CL-20 reverse cut-
He finds that 2-0 Vicryl results in a considerably greater fre- ting needle. He would use a 3-0 or 4-0 Supramid suture, but
quency of suture reactions than 3-0 Vicryl. He has also de- the length of the suture and the needle he prefers are only avail-
creased the number of knots from three to two for each inter- able with the 2-0 Supramid suture. Cole’s loops are approxi-
rupted suture. He inserts the needle in the subcutaneous fat just mately 4 mm apart and his bites are 3 mm to 4 mm from the
below the bulbs. The needle is passed to the upper dermis and wound edges. Unger’s approach is predicated on the same ra-
exits just below the epidermis. He then enters the opposite mar- tionale used by Cole. (See below)
gin just below the epidermis and passes the needle into the Despite the foregoing, because a significant number of
subcutaneous fat. The knot is tied in the superficial subcutane- Cole’s patients come from a long distance, he often closes their
ous fat. He cuts the suture flush with the skin, and closes with incisions with an absorbable suture, 2-0 Chromic, 4-0 Mono-
330 Chapter 10
cryl, or a combination of a 4-0 Chromic suture with a buried These pockets may otherwise fill with scar tissue and result
suture. This approach has the benefit of ensuring that the suture in distortions of hair angles adjacent to the donor scars. Such
will not require removal. Many times, a local physician, friend, distortions are seen much more frequently by Bernstein and
family member, or spouse removes the sutures of the visiting others than by Unger. The minimal wound tension, that results
patient. Even local physicians are prone to miss a running suture from Unger’s narrower strips, allows for the use of deeper su-
within the long hair of the donor region. Using an absorbable tures without impairment of blood supply to hairs in the area.
suture ensures that the missed suture will eventually dissolve In addition, there is only one scar superior or inferior to any
without consequence. A suture must be chosen that will last donor area, regardless of how many sessions are carried out.
long enough for the wound to heal, without lasting so long His needle bites are a relatively wide—5mm to 8 mm apart
that it is annoying to the patient. The disadvantages of most laterally and 3 mm to 5 mm from the wound edges—usually
absorbable sutures are the length of time it takes for them to farther from the superior edge than from the inferior edge. The
dissolve and their greater irritability or tissue reactivity. Patients result of all of the preceding factors is the routine production
look forward to the day their sutures are removed. After the of excellent scars and minimal discomfort. Unger has learned
seventh day, the donor region becomes increasingly pruritic, to take less rather than more from any area, and to close with
yet absorbable sutures are often still present for 21 days. This minimal tension. Over the years, his patients’ problems have
results in an extra 11 to 14 days (or more) of discomfort in only rarely been in the recipient area—they have usually oc-
contrast to the course of non-absorbable sutures, which are usu- curred in the donor area when he attempted to take just ‘‘a little
ally removed after 7 to 10 days. Despite this, Cole cannot think more’’ tissue in order to produce more grafts for an anxious
of a single patient who did not want the absorbable sutures for patient. For out-of-town patients, he may sometimes use 2-0 to
subsequent procedures. Appendix 10A lists a variety of absorb- 4-0 Vicryl rapide instead of Supramid, but generally he prefers
able sutures and the time required for them to dissolve (49). not to do that. His rationale, as noted earlier, is that all dissolving
Shiell routinely closes the donor wound with a 4-0 monofila- sutures cause more irritation than nondissolving ones. Fre-
ment Nylon suture, using a continuous interlocking blanket quently, either Unger or the patient knows someone competent
stitch. (Personal communication by email or fax on or after to remove the sutures, who practices within a reasonable dis-
March 21, 2001.) He removes the sutures in 7 to 10 days. His tance of where the patient lives. These sutures are also used
loops are approximately 5 mm to 6 mm apart and 3 mm to 4 for the galea on those rare occasions when double-layer closure
mm deep. For patients who come from a great distance, Shiell is deemed advantageous because of unexpected closing tension
prefers to use 3-0 plain catgut unless the patient has had a or a past history of wider than usual scars despite no closing
previous reaction to this material. tension.
Bernstein uses 4-0 and 5-0 Monocryl sutures. He notes that
Monocryl is stronger and produces less tissue reaction than WIDE OR NOTICEABLE SCARS
Chromic or Vicryl sutures (50). He also advocates a simple
running stitch, keeping the sutures superficial and a maximum The length of the potential permanent donor area dictates the
of 1.5 mm from the wound edge, with approximately 5 mm maximum length of any donor strip. The width of the strip is
between each loop. He advances the suture on the surface rather more dependent on the physician’s choice. As has already been
than below the skin. The knot tends to unravel more easily with discussed, it is likely that if a donor wound is not closed with
Monocryl than with other materials, so the surgeon must ensure significant tension, the primary factors determining the width
a firm tie. In addition, because Monocryl maintains only 20% of the scar are owed to the individual characteristics of the
to 30% of its tensile strength after 2 weeks, Monocryl may not patient. Some patients tend to form finer scars and some seem
be the ideal buried absorbable suture. to form wider scars. Many years ago, Patrick Frechet noted that
As can be seen from the preceding discussion, different prac- with scalp reduction surgery, tighter scalps tended to form finer
titioners have found different techniques for optimal donor scars. This basic tenet seems to hold true in the donor region
wound closure. A novice may be confused by the number of as well. Parsley lists four reasons for wider scars: greater ten-
choices but should in some respects be reassured by these differ- sion, more inferior occipital donor sites, excision of preexisting
ences in opinion. As is common, there is no single best way. donor scars, and excessive follicle transection. The first of these
There are many factors that must be considered when one is has been previously discussed at length and is the easiest to
deciding how to best close a wound. These include how wide understand. It is widely believed that donor strips taken inferior
a strip is typically being taken, where its greatest width is, if to the occipital notch are more prone to result in scars that are
there are other scars present inferior and/or superior to the cur- much wider than usual. Unger believes that the occipital notch
rent donor site, and whether or not the tumescent fluid—if is too high a defining point if there is no wound tension, but
any—contains epinephrine. Each of these factors, and probably he agrees with the generalization that the more inferior the
others, has an effect on the method of closure. For example, donor area, the greater the likelihood that wider than usual scars
with multiple donor area scars and wider typical strips—and will be produced. It is also important to avoid taking a donor
therefore greater wound-closing tensions—it may be more ad- strip too close to a scar from a previous one. A distance of at
vantageous to use a double-layer closure and/or superficial in- least 10 mm (preferably 20 mm) is recommended, or a wide
terrupted sutures or staples. Unger sometimes employs two rel- scar may be produced. As indicated earlier, many practitioners
atively narrow, usually contralateral donor sites (see later) that find that wide scars are relatively resistant to improvement with
are easily closed with single-layer sutures. In contrast to Bern- scar revision surgery, even with two-layer closures. However,
stein, he also prefers taking somewhat deeper bites with the in Unger’s experience, excising normal donor area scars as part
needle to avoid unclosed deeper pockets of the donor wound. of new donor strips does not tend to produce wider scars. Cole
believes that removing even a fine donor scar predisposes the PROBLEM DONOR AREAS
donor area to wider subsequent scarring. He often closes in
two layers when excising a preexisting scar and believes this Minimal or no closing tension is the ideal situation, but if the
improves the resulting scar. Finally, transection of hairs superior margins of the wound do not approximate with little tension,
and inferior to a donor strip may also result in wider than aver- there are a number of options for dealing with this situation:
age lines of alopecia, but this is not the result of scar formation. 1. Beehner has found that waiting for 45 to 60 minutes,
True scar contains no hair or pigment. Normal skin should retain before closure decreases the degree of wound tension.
its normal pigmentation and is histologically different from scar This interval provides additional time for the large vol-
tissue. ume of tumescent fluid to be reabsorbed, resulting in
The tendency to a wider than usual scar over the mastoid more skin laxity before closure. It is important to keep
area, may be caused by another factor. An incision in this area the wound moist during the delayed closure.
frequently violates Langer’s lines. Brandy has noted that verti- 2. Cole has suggested using skin staples before suturing
cal incisions that do not follow Langer’s lines result in wider a wound under tension. The staples are removed just
scars than those that do. (Personal communication by email or ahead of the advancing running suture closure and have
fax on or after March 21, 2001.) If a donor incision begins at the benefit of controlling excessive bleeding as well as
or near the occipital protuberance and moves to a higher plane, inducing mechanical creep.
superior to the auricle, there must be some vertical component 3. Arnold has described the use of modified towel clamps
to the incision line. As this incision crosses the vertical against to assist the surgeon in increasing the width of excision
Langer’s lines, it can result in a wider scar. from a scalp reduction (51). He later modified use of
As more and more hair is removed from the donor area with the clamps to include assistance with the closing of a
multiple procedures, the patient may find it more difficult to tight donor area wound. Raposio found that exerting
conceal donor area scarring. This is especially true if the number mechanical force on the scalp results in no more scalp
of scars increases (i.e., previous scars are not excised as part removal in AR surgery than occurred with undermining
of new harvests). The problem frequently may be worse for alone (52). He theorized that the inelastic nature of the
patients with fine hair, significant color contrast between hair galea prevented any benefit from mechanical creep.
and skin, or preference for short hairstyles. Shiell has com- This suggests that many of the benefits of mechanical
mented that the angle and type of hair growth in the donor area creep with temporary skin staples or tension clamps
are also important for cosmesis. Some donor regions contain may result strictly from dissipation of the tumescent
hair that curls up so that a natural part is formed around the infiltrate. There may also be some benefit from stretch-
scar, making it more easily noticeable. After several procedures, ing of the skin on the neck, where there is no galea.
it is wise to take additional time to assess the donor region in 4. A fourth solution for tight closure is to undermine one
order to ascertain the effect additional harvesting will have on or both margins of the donor wound no farther than 5.0
the patient’s ability to camouflage the scars. If the surgeon is mm from the edge(s). This act decreases tension but
uncertain of the effect, trimming some of the hair from a specific creates the greatest risk to the donor area vascular bed.
region can provide a better appreciation of any potential nega- Although there are few reported cases of donor area
tive effects. If a scar becomes more noticeable, especially when necrosis, undermining or closing of a wound under ten-
the hair superior to it is moved slightly to the left or right, it sion creates a greater potential risk for this complica-
is better to avoid removal of more hair from this region. The tion.
area that most often develops problems with coverage after 5. As indicated earlier, galeal or dermal sutures, usually
multiple donor harvests is the mastoid region. In addition, as 3-0 Vicryl, 2-0 to 4-0 Vicryl Rapide, 4-0 Monocryl, or
indicated, it is wise to study the patient’s hairstyle. Short hair- Chromic catgut can be employed to take the tension off
styles make scar concealment more difficult. Often, the hair is the superficial skin sutures.
cut much shorter over the auricles. Should the patient prefer 6. Deep plane fixation sutures, as described later by Seery,
this style, it may be prudent to avoid harvesting from the supra- can be tried. Unger used Seery’s technique on an indi-
auricular region, unless the patient is willing to change hair vidual in whom previous attempts at scar reduction re-
style preference. sulted in no improvement despite the employment of
Unger offers two ‘‘pearls’’ for donor area closure: galeal sutures and minimal closing tension. The results
of this last attempt were better.
1. Tie the knots at either end of a donor wound 5mm to 7. Rather than creating a locus of great tension that is likely
10 mm beyond the end of the donor site. Any exudate to break down, Rassman, Marzola, and Seager prefer
from the end of the wound is likely to gather around a to leave a small gap between the wound margins at areas
knot tied at that point and make removal of the sutures of great tension and to close the rest of the wound,
more difficult and painful. which has little or no tension. This is the most conserva-
2. Take the time to flip hair from underneath the sutures tive option, but it results in slower than usual healing
so that it lies more normally, covers the donor site better, by secondary intention at that site, a wider than usual
and is less likely to get caught during combing. The scar—at least initially—and greater exudation from the
latter practice minimizes the likelihood of pulling on open defect. Seager has claimed that if the wound is
the sutures during combing, thereby causing pain and left open to heal by secondary intention, the width of
possibly wider scars. The wound edges should also be the resulting scar is often the same or scarcely greater
properly approximated at the same time. than in the area where the donor region was approxi-
332 Chapter 10
mated, because the scar contracts with the passage of deep plane fixation and is believed to be particularly useful in
time. With this approach, the patient may also have the secondary or tertiary harvesting in a fibrotic donor area or in
least risk of serious postoperative complications such harvesting of a notably wide strip (e.g., 2 cm).
as donor area necrosis and ‘‘railroad–track’’ scars.
1. The donor area strip is removed and hemostasis is se-
All hair restoration surgeons encounter a complicated donor cured.
area, a donor area with wide scars, ‘‘shotgun’’ punch graft scars, 2. A sewing edge is obtained with a sweeping movement
multiple linear scars, and a donor area near depletion. Such a of a no.10 blade through the subcutaneous tissue on
donor area offers more challenges than a virgin one and height- both sides of the wound. This is rarely accompanied by
ens appreciation of a well-considered long-term plan for har- significant bleeding. During initial harvesting, or even
vesting in a virgin donor area. Various techniques exist for secondary harvesting, when the tissues are mobile and
handling complicated donor areas. Some surgeons advocate well vascularized, this step alone usually allows a sim-
avoiding scars, whereas others recommend removal of some of ple one-layer or two-layer closure, as preferred. If, how-
the scarring in sessions that are either devoted entirely to scar ever, the wound remains refractory to closure, step 3
removal or are part of a procedure that includes harvesting of should be performed.
new hair for transplantation. Nordstrom has used his silicone 3. The wound edges are further undermined but not for
suture for treatment of wide donor scars. (Personal communica- more than 1 cm or so than as detailed in step 2. The
tion by email or fax on or after March 21, 2001.) He has seen superior wound edge should be everted and a PDS 2-
scars as wide as 20 mm reduced by 50% or more when this 0 suture should be placed in the deep dermis as far away
suture is employed.
as possible from the wound margin (e.g., 6 mm to 7 mm
With shotgun scars, alterations of hair angles occur wherever
from the wound margin). The suture should be placed as
there is scar tissue. Therefore, excising an ellipse is nearly al-
inferiorly as possible to the deep fascia (not the deep
ways the best way to obtain more donor material. Epstein advo-
dermis) in the bed of the most inferior part of the wound.
cates the use of a power punch to excise round grafts from
Only moderate tension should be used (Fig. 10A–15a).
between round graft scars, and then later excision of the original
scars with the same punch or (the method we prefer) excision The sutures must be placed from deep dermis to deep fascia and
of the entire area with a scalpel, before closing the wound. not from dermis to dermis. Several sutures may be necessary,
With experience, surgeons gain knowledge and master tech- depending on the length of the wound and the degree of diffi-
niques to manage complicated donor sites. Surgeons should culty in closing. Placement of each suture should be alternated;
always avoid making the situation worse. Therefore, a patient that is, from a point as superior as possible in the dermis of the
whose donor area challenges a surgeon’s level of expertise superior flap to a point as inferior as possible in the deep fascia
should be referred to a more experienced practitioner. If a pain the most inferior reaches of the wound. Placement of the
tient has a low donor area hair density or a severely depleted adjacent suture should be from a point as inferior as possible
donor area, it may be wise to avoid further surgery. If there is in the dermis of the inferior flap to a point as superior as possible
little hair to move, the surgeon may have a reduced capacity in the deep fascia of the superior part of the wound (Fig.
to meet the patient’s expectations. Moreover, in all cases, a 10A–15b). Alternating from superior to inferior and inferior to
narrow enough donor area should be taken to allow closure superior should be continued until the wound edges are approxi-
with absolutely no tension. The blood supply in the region is mated. All knots should be buried. The skin should be closed
already severely depleted by scar tissue. Also, postoperative with 3-0 or 4-0 Nylon, placed either as running or interrupted
edema over the first 2 to 3 days increases wound tension to a sutures.
surprising extent. Unger recommends that everyone evaluate The Seery technique is not simple and requires practice to
the donor area in at least one patient; the effect of postoperative perfect. Because of its complexity, it is an excellent five-finger
edema on wounds originally closed without tension may be exercise for improving surgical skills. Its main benefit, how-
shocking. Unger also recommends that (1) the surgeon try to ever, is to facilitate low-tension closure in fibrotic donor areas,
remove strips containing more scar than hair to make the ap-
or in a location where a wide strip is taken, or when the surgeon
pearance of the donor area better than before the surgery; (2)
experiences difficulty in closing the wound for any reason. The
at least one donor wound edge should pass through intact (non-
rationale of the procedure is based on surgically minimizing
scarred) tissue so that blood supply in at least one edge will be
wound tension during closure.
more normal than blood supply in the scar tissue; (3) a solution
of 3% to 4% minoxidil be applied two or three times daily to Seery has also provided a biomechanical rationale for deep
the wound area to increase vasodilatation and minimize delayed plane fixation closure (41), and it is quoted here:
healing and potential temporary hair loss around the donor site; ‘‘Tension created at the wound on closure is responsible
(4) bacitracin ointment be applied two or three times per day for multiple adverse sequelae (see later). The standard
(after the minoxidil application) to minimize potential infection method of combating tension is to attempt to overcome it
in the area with reduced blood supply; and (5) sutures be left with a combination of extensive undermining and traction
in place for 10 days rather than the usual 7 days because of with tension clamps, big needles, heavy suture, and mus-
delayed healing in areas with extensive scarring. cular force. The method of donor site closure, detailed
earlier, is a modification of deep plane fixation. This
THE SEERY APPROACH TO DONOR SITE eschews extensive undermining and traction closure. The
CLOSURE UNDER TENSION rationale for its use depends on two tenets of surgical
practice:
The following protocol for donor area closure is recommended
by Gerard Seery (41). This method is based on the principle of 1. Channeling tension forces through non-undermined
Figure 10A-15 Closure of the donor area. (a), The suture is at first placed as high as possible in the dermis of the superior flap and
fixed as low as possible to the deep fascia in the inferior wound. (b), The next suture is inserted into the deep dermis of the inferior flap
and fixed to the deep fascia at the base of the superior wound. The method of placement is alternated until the wound is completely closed.
tissues notably limits their adverse effects as com- and stretching. The ability of skin to recover from stretch
pared with tension transmitted in extensively un- resides in its elastic component (54). When skin stretches,
dermined tissues (53) and the elastic fibers elongate in the direction of the stretch-
2. tension vector forces channeled away from super- ing force, allowing the convolutions in collagen to
ficial ‘‘at-risk’’ tissue into deep-plane tissues al- straighten out. The resultant elongation is a function of
lows the adverse effects of tension to be dissipated progressive displacement of ground substance and tissue
in tissues other than the wound (54): fluid, which accompanies collagen realignment. This
continues until there is a structure of parallel collagen
The most important criterion in deciding the width of the
fibers that resists further extension. This complies with
strip that may be successfully harvested, without creating
a principle of Physics that states that stress (stretch) is
undue tension at closure, is the laxity of the tissues (55).
directly proportional to strain (elongation) provided the
Donor area tissues may be either naturally tight or tight
elastic limit is not exceeded.
as a result of prior harvesting. A combination of each
is the worst possible scenario. The belief that closure The elastic limit of skin (or any substance) is that point
problems posed by tight scalps can be solved by extensive at which the components commence to rupture and the
undermining and stretching is in serious need of review. stress/strain ratios no longer apply. It is accompanied by
The scalp is made up of collagen, elastic fibers, blood adverse tissue changes. The elastic limit for skin elastin
and lymphatic vessels, and nerve fibers with mucopoly- is about 100% and that for collagen 10%. When skin
saccharide ground substance and tissue fluid. All of these elongates more than 100% of its resting length, the elastic
elements are adversely affected by extensive undermining fibers rupture. The impaired elastic is now no longer able
334 Chapter 10
to return the collagen to its normal resting state, even An acceptable solution to the problems of some of these
when stress is removed. This results in the permanent, patients eventually showed up—also on the Internet—instead
irremediable adverse consequences for the tissues called of in medical journals. It consists of the excision of single FUs
plasticization, better known to surgeons as stretch-atro- directly from the donor area instead of from an excised strip
phy. (thin, dry, brittle, poorly vascularized skin), com- of donor tissue and is most frequently called follicular unit
monly seen after midscalp serial scalp reduction and extraction (FUE). The technique achieved almost a cult status
donor area traction closures. Stretch-atrophied tissues in Internet hair transplant chat rooms by late 2001. Rassman
are relatively unsatisfactory for subsequent hair trans- and associates have published their method of doing this proce-
plantation. Skin stretching also attenuates blood vessels, dure (56). They copied Inaba’s protocol of using a sharp dispos-
decreasing tissue perfusion, which, if allowed to continue able punch to incise approximately 2 mm into the midreticular
unchecked, will ultimately exceed the critical closing dermis, stopping short of subcutaneous tissue. Then, using open
pressure and perfusion stops. Lesser degrees of stretch forceps to press down on the skin surrounding the graft, the top
will reduce circulation. Elongation of nerves and reduced of the graft is firmly grasped with a fine, rat-toothed forceps and
lymphatic drainage causes pain and edema, respectively pulled out with traction (57). This approach avoids accidental
(53). amputation by the punch of the distal follicles in an FU. Folli-
Non-undermined skin is better able to withstand the ill cles in an FU tend to splay out much like wheat-stalks in a
effects of tension stretching than undermined skin. Exten- bundle that are tied together near the top and that spread near
sive undermining is also ineffectual. In a clinical research the bottom. The grafts of some patients are easily extracted
study by Seery (55), two groupings of midline alopecia intact, whereas those of other patients virtually always have
reductions were described, the only difference being that significant damage to the FU. Rassman and associates are at-
one had undermining of 15 cm bilaterally and the other tempting to find guidance on how to judge whether a candidate
only 5 cm of undermining bilaterally. The excision widths for this technique is good, poor, or in between the two extremes.
in each group were identical at 39 mm. There was no For the time being, they recommend excision of 5 to 10 test
significant difference in stretch-back. This suggested the grafts from a prospective patient, rating the ease of extraction
extra undermining of 10 cm bilaterally contributed noth- of intact FUs on a scale of 1 to 5. A rating of 1 indicates that
ing in terms of increased tissue excision. This conclusion all FUs can be extracted intact; 2 means that most of the FU
is scientifically supported by Raposio (52), who, in an is present, but up to 20% of its distal end and most of the fat
excellent paper on tensiometric measurements in serial around the distal follicle may be missing. A score of 4 indicates
scalp reduction, reported ‘‘the benefits of an extensive that most of the fat surrounding the follicle is missing and a
(15 cm) undermining were minimal as compared with significant number of distal follicles are amputated, whereas 5
those obtained with 5 cm undermining.’’ As a practical means that there is significant damage to virtually all of the
matter, it is unlikely that undermining of much more than grafts. (A rating of 3 is deemed neutral). They have named this
2.5 cm from the donor wound edge is worthwhile. a FOX test (FOllicular unit eXtraction) and recommend that,
for the time being that only those who are rated as FOX class
Follicular Unit Extraction I or class II be accepted as candidates for this technique (FOX
positive). In general, patients with coarse hair seem to be FOX
The development of wide, cosmetically embarrassing donor positive more often than those with fine hair, but multiple addi-
area scars has become increasingly frequent since the early tional factors can alter that generalization (56). The results of
1990s. There are multiple possible causes for this complication, using the FOX test in 208 of their patients are shown in.
which are discussed earlier in this chapter. Probably the two It appears that the main advantages of this technique are (1)
most important ones, however, are probably the patient’s ge- FUs can be selected and excised on the basis of how many hairs
netic susceptibility to poor healing and closure of the donor they contain. As Rassman has pointed out, one can facilitate
wound with too much tension. The first is unavoidable and the production of the greatest possible recipient area density,
relatively uncommon. The second is usually the result of a mis- for example, by selectively removing only FUs with three or
judgment on the part of a surgeon who is attempting to get as more hairs. (2) No sutures are required and (3) all donor sites
much donor tissue as possible in a single session. In particular, rapidly shrink and heal with scars that are so small that they
in our opinion, the ‘‘megasessions’’ of 2500, 3000, or even are difficult to find except on very close inspection. FUE, there-
more grafts were a donor area disaster for an undocumented fore, may be advantageous for patients with particularly tight
number of patients, usually those with tighter than average
scalps, who either pushed their surgeon into doing as much as
possible in a single session or who were encouraged by their
doctors to do so. Because a significant number of these wide Table 10A–9 Fox Test Biopsy Data
scars are relatively resistant to successful revision, there is now
a sizable group of patients who have had no apparent solution Fox Class No. patients % of Total
to the problem except that of transplantation of hair into the
scar—if donor hair was even available. For these individuals, 1 53 26.5
2 72 36.0
the thought of another strip being excised, with the possibility
3 23 11.5
of another unsightly scar, was an appalling prospect. In the last
4 20 10.0
few years, they have made their plight widely known, primarily
5 32 16.0
through the Internet, looking for a solution and warning others Total 200 100%
of the dangers of strip harvesting.
scalps or an inherent tendency to heal with wide scars if strips 3. Follicle Damage
are excised. It may also be preferred by those who are frightened It is hard to know how many FUs will be fatally injured
to try strip harvesting either because of their personal past prob- with current methods of FUE. Even in FOX class I and class
lems with this technique or because they have seen, heard, or II patients—and 40% of Rassman’s patients were not class I
read about people who have had such problems. or class II—many more were damaged than could have been
There are, however, a number of significant disadvantages expected with good conventional harvesting. Francisco Jimenez
to the current state of FUE: and others have already noted that unless the insertion point of
1. Cosmetic Factors the arrector pili muscle is severed during the initial incision of
The authors point out that large sections of the donor area each site, it is very difficult to extract an intact FU. Yet follicles
have to be clipped short as preparation for FUE in order to find in an FU begin to splay just proximal to the bulge (into which
a significant number of FUs that are suitable for extraction, the arrector pili muscles insert). Thus, a successful extraction
presenting ‘‘a significant postoperative cosmetic problem’’. To technique depends on a very accurate depth of incision, which
perform a 500-graft procedure, for example, Rassman found is different in different people and which is even difficult to
that 50 cm would have to be clipped from a FOX class II patient consistently replicate in any single individual. Excellent physi-
and 40 cm from a FOX class I patient. (This compares with cian hand-eye coordination and experience will play a large
clipping an area just slightly larger than 5 cm for conventional role in the efficacy of FUE. As noted earlier, there are also
strip harvesting). There is usually insufficient hair superior to other factors affecting the likelihood of obtaining intact FUs,
the clipped donor area to comb over it and thereby camouflage which Rassman is trying to clarify.
it. This is much more cosmetically embarrassing than conven- Fortunately, the operator can choose to leave FUs that have
tional harvesting, in which most of the clipped area is excised been incised but prove difficult to extract in their places, moving
and the donor site can be easily camouflaged, even with 1-inch- on to more cooperative FU sites. Thus, surgeons who are not
long (or shorter) hair. Rassman suggests that clipping all of the too proud to leave resistant FUs can minimize follicular damage
rim hair to 2 mm or 3 mm minimizes the cosmetic prob- with FUE. Transected follicles in extracted FUs also mean that
lem—but does not totally prevent it. As it is described, the some of these FUs remain in the donor area and are still capable
clipped area is still far more noticeable than conventional har- of producing hair. The amount of permanent follicular damage
vesting for at least the first postoperative week. I suspect, how- may, therefore, not be as great as initially surmised.
ever, that a cosmetically better way of harvesting FUs will not Nevertheless, rather than working ‘‘blind’’ in the depths of
be difficult to find and may be facilitated by the development the wound with FUE, FUs carefully prepared from an excised
of a better method of follicular extraction. strip, on a well-lighted surface, with whatever magnification is
2. Donor Area Damage required—ironically an issue Rassman and Bernstein have long
The excision of FUs via FUE involves a tremendous increase championed—is currently, in most offices, almost certain to
in the total length of incisions compared with conventional strip result in less lethal damage follicles. When there are a limited
harvesting—with as yet unknown consequences. For example, number of follicles per patient, anything that increases the risk
if 500 FUs were extracted, 500 grafts with a 1-mm diameter to them is obviously disadvantageous.
would be excised. The perimeter of a circle is calculated with 4. Distortion of Follicle Direction
the formula 2␲R; in this case, 2 ⳯ 3.14 ⳯ .5 ⳱ 3.12 mm. When the small donor sites heal, they create scars that may
Five hundred grafts would therefore involve incisions totaling well distort the hair direction or angle of adjacent FUs. Depend-
1560 mm (500 ⳯ 3.12) or 156 cm or 62.4 inches (156 divided ing on the severity of this effect, these scars can have the result
by 2.5) or 5.2 feet! If, instead, strip harvesting were employed, of making further harvesting by either FUE or conventional
a strip that has a surface area of approximately 500 mm, for means more hazardous to the remaining follicles.
example, 6 mm ⳯ 83 mm, could be expected to produce 500 5. Increased Risk of Infection
FUs. The perimeter of such an area would be approximately If additional FUE procedures are done 1 day apart or a few
83 Ⳮ 83, or 166 mm, plus the length of the tapered ends. It is days apart, in order to avoid distortion of follicle direction, there
unlikely that that would total much more than 200 mm, as op- is almost certainly a greater likelihood of presence of bacterial
posed to the 1560 mm of incisions created by FUE. It may be pathogens in the donor area.
argued that the FUE method can be expected to result in less 6. Increased Operating Time
damage to deeper vessels than conventional strip excision be- FUE—as it is currently practiced—is far more time-con-
cause the incisions go only as deep as the mid-dermis. However, suming than conventional harvesting.
any difference would probably not be that great compared with For all of the reasons mentioned, although FUE will find a
good strip harvesting that includes an effort to limit the depth role to play in hair restoration surgery, until we establish how
of incisions to high subcutaneous tissue. It seems quite likely important or avoidable the disadvantages are, Unger believes
that small vessel damage will be similar, regardless of whether its role should be limited. Patients who have bad scarring that
small vessels in the high subcutaneous tissue are cut with a is resistant to adequate revision, for whatever reason, are the
blade or torn as a graft is pulled out of its bed. The nearly most likely to benefit from current methods of FUE. Patients
eightfold guaranteed increase in incision length with FUE, without such a history should be advised that the likelihood of
therefore, will be hard for Unger to accept in all but special developing a wide scar from the excision of a 6 mm ⳯ 83 mm
situations until the clinical effects of the increased incision strip, for example (to produce 500 FUs), is, in the vast majority
length are better known. (Those effects may be substantial or of people, next to zero. If the patient still wants to proceed with
minimal.) Under the circumstances, it is also hard to accept the FUE (1), the donor area hair should be clipped to approximately
designation of this approach—according to the title of Rassman 2 mm so the hair direction can be clearly discerned. (2), Very
and associates’ article—as ‘‘minimally invasive surgery.’’ sharp punches should be used and replaced as frequently as
336 Chapter 10
a b
Figure 10A-16 (a), A typical donor area scar produced by the excision of an 8-mm wide strip in an area of average hair density and
laxity. It was approximately 0.1 mm to 0.2 mm wide. The hair has been lifted to expose it. (b), A photograph taken at the same time as
that shown in Figure 10A-16a with the hair combed as normally worn. There is no noticeable scarring despite a very short hairstyle. (c),
Schematic of tool for follicular unit extraction (FUE): 12—hollow body punch handle; 16—custom-produced (round or oval, 7 mm through
1 mm); 18A-C—perforator unit consisting of handle and perforating microspikes; 20—tube leading to suction. (d), Schematic drawing of
tool for FUE: 14—tool handle; 16—metal punch; 18—perforator: A) collar, B) spike, C) handle; 22—hollow handle; 24—follicle guard.
(Schematic drawing for parts c and d courtesy of Dr Alan Feller.)
necessary to ensure sharpness. (For example, Miltex dermal patient to shave his head without revealing noticeable
biopsy punches) (3), Maximum tumescence should be em- scars, offers a glimpse of promise, especially to the young
ployed, with frequent reinfiltration of additional fluid to spread patient.
the FUs as far apart as possible and to create a rock-hard work-
2. The ability to expand the total donor area that can be
ing area. (4), Magnification of 4x to 7x should be employed.
removed from a given patient. If you remove 7000 to
(5), A 27-gauge needle should be used to make perforating
8000 grafts and leave a patient with a single scar, the
incisions around the periphery of the FUs as an attempt is made
donor area around the scar will be stretched, often to
to extract them (see later). (6), As recommended by Rassman
its limit, and the surrounding follicular density may be
and associates, 5 to 10 test grafts should be done before agree-
markedly reduced. Therefore, additional attempts to har-
ment is made to do a full session. (7), Subsequent sessions
vest hair might proceed with a completely new donor
should take place 1 or 2 days apart before scar tissue has an
area and an additional scar. This is obviously somewhat
opportunity to distort hair direction, and vigilance should be
disadvantageous to the patient. Follicular isolation offers
maintained to detect any sign of infection.
the ability to extract additional grafts without creating
If a more efficient method and/or instruments can be devised
additional clinically noticeable scars. Thus, the imper-
for harvesting FUs—one that will result in follicular damage
ceptible results of FUs in the recipient area can be joined
rates that are the same as those encountered with strip harvesting
by the elimination of the typical linear donor area scar.
of FUs (or even lower)—, the number of cosmetically undetect-
able FUs that can be extracted from a donor area may be sub- 3. The follicular isolation technique also allows us to
stantially increased. Such a development could represent the harvest from denser areas distal to a donor area scar
next major innovation in hair transplanting; it has, therefore, that has unsatisfactory hair density adjacent to it. This
already attracted a number of investigators and would-be inven- may allow us to expand the total donor area reserves to
tors. Cole and Rose, for example, have developed their own more than 10,000 FUs.
version of the FUE technique, which they call the follicular 4. Follicular isolation may eventually result in 100% of
isolation technique (FIT). They have created instruments that FUs being harvested intact, compared with standard
allow them to precisely control the depth of their punch inci- donor strip harvesting and graft preparations, where the
sions. They first perform a dermal depth analysis. This test percentage of intact FUs ranges between 98% and less
employs a two-hair FU and involves passing a 1-mm cylindrical than 70%, depending on the technique, training, experi-
punch into the skin to a predetermined depth. The punch inci- ence, and psychological state of the physician and staff.
sion allows the dissection of an intact FU out from the surround-
ing dermal and subcutaneous fat. A two-hair FU is chosen to Dr. Alan Feller is also trying to perfect an instrument that
increase the probability of extracting at least one mature hair consists of a sharp 1-mm punch attached to a suction apparatus.
follicle that extends well into the subcutaneous fat and is not The depth of incision of the punch would be adjustable, and a
in catagen or telogen phase. (As noted elsewhere in this text, variable number of small perforating needles would be arranged
many FUs and groups consist of hairs of varied depths, diame- around its periphery to help free the FU from its bed. Unger
ters, and phases of hair growth. The length of the hair shaft and has watched Dr. Feller employ a simple 1-mm disposable bi-
the depth of the dermis are recorded with use of a microscope opsy punch and a no. 27 needle, which he used to make two
and scale or with a Mituyo digital micrometer mounted on a to four perforations around the base of the FU as he was trying
stage. This measurement is then applied to the instruments. The to pull it out of its bed with small forceps and steady traction,
depth of the incision can be precisely controlled by adjustment The tiny perforations had a remarkable effect of rapidly facilitat-
of the depth-control knob. Cole and Rose have postulated sev- ing the extraction of an intact FU. The idea of suction instead
eral important advantages of a perfected method of follicular of traction with forceps would also seem to be a good method
extraction or isolation. In their words: of limiting mechanical trauma to the FU. (Fig. 10A-16c and d)
The evolution of FUE will be a fascinating spectacle.
1. Undetectable scars. Typical strip harvesting leaves a
linear donor scar. Follicular isolation involves punching
out a 1-mm (or less) diameter core that heals by second- 10B. The Unger Approach to the
ary intention. The scar is imperceptible to the naked eye. Donor Area
Young patients often enter hair restoration surgery with-
out regard to the advice they are given about potential Walter P. Unger
future hair loss. This shortsightedness can leave them in
a quandary as they age. The responsibilities of maturity A great deal of information is provided in the preceding section
may constrain their finances such that they are not able of this chapter, which can be confusing to the novice hair resto-
to continue their hair replacement as future hair loss ration surgeon. This section is a summary of Unger’s approach
occurs. They might elect to shave their heads in an effort to the donor area, with repetition of some of the more important
to conceal their hair loss. However, this would expose concepts covered in Chapter 10A. Chapter 10C is a summary
the linear donor area scar and probably could lead to of Cole’s technique.
the patient’s returning to the office and complaining
about the prominence of the scar with the head shaved. INTRODUCTION
Although this scenario is not especially common, it can
and does occur with current conventional harvesting It sometimes seems that the human scalp was specifically de-
techniques. This new technique, which would allow the signed with hair transplanting in mind. Anyone who has been
338 Chapter 10
involved in hair restoration surgery for more than a few years PLANNING IN THE DONOR AREA
has had patients ask how it is possible to take so much hair
from the ‘‘sides and back’’ of the head and to make such a big What should the length and width of each donor area strip be
difference to the ‘‘top’’ of the head without having a corre- for any given patient? The answer is dependent on a number
sponding decrease in hair density in the areas from which the of factors:
hair was removed. This is possible because of three significant 1. The size of the expected SDA. The SDA has been de-
characteristics of the donor and recipient areas: scribed elsewhere in this chapter based on a study of
1. Hair density must be reduced by at least 50% before any 365 men older than 65 years of age (Table 10A-2 and
thinning is noticed in the donor rim. (This varies depending on Fig. 10A-2). In that discussion, however, it was pointed
hair characteristics such as hair angle, caliber, color, wave, and out that this was only a general pattern of the SDA, and
curl.) In particular, the relatively acute angle of hair in the donor that such a pattern should be confirmed on the basis of
area accentuates the effect of shingling of this hair, which in physical examination and consideration of the patient’s
turn creates the illusion of more than actual hair density. This age and family history. The younger the patient, the
latter characteristic of donor area hair has not been noted in the more cautious the surgeon must be in deciding what the
literature, but I believe it is as important in the donor area as dimensions of the SDA will be in the long-term. It is
in the recipient area. (See also later.) also worthwhile pointing out that in the aforementioned
study, measurements were taken in nontumescent
2. Removal of 50 mm of a 70-mm wide donor area, for
scalps. During hair transplanting, the donor area is typi-
example, does not leave a 20-mm wide zone. In other words, the
cally tumesced; for example, what was originally a 9-
hair-bearing rim does not narrow significantly as donor tissue is
mm wide section, may be 91⁄2 mm wide to 10 mm wide
removed from it. Instead, the remaining hair is spread more
after it is tumesced. Thus, if a 10-mm wide strip is
evenly over a similarly sized area, thereby reducing the donor excised from the donor area immediately after tumes-
area hair density. Thus if there is a safe donor area (SDA), that cence has been induced, the excision results in the re-
is 70 mm high in the midline of the occipital area from which moval of perhaps only 9 mm of the original SDA. More-
five strips, each of which is 1 cm wide, are removed during over, as noted previously, the hair of the donor rim does
five separate sessions, that zone has not been reduced to a 20- not decrease by the full width of any strip that is excised
mm width. Its exact size reduction has never been studied, but from it.
it is altered far less than is generally surmised. Just as impor- 2. The second factor to consider when deciding on the
tantly, the hair density does not appear to be reduced by five width and length of donor strips is the number of grafts
sevenths. The change in hair density in the original SDA has required per session to produce the desired effect. This
also never been studied, but some of the stretch has come from in turn is affected by the size of the recipient area, donor
hair-bearing and alopecic areas superior and inferior to the SDA hair density, hair characteristics (the better the charac-
(Fig. 10A-2). teristics, the fewer hairs necessary to produce the same
3. As noted in Chapter 5 and earlier in this chapter, small effect), type of graft, and—perhaps more impor-
amounts of donor hair produce disproportionately large effects tantly—patient coverage objectives. Put differently,
in the recipient areas. One need only look at the amount of hair what proportion of the area of MPB does the patient
that has been clipped from the potential donor area just before want to cover and with what density? If I carry out
the strip is excised and imagine putting that hair on a frontal area a session of microslit grafting, my typical procedure
of male pattern baldness (MPB). This relatively small amount of currently consists of approximately 600 to 800 FUs and
hair is expected to produce—and, amazingly, does pro- 400 to 200 microslit grafts of various types. Alterna-
duce—good coverage in the recipient area after one, two, or tively, I may do a session of 1500 to 2000 FUs, or 800
three sessions, depending on hair characteristics (Fig. 10A-8, to 900 FUs, 200 or more microslit grafts, and 100 or
10A-9, 10B-1a–f). How is this possible? An important part of more slot or small round grafts. Such sessions often last
the answer lies in the fact that the clipped hair is rather short, between 5 and 7 hours, an interval that approaches the
emotional tolerance of most patients unless they are
whereas, when it is placed in the recipient area, it is allowed
continuously sedated. Longer sessions also become
to grow longer. The added length of the hair produces more
more physically strenuous for patients, and test the pa-
total hair fiber in the recipient area without the presence of
tience and physical stamina of technicians and nurses.
additional hair follicles. The grafts are also placed in such a
Longer sessions are particularly disadvantageous when
way that the hairs overlap one another. Just as in the donor constant meticulous work is required of the medical
area, this shingling effect produces the appearance of much staff.
greater density than is actually present. The illusion fails wher- 3. It is important to pace the depletion of the donor area.
ever the hair is not allowed to overlap, such as at the hairline If a patient is interested in only one or two sessions, or
or where the hair parts, or at the center of the whorl of the crown. is past middle-age, the surgeon can use as wide and as
In these locations, additional grafts, larger grafts, follicular units long a strip as can be excised (as long as excessive
(FUs) with three to five hairs, or—more often—additional ses- closing tension is avoided) without concern about what
sions must be done to make the hair in those areas look as thick is being left behind for future use. If, on the other hand,
as the adjacent hair where shingling occurs. Patients should, a series of somewhat smaller sessions over a number
therefore, be forewarned that these nonshingled areas nearly of years is planned, a maximum width or length of strip
always require extra sessions to look as good as the other sites usually cannot be taken out because of the need to leave
in the recipient area. behind sufficient donor area reserves for future sessions.
Because most of my patients come to me relatively early mum width of the SDA exists in the parietal areas, it
in their hair loss, and because they are usually willing should not be assumed that the strips should be widest
to commit to between three and six sessions over their in those areas (at least in the tighter postauricular por-
lifetimes, I have typically limited my sessions to the tions of the parietal areas). Nor should the widest strips
number of grafts described earlier. I frequently choose be taken from the generally very lax but relatively nar-
to take less than I actually can, based on the patient’s row safe temporal and occipital areas. In addition, I
scalp size and laxity. This approach allows me to see have observed that scalp laxity is frequently not the
over a period of years whether the hair loss progresses same on both sides of the scalp. Therefore, the width
as I thought it would and leaves reserves for future ses- of the donor strip should often vary from one side of the
sions if my original projection was wrong. Moreover, I scalp to the other. Disparity in scalp laxity is particularly
am constantly concerned about compromising the blood noticeable in patients who have previously undergone
supply to the recipient area, which would occur if too donor harvesting.
many grafts were transferred in a single session or if As a result of the preceding factors, and as noted
grafts were placed too close together to produce more earlier in this chapter, I usually employ double-bladed
density per session. For example, I do not like to evenly scalpels and frequently use an 8 mm–wide (or occasion-
transplant the entire frontal area and the midscalp area ally 9-mm wide or 10-mm wide) strip in the temporal
during the same session for fear of compromising the area, narrowing it to 7 mm or even 6 mm in the postau-
blood supply to the central area. (As implied, less than ricular or mastoid area and widening it again to 8 mm
solid transplanting of these areas does permit me to treat (or occasionally 9 mm or 10 mm) in the posterior pari-
both of them concomitantly.) etal and occipital areas. A single blade is used to join
It is also important to bear in mind that patients may adjacent strips of different widths and to taper the ends
tell their physicians at the outset what their coverage of the strips. This variation in strip widths in different
and density objectives, but they may well change their areas is similar to Seager’s approach, which was de-
minds after going through the procedure and seeing the scribed earlier in this chapter, except that the width of
results. This is certainly the case in a large number of my strips is generally considerably less than his. Be-
my patients, who often begin by wanting to treat either cause I sometimes use two donor zones (see later), the
the frontal or the crown area only. Once they see how tapered ends of my strips become narrower anteriorly
easy the procedure is and how good the results are, their into the temporal area and posteriorly into the occipital
objectives change. They are either satisfied with fewer area; therefore, by the time the midline in the occipital
sessions than we thought they would require in any area area is reached, I do not excise as wide a strip as when
and expand their objectives to cover a greater proportion I enter the anterior portion of the occipital area. This is
of the MPB, or they decide to acquire more density helpful in allowing me to excise less donor tissue in the
than they originally thought they would want. This has midline of the occipital area, where the width of the
happened to me so often that I am reluctant to take SDA is narrower than in the parietal area. There are, of
maximum widths (as allowed by scalp laxity, for exam- course, many instances in which the strips go from ear
ple) and maximum lengths during the earlier sessions. to ear, and then the width of the donor strip excised
Many patients ask their physicians to do as much as from the midline of the occipital area is often as wide
possible per session. Many physicians also have fees as what is excised from the parietal areas. However,
that are based on the number of grafts transplanted. It over a course of five or six sessions, the overall width
can, therefore, be highly attractive to patients and physi- of what is excised from the occipital area is less than
cians to do exactly what the patients ask and to believe that removed from the parietal areas. Cole has pointed
that one or two sessions will be sufficient to complete out in this chapter the increased rates of follicle transec-
the treatment. Whether this is the best way to proceed, tions in which excisions are tapered in high hair density
however, is a more debatable matter. After many years locations such as the occipital area. I try to minimize
of practicing medicine, I have learned to respect the the problem by making my midline tapering as short as
old adage that in the long run, ‘‘moderation is the best possible, and I am also trying out Seery’s trapezoid
policy.’’ In brief, I prefer to keep more grafts in reserve, ends. In addition, I address Cole’s concerns about use of
in case I have misjudged the eventual size of the area double-bladed knives on a curved scalp by (1) inducing
of MPB or the patient changes his coverage objectives tumescence in the donor areas until they are rock-hard
with the passage of time. immediately before I incise them and (2) using double-
4. As implied earlier, the fourth factor to consider when bladed knives, which are nearly always only 7 mm to
planning the width of strips of donor tissue is the laxity 8 mm apart. Because of both of these factors, the effect
of the scalp combined with the parameters of the SDA. of the curvature of the skull on hair angle from the
As has been noted elsewhere in this chapter, the donor superior to the inferior blade is minimal, and hair tran-
area is frequently most lax in the midline of the occipital section, because of the latter, is similarly minimal. In
area and in the temporal area. It is tightest in the postau- any case, I believe the positive aspects of my pattern
ricular, or mastoid, area. Unfortunately, the SDA is ap- of harvesting outweigh the negative ones.
proximately only 50 mm wide in the temporal area and 5. I imagine the donor area as consisting of six sections:
approximately 70 mm wide in the midoccipital area, the left and right supra-auricular, parietal and occipital
but it is nearly 80 mm wide in the parietal areas, which areas. In choosing the donor area, the physician may
include the tighter mastoid areas. Although the maxi- include one to three or all six regions, and excise one
340 Chapter 10
or multiple strips from each. As indicated earlier, in area, one superior to the other, or a single unilateral donor zone
some cases, I prefer to remove two donor strips from equal in width to the two strips harvested would result in more
contralateral sides of the scalp. One donor zone is usu- tension at the sites of donor wound closure than if contralateral
ally in the left or right inferior occipital area, where the sites were used. In addition, two donor strips on the same side
hair has a fine texture but where I believe it is also likely of the scalp could compromise the blood supply to that side of
to be permanent. Fine-textured hair in the most inferior the donor region—especially to the tissue lying between the
occipital area is often not permanent, but quite often two strips, if they are too close to each other. A single, wider
hair slightly superior to those areas combines both fine but unilateral donor zone would also nearly always contain a
texture and likely permanence. The inferior border of more limited number of hairs with substantially different cali-
my inferior donor zones frequently lies on (or slightly bers and colors (now or in the future) because of its more consis-
inferior to) a line drawn horizontally from the superior tent location in the donor area.
reflection of the skin of the external ear and scalp. This A second pattern, used in approximately 80% of my patients,
hair is ideal for transplanting the hairline and sometimes consists of a single donor strip passing through the densest
the center of the whorl of the crown. I inspect the infe- portions of the six donor zones. This strip is typically 8 mm
rior occipital area, looking for a hair density of approxi- wide and (nearly always) no more than 10 mm wide. As de-
mately 12 hairs per 4-mm circle. I trim the hair on the scribed earlier, it varies in width along its length. It extends
left or right side to a length of 2 mm to 3 mm in a into the temporal areas to the same points described earlier for
horizontal band that is 10 mm to 12 mm wide, using the unilateral superior strips. This second pattern is used (1) if
curved Metzenbaum scissors. I then trim a similar linear hair caliber is fairly consistent throughout the donor region,
strip of hair on the contralateral side of the donor area especially if it is fine-textured; (2) if a larger than usual number
at a level superior to the inferior donor zone and at the of grafts are required and a satisfactory mixture of finer and
superior border of what I expect will be the most supe- coarser hairs are present in such a proposed strip; (3) if donor
rior extent of the SDA (Figs.10B-2a and b). Contrary hair density is lower than usual, necessitating longer (and/or
to the schematic drawing, this line is almost always not wider) donor strips to achieve the desired number of grafts; and
horizontal; rather it follows the angle of the superior (4) if a narrower than usual SDA is anticipated—for example,
border of what is perceived to be permanent hair. As if there is a family history of type VI or type VII MPB that I
such, it almost always heads more superiorly from its think the patient is likely to develop. As implied, this would
origin in the occipital midline to its anterior-most point be the safest harvesting pattern for all patients in the long run,
(Fig.10A-2). The anterior limit for the superior strip is and I have pondered using it for all patients. The previously
on a line drawn vertically from the tragus or as far as noted advantages of my current approach have so far stopped
28 mm anterior to this line (10A-2). This second donor me from doing so. However, I find myself employing this long
area contains hair of greater caliber, which is advanta- single donor area pattern more and more often. This is mostly
geous for areas where more coverage, or body, is cos- because I tend to want large numbers of grafts per session; for
metically appropriate. If it extends into the supra-auric- example, 800 to 1000 FUs and 200 to 350 minigrafts, or 1500
ular and temporal areas it also contains hair that will to 2000 FUs.
nearly always turn gray or white earlier than hair in If two donor zones have been used in the first session, similar
the occipital and (often) parietal areas, with long-term but contralateral strips are excised in the second one. The result
advantages that have already been described. is the lengthening of the preexisting scars into the virgin contra-
In the last two or three sessions, the most medial end lateral sides of the scalp, but, after this session, there are still
of either the superior or inferior donor strips is often only two longer scars. If one long donor zone has been used
not the occipital midline but an area that is located more during the first session, the second strip is similar to the first,
anteriorly to avoid intersection with previous donor area or 1 mm to 2 mm wider if there is sufficient laxity. A two-
scars. This also results in the total amount of donor bladed scalpel is usually employed for the entire strip. The scar
tissue that is removed from the occipital area being less from the first session is included toward the center of the new
than the total amount that is removed from the wider strip to avoid transection of hairs whose direction has been
parietal areas of the SDA. For follicular unit transplanta- distorted by the adjacent scar tissue (see later). Thus, only a
tion (FUT), both donor areas are excised by means of single scar is present, even after the second harvest. In third
a double-bladed scalpel. For microslit grafting or micro- and later sessions, either of the two patterns may be employed,
minigrafting, either the inferior or superior donor zone but previous scars are virtually always included near the center
is excised with a double-bladed scalpel. The other zone of new strips so that, with few exceptions, there are two scars
is excised with either a double bladed or a multibladed at most in the donor area, regardless of the number of sessions
scalpel. A double-bladed scalpel is always used if a scar carried out.
from previous harvesting(s) is to be included in the new As noted earlier, a multibladed knife is usually used to excise
strip, or if hair directions and/or angles are more diverse donor tissue to be used for producing slot and round grafts.
than usual. Because my technicians have gradually Usually only two adjacent strips are incised and their widths
come to prefer the strips obtained with a double-bladed vary from 3 mm to 7 mm depending on the type of graft to be
knife, I now use a multibladed one only when I want produced and the hair density. For example, 3-mm wide strips
to produce slot or round grafts of a particular size (see are nearly always used for slot grafts and 2 mm2 grafts.
later). Rock-hard tumescence before incision with single-bladed,
double-bladed, or multibladed instruments results in a stable
Contralateral sides of the donor area may be used for several block of tissue through which the knife blades pass, rather than
reasons. Two donor excisions on the same side of the donor dissection out of the body of a more mobile strip—as is the
a b
c d
Figure 10B-1 (a), A patient 3 days after the first hair transplant showing the extent of alopecia and the outline of two proposed alopecia
reductions (ARs). His objective was to achieve maximum coverage. (b), Six months after the fifth transplant session and after two ARs,
the patient had relatively light coverage over a larger area instead of denser coverage over a smaller area. (c), Frontal view photograph
taken at the same time as that shown in Fig. 10B-1b. (d), Side view photograph taken at the same time as that shown in Figure 10B-1b.
(e), The donor area. This patient had very sparse hair in his inferior-occipital and parietal areas. Only a zone of dense hair 40mm wide to
50 mm wide was available as a source of grafts; nevertheless, five sessions were done and the coverage shown in Figures 10B-1a to 10B-
1d was obtained. (f), This was the only scar in the donor area after five sessions. The patient returned for a sixth session because donor
hair was still available! The sixth session was an FUT procedure to the untreated crown area.
342 Chapter 10
e f
Figure 10B-1 Continued.
case with dissection of all elliptical excisions. The hairs within area, or possibly in both. Thus, transection of hairs at the periph-
the donor area are also spread apart maximally, making their ery of a donor strip excised with a double bladed knife is likely
transection less likely. In addition, the use of a multibladed to be less problematic than it might seem at first, and is far less
knife allows the physician to do part of the graft preparation important than other aspects of the techniques used to prepare,
rather than leaving it entirely in the hands of technicians. Fi- store, and insert grafts.
nally, minigrafts can be more uniform and more rapidly pro- Notwithstanding the previous discussion, my technicians are
duced from narrower strips and are therefore out of the body instructed to produce microslit grafts and slot grafts with a spec-
and in storage fluid for a shorter period of time. It is worth ified number of preferably intact hairs, or an intact FU. We
repeating that all transected follicles are transplanted along with have, therefore, moved away from the use of multibladed knives
intact follicles in the minigrafts produced from these strips. As except for the production of slot and round grafts.
discussed in Chapters 9 and 11, there is evidence to suggest
that if this is done, hair survival may well be little different
from (and may be greater than) that seen when all transplanted
follicles are intact. The instinct is to keep all follicles intact and 10C. The Cole Approach to the
to employ only intact follicles in the recipient area, but until Donor Area
new evidence shows that this is truly important, the supposed
disadvantages of using a multibladed knife should not be ac- John Cole
cepted at face value.
Here is another thought on hair transection that occurs as Cole conceptually approaches the donor area as four regions.
donor strips are cut. If hairs are transected at the borders of the There is a left and right hemiscalp. Each hemiscalp may be
donor strip as it is being excised, a portion of each such hair divided into a superior aspect and an inferior aspect. The two
is left in the donor area as well as in the donor strip itself. The hemiscalps meet at the midsaggital plane and the occipital pro-
effect of transplanting the partial follicles on the strip into the tuberance. The distance of the parabola from one external audi-
recipient area has just been discussed, but the transected follicle tory meatus to the other is generally 28 cm to 30 cm but may
in the donor area may also regrow—perhaps even through the be shorter or longer depending on the size of the cranium. As
scar, as occurs when scalp flap edges are intentionally beveled. noted before, the average follicular density from one hemiscalp
(see Chapter 21). It is highly likely that at least one portion of is 80 follicular units (FU)/cm2 (range 50 to 艐120). Cole gener-
each transected hair will grow either in the donor or the recipient ally begins his donor area at the level of the occipital protuber-
Figure 10B-2 (A), ‘‘A’’ is an example of strip harvesting with six donor zones (A, B, C, D, E, and F for sessions 1, 2, 3, 4, 5, and
6). The width of the strips is shown on the right side of the figure. A 1-mm space has been left between donor sites from different sessions
and represents scar lines. A total of 48.5 mm of donor tissue was used for six sessions, each of which yielded approximately 340 to 400
FU and 450 to 500 or more minigrafts per session. For each session, an inferior donor zone was used (e.g., inferior A) for the hairline or
the center of the whorl of the vertex, as well as a superior and contralateral donor zone (e.g., superior zone A) to obtain coarser, denser
hair more posteriorly or peripherally in the vertex area. (From Unger W, [ed]. Hair Transplantation, 3d ed. New York, Marcel Dekker,
1995). (B), ‘‘B’’ shows typical widths of strips excised for standard grafts, minigrafts, and FU. A total of 57 mm of donor tissue is required
to yield six sessions of grafts consisting of approximately 300 to 350 minigrafts, 350 to 400 FU, and 50 to 60 standard round grafts per
session. Any scar tissue from previous harvests is re-excised during each subsequent harvesting session so that at most only two continuous
scars are left in the donor zone, regardless of the number of sessions carried out. The widths of the strips shown in both ‘‘A’’ and ‘‘B’’
may be increased slightly if donor area hair density is lower than average, or decreased slightly if it is higher than average. In areas where
fine hair texture is not cosmetically critical or if a larger than usual amount of donor tissue is required, two superior donor zones can be
used instead of one inferior and one superior zone (e.g., superior ‘‘A’’ can be combined with superior ‘‘B’’).
344 Chapter 10
ance. The hair is pinned up with hair clips and trimmed with quent donor area yield if previous scars are included in the new
an electric razor (Wahl model 8900 from Sally’s Beauty Supply, donor strip.
Atlanta, GA) to a length of approximately 1 mm to 3 mm. The Harvesting from more than one donor region, in Cole’s opin-
length and width are estimated based on the required number ion, is not necessary to obtain finer hair for the hairline, because
of grafts, type of grafts, and scalp laxity. For example, the pres- it is usually possible to obtain hair of different types from a
ence of any scarring from any previous procedures may necessi- single strip, especially if it is long enough. As has been de-
tate a larger donor area. The strip is excised by means of a two- scribed earlier, additional strips complicate future donor har-
bladed knife or is removed as an ellipse with a single no.10 vests. In addition, donor areas excised as ellipses or rectangles
blade. He generally likes to obtain as much donor tissue as have tapered ends, which often contain the highest percentage
possible from the left or right hemiscalp. This results in one of transected hairs. Two donor strips necessitate the creation
surgical scar on one side of the head. The preceding description of at least two additional tapered ends and, therefore, more
assumes that he intends to produce 1200 to 2350 FUs and de- follicular transections. Multiple donor strips do, however, pro-
pends on suitable follicular density, laxity and, as mentioned, vide a safety net to ensure sufficient appropriate hair for long-
presence of scarring in the area. Loose scalps and scalps with term color advantages and for the hairline. With a single donor
a higher mean follicular unit density (FUD) produce more FUs strip, each section, for example, must be clearly marked so that
from the same hemiscalp unless the donor region is also scarred. the staff allocates the finer hair for the frontal hairline and the
Occasionally, the donor strip must extend from ear to ear, coarser hair for other sections of the recipient area. The multiple
but obvious advantages of hemiscalp excisions include having site harvest helps to ‘‘quarantine’’ the finer hairs and hairs with
a completely virgin donor area on the contralateral side of the different color prospects, whereas the single-strip harvest re-
scalp for the second session and leaving a nonsurgical region quires greater discipline on the part of the staff and the surgeon.
for the patient to sleep on at night. (Cole has pointed out, how- The approaches of both Cole and Unger to the donor area
ever, that unless a second session [at least] is carried out, some most often result in harvests from virgin areas on first and
of the advantages of a hemiscalp approach are lost). There are second treatments. Cole leaves open the option of creating a
other advantages that are not readily apparent. (1) Approxima- second level of scar in third or later sessions, whereas Unger
commits to two–but only two–scars in his first session except
tion of the donor wound margins requires stretching the remain-
for the 10% to 20% of individuals in whom he only uses one
ing donor area so that the defect is obliterated. The donor stretch
donor area and whose characteristics have been previously de-
reduces the FUD on either side of the remaining surgical wound
scribed.
after closure. (2) The wound heals with the formation of a scar.
Update: Since beginning the preparation of this chapter over
These two phenomena and their relationship to future hair yield
two years ago, the philosophy of the practitioners quoted in it
are further elaborated on later. may or may not have changed. I therefore sent out the following
The second donor strip is taken from the virgin contralateral questionnaire to them on October 24, 2003:
side of the scalp and still results in one scar that now extends from
ear to ear. For a third procedure, the donor area is taken superior
to the first or second donor site and, in most cases, includes the old
scar. Cole’s typical first excision is 1.2 cm in width. The second I’m going over the galley proofs of the Donor Area for the
excision, in the same region, is generally between 1 cm and 1.2 textbook. Over two years ago, John Cole contacted you and
cm in width, including the previous donor scar. The previous asked you for some information as to your philosophy of
donor scar generally measures between 0.75 mm and 3 mm in donor area harvesting. Your technique may have changed
width. The total width of actual hair-bearing donor tissue excised since then so I’m inquiring again as to the following:
in the same location after two sessions, therefore, becomes (2.2
1. The range of width of donor strip that you employ, as
cm to 2.4 cm total donor strip width) – (0.75 mm to 3 mm scar
well as the typical width of donor strip
width) ⳱ 1.9 to 2.325 cm of hair-bearing skin. The second donor
2. Whether you use a single blade to obtain it, a double
area excision also tends to result in a wider donor scar than the
blade, or multi-blades
first. This anecdotal finding supports the argument of Dow 3. Whether you believe in undermining superiorly, inferi-
Stough and Marc Avram, that the total width of excision may orly, or both, or neither
have an effect on scar width. It also suggests that, in general, the 4. Whether you close in two layers or one
maximum width of excision that can be carried out without pro- 5. What suture material you currently prefer to use in the
ducing a wider than usual scar is 1.2 cm. This approach generally skin and galea, in addition to needle information related
allows for five or more large procedures, each of which exceeds to the suture material
1200 FUs or a total of 6000 to 7000 FUs. Low FU densities yield 6. Whether or not you prefer staples
fewer FUs, whereas high FU densities yield more FUs. Minimiz-
ing the amount of resultant scar tissue helps to maximize subse- The replies are summarized below. (WU)
Donor Area Closure
Closure
Name Strip width Blade type Undermine (one or two layers) Suture type Staples
Avram M. 8 mm Double Rarely One n/a Always

Beehner M. See below
Cole J. See below
Gandelman M. 10 mm Single Never One Monocryl 4–0, No
Circular needle
Limmer B. 12 mm Single Neither flap Always two Deep: 3–0 Vicryl Never
1st procedure; less on w/X1 cutting
later ones needle. Skin: 4–0
Ethilon with FS2
cutting needle
Mangubat T. 10 mm, (4 mm–15 Multi-blade Neither flap One n/a Always
mm based on almost
laxity) exclusively
Parsley B. 10 mm (8–15 mm) Single Neither flap Two Deep: 3–0 Vicryl with No
X1 cutting needle.
Skin: 3–0 Ethilon
with FS1 cutting
needle
Rassman W. 12 mm (10–15 mm) Double Never One on “virgins” Monocryl 5–0 Never
Two on repeat
cases
Shapiro R. 10 mm Double in past, Occasionally One in the past, Deep: 4–0 Monocryl On occasion
recently single recently two w/PSI needle. Skin:
4–0 Ethilon
Shiell R. 8 mm (up to 12 mm Multi-blade or Almost never Usually single Deep: 3–0 Vicryl Never
for first procedure) single (for new but two if (when used). Skin:
FU cases) previous scar 4–0 Monofilament
wider than 2 nylon w/ 24-mm
mm reverse cutting edge
needle
Stough D. 7–9 mm Single Rarely One N/A Always
(Pathomvanich
Technique-
variation)
Unger W. 8*–10 mm Single Occasionally Almost always Supramid 2–0 CL 20 Never
superior flap, one needle Deep 3–0
rarely both Vicryl
(10mm max)
Beehner M:
1. I most commonly use a triple blade, multi-blade knife holder and take two strips all the way around. They are slightly wider in the flat occipital area in back
and always narrower at the “corners” and laterally. At first sessions my occipital strips are 5 mm and 4.5 mm at the angles and sides. At subsequent visits, I
feel laxity present first and the two strips are then between 4–4.5 mm each posteriorly and 3.5–4.5 mm each laterally.
2. I use a multi-blade holder with three blades in 80% of cases. In 20% of cases, especially when there is distortion of hair direction in the area (cow-licks, etc.)
or if the angle of the hair is very acute, I then draw out with a purple surgical marker, the borders of the ellipse and do it free-hand with a #10 blade.
3. I never try to undermine unless it is necessary to close the wound—which occurs rarely.
4. Two layers. Inverted, interrupted intra-dermal 3–0 Vicryl sutures every 2.5–3 cm of the donor closure.
5. 3–0 Vicryl for the “deep” dermal sutures and skin closure with 3–0 Prolene.
6. Have never used staples.
Cole J:
There have been many changes in my philosophy regarding donor harvesting since I co-wrote this chapter. While my approach to strip harvesting is essentially
the same, my approach to how the donor area is harvested is drastically changed. I have adopted and modified the follicular extraction technique that was de-
scribed by Rassman. My new technique is called Follicular Isolation Technique or FIT. There are several individual characteristics of the patient, which af-
fects how I approach the donor area. The four most important ones are, degree of hair loss, scalp laxity, and available donor area. With the younger patient I
prefer FIT. I believe that a properly performed FIT procedure is the only true stand-alone hair transplant. No other procedure allows you to shave your head
without any visible evidence that a surgical procedure was done. The more mature patient with a limited degree of hair loss and especially the younger patient
with a more advanced degree of hair loss should consider FIT. The patient with a depleted donor area may also be able to garner many more grafts from FIT
than strip harvesting. In addition, the patient with a tight scalp may achieve more hair from FIT than a strip.
346
APPENDIX 10A Donor Area Suture Material Options, Materials, Characteristics, and Applications
Tensile
Color of Raw strength Absorption Tissue Contra- Frequent How Color code
Suture Types material material retention in vivo rate reaction indications uses supplied of packets
Surgical gut Plain Yellowish-tan Collagen derived Individual patient Absorbed by Moderate Because of General soft tissue 7–0 through 3 Yellow
suture Blue dyed from healthy characteristics proteolytic absorbability, approximation with and
beef and sheep can affect rate enzymatic should not be and/or ligation, without
of tensile digestive used when including use in needles, and on
strength loss. process. extended ophthalmic Ligapak
Tensile strength Absorption is approximation procedures. Not dispensing
is usually usually of tissues for use in reels 0 thru 1
maintained 7 to complete by under stress is cardiovascular with Control
10 days 70 days required. and Release needles
Should not be neurological
used in tissues
patients with
known
sensitivities or
allergies to
collagen or
chromium
Surgical gut Chromic Brown Collagen derived Individual patient Absorbed by Moderate Less Because of General soft tissue 7–0 through 3 Beige
suture Blue dyed from healthy characteristics proteolytic tissue absorbability, approximation with and
beef and sheep can affect rate enzymatic irritation should not be and/or ligation, without
of tensile digestive causes less used when including use in needles, and on
strength loss. process. tissue extended ophthalmic Ligapak
Tensile strength Absorption reaction than approximation procedures. Not dispensing
may be delayed up to plain surgical of tissues for use in reels 0 through
maintained for 90 days gut under stress is cardiovascular 1 with Control
10 to 14 days because of required. and Release needles
with some treatment Should not be neurological
measurable with used in tissues
strength up to chromium patients with
21 days salt solution known
to resist body sensitivities or
enzymes allergies to
collagen or
chromium
Coated Vicryl Braided Violet Copolymer of Approximately Essentially Minimal Because of General soft tissue 8–0 through 3 Violet
(polyglactin lactide and 65% remains at complete absorbability, approximation with and
910) suture glycolide 2 weeks. between 56 should not be and/or ligation, without needles
Monofilament Undyed coated with Approximately to 70 days. used when including use in and on Ligapak
(natural) polyglactin 40% remains at Absorbed by extended time ophthalmic dispensing
370 and 3 weeks hydrolysis of procedures. Not reels 4–0 thru 2
calcium approximation for use in with Control
sterate of tissue is cardiovascular Release needles
required and 8–0 with
Chapter 10
neurological attached beads
tissues for ophthalmic
use
Donor Harvesting
Monocryl Monofilament Undyed Copolymer of Approximately Complete at 91 Slight Because of General soft tissue 6–0 through 2 Coral
(natural) glycolide and 50% to 60 % to 119 days. absorbability, approximation with and
epsilon- remains at 1 Absorbed by should not be and/or ligation. without needles
caprolactone week. hydrolysis used when Not for use in 3–0 through 1
Approximately extended cardiovascular with Control
20% to 30% approximation or neurological Release needles
remains at 2 of tissues tissues,
weeks. Lost under stress is microsurgery,
within 3 weeks required, such or ophthalmic
as in fascia procedures
PDS II Monofilament Undyed Polyester Approximately Minimal until Slight Because of All types of soft 9–0 through 2 Silver
(polydioxan (natural) polymer 70% remains at about 90th absorbability, tissue with needles
one) suture 2 weeks. day. should not be approximation, 4–0 through 1
Approximately Essentially used when including with Control
50% remains at complete prolonged pediatric Release needles
4 weeks. within 210 approximation cardiovascular 9–0 through
Approximately days. of tissues and ophthalmic 7–0 with
25% remains at Absorbed by under stress is procedures needles 7–0
42 days. slow required. through 1 with
Approximately hydrolysis Should not be needles
25% remains at used for
6 weeks placement of
vascular
prostheses and
artificial heart
valves
Ethilon Nylon Monofilament Black Long-chain Progressive Gradual Minimal acute Should not be Abdominal wound 10–0 through 7 Yellow-ochre
suture Undyed aliphatic hydrolysis may encapsulatio inflammatory used where closure, hernia with and
(clear) polymers result in gradual n by fibrous reaction. permanent repair, sternal without needles
nylon 7 or loss of tensile connective retention of closure and
nylon 6, 6 strength tissue tensile orthopedic
strength is procedures
required. including
cerclage and
tendon repair
Prolene Monofilament Clear Isotactic Not subject to Nonabsorbable Minimal acute None known. General soft tissue 6–0 through 2 Deep blue
Polypropyl Blue crystalline degradation or inflammatory approximation (clear) with and
ene suture stereoisomer weakening by reaction. and/or ligation, without needles
of action of tissue including use in 10- through
polypropylene enzymes cardiovascular, 8–0 and 6–0
ophthalmic and through 2
neurological (blue) with and
procedures. without needles
0 thru 2 with
CONTROL
RELEASE
needles
347
348 Chapter 10
REFERENCES 28. Kadach D. Hair Transplant Forum Int 1999; 9:46.

29. Pathomvanich D. Donor harvesting, a new approach to minimiz-
Donor Harvesting ing transection of the hair follicle. H T Forum Int 1998; 8:1–20.
30. Limmer B. Follicular holocaust. H T Forum Int 1998; 8:11.
1. Unger W. The donor site. In:. Unger W, ed. Hair Transplantation 31. Bernstein B, Rassman W. Dissecting microscope versus magnify-
3rd ed. New York: Marcel Dekker, 1995:183–212. ing loupes with transillumination in the preparation of follicular
2. Rassman W, Carson S. Micrografting in extensive quantities. Der- unit grafts. Dermatol Surg 1998; 24:875–880.
matol Surg 1995; 4:306–311. 32. Bernstein R, Rassman W. Follicular unit graft yield using three
3. Bernstein R, Rassman W. The logic of follicular unit transplanta- different techniques. Hair Transplant Forum Int 2001; 11(1):
tion. Dermatol Clin. 1999; 17:277–295. 11–13.
4. Nordstrom EA. An alternative method of evaluating efficacy of 33. Bernstein R. The future of hair transplantation. Aesth Dermatol
technique. In:. Unger W, ed, ed. Hair Transplantation. New York: Cosm Surg 1999; 1:55–89.
Marcel Dekker, 1995:67–68. 34. Reed W. Micro/minigrafting vs. follicular unit transplanting: an
5. Haber R, Stough D. Accurate estimation of graft requirements assessment of the recent Bernstein/Rassman article, ‘‘Follicular
when using multi-bladed knives. In:. Haber R, Stough D, eds. unit graft yield using three different techniques.’’ HT Forum Int
Hair Replacement Surgical and Medical. St. Louis: Mosby, 1996: 2001; 11:103.
138–142. 35. Unger W. A response to ‘‘Follicular unit graft yield using
6. Jimenez F, Ruifernandez JM. Distribution of human hair in three different techniques.’’ Hair Transplant Forum Int 2001; 11:
follicular units: a mathematical model for estimating the donor 106.
size in follicular unit transplantation. Dermatol Surg 1999; 25: 36. Blugerman G. Vertical strip harvest. H T Forum Int. 2001.
294–298. 37. Alkek DS. Combining vertical strips and ellipse in saving time
7. Cole J. Mathematics of follicular transplantation, Italian Society and follicles. Dermatol Surg 1998; 24:1061–1064.
of Hair Restoration Meeting. Rome. Italy, May 1998. 38. Al-Ghamdi W, Kohn T. Vertical harvesting in hair transplanta-
8. Bernstein R. Standardizing the classification and description of tion. Dermatol Surg 2001; 27:597–600.
follicular unit transplantation and mini-micrografting techniques. 39. Bernstein R. Follicular transplantation physician course. 2001.
Dermatol Surg 1998; 24:957–963. 40. Cole J. A calculated look at the donor area. H T Forum Int 2001;
9. Bernstein R. Follicular transplantation. Int J Aesth and Restor 11(5):150–154.
Surg 1995; 3:119–132. 41. Seery G. Hair transplantation: management of the donor area.
10. Cole J. A calculated look at the donor area. H T Forum Int 2001; Dermatol Surg 2002; 28:136–142.
11:150–154. 42. Ott DE, Gray RI, Skees L. Standardized methodology for evalua-
11. Headington JT. Transverse microscopic anatomy of the human tion of laser and electrocautery plume capture by suction evacua-
scalp. Arch Dermatol 1984; 120:449–56. tion. Lasers Surg Med Suppl 1992; 4:40–41.
12. Cole J. Donor Harvesting, Beginners Program. International Soci- 43. Smith JP, Topmiller JL, Shulman S. Factors affecting emission
ety of Hair Transplantation. San Francisco, 1999. collected by surgical smoke evacuators. Lasers Surg Med Suppl
13. Cole J. H T Forum Int 2000; 10:19. 1990; 10:224–233.
14. Chang S. Estimate number of grafts and donor area. H T Forum 44. Sawchuk WS, Weber PJ, Lowry DR, Dzubow LM. Infectious
Int 2001; 4:97–102. papillomavirus in the vapors of warts treated with carbon dioxide
15. Farjo B. Estimating graft numbers made easy for the recipient laser or electrocoagulation: detection and protection. J Am Acad
site. H T Forum Int 2001; 11:101. Dermatol 1989; 21:41–49.
16. Cole J. Moustache Hair Restoration. World Hair Society Meeting 45. Unger W. What’s new in hair replacement surgery. Dermatol Clin
and Live Surgery Workshop. Orlando, FL, 1999. 1996; 14:783–802.
17. Unger W. The hairline. In: Unger W, ed. Hair Transplantation 46. Griffin E. In:. Stough D, Haber S, eds. Hair Replacement Surgical
1st ed. New York: Marcel Dekker, 1979:87–100. and Medical. St. Louis: Mosby, 1996:131–142.
18. Seery G. Surgical anatomy of the scalp. Dermatol Surg 2. July 47. Stough D. In:. Stough D, Haber R, eds. Hair Replacement Surgi-
2002; 28:7, 581–587. cal and Medical. St. Louis: Mosby, 1996:131–142.
19. Bosley LL. Reduction of male pattern baldness in multiple stages: 48. Bernstein R. Staples versus Monocryl. Dermatol Surg 2001; 27:
a retrospective study. Dermatol Surg Oncol 1980; 6:498. 5–11.
20. Keene SA. Improving visualization of white and gray hair folli- 49. Ethicon, Wound Closure Manual.
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21. Traynor S, Adams JR, Anderson P, Everts PE, Cohen J. Appropri- 5–11.
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1998; 176:5–17. 52. Raposio E, Santi L, Nordstrom REA. Serial scalp reductions: a
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during salpingoscopy: a new in vivo method to evaluate vitality 53. Gibson T. Physical properties of skin. In:. Converse JM, ed, ed.
of tubal epithelium. Hum Reprod 1998; 13:3414–3417. Reconstructive Plastic Surgery. Vol. 70. Philadelphia: WB Saun-
23. Cole J. The physics of light and nanotechnology. Meeting of the ders, 1977:74.
International Society of Hair Restoration Surgery. Guadalajara, 54. Edsberg L, Maier RE, Mates RF, Lauren M. Mechanical proper-
Mexico, 2001. ties of human skin subjected to static versus cyclical normal pres-
24. Randall JK. Surgical microbiology and antibiotic prophylaxis sure. Rehabil Res Dev 1996; 26:133–141.
for hair restoration surgery. In: Stough DB, Haber R, eds. Hair 55. Seery G. Improved scalp surgery results by controlling tissue
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68–76. Dermatol Surg 2001; 27:569–574.
25. Blugerman G. H T Forum Int July/August:10. 56. Rassman WR, Bernstein R, McClellan R, Jones R, Worton E,
26. Coiffman F. Use of square scalp grafts for male pattern baldness. Uyttendaele H. Follicular unit extraction: minimally invasive sur-
Int J Plast Reconstr Surg 1977; 60:228–32. gery for hair transplantation. Dermatol Surg 2002; 28:698–703.
27. Vallis CP. Surgical treatment of the receding hairline. Int J Plast 57. Inaba M. Androgenetic Alopecia, Medium Concepts of Pathogen-
Reconstr Surg 1968; 33:247. esis and Treatment, Springer-Verlag 1996:238–245.
11
Graft Preparation
11A. A Personal Approach to cal and technical principles to workplace conditions. The appli-
cation of ergonomics to the production of grafts is targeted
Ergonomics in Graft toward simplifications at every stage of the process, with special
Production attention to preserving workers’ health and productivity. Thus,
the time available is used more effectively and procedures are
Guillermo Blugerman and Diego Schavelzon
shortened. Physicians and assistants work in a more relaxed
way and more treatments can be provided to a larger number
INTRODUCTION of patients in the same amount of time. In brief, ergonomics
contributes to better productivity with less fatigue and higher
Hair restoration surgery with use of micrografts and/or mini- quality at lower operative cost.
grafts is notoriously lengthy and tedious. One of the most time- Workstations (Fig. 11A-1) should be designed in a way that
consuming and effort-consuming stages in this procedure is the simplifies the production of grafts and takes into account the
preparation of grafts. In our opinion, many of the mechanical following principles:
methods implemented for the purpose of speeding up this pro-
cess have done so at the cost of quality. It is not advantageous A good body posture should be maintained during work.
to save time in the production of grafts if this means sacrificing Illumination should be generous but not too bright.
graft quality and potential graft viability. In simple economic Room temperature should be kept comfortable and not too
terms, any innovation in graft preparation are only worthwhile high.
if the surgeon and assistants have to work fewer hours to accom- The seat or stool should be comfortable, and the height
plish the same or better results. Applying ergonomic principles should be adjustable.
to mechanical and technical innovations can help in obtaining Optical magnification elements should be available and
this goal. should facilitate a proper posture at work by location at
an appropriate focal distance.
Arms and wrists should rest on padded supports to prevent
VALUE OF APPLIED ERGONOMICS damage or injuries to joints from awkward or strained posi-
tion (e.g., carpal tunnel syndrome).
High-quality equipment, an adequate surgical environment,
manual skills, and pertinent expertise do not always ensure that In the search for more efficient movement, consider the follow-
work is done in the most efficient manner. Unnecessary maneu- ing recommendations should be considered:
vers, incorrect movements, uncomfortable work positions, Choose movements that involve the shortest distance and
changes in sight fixation, and variations in lighting are factors take the shortest time.
that can lead to fatigue. Fatigue is the cumulative effect of work Reduce the total number of movements.
effort on mind and body. It has a negative effect on the subject’s Reduce the duration of movements.
capacities and reduces quality and productivity compared with Place all tools in a pre-established order before starting work.
results obtained under optimal work conditions. With respect Place tools within the visual field, as close as possible to
to graft production, which involves important but monotonous the place where they are going to be used.
manual skills, it is essential to avoid fatigue, boredom, and
inattention. The right tool placed at the right position at the right time is
In an attempt to improve both work efficiency and results, we work simplification. Hair transplant technicians suffer from the
studied graft production from a rational ergonomic perspective. same types of problems that afflict computer operators or other
Ergonomics is the science that studies the application of biologi- professionals who need to stay seated and perform repetitive
349
350 Chapter 11
cutting edge of the scalpel should be aligned parallel to the

hair shafts and cut between the bulbs. We are convinced that
interfollicular infiltration with tumescent anesthesia and a plas-
matic expander (Fig. 11A-2) is essential for facilitating both
initial donor tissue harvest and later dissection of donor tissue
without transection of follicles. This maneuver separates the
bulbs and creates a greater space between the hair shafts than
that found in nature.
Because these steps require a certain amount of time, we
prefer to use a solution that remains in the ex vivo tissue longer
than the traditional standard saline tumescent solutions. We
have selected Polygelatin, a preparation generally used as a
blood replacement, which is known by brand name Haemaccel
(Hoechst). It is hydrophilic, and this feature prolongs its tissue
expansion effect. Polygelatin increases the interfollicular space
and also creates a firmer donor strip, which allows neater and
more accurate cuts on a more stable plane.
Once the donor strip is obtained, special attention should be
given to appropriate temperature and humidity. Gandelman (1)
has already reported that dehydration may pose a threat to the
viability of the follicles. We therefore recommend that the donor
Figure 11A-1 Typical ergonomic workstation. Note the good strip be wrapped in 18␮ polyvinyl chloride (PVC) foil to pre-
body position, comfortable chair, and proper table and chair height, serve humidity. To avoid thermal damage, heat-producing light
which provide comfortable positioning of arms and wrist on the sources (e.g., regular and halogen incandescent lamps) should
padded support. The Mantis microscope enables the assistant to not be placed near the work site.
maintain a good body position by looking forward through the
microscope rather than down.
Stage 2: Initial Slivering of the Donor Strip
We believe that the use of magnification equipment is essential
for the creation of slivers at this stage of graft production. Cur-
rently available magnification options include loupes; binocular
movements for long hours. When ergonomics are applied and microscopes; stereoscopic microscopes (Mantis) or video mi-
rigorously followed, the surgical team becomes more efficient croscopes. Each of these options has relative advantages and
and these problems are minimized. disadvantages that can be compared in Table 11A-1, (where 10
is the best on a scale of 1 to 10).
Based on our experience, we consider the Mantis (Fig. 11A-
GRAFT PRODUCTION FROM AN ERGONOMIC 1) and video microscope worthwhile investments because they
STANDPOINT combine correct magnification with a nonstressful work posi-
The graft production technique that we use can be broken down
into three stages:
Stage 1 is the initial harvesting of the donor strip.
Stage 2 is dividing the donor strip into sections (or slivers)
of variable widths according to the desired graft size. This
has also been called slivering by Seager (1).
Stage 3 is further subdivision of the slivers into the final
individual grafts of different sizes.
In this section, we discuss some of the ergonomically sound
technical and mechanical innovations that we have included in
our graft production process.
Stage 1: Initial Donor Strip Harvesting

Until it is satisfactorily proven that hair follicle transection does
not endanger graft survival, every care should be taken to pro-
tect the limited, nonrenewable donor supply from this form of
trauma. To that end, attempts to preserve follicular integrity Figure 11A-2 Interfollicular infiltration with tumescent anes-
should start at the onset of donor tissue harvesting. During this thesia and a plasmatic expander. Polygelatin (Haemaccel) facili-
maneuver, surgeons should try to preserve the integrity of the tates both initial donor tissue harvesting and later dissection of
hair bulbs growing on both sides of the incision. Therefore, the donor tissue without transecting follicles.
Graft Preparation 351
Table 11A–1 Comparing Different Methods of Magnification
Instrument Eye fatigue Position Work distance Cost Effectiveness Speed
No magnification 7 7 10 10 1 10

Magnifiers 7 3 10 10 4 4
Binocular microscope 3 0 5 6 10 6
Mantis microscope 9 10 10 5 10 8
Videomicroscope 8 10 10 2 10 8
tion. The Mantis microscope uses a 6x lens with an ample depth

of field. This enables the operator to focus on the entire width
of the strip that is being dissected, without having to make
frequent adjustments. The Mantis has its own good-quality
light, which does not emit heat. It is mounted on a clear acrylic
footplate designed by James Arnold, which allows the use of
concurrent backlighting, if desired. The Mantis has a wide
screen through which the work in progress can be clearly seen,
with the observer facing forward and not having to bend the
neck. This is an ergonomically sound position. It limits fatigue
and lumbar-cervical pain, which can lead to decreased produc-
tion, mood changes, a negative atmosphere within the team,
and increases in absenteeism. We rely on a number of well-
trained assistants, and it is cost effective to invest in equipment
that keeps them healthy and productive.
Fixation of the donor strip to a cutting board and the subse-
quent application of steady lateral tension facilitate slivering.
To that end, we have designed a specialized cutting board
(Blugerman cutting board supplied by Ellis Instruments) that Figure 11A-3 Specialized cutting board (Blugerman Board)
has two working surfaces positioned perpendicular to each that facilitates slivering: ‘‘x’’ designates the silicone block for the
other. The vertical surface, which is built from a block of sili- fixation of donor strip. ‘‘y’’ is the location of the translucent poly-
cone elastomer, allows the donor strip to be fixed with two 25- urethane cutting surface with a cuplike recession, where slices can
gauge hypodermic needles. The horizontal cutting surface is be stored in cool saline.
made of translucent polyurethane that makes backlighting pos-
sible. The horizontal polyurethane surface also has also a cup-
like recession where the tissue slices can be stored in cooled
saline. (Fig. 11A-3 and 11A-4)
After the strip has been correctly fixed to the cutting board,
the 18␮ PVC foil that we use to prevent dehydration is removed
from the portion to be slivered (Fig. 11A-4). The distal end of
the strip is secured with forceps and steady lateral tension is
applied. We have observed that most forceps used to pull the
strip at this stage of the surgery have sharp, smooth ends, which
make them ineffective at grasping the tissue. We therefore rec-
ommend the use of specialized Miltex forceps (Miltex 18–854
supplied by A to Z) with spatula-shaped tips and little teeth in
the distal border (Fig. 11A-4). Additionally, these forceps have
a locking mechanism, which enables the assistant to grab and
hold the tissue without squeezing it. This relaxes the assistant’s
hand and forearm muscles, dramatically reducing fatigue. An
alternative method is to bend both tips of a regular jeweler’s
forceps so they will hook in and are able to grab the donor
tissue during slivering.
For a cutting blade, we prefer a no. 15 bladed scalpel (Fig.
11A-4), because the cutting edge of this blade consists of multi-
ple shapes. The blade has three areas—pointed, curved, and
straight, which are most convenient at different times during Figure 11A-4 A sliver is cut by attaching it to the board and
slivering. The thickness of the slivers can be made the width applying lateral tension with the specialized spatula forceps (x);
of either one or two follicular units (FUs), and this decision is the 18-␮micron PVC foil (y) is wrapped around the sliver to keep
made based on the size of the grafts desired. it moist. (z), The no. 15 blade scalpel.
352 Chapter 11
Stage 3: Creation of Individual Grafts from Slivers Our first approach was to try dissecting the grafts in a liquid
element (i.e., the saline solution). We designed a small tray for
The third stage in the preparation of grafts consists of the con-
comfortable dissection of FUs under a saline solution. This tray
version of individual slivers into appropriately sized grafts. To
also permitted use of transillumination. Physicians considered
facilitate this process, we have prepared a workstation that ad-
the results to be amazing. Cutting the grafts under saline pre-
dresses different areas important to comfort and work effective-
vented dehydration and, in addition, offered other benefits such
ness. The areas we have addressed include the following:
as the following:
1. Stool Immersing the tissue in liquid causes a magnifying effect
2. Table surface and height that adds to the existing magnification.
3. Lighting The subcutaneous cells hydrate. Thus, there is a greater dis-
4. Hydration tance between the hair follicle and the tissue, and, conse-
5. Transillumination quently, dissection is easier.
6. Appropriate cutting surface The subcutaneous cell becomes practically transparent with
7. Proper magnification the addition of transillumination.
8. Containers for graft classification
9. Strict control of the number of grafts prepared Our assistants did not like or easily adapt to the technique of
10. Specific instruments used cutting grafts under saline. Therefore, we tried another approach
and developed a humidified dissection chamber (Fig. 11A-5).
This is a dome made of transparent acrylic with two lateral
Stool
apertures for the introduction of the assistant’s hands. This de-
The stool should be very comfortable and properly padded. vice is equipped with an adjustable ultrasonic spray that sends
Hands should not be used to regulate its height. a fine saline mist into the dome during graft dissection. With
this new device we are able to preserve the hydration status of
Table Surface grafts to a similar degree as cutting under saline.
This surface should be washable and, occasionally, some pad-
Transillumination (Fig. 11A-5)
ded supplements should be added for the forearms and, above
all, for the wrists. These additions may reduce the incidence of Whenever possible, the technique of transillumination should
carpal tunnel syndrome. be used, as this helps to make the hair bulbs visible by increasing
the contrast between hair and subcutaneous tissue. This tech-
nique is especially useful when gray hair or salt-and-pepper
Lighting hair is being cut. This type of hair is difficult to see, and we
Diffuse, cool light should be used to prevent graft dehydration think that atraumatic dissection of this type of hair without the
and a rise in temperature. use of transillumination is almost impossible. The backlight
used for this technique should fulfill the following specifica-
Hydration tions:
The damage that dehydration causes to tissue is well known by Strong white light (5000 minimum)
general surgeons and plastic surgeons. Marcelo Gandelman has Small surface so as not to blind the assistant
presented a study that has clearly shown tissue dehydration to
be one of the major causes of graft damage and potential loss
during the hair transplantation process (2).
The potential for dehydration during Stage 3 is higher when
we work with tiny grafts that have a larger surface area to
volume ratio, and, therefore, a greater relative amount of surface
area exposed to the environment. The potential for dehydration
is also increased by certain existing factors in the operating
theater, such as air-conditioning, the microscope lights, and the
absorbing surfaces used (e.g., wood, gauze). A phase of graft
production that is not usually addressed, regarding vulnerability
of follicles to dehydration, is the time they spend on the cutting
surface during Stage 3. In our experience, grafts are on the
cutting surface for a longer time when FUs are created with
the binocular microscope than when minigrafts are produced
with simple loupe magnifiers. It is interesting to note that the
introduction of a new technique in the form of FUs and the
binocular microscope has potentially increased the risk of dehy-
dration during this phase of graft production. In an attempt to
address this problem and the concerns raised by Gandelman’s Figure 11A-5 Humidified dissection chamber. (x), Backlight-
research, we started to analyze various ways of preserving the ing with Visual Plus. (y), Three separate pin cups for selective
temperature and humidity of grafts during the time they spend storage of different sizes of grafts. (z), Mag-Eye magnification
on the cutting surface. loupes.
Small amount of cabinet thickness

Cold or low heat-emitting light
C. C. power and long use resistance
Long life
Our preference is the Visual Plus Model VP-6050V, which can
be obtained from A to Z.
Cutting Surface
The cutting surface used for transillumination should be as fol-
lows:
Translucent
Rough enough so the tissue does not slide
Soft enough to prevent cutting-edge blunting
Hard enough so material particles do not come out
Atoxic
Sterilizable
Economical a
Nonhydrophilic to prevent absorption of fluid from grafts
This graft-cutting surface should be translucent, nonslippery,
and sterile. It should preserve the scalpel’s edge. It should be
hard enough that small particles cannot scrape off and act as
foreign bodies if implanted as contaminants. Various appropri-
ate materials may easily be found on the market to satisfy these
needs. After testing different cutting surfaces (glass, acrylic,
marble, and silicones), we reached the conclusion that a white,
rough, polyethylene surface is the best element because it ful-
fills the aforementioned properties.
Magnification
We think that magnification in stage 3 does not have to be as
high as during stage 2. Occasionally, there is no need for it at
all. We prefer to use Mag Eye magnification loupes (supplied b
by A to Z). They allow a good neck position, a good focal
distance (27 cm. with 4x), and can be worn together with the Figure 11A-6 (a), (x), Pin cups pinned to the recipient area.
surgeon’s own glasses (Fig. 11A-5). They are lightweight and (b),(x), Close-up of pin cups pinned to the recipient area.
rest on the forehead, so they do not exert any pressure on the
nose and ears. We regularly use a 2x or 4x magnification.
Graft Containers
For more than 4 years, we have been placing our grafts in small
containers, called pin cups, which are small, disposable, sterile
plastic cups filled with cold saline solution to keep the grafts
hydrated (Figs.11A-5, 11A-6, and 11A-7). They are used for
graft separation and classification according to size during graft
production. They are also used to keep the grafts cool and moist
during graft insertion. When we initially looked for a graft con-
tainer, we searched for one with the following properties:
Keeps grafts wet
Prevents germ contamination
Prevents adherence of substances such as talcum, powder,
latex, gauze etc.
Leaves the hands free when working
Keeps grafts available at a short distance from the insertion
place
Prevents graft crushing and handling
Diminishes graft air transport with the implied risk of drop-
ping
With these properties in mind, we came up with the idea of Figure 11A-7 Electronic counter for enumerating incisions and
using a small, lightweight, disposable, sterile plastic container. cuttings of grafts.
354 Chapter 11
The container that we call a pin cup is 31 mm in diameter, 10 In summary, the main advantages for the use of the counter
mm in depth, and 2 g in weight. The plastic material is thin are as follows:
enough to permit the passage of a small-gauge needle. This in
Exact evaluation of the number of holes or slits made
turn allows the cup to be secured or pinned to the patient’s
Quick evaluation of the number of grafts to be obtained from
scalp during placement.
the donor area
During the cutting stage, the cups are filled with cold saline
Insertion control in all the incisions
solution and placed between the cutting surface and the opera-
tor. Three cups are used per workstation so that grafts can be Photographic record of the work done for medicolegal and
separated by size. This facilitates selective use of different sized commercial purposes
grafts in specific areas later during insertion (Fig. 11A-5).
When the grafts are to be inserted, a pin cup containing Specific Cutting Tools
grafts of the desired size is taken and pinned into the scalp skin The two tools that need to be mentioned with respect to prepar-
in a place near the area where they are to be placed (Figs.11A- ing individual grafts from slivers are:
6a and 11A-6b). By doing this, we observed fewer visual Type of forceps used to hold and manipulate the donor tissue
changes and fewer head and arm movements. Reduced move- Cutting blade used to dissect the donor tissue
ment resulted in less fatigue of the surgical staff and shortened
the time for insertion of grafts. In summary, the main advan- We prefer to use forceps such as the Forester 61–6041 (supplied
tages we find for the pin cup are as follows: by A to Z) or a 5 or 5A jewelry forceps. A number of cutting
Double function of container and dispenser blades may be used according to the assistant’s preference. Some
Keeps the grafts wet and cool prefer no. 10 Personna scalpel blades, whereas others prefer Prep
Has reduced dimensions Blades. Some assistants prefer regular razor blades mounted on
Is lightweight, sterile, and disposable special handles. No matter which blade is used, at this stage of
Saves time and effort the process it is most comfortable to place the slivers at a 90-de-
Leaves hands free for working gree angle with respect to the worker’s body, as previously sug-
Reduces contamination and allergic risks gested by Arnold. It is also very important to change the cutting
blade regularly to preserve the graft quality and diminish the
Economical force necessary to cut scalp tissue, which in turn keeps the assis-
Graft Counting tants from succumbing to fatigue.
We are working on a padded ergonomic workstation that
Throughout our practice and in visits to our colleagues, we have
enables operators to support their thorax, head, and forehead
noticed a certain difficulty in keeping track of the number of
(Fig. 11A-8). This workstation is highly ergonomic and dramat-
grafts that are manufactured and those that are placed. To make
this task a lot easier, we have designed an electronic hair graft
counter (Fig. 11A-7). The counter is formed of the following
two components:
Viewfinder
Shutter
The viewfinder is digital and easy to read. Mainly, it counts
the electric impulses triggered by the shutter. This shutter may
include the following components:
Foot switch
Contact sensor
Photoelectric cell
The counter can be used by the physician when creating incision
sites or by the assistant when producing grafts. It is also possible
to use the counter during graft insertion to be completely sure
that no holes have been left partially filled or empty.
It is very useful to have an accurate count of grafts produced
by assistants for the purpose of approximating the number of
grafts that will be obtained from the harvested donor strip. By
counting the number of slivers we obtain from the initial donor
strip and multiplying that by the number of grafts obtained from
one sliver, we obtain an early estimation of the total amount
of grafts that may be produced. From this calculation, we can
assess the number of slits or holes to be made.
This small instrument is useful from a medicolegal stand-
point because it supplies a record of the number of grafts in a
photograph of the viewfinder of the instrument placed next to
the operative field. The counter is also useful for figuring out
the surgeon’s fees if they are directly related to the number of Figure 11A-8 Experimental cutting station for the final phase
grafts made. of graft production with use of backlighting (still in development).
ically reduces fatigue as well as neck and back pain (in the croscope for dissection of FU micrografts, let us now methodi-
cervical and lumbar-dorsal areas). With this workstation, the cally examine some of the very real and legitimate advantages
stools will not have wheels, which will enable the whole body to of classic microscope dissection for FUs.
rest completely on padded elements without the stool remaining
immobile. At the time of this writing, the workstation is not
available, but it seems worthwhile to present the concept. General Principles for Dissection of Follicular Units
Follicular units are more fragile than standard grafts and mini-
grafts and therefore more easily damaged. Standard grafts and
11B. Classic Microscope Dissection minigrafts generally have more protective skin around their pi-
of Follicular Units losebaceous units, which affords them greater protection against
trauma and drying. On the other hand, FUs lack this extra pro-
David J. Seager
tection and therefore need to be treated with greater care than
their larger ‘‘cousins’’ if they are to achieve full survival. Care
INTRODUCTION must be taken to adhere meticulously to the following points:
Follicular unit (FU) micrografts are so small and fragile that
1. Minimize time out of the body between harvesting and
the aid of microscopes for their dissection from donor hair into
planting grafts.
micrografts is mandatory to obtain optimal yield, particularly
when minigrafts are used exclusively and in large numbers. 2. Minimize physical trauma during handling of the grafts.
To obtain the benefits that the binocular Stereoscopic Dis- 3. Keep the grafts cool and moist while they are out of
secting Microscope has to offer, a specific, elaborate dissecting the body between harvesting and planting.
technique, which is described in detail later in this chapter, has 4. Minimize transection and wastage (discarding) of hairs
to be employed. This technique was originated and developed during the graft preparation process.
by Dr. Bobby Limmer of San Antonio (1). Dr. Limmer invented
The most crucial of these points for graft survival is the minimi-
and practiced classic microscope dissection and follicular unit
zation of trauma, transection, and wastage of hairs by using
hair transplantation (FUHT) years before anyone else ever
specific microscope dissection techniques. Slivering, the key
understood the concept, although he did not publish anything
special technique used to dissect donor hair into FUs, is de-
about his novel method until some years later.
Controversy exists among physicians over the benefit of scribed in detail later in this chapter.
using the stereoscopic dissecting microscope. Many long-estab-
lished hair transplant physicians have simply purchased the ap- Advantages of the Use of the Binocular Stereoscopic
propriate microscopes but have then proceeded to dissect the
Dissecting Microscope for Dissection of Follicular
donor tissue into micrografts with microscopic visualization,
using exactly the same technique they had been using for years Units
with the naked eye. In this scenario, unfortunately, ‘‘old tech- There are several advantages to using the binocular stereoscopic
niques with new instruments’’ produces no benefit whatsoever. dissecting microscope (hereafter referred to as the stereoscope)
As stated earlier, to benefit from use of the microscope, a spe- for the preparation of all grafts in procedures that involve exclu-
cific dissecting technique is needed in addition to the use of sive use of larger numbers of FUs. These are conservation of
the microscopic magnification. This is one factor that has led
donor hair, ease in viewing nonpigmented hair, greater accuracy
many operators to conclude that the claimed benefits of micro-
in producing actual single-haired grafts for the hairline, and the
scope-aided donor dissection are exaggerated, and that they
ability to more precisely dissect ideally sized and shaped FU
have detracted from the general adoption of microscope use in
micrografts. I believe that the more precise the size and shape
hair transplantation.
Another popular misconception that has also contributed to of FU micrografts, the higher the quality of the grafts. The
the slowness of the majority of hair transplant physicians to resulting is better growth owing to increased survival and inclu-
adopt microscope dissection is the misconception that micro- sion of telogen bulbs.
scopically dissected grafts should enhance the cosmetic appear-
ance of a hair transplant. An individual FU created by micro- Conservation of Donor Hair
scopic dissection appears no different after it grows out than
an FU created without the microscope. This point has been used The main advantage of using the stereoscope is less wastage
by detractors of the microscope to ask the question, Why should of donor hair. Between 10% and 30% more hairs are able to
the microscope be used to prepare FUs? The main benefits of be harvested from the same-sized donor area than are obtained
classic microscope dissection for FUs, as are described later, with performance of the same dissection using either the naked
are ‘‘hidden benefits mainly regarding conservation of hair.’’ eye alone or simpler, more conventional methods of magnifica-
These advantages become apparent only by evaluating the max- tion such as with loupes and backlighting. In addition to provid-
imum amount of hair that can be successfully transplanted in ing increased magnification, the stereoscope is accompanied by
one session, or the total amount of hair that will be ultimately an extremely bright light-beam focused on the minute area that
available to treat the area of baldness that usually enlarges as is viewed through the microscope eyepieces (Fig. 11B-1). This
the patient ages. combination of greater magnification and extremely powerful
Having examined some of these invalid (but understandably illumination makes the donor-area tissue appear translucent.
hypothesized), frequently quoted reasons for not using the mi- The hair shafts and other components of the pilosebaceous units
356 Chapter 11
Figure 11B-1 A Meije binocular stereoscopic dissecting mi- Figure 11B-2 This figure demonstrates the translucency of the
croscope. Note the intensity of the focused light beam. tissue, which enhances visibility of follicular units (FUs). This in
turn allows the operator to maneuver the blade around the hair
shafts and follicles without damaging them. The section of donor
strip is fixed here only for the purposes of photography, and the
angle of the blade is changed to better show the intact FUs.
that make up the FUs are highly contrasted against the surround-
ing translucent tissue.
This greater translucency, together with the greater magnifi-
cation, allows the operator to curve and maneuver the dissecting
blade around and in between FUs, while avoiding transection the hair transplant physicians and staffs (whom I personally
of adjacent hair shafts and follicles (Fig. 11B-2). Without the know) who exclusively use the dissecting technique (or a very
use of the stereoscope, there is a much greater likelihood of close modification thereof) advocated in this chapter have also
transection and damage to adjacent hair shafts, as well as other claimed similar quantification of of donor hair salvage. These
potentially important structures of closely approximated pilo- hair transplant physicians are: Dr. Robert Bernstein of New
sebaceous units, such as sebaceous glands and dermal papillae. Jersey and New York; Dr. Bobby Limmer of San Antonio; Dr.
Use of the stereoscope for dissecting donor hair strips into Mario Marzola, of Adelaide; Dr. Constantine Minotakis of the
FUs thus facilitates reduced wastage of donor hair, such as Dhi Group, Athens; Dr. O’Tar Norwood of Oklahoma City
occurs when simpler methods of magnification are employed. [Oklahoma]; Dr. Bill Parsley of Louisville; Dr. Paul Rose of
This increased yield from donor hair varies with the type of New Port Richey [Florida] Dr. Ron Shapiro of Minneapolis and
hair. Straight, coarse, sparse, jet-black donor hair—such as is Clearwater [Florida]; Dr. Barry White of Melbourne; Dr. Brad
commonly seen in people of Asian descent—is fairly easy to Wolf of Cincinnati; and probably many others who are not
dissect with the naked eye alone without damage to many hairs. known to me personally.
Therefore, the increased yield with use of the stereoscope is The only confirmed scientific paper on this subject is that
approximately 10%. Nonpigmented, gray/white, very fine, very of Robert Bernstein (2). However, Bernstein’s technique did
dense, or very curly hair, however, is much more difficult to not include slivering with a stereoscope. The stereoscope was
dissect without occurrence of ‘‘collateral damage.’’ With these used only for dissecting slivers sliced with the naked eye from
types of hair, the increased hair yield resulting from skillful the donor strip. Seventeen percent more hairs were obtained in
microscope dissection is much greater. There may be more than the stereoscope group than in the control group. One can assume
30% more hair obtained from the same-sized donor area, than that had the stereoscope been used for slivering too, the in-
is possible without skillful use of an appropriate microscope creased number of hairs obtained by the stereoscope group
technique. would have been much greater than 17%. This is because the
There is little documented quantitative evidence in favor of majority of transections of donor hairs during dissection occur
the aforementioned conservation of donor hair. However, all during the slivering process rather than the graft-cutting pro-
cess. Moreover, at the time of Dr. Bernstein’s landmark trial, his dermal papilla. This is important because the planters need to
staff was still relatively inexperienced at stereoscope dissection. grasp this fat pad with forceps to avoid traumatizing the dermal
Today, the demonstrated savings would surely be very much papilla. It is also easier to preserve the integrity of the sebaceous
greater. gland with the guidance of the stereoscope rather than with the
naked eye. Although this point is controversial, the sebaceous
Viewing of Nonpigmented Hair gland is believed by some to have as yet undefined benefits
It is much easier to see nonpigmented hairs such as gray, white, (3) apart from its job of lubrication of the hairs. Ideally, FU
or virtually transparent hairs through the stereoscope than with micrografts are pear-shaped, with the epidermis trimmed as
the naked eye or with lesser forms of magnification. Gray hair is closely as possible to the hair (Figs. 11B-4 and 11B-5).
very difficult to cut into FU micrografts without the stereoscope. The foregoing discussion does not imply that there are not
Gray or white hair is frequently very difficult to see under the extremely talented and experienced technicians who can cut
skin, because it is usually quite transparent and the dermis is equal, optimally shaped and optimally sized grafts with the
a whitish color (Fig. 11B-3). With the stereoscope, one can see naked eye alone. These, however, are very rare individuals, and
a white ‘‘cap’’ above the transparent dermal papilla. The hair in my experience, it takes many years of continuous practice
can then be viewed from the surface to this cap. Cutting white- before technicians are able to perform to this degree of accuracy
haired FU micrografts without the stereoscope often leads to a with the naked eye. In contrast, almost any motivated technician
tremendous amount of transection and wastage of hairs. who has reasonable manual dexterity can learn to cut ‘‘perfect’’
FU micrografts after only 2 weeks of training using the stereo-
More Appropriately and Precisely Shaped Grafts scope. This level of skill is quite impossible for a novice techni-
cian to achieve without the use of the stereoscope. Of course,
The stereoscope facilitates the cutting of more precisely sized
novice technicians must work slowly to produce these grafts.
and shaped grafts, leaving an optimal amount of tissue around
However, with only a few months of experience, they should
them. These grafts are small enough to plant in a minimally
be able to cut perfect grafts at a respectable speed. These re-
sized recipient site but large enough to contain enough dermis
and fat for protection (and possibly initially required nutrition).
They are also large enough to include any invisible telogen
follicles (i.e., those that have shed telogen hair but not yet grown
new anagen hair) that may be associated with the FU in ques-
tion. It is also easier to leave a protective fat pad inferior to the
Figure 11B-4 Close-up of a perfectly cut, three-haired chubby

micrograft that was preserved as an intact, naturally occurring fol-
licular clump. This is excellent depiction of the sebaceous glands,
over which can be seen lying a miniaturized hair. An ample fat
pad deep to the dermal papillae has been deliberately left to provide
Figure 11B-3 Transparent hairs with the characteristic white an area that can be grasped with jewelers’ forceps for insertion,
cap above the transparent dermal papilla (arrow). etc. without damaging any vital structures.
358 Chapter 11
contains fewer and fewer bits of hair and dermal papillae. Even-
tually, this waste tissue becomes just a small amount of surplus
fat, dermis, and occasional bits of galea, with hardly any hair
shafts or dermal papillae.
In sharp contrast is the waste tissue produced by experienced
technicians who perform dissection of donor hair into FUs using
the naked eye alone. Usually, many more spicules of hair, der-
mal papillae, etc., can be seen in the waste tissue. The amount
of waste tissue varies from facility to facility and from staff
member to staff member (and, as mentioned earlier, according
to the patient’s hair type). Under ideal circumstances, compara-
tively little waste tissue is produced. Fairly ‘‘chubby’’ FU mi-
crografts should be cut, without removal of a lot of ‘‘empty
skin’’ between the FUs. Some other expert FU hair transplanters
deliberately cut their FUs ‘‘skinnier,’’ discarding more empty
Figure 11B-5 Pear-shaped, chubby, one-haired, two-haired, skin between them. It is my belief, however, that the chubbier
three-haired and four-haired follicular unit micrografts. Note the the FUs are, the better, as long as they are still narrow enough
intact sebaceous glands and the fat pads below the dermal papillae. to be planted atraumatically into recipient sites made with a
19-gauge hypodermic needle. Herein lies the dilemma. How
can sizable grafts be planted extremely close together in minute
recipient sites? This is the greatest challenge in producing a
marks apply only to graft cutting and not to slivering. However high quality, densely packed, hair transplantation. However, the
good the operator’s eyesight, it is quite impossible to sliver details of this technique are beyond the scope of this chapter.
without damage to an unacceptably large number of hairs unless Accomplishment of graft planting by means of the stick and
aided by a stereoscope. place technique is discussed in Chapter 13B.
Senior technicians from hair transplant facilities that use the
stereoscope exclusively have reported their findings after visit- Minimization of Poor Growth
ing clinics where the stereoscope was not used. They found that Before stereoscope dissection was used in my practice, I noticed
most veteran graft cutters were not able to produce as high- about the same amount of poor growth in my patients as that
quality grafts without the stereoscope as trainees who had used confidentially admitted by physicians in most other facilities at
the stereoscope for only 2 weeks, despite the fact that these the time. That is, 1% to 3% of cases would produce obviously
veterans had been cutting grafts for more than 8 years. less than optimal growth. For the more than 5 years that stereo-
scopic dissection of donor tissue has been used in my practice,
The Preparation of Single-Haired Micrografts
the survival and growth rate of transplanted hair has been con-
Ideally, single-haired micrografts should be used for hairline sistently excellent, with less than one-fifth of a percent of ob-
construction. No matter how carefully the micrografts are previously less than optimal growth. With micrografts
pared and selected so that they contain only one hair, when the
cutters use either the naked eye or loupe dissection alone, many Disadvantages of Stereoscope Dissection of Donor
of the one-haired micrografts frequently grow two or more Hair for Follicular Units
hairs. The magnification of the stereoscope, however, enables
the viewer to discern that what appeared to be a one-haired FU There are clearly advantages to using the stereoscope. Unfortu-
with the naked eye was in reality a graft containing two or more nately, there are also significant disadvantages. At the outset,
hairs. These hairs could be nonpigmented hairs or miniaturized the cutting progresses more slowly, and the equipment and
hairs, which could be immature anagen hairs that require high training (especially) are initially extremely expensive. Although
magnification with the stereoscope to be seen. the surgeon may be convinced that use of the stereoscope is a
In my practice, far fewer two-haired or three-haired mi- better method, convincing the staff to change their technique
crografts have been seen growing in the front hairline since the can be difficult. Finally, some argue that invisible telogen hairs
introduction of the stereoscope, despite the fact that my staff may be discarded. However, this last point is disputed.
and I carefully selected what appeared to be one-haired grafts
before we used the stereoscope. It has been postulated that cut- Labor and Speed
ting off the papilla or root of a graft may produce a finer caliber Stereoscope dissection is a lot slower in the hands of novice
of hair for the most frontal aspect of the hairline. Use of the and intermediate cutters compared with dissection by naked eye
stereoscope would enhance the accuracy of this procedure. or loupe, and likely somewhat slower even in the hands of
experienced cutters. There is a long training period (and, for
Reduction of Waste Tissue most technicians, a slow learning curve) required to cut quickly
When FUs are dissected from donor tissue, there is inevitably under the stereoscope. New staff can be taught to cut perfect
some waste tissue produced that must be discarded. On magnifi- grafts after 2 weeks of close training on the stereoscope. As
cation, the novice’s waste tissue can be seen to consist of subcu- mentioned earlier, after 2 weeks of instruction and practice,
taneous fat, dermis, (occasionally) galea, many hair spicules, technicians are able to cut better grafts than most experienced
and (usually) dermal papillae. As stereoscope trainees become veteran graft cutters can achieve after years of practicing with
more experienced, the waste tissue decreases in volume and the naked eye. However, the novice stereoscope practitioners
are much slower. To reach speed at cutting grafts while using telogen hairs (Fig. 11B-6). Dr. Limmer has also published a
the stereoscope takes much longer without the stereoscope. letter and a photograph demonstrating this phenomenon (4).
After 2 weeks a cutter may, on average, be able to produce 50 Second, unless the invisible telogen hair is in a one-haired
perfect grafts per hour. An experienced cutter can produce 300 FU, it has adjacent visible hairs. Within any FU, there exist
grafts per hour in an average case. one to four terminal hairs (rarely five), usually at different stages
in the growth cycle from anagen to catagen to telogen.
Around 18% of all FUs harvested contain only one hair.
Cost This figure is quite variable because certain individuals and
Initial costs include expenditures for stereoscopes and equip- individuals from different ethnic backgrounds have a much
ment and for modifications to the surgical suite to accommodate higher percentage of one-haired FUs, and a few young people
the use of stereoscopes. Staffing costs are the greatest expense with dense hair may have a much smaller percentage with only
in implementing microscopic dissection. There are costs for one hair.
training time and, at first, more staff hours are required to cut Table 11B-1 demonstrates that in a typical Caucasian donor
the same number of grafts. Later, as the surgeon progresses scalp, only 18 of 230 hairs are one-haired FUs; that is, one-
to larger megasessions of dense-packed follicular unit grafts haired FUs comprise about 7.83% of all hairs. Only 8% to 12%
(FUGs), the number of staff required and the number of hours (average 10%) of these are in telogen state at any one time.
Therefore, only 0.783% of total donor hairs are telogen hairs
required both increase substantially.
that exist as isolated one-haired FUs.
If 50% of these isolated telogen state, one-haired FUs had
Staff Reluctance to Change a telogen hair that had been pulled out of its follicular sheath
Another difficulty hair transplant physicians face when adopt- before its succeeding anagen hair became visible, only 0.39%
of the hair could be totally invisible and at risk of being wasted
ing microscope dissection is that existing staff, who have been
in this manner.
used to cutting with the naked eye and/or with simple magnifi-
This loss is absolutely negligible compared with the reduc-
cation, are very resistant to adopt the stereoscope. I know some tion of wastage of hair through transection and excessive trim-
very well-established, internationally prominent hair transplant ming during cutting of FU micrografts without the use of the
physicians who encountered staff resistance when they endea- stereoscope.
vored to switch to the exclusive use of the stereoscope for dis-
secting donor hairs.
There are some ways to encourage staff to switch to use of
the stereoscope:
1. Take staff members to visit a colleague who uses the

stereoscope exclusively and allow them to observe. In
my experience, when the reluctant staff saw experienced
stereoscope cutters in action, they were amazed at both
the speed of the dissection and the quality of the grafts
produced. If technicians take pride in their work, they
will likely no longer need further convincing.
2. Hire a new technician who has not had previous experi-
ence in hair transplantation. When the new technician
is trained in stereoscope dissection and becomes adept
at it, the rest of the staff will be motivated to use the
stereoscope as they watch their rookie colleague surpass
them. The improved quality of the newcomer’s grafts,
the reduction in wastage, and the general ease of dissec-
tion after a variable training period usually convince
the most resistant staff members to switch to exclusive
stereoscope dissection.
Invisible Telogen Hair Loss

Critics of the use of stereoscope dissection for FUHT have
argued that there is a chance that isolated ‘‘telogen-state’’ invis-
ible hairs that are in empty skin between visible FUs may be
inadvertently discarded because they cannot be seen. Approxi-
mately 8% to 12% of hairs are in telogen at any one time, and
it has been argued that this number of hairs may be inadvertently Figure 11B-6 A telogen hair on the right side of the two-haired
discarded. I believe that this hypothesis is false. follicular unit. The follicular sheath appears empty below this
First, not all these telogen hairs are invisible. For a signifi- clubbed telogen hair. However, a new anagen hair can be seen
cant part of the telogen state, the follicular sheath is not empty; starting to grow at the base of the sheath (arrow). It is essential to
new anagen hairs can be seen pushing out the still present old avoid dissecting this anagen hair.
360 Chapter 11
Table 11B–1 Number of Hairs in Dr. Richard Shiell has commented, ‘‘Those of us who know
Different Types of Follicular Units
Drs. Limmer, Seager, and Bernstein have no doubt whatever
Follicular units Hairs that they are able to produce outstanding results with the tech-
niques which they advocate (FUHT). What is not so clear is
1% contain 5 hairs 5 hairs whether other practitioners will be able to get similar results if
4% contain 4 hairs 16 hairs the proposed methods are introduced into routine practice. .|.|.
37% contain 3 hairs 111 hairs there are many things which can go wrong with this technique
40% contain 2 hairs 80 hairs if not faultlessly executed. I am only too aware of the inability
18% contain 1 hair 18 hairs of Juri flap and the Frechet triple flaps to gain widespread accep-
100 follicular units 230 hairs tance. They remain useful techniques, but confined to the hands
of a very few skilled specialists (5).’’
Summary of Advantages vs. Disadvantages for

Stereoscope Dissection
To give complete coverage to this matter, it must be stated
that there is a risk that if the grafts are dissected too closely to More grafts can be produced from a donor strip by stereoscope
the hair shafts (i.e., if they are too skinny), telogen hairs within dissection of FUGs than from a strip of the same size without
the FU’s collagen sheath (or perifolliculum), may be stripped stereoscope guidance; moreover, the former method reduces
away and inadvertently discarded. This risk is greatly reduced wastage and conserves precious, nonrenewable donor hair that
by identifying and protecting small anagen hairs and by ensur- would be wasted if the area were dissected into FUs by means
ing that chubby grafts are cut. of the latter approach. This is particularly important for the
slivering component of dissection. Slivers can be cut perfectly
after 2 weeks of training. Use of the stereoscope enables the
Successful Results Are Not Obtained by All Who technician to cut true single-hair FUGs for the hairline. Even
Attempt FUHT nonpigmented hair and small anagen hairs can be seen. Because
It should be mentioned for the sake of completeness that suc- of the strong illumination and magnification, far less transection
cessful FUHT (meaning the exclusive use of large numbers of and collateral damage occur. Grafts cuts can be made chubby
FUs) is extremely difficult to perform from a technical stand- to allow protective tissue to surround the hairs and papillae.
point. It takes a highly selected, extremely talented team of This tissue can aid in protecting the grafts against trauma during
nurses/technicians to do precise cutting viewed through the eye- planting, which in turn can improve survival and minimize poor
pieces of a microscope. Moreover, this procedure is very tedious growth.
and has to be done for many hours, which lends itself to fatigue Contrary to what some may claim, any potential (and infini-
and reduction of quality. Not every technician, even those in tesimal) loss of invisible telogen state hairs is far outweighed
established practices, is capable of consistently cutting grafts by the gain in hairs saved from the damage or transection that
with the accuracy needed. Moreover, there has to be an ex- would occur without use of the stereoscope.
tremely oppressive and continuously implemented quality-con- The best way to overcome staff resistance to use of stereo-
trol program to maintain the high standards required needed scopes is by giving them an opportunity to directly observe the
for the desired results. Even in a carefully selected and highly advantages of the technique.
experienced team, some members are always able to work more The only true disadvantages that remain are the initial cost;
quickly and to a higher standard than others. Natural talent in the ongoing staffing costs to implement and use the stereoscope;
this field is a very significant factor. and the increased effort, labor and time it takes to cut the grafts.
In various cases, attempts have been made to convert first- In my practice, we all believe that the advantages far outweigh
class hair transplant facilities to FUHT when the technical staff the benefits.
had no prior experience with the stereoscope. In such cases, the
desired degree of success has not been achieved. The nurses/ Implementation and Instrumentation in
technicians doing the cutting and planting must be carefully Stereoscopic Dissection of Follicular Units
handpicked and undergo a lengthy training period (1 to 3 years
to produce optimal results at an acceptable speed). To produce The advantages and disadvantages of stereoscopic dissection
this caliber of staff and to ensure that the necessary high stan- of FUs have been discussed; this section helps to determine
dards are maintained, the hair transplant physicians in charge what changes and instruments are required to implement stereo-
must be particularly rigorous about insisting on quality. They scope dissection.
must be prepared to put in the extra time and effort to supervise Ergonomics is important for stereoscopic dissection. Every-
the training, quality control, and, eventually, a thorough critical thing should be done to promote the comfort of the surgical
evaluation of results. It is rare to find this combination. Extreme staff during their work. Counters, stereoscopes, and adjustable
dedication is required on the part of hair transplant physicians chairs should be set up so that the operators can keep their
and their teams. necks and backs straight and their arms, elbows, and wrists in
For these and other reasons, many hair transplant physicians a neutral position while the technicians are slivering or cutting
attempt FUHT without being able to consistently produce and grafts. The chair should have adequate back and lumbar support
maintain the conservation of donor hair described herein, and because cutters may spend long hours in the same position in
the beautiful end-quality and natural appearance of the finished front of a stereoscope. Proper ergonomics is essential to prevent
hair transplant. fatigue and repetitive strain injury. After 60 minutes, each tech-
nician should spend at least 5 minutes exercising and stretching. the dissection procedure without damaging a single piloseba-
Hand dermatitis from prolonged wearing of gloves used to be ceous unit.
common in hair transplant surgery, but discussion of the details The slivers (slices of bread) are dissected from one of the
of its prevention is beyond the scope of this chapter. cut sides of the strip (Fig. 11B-7). The strip is placed on a
The stereoscope that is selected should provide adequate tongue depressor and grasped by its epidermis with the left hand
illumination and magnification. The Meije EMT turret stereo- by a pair of jeweler’s forceps. At the same time, the operator’s
scope with 5x or 10x magnification is a good choice. A Meije right hand holds the razorblade (encased in a razorblade holder
stereoscope with a zoom lens is also available. A halogen-light to prevent injury to the fingers from the other sharp edge of
source and a transformer are required. More elaborate and ex- the razorblade). Holding the strip steady with the left hand and
pensive stereoscopes are available but not necessary. Less ex- applying gentle traction on the left of the ‘‘sliver-to-be,’’ the
pensive stereoscopes made in China are also available, but, operator gradually dissects across the width of the donor strip
usually, the necessary depth of field they provide is inadequate (usually about 1 cm wide). The strip cannot be cut into serial
for slivering. The Mantis microscope is popular at several facili- adjacent slivers that are one FU wide with a single slice or
ties because of its superior ergonomics. My technicians and I ‘‘chop,’’ as is usually performed with the traditional naked eye
have tried the Mantis microscope but have found problems that method of dissection. As the razorblade cuts through the strip
have, unfortunately, precluded us from using it. The Mantis is to create each sliver, it is wiggled and curved in between and
available with two powers of magnification: 3x and 5x. The 3x around each hair shaft, with many precise, minute, forward and
power Mantis is extremely comfortable and attractive to work backward cuts—into the apex of the incision and out again.
with; but some surgeons generally regarded as experts and I These minute to- and-fro cuts are made between and around
myself believe that 3x magnification is not enough for the opti- the FUs as the slivers are teased apart from the rest of the donor
mal visualization required for slivering. Most loupes have 3x strip. By means of this process, the blade is gradually advanced
power, and most experts consider 5x magnification to be the until one whole FU-wide strip is separated from the rest of the
minimum needed for expert slivering. In my practice, we have donor strip, thereby avoiding transection and damage. The sliver
found that the Mantis microscope with 5x magnification has a (actually shaped like a slice of bread) does not have a flat and
very narrow depth of field, which, in our opinion, is inadequate even topography. The blade has been maneuvered in between
for expert slivering. and around the hairs located in the sliver and, therefore, the
In addition to the stereoscope, necessary equipment includes side surface of the sliver viewed tangentially has an undulated
autoclavable glass platforms, sterile gauze, sterile tongue de- topography, with each hair shaft visible and intact. This is in
pressors, autoclavable stage clips, and occlusive wrap such as contrast to the traditional method, whereby the strip is simply
Saran plastic wrap. cut though with an even slice, producing a flat, planed surface,
There should be four autoclavable glass bowls (one for each with the irregular and nonparallel hair shafts severed. Each
size of FUs) or (less advisably) four petri dishes per cutter as sliver in a 1-cm wide strip usually contains five to eight FUs.
well as ice packs that can be sterilized, plastic razorblade hold- A close-up photograph of a typical sliver is shown in Fig. 11B-
ers, razorblades, and sterile normal saline solution. 7.
Finally, a cutter needs a high-quality jeweler’s forceps to
use in cutting grafts. These forceps do not have to be as perfect Slivering Techniques: Finer Points
as those used by planters. Often forceps whose tips no longer
oppose well for planting can be repaired well enough to be used When the donor strip is handed over to the cutter, it is washed
as cutting jewel forceps. in sterile normal saline solution (without preservative). A staff
With a good stereoscope, a good chair, and a minimum of
other basic equipment, a cutter is prepared to do stereoscopic
dissection of FUs.
Slivering Techniques: Basic Principles

Dissecting the elliptical donor strip into slivers is analogous to
slicing a loaf of bread. In this analogy, the donor strip is the
loaf of bread and the slices are the slivers. Each sliver (in this
‘‘classic method’’ of dissecting donor tissue into FUs) is a thin
wafer of donor skin, one FU wide (see Fig. 11B-5).
In this method, the donor strip is excised freehand with a
single-bladed scalpel. The beauty of this method is that the only
‘‘blind’’ dissection is the cutting of the upper and lower edges
of the donor strip. After this point, all further dissection is per-
formed with the aid of direct stereoscopic visualization. The
upper and lower edges of the strip are susceptible to transection
of and damage to pilosebaceous units, which cannot be seen
while they are being cut. Once the strip is removed from the Figure 11B-7 A sliver that is 1 follicular unit (FU) wide con-
body and handed to the cutters, however, slivering and graft taining seven intact FUs. Examination of the epidermis reveals
cutting are all done under stereoscopic observation. Theoreti- the undulating path on which the blade was maneuvered to avoid
cally, it should be possible to perform the entire remainder of transecting or damaging the hair shafts of the follicles.
362 Chapter 11
member then measures its length and width at varying points. tured synthetic cutting boards. Under stereoscopic vision, the
At my facility, the strip is usually widest in the occipital area, epidermis of the sliver is held in the technician’s left hand by
narrowest in the postauricular area (where there is usually the jeweler’s forceps, whereas the right hand cuts longitudinally
least flexibility), with the mean width found in the temporal from the epidermal border to the subcutaneous border between
areas. The superior and inferior cut edges of the strip are exam- the FUs (Fig. 11B-9). If the donor hair is sparse in the area of
ined carefully through the stereoscope for transection of hair the strip, there may be some empty skin (epidermis, dermis,
shafts and then, as part of our quality assurance program, graded and subcutaneous fat devoid of components of pilosebaceous
by a senior staff member with a numerical score. units), which may be discarded. Unless the hair is very dense,
Immediately before the slivering process is begun, the donor some trimming of surplus tissue is usually necessary to optimize
strip is inspected for ‘‘rows’’ and ‘‘channels’’ between the rows the size and shape of the graft. As the FUs are dissected, they
in which the FUs usually naturally grow. The rows and channels are counted and recorded on a log sheet and placed into a deep
running between them are more apparent in the temporal areas bowl filled with saline solution, which is set on top of ice.
of the donor strip, because this area is usually less dense. Usu- Five other important components of graft cutting are as fol-
ally, the rows and channels run diagonally, but rarely they can lows:
be seen running in vertical straight lines at right angles to the
1. Leave enough protective dermis and subcutaneous fat
longitudinal axis of the donor strip (Fig. 11B-8).
around each FU to produce a fairly chubby graft that
Initially, the donor strip is divided by the slivering technique
is large enough to fit into an 18-gauge needle site.
not into slivers but into shorter strip sections. These sections
2. Preserve the sebaceous glands.
are then distributed to other sliverers on the same cutting team.
3. Leave a large enough fat pad around the dermal papilla
As the smaller sections of strip are dissected into actual
for the planters to grasp as they plant the grafts. Without
slivers, each piece of donor strip may have to be rotated so
this fat pad, the dermal papilla frequently becomes trau-
that the blade cutting the strip into slivers can be more easily
matized during the planting process;
maneuvered among the empty channels between the usually
4. Trim surplus epidermis from the graft without damaging
diagonal rows of FUs.
the 1-mm to 2-mm stubble of hair exiting the epidermis;
The FUs are best identified at the epidermal edge of the
5. Make the resulting FU micrografts pear-shaped or tear-
strip, where they are most obvious. Inferiorly, into the dermis,
drop-shaped. (Fig. 11B-5).
the hair shafts splay out laterally, making it potentially impossi-
ble to tell which hair shaft belongs to which follicular unit. The
sliver on the left side of the strip is teased away to the left by Cutter Discretion in Sizing the Grafts
the technician’s forceps, as the sharp edge of the razorblade, Seager (6) first noted and described that it is not always obvious
maneuvered and curved around obstructing hair shafts so as not where one FU ends and the next begins. In other words, there
to damage them, is used to cut through the rest of the sliver. are intermediary hairs between two FUs that could belong to
either of them. The reason is that not all hairs of one FU always
Graft Cutting exit from the same orifice, and the hairs splay out laterally
During the process of creating FU micrografts, each sliver is deeper into the dermis. As a result, one cutter may divide a
laid on its side on a cutting surface, which is usually either a sliver with nine hairs into three three-haired FU micrografts,
tongue depressor or one of various types of specially manufac- whereas another cutter may divide the same sliver into four
two-haired FUs and one single-haired FU (this is an extreme
example to describe a point; usually, each FU is a fairly obvious,
Figure 11B-8 Examination of this close-up photograph of the

surface of a donor strip shows that there are natural diagonal chan-
nels between the follicular units (FUs). Some of these channels Figure 11B-9 The process of graft cutting. Notice that the cut
have been indicated by lines. There are fewer vertical paths, which of the grafts will be chubby. Hairs will be avoided and sebaceous
do not transect follicular units. glands will be left intact.
visibly distinct entity. However, there is definitely some ability

to manipulate the size of the many FU micrografts to fit the
needs of the particular case (6,7).
Clinical Natural Hair Groupings Compared with

Anatomically Precise Follicular Units
True anatomical FUs can only be accurately identified as such
by histological examination under special staining techniques.
This is not possible during clinical hair transplantation. It is
obvious from the previous paragraphs and other more scientific
evidence that many of what hair transplant physicians call FUs
may be part of a larger actual FU or an actual FU with one
or more extra hairs included. It has been suggested that hair
transplant physicians not use the term follicular units, but in-
stead call these grafts ‘‘natural hair groupings’’ or similar termi- Figure 11C-1 Basic steps in elliptical excision and micro-
nology. This suggested change in clinical nomenclature has not scopic dissection (EEMD).
been accepted, and FUHT practitioners ubiquitously, rightly or
wrongly, call their grafts ‘‘follicular units’’ (FUs).
Conclusion individual grafts with the aid of backlighting and magnification

(Fig. 11C-2). We refer to the combined stages of the latter
Stereoscopic dissection of FU grafts has many advantages. technique as MBHⳭB&M (MultiBladed Harvest Ⳮ Backlight-
However, to be effective, it requires a disciplined approach that ing and Magnification). In MBHⳭB&M, the magnification
adheres to the highly specialized techniques described in this most commonly used for the final phase of graft production
chapter. It is clear that these advantages outweigh the disadvan- comes from loupes of varying levels of power; however, some
tages, which are also described. The stereoscopes and instru- physicians use microscopes for the final phase (Fig. 11C-3).
ments required are readily available. A novice can be trained These are the two most common methods of graft production.
to perform excellent, although slow, stereoscopic dissection in A third, less common method of graft preparation uses MBH
2 weeks. An experienced cutter can dissect grafts more quickly to harvest multiple thin donor strips combined with use of an
and can eventually master the essential skill of slivering. automatic graft-cutting device to convert the thin strips into the
The extra training, work, and cost are worth the investment final grafts (Chapter 11D).
when precise, padded, and protected FUGs are prepared that Arguments exist for and against all of these approaches. To
exhibit better growth and—most importantly—conservation of understand the relative benefits of different methods of graft
precious, nonrenewable donor hair. production, a distinction must be made between two separate
questions:
1. The first question to answer is ‘‘What types and num-
11C. Combining Microscopic bers of grafts are best to use for an individual patient
Slivering with Backlighting and specific situation?’’
2. Once this question is answered the second question to
Loupe Magnification to
Efficiently Produce Grafts
Paul T. Rose and Ron Shapiro
INTRODUCTION
Graft preparation is an integral part of hair transplantation, and
the increasing use of large numbers of small grafts has sparked
innovations to produce viable grafts more efficiently and effec-
tively. Although controversy exists over the best method of
graft production, all methods begin with harvesting tissue from
the donor area ends and converting the tissue into individual
grafts. Some physicians advocate the exclusive use of elliptical
excision and microscopic dissection (EEMD) (Chapter 11B).
Through this method, surgeons initially harvest donor tissue as
a single ellipse. Next, under the microscope, they convert the
ellipse into thin strips called ‘‘slivers.’’ Finally, still using the
microscope, they dissect these slivers into individual grafts (Fig.
11C-1). Other physicians advocate using a multibladed knife Figure 11C-2 Basic steps in multibladed harvest plus back-
to harvest multiple thin donor strips that are then converted into lighting and magnification (MBHⳭB&M).
364 Chapter 11
ing transection and waste. Finally, we discuss a system for com-

bining the use of microscopic slivering with backlighting and
loupe magnification in a specific way that maintains much of the
microscope’s benefits while minimizing its commonly voiced
disadvantages.
GOALS AND DEFINITIONS

Our primary goal during graft production is to produce the spe-
cific types and quantities of grafts desired without decreasing
follicular survival on increasing follicular waste to a clinically
significant extent. Follicular survival and follicular waste are
distinct entities, and it is important to understand their differ-
ences:
1. A decrease in follicular survival (or poor growth) refers
to transplanted follicles that either do not grow at all,
Figure 11C-3 Different types of loupe magnification: Goose or grow with a decreased caliber. A decrease in caliber
neck magnifier (x), high-power surgical loupe (y) s, and low-power is considered a form of relative decreased survival in
magnifying glasses (z). this discussion.
2. Follicular waste is the loss of available hair follicles
during the donor harvesting and graft preparation phase
of a hair transplant procedure. It occurs when hairs are
answer is now ‘‘What is the best method of producing accidentally discarded (left on the table) during the graft
these ‘‘chosen’’ grafts?’’ production process. The following is an example of fol-
licular waste: A virgin 10-cm2 area of donor tissue has
In our opinion, the optimal method of graft preparation 2000 hairs available before donor harvesting and graft
largely depends on the specific type and number of grafts de- cutting. After waste, however, the donor tissue produces
sired. We believe that follicular unit grafts (FUs) are intrinsi- as few as 1500 hairs if as much as 25% wastage occurred
cally more vulnerable than minigrafts to the effects of transec- during graft preparation.
tion and waste. For this reason, when a large number of FUs
are to be produced, we suggest using a method of graft produc- Clinically significant decreased survival and increased waste
tion, such as EEMD, that minimizes transection and waste. On are obviously undesirable because they decrease the potential
the other hand, when producing minigrafts, cut ‘‘to size’’, sur- maximum degree of density achievable in a given patient.
geons trim less and use most of the tissue, therefore, the total
elimination of transection and waste is not as clinically impor-
tant. FU GRAFTS VERSUS MINIGRAFTS:
It is generally accepted that EEMD is an extremely effective SUSCEPTIBILITY TO TRANSECTION AND
method of minimizing transection and waste in the preparation WASTE
of large numbers of FUs (1–5). However, physicians commonly
voice a number of arguments against this technique. These argu- One way to categorize grafts is to divide them into two broad
ments include the following: groups described as grafts cut to size and grafts cut to the num-
ber of hairs (7,8). Grafts within these two groups share certain
1. The need (and expense) for multiple microscopes properties that affect their vulnerability to transection and
2. The difficulty and high level of skill required to master waste. Surgeons typically cut FU grafts to the number of hairs.
the technique of slivering In this process, the surgeon instructs assistants to search for
3. The substantial time and effort necessary to train multi- and o isolate naturally occurring groupings that contain from
ple assistants to produce excellent slivers one to four hairs. The assistants then dissect these groupings
4. The existing staff’s resistance to switch over to use of and convert them into individual grafts while carefully trimming
the microscope away a safe amount of excess epithelium and tissue. If FUs are
There are some who, despite agreeing with the fact that EEMD created in this manner, they are intrinsically more susceptible
decreases transection and waste, voice the additional argument to the effects of transection and waste for the following reasons:
that the decrease is not statistically significant enough to justify
the increased effort it requires (6). We disagree with this argu- FUs Susceptibility to Transection
ment and think that its conclusion arises from an inaccurate
comparison of the value of using EEMD for the creation FU’s The increased amount of cutting and trimming inherently in-
versus the creation of minigrafts. volved in the creation of large numbers of FUs increases the
In this chapter, we discuss why the elimination of transection absolute numerical amount of cuts required and, therefore, the
is particularly important and clinically significant when large absolute number of hairs at risk of transection. Obviously, what-
numbers of FUs are produced. We also compare EEMD and ever effect transection has on survival and waste is magnified
MBHⳭB&L with respect to their relative efficacy in eliminat- by an increase in the absolute number of transections.
The survival rate of a transected follicle is a frequent subject on the average number of hairs desired per graft. Minigrafts
of controversy. At one time, surgeons proposed that a transected cut to size are ‘‘less’’ susceptible to the effects of transection
follicle might yield two potentially beneficial hairs (9). Studies and waste for the following reasons:
by Kim, Martinick, and others, however, contradict this claim
1. The surgeon makes fewer total numbers of cuts when
(10,11,12). Kim shows that, depending on the level where the
preparing minigrafts, which decreases the absolute
surgeon cuts the hair shaft, the survival of the remaining portion
number of hairs at risk of transection;
of a transected hair ranges from 27% to 80%. Kim’s numbers
2. The process of cutting minigrafts to size involves only
indicate that the combined survival of both sections of a tran-
minimal trimming and discarding of donor tissue. Sur-
sected hair is usually less than 80% (11) (Chapter 9C). In addi-
geons use most of the donor tissue and put it back into
tion, even if a transected hair does survive, the caliber of the
the recipient area. Therefore, they do not discard invisi-
hair shaft may decrease, which reduces the ability of the hair
ble telogen follicles and partially transected hairs, which
to create the illusion of coverage (11).
instead remain as part of the graft. Although the viabil-
ity, caliber, and contribution of these partially transected
FUs Susceptibility to Waste hairs are subjects of controversy, at least such hairs are
not discarded.
Intrinsic to the production of FUs is trimming and discarding
excess tissue, which makes FUs particularly vulnerable to the For these reasons, a method of graft production that nearly
following types of waste: eliminates transection may not be as necessary when performing
CMM procedures that primarily use minigrafts cut to size.
1. Partially transected hairs are at risk of being acciden-
Opinions vary among physicians regarding the best types
tally discarded and wasted during trimming (1). In the
and number of grafts to use in an individual patient. We believe
past, many physicians purposely discarded these partial
that there is a population of patients whose goals can best be
hairs or spicules because of fear of reaction from a for-
met if the surgeon uses large numbers of FUs (Chapter 12C).
eign body. At present, we attempt to keep most partial
Logic dictates the following:
hairs in the hope that they may be viable.
2. Unseen telogen follicles or tiny hairs in the early anagen 1. Suppose that at least ‘‘some’’ patients benefit from the
phase may also be unknowingly trimmed away and disuse of large numbers of FU.
carded. In an attempt to avoid accidentally discarding 2. Suppose also that a method of graft production that
telogen follicles, there is currently a move toward leav- limits transection and waste is ‘‘particularly’’ impor-
ing a little more tissue around FUs than in the past tant when creating large numbers of FU.
(chubby FUs) (13) (Fig. 11C-9). The hope is that most 3. The conclusion is that, ‘‘at least for these patients,’’
of the tiny or unseen hairs exist in fairly close proximity physicians should have in their armamentarium a
to the rest of the hairs in an FU graft. method of graft production that minimizes transection
and waste.
The trimming and discarding of hairs have another negative
effect specifically significant in FUT procedures. The risk and In the following sections, we evaluate the graft preparation pro-
tendency to discard partially transected hairs leads to a popula- cess of both EEMD and MBHⳭB&L. We will look at the steps
tion of grafts containing a smaller proportion of the larger three- involved and their potential affect on transection and waste
hair and four-hair FUs (1,3,7) (Table12A-7 in Chapter 12A). when preparing large numbers of FUs.
Discarding partially transected hairs makes four-hair FUs be-
come three-hair FUs, three-hair FUs become two-hair FUs, and
two-hair FUs become one-hair FUs. Part of the power of FUT MULTIBLADED HARVEST WITH BACKLIGHT
rests in its ability to obtain and use the larger three-hair and AND LOUPES MAGNIFICATION (MBHⴐB&M)
four-hair FUs for selective distribution and creation of density
(2). We lose this ability, however, if a significant amount of Graft production with MBHⳭB&M consists of the following
transection leads to a smaller population of these larger FU three steps (Fig. 12C-2):
grafts (Chapters 12A and 12C). 1. Initially harvesting of multiple thin donor strips with a
For all of the aforementioned reasons, a method of graft multibladed knife
production that increases visibility and minimizes transection, 2. Cutting of these strips into smaller, more manageable
such as EEMD, should be used when attempts are made to pieces
produce large numbers of FUs. 3. Converting the strips into individual grafts with the aid
of backlighting and magnification
TRANSECTION AND WASTE WITH The introduction of the multibladed knife changed the manner
MINIGRAFTS CUT TO SIZE in which surgeons harvested tissue-prepared grafts. Vallis ini-
tially introduced the multibladed knife in 1968 (14) to create
Most minigrafts are categorized as cut to size (7,8). When mini- linear strip grafts. In 1976, Coiffman (15) used a multibladed
grafts are created, the surgeon instructs an assistant to cut a knife to create square grafts. Later, others, including Bisaccia
population of grafts that specifically fit an incision of prese- in 1990 (16) and Brandy in 1992 (17), modified the use of the
lected size and shape. This type of graft has a range of hairs multibladed knife to create minigrafts and micrografts.
depending on the size requested and the density of the donor The multibladed knife contains multiple parallel blades,
area hair. The physician chooses a specific size and shape based which obtain multiple thin donor strips of various predeter-
366 Chapter 11
Figure 11C-4 Multibladed harvests: (a), Harvesting the donor area with multiple blades to get multiple thin strips. (b), Multiple thin
strips after harvesting.
mined widths (Fig. 11C-4a). By changing the number of blades minigrafts may be varied by changing the distance between the
and the distance between them, the surgeon varies the total and blades of the multibladed knife and by altering the thickness
individual widths of the donor strips (Fig. 11C-4b). The surgeon of the individual slices. Micrografts or FUs can also be obtained
usually cuts the strips into smaller, more manageable sections either by trimming one or two hair grafts away from the periph-
before converting them into individual grafts (Fig. 11C-5). In ery of a larger minigraft or by searching for individual FUs
the final step minigrafts of different sizes are then sliced off within the strip itself.
the edge of the previously harvested thin strips. To envision The initial step of harvesting multiple thin donor strips with
this process, imagine slicing a loaf of bread into individual the multibladed knife is highly vulnerable to transection because
pieces. In this analogy, the loaf of bread represents the thin it is a blind cut. The changing angle and direction of hair in
donor strip and the slices of bread represent the individual mini- the donor area make it nearly impossible to align all of the
grafts. Depending on the physician’s preference, the size of the blades parallel to all of the hair. Hard tumescence, loupe magni-
fication, meticulous technique in following the angle of hair
growth, and a high level of skill decrease the degree of transec-
tion that occurs during this step.
The average amount of transection that results from MBH is
unknown. There are very few statistically significant published
studies. Much of our information comes from the empirical
observations of physicians. The following generalities derive
from editorials (18–20). and information supplied by physicians
skilled in this technique (Cole J, Mangubat EA, Reed W, Wolf
B, Rose P, and Limmer B, personal communications). Some
physicians are extremely skilled with MBH and claim to
achieve nearly perfect strips. However, after questioning sur-
geons more closely, we find that nearly perfect means transec-
tion rates averaging from 8% to 15%, as shown in the following
list:
1. Limmer states that he averages a rate of 8% to 15%
(average 12%) when producing only three strips (each
3 mm wide) by means of a slow, meticulous technique.
2. Pathomvanich states that his best rate averages approxi-
mate 10%, but that he did not achieve these results until
Figure 11C-5 Strips obtained by multiblade harvesting are sep- after he had mastered the technique.
arated and cut into smaller pieces; small pieces are placed in a 3. Cole believes that skilled hands can achieve a transec-
saline solution. tion rate of about 10% to 15%.
4. Reed, an advocate of MBH, compared average transec- With the conventional method of cutting on an opaque sur-
tion rates between EEMD and MBH (See Chapter 12C). face, assistants cannot see through the donor tissue to any signif-
While performing his study, he separated the results of icant depth, and this ‘‘blind’’ dissection often results in inad-
transection rates for FUs and minigrafts. A close look vertent transection of deep unseen follicles. When the light-
at his numbers for the subpopulation FUs shows that: transmission properties of fat are exploited, it becomes evident
that with backlighting, the tissue appears translucent and the
● Reed obtained the lowest rate of transection (6%) darker follicles do not. Deep follicles can more easily be dis-
when his most experienced technician produced cerned against the background of translucent fat (Figs.11C-6a
FUs exclusively with EEMD. and b). With use of backlighting, more precise dissection of
● The production of FUs with use of MBH caused donor tissue is possible, which results in less transection and
the highest rate of transection (16%). This number waste. The results of backlighting are further aided by various
may be falsely low, because of the protocol of degrees of loupe magnification and limited room illumination.
Reed’s study. He compared transection rates of FUs This technique is less useful for light-colored or white hair
and minigrafts while using MBH for the simultane- because of its lower color contrast. It is most useful when ap-
ous creation of both FUs and minigrafts. His proto- plied to very thin strips of tissue that permit the passage of
col for creating high quality FUs is to ‘‘cherry pick’’ light. As the strips become thicker and less light passes through
untransected FUs. Cherry picking is a good method them, the benefit decreases. Although backlighting and loupe
of selecting a subpopulation of nontransected FUs, magnification effectively limit transection and waste during the
but it is necessary only in the presence of transection final stage of graft production, they lose much of their benefit
in the strip. When included in the protocol of the when the donor strips obtained through MBH already contain
study, cherry picking skews the data, because many significant amounts of transection. Conservatively, this final
of the transected hairs are designated as minigrafts. step of graft production may add another 2% of transection,
It underestimates the amount of transaction that bringing the total estimated transection rate for MBHⳭB&M,
would exist if only FUs were being created. in skilled hands, from about 17% to 19%.
Alternatively, to estimate the amount of transection that occurs

with MBH, add the hypothesized amounts of transection that ELLIPTICAL EXCISION AND TOTAL
occur per blade. It is estimated that a skilled physician can limit MICROSCOPIC PREPARATION OF
transection with a single–bladed knife to about 2% by carefully FOLLICULAR UNITS (EEMD)
observing and following the angle of the hairs while making Graft production with EEMD also consists of the three follow-
his incision. If this rate were consistent for all the blades, skilled ing steps (Fig. 11C-1):
physicians who use six blades to produce five strips would have
a total transection rate of 12%. Cole correctly estimates that 1. Initial harvesting of donor tissue as a single ellipse (Fig.
the transection rate of 2% can be achieved only with visibility 11C-7).
of the top blade and that inferior blades used to cut blindly have 2. Cutting the donor ellipse into thin slivers with the aid
a higher transection rate because of the changing angle of the of the microscope (Figs. 11C-8a–c).
hair and the altering slope of the scalp. If the transection rate 3. Dissecting the thin slivers into individual grafts while
for the inferior blades is conservatively increased from 2% to still using the microscope (Figs. 11C-9a b).
3%, the total transection rate for six blades (five strips) is 17% As early as 1988, Bob Limmer started using elliptical strip
(2%Ⳮ3%Ⳮ3%Ⳮ3%Ⳮ3%Ⳮ3%⳱17%). harvesting followed by use of the stereoscopic microscope to
Consistency also poses a problem. From physicians skilled prepare small minigrafts and micrografts (4). Harvesting a sin-
in multibladed harvesting (Cole J, Mangubat EA, Reed W, Wolf gle elliptical donor strip decreases the risk of transection com-
B, Rose P, and Limmer B, personal communications), we have pared with simultaneous harvesting of multiple strips with a
learned that although surgeons average 8% to 15% transection multibladed knife. The explanation for the difference is that
rates, many admit their range is much wider, with transection single elliptical donor strips require only two incisions, whereas
rates ‘‘occasionally reaching as high as 15% to 20Ⳮ %.’’ Pa- a multibladed knife creates multiple cuts. In addition, the sur-
tients with curly hair or scarring in the donor area are at greater geon makes the incisions with a single blade under direct obser-
risk of transection during this step of transplantation. We be- vation, whereas when the multibladed knife is used, many of
lieve that less skilled physicians who do not perform enough the cuts are blind. The transection rate from this method of
cases to become proficient at this technique have even higher donor harvesting consistently ranges from 2% to 4% (in skilled
transection rates. hands sometimes less than 2%) (5). In addition, elliptical inci-
The donor strips harvested with the multibladed knife must sion is an easier technique to master and develop consistency
be converted into individual grafts (Fig. 11C-1). During this with than MBH.
stage of graft production, additional transection occurs. More During the next step of EEMD (Fig. 11C-2), in which the
importantly, however, in this stage, previously transected hairs surgeon converts the single ellipse into multiple thin strips or
and unseen telogen hairs may be discarded and wasted. In late slivers, the follicles in the ellipse remain vulnerable to transec-
1993, Rose began exploring the use of backlighting (transillu- tion. If the surgeon simply slices the ellipse blindly at this step,
mination) and loupe magnification to allow more precise con- the potential for transection becomes even higher (3).
version of multibladed harvested strips into minigrafts and mi- Limmer, and, subsequently David Seager, therefore, have
crografts. emphasized the importance of using the microscopic slivering
368 Chapter 11
Figure 11C-6 (A), With backlighting, dark follicles are more visible against a background of translucent fat; (B), magnification increases
the effect.
technique for this step. They demonstrate that an ellipse of Bernstein and Seager independently reported the ability to pro-
donor tissue may be converted into multiple thin slivers that are duce between 17% and 25% more FUs with EEMD than with
approximately one to two FUs wide; little additional transection MBH&BⳭM (1,2) when two similarly sized strips were used.
occurs if they are slivered under direct microscopic observation. Bernstein has also published a study showing that EEMD in-
The slivering technique is discussed in detail in Chapter 11B. creases the proportion of four-hair grafts from 0.5% to 6%, that
We believe that most of the value of EEMD results from the the number of three-hair grafts increases from 12% to 34%,
combined benefits of the first two steps: single-strip harvesting and that the proportion of one-hair grafts decreases from 38%
and subsequent microscopic slivering. Once the surgeon pro- to 14% (1) (Table 12A-8 in Chapter 12A).
duces these thin, nontransected slivers, dissecting them into in- Although the validity of these reports has been questioned,
dividual grafts with the continued aid of the microscope is fairly it is defended by the empirical experience of many physicians
easy. who have switched from MBHⳭB&L, to EEMD to produce
The transection rate for the total process of EEMD has been large numbers of FUs. These surgeons report obtaining higher
reported to be consistently as low as 2% to 5% in skilled hands. numbers of FUs from their strips and a greater proportion of
three to four-hair FUs (1,3,18). Physicians who have switched
to EEMD for the production of large numbers of FUs often
comment empirically, ‘‘I don’t have to take as large a strip to
get the same number of grafts.’’
Table 11C-1 and Chart 11 C-1 show the potential difference
in the total number of hairs transected in a single session when
attempts are made to produce different numbers of FUs. EEMD
creates a total transection rate of 3% (consistent rate in skilled
hands); and MBHⳭM&B creates a total transection rate of 18
% (estimated average rate in skilled hands). If these estimates
are accurate, the MBHⳭM&B method potentially transects
about 690 more hairs than EEMD in a 2000 FU graft case.
A SYSTEM OF COMBINING THE

MICROSCOPE WITH BACKLIGHTING
Figure 11C-7 Elliptical strip harvesting: A single ellipse or
strip from the donor area with a single-blade knife. Although called Although the value of EEMD in the production of FUs is gener-
an ‘‘ellipse,’’ most of the time it has the geometric shape of a long ally well-accepted, valid problems arise when converting and
rectangle with tapered ends. Some physicians use a single blade training a staff to use the microscope and training them to be
and shape the ellipse freehand, whereas others use a multibladed proficient with this technique. As stated earlier, some of the
knife that has only two blades. commonly voiced dilemmas include the following:
Figure 11C-8 Slivering Process in elliptical excision and microscopic dissection (A), Multiple assistants slivering under the microscope;
(B), Close-up view of slivering; and (C), actual sliver, one follicular unit wide, after it has been cut.
1. The expense and need for multiple microscopes its commonly voiced disadvantages. Although this system is
2. The high level of skill needed to master the technique very similar to EEMD, there are modifications at each stage
of slivering that make it easier to perform.
3. The substantial time and effort required to train multiple The basic stages (Fig. 11C-10) are as follows:
assistants before they can produce excellent slivers
● Stage 1: Harvesting donor tissue as a single strip
4. The staff’s resistance in converting to this technique
● Stage 2: Training one ‘‘specialist’’ to convert the strip
In this section, we discuss a system of combining the best ele- into thin slivers for the other assistants
ments of EEMD and backlighting in a specific way that main- ● Stage 3: Dissecting individual grafts from thin slivers
tains most of the benefits of EEMD, and minimizes some of by means of backlighting and magnification
Figure 11C-9 (A), The thin sliver has easily discernible follicular units (FUs) that can be (X) isolated and into which the surgeon can
cut. (B), Individual one-hair, two-hair, and three hair FUs shown under the microscope.
370 Chapter 11
Table 11C–1 Comparison of Potential Number of Hairs Transected Between EEMD and MBHM&B in a Single
Session When Different Numbers of FUs Are Produced
FUs created in a Hairs in FUs created Potentially transected Potential transected hairs
single sessiona (2.3 hairs/FU) hairs with EEMDb with MBH M&Bc
500 FUs 1150 Hairs 36 Hairs 207 Hairs

a
These data are intended to compare the effect of transection only when different quantities of follicular units are produced.
b
These numbers are derived by using a transection rate of 3% for the total process of graft production with elliptical excision and microscopic
dissection, which has been shown to be consistently produced once proficiency is developed with this technique.
c
These numbers are derived by using a total transection rate of 18% (15% for multibladed harvesting and 3% for the final phase of graft pro-
duction). As stated in the text, this is the rate for skilled physicians. This rate is inconsistent and may occasionally be higher (20%), even in
experienced hands.
EEMD Elliptical excision and microscopic dissection; MBH M&B multibladed harvest and backlighting magnification.
Stage 1: Harvesting the Donor Area as a Single

Strip
This stage is basically the same as that for EEMD (Fig. 11C-7).
Most physicians agree that this part of the technique is relatively
simple and actually takes less skill than using a multi-bladed
knife. Follicle transection can be consistently minimal. When
first training new assistants, surgeons often introduce the use
of a double-bladed knife, which is a minor modification. We
favor using such a knife at the beginning of training because
the knife helps to keep the uniform width and shape of the
resulting strip. This consistency is helpful when new assistants
are being trained to sliver and, in our opinion, is worth the
slight potential increase in transection.
Stage 2: Use One Specially Trained Assistant to

Figure 11C-10 Schematic of combination of the microscope Sliver the Strip
with backlighting and magnifications (MSⳭB&M).
Rather than training all of the assistants to use the microscope
and teaching them to sliver, train only one assistant to specialize
in slivering (Fig. 11C-11). It is easier to train one appropriately
talented assistant to specialize in slivering than to attempt im-
mediate training and conversion of a whole staff. In some cases,
hiring a new assistant who is not resistant to the microscope is
helpful.
Initially, the specialist should be trained with strips that are
no more than 0.5 mm wide. Strips of this width lie firmly on
their side and do not flop over like their wider counterparts. It
is easier to learn to sliver on thin strips, of about 0.5mm, and
then gradually build up to wider strips of about 1 cm. This
evolution prevents the specialist from becoming frustrated early
in the training process.
The new slivering boards and the principle of lateral traction
make slivering easier. The ‘‘Blugerman board’’ (Ellis Instru-
ments) is one device (Fig. 11C–12). That allows the technician
to apply lateral traction. Rather than slicing between the FUs,
the assistant simply touches the blade between FUs and uses
the lateral traction to let the tissue peel away. Understanding
Chart 11C-1 Comparison of potential number of hairs trans- and applying this principle makes slivering easier.
ected between EEMD and MBH + M&B in a single session The specialist should supply high quality, untransected sliv-
when different numbers of FUs are produced. ers for the rest of the staff to cut, using backlighting and loupe
cian converts the donor tissue into very thin strips that can
be illuminated and subjected to the benefits of backlighting.
Moreover, the rest of the staff does not usually resist cutting
these untransected slivers with backlighting and loupe magnifi-
cation. The specialist usually produces enough slivers to keep
up with the graft cutters. With experience over time, we have
found that assistants often prefer switching to the microscope
for this final phase because it is less stressful on their backs,
necks, and arms.
This method addresses many of the problems associated with
classic EEMD in the following way:
1. Initially, only one microscope is required.
2. The whole staff does not have to be converted to the
new technique at once; many can continue cutting grafts
in their accustomed way.
3. Resistance to the change decreases.
4. The training process and new equipment make it easier
Figure 11C-11 One specially trained assistant using Mantis
Microscope (x) and Blugerman slivering board (y) to cut a single to train at least one assistant to be proficient in slivering.
strip (z) into slivers. This specialist creates slivers for the rest of
the assistants. Miscellaneous Points
● We trim the donor hair to only about 4 mm in length.
Leaving the donor hair a little longer aids in placement
of grafts later in the procedure (Chapter 13A).
● We selectively separate our one-hair to-four hair FUs to
facilitate selective distribution and/or FU pairing. FU
pairing is described and referred to as ‘‘recombinant FU
grafting’’ by Harris in Chapter 12E.
● The size of the donor strip needed varies, depending on
the number of FUs desired and the density of the donor
area. It also varies from office to office, depending on
the amount of tumescence, the skill of the assistants, and
the amount of waste. There are many ways to estimate
the size of the desired donor strip. In our office, we are
accustomed to use 6 to 8 slivers/cm. We also generally
achieve a range of 8 to 20 FUs/per sliver (average 14
FUs/sliver in virgin donors with average density), de-
pending on the donor density and the amount of scarring.
This calculates to about 84 FUs/cm2 (14 FUs/sliver ⳯
6 slivers/cm⳱84 FUs/cm). We do not achieve 100 FUs/
Figure 11C-12 The principle of Lateral Traction applied by cm2 because preharvesting tumescence decreases donor
attaching one end of the strip to a specialized slivering board (x)
density by about 10% to 20%. To estimate the amount
and pulling the other end with forceps (y), which separates the
of donor tissue needed, we divide the total number of
follicular units and makes slivering easier. One simply touches the
blade to the space between the FUs, and the tissue peels away (z).
FUs desired by the numbers of FUs/cm. If we want an
1800 follicular unit graft and the patient has normal den-
sity, 1800 FUs ⳰ 84 FUs/sliver is about 24 cm. We
divide by a higher or lower number of FUs/cm if war-
ranted by different donor densities or degrees of scarring.
magnification. Over time, a second and third slivering specialist We use a counting sheet to keep track of the actual
can be added to the staff. number of FUs to estimate and update the number of
grafts we ultimately achieve. We hope that this number
Stage 3: Dissect the Very Thin Slivers into matches our initial estimation. However, we can alter
Individual Grafts with Backlighting and the number of incisions or harvest more donor tissue if
Magnification necessary. We use a specialized cutting sheet for these
modifications (Figs. 11C-8 and 11C-9).
During the final phase of graft preparation, the technician can ● We test the size of our grafts very early in the graft
now more easily convert the thin slivers into grafts, employing preparation phase to make sure they can be easily placed
only backlighting and loupe magnification (Figs. 11C–13a and throughout the procedure. It is important for the size of
b). This is because the slivers created up to this point should the graft to fit the size of the incision. Grafts with equiva-
be relatively free from transection. Backlighting and loupe mag- lent amounts of hair vary in size for a number of reasons
nification pose little risk of follicle transection once the techni- (see Chapter 13).
372 Chapter 11
Figure 11C-13 (A), Typical backlight and magnification set up with (x) visual plus backlight and (y) translucent plastic cutting strip
and gooseneck magnifier for magnification. (B), Appearance of sliver with backlight and magnification.
CONCLUSION high-quality minigrafts and micrografts for hair transplantation.

The impulsive force technique greatly reduces the time needed
In summary: for graft preparation and total staff required per procedure; in
● The use of large numbers of FUs is beneficial to some addition, any hair restoration surgeon can use it.
patients. Modern hair transplantation (HT) techniques have evolved
● The risk and clinical significance of follicle transection to the point where they require the extensive use of greater
and waste is potentially of greater significance when and greater quantities of minigrafts and micrografts. Most HT
large numbers of FUs are produced. surgeons agree that large numbers of small grafts are essential
● A physician should have a method of graft production to achieve excellent results. Several HT surgeons advocate the
that nearly eliminates waste when large numbers of FUs exclusive use of stereoscopic microscopic dissection to produce
are created. follicular unit (FU) grafts that can provide the best results (1).
● Single-strip harvesting combined with microscopic dis- Although the natural results achieved by this technique are ex-
section to produce grafts is one method of limiting tran- cellent, the use of microscopic dissection has not been shown
section. However, there are practical disadvantages asso- to be superior to other methods of graft preparation.
ciated with using this technique. The nature of modern hair restoration surgery (HRS) re-
● Combining (1) single-strip harvesting, (2) microscopic quires considerably large staffs who must have increasingly
slivering by specialists to create nontransected thin strips refined skills that will serve fewer patients the results are in-
of donor tissue, and (3) the division of the slivers with creased cost and reduced productivity. Regardless of technique,
use of backlighting and loupe magnification, maintains however, the common theme of HRS today is the transplanta-
many of the benefits provided by the microscope and tion of large quantities of small grafts that more closely approxi-
eliminates many of its disadvantages. mate what occurs in nature.
Contemporary HT techniques are repetitive, from harvesting
and preparation of minigrafts and micrografts to graft place-
11D. Impulsive Force Graft ment. This repetitive nature lends itself to automation because
Preparation the same tasks are repeated hundreds, if not thousands, of times
for each patient.
E. Antonio Mangubat Automated graft cutters (Kahn S. Personal communication,
INTRODUCTION 1995) have been described previously (2)]. They are similar in
design, containing a series of parallel blades on which a thin
This chapter introduces the physical concept of impulse force strip of donor tissue is placed; pressure is applied to force the
and its application in rapid preparation of large numbers of blades through the tissue. Criticism of graft cutters has focused
on the potential for follicular transection and the potential for shafts below the skin surface. Local anesthetic mixture contain-
reduced hair growth. My limited experience with these devices ing 0.5% lidocaine and 0.125% bupivicaine with 1:150,000 epi-
compelled me to investigate different methods of producing nephrine (created by mixing equal parts of lidocaine 1% with
better grafts. 1:100,000 Ⳮ 0.25% bupivicaine with 1:200,000 epinephrine) is
Impulse force (3) is a physical concept defined by the equa- used in the field block for both donor and recipient sites. Care is
tion: taken to avoid injection directly into the donor or recipient fields.
High-concentration epinephrine solution (commonly known as
(mass velocity)
Force {impulse} =
‘‘super juice’’) is not used. Normal saline or lactated Ringer’s
Δt (11d.1) solution containing 1:1,000,000 epinephrine is injected in the
dermal and subcutaneous planes of the donor scalp using a 3-mL
Where ⌬t is the length of time during which the external force syringe and a 27-gauge needle to increase tissue turgidity for
is applied. Examination of the equation demonstrates that the donor harvest. The needle should initially be inserted only 1 mm
smaller the ⌬t for any given external force, the larger the im- to 2 mm below the skin surface (Fig. 11D-1) to stiffen the dermis
pulse force and the greater the cutting power. Older graft prepa- before deeper injection into the subcutaneous space. It is note-
ration devices do not take advantage of this physical property worthy that as the intense tissue turgor increases, the protruding
and thus crush-injury to the grafts may occur, especially if the hair follicles straighten, increase angular projection, and become
blades have been dulled by prior use. This technique is simple more perpendicular to the skin surface, greatly facilitating the as-
but effective for applying large impulsive forces to greatly im- sessment of the proper blade angle and greatly improving the
prove the speed preparation of hair grafts and the quality of the quality of the donor strip harvest. Also, the depth of the subcuta-
grafts produced. neous space is increased significantly, pushing the neurovascular
Hand-cut production of grafts, even with microscopic dissec- structures under the muscle fascia away from the knife-edge and
tion, has the potential for follicular wastage. Follicles that are minimizing unnecessary injury.
transected are often trimmed and discarded. In addition, telogen A multibladed scalpel (Universal Knife by Ellis Instruments
follicles, which can account for up to 13% of the donor follicles, and The Staggered Arnold Knife by A to Z Instruments) with
may not be recognized and may be trimmed and discarded. no.10 Persona Teflon-coated blades spaced 1.0 mm to 1.75 mm
Unfortunately, many of these discarded follicles would proba- is used to harvest the donor strips. The amount of donor tissue
bly have produced viable hair. Follicular wastage decreases with required to produce the desired number of grafts can be precal-
better equipment, increased staff skill, and experience; how- culated with this technique and is described later. The knife is
ever, the training of highly skilled staff is long, tedious, and inserted by thrusting the blades perpendicular to the skin and
expensive. For many surgeons, whose practices are not limited parallel to the existing follicles while standing to the side and
to HRS, microscopic dissection is impractical. observing the follicular angles at the skin surface (Fig. 11D-
Criticism of graft-cutter technology has been mainly directed 2a). With a firm grasp of the knife, slight inferior pressure
toward follicular transection. Although most hair restoration (toward the patient’s feet) and slight upward tilt, the blades
surgeons agree that it is prudent to avoid follicular transection, continue to be held perpendicular to the skin while the incision
independent investigations by Kim (4) and Oliver (5) demon- is made (Fig. 11D-2b).
strate that transected hair follicles often survive and produce The ends are incised to an elliptical shape and the donor
hair. Moreover, a transected follicle may produce two hairs strip is removed with forceps and scissors sliding along the
when both segments are transplanted. A preliminary report by smooth surface of the superficial occipitoparietal muscle fascia
Kolasinski (6) showed that there was significant growth of hair
from grafts without visible follicles. The explanation for this
phenomenon has not been given; however, it is clear that dis-
carding excess ‘‘non-follicle-containing’’ tissue may result in
a lower yield. The graft-cutter technique uses all of the tissue
harvested; therefore, all tissue with potential growth is trans-
planted, including transected telogen and unseen exogen folli-
cles (telogen follicles that have shed their hair shafts).
Materials and Methods

The critical step in producing high-quality grafts by means of
the impulse force technique is obtaining a high-quality donor
strip with a multibladed knife. The essential elements of the
technique of multibladed harvest are intense donor tissue tumes-
cence and proper blade angle that lines up with existing hair
follicles. Alt described the original technique, which used plugs
(7), and Arnold described the details of harvesting high-quality
donor strips (8).
My technique begins with designing and marking the appro-
priate hairline. Hair is trimmed over the donor site, leaving ap-
proximately 1.0 mm of follicle length above the epidermis, which
is critical to give a visual cue in determining the angle of the hair Figure 11D-1 Dermal injection of donor tumescent fluid.
374 Chapter 11
Figure 11D-3 Donor site is marked and the length is measured

to calculate exact number of grafts to be produced.
which equals the number spacers required on the multibladed

knife, is calculated as follows:
1200 grafts
# Strips = = 6 Strips
200 mm / strip ÷ 1.0 grafts / mm
b
In actual practice, the elliptical pieces at the ends of the donor
harvest are roughly equivalent to one strip when dissected into
Figure 11D-2 (a) The blades are inserted perpendicular to the micrographs, which should be included in the strip count; there-
skin and parallel to the follicles. (b) The knife is held perpendicular fore, in this example, a total of five spacers would be used on
to the skin and parallel to the follicles. the multibladed knife.
I have settled on using a standard 1-mm blade spacing for
the graft cutter device. Creation of larger minigrafts is achieved
by increasing the spacing of blades on the multibladed knife
and avoiding the neurovascular structures that lie only microns while using a constant 1.0-mm blade spacing on the graft cutter
deeper. device. The typical multibladed knife spacings that I use are
Accurate calculation of how much donor tissue is required 1.25 mm for micrografts and 1.75 mm for minigrafts (Fig. 11D-
to create a predetermined number of grafts greatly facilitates 4).
the procedure. Because the impulse graft cutter technique relies A combination of spacers may be used on the same knife,
on grafts of uniform size and shape, it is simple to calculate facilitating the simultaneous harvesting of micrografts and min-
the precise amount of donor tissue to be harvested, which is
represented by the number of donor strips of a given length
(Fig. 11D-3). If
X ⳱ total grafts desired
Y ⳱ length of donor area in mm
Z ⳱ spacing between blades in millimeters on the graft
cutter device
S ⳱ no. of strips ⳱ no. of the spacer in the multibladed
knife
Then:
# Grafts
# Strips = or
Length, mm ÷ Graftcutter Blade Spacing, mm
X
S=
Y÷Z
For example, if the total length of the prepared donor area ⳱
200 mm, the total number of grafts desired ⳱ 1200, and blade Figure 11D-4 Arnold multibladed knife set up to harvest eight
spacing on the graftcutter is 1.0 mm, the total number strips, strips.
igrafts. The rationale for this spacing lies in the observation by The donor strips are processed with the graft-cutting device
Headington (9) that FUs are spaced uniformly approximately (Fig. 11D- 5a). It is similar to the devices described previously,
1 mm apart. Because donor tumescence temporarily increases however, the blades are held in place by a pair of parallel
the surface of the donor tissue by approximately 25% (Khan grooves integrated directly into the surgical stainless steel base.
S. Personal communication, 1998.) the spacing of the blades The blade spacing can be set at 1.0 mm or 2.0 mm (by placing
was increased by approximately 25% for donor harvest. Of every other blade). The donor strip is placed on the raft cutter,
course, the ultimate knife-blade spacing is a clinical decision ith extreme care taken to align the hair follicles within the donor
to be made during the procedure. The wound edges are reap- strip precisely parallel to the blades (Fig. 11D-5b).
proximated temporarily with towel clamps and then closed with The orientation of the strip need not be exactly perpendicular
skin staples without deep sutures. to the blades. A force spreader is then placed over the entire
My rationale for using staples is not only for speed but also length of the donor strip and manual pressure is applied to hold
because the depth of penetration of the staple is only 2 mm to the tissue in place without disturbing the follicular alignment
3 mm. This depth protects the follicle-producing cells that lie with the blades. The force spreader can be made of any hard
at least 4 mm to 5 mm deep. The resultant donor scar is reliably material such as wood or plastic, however, after testing several
as fine as those obtained with sutures that are not placed deep. materials, I have found that a simple wooden tongue depressor
a b
Figure 11D-5 (a) Second generation graft-cutter device with integrated 1-mm blade spacers. (b) Follicle aligned precisely parallel to
graft-cutter blades. (c) Impact drives the donor strip beneath the tongue blade through the blades.
376 Chapter 11
works best. Impulse forces (discrete impacts of a very brief includes cutters as well as placers. With the use of the graft-
duration, ⌬t) are then applied to the graft material. These are cutter, staff efficiency rose to approximately 1 assistant for
best delivered by multiple blows from a rhinoplasty mallet di- every 1000 grafts placed per day.
rectly to the force spreader (Fig. 11D-5c). Examined in a more practical way, approximately 20 man-
The grafts typically stick to the wooden tongue blade as it hours (excluding the surgeon’s time) were required to perform
is removed from the graft utter, with the grafts lined up ready a 1000-graft HT procedure before the implementation of the
to be implanted into the recipient sites (Fig. 11D-6). graft cutter. Four assistants (three cutting and one placing)
I create recipient sites with a Havel 67 or Sharpoint (15- would take approximately 5 hours. Today, one assistant and
degree or 22.5-degree) microblades for the micrografts and an the surgeon can perform the same procedure in an average of
Ellis spearpoint blade (1.5 mm or 2.0 mm) for the minigrafts. 4 hours, which is equivalent to 4 man-hours. The conservation
Experienced HT assistants can manually place grafts at an of resources is enormous, and the surgeon can either downsize
average rate of 300 grafts per hour; therefore, the typical session staff or perform more procedures in the same amount of time.
of 1000 grafts takes approximately 4 hours to complete with a
single HT assistant and the surgeon. At the completion of the Discussion
procedure, the donor and recipient sites are cleaned of excess
blood and dried with cool blowing air. The patient is instructed With the evolution of contemporary HRS techniques, the need
to place Grafcyte (a copper peptide product that speeds wound to prepare grafts rapidly and precisely is important. Commer-
healing) on the recipient site, as directed by the manufacture’s cially available devices were available but were relatively ex-
protocol. On the second day postoperatively, the patient is al- pensive and did not deliver the quality of grafts desired; there-
lowed to wash the hair gently twice daily with a Grafcyte sham- fore, they are not ubiquitously used today. The potential reasons
poo containing. Staples from the donor area are removed after for their decline are as follows:
10 to 14 days.
1. Poor donor harvest techniques causes follicular
wastage.
RESULTS 2. The donor strip is inaccurately aligned on the graft-
cutter blades. To minimize transection, the hair follicles
Macrophotography examination of grafts prepared with the must be precisely aligned with the cutting blades.
graft cutter demonstrates satisfactory morphology, with each 3. Tissue shimmy occurs owing to the smooth silicone
consecutive graft containing approximately one follicular unit sheet placed over the donor strip before pressing (as in
(Fig. 11D-7 a and b). the Boudjema Hairtome). The slippery nature of the
silicone may allow the donor strip to shift during the
Follicular transections were more likely to be produced dur- pressing, causing more transections. The use of a tex-
ing donor harvest and not with the use of the impulse graft tured material, such as a wooden tongue depressor, not
cutter. Grafts are taken directly off the tongue blade and placed only minimizes tissue movement but also has the added
directly into recipient sites. advantage of ‘‘self-extracting’’ the processed grafts
More than 1000 procedures were performed with use of the from the cutting blades in a very neat line.
impulse graft-cutting technique from April 1997 to August 4. Crush injury is made worse when the slow (low-im-
2003. Results are reproducible and patient satisfaction contin- pulse) force is applied, especially if the parallel blades
ues to be high (Fig. 11D-8 a, b, and c). have been dulled previously. The use of large impulse
Assistants were also pleased with the grafts produced by the forces produces a cleaner cut, even with moderately
graft utter because they were of uniform size and shape, making dulled blades, as if the tissue were sheared in the appro-
the process of placing them unusually consistent. Before imple- priate tissue plane.
menting the impulse graft cutter, the average staff load required
to perform a typical hair transplant procedure was approxi- Some surgeons advocate the exclusive use of FUs dissected
mately one assistant for every 200 grafts placed in a day. This from elliptical donor harvest under stereomicroscopy. Although
this concept is as admirable as their results, there are other
surgeons with equally impressive results who use more tradi-
tional methods. I am aware of only two quantitative studies
comparing follicular survival in FUs with non-FU dissection
(10,11). Both studies demonstrate equivalent follicular survival
rates between the two groups.
The economic impact of effective graft-cutting technology
cannot be overstated. There are many highly skilled surgeons
with equally skilled teams who advocate microscopic FU prepa-
ration. All of these surgeons agree that they must invest 6 to
12 months to adequately train their technicians to attain these
demanding skills. The number of follicles discarded during the
training process cannot be considered insignificant. Further-
more, staff turnover is common with the concomitant loss of
Figure 11D-6 The grafts are lined up consecutively on the the investment in time and training and the potential of crippling
tongue blade. A few grafts display excellent morphology with con- a hair transplant practice should several assistants decide to
sistent size and shape. leave simultaneously.
a b
Figure 11D-7 (a), Close-up view of consecutive grafts prepared with impulse graft cutter. (b) Macrophotograph of grafts processed
with the impulse graft cutter. Note the intact adnexal structures surrounding the follicles.
Figure 11D-8 (a), Norwood type VI male pattern baldness 2 years after placement of 2700 minigrafts and micrografts. (b) Norwood
typeV male pattern baldness 2 years after placement of 2600 minigrafts and micrografts produced with the impulse graft cutter. (c) Close-
up of hairline.
378 Chapter 11
Figure 11D-8 Continued.
There is also a great paradigm shift with use of the impulse

graft cutter. The surgeon is no longer dependent on maintaining
a full complement of skilled staff to produce hair grafts. The
critical skills of donor harvest and graft preparation are returned
to the hands of the surgeon. Furthermore, training in the use
of the impulse graft-cutting technique is surprisingly brief. The
average physician or HT assistant can learn the use of the tech-
nique in a matter of minutes as opposed to months. In my clini-
cal practice, many beginners (visiting physicians, cosmetic sur-
gery fellows-in-training, and new assistants) learn the technique
rapidly and produce excellent grafts the first day. Graft prepara-
tion is no longer the rate-limiting step in an HT procedure.
In the ideal world, no follicular transections would occur
and all telogen follicles would be identifiable. Clearly, this is
not possible; however, at least one piece of a transected follicle
does grow, and the same is true of telogen hairs. As a result,
I advocate transplanting virtually all donor tissue that is har-
vested. This potentially minimizes follicular wastage.
c Graft survival is not exclusively a function of follicular tran-
section. In fact, follicular trauma may include crush, desicca-
Figure 11D-8 Continued. tion, and extended time out of body (12). Interestingly, only
desiccation has been demonstrated to be absolutely lethal to
Fortunately, the impulse force graft-cutting technique is not

device dependent. Surgeons who have invested in the Hairtome
or who have manufactured their own devices with parallel
blades can benefit from the technique. A device with parallel
blades, however, is mandatory to employ the technique. My
primary motivation in designing a simpler device was to provide
a significantly lower cost alternative to other commercially
available products. Backlighting capability will be among the
future improvements that will provide better visibility for align-
ment of the hair follicles with the graft cutter blades.
The technique has been reliable in more than 1000 proce-
dures over a 7-year period, with excellent satisfaction among
doctors, staff, and patients.
Also, the larger the megasession, the more costly the proce-
dure becomes, with greater demands on staff and time. The
a impulse graft cutter allows surgeons to employ their staff almost
exclusively for graft placement, which will yield manyfold in-
creases in the capacity of HT teams.
CONCLUSION
The application of the physical property of impulse force to
the graft-cutting technique has yielded improved surgical team
efficiency, decreased expenses, and rewarding results for me.
Other surgeons have reproduced this work (15,16), adding sup-
port to a technique that could have widespread application in
contemporary hair restoration surgery.
b 11E. PREPARATION OF
MULTIFOLLICULAR UNIT
GRAFTS
Walter P. Unger
PREPARATION OF SLIT AND SLOT GRAFTS

As described earlier in this text, both microslit and slot grafts
are prepared from slivers sliced from ellipses that are sectioned
in a fashion similar to that described for the preparation of
Follicular Units (FUs). In the case of double follicular unit
(DFU), triple follicular unit (TFU), and quadruple follicular
unit (QFU) grafts, however, a sliver, which is one FU wide is
respectively divided into sections that contain two FUs, three
c FUs, or four FUs, one behind each other. These grafts are also
‘‘cherry-picked’’ from the sliver wherever the FUs are closer
than average to one another. In the case of slot grafts, a strip
Figure 11D-9 (a), Graft cutter results on the left side. Micro- is usually obtained with two blades spread 3 mm apart from
scope results on the right side of the figure. Both techniques have
each other rather than starting with a wider ellipse (see Chapter
a natural appearance. (b), Hair parted on graft cutter side. (c), Hair
10B.) Using a sharp Personna razorblade in a specially designed
parted on microscope side. Photos taken 9 mos postop.
razor holder (available from A-Z Surgical Inc.) (Fig. 11E-1),
the 3-mm wide strip is divided into sections that are approxi-
mately two FUs wide and three FUs long. An effort is made
follicular survival (13). In fact, crush injury, extended time out to keep the FUs intact, but some longitudinally divided FUs
of body, and transection taken all together are not nearly as are frequently included in slot grafts. Magnification of various
devastating as graft desiccation. types is nearly always employed during the sectioning of the
A study has been conducted that compared results obtained slivers into microslit and slot grafts. Many of my technicians
with the impulse graft cutter with those achieved by FU trans- can produce excellent grafts if they wear 1x to 4x magnifying
plantation (14). Although the quantitative study was flawed, glasses. Nevertheless, the use of a Mantis stereoscopic micro-
resulting in data that could not be interpreted, the qualitative scope has become increasingly popular with the techni-
results were strikingly similar (Figs. 11D-9a, b, and c). cians—whether or not they require 6x magnification. This is
380 Chapter 11
from strips harvested with blades that are approximately 3 mm

apart and are sectioned into pieces that are roughly 2 mm2. We
prefer to prepare such grafts from narrower strips rather than
from a larger ellipse, because the sizing of the grafts is likely
to be more consistent. In the past, all nonviable transected folli-
cles and debris, which ‘‘could act as foci for inflammation,
granuloma formation, or infection,’’ were removed from the
peripheral surface of the graft. If a transected follicle consisted
of more than half of the follicle, it was left on or in the round
graft; if it was less than half of the follicle and on the periphery
of the graft, it was removed and usually discarded. Today, all
transected follicles remain as part of the graft. We now know
that many of these partial follicles do regenerate and are viable.
The following equipment is required: 1 Adson forceps; 1
a jeweler’s forceps;, 1 3-inch straight scissors; 1 petri dish; 5 to 6
escargot dishes (Fig. 11E-1a); 250 mL of normal saline solution
(0.9% sodium chloride for irrigation); a razor blade in a holder;
a cooling dish (Fig. 11E-1b); a translucent plastic tongue de-
pressor; a spray bottle filled with saline solution; a backlight;
1 incontinent pad; and, generally, a well-lighted area where
assistants may sit comfortably. Nearly always, a Mantis micro-
scope or some form of magnification is also employed. In addi-
tion, each technician has a counting sheet and pencil to tabulate
the number of grafts they have prepared.
The wells of the escargot dishes, which are filled with
enough normal saline solution to completely immerse any grafts
that are placed into them, are marked with a grease pencil indi-
cating what type of graft they contain. Each escargot dish is
placed on an ice-filled container (available from A-Z Surgical
Instruments and George Tiemann & Company) (Fig. 11E-1b).
A petri dish filled with saline solution is used to receive the
strips as they are removed from the donor area, and each escar-
b got dish is used to receive the grafts after they are prepared and
waiting to be inserted into the recipient sites. The benefits of
Figure 11E-1 (a), An escargot dish is used to receive the pre- cooling the solution in which the strips and grafts are stored
pared grafts. Each escargot well is filled with a sufficient amount are debatable. No scientific studies have been carried out to
of saline solution to completely immerse the grafts that will be put confirm the theoretical benefits of doing this. Nevertheless,
into it and is marked with a grease pencil indicating what type of keeping the dishes on ice is a relatively simple thing to arrange,
graft is in it. The initials of the technician who has prepared the so we routinely do it.
grafts are written on the escargot dish handle. (b), On the right It is of the utmost importance that the grafts be kept moist
hand side of the photo is a specially designed razorblade holder, at all times. The best way to accomplish this is to work on only
available from A to Z Surgical Suppliers as ‘‘Blade–Ades.’’ The 5-cm sections to 10-cm sections of the strip at any time, quickly
Personna double-edged surgical razor blades, which we routinely reinserting prepared grafts into the saline-filled wells of the
use for dividing the donor tissue, are also available from A to Z escargot dishes. A graft should always be grasped at the epider-
Surgical Suppliers. The blade holder enables the technician to hold mal edge with the Adson forceps. It should never be handled
razorblades safely with a comfortable ergonomic grip. The con- in such a way as to injure the hair follicles or matrix, for exam-
tainer shown here is filled with water and then frozen. The escargot ple, by grasping it at its midsection or base. The graft is placed
dish is placed on top of it. horizontally on the translucent tongue depressor. It is rotated
until the epidermal surface rests at a 135-degree angle and held
securely in this position with the Adson forceps. A sharp no.11
blade or razor is used to trim the fatty tissue from the base of
because use of the Mantis results in less neck and back strain. the graft by cutting on a line parallel to the epidermal surface
Storage of the strip and the prepared grafts is described later. of the graft (at the same 135-degree angle) to 1 mm below the
deepest hair follicles (Figs. 11E-2). It is better to leave too much
Preparation of Round Grafts subcutaneous tissue than to trim too closely and injure the hair
follicles. It is also wise to leave extra subcutaneous tissue in
As described earlier in this text, round grafts are, in fact, more place when the grafts of blonde and white-haired patients are
square or rectangular than round. Grafts of 3.25 mm2 are rou- cleaned. It is difficult to see the hair matrices in these patients
tinely prepared from strips harvested with blades that are 3.50 because of their light coloring. The use of a 2% solution of
mm to 3.75 mm apart that are sectioned into pieces that are methylene blue to enhance the visibility of white or light-col-
roughly 3.25 mm2 to 3.50 mm2. Our 2 mm2 grafts are prepared ored follicles has been described elsewhere in this text. (.02
unit grafts: a bilateral controlled study. J Dermatol Surg 1998;

24:875–880.
2. Bernstein R, Rassman W, et al. Follicular unit transplantation.
Int J Aesth Restor Surg 1995; 3:119–132.
3. Seager D. Binocular stereoscopic dissection microscopes: should
we use them?. Hair Transplant Forum Int 1996; 4:2–5.
4. Limmer B. Elliptical donor stereoscopically assisted micrograft-
ing as an approach to further refinement of hair transplantation.
J Dermatol Surg Oncol 1994; 20:789–793.
5. Limmer B. On follicular unit hair transplantation. H T Forum Int
1998; 8:1–6.
6. Reed W. A blinded comparison study of the ability of follicular
unit transplantation. Hawaii: International Society of Hair Resto-
ration Surgery, November 2000.
7. Shapiro R. A method of using the one microscope and one assis-
tant for slivering to create FUs. San Francisco: International Soci-
Figure 11E-2 Depiction of the graft lying horizontally, with ety for Hair Restoration Surgery, 1999.
8. Bernstein R, Seager D. Standardizing the classification and de-
the face of the graft resting at a 135-degree angle. The fatty tissue
scription of follicular unit transplantation and mini/micrografting
is trimmed, at the same 135-degree angle as the face of the graft, techniques. J Dermatol Surg 1999; 24:957–963.
to 1 mm below the deepest hair matrix. 9. Mayer MA. Follicular regeneration, Presented at the annual meet-
ing of the International Society for Hair Restoration Surgery,
Sept. 17, 1998, Washington, DC.
10. Martinick J, The results at eighteen months of the longitudinal
mL of methylene blue mixed with 20 mL of sodium chloride clinical research into the importance of transplanting intact follic-
solution.) Just as with microslit grafts, to facilitate graft selec- ular units vs. follicular units that have been traumatized using a
tion during the insertion process, the cleaned grafts are arranged variety of methods including transection at the ‘‘bulge.’’ 8th an-
in groups according to their various sizes, colors, and hair tex- nual meeting of the International Society of Hair Restoration Sur-
tures. The grafts remain categorized in this manner until they gery.
11. Cole J. The effect of hair caliber on the appearance of density.
are inserted into the recipient area.
Washington, D.C: International Society for Hair Restoration Sur-
gery, 1998.
12. Kim JC. Regeneration of the human scalp hair follicle after hori-
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12
Recipient Site Grafts and Incisions
12A. The History of the Follicular was possible and that it produced the degree of naturalness and
hair density we thought were both desirable and acceptable.
Unit Micrografting Technique: In 1988, there were many scientific questions that needed
A Personal View to be answered: (1) Is the process feasible; that is, could enough
hair be moved in this manner to provide a suitable cosmetic
Bobby L. Limmer
result? (2) What would the survival of such small grafts be?
(3) How long could these grafts be held outside the skin and still
This chapter is not a scientific treatise on the merit of follicular survive? We had been taught with the plug method to attempt to
unit transplantation (FUT). It is a simple historical and personal remove and replace the grafts within 2 hours. (4) What is the
review of why and how FUT developed within my practice. best recipient area—slits, punches, or needle tunnel recipient
During my dermatology residency, the study of hair loss sites? (5) What is the recipient zone tolerance in terms of grafts
and restoration by hair transplantation was a component of the per unit area? (6) What hair density in numbers of grafts and
medical and surgical curriculum. Hair transplantation by the in hairs per cm2 is required to produce the desired cosmetic
Okuda-Orentreich method became a standard part of my private result? (7) What are the specific equipment and support person-
practice of dermatology, begun in 1974. During the next 10 nel requirements? (8) Will the final cosmetic result justify the
years, I slowly became disenchanted with the punch grafting additional time and effort required? (9) Will the extensive mi-
method and discouraged the majority of patients from proceed- crografting process have complications that are not seen with
ing with hair transplantation for a number of reasons. In my larger grafts? There must have been many other questions as
opinion, the cosmetic results often did not justify the nuisance well. Nevertheless, in October of 1988, the initial clinical re-
of slow healing and the obvious visibility of the procedure. The search was started with a group of volunteer patients.
final results in many cases of extensive hair loss were usually The first patient was transplanted with FU micrografts on
recognizable as hair transplants, and the donor area was often October 21, 1988, with 41 FU micrografts placed in slit recipi-
depleted well before the recipient zone could be completed. To ent sites. The no.11 blade slit recipient sites were far too large
me, only those cases of limited hair loss and good hair/skin for the small size of the FU micrografts (Fig. 12A-1), and be-
color match seemed to be reasonable candidates. The evolution cause of this misfit of graft to recipient sites, some dimpling
from plugs to minigrafts, occurring in the middle and late 1980s, occurred postoperatively. Subsequent recipient sites were re-
represented improvement but still fell short of sufficient natural- duced to 16-gauge, 17-gauge, and 18-gauge needle tunnels, and
ness to make them totally undetectable. I began to consider graft numbers were slowly increased with each session. The
ways that the micrograft method described by the Japanese phy- naturalness of final results became obvious by the time we had
sicians in the 1930s (and reintroduced to hair transplantation reached 440 grafts in the first patient (Fig. 12A-2). Today, our
by Dr. Rolf Nordstrom and Dr. Emanuel Marritt in the early grafts are placed in even smaller needle tunnels with three-hair
1980s) could be used for the total procedure. In 1988, my hair and four-hair FUs in 18-gauge and 19-gauge needle sites, and
transplant surgical team, along with about a dozen patient vol- with one-hair to two-hair FUs in 20-gauge to 22-gauge needles
unteers, launched into what eventually evolved into FUT as we sites; these developments allow grafts to be transplanted much
know it today. This method might better be described as total more densely during each session.
micrografting, making use of only naturally occurring follicular Figs. 12A-3 and 12A-4 show another individual from the
units (FUs) dissected under the binocular stereoscopic micro- original series of patients after two sessions. He was developing
scope and implanted into very tiny recipient site incisions. The a beautiful frontal coverage, but he taught us that the hairline
evolution and perfection of the procedure required approxi- could be made too straight even when one-hair and two-hair
mately 3 years. By 1991, we were certain that the procedure FU micrografts were used. We had obviously incorporated the
383
384 Chapter 12
Figure 12A-1 First follicular unit transplantation case, October Figure 12A-4 Clinical research case, V.J., after two sessions
21, 1988. Slit recipient sites were far too large for the micrografts. of follicular unit grafts. Note the unnaturally straight hairline.
Figure 12A-2 First follicular unit transplantation case after 440

grafts to the frontal forelock zone.
Figure 12A-5 Six test implant sites on the crown growing hair
6 months after transplantation at 2, 4, 6, 8, 24, and 48 hours (top
left to lower right) after removal of donor tissue.
Figure 12A-3 Clinical research case, V.J., before transplanta-
tion.
Recipient Site Grafts and Incisions 385
Figure 12A-6 Stereoscopic 20x magnification of donor tissue. Figure 12A-8 Follicular unit grafts over a large recipient zone
Note the clear definition of each follicular unit at the epidermal at a density of 10 or less per cm2.
level.
in hair survival if the grafts are held at room temperature for

linear method of the Orentreich plug technique into the FU up to 5 hours.
method; this case, however, taught us that frontal hairlines need Concerned that follicular transection would reduce survival
to be substantially more irregular to achieve naturalness. of the grafts; we transplanted 1391 transected half follicles into
Some of the original volunteers allowed us to plant test the crowns of four volunteers. These follicles were transected
sites—‘‘little gardens of grafts’’—on their heads at 2, 4, 6, 8,
24, and 48 hours after their removal from the donor area (Fig.
12A-5). If we held these grafts in chilled saline solution at
approximately 4⬚C, we found that we lost less than 1% per hour
up to 48 hours after removal from the donor area. These FU
grafts had a survival rate of greater than 90% up to 8 hours
after removal from the recipient site before implantation. There
was no statistical difference in the survival among those groups
planted at 2, 4, 6, and 8 hours after removal from the donor
area (see Chapter 9). Drs. Kim and Rapozio have repeated this
work, except that they employed in vitro systems. They have
demonstrated that there is no statistically significant difference
Figure 12A-7 A photograph taken on January 5, 1990, showing

follicular unit grafts containing one, two, and three terminal hairs.
For size comparison, 16-gauge (right side) and 18-gauge needle
tips are shown. Figure 12A-9 Resultant density of 10 or less grafts per cm2.
386 Chapter 12
at the level of the bulge, and the top and bottom halves of that FU grafting can give only a ‘‘see-through look.’’ In our
the follicles were transplanted on opposite sides of the crown. experience, this is simply not accurate. With the use of FU
Follicular survival, counted at 5 to 6 months after implantation, grafts, we found it necessary to transplant 20 to 40 grafts per
was reduced from the expected 90% to 34%. This reduction in cm2 to achieve satisfactory cosmetic densities in one to three
survival reinforced our belief that maintaining the anatomical sessions (Figs. 12A-10 and 12-11).
integrity of the individual hair follicle is critical to optimal sur- The procedure of FU micrografting has greatly expanded
vival. Other investigators have confirmed varying degrees of the number of candidates for, and uses of, hair transplantation.
reduced survival of traumatized follicles (see Chapter 9). This procedure has allowed us to do repair work (Fig. 12A-12a
Technically, we found that we needed some form of magnifi- and b), to create a frontal and temporal hairline and temporal
cation to dissect the small grafts from the donor ellipse without points (Fig. 12A-13a and b), and to enhance eyebrows (Fig.
transecting the follicles. We tried a number of standard magni- 12A-14); overall, it has added a huge degree of flexibility in
fiers, but what really opened our eyes was a binocular zoom the general field of hair transplantation. No other method of
stereoscope borrowed from the University of Texas Health Sci- hair transplantation provides my patients with such natural re-
ence Center Dental School. Every follicle and FU grouping was sults that I can tell them they can undergo one procedure and
clearly definable under such microscopic magnification (Fig. never have to have another unless they want greater density or
12A-6) and easily dissectable into individual FU grafts under coverage of areas not addressed in the initial session. To date,
the microscope (Fig. 12A-7). Such magnification made it possi- after 14 years of experience with FUT, it is my opinion that
ble to dissect the individual FUs with virtually no follicular no other method can match the combined cosmetic aspects of
wastage—the skilled assistant consistently transects less than naturalness and density that this procedure, properly done, con-
2% of the follicles in the donor tissue. sistently and predictably produces (Fig. 12A-15). As other phy-
The years after 1991 were simply devoted to the cosmetic sicians have adopted this procedure into their practices (Mar-
and density aspects of the final product. We found that if we cello Pitchon, 1992; Bill Rassman and Bob Bernstein, 1995;
planted eight to ten FUs per cm2 (Figs. 12A-8 12A-9), the re- David Seager, 1995; O’Tar Norwood, 1997; Mario Marzola,
sults were natural but far too sparse. Such levels of density 1998; and many others), it has slowly gained credibility. It al-
formed the basis for the inaccurate and unjustified criticism ways has been, and always will be, a time-intensive and labor-
Figure 12A-10 (a), Frontal forelock grafting at 20 to 30 grafts per cm2. (b), Hair density after a single session.
Figure 12A-11 (a), Frontal forelock grafting at approximately 25 grafts per cm2. (b), Hair density after a single session.
Figure 12A-12 (a), Status after transplantation with punch grafts before follicular unit grafting. (b), Status 1 year after a single repair
session of follicular unit transplantation.
Figure 12A-13 (a), Frontal and temporal hairline drawn pre-operatively (A). (b), Results of two sessions of frontal, frontotemporal,
and temporal point restoration (B). Punch removal of prior punch grafts was done synchronously with follicular unit transplantation.
388 Chapter 12
room to room to do this most important step, a method

followed by many practitioners who use the elliptical
donor method to this day. I also remember Kimberly
dropping and destroying my most expensive zoom
stereoscope trying to catch the plane out of Toronto
back to San Antonio after a week in Dr. David
Seager’s office. That microscope was a small price to
pay for the joy of watching follicular unit
transplantation evolve and be adopted into other
practices.’’
12AA. The Rationale for Follicular

Unit Transplantation
Figure 12A-14 Tattooed eyebrows (left) restored with two ses-
sions of graftings. Robert M. Bernstein and William R. Rassman
Follicular Transplantation is the logical end-point of

over 30 years of evolution in hair restoration surgery,
intensive procedure, but, from my personal viewpoint, the final beginning with the traditional large plugs and
cosmetic results justify the effort and the patient deserves it. culminating in the movement of one, two, and three-
With FUT, in my opinion, we have reached the end refinement hair units, which mirror the way hair grows in nature.
of surgical hair restoration. Results can consistently equal na- The key to Follicular Transplantation is to identify the
ture, and it is difficult to improve on what nature does. The patient’s natural hair groupings, dissect the follicular
future advances in hair preservation and restoration will come units from the surrounding skin, and place these units
through better drugs and genetic engineering. in the recipient site in a density and distribution
appropriate for a mature individual (1).
The latter half of the 1990s was marked by the emergence
ADDENDUM
of a new technique of hair restoration surgery that was both
Since he originally wrote this section of the text, Limmer has conceptually and technically different from the methods used
published some reminiscences of his practice (1). At least one during its previous 35-year history. In the new millennium, this
part of that article is worth reprinting here. (WU) technique has become as controversial as it is new, with the
follicular unit (FU) zealots on the one hand proclaiming it to
‘‘I remember Kimberly Sczech bringing her college be the ideal hair restoration procedure and those at the other
biology dissecting scope to the office for backup and extreme questioning its benefits and its uniqueness as a hair
deciding to call the first step on donor dissection restoration technique. In this section, we explain the rationale
‘‘slivering’’. I remember assigning her to float from behind follicular unit transplantation (FUT) and its potential
benefits, as seen through the eyes of its most staunch advocates.
THE REASON FOR PRESERVING THE

FOLLICULAR UNIT
The follicular unit (FU) (Fig. 12AA-1) was first defined by
Headington in his landmark 1984 paper (2). The FU includes
the following components:
● One to four terminal follicles

● One, or rarely two, vellus follicles
● Associated sebaceous lobules
● Insertions of the arrector pili muscles
● Perifollicular vascular plexus
● Perifollicular neural net
● Perifolliculum–circumferential band of fine adventitial
collagen that defines the unit
Figure 12A-15 Frontal hairline restoration at a density of 119 In 1998, Limmer developed single-strip harvesting followed
hairs per cm2, with use of only single-hair follicular units at the by stereomicroscopic dissection, the technique essential for the
frontal margin. isolation of intact FUs from donor tissue. He detailed the proce-
duced by Seager at the 1996 meeting of the International Society

for Hair Restoration Surgery (ISHRS) and described in his clas-
sic study in which he showed that when single-hair micrografts
were generated by breaking up larger FUs, their growth was
less than when the FUs were kept intact (7). In a bilateral,
controlled, single-case study, matched for the number of hairs,
Seager showed that at 51⁄2 months, single-hair micrografts had
an 82% survival rate, whereas the intact FUs had a survival
rate of 113%. He assumed that a growth rate greater than 100%
for FUs was owed to the growth of telogen hairs that were not
initially counted.
Variations of this work were conducted independently by
Beehner and Martinick but led to a different conclusion. At
the 1999 meeting of the ISHRS, Martinick presented a study
showing that there was no effect on growth when three-hair
FUs were vertically dissected into one-hair and two-hair units.
At the same conference, Beehner presented the results of a study
Figure 12AA-1 Transverse histological section of an adult in which he had examined the growth of single follicles verti-
male scalp at the level of the sebaceous glands showing 2-hair, 3- cally separated from two-hair and three-hair FUs. He also con-
hair, and 4-hair FUs (hematoxylin-eosin stain, ⳯40). cluded, ‘‘The intact follicular unit graft (FUG) does not appear
to possess any inherent advantage for growth over a cut-to-size
graft of the same size.’’
Although the possibility that intact FUs have superior growth
remains one of the most controversial aspects of FUT, there is
dure in a paper published in 1994 (3). The idea of using the no doubt that the FU is a physiological as well as an anatomical
FU exclusively as the fundamental element of a hair transplant entity. The grouped follicular structures share a common neuro-
was proposed by Bernstein and Rassman in 1995 (1) ‘‘Follicular vascular network and are surrounded by connective tissue that is
Transplantation.’’ Follicular unit transplantation received its anatomically distinct from the surrounding stroma. This would
‘‘official’’ name in 1998 (4). logically offer protection in the ‘‘hazardous world’’ of the trans-
The underlying premise of FUT is that FUs are ‘‘sacred.’’ planter’s dissecting tables, an environment often far different
They should neither be broken up into smaller units, nor com- from the milieu encountered in a controlled experiment.
bined into larger ones (1,5,6). The rationale for using intact, Although there is controversy regarding the benefits in graft
individual FUs exclusively during the hair transplant process survival as a result of keeping this complex structure ‘‘whole,’’
there is indirect evidence that the intact FU fares better. Gandel-
was first described in 1995 (1). In this paper the authors stated:
man has shown that desiccation is extremely detrimental to graft
The advantages of using follicular implants in contrast survival (8), and there has been much anecdotal evidence that
to traditional grafts include: survival rates of chubby micrografts and chubby FUGs are bet-
ter than those of skinny ones. Logic dictates that splitting the
● Surgical wound size at the recipient site is minimized. naturally occurring FU would not only risk damage in the dis-
● Skin surface deformity is eliminated. section process but also expose at least part of the otherwise
● Distortion due to fibrosis associated with healing is re- protected follicle, to environmental insults, and threatening its
duced. optimal survival.
● Natural scalp contour is preserved. In an unpublished study, a plug was removed from the donor
● Oxygen diffusion to implants is maximized. area and subsequently transected horizontally just above the
● Interruption of blood supply is minimized. level of the bulbs. The top portion was replaced in the donor
● Postoperative recovery time is reduced. area and the bottom portion transplanted into a bald portion of
● Hair units may be placed extremely close together. the scalp. Both subsequently grew the normal number of termi-
● Extensive numbers of implants may be moved per ses- nal hairs. The fact that the regrowth rate was higher than with
sion. transected individual hairs suggests that there are local factors
● Hair may be distributed in a natural pattern. in the vicinity of the follicle that are important for optimal
● There is great flexibility in recipient site design. growth. Although this may be an argument for the use of larger
grafts, it certainly argues for at least keeping FUs intact. (Per-
These proposed advantages of FUT center on two fundamental sonal communication from Amanda Reynolds, 2000.)
arguments. The first is that using FUs maximizes hair-to-skin One of the most puzzling claims of the detractors of FUT
ratios in the graft and allows recipient wounds to be kept small. is their insistence that FUs need not be kept whole. Even if it
The second is that using individual FUs exclusively during the were true that carefully separated follicles may grow as well
procedure produces the most natural results. These two argu- as intact units, one might reasonably ask if splitting up FUs is
ments form the basis of much of the present discussion. even worth the effort. Certainly, breakup of these units risks
An additional potential advantage of FUT—that intact FUs more damage than keeping them together and offers no advan-
may have superior growth—was not part of the original 1995 tage other than expediency (i.e., when the goal of the transplant
article on follicular transplantation. This concept was intro- is to perform it as fast as possible and with as few staff as
390 Chapter 12
possible). As discussed later in this chapter, when sessions of FUT over extensive micrografting is that it eliminates the ‘‘see
FUT are properly planned, adequate numbers of one-hair grafts through’’ look that was characteristic of the latter procedure.
are generated from naturally occurring single-hair FUs without
even a single one having to be split.
Proving the hypothesis that, in FUT, the whole is greater THE REASON FOR KEEPING RECIPIENT
than the sum of its parts will require much future research. SITES SMALL
Regardless of the outcome, the main benefits of the intact FU
are its ability (1) to get the most hair into the smallest possible The importance of minimizing the size of the wound in any
recipient site (and thus have the smallest possible recipient surgical procedure cannot be overemphasized. Hair transplanta-
wound) and (2) to make hair transplantation a procedure that tion is no exception. In hair restoration, it is probably preferable
can produce consistently natural results. These benefits will to refer to a recipient ‘‘site’’ as a ‘‘wound’’ to emphasize this
ensure a central role of FUT in hair restoration surgery for years point. The effects of recipient wounding are felt at many levels.
to come. Large wounds damage blood vessels, and although the blood
supply of the scalp is extensively collateralized, any injury to
these vessels has an impact on local tissue perfusion. An equally
THE REASON FOR TRANSPLANTING important issue is to minimize the disruption of the microcircu-
INDIVIDUAL FOLLICULAR UNITS lation. This disruption is an unavoidable aspect of all scalp
surgery, regardless of the size or depth of the wounds, but keep-
The growth of scalp hairs in FUs rather than as individual enti- ing it to a minimum is a crucial part of the surgery. This is
ties is most easily observed by densitometry, a simple technique especially important when grafts are transplanted in large quan-
whereby scalp hair is clipped to approximately 1mm in length tities. The compact FU is, of course, the ideal way to create
and then observed via magnification in a 10-mm field (9). What the smallest possible recipient wound, and has made the trans-
is strikingly obvious when the scalp is examined by this method plantation of large numbers of grafts technically feasible (1).
is that FUs are relatively compact but are surrounded by sub- Although studies that specifically examine the relationship
stantial amounts of non–hair-bearing skin. The actual propor- between blood flow and graft survival are lacking, there has
tion of non–hair-bearing skin is probably on the order of 50% been ample anecdotal evidence that this is important. It has
(10); therefore, its inclusion in the dissection has a substantial been the experience of a number of practitioners that: (1) larger
effect upon the outcome of the surgery by increasing the wound grafts, with their concomitant larger wounds, may result in hair
size. loss in the graft centers as a result of poor oxygenation (a pro-
When a graft contains multiple FUs, the contribution of the cess called doughnutting); (2) with repeat sessions of large
intervening skin is magnified, greatly increasing the volume of grafts into the same region, growth may be diminished; 3) large
the graft. To illustrate this point, use any of the ‘‘videoscans’’ numbers of large grafts placed into the central scalp may com-
in Fig. 12AA-2a, b, and c. Draw a circle around a single FU; promise the blood supply so extensively as to predispose the
then draw a circle encompassing two units, then three, etc. What site to central necrosis; and (4) megasessions of densely packed
can be observed is that as single FUs are combined to form grafts may result in a thin look, especially in the central scalp.
larger groups, the total volume of tissue included is not additive Although other factors may contribute to these phenomena, it
but geometric. appears reasonable that decreased blood supply is a common
When the actual transplant is performed, two additional fac- thread underpinning these problems.
tors act to compound the effects of this increased volume. The When the impact of the wounding on the recipient skin is
first is that the donor and recipient sites are not always a perfect assessed, the size of the individual wound is as important as
match for one another. The reason is that bald scalp becomes that of the total wound. It has been our consistent experience
atrophic over time, as the diminution of the follicular appen- that multiple small wounds cause less injury than fewer large
dages is associated with a decrease in the other cutaneous ele- wounds. For example, 10 3-mm wounds cause significantly
ments. Therefore, when the donor skin is already thicker than more surface irregularities and scarring than 20 1.5-mm
the recipient skin, planting grafts containing the non–hair-bear- wounds. In our experience, linear wounds of 1.7 or less gener-
ing tissue between units tends to accentuate any surface defor- ally heal with no detectable skin surface change in the majority
mity caused by the bulkier grafts. of patients. Linear wounds of 1.2 mm or less heal without sur-
The other problem is that the transplantation of multiple FUs face change in virtually any patient. Because of this, we use
often requires recipient skin to be removed (via punch or laser) wounds of 1.2 mm or less at the frontal hairline and 1.7 mm
to allow the new volume of tissue to fit into the recipient site or less in other parts of the scalp. The smaller sites can accom-
and/or to avoid unsightly compression of the newly transplanted modate one-hair and two-hair FUs, and the larger sites can
grafts. In effect, richly vascular scalp of maximum thickness is receive FUs of any size, even the bulky units seen in the African
transplanted into a somewhat atrophic recipient area, in which races.
tissue is further removed to accommodate the graft. Not surpris- Clearly, excision of tissue, either by punch or laser, causes
ingly, the results of this technique often look unnatural! more damage to tissue then an incisional slit, but it is important
The great benefit of using individual FUs is that the wound to stress that all the parameters affecting recipient wounds have
size can be kept to a minimum, while, at the same time, the not been determined. Therefore, there are no absolute guidelines
amount of hair that can be placed into the wound can be maxi- as to the ideal number or density of grafts that can be used and
mized. Having the flexibility to place up to four hairs in a still ensure maximum growth. The practitioner must rely on
tiny recipient site has important implications for the design and clinical judgment in this regard, and a conservative approach
overall cosmetic impact of the surgery. A major advantage of is recommended until the surgeon has significant clinical expe-
Figure 12AA-2 Densitometry (17) recorded by a videografting system (12) showing the natural follicular groupings in the donor scalp
of a patient with (a), low density; (b), average density; and (c), very high density (⳯50). These photographs vividly illustrate that as the
absolute hair density increases, the size of the individual follicular units (FUs) increases, whereas the density of the FUs (spacing) remains
relatively constant.
rience with the close placement of large numbers of grafts. In tablished. In addition, with the elimination of dead space, there
addition, there are a host of systemic and local factors that is less coagulum formed and wound healing is facilitated. Be-
should be taken into account in planning the number and spac- cause oxygen reaches the follicle by simple diffusion, its ability
ing of the recipient sites, regardless of their size (6). to do so is a function of tissue mass. Unlike larger grafts whose
Another important advantage of the small wound is a factor centers can become hypoxic, the slender FU is a little barrier
that can be referred to as the ‘‘snug fit.’’ Unlike the punch, to this diffusion, thus ensuring uniform oxygenation.
which destroys recipient connective tissue, a small incision Another aspect of wound healing is the concept of ‘‘mem-
made with a needle retains the basic elasticity of the recipient ory.’’ Physicians, who routinely perform cutaneous surgery un-
site wall. When a properly fitted graft is inserted, the recipient derstand the advantage of wounds that heal by primary inten-
site will then hold it snugly in place. The snug fit has several tion. When tissue is removed by a punch or destroyed by a laser,
advantages. During surgery, it minimizes popping as well as the resulting defect heals by secondary intention. A justifiable
the need for the sometimes-traumatic reinsertion of grafts. After argument is that when a graft is placed in the defect, the area
the procedure, it ensures maximum contact of the implant with does not need to granulate. However, because the underlying
the surrounding tissue so that oxygenation can be quickly rees- defect is still present, the wound invariably causes more scarring
392 Chapter 12
than when a simple incision is made (thus the term ‘‘memory’’). are often the areas that have the most tenuous blood supply
This is readily evidenced in the scarred skin around the healed (Fig. 12AA-3). Although the blood supply of the scalp is very
punch or laser sites. Although, not always visible, this tissue rich, it is not unlimited. As we discussed in the section, ‘‘The
has lost its resilience and cannot support grafts of the same Reason for Keeping Recipient Sites Small,’’ minimizing the
density of in subsequent procedures. recipient wounds helps to preserve the blood flow to the grafts
When larger grafts of any shape are used, compression is and, ultimately, to ensure maximum graft survival. By sorting
an undesirable consequence and may result in a tufted appear- and using the larger FUGs in select areas, we can create greater
ance. In contrast, when FUs are transplanted, there are no ad- density in these areas without increasing the wound size or the
verse cosmetic effects of compression because FUs are already density of the recipient sites.
tightly compacted structures. In addition, these larger grafts and In FUT, the numbers of grafts present in any given size donor
corresponding wounds cause a host of other cosmetic problems strip are determined by nature, because each graft represents one
including dimpling; pigmentary alteration; depression or eleva- FU. In contrast, in mini-micrograftingtechniques, these num-
tion of the grafts; or a thinned, atrophic look. The key to a hair bers are determined by the surgical team members who cut the
transplant that appears natural is to have the hair emerge from grafts to size, depending on how many of each size the surgeon
perfectly normal skin. The only way to ensure this is to keep needs (4). When greater density is desired, a mini-micrografter
the recipient wounds small. may use larger grafts to satisfy the requirements, but this tactic
results in larger wounds if the grafts encompass one or more
FUs. For example, a four-hair minigraft composed of two
THE REASON FOR NOT USING LASERS IN smaller FUs always has greater volume than a single four-hair
FOLLICULAR UNIT TRANSPLANTATION FUG, because the minigraft contains some of the intervening
tissue between the FUs. The minigraft thus requires a larger
In the mind of the public, no single word in medicine evokes recipient wound. In contrast, the FU graft always allows the
a stronger image of state of the art than the word ‘‘laser,’’ and most hair to fit into the smallest possible site.
‘‘laser hair transplantation’’ is no exception (11). However, The ability of FU sorting to create areas of greater density
when the image begins to fade and the actions are examined can be illustrated from data in our own practice (2). In a retro-
logically, it can be seen that the laser is not only inappropriate spective study we examined 90 recent cases of FUT performed
for FUT but is actually detrimental. with single-strip harvesting and stereo-microscopic dissection.
Lasers are used in hair transplantation to create recipient These data are presented in greater detail in a later section. We
sites. In contrast to other fields of medicine where the properties found the average case to have an FU distribution as follows
of selective photothermolysis play a positive role, the role of (Table 12AA-1) In a typical case of 1525-grafts, an average
photothermolysis in hair transplantation is purely destructive. session yields more than 500 three-hair and four-hair FUGs
Lasers can create a hole with little surrounding thermal injury, with an average of 3.2 hairs in each of these larger FUGs. (Table
but that does not alter the fact that the tissue is directly destroyed 12AA-2).
by the beam. The claim for the newest lasers—that they can If these FUs are transplanted at a density of only 20 grafts/
make a recipient site with no thermal burn at all—sounds ad- cm2, hair density of 64 hairs/cm2 can be produced over a 25-
vantageous, but it misses the whole point. The point is that no cm area. This would be sufficient to give the central forelock
matter how precise the laser is, it still makes a hole by removing
area one quarter of the patient’s original density in one session.
tissue and is, therefore, a throwback to the old punch technique.
A second session would bring the density to approximately half
Removing tissue destroys blood vessels and collagen, weak-
of the original; a density that many feel is the ideal density
ens elastic support, increases coagulum, decreases perfusion,
for hair restoration, because the eye sees this as approximating
and retards healing. Essentially, the laser loosens the snug fit
normal when the hair is groomed (6,13). The important point
that is such a benefit in FUT. Simply stated, if the goals are to
is that this can be done with a minimal amount of recipient
maximize the growth of FUs and keep recipient wounds to a
wounding.
minimum, the laser beam should be pointed the other way.
At the other end of the spectrum, the sorting of one-hair
and two-hair FUs can provide enough small grafts that natural
hairlines can be created without splitting intact FUs. For exam-
THE REASON FOR SORTING FOLLICULAR ple, if a mini-micrografter needed 200 single-hair grafts but
UNITS only had 100, the solution might be to divide 50 two-hair grafts
Sorting FUs enables varying densities to be created in different to produce the additional 100. In contrast, when FUs are sorted,
areas of the scalp without altering the spacing of recipient sites the FUT session generally produces an adequate supply of one-
or changing the wound size. Through the use of larger FUs, hair and two-hair grafts from naturally occurring single-hair
one can create greater density without increasing the wounding FUs without having to split up the units and risk damage from
in that area (usually, the frontal forelock). Sorting out smaller the dissection or risk having a thinner, more friable graft.
FUs provides a supply of one-hair and two-hair grafts to pro-
duce a soft frontal hairline without the need for splitting up
larger, naturally occurring groups. Sorting takes advantage of THE REASON TO TRANSPLANT FOLLICULAR
the inherent anatomical compactness of FUs, which allows units UNITS IN LARGE SESSIONS
of varying sizes to fit neatly into basically the same size site.
The importance of this is that the regions of the scalp in which Although larger sessions are made possible by the ability of
the greatest density is desired (e.g., the central forelock area) FUs to fit into very small recipient sites and to minimize wound-
Figure 12AA-3 (From Salasche SJ, Bernstein G, Senkarik M. Surgical Anatomy of the Skin, Connecticut: Appleton & Lange, 1988:
151–162, with permission. Courtesy of Gerald Bernstein, M.D.)
ing, the next logical question to ask is, What is the actual advan-
tage of performing these large sessions? After all, they are time-
Table 12AA–1 Percent Distribution of consuming, require a larger staff, and are more expensive for
Different Size Follicular Units Using Single- the patient (at least for the cost of the initial surgery).
Strip Harvesting and Microscopic Dissection There are a number of very important reasons to transplant
FU Size Percentage
in large sessions. Some of them are specifically related to the
use of FUs and some to hair transplantation in general, but
1-hair 14% all significantly affect the patient’s well being. They may be
2-hair 52% summarized as follows:
3-hair 29%
4-hair 6% ● Social reasons
● Planning for telogen effluvium
● Economizing the donor supply
● Enhancing the complexion of the FUs
Social
The social implications of the surgery are rarely discussed at
Table 12AA–2 Number of Grafts and Hairs in a
Typical 1525 Graft Case
medical meetings but they are in the forefront of almost every
balding patient’s mind. Putting aside anatomical, physiological,
FU Size # of FUs # of Hairs and technical issues, it is important to emphasize the practical
reasons to strive toward large sessions. The specific events that
1-hair 212 212 bring a balding patient to the doctor for hair loss vary, but the
2-hair 790 1580 common denominator of those seeking hair restoration is to
3-hair 435 1305
improve their appearance and, although generally unspoken, to
4-hair 88 352
Total 1525 3449
improve the personal, professional, and/or social quality of their
life.
394 Chapter 12
Figure 12AA-4 (a), Man, 48 years old, with a thinning Norwood type VA balding pattern, with medium-weight brown hair (donor
density 2.2 hairs/mm2). (b), Patient 13 months after one procedure of 2803 FUs. (c), Close up of frontal hairline. (d), Seamless integration
of follicular unit transplant with existing hair.
There is probably no better way for a surgeon to undermine of the germinative elements in the follicle. Miniaturization is
this goal than to subject an already self-conscious patient to a a universal aspect of androgenetic alopecia and accounts for
protracted course of small, incomplete procedures. Until the most of the early cosmetic changes in hair loss. In other words,
transplant is cosmetically acceptable, the disruptions caused by early in the balding process, the thinning that one notes is really
scheduling multiple surgeries, limitations in activity, and the due to thinning (i.e., miniaturization) of the hair shafts, rather
concern about their discovery of the transplantations, can place than the actual loss of hair itself (1).
a patient’s life on hold. It should, therefore, be incumbent on Regardless of the technique, an inevitable aspect of hair
physicians to accomplish their objectives as quickly as possible. transplant surgery is that the patient’s existing hair in and
The results of using FUs in large numbers in just one session around the transplanted area has a chance of being shed as a
are shown in Fig. 12AA-4a, b, c, and d; Fig. 12AA-5a and b, result of the procedure. The hair that is at greatest risk of being
and Fig. 12AA-6a and b. The results of one session of FUs in lost is that which has already begun the process of miniaturiza-
a patient who had one previous session of mini-micrografting tion; if this hair is at or near the end of its normal life span, it
are shown in Fig. 12AA-7a and b. What can be achieved in may not return.
two sessions is shown in Fig. 12AA-8a, b, c, and d and Fig. Often, this shedding is mild and insignificant, but at times
12AA-9a and b. The important point is that even if patients do it can be substantial enough to leave the patient with hair that
not accomplish all of their goals in one or two transplant ses- looks thinner after the procedure than before. The reason is that
sions, they can still continue with normal activities while await- in some patients, especially those who are younger and in very
ing subsequent procedures. active stages of hair loss, large amounts of hair can be undergo-
ing the process of miniaturization. Identifying patients who are
especially at risk, educating all patients that this process can
Telogen Effluvium occur, and planning for it surgically are integral parts of hair
Balding is a progressive process whereby full-thickness termi- transplantation (5).
nal hairs gradually decrease in length and diameter in a process The following list outlines how one can plan surgically for
called miniaturization. This is a consequence of shortening of a possible effluvium:
the anagen (growing) phase of the hair cycle and diminution 1. Defer transplanting patients who are very early in the
Figure 12AA-5 (a), Patient, 43 years old, Norwood class VI, with medium-fine dark brown hair and light skin. (b), Patient 11 months
after a second session of follicular unit transplantation totaling 4295 follicular unit grafts.
396 Chapter 12
Figure 12AA-6 (a), An early Norwood type VA patient with salt and pepper hair. And a donor density of 2.1 hairs/mm2. (b), Patient
10 months after a single session of follicular unit transplantation of 1801 grafts.
balding process (i.e., those who are content with the with a much smaller amount of permanent, full-thick-
way they look but are concerned about future hair loss). ness terminal hairs. In areas of extensive miniaturiza-
A good rule of thumb is to wait until the patient needs tion, it may be appropriate to transplant FUs in the same
a minimum of approximately 600 to 800 FUs before density as if the area were totally bald.
considering surgery. Often medical therapy rather than
surgery is appropriate for these patients. Economizing the Donor Supply
2. When considering surgery, carefully define by gross
visual inspection the boundaries to be transplanted as The finite nature of the donor supply is the ultimate limiting
well as densitometry, which is a more sensitive indicator factor in all hair restoration surgery. The importance of proper
of miniaturization. harvesting techniques and precise follicular dissection in ensur-
3. Transplant through (rather than around) an area that is ing maximum donor yield is well recognized and is covered in
highly miniaturized, because it is likely that this area later sections. Using a smaller number of larger transplant ses-
will be lost by the time the transplant has grown in. sions rather than multiple small sessions also helps to maximize
Two examples of this are (1) a forelock composed of this supply. The donor supply is more sensitive to donor density
wispy, miniaturized, hair rather than strong terminal than it may seem. In fact, for every unit change in donor density,
hair, and (2) the bridge that is beginning to break down there is a twofold change in the amount of movable hair (1).
in a Norwood type V patient. Although it is not immediately obvious, the logic of this is
4. Plan to use enough FUs so that, if possible, the volume illustrated in Table 12AA-3. As discussed in the section,‘‘A
of transplanted hair is greater than the volume of hair Mathematical Look at Balding,’’ individuals may lose 50% of
that will likely be lost from telogen effluvium. Remem- their hair volume before it is clinically noticeable. Although
ber that surgery never replaces ‘‘hair for hair.’’ In effect, we commonly think of this in terms of the balding scalp, it
a large number of fine, miniaturized hairs are replaced applies to the permanent zone as well (6). Therefore, in the
Figure 12AA-7 (a), A Norwood type VI patient with straight brown hair. The patient had a previous session of mini-micrografts on
the top of his scalp (b), Patient 15 months after one session of 1750 follicular unit grafts to the front and top of his scalp, completing the
anterior portion of the transplant in one session.
average person with a density of one FU/mm2(2 hairs/mm2), These numbers serve to underscore the importance of trying to
the follicular unit density (FUD) can be reduced to approxi- conserve donor hair in every aspect of the procedure.
mately 0.5 units/mm2(1 hair/mm2) before the donor area appears It is interesting to note, for example, that although the patient
too thin. In those with high hair density, a greater percentage with a donor density of 1.5 hairs/mm2 has half the FUGs avail-
may be removed (see Table 12AA-3). Therefore, a patient with able of a patient with a density of 3.0 hairs/mm2(4167 grafts
a hair density of 2.5 hairs/mm2 has 50% more movable hair vs. 8333 grafts), each of the grafts has, on average, only half
than the average patient with a hair density of 2.0 hairs/mm2, the hair content of the patient with the density of 3.0, so that
although the hair density is only 25% more. The amount of the transplant of the former individual will appear only one
movable hair also depends on other characteristics of the pa- fourth as full (4167 grafts averaging 1.5 hairs per graft vs. 8333
tient’s FUs (see the section, ‘‘The Reason Why Follicular Units grafts averaging 3 hairs per graft).
Vary’’) as well as scalp dimensions and laxity. Each time an incision is made in the donor area and each
Although rarely discussed, each hair transplant diminishes time sutures are placed, hair follicles are damaged or destroyed.
donor density. If a person has a hair transplant procedure(s) This damage can be minimized by keeping the sutures very
that decreases donor density by 25%, half of the movable hair close to the wound edges so that they do not encompass much
is exhaustedbecause the FUD is reduced to 0.75 units/mm2(1.5 hair and/or removing them soon after the procedure by means
hairs/mm2). If the same patient began with 25% less hair density of nontension closures. In patients with loose scalps and high
(i.e., 1.5 hairs/mm2) (remember that the FUD in the virgin scalp density, staples may minimize damage to surrounding hair folli-
is constant and is still 1 unit/mm2), the same transplant(s) would cles (14). However, staples cause significant postoperative dis-
reduce the FUD to 0.75 units/mm2 and would leave a hair den- comfort and may produce greater scarring owing to less con-
sity of 1 hair/mm2 (0.75 units/mm2 ⳯ 1.5 hairs/unit). This level trolled approximation of the wound edges. In subsequent
of density would be too thin to permit further transplantation. procedures, using the previous scar as the upper or lower border
398 Chapter 12
Figure 12AA-8 (a), A 36-year-old man with early Norwood type VA/VI balding pattern, with medium fine, dark brown hair of high
density (2.8 hairs/mm2). (b), Top view of the same patient. (c), Patient after two procedures of follicular unit transplantation spaced 91⁄2
months apart, consisting of 2747 FUs in the first session and 2400 in the second session. (d), Top view of the same patient.
of the new excision can reduce damage to follicles. In this way, sorting becomes a powerful technique for producing greater
the amount of distortion and possible damage to existing hair density in specific areas.
is limited to only one free edge. However, regardless of how The benefits of sorting can be illustrated by examining the
impeccable the technique, each surgical procedure is associated transplantation of a Norwood type IV-A patient with one session
with some degree of hair wastage. of 1800 FUs compared with two separate sessions of 900 FU
There are other, more subtle effects of the surgery. In all grafts. Let it be assumed that to minimize wounding and to
healing, even with primary intention closures, collagen is laid decrease popping, a decision was made to keep a maximum
down and reorganized. This distorts the direction of the hair site density of 20 sites/cm2 (see section,‘‘Why Keep Recipient
follicles and increases the risk of transection in subsequent pro- Sites Small?).
cedures. In addition, the fibrosis makes the scalp less mobile As shown in Table12AA-4, when the procedure is performed
for subsequent surgeries, thereby decreasing the amount of ad- in two sessions, there are not enough single-hair grafts in a 900-
ditional donor tissue that can be harvested. With each surgery, graft case to complete the frontal hairline (a minimum of 200
these factors come into play, so that transplanting in large ses-
to 250 is usually required). To complete the frontal hairline, it
sions, which minimizes the total number of individual proce-
would be necessary to split up 2-hair, 3-hair, or 4-hair units to
dures, conserves the total donor hair.
generate the single-hair grafts, risking injury to them and, in
addition, decreasing the hair value of the remaining grafts.
Enhancement of Graft Sorting To create density in the central forelock area (an area of
A final advantage of using large sessions is that they permit approximately 25cm2), the smaller case would allow a maxi-
greater enhancement of the complexion of FUs in select areas mum density of only 2.7 hair/cm2. On the other hand, the larger
through the process of sorting. The concept of sorting was intro- case of 1800 would allow a density of 3.2 hairs/cm2 over the
duced in an earlier section, but with larger transplant sessions, entire 25cm2 area. To create this density with the smaller proce-
Figure 12AA-8 Continued.
dure, FUs would need to be combined, thereby creating mini- relative constancy of the follicular unit density was deduced
grafts and increasing the wound size. after performance of densitometry on thousands of patients and
In sum, when larger sessions are used, the greater number was observed histologically by Headington as early as 1984
of one-hair grafts l allows the creation of soft, natural hairlines (1,2).
from naturally occurring ‘‘protected’’ single-hair FUs. The The FUD is not exactly 1/mm2, but, when measured several
greater numbers of three-hair and 4-hair units provide the natu- centimeters to the right or left of midline at the level of the
ral resources to create significant fullness in select areas. There- occipital protuberance in the posterior scalp, it is close enough
fore, another reason for using larger procedures is that they offer to this number in most white and Asian patients that this mea-
the surgeon the greatest flexibility in designing the transplant, surement can be extremely useful during surgery. It is signifi-
without having to combine or split FUs. cantly less in black patients, averaging around 0.6/mm2, and it
decreases in most scalps in a lateral direction from the densest
part near the midocciput to the thinnest part at the temples
THE REASON WHY THE FOLLICULAR UNIT (see Table 12AA-5). The FUD also tends to remain relatively
CONSTANT IS USEFUL constant in this area through adulthood (1). Finally, it is impor-
tant to differentiate FUD, which is relatively constant, from hair
One interesting aspect of transplanting with FUs is that nature density, which can vary significantly from 1.5 hairs/mm2 to 3
was kind in spacing them at approximately 1/mm2. This not hairs/mm2 or more in the general population (1).
only makes the mathematical calculation easy but also makes Once it is acknowledged that the FUD is relatively constant
the estimation of the donor harvest easy and gives a logical and that hair density varies, it follows that the number of hairs
basis for planning the density and distribution of the grafts. The per FU largely determines hair density. In other words, patients
400 Chapter 12
Figure 12AA-9 (a), A Norwood Class VI patient with very fine, blonde hair and a donor density of 2.5 hairs/mm2 (b), 11 months after
second session. A total number of 4514 follicular unit grafts were transplanted over the two sessions.
Table 12AA–3 Theoretical Effects on Transplantable Hair Caused by Changes in Donor Densitya
A Donor Hair Density (hairs/mm2) 3.0 2.5 2.0 1.5 1.0

B Follicular unit density (units/mm2) 1.0 1.0 1.0 1.0 1.0
C Total hair in permanent zone 37,500 31,250 25,000 18,750 12,500
D Follicular units in permanent zone 12,500 12,500 12,500 12,500 12,500
E Hairs that must remain in permanent zone 12,500 12,500 12,500 12,500 12,500
F Movable Hairs (C-E) 25,000 18,750 12,500 6,250 0
G Average hairs per follicular unit (G⫽A) 3.0 2.5 2.0 1.5 1.0
H Transplantable Follicular Units (F/G) 8,333 7,500 6,250 4,167 0
a
These numbers serve to illustrate the effects on hair supply caused by changes in donor density. The actual number of grafts that can be harvested depends on
a multitude of factors including donor dimensions, scalp laxity, hair characteristics (such as hair shaft diameter and wave), and skin/hair color contrast. It also
assumes that the efficiency of the harvest is 100% and that this can be maintained between procedures (see discussion later).
Table 12AA–4 Distribution of Different Size Follicular Units Table 12AA–5 Racial Variations in the Follicular Unit
Using Single-Strip Harvesting and Microscopic Dissection
Caucasians Asians Africans
FU size Percentage 900-Graft case 1800-Graft case
Follicular units/mm2 1 1 0.6
1-hair 14% 126 252 Average density (hairs/mm 2) 2.1 1.7 1.6
2-hair 52% 468 936 Predominant hair grouping Two Two Three
3-hair 29% 261 522
4-hair 6% 54 108 (From Bernstein RM, Rassman WR. 1997. The aesthetics of follicular
transplantation. Dermatol Surg 23 : 785–799, with permission.)
with high hair density have more hairs per FU rather than closer
tempt to give the patient with fine hair and low density a thick
spacing of FUs, and those with low hair density have fewer
look by combining FUs simply results in exhaustion of the
hairs per FU, rather than FUs spread further apart. This relation-
donor hair supply. Moreover, combining the units tends to pro-
ship can easily be seen in the three videografts shown in Fig.
duce a pluggy, unnatural appearance.
12AA-2a, b, and c, as well as in the schematic diagram shown
For most patients, the limitations of the donor supply com-
in Fig. 12AA-10. This relationship has enormous implications
pared with the demands of the recipient area are such that trying
are in hair transplantation, which can be summarized as follows:
to transplant hair in a way that approaches (or equals) the origi-
● Because the FUD is relatively constant, the same number nal donor density limits the ability to properly distribute the
of FUs should generally be used to cover a specifically hair over the long term. Fortunately, surprisingly small amount
sized bald area regardless of the hair density of the pa- of hair makes a significant difference in the appearance of a
tient. bald individual. For those with thinning hair, the addition of
● With low hair density, using of the same number and even a limited amount of full terminal hair, properly distributed,
spacing of FUs as in a patient with high density helps can radically change the appearance.
to ensure that there is proper conservation of donor hair
for the long term.
● Hair density is a characteristic of the FU specific to each THE REASON WHY FOLLICULAR UNIT
individual. Together with hair shaft diameter, color, and TRANSPLANTATION MAKES SENSE
wave, density determines the cosmetic impact of the MATHEMATICALLY
transplant.
Normal hair density is approximately 2 hairs/mm2 or one follic-
Traditionally, hair restoration surgeons have ‘‘sold’’ the hair ular group/mm2. Average individuals can lose up to 50% of
transplant procedure to patients by promising the high density their hair population with undetectable thinning (6,13). There-
of larger grafts. In reality, the results are determined by the hair fore, only one FU/2 mm2 needs to be restored in the hairline
characteristics of the patient rather than by the promises of for the density to appear normal from a frontal view. In areas
the physician. In a patient with low hair density (or poor hair behind the hairline, where layering of the hair can add value,
characteristics), each FU has less cosmetic value, so the results significantly less than 50% of the original density may suffice
appear to be less full. On the other hand, in patients with high to produce adequate fullness. For example, with modest styling
hair density and greater hair shaft diameter, the same number considerations, significantly less than one eighth of the original
of FUs provides fuller coverage. Because the follicular density density can appear to look full if placed behind a well-con-
in each patient’s donor area is approximately the same, an at- structed hairline.
Figure 12AA-10 Size of follicular units as hair density varies. (From Bernstein RM. 1998. Measurements in hair restoration. H T
Forum Int 8:27; with permission.)
402 Chapter 12
In a typical patient, whose scalp contains 50,000 FUs, the one twentieth the density of the donor area; therefore, this
permanent donor area represents approximately 25% of this amount that is all that should be placed from the outset. Too
total number, or 12,500 units, with the remaining 37,500 at risk often, a young patient, with a small area of balding is ‘‘packed’’
of loss. Of the 12,500 units in the donor area, approximately with hair to approximate the surrounding density; later on, the
half are available for harvesting (i.e., 6250). This leaves a total patient is left with a distribution so unnatural it cannot be re-
of 6250 units available to cover an area that originally had paired.
37,500. Therefore, only one-sixth (6250/37,500) of the original
units remain. There are many creative ways to distribute the THE REASON WHY FOLLICULAR UNITS
grafts so that the transplant has the appearance of being much VARY
fuller (6). The point is that combining units to create more
density is not an option. When considering the cosmetic impact of the hair restoration
Problems with the distribution of grafts larger than individ- procedure, it is important to consider all of the patient’s hair
ual FUs can be illustrated in the following example. If only characteristics because they can be of equal or even greater
individual FUs were to be used, the average spacing between importance than the absolute number of hairs. For example, a
units, once they have been transplanted into the recipient area, close match of hair color and skin color significantly contributes
would be six times farther apart than their original spacing in to the appearance of fullness, as does coarse or wavy hair. In this
the donor area, or six times farther apart than in the prebalding context, the FU can be characterized by the following features:
scalp. If the FUs were combined (e.g., three units into one), ● Hairs per FU
the spacing would become 18 times greater. Envisioning the ● Hair shaft diameter
transplant process in this way, it can easily be seen that there ● Hair color
is little logic in combining grafts to give more density. Combi- ● Texture (wave, curl, kink)
nation results only in larger spaces and a more uneven distribu- ● Other factors (emergent angle, static, oiliness, sheen,
tion, but never more hair. Fortunately, the patient with the thin- etc.)
looking donor area will look appropriately balanced and natural It has often been assumed that the number of transplanted hairs
with a thin transplant. The surgeon should promise no more. is the major determinant in the cosmetic impact of the trans-
Although grafts cannot be combined to produce more full- plant. In reality, hair shaft diameter plays a more significant
ness, how can the follicular constant be used to design the trans- role than the absolute number of hairs. The diameter of coarse
plant and maximize the cosmetic impact? The issue is always hair can be greater than twice the diameter of fine hair, so that
one of long-term planning. Unfortunately, the patient does not when the area (␲r2) of the hair shafts are compared, coarse hair
seek treatment with a final balding pattern. Therefore, when a has more than five times the cross-sectional area (and thus more
patient undergoes early transplantation, the density and distribu- than five times the cosmetic value) of fine hair (15).
tion must be similar to how transplantation would have been If we compare this variance in hair shaft size to the natural
performed if the patient were further along in the process. Thus, variation in hair density is compared, it can be seen that the
if a patient has temporal recession at 25 years of age, density impact of the hair shaft diameter, and thus volume, is more
such as a 45-year-old individual would have in this area should than two and a half times as significant as the absolute number
be offered. Otherwise, when the patient is 45 years old, the of hairs. Table 12AA-6 shows the range of hair density and
transplant will look unnatural. hair shaft diameter commonly seen in the population of patients
An understanding of concept of follicular density is invalua- who are candidates for hair transplantation surgery and summa-
ble. If there is only one-sixth of the original overall follicular rizes the relationship between the two. The data illustrate the
density to work with and the surgeon wants to use half the importance of understanding both aesthetic and mathematical
donor density in a certain area (i.e., 3x the average), only one elements of transplantation to predict the outcome of the sur-
eighteenth of the donor density (one third of the average) can gery.
be used in another area given that these areas are of equal size;
otherwise, the hair supply will be exhausted. For example, if THE REASON FOR USING SINGLE-STRIP
50% of the patient’s original density in the forelock area is HARVESTING
eventually to be replaced, some other region of the scalp must
give hair. This might be accomplished by transplanting less on The use of the multibladed knife is incompatible with FUT.
top of the scalp or transplanting the crown very lightly if at all. When FU anatomy is related to the construction of the mul-
In the example of the 25-year-old transplantation candidate
cited earlier, it may be decided that the final density of the
lateral aspects of the frontal hairline should be only half the Table 12AA–6 Relative Significance of Hair Density and Hair
density of the central forelock. Once this density has been Shaft Diameter
achieved, no additional hair should be transplanted in that area,
or the long-term distribution will be inappropriate. Range Variance
The same type of management applies to early treatment of A Hair density 1.5–3.0 hairs/mm2 2
the crown. If a patient has only crown balding but is expected B Hair shaft diameter 0.06–0.14 mm 2.3
to be completely bald because of density, age, or family history, C Cross-sectional area 0.0028–0.0154 mm2 5.4
a limit must be placed on how much hair should be transplanted D Area/density (C/A) — (2.7)
to this area. For example, it can be assumed that when the
patient is completely bald and has undergone total transplanta- * Patients with a donor density less than 1.5 hairs/mm2 or hair shaft diameter
tion, the crown should have a density that is no greater than less than 0.06 mm are rarely candidates for hair transplantation.
tibladed knife, the reason should be obvious. The multibladed the further dissection of these pieces into individual FUs. The
knife has blade spacing that generally ranges from 1.5 mm to first part of the procedure, the handling of the intact strip, has
3 mm. When these blades pass through a donor area that has always been the most problematic. This is the main reason for
FUs randomly distributed at 1/mm2, few FUs are left unscathed. the continued popularity of the multibladed knife, which, in
At the extreme are the automated graft cutters that use multiple effect, bypasses the first part of the procedure by generating
blades with a spacing as close as 1 mm (16,17). Clearly, one thin sections that can be placed on their sides. The thin sections,
pass with any multibladed knife would break up many of the resting on their broad surface, have good stability for further
naturally occurring FUs even before they left the scalp and dissection and permit transillumination by means of backlight-
would immediately reduce the follicular transplant procedure ing. The intact strip, however, is difficult to stabilize and is too
to one of mini-micrografts cut to size (4). opaque for useful transillumination.
The lure of the multibladed knife is that it quickly generates The dissecting microscope allows the strip to be divided into
fine strips of tissue that can easily be dissected into smaller sections (or slivers) by actually going around FUs and leaving
pieces; and the finer the strips, the easier the dissection. But, them intact. The dissecting stereomicroscope is able to accom-
besides destroying the integrity of the FU, the multibladed knife plish this because of its high resolution (usually five times more
also causes transection to the follicles themselves; and the finer powerful than magnifying loops) and its intense halogen top-
the strips, the worse the transection. As discussed in the first lighting, which provides continuous illumination as dissection
section, the multibladed knife uses a form of blind harvesting proceeds through the strip. Stability can easily be achieved if
that makes all of its incisions in a horizontal plane, where the slight traction is applied to the free end of the strip. The thin
angle of the emerging hair is the most acute and incisions can slivers are then laid on their sides and the microscopic dissection
cause the most damage. Another issue complicating the harvest- of the individual units is completed. With stereomicroscopic
ing is that FUs actually traverse the skin in a slightly curved dissection, except for the outer edges of the ellipse, every aspect
path, because the bulbs are random in the fat and ‘‘gathered’’ of the procedure is performed under direct observation; thus,
into bundles in the dermis (18). Regardless of the instrument, follicular transection can be minimized and the FUs maintained.
the initial incision is always relatively blind; therefore, the most
sensible approach is to remove the strip with as few incisions
as possible and then perform all further cutting under direct THE REASON FOLLICULAR UNIT
observation. This is the rationale for single-strip harvesting. TRANSPLANTATION CANNOT BE
It is argued by some that structuring a freehand ellipse is the PERFORMED WITH MINI-MICROGRAFTING
preferred method for removing the strip; therefore, the cutting of TECHNIQUES
each wound edge can be controlled separately (the upper edge
should be cut first for greater stability). Others argue that two In 1998, 21 prominent hair restoration surgeons (including Dr.
parallel blades offer more stability and avoid the problem of William Unger) embarked on a collaborative effort to ‘‘Stan-
cutting through a mobile and partially distorted second edge, dardize the Classification and Description of Follicular Unit
owing to the greater contraction of the dermis relative to the Transplantation and Mini-Micrografting Techniques (4).’’ It
epidermis and fat. Regardless of the personal preference of the has been argued by some that strict definitions of FUT are
surgeon, the concept is the same. Single-strip harvesting is the unnecessary (4 Commentary). However, it has been this au-
best way to minimize transection and the only way to provide thor’s opinion, and that of others, that strict definitions are es-
adequate tissue for FUT. sential in comparing different techniques and in enabling physi-
THE REASON FOR USING

STEREOMICROSCOPIC DISSECTION
There is probably no other aspect of FUT that has generated
more controversy than the use of the microscope. Fortunately,
in no other area is the rationale more straightforward. Stereomi-
croscopic dissection was introduced into the field of hair trans-
plantation by Dr. Bobby Limmer (3), who recognized the bene-
fits of this instrument as early as 1987. Its full value and impact
are only now being appreciated. The following three statements
summarize its use:
● Only if there are FUs to transplant can FUT be per-
formed.
● In order for individual FUs to be dissected intact they
must be clearly visible.
● Only the microscope allows individual FUs to be seen
clearly in both normal and scarred skin, independent of
the specific hair characteristics of color, hair shaft diam-
Figure 12AA-11 Mini-micrografting technique. Harvesting
eter, and curl.
with a multibladed knife (blades set 3 mm apart), divided into
Follicular dissection can logically be divided into two parts: smaller sections of approximately 1 cm (this step shown in figure)
the subdivision of the initial donor strip into smaller pieces and and subsequent dissection with loupe magnification (1.5⳯).
404 Chapter 12
to merely cut into smaller pieces the strips generated by the

multibladed knife, depending on the size or number of hairs
desired (mini-micrografting cut-to size). Hair fragments were
not counted in any measurements in the study but were planted
if they were deemed to be of sufficient size to have stability in
the recipient site made by an 18-gauge Nokor needle.
The second method, which was called ‘‘Vertical Section-
ing,’’ was to harvest the donor tissue as one intact strip. This was
accomplished by using only the outer blades of the multibladed
knife. Once the strip was removed, smaller sections were gener-
ated by cutting vertical slices located approximately 2.5 mm
from one another. The pieces generated by this technique were
further dissected into individual FUs under loupe magnification
(Fig. 12AA-12).
In the third method, FUT was performed as defined by the
1998 collaborative effort, by means of single strip harvesting
Figure 12AA-12 Vertical section. Single-strip harvesting fol-
and stereomicroscopic dissection. (Figs. 12AA-13a and b).
lowed by vertical slices of the intact strip at a spacing of approxi-
After the removal of the donor tissue as a single strip, the tissue
mately 2.5 mm and then dissection with loop magnification (1.5⳯).
was divided into smaller pieces under stereomicroscopic control
by a process called slivering, whereby the blade was passed
around FUs without disrupting them. Individual FUs were then
dissected from these pieces, again with use of stereomicro-
cians to communicate clearly with their patients and with each scopes.
other. Of importance is that in the multibladed knife technique and
A common objection to the strict definition of FUT is that in the method of vertical sectioning, the initial cuts through the
it states, ‘‘Single strip-harvesting and stereomicroscopic dissec- strip are performed blind. In other words, the surgeon does not
tion are required (4).’’ To test the validity of the argument that have the visual control to avoid splitting FUs or transecting
these two techniques are essential aspects of FUT, a retrospec- individual follicles. The theoretical advantage of vertical sec-
tive study was conducted to ascertain the effectiveness of ob- tioning over the multibladed knife technique is that these initial
taining FUs. blind cuts are vertical rather than horizontal, so that potential
The study compared three distinct techniques. The first tech- damage from not following the incident angle of the emerging
nique is the one most similar to that used by mini-micrografters; hair can be reduced.
namely, harvesting with a multibladed knife with blades set 3 The difference between vertical sectioning and the slivering
mm apart, division into smaller sections (of approximately 1- of FUT is that in the former procedure the sectioning can follow
cm) followed by subsequent dissection with loupe magnifica- the emerging angle of the hair but is unable to avoid transecting
tion (1.5x) (Fig. 12AA-11). The major difference between this the randomly placed FUs, because the cutting of the sections
technique and traditional mini-micrografting was that there was is done with a linear motion. This contrasts with the slivering
a conscious effort to dissect intact individual FUs rather than technique of FUT in which, under direct stereomicroscopic con-
Figure 12AA-13 (a), Follicular unit transplantation. Single-strip harvesting followed by stereomicroscopically controlled slivering. (b),
Subsequent stereomicroscopic dissection into individual follicular units.
trol, the dissector’s blade passes around FUs to isolate them Table 12AA–8 Size of Follicular Unit Grafts Used with Each
Technique
and to preserve their structure.
The data in this study were compiled from operative reports Multibladed Vertical
completed during the stated periods. The staff’s instructions knife sectioning Stereomicroscope
during this period were to count only largely intact follicles but
to place everything that they deemed to be viable. Diagrams of 1-hair 38% 27% 14%
different follicular components and FU/split hair combinations 2-hair 49% 48% 52%
were discussed and posted to standardize policy, and this policy 3-hair 12% 23% 29%
remained relatively unchanged during the study period. Graft 4-hair 0.5% 1.5% 6%
sizes were determined by the method of magnification used for
the dissection (i.e., loops or microscope) and were recorded by
the staff as they came off the dissecting block. It is important
to point out that because this was a retrospective study that
spanned 5 years, it was impossible to maintain uniformly con-
sistent criteria to determine exactly what was a hair fragment with use of densitometry, indicating that this technique seems
and what was an intact follicle. The data should be viewed to preserve the entire FU.
in this context. The criteria also differed from our Bilaterally Table 12AA-8 examines the type of FUs generated as a
Controlled Study of 1998 (19), in which all hair fragments that percent of the total yield. It is striking that with stereomicro-
were deemed viable were counted. scope dissection, 35% of the grafts contained either three or
It is also important to note that in this study grafts consisting four hairs, whereas with the multibladed knife technique, only
of only transected hairs and/or hair fragments were not counted 12.5% contained that many hairs. Even more dramatically, the
but were often planted. This point tends to exaggerate the differ- number of 4-hair grafts obtained with the stereomicroscope was
ences in the data between the techniques. The point of the study, 10 times as great as that obtained with the multibladed knife.
however, was to examine the ability of the techniques to dissect This helps to explain the greater fullness seen when FUT is
FUs and not specifically to compare clinical results. When mini- performed with the latter technique.
micrografting is performed in clinical practice, essentially all of It is extremely important to emphasize that this present study
the harvested tissue is planted; thus, most, if not all, transected looked at the ability of mini-micrografting techniques to gener-
follicles and hair fragments are transplanted as well. Because ate FUs rather than at the performance of true mini-micro-
a portion of these follicles would be expected to be viable, this grafting.
would significantly affect the clinical results. The results of the In clinical practice, physicians who perform mini-micro-
study are summarized in Table 12AA-7. grafting do not try to isolate FUs and so transplant essentially
Table 12AA-8 examines the actual complexion of the indi- all of the harvested tissue; therefore, transected hairs and hair
vidual FUs generated by each technique. A multibladed knife fragments are transplanted as well. In FUT, transected hairs are
was used and then loop dissection was performed; each FU also transplanted; however, the issue is moot because, with good
contained an average of 1.74 hairs. When vertical sectioning technique, few are actually generated. The problem arises when
was used in the initial sectioning of the harvested strip, there FUT is attempted with techniques that can neither keep FUs
were two hairs per FU, an almost 15% increase over the mul- intact nor avoid follicular transection. In this case, attempting
tibladed technique. With single-strip harvesting and complete to isolate FUs generates too much hair wastage; moreover, the
stereomicroscopic dissection, 2.26 hairs per FU were obtained, FUT procedure offers more limited benefit.
15% more than with vertical sectioning and almost 30% more In summary, this study offers strong support for the argu-
than with the multibladed knife technique. Interestingly, the ment that if one wants to perform FUT (i.e., ‘‘a method of hair
2.26 hairs per FU obtained with single-strip harvesting and ste- restoration surgery whereby hair is transplanted exclusively in
reomicroscopic dissection is similar to what has been observed its naturally occurring, individual FUs’’), then for the vast ma-
Table 12AA–7 Size of Follicular Unit Grafts with Each Technique
Multibladed knife Vertical sectioning Stereomicroscope
Year data collected 1996 1996–1997 2000

Number of patients 113 113 90
Avg. total FUs per case 1861 1926 1525
1-hair 713 512 212
2-hair 906 934 790
3-hair 226 450 435
4-hair 8 30 88
Hairs/FU 1.74 2.00 2.26
Increase – ⫹14.9% ⫹29.9%
FU ⫽ Follicular unit.
406 Chapter 12
jority of patients, ‘‘single-strip harvesting and microscopic dis- option, I ask myself whether I have been fair to patients
section should be required.’’ whom I believe have excellent long-term donor/recipi-
ent area ratios and who have asked for maximum hair-
Editor’s Comment line density.
This presentation by Bernstein and Rassman (B & R) amply 5. We agree on virtually everything B&R have written
demonstrates their dedication to painstaking analysis of every regarding the theoretical effects of changes in donor
facet of FUT. Few practitioners have spent so much time think- area hair density on transplantable hair. I would add
ing and writing about what they are doing. We are all indebted only that excising half of the tumesced area of perma-
to them. William Reed, in Chapter 12C, presents a different nent, good-density hair in an individual does not reduce
view of micro-minigrafting (M/M) that is as well thought out the hair density in that limited area by 50%. The stretch
as that of B & R’s on FUT. His comparison of M/M with FUT used in closing the donor wound extends over a wide
is a far more favorable one than that of B & R. The reader zone of hair-bearing areas superior and inferior to the
is urged to read views and evidence supplied by Reed before densest zone. It also may involve some stretching in
accepting at face value any of the theoretical advantages of non–hair-bearing areas of the scalp on some patients.
FUT over M/M as posed by B & R. As one of the editors of Moreover, tumesced donor tissue that is 8 mm to 15
this text, I am taking this opportunity to add a few comments mm wide actually represents less than those widths in
of my own. the donor area’s nontumesced state (see Chapter 10).
Let me begin by saying that I agree in large part with a There remain large parts of B & R’s discussion that I find
number of B & R’s conclusions. These include the following: problematic. As implied earlier, they are, in many cases, based
on what I view as B & R’s misunderstanding of the current
1. FUT produces maximum naturalness. The only excep- methods used by many practitioners of M/M. We all think we
tion is that I believe that differences between FUs and know what others are doing, but often we do not. B & R’s
grafts that are, for example, one FU wide and two to description of what M/M practitioners are doing certainly does
three FUs long, are frequently cosmetically insignifi- not reflect what I am doing today (see Chapter 12F and 12G
cant. In properly selected individuals, such differences for details). I am sure the same would be true of others. Tech-
can be seen only on very close inspection, after one, niques of FUT have evolved over the last 4 to 5 years, and the
two, or three sessions (depending on the amount of orig- same is true of M/M. When we see a patient in our office who
inal hair still present at the time of the earliest sessions had FUT or M/M several years ago either, we should not assume
and on hair characteristics such as color, texture, curl, that we know what the practitioner who performed the surgery
etc.). Inserting FUs between these slightly larger grafts is doing or achieving today. B & R, for example, no longer
makes them even less noticeable. I elaborate on this routinely do sessions of 3000 or more FUs, and many (although,
position later in this chapter (see Chapter 12F), as well unfortunately, not all) of those who kept increasing the number
as on the cosmetic advantages of multi-FU grafts, of FUs/cm2 they were using, have reversed course; now, for
which, in my opinion, can more than compensate for the most part, they (B & R included) prefer 20 to 25 FUs/
slightly greater detectability. cm2. Both changes have probably evolved for good reasons (see
2. Elliptical excision and microscopic slivering of the Chapter 12B Editor’s Comment and and later in this subchap-
donor tissue is the ideal way of preparing FUs. We differ ter). We would, therefore, be wrong to criticize FUT today on
only in that I believe that once the slivering is complete, the basis of the techniques of yesterday. In a similar fashion,
lesser magnification can produce equally good results FUT practitioners would be wrong to criticize yesterday’s M/
in the hands of well-trained technicians with good eye/ M techniques as if the same techniques were being used today.
hand coordination. I am also more concerned than B& When we see patients from other hair transplant surgeons, we
R about the risk of accidental removal of invisible (at frequently see examples of that practitioner’s worst results
10x magnification) and hairless telogen follicles unless rather than their typical results. Poor results may also be caused
FUs are chubby when they are made. Fortunately, the by the physician, or by the patient’s failure to follow instruc-
significance of this difference has probably been greatly tions properly. Both of these factors should be borne in mind.
reduced as more and more FUT practitioners have Finally, even when we compare our own current results with
adopted chubby FUs as their standard in the last few those we achieved with other methods years ago, we should
years. remember that years ago others might have been getting better
3. We agree that for a variety of reasons a density of 20 results with supposedly the same techniques. This was certainly
to 25 FUs/cm2 per session should be cosmetically ade- true with the old ‘‘standard’’ grafts. There were only a handful
quate after one or two sessions. In most offices, this of practitioners who achieved excellent cosmetic results with
level of density is safer for FU survival than the higher these grafts, although all hair transplant surgeons were suppos-
densities that were sometimes advocated in the past by edly performing the same procedure. In addition, if your M/M
FUT practitioners (and, in some cases, still are). was not as good in the past as your FUT is today, perhaps if
(Seager, for example, believes that FU density should persistence had been shown and changes had been made (as I
routinely be somewhat higher.) describe in Chapters 12F and 12G), your M/M might now be far
4. We agree that hairline zones are best produced with more acceptable. The fact that some practitioners have switched
FUT. However, I sometimes wonder about this policy from M/M to FUT is not proof that FUT is superior. The ones
when I see some of my older patients who were treated who embraced FUT most rapidly were, quite reasonably, doing
with round grafts to which micrografts were later added so because they found the older methods unsatisfactory. Many
(see later in this chapter). If I have not offered this who have embraced FUT more cautiously have done so because
M/M, or supposedly more demanding techniques were, in their tage. To obtain the same number of hairs, many more FU grafts
hands, producing good results and making their patients happy. are necessary than multi-FU grafts. Put differently, the same
It should be clear to everyone that routine production of the number of hairs might be transplanted with one session of FUT
type of results B & R think M/M practitioners create would or one session of M/M, or micro-slit grafting, but more and
be self-defeating—particularly in today’s competitive world of smaller grafts with the former means more work, higher cost
hair restoration surgery. to the patient, and potential danger to the follicles. How are
With current M/M and micro-slit sectioning techniques, these elements deemed to be advantageous? Yet, somehow,
follicle transection rates are far lower than those suggested by B & R present 1500 FU sessions as better than 800 graft
B & R (see Chapter 12F). In addition, if all fragments of tran- M/M sessions.
sected follicles are planted, surprisingly superior hair growth Just as important as misunderstanding what each of us is
rates and hair shaft calibers can sometimes be produced, without doing is the realization that there is a difference between theory
plugginess, as Bill Reed describes later in this chapter. The and reality. What is seen firsthand is more meaningful than what
statement, ‘‘physicians who perform M/M do not try to isolate is supposed to be seen based on theory. Theory, unfortunately, is
FUs’’ is currently incorrect for many practitioners. (See Chap- always based on the fallacious idea that all the relevant factors
ters 12F and 12G.) Furthermore, in many instances M/M sur- are known and understood and have been taken into account. Put
geons do not need to vertically split multi-hair FUs to obtain differently, theory has to contend with ‘‘the law of unanticipated
sufficient one-haired FUs for the hairline zone, although, if consequences.’’ Both M/M and FUT have had to evolve over
that were necessary, there is abundant evidence that this is not the years because carefully thought out theories have come up
normally detrimental to hair survival (See Chapter 9A). Nor is against the reality of unanticipated consequences.
it any more true of M/M than it is of FUT, that if we try to I am sure that B & R could develop some credible answers
give a patient with fine hair and low density a thick appearance to what I have written, and I am just as sure I could come up
by using multi-FU grafts, ‘‘we will simply run out of hair,’’ with credible replies. I have, however, used the aforementioned
as well as producing a ‘‘pluggy’’ and unnatural result. Each examples only to demonstrate that proponents on both sides
technique seeks to produce different densities in different and claim knowledge of everything their opponents know and do
limited areas to create the appearance of more density. Whether and believe they have taken into account all the pertinent fac-
this is done by: (1) planting of FUs with three or more hairs tors, but, in fact, they are almost always wrong in these assump-
in such areas, (2) planting FUs more densely in one or more tions. They also frequently overlook the disadvantages of their
sessions, (3) employing recombinant FUs (see Chapter 12E), own technique. Thus the premises of each proponent are faulty,
or (4) using a combination of FUs and somewhat larger multi- and their theories are frequently at odds with what unbiased
FU grafts, if the hair density objectives are the same, no more observers can see with their own eyes. As discussed earlier,
than the same number of hairs need to be transplanted. The many of B & R’s concerns with M/M and many of their kudos
difference is that if a density of 150 hairs/cm2, 200 hairs/cm2, for FUT are not borne out by my personal experience with either
or more in limited areas is deemed both desirable and prudent, of them. Let surgeons look at their own results with various
it can be produced with ‘‘mixed’’ grafting but thus far not with techniques and relay them to their colleagues. Let them not
FUT. Moreover, in multi-FU grafts, I believe fewer hairs can assume everyone means the same thing when using the same
produce an appearance of greater density than hairs trans- terms—sad as that reality might be. Let theory suggest the roads
planted exclusively as FUs. (See Chapter 12F.) we should follow but let surgeons ultimately keep their eyes
Interestingly, the ‘‘minimal’’ damage caused, for example, open and believe what they actually see on those roads. What
by 1500 or 2000 incisions for FUs, is not as minimal as it at is certain is that the smaller the graft is, the more fragile, and
first might seem. I discuss the total length of wounding with the more perfect the technique of all those involved in the sur-
FUT in my commentary on Chapter 12B, so I will not do that gery must be. Moreover, the smaller the graft, the more people
here. Suffice it to say that when large numbers of FUs are are involved, and the more difficult it becomes to use a consis-
transplanted in a single session, a total of 10 to 15 or more feet tently perfect technique. There is something enormously com-
of incisions may be created—in an area no larger than the palm pelling about the naturalness that can be achieved with FUT. I
of an average man’s hand. And which hairs would have a better am not immune to this attraction. I currently treat 20% to 40%
chance of surviving—those in the smallest grafts with the least of my patients with FUT because I think that approach is more
tissue insulation from handling and dehydration or those in the suitable to their situation and goals (I seem to be seeing more
larger ones with more insulation? patients who consult me with totally alopecic areas of MPB,
Finally, a number of factors suggested by B & R as advan- and I prefer to use FUT for most of those patients.) But given
tages of FUT could also be seen as disadvantages. The use the equally enormous need for perfection with FUT, and given
of minimum wounding—but 1500 or more such wounds—as the results I have personally seen with a mixture of FUs, micro-
discussed earlier, is just one of those disadvantages. Larger slit grafts, minigrafts and even standard grafts, I continue to
numbers of grafts per session are presented as an advantage of believe that there is something irrational about dogmatically
FUT, but they are actually more of a necessity than an advan- insisting that only FUs should be used in all patients. (WU)
408 Chapter 12
12B. Pitfalls of Follicular Unit Hair

Transplantation and How to
Avoid Them
David J. Seager
When follicular unit hair transplantation (FUHT) is performed
by knowledgeable and experienced surgeons, there are very few
complaints regarding the outcome. Naı̈ve and inexperienced
surgeons with inexperienced staff, however, are likely to wit-
ness the following complaints or complications in some of their
patients.
Six of the most common pitfalls related to FUHT are de-
scribed and discussed:
a. Inadequate density
b. Poor or no growth Figure 12B-2 The area covered by 3000 densely packed follic-
c. Necrosis in the recipient area ular units.
d. Stretched scars/necrosis in the donor area
e. Technical difficulties due to scalp characteristics
f. Unsuitable hair characteristics
Inadequate Density
Some patients think that the growth after the FUHT looks too
thin. The most common cause of this complaint is that not
enough follicular unit (FU) micrografts were placed in the area
treated to provide sufficient density. Remember that it takes
approximately 300 FUs to transplant a male eyebrow. It takes The ‘‘half moon’’ that took 350 standard grafts—or, alterna-
1000 FUs to transplant a 2.5-cm lowering of a male hairline tively, took three sessions of 500 minigrafts with some mi-
from temple to temple (Fig. 12B-1). It takes 3000 FUs to trans- crografts in the hairline—takes 3000 to 4000 FUs to cover with
plant a forelock as far back as 9 to 10 cm from the hairline in the same density.
a Norwood type VI patient (Fig. 12B-2). Unfortunately, most novices to FUHT do not realize that
these enormous numbers of FUs are necessary to produce ade-
quate density over a given area. Often, their offices are not
prepared for large enough numbers of these grafts to be trans-
planted in one session. Microscope dissection and planting of
micrografts into tiny needle sites is more strenuous and exacting
than traditional hair transplantation. Therefore, fewer grafts
tend to be planted by novices to FUHT in each session. It is,
therefore, no surprise that patients are disappointed with the
results of the first or second session. FUHT looks so natural
that if there is any existing hair at all and the transplanted grafts
are not densely packed, patients frequently deny that any new
hair has grown at all. The way of avoiding this pitfall is obvious:
Plant more grafts per session.
Poor or No Growth
The second cause of the hair transplant’s not growing in densely
enough is poor growth. When enough grafts in the given area
were planted to achieve density and that density never material-
ized, the cause is usually some fault of technique.
Faults of Technique Leading to Poor Growth:

The most common error of technique is damage to vascular-
ity—the more densely the grafts are packed, the smaller each
recipient site must be. With any dense packing, no recipient
site should be any larger than that made with an 18-gauge hypo-
dermic (not NoKor) needle. We, in fact, exclusively use 19-
Figure 12B-1 The area covered by 1000 densely packed follic- gauge or 20-gauge hypodermic needles. Even more damage to
ular units. vascularity is caused by drilling out tissue. Even when minute
punches with a diameter of 0.9 mm are used to drill out recipient

sites, more damage to the vasculature is caused than by 19-
gauge needle slits (Fig. 12B-3).
The second most common error of technique leading to poor
growth is drying of grafts: Dr. Marcelo Gandelman has demon-
strated that one of the greatest dangers facing grafts on their
journey from the donor area to the recipient area is drying (1).
It is essential that the time between harvesting and planting
should be minimized. For a 3000-graft session, we generally
take four donor strips at four separate time intervals, so that no
graft is out of the body for more than 3 hours, and most grafts
are out for less than 11⁄2 hours. Grafts must be kept in chilled
saline solution at all times.
We no longer use petri dishes because they do not hold as
much saline solution as glass bowls (Fig. 12B-4). Petri dishes
have a habit of eventually tilting in such a way that the saline
solution shifts more to one side. This leaves less saline solution Figure 12B-4 The volume of saline solution contained in a
on the other side to bathe the grafts. With evaporation of saline bowl vs. a petri dish. It also demonstrates that if the petri dish is
inadvertently tilted, it can reduce the amount of saline on one side
solution, there is even more exposure of the grafts to the air.
of the dish.
Sometimes, the grafts have a chance to desiccate before the
staff notices and before they are able to replenish and refill the
petri dishes with saline. This does not happen with deeper glass
bowls. During the planting process, staff should not be allowed haired minigrafts into 15c blade-sized slits (or equivalent). Pro-
to place more grafts on their glove than they can plant in a 60- spective trainee planters should be selected based on their dem-
second interval. They must ensure that the grafts are glistening onstration of excellent manual dexterity and dedication. It gen-
with moisture at all times while they are resting on the glove. erally takes 18 months to train these highly selected new
The third most common error of technique in causing poor planters to densely pack chubby FU micrografts with minimal
growth is trauma. Impeccable precision combined with the gen- trauma and with enough speed to finish their half of a 3000-
tlest handling of grafts is required during both donor dissection graft case in less than 10 hours.
and planting of FU micrografts. To achieve optimal results, Many hair transplant physicians who are expert at traditional
exclusive use of binocular stereoscopic dissecting microscopes methods and attempt this new technique insert FUs into 18-
during graft preparation is essential. Planters must be highly gauge needle sites. Unfortunately, the grafts are often either cut
skilled and trained to plant grafts with minimal trauma. It is too narrow without enough ‘‘padding’’ to protect them during
not at all easy to plant chubby micrografts into 19-gauge or 20- the planting process, or they are correctly left chubby but are
gauge hypodermic needle recipient sites. The details of this then more easily and excessively traumatized during the plant-
technique are beyond the scope of this chapter, but this specific ing process.
technique is much more technically difficult than planting 4-
Necrosis in the Recipient Area
This is a rare cause of poor growth in the hands of a competent
FUHT physician, but it is probably the commonest cause of
poor growth in the hands of experienced hair transplant physi-
cians who are novices at FUHT. Recipient area necrosis is
caused by overloading the circulation in that area. Making too
many large recipient sites too close together is the usual cause
of damaging or overloading the circulation. As with necrosis
of other sizes of grafts in hair transplantation, it is seen more
often in heavy smokers, diabetic patients, patients with preexist-
ing scarring of the scalp, and so on. Necrosis in hair transplanta-
tion—both in the recipient area and the donor area—is charac-
terized by what seems like prolonged scabbing. Sometimes the
area, instead of looking like a scab, looks like a black raised
patch of skin. What one initially believes is a prolonged, adher-
ent, dark scab often takes 2 to 4 weeks to separate from the
underlying skin. The skin then appears as a white, shiny, and
depressed scar. It is also usually devoid of natural pores. If
Figure 12B-3 The different sizes and shapes of recipient sites the black scab is removed before it separates spontaneously,
made by various instruments. From left to right, these instruments granulation tissue can be seen underneath. This tissue eventu-
are: a 3.5-mm punch; a 1.15-mm punch; a 16-gauge hypodermic ally develops into the white, shiny area described.
needle; an 18-gauge NoKor needle; an 18-gauge hypodermic Sometimes the vascularity is impaired in local areas by too
needle; and a 19-gauge hypodermic needle. many overly large recipient sites in too small an area, but not
410 Chapter 12
to the extent to which frank necrosis of skin occurs. Quite fre- The donor area of the scalp should be assessed for ‘‘tight-
quently, however, either poor or no growth occurs. This often ness’’ at the consultation, and again immediately preopera-
appears as a number of small, localized patches of bare skin tively. If lack of donor area flexibility is noticed at consultation,
with just a few stray hairs growing from some of these affected as it should be, the patient should be encouraged to massage
patches (Fig. 12B-5). their scalp as is commonly taught before scalp reduction.
In cases in which tightness is suspected, a very small portion
Stretched Donor Area Scars and Donor Area of strip—2 cm to 3 cm long—should be excised initially, and
Necrosis the actual tension on closure of this portion should be tested.
The width of the rest of the strip to be excised can then be
Wide scars and donor area necrosis are classified together be- adjusted accordingly.
cause they share many common causes. Necrosis is often just If the strip is removed, and there is any tension at all on
a more extreme result. apposing the two wound edges, my own practice is to not close
Causes of wide donor area scars and necrosis that are com- the gap completely at these points. Not uncommonly, I leave a
mon to all methods of hair transplantation include poor strip 2-mm to 5-mm wide gap at the tightest points when I encounter
excision technique, excessive cautery, improper closure such unexpected tension on closure, especially in a patient with the
as suturing too tight, and reaction to absorbable suture material. previously mentioned vascular risk factors. This gap closes and
However, for reasons that are discussed later, the biggest con- heals by a combination of scar contracture and granulation. One
cern in FUT is closure of the donor gap under excessive tension. would expect such a gap to leave a wide scar. However, one
Closure under tension can lead to stretched scars in many would be amazed at the number of times there is enough scar
cases, and necrosis in a few. Usually, with necrosis, there is contracture to leave only a narrow scar. When a significant scar
some additional impairment of vascularity. Diabetes, athero- remains after a gap is left, it can usually be easily treated by
sclerotic disease, and/or heavy smoking can compromise vascu- simple excision later. There is much greater flexibility around
larity. Damage to vascularity may be the result of multiple pre- this scar than around those formed after excessive stretching
vious hair replacement surgeries. Older men are also prone to of skin.
reduced vascularity. With any of these risk factors, it is espe-
cially important to avoid tense closure. Technical Difficulties
Tension in closure follows excision of strips that are too
wide. There is inherently a great temptation with FUT to harvest Unfortunately (for both the patient and the hair transplant team),
as many grafts as possible and thus be aggressive about the the occasional patient has one or more of the following prob-
width of the donor strip. This pressure comes from the enormous lems:
numbers of grafts required to fill an area in one session that
Excessive and profuse intractable bleeding from recipient
would have required three or four sessions with standard grafts
sites
or combined minigrafts and micrografts. Whereas minigrafts or
‘‘Mushy dermis’’
standard grafts often stand out against a background of thin
Excessive ‘‘popping’’
existing hair, FUHT results are so natural that the increase in
density is harder for the patient to perceive unless it is dramatic. Unfortunately, there is no way of identifying patients who are
To the patient, permanent transplanted FUs and temporary ex- going to have these characteristics, which are uncommon but
isting hair look alike. Thus, again, there is pressure to harvest very difficult to manage, before one actually commences sur-
and transplant as much hair as possible. gery.
I remember one 2000-graft case that took 17 hours to finish
and was not finished until after midnight because the patient
had all these characteristics. There are however, many ‘‘tips
and tricks’’ (unfortunately, not always successful), on how to
minimize these particular difficulties, but they are beyond the
scope of this chapter.
The danger from this type of scenario, apart from extreme
inconvenience to both the patient and staff, is that the grafts will
suffer from excessive manipulation even when the procedure is
performed by the most experienced technicians. This is all the
more so because after these many hours, even the best and most
experienced technicians and nurses become tired, frustrated,
and unable to perform their duties with their usual high degree
of skill and care. Moreover, many of the grafts may be out of
the body for longer than advisable. This is another good reason
to take multiple, smaller strips hours apart. Although most of
these patients do end up very pleased with the results, careful
inspection does show that less than optimal growth generally
Figure 12B-5 A circled area demonstrates poor growth. On occurs.
the patient’s right, there are small areas of shiny skin without hair. Fortunately, such patients are rare. It is good practice, how-
These areas represent recipient area necrosis. Adjacent to these is ever, to warn all patients that although they are being booked
an area of poor growth caused by vascular compromise. for a larger megasession, it is possible that their particular bio-
logical characteristics may make the procedure much more tech- usually limited to sessions of approximately 3000
nically difficult than usual, and it may be impossible to complete grafts or fewer. Wider donor strips, in most patients,
the proposed number of grafts on that day. What may have been risk wider scars. It generally takes 8 to 12 hours to
booked as a 2500-graft session may be limited to, possibly, a transplant 3000 grafts in one session. Sessions of more
1000-graft session, and the patient may have to be brought back than 3000 grafts can be very exacting and exhausting
later to have the balance of the originally arranged number of for both the patient and staff, particularly if there is
grafts transplanted. In our Consent Form we include this provi- bleeding and popping.
sion and ask that each patient initial the section to verify that
they understand that this remote possibility exists. These pa- Seager prefers a ‘‘one-pass hair transplant’’ in which suffi-
tients, despite their disappointment, are generally very under- cient density is achieved with a single session that a second
standing if warned beforehand that this may be a possibility. becomes unnecessary. He lists many possible advantages to this
approach, which can be found in the referenced article (1). The
Unsuitable Hair Characteristics reader is urged to review it in order to balance the disadvantages
Hair characteristics should be taken into account for any method that I discuss later. He notes, ‘‘Most transplant physicians at-
of hair transplantation. Hair coarseness, color, and consistency tempting a one-pass hair transplant have difficulty placing the
are even more important considerations when FUHT is planned. grafts closely enough together to provide adequate density
Thin, black, straight hair transplanted in the same density as (without compromising the vascularity of the area). When this
coarse, white, curly hair looks far sparser. difficulty is overcome, there are myriad difficulties in coping
When the donor area is sparse and contains mostly one- with the enormous number of grafts required to cover a large
haired and two-haired FUs, the result also looks much less dense enough area to provide a worthwhile cosmetic benefit. These
than the result when the donor area contains mostly two-haired significant difficulties are probably the reason why the one-pass
and three-haired FUs. technique hair transplant has not been adopted and promoted by
These factors should be discussed to allow a patient to have more hair transplant practitioners.’’ He then goes on to discuss
realistic preoperative expectations. They should also be taken his views on previously noted problems with megasessions and
into account in designing the hairline and plan and in determin- dense packing and how he has overcome them. I quote, with
ing the balance between density and coverage.
some sections I have chosen to slightly modify or italicize for
More detailed discussion about modification of the hair
emphasis:
transplant design based on hair characteristics is beyond the
scope of this chapter.
Dense Packing
SUMMARY
Some studies have demonstrated that dense packing
The foregoing is an overview of the common pitfalls that await over 40 follicular units per cm2 results in poorer
the unwary novice to FUHT. The novice to FUHT is strongly growth. Most of these studies, however, have used 18-
advised to start with a few, very small, loosely packed sessions. gauge needles (Stough, Orlando, 2000; Bill Reed,
After seeing good results, the number of grafts per session and presentation in Puerto Vallarta, 2001).
their density can be increased in a stepwise fashion. After seeing
good results from the previous step, the next step can be taken. The secret of success in dense packing is to use as small a
If all the foregoing advice is followed, the now wary practi- recipient site as possible. This necessitates using a 19-gauge
tioner is likely to avoid many of these more common complica- hypodermic needle or smaller. An 18-gauge hypodermic needle
tions. In hair transplantation, as in many other facets of life, it simply produces too much vascular damage per incision for
is easier to stay out of trouble than to get out of trouble!
the necessary number of incisions per cm2.
ADDENDUM
In other words, 40 incisions the size of an 18-gauge
Since writing the above contribution, Seager has written an
excellent article outlining other methods of increasing hair yield needle site will cause MUCH more vascular
with FUT but, more specifically, if one is attempting dense embarrassment than would 40 incisions the size of a
packing (35 to 40 or more FUs/cm2) and megasessions ap- 19-gauge needle in the same 1 cm2 area (Fig. 12B
proaching 3000 or more FUs per session. His suggestions for Addendum-1). This increased vascular damage, with
increasing hair yield in such procedures are also valid for less 18-gauge needles, is what in practice makes the
densely packed and smaller FUT sessions, but strict adherence difference between success and failure of attempts at
to them would probably be less critical. The following is ex- dense packing, and what invalidates most of the
cerpted from that article (1): previous trials demonstrating poor survival after dense
It is seldom that more than 3000 grafts are packing. The author favors the ‘‘stick-and-place’’
transplanted in one session. The donor scalp of average method of planting. With this method, the needle used
density rarely yields more than an average of 100 FUs/ to make the recipient site is first used as a dilator; and
cm2, and removal of more than 30 cm2 of donor area then, as the needle is being withdrawn, it is used as a
can be problematic. One tries to keep the anterior ends shoehorn to help guide the graft into the minute
of the donor incision posterior to the superficial recipient tunnel.
temporal arteries, which in most patients limits the
donor strip to 28 cm in length. If one tries to keep the The author believes that, in the majority of patients, it is
average donor strip width to less than 1.2 cm, one is technically impossible to plant large numbers of 2-haired and
412 Chapter 12
Staff Recruitment and Training

Many technicians whose manual dexterity skills are
good enough to plant minigrafts may never be able to
successfully densely pack FUs. Recruiting staff with
the right qualities is difficult and time consuming.
Long probationary periods are mandatory. A technician
may seem talented at first, and may show steady
improvement in the beginning months. All too often,
however, after a 3-month or 4-month period, progress
plateaus, and it gradually becomes obvious that this
technician will never be able to densely pack follicular
unit micrografts expertly.
Technical expertise is not the only quality required. The
mental and physical fortitude to concentrate immensely on a
repetitive, tedious, task, and to be able to emotionally tolerate
rigorous, critical ongoing quality control are other rare qualities
Figure 12B-A1 The difference in diameters of 19-gauge and a good technician must possess.
18-gauge needles and the resulting difference in the size of recipient Additionally, the successful technician must have a person-
tunnels. ality suitable to working closely, for long hours, with his or her
teammates in a harmonious and friction-free way.
Staff selection and training are the most difficult and
expensive components of the whole enterprise.
3-haired FU grafts of hair with average shaft diameter greater
than 70 ␮ into 19-gauge hypodermic needle sites, as closely Prolonged Duration of Densely Packed
as it is routinely done in the author’s practice, without the use Megasessions
of stick-and-place planting (Fig. 12B Addendum-2).
One must also be prepared to accept that, even with
Knowledge alone of the two previously described highly trained and efficient staff…
crucial factors (use of 19-gauge needles combined with
stick and place) does not give a hair transplant facility …it usually takes twice as long to pack the same number
the capacity to carry out successful dense packing of of grafts to a density of 35 to 40 FUs/cm2 as it does to place
grafts. Implementation of theory into practice is the grafts less densely (say 20 to 25 FUs/cm2) into premade
extremely difficult. Exceptional natural talent and recipient sites.
around 18 months of constant tutored practice are Because of this inherently slower planting technique,
required before the long learning curve gets mastered, and with the greater number of grafts required, the
and staff members become expert at these techniques. surgery time of these sessions can be extremely
prolonged.
Difficulties Associated with More Conventional

Follicular Unit Transplants
These include the need for binocular stereoscopic
microscope dissection, skillful atraumatic graft
planting, and, above all, the need to keep the grafts
completely moist. The latter is by far the most
important factor influencing the success of FU
transplantation. Partial drying of grafts is the most
common reason why so many practitioners are unable
to get good growth from FU transplantation, despite
otherwise excellent technique. I strongly believe that
these grafts must remain totally immersed in saline
solution rather than simply sitting atop a moist pad, if
high hair growth rates are to be realized.’’
(These comments on FUT in general have been made earlier
in this chapter and are repeated here because of their probable
major importance now, and their increasing importance as the
Figure 12B-A2 Different densities of graft placement with use FU density increases and the number of FUs/session steadily
of the stick and place method. From the right square to the left increases, making the time out of body longer and longer.
square, the are 45, 40, and 35 grafts/cm2. [WU]).
Difficulties Specific to Large Prolonged

Megasessions
Practical Problems Related to Staff
In addition to the extra recruitment and training, there
is the problem of staffing the clinic for the prolonged
hours that the longer sessions take. Aside from
overcoming the staff’s dislike of working long hours,
day after day, planting for many on a daily basis can
and does lead to physical ailments, such as ‘‘repetitive
strain syndrome.’’ To combat this, close attention must
be paid to ergonomics. For instance, it is important
that planters rest either their elbows or forearms on a
firm, supporting surface while planting with wrist and
finger movements.
If the planters have to support the entire weight of
their arms throughout their planting, they often
develop muscle strains in their neck, shoulders, and
forearms. Older and slightly built staff who have been
working at this for years seem to be especially prone
to such problems. The planting staff must also rotate
duties; that is, after a certain interval of planting, they
should do some other type of work, such as cutting
grafts or administrative work, before returning to their
graft planting. They must have frequent relaxation
breaks; and they must do regular stretching exercises
at least every hour during their planting and cutting of
grafts. Figure 12B-A3 Planning from back to front allows previously
planted grafts to be gently held in place with gauze.
Bleeding and Popping
Bleeding and popping, which are tolerable nuisances in
small or intermediate-sized sessions, can cause almost
approach to popping is to reduce the density of the
insurmountable difficulty in a large megasession.
planting (i.e., to space the grafts further apart). A third
Advising patients not to do any vigorous workouts for method of reducing popping is to plant from the back
1 week before surgery can greatly help reduce of the recipient area to the front. This makes it easier
bleeding. We also give each patient an injection of to hold the previously planted grafts in place with
vitamin K as early as possible on the morning of gentle pressure while the next recipient site is created
surgery, or, better still, the day before surgery, if (Fig. 12B Addendum-3). If one attempts to hold down
possible. We try to avoid infiltrating lidocaine directly previously planted grafts while planting from front to
into the operative field. It is a vasodilator, and back, the fingers obstruct proper needle placement.
therefore increases bleeding because the half-life of Planting from back to front also prevents the skin
lidocaine is longer than the half-life of adrenaline. We resistance forces from acting in a direction that would
therefore use supraorbital and supratrochlear nerve displace the previously placed grafts (Figs. 12B.
blocks and a ring block and/or field block. We Addendum-4 and 12B Addendum-5).
infiltrate the recipient area with either a 1:100,000 or
1:50,000 adrenaline saline solution. If we use a 1: Dehydration and Hypoglycemia
50,000 adrenaline solution, we do not infiltrate the Without attention to nutrition and hydration, many
entire recipient area at once. Instead we infiltrate a patients feel weak and faint toward the end of the day.
small area the size of a quarter or a silver dollar before Dehydration and hypoglycemia can be avoided by
that area is planted, while a similar area that has encouraging the patient to drink large amounts of
already been infiltrated is planted. either fruit juice or pop, and by making sure that they
Popping can also be very frustrating and can prolong have ample meals, including breakfast, midmorning
surgery. Popping, of course, refers to previously snack, lunch, and, when applicable, an early supper.
transplanted grafts ‘‘popping’’ out of the skin during
the transplantation of a new graft. If the patient’s skin Preventing of Deep Vein Thrombosis
characteristics lead to popping, we try varying the If patients have spent a long time traveling to have
recipient site size or trimming the grafts a little surgery, that is, more than a 5-hour drive or flight
narrower or not trimming them as much. Another within a day of their hair transplant, one should bear in
414 Chapter 12
Figure 12B-A4 In planting from front to back, skin forces tend to displace the graft when the needle is inserted behind it.
mind the potential for deep vein thrombosis. This is quoted maximum amounts allowable were assessed on
especially so if there is a prior history of deep vein the basis of surgeries of shorter duration. With the
thrombosis, or if the patient has other risk factors. The short half-life of lidocaine, most of the lidocaine that
patient should ambulate, moving them around the was given earlier on in the 12-hour surgery would be
office at mealtimes, and, possibly, additionally in metabolized before lidocaine administered toward the
between meals. At-risk patients should also wear end of these lengthy surgeries would be added to
elastic support stockings and should exercise their legs blood levels.
between walks. Such patients should be advised not to Throughout the planting of the hair transplant, the
fly in and out on the same day as the surgery. patient usually lies back at approximately 45 degrees
in a dental chair, putting pressure on the donor area.
Lidocaine Toxicity When the local anesthesia in the donor area wears off,
Larger and more prolonged sessions require larger total these patients usually complain that the back of the
doses of lidocaine. One has to ensure that the total head is painful as they lie on it. Re-anesthetizing them
dose of lidocaine does not mount up to what could with lidocaine is an easy and quick fix, but
become toxic levels. However, it probably does not tachyphylaxis occurs, and they need more and more
matter very much if slightly greater than the frequent infiltration into the donor area. This can
‘‘maximum allowable amount of lidocaine’’ is given cause cumulatively enormous amounts of lidocaine to
throughout a 12-hour megasession period. The usually be used. It is better to try to put a wedge under the
Figure 12B-A5 In planting from back to front, there are fewer displacement forces on the graft when the angled needle is inserted in
front of the graft. Some forces push the graft against the back wall.
patient’s neck to keep the head propped up so that the sit up or stand. The etiology of this is unknown, but it
donor area does not bear the weight and pressure of seems to be related to volume depletion, excessive
their head against the backrest of the chair/operating administration of benzodiazepines and/or narcotics, and
table. If this is not possible, depending upon the increased vagal tone. It frequently occurs, however, in
amount of lidocaine used so far, and the projected the absence of one or more of these purported factors.
amount that may need to be used throughout the rest Prevention of nausea and vomiting with postural
of the session, it may be better to give a narcotic hypotension can be achieved by preventing the patients
analgesic rather than keep on using more and more from becoming volume depleted and ensuring adequate
lidocaine in this area. fluid intake. If the patient is reluctant to drink or is too
sedated to readily drink, intravenous fluids such as
Orthostatic Hypotension, Nausea, and Vomiting normal saline solution should be administered. It is
Lastly, toward the end of large megasessions, some important to minimize medications/drugs as much as
patients tend to develop postoperative orthostatic possible. The more benzodiazepines and narcotics
hypotension, getting nauseous and vomiting when they patients have, the more likely they are to get
416 Chapter 12
orthostatic hypotension and nausea at the end of a approach is entirely safe in their offices, both for the follicles
prolonged hair transplant. Patients should also be and the patients. Nevertheless, the trend toward larger and larger
mobilized actively toward the end of their surgery. In numbers of FU/sessions, and more and more ‘‘dense packing’’
other words, rather than allow them to remain of FUs by a growing group of physicians (generally not includ-
immobile and almost horizontal for 8, 10, or 12 hours, ing those who, in the late 1990s, tried and then abandoned
and then at the end of the procedure suddenly have megasessions of 3000 or more FUs/session) is particularly trou-
them stand erect, it is better to make sure they get up bling to me. Aside from technical difficulties, there is also the
and walk around at various time intervals, such as question of blood supply. Three thousand FUs densely packed
when they have their snacks, juices, and so forth. into a frontal area, for example, produce 15 feet of incisions in
an area approximately the size of the average man’s palm if
Also, during the last hour or so of the surgery, the
the recipient sites are 1.5 mm long; 10 feet if all the recipient
patient should sit forward with both feet on the floor
sites are made by a 19-gauge needle and are approximately 1
while the planters, who will need to stand, finish their
mm long (see Fig. 22C-14a). Fifty FUs/cm2 require 7.5 cm, or
work.
3 inches, of incisions in an area that is only 1 cm ⳯ 1 cm if
the recipient sites are 1.5 mm long; and 2 inches of incisions
Editor’s Comment if they are 1 mm long. Now, some practitioners are advocating
Seager’s initial attraction to the ‘‘one-pass’’ technique was his even more FUs per session and even denser packing of FUs.
strong suspicion that better growth could be obtained by plant- On the one hand, most people would expect that such a degree
ing, for example, 100 grafts into a virgin area once (provided of laceration of a recipient site would lead to decreased hair
the vascularity was not impaired) than by planting 50 grafts in survival. On the other hand, we are asked to believe counterin-
the same size area in an initial session and then, later, a second tuitively that all, or virtually all, of the hairs that are transplanted
50 grafts during the second session into the same area. This into such an area will survive. This claim is based on a few
theory, based on the concept that ‘‘one-pass’’ results in less studies, a few patients, a few areas surrounded by intact skin,
vascular damage than two passes of half size each is, in my and a few highly skilled technicians in an office where they are
opinion, very suspect. Why should 100 cuts at one time be working under ideal conditions (see Chapter 9A). The debate
better than 50 scars and 50 cuts during a second session? Is a reminds me in some ways of the counterintuitive arguments
scar worse than a cut? In addition, when a vessel is occluded of those who believe that transection of follicles during graft
or cut, one would assume that collateral vessels would grow preparation may result in growth of more rather than fewer hairs
around the site of obstruction in the following weeks or months. (see Chapter 12C). Arguments that offend common sense are
If this is so, vascular supply would be better for the second difficult for me to accept, although they may possibly be correct.
session of half of the grafts than if they had instead all been That is why, in my office, we go to extraordinary lengths to
inserted in one pass. Alternatively, fibrosis from a first session avoid follicle transection and why we do not make 10 to 15
might result in decreased blood supply, or there might be other feet of incisions in a frontal area. It is ironic that many of those
factors that could cause decreased FU survival rates. Studies who vigorously reject the counterintuitive position of follicle
are under way to see what happens to this concept when it is transectors are the leaders of the group who vigorously advocate
put into practice. Until the theory is proved to be true, however, the counterintuitive proposition of more and more grafts per
the inherent technical demands and potential pitfalls of the one- session, with FUs closer and closer together. We must all re-
pass approach that Seager lists earlier suggest to me that it is member that what is most important is not how many hairs we
better to do two sessions of 20 or 25 FUs/cm2, instead of one transplant but how many hairs grow.
session of 40 or 50 FUs/cm2. Mayer’s studies on the apparently So that fairness is preserved, Seager’s comments on my con-
negative effect on hair survival caused by increasing FU densi- cerns follow. I am particularly empathetic to his contention that
ties (see Chapters 9A and 23I), give added support to my posi- although most hair restoration surgeons may not be able to
tion. Seager’s comments make it clear that everyone involved produce his results, expert and experienced ones could learn to
must be so psychologically suitable, as well as so well trained do that if they carefully followed his protocols. It parallels my
and rested, that their actions are close to perfect. This begs the opinion that although the ‘‘average’’ hair restoration surgeon
question as to whether it is in fact possible to consistently pro- will not get satisfactory results with slot and round grafts, ‘‘a
duce good results with FU densities of 40 to 50/cm2. Many relatively few, highly skilled, and dedicated’’ practitioners
physicians who were enthusiastic about megasessions of 3000 could do so with enough effort to learn the technique and its
or more densely packed FUs have all but abandoned them—and demands (see Editor’s Comment in Chapter 12D). Nevertheless,
this lends weight to my fears. Is it worthwhile subjecting the after reading both of our opinions, readers must decide which
FUs to increased danger to save the patient one trip? If Seager’s way they would choose to undergo transplantation with FUs if
theory of lower survival in second sessions is not true, one they were the patient, and then proceed accordingly. (WU)
could also expect to get better density in two passes, because
a larger total of grafts could be transplanted in the two sessions.
Seager’s Response to the Addendum and to Walter
It is perfectly understandable that some patients may prefer
one session instead of two, despite the lengthy treatment time
Unger’s Editor’s Comments
and the noted possible side effects of megasessions with dense The ‘‘Addendum’’ quotes verbatim all of my candidly dis-
packing. What is less obvious to me is what the day-to-day cussed difficulties with the one-pass technique but mentions
follicular cost of doing this may be, as well as how close and none of the advantages discussed in the original article. Dr.
how frequently one is coming to severe patient distress in the Unger has suggested that the readers review that article, but it
pursuit of this goal. Seager and others are confident that this is worthwhile emphasizing that a fair assessment of the pros
Figure 12B-R1 (a, b, and c), Photographs taken before and after one session of one-pass technique.
418 Chapter 12
and cons of megasessions and dense packing is not possible week. During this time, I cannot recall any patient having been
without, in fact, doing that. significantly distressed by my one-pass technique megases-
In his editor’s comment Dr. Unger also states, ‘‘…when a sions. During the first 3 of the more than 6 years we have been
vessel is occluded or cut, one would assume that collateral ves- using this method, there were no severely distressed patients,
sels would grow…’’ It is true that neither hypothesis has yet but there were quite a number who experienced moderate dis-
been scientifically tested . My hypothesis is that the impairment tress. It was during these initial years that I had to evaluate why
of the circulation is more likely due to fibrosis than to direct these patients were becoming distressed and to learn how to
vascular damage. The growth of collateral vessels may be a prevent the causes. It was during this time that I developed the
partial compensation but will not return the circulation to its protocols described earlier. With these protocols, virtually every
original health. patient now leaves smiling and feeling grateful. (DS)
Dr. Unger then goes on to say, ‘‘…Until the theory is proved
to be true, however, the inherent technical demands and poten-
tial pitfalls…suggest it is better to do in two sessions…what
can be done in one session…Is it worthwhile subjecting the
12C. Micro-Minigrafting: The
FUs to increased danger…?’’ In my opinion, there is no in- Substance and Theory for Its
creased danger to FU survival, provided that one adheres to the Use
precautions, stipulations, and protocols I describe. In fact, I can
assure the reader that, in my practice, hair survival when 40 William H. Reed
FUs/cm2 (i.e., approximately 90 hairs/cm2) are planted is as
good as, or better than, the hair survival my critics obtain when Since the early 1980s, there has been increasing velocity toward
they plant one session of minigrafts. However, I do agree with smaller grafts in hair transplanting. In 1996, the International
Dr. Unger that ‘‘the average clinic’’ will not be able to duplicate Society for Hair Restoration Surgeons (ISHRS) scientific as-
my results. The one-pass technique, like the Juri flap or the sembly showed small grafts to have a significant although rela-
Frechet triple flap, is not for the average practitioner. They tively disorganized presence (1–9). Within 4 years, however,
remain good procedures when confined to the hands of a rela- proponents of grafts composed exclusively of single follicular
tively few highly skilled and dedicated experts. units (FUs) were advocating that FUs could accomplish all of
Finally, Dr. Unger’s doubt as to ‘‘…how frequently and how the tasks of hair transplantation and, most questionably, the
close is one coming to severe patient distress in the pursuit of achievement of hair density and volume. Furthermore, they
this goal…’’ must be addressed. For more than 3 years, we specified that FUs must be obtained from elliptical excision
have been performing an average of 10 such megasessions per and microscopic dissection (EEMD) for the technique to be
Figure 12B-R2 (a and b), Photographs taken before and after one session of one-pass technique.
validly called follicular unit transplantation (FUT) (10). Has ● The most efficient and, therefore, probably the most eco-
this velocity, undeniably overdue in replacing suboptimal uses nomical surgical technique
of the 4-mm plug, overshot the optimal role of the transplanted
single FU? Is there no role for combining FUs to make a mini-
graft as advocated by micro-minigrafting (MM) proponents? Is
With Reference to ‘‘Goals to Be Achieved’’ in
evidence for the stereomicroscope and elliptical excision so Order of Reversed Importance
compelling that their superiority eliminates the use of mul- 1. Which surgical technique is more efficient and eco-
tibladed harvest (MBH) and forms of magnification other than nomical? The superior surgical technique is MM. On
the dissecting microscope? Have the theoretical concerns re- a per hair transplanted basis, MM has the following
garding the use of a smaller graft been acknowledged and evalu- requisites:
ated? What might these concerns be regarding FUT as the ‘‘one-
answer-fits-all-needs’’ approach to hair transplantation and its ● Fewer technician hours are needed with loupes vs.
associated surgical technique? These are the questions to be the microscope of FUT. My current impression is
answered while addressing the considerations that argue for that, ultimately, technicians will want to use the
continued use of grafts composed of more than one FU. stereoscopic dissecting microscope because it is
It should be helpful in interpreting of this chapter to know more comfortable for them, but an adequate level
that I do not favor exclusive use of either MM or FUT. At the of proficiency and speed is reached earlier if tech-
time of writing, harvesting of approximately 15% of the donor nicians learn with loupes and are slowly intro-
tissue from a typical case in my practice is performed by means duced to dissecting MM strips or to slivering an
of FUT (i.e., EEMD), whereas MM is employed for the rest of FUT ellipse with the microscope.
the donor tissue. I will be happy to embrace FUT more com- ● Fewer technician hours are necessary because the
pletely if and when I think my patients will benefit. physician’s use of the multibladed knife is quicker
to define the transverse plane of dissection relative
to the dissection of the ellipse with FUT.
MICRO-MINIGRAFTING
● Fewer incisions of donor tissue and recipient tissue
For clarity, the following definition of micro-minigrafting is are required per hair transplanted (i.e., some FUs
used: are grouped to make the minigrafts) and, therefore,
● Fewer graft sites require graft implantation by the
● Multibladed knife harvest is performed. technicians.
● Five 2-mm strips are obtained.
● Loupe dissection with 4x to 5x loupes serves as the stan-
dard of comparison for whatever optical enhancement I believe that few, if any, transplant surgeons disagree with
the technician would like to use (dissecting microscope, the statement that MM is an easier procedure to offer patients
loupes, naked eye). and is less expensive (all other factors equal) on a per-hair basis
● ‘‘Cherry picking’’ of the easily dissected FU for mi- compared with FUT.
crografts is employed (and is also used for FUs with It is legal in some parts of the United States and in some other
three or more hairs if focal maximum density is desired). countries to have two technicians rather than one physician and
● The more closely approximated FUs are doubled up to one technician, carry out the ‘‘stick-and-place’’ method of FUT
produce three-hair to five-hair minigrafts. Higher num- (14) (see also Chapter 12B) In those instances, the stick-and-
bers of hairs per graft can occasionally be indicated. place method can be priced competitively because it requires
● Micrografts are placed into a 1-mm slit made with an little involvement on the part of the physician for the majority
18-gauge, hollow-core needle. Minigrafts are generally of the procedure.
placed into a 2-mm to 3-mm slit made by a Beaver mini- 2. Regarding reproducibility, what is the superior
ES blade, which is honed to fit the donor density and surgical technique? The superior surgical technique
the size of the minigrafts desired. is MM. The reasons are the following:
● Follicles within ‘‘chubbier’’ grafts are considered
FOLLICULAR UNIT TRANSPLANTATION to be safer (15–18). Of course, minigrafts are
chubbier than FU grafts. This fact contributes to
● Employs an elliptical excision of donor tissue with a
MM’s shorter learning curve because the grafts
single or double-bladed knife.
are theoretically more forgiving of technician graft
● A dissecting microscope (6x to 10x) is mandatory.
production technique and subsequent storage (hy-
● All grafts are composed of FUs that average 1.7 to 2.5
dration) and manipulation than the grafts of FUT.
hairs/graft (11).
Studies have shown that FU grafts are more fragile
and are associated with lower growth rates (19,20).
In Evaluating Surgical Techniques, What Goals Are
● The theoretical basis of chubbier grafts being more
We Trying to Achieve? resilient is probably related to the graft’s surface
● Graft growth that is the most aesthetically pleasing area/volume ratio. The graph shown in Fig. 12C-
● The optimal use of donor and recipient areas 1 shows the linear relationship of the surface area
● A surgical technique that is most capable of being relia- of a graft to its increasing radius and the geometric
bly reproduced day in and day out relative to other surgi- increase of the graft’s volume to the increasing
cal options radius. The stem cells of larger grafts may benefit
420 Chapter 12
from geometric increases of insulation from tissue having a more experienced technician sliver the
volume as the radius of the graft becomes larger. ellipse into pieces of tissue the width of one to two
● Even if the number of surviving hairs is satisfac- FUs, which the less experienced technician divides
tory, the hairs in FU grafts and micrografts are further into FU grafts. The problem then becomes
almost certainly more vulnerable to miniaturized employing and retaining the sliverer as well ensur-
growth because of their unfavorable surface area/ ing day-to-day high quality of work. Additional
volume. My suspicion that miniaturization is a reasons for the longer learning curve are that the
likely outcome of less-than-lethal follicle damage dissecting microscope requires a modification of
was reinforced by a paper delivered by William direct hand-eye co-ordination, has a higher magni-
Parsley at the live workshop of the joint meeting fication with associated motor skill ramifications,
of the World Hair Society and the International and has a restricted breadth of visual field.
Society for Hair Transplant Surgery (ISHRS) in ● More technicians are needed with FUT because
Orlando in February 2002. In brief, he reported more technician hours are required per trans-
that ‘‘skinny’’ FUs produced skinnier hairs, (as planted hair. Most hair transplant surgeons agree
well as fewer hairs). Because a decrease in hair- that at least 50% to 100% more technician hours
shaft diameter of as little as 0.01 mm decreases are required for FUT (12,13,22,23).
hair volume by approximately 36% (21), I am very ● Even if all the preceding arguments are deemed
uncomfortable with FU grafts being used for hair to be unproven speculations by some critics, cer-
volume/density. All physicians remember from tainly it can be agreed that the fewer dissecting
their training the increased vulnerability of small incisions there are, the less opportunity there is
children to environmental factors. They become for accidental follicle injury—and MM involves
hypothermic in response to exposure, hyperther- fewer incisions.
mic to bundling, and dehydrate much more easily
Therefore, on any randomly selected day, from the
than adults because of their unfavorable surface
physician’s perspective, a good outcome involves the
area-to-volume ratio (see also the discussion on
following:
the optimal use of donor tissue later).
● There is a longer learning curve for each technician ● It is inversely proportional to the length of the
to reach adequate proficiency with FUT. A major learning curve of the technicians.
reason for this is that the technician is typically ● It is inversely proportional to the number of techni-
reducing a 1-cm to 1.5-cm wide strip to individual cians. Technician turnover is a fact of life. The
FUs with FUT. In MM, the technician performs higher the number of technicians required by a
the less complex task of dissecting a 2-mm wide surgical procedure, the less likely that all will be
strip. This problem with FUT can be overcome by at the top of their learning curve and/or proficiency
Figure 12C-1 The straight-line slope of the surface area of a graft as its size increases in contrast to the exponentially shaped increase
of its volume.
on any random day. This is especially true if the Hair Follicle Transection Rates
larger number of required technicians has to pur-
It has frequently been said that FUT has lower transection rates,
sue a longer learning curve to proficiency.
at least when performed by experienced technicians
● It is substantially affected by the technique’s al-
(15,23,25,27,28). Limmer believes that the surgeon’s FUT tran-
lowing the simplest, most consistent, most effec-
section rate can be 3% in creating the ellipse (i.e., 1.5% transec-
tive quality control.
● It is more likely if the technique allows the physi- tion for each of the two incised planes of the ellipse) and the
cian to personally maintain the consistency of the subsequent technician transection rate to produce FU grafts
procedure’s quality, by regularly performing strip from the ellipse can be 3% to 5% (27). He opines that mul-
harvesting. tibladed harvest transection rates to obtain three 3-mm strips
are in the range of 8% to 15%, averaging 12%. Technicians
then produce grafts from these strips with a 3% to 5% transec-
If just one surgical technique has to be chosen, the superior
tion rate. Table 12C-1 represents data from the ongoing quality
technique based on these factors is MM vs. FUT. I see no advan-
control routinely done in my practice. The results are compara-
tage, however, to forcing physicians to choose between FUT
ble with my other studies that address follicle transection
and MM. A full-time hair transplant practice should, in my
(30,31) and fail to show significant FUT superiority.
opinion, refine all elements of both techniques.
Our data show a higher transection rate with FUT than that
3. Which technique (FUT vs. MM) results in the opti- which Limmer and Bernstein implied as being relatively easily
mal use of donor tissue and treatment of the recipi- attained. It would appear from our data that the learning curve
ent area? for FUT is a long one, even for very experienced technicians.
Most of our technicians, although very experienced with MM,
As is discussed further in this section, FUT proponents allege currently produce levels of transection during FUT that are only
superior clinical results with FUT vs. MM because of the lower competitive with MM if expert slivering is first done for them.
transection rate of the hair follicle, the integrity of the FU, the Even if Limmer’s data are more representative of practices-
number of multihair FU grafts obtainable from the donor area,
at-large than mine, the superiority of FUT’s transection rate vs.
and the total number of hairs or grafts produced from an area
MM’s rate appears to be modest; in the range of 5%. Addition-
of donor tissue. Subjective assessments of hair volume have
ally, it is well documented that transected follicles grow at a
been made (24,25), but valid objective studies of clinical out-
rate that is comparable with, and sometimes superior to, that of
comes favoring FUT (vs. MM) do not exist at the present time.
intact follicles (30,36,37–40), although the hairs of transected
follicles are probably miniaturized to an undefined degree (see
Chapter 9). One should also recall that a significant percentage
THE MOST OPTIMAL USE OF THE DONOR
of transection is through the follicular infundibulum. The infun-
TISSUE dibulum has nothing to do with the follicle’s regeneration, and,
In evaluating the most optimal use of donor tissue, the following in some centers, is intentionally transected to ‘‘de-epithelial-
parameters should be considered: ize’’ the micrograft before implantation. ‘‘Clinically signifi-
cant’’ transections are accordingly even smaller than the per-
centage recorded for either technique.
In Vitro Factors I would conclude from the preponderance of the transection
These were ranked in the order of importance by a consensus data that technicians become proficient in minimizing graft
of 10 leading hair transplant surgeons (26). damage via transection quite quickly with MM and with FUT
if proficient slivering is done for them. Further efforts are re-
● Dehydration of grafts warded with increased speeds and improved finesse of the dis-
● Rough handling or too forceful insertion of grafts section of the ellipse rather than in significantly diminished
● Hair left on the table (i.e., transected hairs that are not injury via improvements in transection rates. Such ongoing ef-
transplanted) forts and experience, however, do produce improvement with
● Transection of follicles other in vitro parameters that do markedly improve clinical
Note the relatively low level of importance these physicians results. It is these other parameters as well as improved judg-
placed on FU physical integrity. ment in graft selection during placement that makes technician
experience so valuable (Table 12C-1).
Studies do exist, and opinions have been expressed regarding
Other Considerations the fact that small grafts have lower growth rates than larger
● Maximizing the numbers of grafts or hairs produced for grafts (17–19,30–33). The same is true regarding dehydration
transplantation (34) and crushing injury (35), such as can occur during implan-
● Maximizing multihair FU grafts to obtain maximum tation, while the graft is out of body and during in vitro tempera-
density ture of grafts (57). All of these problems may be worse during
● Sacrificing invisible telogen follicles by creating an un- FUT, with its propensity to have prolonged in vitro times for
necessarily small graft its exclusive production of small grafts. To repeat, my opinion
● Features of the stereoscopic dissecting microscope is that the technician’s finesse in these areas and improved judg-
● The fundamental question: What are we trying to trans- ment in graft selection, rather than the minimal improvement
plant anyway? possible with lowering transection rates, brings the improve-
422 Chapter 12
Table 12C–1 Transection Data, La Jolla Hair Restoration
Technician No. 1b 2 3 4 5 Avg. Samplesc
Total years of experience 8 2 1 8 6

Prior microscope experience ⬎6 yrs ⬍3 mo ⬍3 mo ⬍6 mo NA
TRANSECTION RATEa
Minigrafts (multi strips and loupes) 9% 12% 12% 11% 12% 11% 228
Minigrafts (multi strips and microscope) 8% 9% 9% 14
Minigrafts (slivers and microscope) 10% 16% 12% 12% – 13% 49
Micrografts (multi strips and loupes) 16% 15% 14% 16% – 16% 216
Micrografts (multistrips and microscope) 8% 11% 8% 9% 17
Micrografts (FUs) (slivers and microscope) 11% 10% 10% 10% 19
Technician No. 1 both slivered and cut FUs. The 6% 6% 23
rest of the technicians cut FUs from slivers
created by Technician No. 1. Technician No. 1
results are listed separately
FUs ⫽ Follicular units; FUT ⫽ follicular unit transplantation; MM ⫽ micro-minigrafting.
a
The transection rate for multi-blade harvest (MBH) of 82 almost consecutive cases was 9% of five 2-mm strips that were produced. This percentage is com-
parable with Limmer’s data: 1.5% (1.5% per cut of surface X; six cut surfaces to produce five strips ⫽ 9%.) The refuse was subjectively examined after graft
production, and follicle debris was found to be “very minimal.” A sample consists of 25 randomly selected grafts for a particular technician and a particular
graft category. As mentioned later, microscopes have only recently been used in my practice; hence, the small sample sizes for microscopes. Assessment con-
tinues as part of the routine quality control process.
b
This remarkable lady is the “sliverer” in my practice, who has, on occasion, produced FU grafts from elliptical incision and microscopic dissection (EEMD)
as quickly as she produced the micro/minigrafts from the same procedure for the same case. Her 6% rate compares with the lower rates of Limmer’s experi-
ence and is additional proof that his numbers are possible.
c
With the exception of Technician No.1, the transection rates reflect the “sliver-to-FU graft” phase of FUT for that particular technician.
d
The MM transection rate assumes a case consisting of equal numbers of minigrafts and—micrografts and picks the better form of magnification for that par-
ticular technician
ment in clinical results seen when a technician has gained expe- FU integrity. Bernstein and Rassman, two of the most prolific
rience. researchers in refining FUT, have carried out two studies com-
The integrity of the FU is preserved by FUT, and proponents paring MM with FUT graft production (25,28). I have also
of this technique assume that FU integrity is important to growth performed a study comparing MM with FUT (31).
of the transplanted follicle (25,28). In fact, however, a variety of The first study by Bernstein (28) found that the use of a 10x
studies assessing this parameter do not support this contention microscope to dissect 3-mm strips produced 17% more hair and
(31–37,41) (see also Chapter 9). In particular, samples of 30x 10% more grafts compared with dissection with use of 2x
photographs from the Reed study (31) compared the area trans- loupes. Unfortunately, the study has several design issues that
planted with the alleged ‘‘split FU’’ of MM and the intact FU limit its usefulness in clarifying the matter of the superior
grafts of FUT. The study randomly sampled more than 50% method of graft production. In my opinion, the only conclusion
of the grafted areas. A difference in quality of growth is not that can be drawn from this study is that in one practice that
discernible. Other findings of this study are discussed later. strongly favors the use of FUT, the 10x microscope was be-
It is worth remembering that FUT was originally based on lieved, when assessed in a nonblinded manner, to produce 17%
the importance and perceived superiority of FUT regarding more hairs and 10% more grafts from the dissection of 3-mm
transection rates and the assumed importance of FU integrity. strips compared with 3-mm strips dissected by the same techni-
Now, years later, consensus has relegated these parameters to cians using 2x loupes and backlighting. The transected follicle
relatively low rankings on the list of concerns (26). With its fragments were judged to be capable or not capable of growing
longer in vitro time, longer learning curve, and larger number a transplanted hair. When judged capable, a fragment was
of technicians required, FUT is at risk of posing increased risk counted as an intact follicle. Therefore, no distinction was made
to the hair follicle than MM as far as these other parameters between such fragments and intact follicles in the total hair
are concerned. Additionally, this alleged FUT superiority does count. Fragments were judged capable of growing a hair on a
not address the real interest; that is, clinical results assessed by person-to-person undefined basis and in a nonblinded manner.
the transplanted hair survival rate and, more importantly, the Transection rates and their contribution to the total hair count
transplanted hair volume. Transection and FU integrity do not were not assessed. Thus, the microscope could have produced
necessarily correlate with hair growth or hair volume because its superior results by creating an increased transection rate
they do not take into account the other variables mentioned (i.e., one transected follicle that produces two fragments counts
earlier. as two hairs if each fragment is judged capable). That such a
The claims made for FUT of higher numbers of hairs and conclusion cannot be refuted shows the weakness in the study’s
grafts available for transplanting come a step closer to clinical design, a weakness that results from the lack of a clear definition
relevance compared with its concern regarding transection and of what ‘‘capable of growing a hair’’ means and from failure
to assess transection rates. What is capable of growing a hair I did a third study evaluating hair and graft quantities avail-
is, in turn, still being assessed by investigators years after these able for grafting (31). This study, however, also looked at actual
technicians were deciding this for us (see Chapter 9). clinical outcomes by assessing hair growth and hair volume. In
Even if the study had been clearer on those components, the a blinded, single-subject study, MM and FUT were compared.
lack of blinding at critical points in the study invalidates its Each technique produced exclusively FU grafts, (i.e., no mini-
data. Points in a study that require fine motor skills or subjective grafts were produced with the MM). The respective techniques
impressions exemplify situations in which blinding is manda- were performed by an advanced-level technician with more than
tory to obtain credible results. Moreover, even if the authors 6 years of experience. The technician for FUT was from another
were in complete control of their conscious and unconscious practice, where she had practiced FUT exclusively for several
wishes for a particular outcome, they were unable to speak for years. Therefore, each technician was motivated to perform op-
the other participants (presumably, their technicians) who also timally for the respective surgical technique in the areas of the
had an opportunity to inject their bias (consciously or uncon- study that could not be blinded. The grafts were placed in 1-
sciously) in qualifying and quantifying the data. mm slits made by a hollow-core no.18 needle, with a density
The second study by Bernstein and Rassman (25) offers of approximately 40 sites/cm2. The following parameters were
retrospective data comparing three surgical techniques: FUT, measured at 0, 4.5, 10, and 15 months, when indicated: total
MM, and vertical sectioning. Their data for MM is from 1996; number of FUs, total hair in grafts, percent of donor hair repre-
the data for FUT from 2000. The data are striking and suggest sented as graft hair, number of multihair FU grafts, number of
unequivocal FUT superiority relative to MM. Further assess- transplanted hairs growing, degree of miniaturization, total hair
ments of the study’s data and method, however, compel reserva- volume, and transection rates. The data are presented in Table
tions about the validity of the comparisons of the surgical tech- 12C-1 and Fig. 12C-2 and are discussed here.
niques. Suggestions that could improve the method of their MM It is important to emphasize that the MM results may have
technique, as well as other concerns about their method and been even stronger if the chubbier minigrafts had been used in
conclusions, are addressed in separate articles by Unger (43) the aforementioned study design. Minigraft use would have
and Reed (42). Suffice it to say that the data of Bernstein and taken advantage of the chubbier graft advantages discussed and
Rassman were presented in terms of FU graft yield and FU referenced earlier. Additionally, it may have allowed a lower
graft size comparison. These data (although not calculated in injury rate by allowing the ‘‘easily obtainable FUs’’ to become
their study) translate into a transection rate for MM of 71% (if the micrografts and the ‘‘tightly packed’’ FUs to be dense mini-
it is assumed, for the sake of simplicity, that the transection grafts.
rate for FUT is 0%). This transection rate for MM is far out of Because this study represents a single pair of advanced-level
line with other studies (27–30,31) and is incompletely exam- technicians working on a single patient, the conclusion, in my
ined in the study’s discussions and conclusions. opinion, should be: ‘‘Aside from the fact that FUT required
Figure 12C-2 (a), From the Reed follicular unit transplantation vs. micro-minigrafting (MM) study. A random sampling of one-hair
to four-hair micrografts after they have grown out, prepared with the MM technique (multibladed knife and loupe magnification). (b), From
the Reed follicular unit transplantation (FUT) vs. micro-minigrafting study. A random sampling of one-hair to four-hair FUs after they
have grown out, prepared with the FUT technique (single strip and microscopic dissection).
424 Chapter 12
50% more time than MM, neither MM nor FUT proved superior are at risk of being dissected away by the process of going
to the other when experienced technicians produce grafts con- from a chubby to a skinny graft. Such dissection occurs when
taining a single FU and the noted parameters were measured.’’ a minigraft is processed into an FU graft as well as when a
Even though some rather interesting differences exist between chubby FU graft is trimmed into a skinny FU graft, as is a
the two techniques, I think we are becoming aware of the ten- tendency of microscopic dissection.
dency in our literature to extrapolate too many generalizations Proponents of FUT believe that a study by Marritt (45,46)
from studies that are too ‘‘situation specific’’ to warrant such effectively puts this concern to rest. In this study, Marritt found
generalizations. Nevertheless, the data of this blinded study no evidence of telogen follicles in the trimmings of sample
stand in strong contrast to the nonblinded and/or retrospective cases from Dr. Bobby Limmer’s practice. However, a thought-
studies of Bernstein and Rassman, which allege substantial FUT ful, well-referenced article by Unger (48) raises doubts regard-
superiority. This study does not support their conclusions that ing the study’s method. Unger’s article is reprinted (with per-
FUT produces superior numbers of FU grafts, hairs or multihair mission) as Appendix A at the end of this discussion because
FU grafts compared with MM. What the data do support (by of important possibility of accidental discard of tissue that could
their lack of supporting either technique) is the integrated use contain 10% or more of the follicles in the donor strip that are
of the microscope and MBH to allow the individual hair trans- in the invisible exogen phase (see also later).
plantation practice, its physician and its technicians, maximum There are additional concerns about the study design and
choice to use any tool for graft production (FU grafts and/or subsequent data. One concern is the article’s failure to state
minigrafts) that is most suitable for their particular stage of clearly that the technicians’ behavior was not modified, for
proficiency. Such integrated use of the microscope has been instance, by having a bottle of formalin placed by their micro-
previously proposed by others including, Rose, Cole, Arnold scopes at the beginning of the procedure, with instructions to
and Shapiro (44). Knudsen has called for less stringent technical place all refuse into the bottles. This is unlikely to have modified
restrictions on the term FUT, noting that FUT is an anatomical the telogen considerations as described later, but it very well
approach to hair transplantation with which few disagree. His could have altered the follicle fragments that normally would
disagreement comes from the proposed, rigid dogma concern- be removed from the grafts with dissection. Accordingly, graft
ing surgical technique (59). Bernstein and others oppose this
transection rates for the dissected tissue would have been a very
view (60).
informative parameter to include with the study. Additionally,
in view of the technical complexities of FUT, other important
Maximizing Multihair Follicular Unit Grafts to facts about the technicians, such as years of experience, should
Obtain Maximum Density have been include before conclusions were made about FUT
in general.
With respect to more multihair grafts, Shapiro thinks he can
Further questions about the study’s method and conclusions
harvest larger numbers of such grafts with FUT and is in agree-
are raised by Headington’s article (47). This article, which gave
ment with Bernstein et al about their theoretical utility (9). The
data, however, are unclear that FUT is superior to MM in pro- birth to the FU concept, also addressed the morphology of the
ducing these multihair FU grafts and two studies have contradic- telogen follicle. To briefly summarize the article, if a follicle
tory data (23,25). Consequently, and in view of the usefulness in telogen is not identifiable by its hair in the ‘‘club hair’’
of multihair FU grafts, I have started looking at this as a parame- phase (i.e., the preliminary stage of telogen), it is unlikely to
ter for quality control. At present, with only eight cases for the be identified by the method described by the Marritt study (and
sample size, the MM multihair FU graft/FUT has only a mul- is not detected by the 10x dissecting microscope). Such a telo-
tihair FU graft ratio of 96% for one technician and 107% for gen follicle is unidentifiable because the random fragments of
another. Interestingly, the 107% rate is that of a less experienced tissue that compose the discarded trimmings of a microscopic
technician and is associated with a 100% increase in dissection dissection are very unlikely to include histological structures
time with use of FUT (vs. MM) and a 15% transection rate, that allow identification of the true resting stage of telogen, the
whereas the 96% is that of the most experienced technician, ‘‘telogen germinal unit’’ and the ‘‘follicular stele.’’. Even the
requiring only 50% more dissection time and associated with best efforts by Marritt to achieve the orientation of the discarded
a 6% transection rate. This would imply that, not surprisingly, tissue could not approach the benefit derived from the spatial
the multihair FU grafts are inversely proportional to transection relationships of a vertical paraffin section, and Headington
rates and directly proportional to technician experience. A deems such vertical sections inadequate. Additionally, only a
larger sample may confirm that a minimal superiority of mul- few sections, rather than serial sections, were taken through
tihair grafts may be seen in FUT when the transection rate is each block of tissue submitted in Marritt’s study (39). Further-
very low. more, special stains, specifically elastin stains, are probably
necessary to achieve adequate sensitivity in identifying the
Regarding the Loss of ‘‘Exogen’’ Follicles from the stele.
Donor Tissue Based on the Headington article, it is likely that a high per-
centage of telogen follicles are hairless. Additionally, the telo-
One issue of concern to many surgeons about FUT is the inher- gen resting state does not have hair fiber appreciably deeper
ent risk of over dissection the donor tissue during the exclusive than the entrance of the sebaceous duct into the follicle. To
production of FU grafts and the sacrifice of the exogen follicles quote from the Headington article:
(telogen follicles that have lost their hairs). Because telogen
follicles cannot be detected by the 10x dissecting microscope Telogen follicles in the club-hair stage can be microscopi-
unless they retain their hair shafts (47,48), it is feared that they cally recognized within the dermis below the level of the
Figure 12C-3 (a), Photomicrografts showing the follicular stele (arrow) that extends in telogen from the telogen germinal unit at the
level of the sebaceous duct into the subcutis. With anagen, the dermal papilla and sheath and adjacent epidermal matrix cells interact to
result in an explosion of mitotic activity as the papilla extends down the stele to its subcutaneous end-point in anagen. (b), In this photograph,
about 25 follicles are seen. If 10% to 20% of the follicles are in telogen at any given time, an additional two to five follicles are present
in this area but not seen. The ‘‘blank spots’’ are likely the areas that will be filled when telogen follicles are once again in anagen. That
telogen follicles are not visible without staining seems apparent.
sebaceous duct by the usual bulbous configuration of the ingly may sacrifice many of the hairless telogen follicles as
proximal end of the hair shaft and by loss of the inner they diverge from the other members of the FU.
root sheath. . . . Volumetric reduction of the outer sheath That a high percentage of telogen follicles are in exogen
is, however, incomplete with the formation of a club hair. phase—that is, they lack hair-without fibers in their infun-
After the club hair is lost, there is continued volumetric dibula—is suggested by the following points:
reduction of the outer sheath until the epithelial sac for-
merly containing the club hair has been eliminated. [Em- ● Empirically, there is a lack of club-hair papillae at the
phasis is the author’s.] Therefore, a true resting state of level of the sebaceous duct when strips are examined at
the follicle (i.e., telogen), is achieved when the last ves- the time of MBH. Not infrequently, miniaturized fibers
tige of the preexisting outer sheath below the sebaceous are seen with their papillae in the dermis, but these do
duct has disappeared. . . . The resting or end-stage telogen not represent the club-hair fiber of terminal follicles in
follicle is defined as the ‘‘telogen germinal unit’’ (see catagen or early telogen as is sometimes suggested. Ter-
Figs.12C-3a and b and 12C-4a and b). minal fibers in early telogen do not lose their diameter
as they rise to their final level of end-stage telogen.
It is interesting to speculate about the possibility that 10% ● Theoretically, there is little adhesiveness of the fiber to
to 20% of follicles that happen to be in exogen phase could be the infundibulum in end-stage telogen. As noted earlier,
unwittingly lost during the production of FU grafting, particu- the inner root sheath has disappeared. The outer root
larly if they are too skinny. As the discussion of hair follicle sheath has shrunk from a sac forming and interacting
anatomy in Headington’s article points out, this could be be- with the dermal papilla to a flat circular plane of epithe-
cause of the progressive divergence of follicles as they enter lial matrix cells (i.e., the telogen germinal unit). The
the deeper tissue planes from the epidermal orifice that would epidermal cells of the infundibulum add little additional
usually be shared with the other members of the FU (Fig. 12C- sheathing and, therefore, create minimal adhesion to the
5). There is increasing evidence that the lower two thirds of fiber as it passes through the infundibulum. This, in com-
the follicle, consisting of the papilla and dermal sheath, is the bination with the mechanical forces to which most scalp
area critical for follicular regeneration (49–50,58). I find it curi- hair is subjected by frequent brushing and washing, is
ous that the anatomical area defining the FU is actually above likely to dislodge the loosely connected fiber from the
or at the highest border of this most important part of the follicle. follicular infundibulum.
This physiological fact and the implications of it with regard
to follicle regeneration is extraordinarily important for hair Caution should be exercised in the use of unnecessarily small
transplantation; it may ultimately limit the significance of the grafts until the percentage of hairless telogen follicles—exogen
anatomical structure called the FU and its associated concepts as follicles—is quantified (see also the updated Addendum to this
they apply to hair transplantation. In brief, FUT graft dissection, discussion). This caution, in my opinion, should apply to the
which respects only the visible members of the FU, unknow- use of FU grafts to achieve density in areas where minigrafts
426 Chapter 12
Figure 12C-4 (a), A transverse section of a telogen germinal unit that sits on top of a follicular stele at the level of the sebaceous duct.
The dermal papilla (dp) and dermal sheath (ds) stem cells are labeled and await activation and interaction with the adjacent epidermis (ep).
(b), Activation of a telogen germinal unit and early anagen. (sg ⳱ sebaceous gland). Note the activated epidermal cells wrapping around
the margins of the activated, dark mesenchymal cells as they amplify the dermal papilla and begin to extend down the follicular stele.
Whether the dermal sheath is lined with stem cells in telogen, as is known to be the case in anagen, is central to the chubby/skinny graft
discussion.
could be employed. Of course, this also applies to the use of

skinny instead of chubby FU grafts.
In support of this disturbing theoretical consideration are the
studies that show the capacity of chubby grafts to grow numbers
of hairs in excess of the number of visible hairs as well as studies
showing superior hair counts with chubbier grafts (17–18,30). It
was partly with tongue in cheek that I proposed, in the open
forum of the ISHRS meeting in San Francisco in 1999, that the
society should support a ban on using FU grafts for density
production. Now, I am more genuinely concerned that we are
doing our patients a disservice by failing to acknowledge the
potential magnitude of follicular destruction and miniaturiza-
tion being created by FUT. This potential problem is one that
should be easily quantifiable. It seems reasonable to exercise
caution until such clarification is forthcoming.
In summary, reflection on Headington’s discussion has led
me to the following conclusions: (1) disoriented, fragmented
pieces of the hairless, resting telogen follicles (consisting of a
follicular stele and a telogen germinal unit), which are poten-
tially scattered throughout the refuse of the Limmer FUTs as-
sayed by Marritt are unlikely to be identified, much less quanti-
Figure 12C-5 A stylized photograph of horizontal cross-sec- fied, by the technique described. (2) An imprecise but
tions through a follicular unit (FU) showing the progressive significant percent of telogen follicles do not have hair in their
divergence of the unit’s follicles as they extend from the level infundibula and are therefore invisible to the 10x microscope.
of the bulge to the level of the anagen papilla in the subcutis. Therefore, (3) in general, there is likely to be a significant num-
At this lower level, any evidence of FU grouping has dis- ber of telogen follicles lost in the creation of smaller grafts.
appeared. This includes making small minigrafts from large minigrafts
and micrografts/FU grafts from minigrafts, as well as making ● Preservation of FU integrity is sufficiently important to
skinny FU grafts from chubby ones. accept the shortcomings of microscopic dissection.
It is conceivable that by going from the ‘‘too fat’’ graft of ● FUT is the superior surgical technique to achieve either
the 4-mm punch to the ‘‘too skinny’’ graft with FUT, we are of these goals when its performance is randomly sam-
naively repeating O’Tar Norwood’s lament about earlier days pled.
without microscopes, ‘‘It seems hard to understand how we
On the basis of the previous discussion, it is worthwhile remem-
managed to produce reasonable results. … I suspect that we
bering that sufficient data are lacking regarding either the im-
destroyed many, many hair follicles. … I think here is the great-
portance of these parameters in actually producing more hair
est tragedy of hair transplant surgery; namely, the quiet death
volume in the recipient area or the microscope’s superiority in
of many donor follicles in the transplant process (51).’’
achieving these parameters.
Are the Stereoscopic Dissecting Microscope and Other considerations for advocating FUT and the micro-
scope appear to be:
Ellipse the Right Tools for the Job?
● With FUT, physicians are able to leave the operating
Before the ISHRS meeting in 2000, the title I had for this section
room sooner to carry on the rest of their practice, espe-
was, What does a microscope used in hair transplantation have
cially when FUT is combined with the ‘‘stick-and-
in common with a Ferrari being driven on a city street? Answer:
place’’ method, which is legal in several of the United
Each is cool; each is sexy, but each is the wrong tool for the
States and in other countries. This approach requires the
job.
physician only to excise the donor tissue. Nonphysician
I had based this opinion on what I thought was a fair evalua-
health care providers can then close the donor area, pro-
tion of the dissecting microscope. I had used a Meiji stereo-
duce the grafts and recipient sites, and plant the grafts.
scopic dissecting microscope and had even tried to improve
● Fewer surgical skills from the physician are required by
upon its light source with a fluorescent light ring attachment.
FUT (but more managerial skills are needed to oversee
However, at that meeting, I was introduced to the Zeiss Stemi
employees).
DV4 and that has changed my attitude toward the usefulness
● Many people (both lay and professional) intuitively be-
of the dissecting microscope. Currently, all of my technicians
lieve that the microscope should be beneficial.
prefer and use the Zeiss microscope for both MM and FUT.
● The microscope appears to be an effective marketing
They prefer the comfort of the microscope because of its supe-
tool and is used as such by many practices.
rior lighting and the superior posture that its use requires com-
pared to the use of loupes.
Nevertheless, denying the technician the opportunity of What Are We Trying to Transplant, Anyway?
gradually becoming proficient with a microscope by having at As Marritt has stated, ‘‘For almost 40 years, the very founda-
least the option of the interim use of loupes for dissection creates tion, indeed the cornerstone, of all hair replacement surgery has
several problems. The use of the microscope is slower and takes been the preservation of intact and uninjured hair follicles. No
longer to learn to use than loupes (12,22,28,31), thereby risking technological tour de force accomplishes this goal with greater
increased exposure of the donor tissue to increased in vitro predictable consistency than the stereoscopic dissecting micro-
adversity and increased variability of technician proficiency. scope (46).’’
These are manageable difficulties, but they require a more vigi- What if during all of these years the cornerstone has un-
lant quality control, which is, ultimately, the physician’s respon- knowingly been the stem cell and not the architectural unit
sibility. Why ask for trouble unless there is a clear advantage (i.e., the follicle)? This makes the importance of ‘‘intact and
to be gained? Why force a microscope on technicians before uninjured hair follicles’’ less clear and renders the FU some-
they want to use the instrument if there are no compelling data thing of an anachronism because the importance of preserving
pressing this issue? Why be dependent on a sliverer when the physiological integrity of the stem cells supersedes architecture
physician’s own proficiency with strip harvesting shows up to in importance.
work every day that the physician does? Work presented by Jahoda (49) at the Hair Research Society
Few would disagree that the dissecting microscope is supe- meeting in November 1998, suggests that such may be the case.
rior for breaking down an ellipse of donor tissue (1.0 cm to The interaction of cytokines between the stem cells of the mes-
1.5 cm wide) into grafts. However, the exclusive use of the enchyme and those of the epidermis in the absence of follicular
microscope has the aforementioned problems. Thus, the ellipti- architecture appears to be sufficient to grow hair. Additional
cal excision is inferior to the excision of donor tissue with a support for follicular growth’s being at least semi-independent
multibladed knife used by a physician who has developed opti- of intact architecture is provided in a study by Mayer (38), in
mal proficiency with it. The latter is at least as good as elliptical which he demonstrated that follicles grew despite deliberate
dissection at most points of the FUT learning curve, and MBH disruption of follicular architecture. Reed (30) showed 51% and
is not dependant on the microscope in giving reliably reproduci- 64% growth of implanted upper and lower two-thirds follicle
ble results, day in and day out. fragments, respectively, at 8 months. Kim (58) has shown 60%
The microscope and elliptical excision have been proposed growth when only the upper two thirds of the intentionally tran-
as the optimal tools, in fact the sine qua non, for FUT (10). sected fragment is transplanted. Martinick showed that 97% of
This, however, has been based on three incorrect assumptions follicles split in half produced some fiber (37) (see also Chapter
that have been previously discussed: 9).
● Graft growth adversity from follicular transection out- Although counterintuitive, it is therefore not inconceivable
weighs all other in vitro considerations. that the proper timing of the use of the impulse microtome
428 Chapter 12
developed by Mangubat (52,53) (see Chapter 11), which mini- Minimizing Vascular Injury to the Recipient Area
mizes in vitro time, could better serve the vitality of the stem
cell. This in turn might create more optimal hair growth than the One might think the ‘‘small grafts’’ and incision sites of FUT
more laborious, time-intensive FUT, with its more prolonged are superior. However, beyond a certain low donor area hair
periods of exposure to harsh in vitro elements. Early compari- density, two FU grafts make a longer wound than if the same
sons of these two methods show similar outcomes (56). Ongo- FUs were left together within a single minigraft. The two rea-
ing evaluation of the microtome (54), which is reported to have sons for this are the following:
up to 35% transections (55) should help clarify the effectiveness ● Often, two FUs are sufficiently close that the wound
of the microtome as well as indirectly establish the importance required to implant them together as a minigraft is less
of maintaining architectural integrity (i.e., minimize the transec- than the combined length of the wounds created by the
tion rate). two 18-gauge needle sites required to implant the units
Perhaps the follicular architecture is only a template to allow separately (Fig. 12C-6a). This point is even truer if a
the maximum and appropriate quantity of stem cells to be trans- no.18 NoKor needle, with its 1.75-mm slit, is employed
planted. On the other hand, the follicular stele as described by for the FU graft sites.
Headington may serve as an important anatomical cylinder of ● Two FU graft sites require a wound volume that allows
capillaries and loose, elastin-rich connective tissue that is neces- not only the volume of the grafts themselves but also
sary in anagen to obtain optimal fiber volume from the stem the volume of the inserting forceps to be used twice (i.e.,
cells as the papilla descends into the subcutis. Conclusions once for each graft). Were these FUs transplanted as a
about the appropriate surgical technique will change as the rela- minigraft, the volume of the inserting tool would be used
tive importance of physiological factors (stem cell vitality), and only once. The smaller wound gained by having to use
anatomical factors (the architectural integrity of the follicle) is the inserting tool only once is partially or completely
better understood. Whether stem cells reside along the length offset (depending on donor area density) by the increased
of the stele during telogen or whether they retreat to the telogen volume of tissue between the FUs. Theoretically, how-
germinal unit is also very important and remains to be conclu- ever, there are the benefits to be gained from the chubbier
sively elucidated. graft because of the option to use the FUs as a minigraft
as discussed earlier and elsewhere (3).
THE BEST TREATMENT OF THE RECIPIENT
AREA WHICH TECHNIQUE PRODUCES THE MORE
What the superior surgical technique is for this area is also not AESTHETICALLY PLEASING RESULT?
clear. Recipient area considerations include minimizing the size Parameters to consider are the following:
of the area that needs grafts, minimizing the alteration of its
surface appearance, and minimizing injury to its blood supply. ● Hairline design and distribution of the transplanted hair
● Ability to achieve density
Minimizing the Size of the Recipient Area ● Ability to achieve subtlety
The variety of alopecia reduction (AR) techniques that could Hairline Design and Transplanted Hair Distribution
be considerations for reducing recipient area size is discussed
in Chapter 19. At one time, the creation of recipient sites with These aspects of the art of hair transplantation are not impacted
the punch was thought to be superior to creation of slits, because by the choice of MM vs. FUT. (The size of the graft in the
the punch removes tissue and thereby brings about a form of planned pattern is considered later.)
AR. This idea has never been objectively studied (and would
be rather difficult to study). In any case, AR appears to have Ability to Achieve Density and Hair Volume
fallen out of vogue.
Shapiro has succinctly summarized my views on this subject
Minimizing Surface Deformity of the Recipient by stating, ‘‘The controversy over using only FUs in the central
Area area has to do with their ability to produce the appearance of
density. Density is a function of the number of hairs in an area,
The fact that the minigraft requires a larger incision probably not the size of the graft. Above a certain threshold the same
results in an increased potential for deformity of the skin’s sur- amount of hair should produce the same appearance of density
face at the site of the transplanted graft. On the other hand independent of the type of grafts used. The problem with FU
dimpling can occur with FU grafts. In either instance, refine- is not that density can’t be produced, but that density is more
ment of the surgeon’s technique should make the phenomenon difficult to produce (24).’’ The lack of hair (i.e., hair volume)
uncommon. is the reason why patients come to see hair transplant surgeons
Some believe that compression of a four-hair minigraft, even in the first place. The ability of a surgical technique to achieve
without dimpling gives a suboptimal appearance. With clusters density is, therefore, of paramount importance. The arguments
of four hairs occurring in nature as an FU, this seems a more for superior density (FUT vs. MM) are largely theoretical at
minor criticism as long as the compressed multi-FU graft occurs this time. Studies comparing parameters of clinical results are
where the four-hair FU normally would (i.e., in a fairly dense limited, but they do show that the smaller the graft, the lower
setting). These aesthetic considerations are discussed more the survival rate and, as previously noted, perhaps the greater
completely later. the risk of miniaturization.
Figure 12C-6 (a), A 30x photograph of the donor area, measuring 9 mm ⳯ 7 mm, contains a 1-mm recipient site made with a no. 18
hollow-core needle. An adjacent 2-mm line is drawn for comparison to represent the size of a small minigraft site. There are numerous
examples of two FUs grouped close enough to fit into the 2-mm site. The conclusion is that two separate FU grafts cannot be placed as
close together as the two FUs in a naturally occurring group. (b), Intraoperative photograph taken during procedure no. 2 shows the close
approximation of FUs achieved with one session of previous minigrafts containing linearly oriented FUs. The ‘‘end-on’’ view (arrow no.
3) demonstrates the importance of minigraft orientation in low-density settings. The density of two FUs in a minigraft (Eq. 1) is higher
than that of two FUs placed separately, even when closely packed (⬎ 40 site/cm2).
Theoretically, MM is superior to FUT in achieving density the grafts with the surgical technique that would best achieve
for the following reasons: FUT’s ‘‘tool’’ for density is limited this goal. Even with the availability of these optimized FU
to the three-hair FU graft and a small percentage of FU grafts grafts, however, the usual clinical situation is one in which the
with more than three hairs. Such grafts placed in close proximity proportion of the recipient surface area calling for maximum
to one another could theoretically produce superior density to density (vs. subtlety) far exceeds the 25% to 30% frequency of
minigrafts of comparable numbers of FUs. Whether this could such FU grafts obtained by FUT. In addition, an unfortunate
occur, however, depends on the donor tissue’s FU density and corollary of that approach is that if all the three-hair and four-
the number of hairs per FU. When FU grafts can produce greater hair FU grafts are used in certain areas, none are left for other
hair density, as they often can, it is because such a concentration areas. The result is lower hair densities in these areas than would
of FU grafts with three or more hairs would not occur naturally have been possible if a more even distribution of had been
in the donor area. The limitation of FUT in accomplishing den- allowed by the additional use of minigrafts. Put differently,
sity is the number of such FU grafts in the donor tissue. This solving the density problem of FUT in some parts of the area
varies significantly from patient to patient, but, commonly, its results in the worsening of the density problem in the rest of
occurrence is in the range of 25% to 30% of total FU grafts. the recipient area, which, in fact, is the majority of the recipient
Elsewhere in this text, Shapiro and Harris discuss ‘‘pairing’’ area.
of FUs with two or fewer hairs into single-needle holes. How- The next densest FUT graft, the two-hair FU graft, usually
ever, I agree with Unger’s commentary on Harris’ Chapter 12E, cannot be surgically placed as close as two FUTs usually occur
that for patients with average hair density, there seems to be in nature. This is apparent in the photographs in Fig. 12C-6a,
something illogical about dividing tissue into single FUs (with even though the FU density in this patient, at about 90 FUs/
all of the previously discussed potential disadvantages of doing cm2, was below average. This is certainly true of the density
this), only to put them back together again. obtainable from one session of FUT, and probably generally
It is assumed that EEMD produces greater numbers of FU true for the result of two sessions of FUT. The close approxima-
grafts with three or more hairs than multibladed harvesting of tion of FUs in minigrafts that contain linearly oriented multiple
MM. The degree to which this is true is unclear, but from evolv- FUs is shown in Fig. 12C-6b.
ing data in my practice, when this parameter has been included These two facts—the limited number of FU grafts with three
in our routine quality control protocol, EEMD appears to have, or more hairs and the inability to surgically mimic the density
at most, a rather modest benefit. Others disagree (25). All are of nature—are the reasons why, theoretically, FUT is inferior
in agreement, however, that if such multihair FU grafts are a to MM in producing hair density. Of course, as donor area
technique’s only tools for density, it makes sense to optimize density decreases, the argument for all FU grafts increases
430 Chapter 12
Table 12C–2 Blinded Assessment of EEMD vs. MBH for FUs on Single Subject
Graft preparation numbers
Graft preparation method EEMDa MBHb
Theoretical FUs presentc 600 600

Actual FUs captured 488 570
Total hairs captured 929 1049
Average Hairs/FUG (calculated) 1.9 1.8
Three-Hair FUGsd 32 68
Transection rate 12% 14%
Recipient area result numbers
Months after EEMD MBH EEMD MBH EEMD MBH

surgery 4.5 mo 4.5 mo 10 mo 10 mo 15 mo 15 mo
579/79 805/104 573/79 727/104 606/79 925/104

Number of transplanted hairs growinge 3 9 3 9 3 9
Percentage of transplanted hairs growing 73% 77% 72% 69% 77% 88%
Average shaft diameter of transplanted hairf 42 ␮ 44 ␮ 50 ␮ 51 ␮ 53 ␮ 51 ␮
⬃Percentage of miniaturization of transplanted hairg 66% 72% 93% 98% 102% 98%
⬃Percentage of miniaturization of transplanted hair 48% 55% 67% 67% 80% 85%
factoring in “no growth” hairh
EEMD ⫽ Electronic excision and microscopic dissection; FU ⫽ follicular unit; FUG ⫽ follicular unit graft; MBH ⫽ multibladed harvesting.
a
EEMD ⫽ Harvesting with an ellipse, slivering with a microscope, and cutting final FUs with a microscope.
b
MBH ⫽ Harvesting with five 2-mm strips with a multi-bladed knife and cutting final grafts with a microscope.
c
Based on an ⬃ FU density of 45FUs/0.63mm2, which equals a total of 600FU’s for the 7 ⫻ 1.2 cm2 donor area used for both EEMD and MBH sides.
d
Transection rate for the step of harvesting the five 2-mm strips was ⬃8%. The total transaction rate when the final step of producing what is listed in the table
is added. The final graft transection rate was calculated by counting the transection of two-hair FUs.
e
It is possible, because transection rates were counted only for the two-hair FUGs, that the fewer FUGs with FUT were to the result of more transection in the
MM three-hair FUGs. However, MM had only slightly lower two-hair FUGs (343 vs. 355) and higher numbers of one-hair FUGs (150 vs. 123) and a similar
total transection rate.
f
The average hair shaft diameter was measured in microns. The average diameter of the hair shaft of the donor hair before transplantation was 52 microns.
g
This divides the calculated total hair shaft diameter of the transplanted hair by what it would have been if it had retained the donor hair shaft diameter of 52
microns.
h
This is the same as the above only it factors in what the additional loss is from non-growing hairs assuming the diameter of hairs that did not grow ⫽ 0.
owing to the ‘‘dead space’’ of tissue between FU dead space the units, the denser the hair. You’ll notice that the same final
(which, nevertheless, may or may not include invisible exogen density that I achieved in four sessions in 1997 took me only
follicles as discussed earlier). In a thought-provoking article in two sessions to achieve in 1998 and would probably only take
the December 2001 issue of Hair Transplant Forum Interna- one session today. … (45)’’ Dr. Limmer, one of the hair trans-
tional, Jerry Kolasinski reported the growth of 35 hairs from plant specialty’s most respected surgeons, had demonstrated the
15 clinically hairless grafts that were prepared with 3x magnifi- value of evolution in his practice. Other practices similarly will
cation. This study is fully described in Chapter 9. Intuition or never stop their maturation process. In the meantime, why
common sense would seem to suggest that a combination of should patients be subjected to the present uncertainties of FUT
density tools is optimal and gives the most flexibility in achiev- if the goal is hair density and if viable alternatives such as
ing the highest density (i.e., using the three-hair FU graft to minigrafts exist? As noted at several points earlier, there is
‘‘snuggle up’’ next to a minigraft planted by a prior session). growing evidence for lower follicle survival rates and possible
This entails some ‘‘process plugginess’’ as described by Marritt miniaturization with smaller grafts. Nonminiaturized growth
(61), but it is an effect that, in my opinion, is usually cosmeti- rates that can compete with larger, multi-FU grafts will likely
cally very acceptable for most hair characteristics. The photo- never be reliably produced by FU grafts. Why not improve our
graphs in Fig. 12C-7a, b, c, and d) demonstrate this point by proficiency with FU grafts while restricting their use to the
demonstrating various stages of a patient who received two hairline and to other situations calling for subtlety? As one’s
sessions of MM. practices become more proficient with FU grafts, perhaps they
In 1997, Marritt asked how Dr. Robert Limmer had managed will be appropriate in more situations.
to alter his technique so that he no longer had to apologize for
inferior hair density with FUT. Dr. Limmer responded, ‘‘… by Ability to Achieve Subtlety
practice and perseverance. Achieving density with FUT is a
tedious, difficult, and frustrating experience, but the more you A subtle transplant is more important than a dense transplant.
practice, the closer you can place the FUs. The closer you place All agree that forgoing a hair transplant is better than having
Figure 12C-7 A patient example of intermixed micrografts and minigrafts showing the density achievable with the two procedures.
(a), Area to be transplanted, shown before surgery. (b), Same area immediately after transplantation, showing pattern of narrow row of
micrografts in front of minigrafts.(c), Six months postoperative procedure no. 1, showing slight process plugginess from one session of
combination micro-minigrafting. (d), Postoperative procedure no. 2, showing results after a second session of micrografts interspersed with
minigrafts to maximize density.
an obvious hair transplant. Which technique, MM or FUT, is more frequently with either technique (31). This is probably
subtler? Is either technique insufficiently subtle? Can one tech- the only indication for close trimming of FU grafts, because on
nique ensure subtlety only at the expense of density? Can one the hairline’s leading edge, as opposed to its interior, no growth
technique better avoid unwanted growth of multihair FU grafts of a micrograft is better than the growth of a two-hair or three-
at the leading edge of the hairline? These are important ques- hair graft.
tions that immediately come to mind. FUT, with its exclusive use of FU grafts, can guarantee supe-
Neither technique is universally superior. Both FUT and rior subtlety relative to MM. This is because MM offers the
MM are equally capable of creating grafts containing single option of using grafts composed of multiple FUs and, accord-
FUs to establish a hairline, as documented earlier by the 30x ingly, the grafting of FUs that are closer together than FUT.
photos from the Reed study. With closely cut micrografts and However, MM achieves this only by placing these minigrafts
with conscientious graft selection, the unexpected growth of a farther apart from one another, and is therefore more likely to
two-hair graft on the leading edge of the hairline occurs no look pluggy if there is no persisting original hair in the recipient
432 Chapter 12
area, or, if the recipient area is originally alopecic until further cool-holding solution; and technical markers such as
sessions are carried out. Accusations of plugginess can be made transection rates, multihair FU graft counts, follicle frag-
against FUT by hypersensitive individuals only because of the ments in the ‘‘refuse’’ and graft production rates.
lack of miniaturization of its hairs when the overall hair density ● Have the other technicians learn dissection of the ellipse
is low (low density implies androgenetic alopecia, which im- as quality-control assessments and overall graft produc-
plies miniaturization in addition to the low density). Therefore, tion allow.
although FUT may be detrimental to density and hair volume ● The profession of hair transplantation technician re-
because it prohibits the combining of FUs to create a minigraft, quires dedication and unrelenting attention to detail. Ex-
it does help prevent the poor use of minigrafts, which could be pect to pay for such professionalism accordingly.
too pluggy for their location. (The solution, should this subopti-
Such an approach will not only help the practitioner best evolve
mal outcome occur, would be to increase the density with fur-
and use the current options in surgical technique but will also
ther grafting and/or to widen a transition zone of FU grafts into
develop the skills to position the practice for the assessment
the alopecic intergraft spaces in the area of minigraft plugginess
and assimilation of future developments.
(see also Unger’s discussions in this chapter).
Whether a particular position for a particular size of mini-
graft is judged suboptimal is, of course, a very subjective con-
ADDENDUM
sideration. Transplanted hair from either FUT or MM is rarely
undetectable to a highly trained eye that is given the opportunity My style of practice has changed over the 2 years since the
for close investigation of the transplanted scalp. At times, hair bulk of this chapter was written. I appreciate the opportunity
transplant surgeons, who have such trained eyes, seem almost to evaluate the changes in technique and the milieu of influences
phobic about a pluggy appearance. If unchecked, this attitude within which the changes occurred. Perhaps the influential
may exist at the cost of unnecessarily lower densities, not to forces can be thought of in two general categories:
mention at the cost of increased expense to the patient who
pays for more small grafts to get (at best) the same amount of 1. The evolution of theory, scientific evaluation, and the
hair. Often, hair transplants that are considered pluggy by the subsequent practical applications and aesthetic results
surgeon evade detection by the patient’s hairstylist. In such a 2. Popular sentiment or pressure, from both colleagues and
scenario—quite common in my experience—who is the better patients, regarding their perceptions of the issues men-
judge, the hairstylist or the surgeon? Unfortunately, I think the tioned in point no. 1.
hairstylist is the better judge, and I think that transplant sur- More specifically, the following questions can be considered
geons, because of their overly trained eyes, are not the best from each of the above perspectives:
critics of the appearance of the ideal hair transplant. I say ‘‘un- How have the issues of no.1 changed? What premises and
fortunate’’ because, if this opinion is true, we have no concrete practices have been rejected; which reaffirmed? What new con-
‘‘standard of quality’’ for our discourse. cepts have been incorporated and have these changes been as-
similated by replacement, by modification, or by adjunct service
Conclusions to the components of the earlier style? What concepts are cur-
In conclusion, for the reasons discussed, I think the following rently being defined as to their utility?
is the most advisable approach for organizing a hair transplanta- It is helpful to approach these questions by considering the
tion practice: various areas of the anatomy and physiology that can be helped
or injured. These areas of concern are the following:
● For optimal grafted hair survival, the physician should
transplant the largest graft that is aesthetically acceptable ● The impact on the recipient area’s vascular supply
in the recipient area, provided it can be adequately nour- ● The size of the graft and its impact on the number of
ished by, and does not disproportionately harm, the re- hairs that grow after transplantation
cipient vasculature ● The excised donor tissue in its in vitro phase
● The physician should develop his MBH techniques for ● The donor area
consistently high quality.
Other categories affected by hair transplantation’s evolution
● Technicians should develop proficiency with strip dis-
are:
section and any form of magnification they choose. They
will probably evolve into preferring the dissecting mi- ● Aesthetics
croscope as their proficiency develops. ● Plugginess or noticeability and fullness vs. homogeneity
● Develop FUT by designating an appropriate technician and see-through hair
to become the sliverer and have this staff member focus ● Donor scar
on proficiency in slivering small amounts of donor tis- ● Systems (i.e., the practical aspects of producing the re-
sue, at the expense of speed and ‘‘productivity,’’ if nec- sults)
essary.
● As the sliverer becomes efficient, have other technicians Recipient Vasculature
develop FUT proficiency by switching from microscopic
dissection of strips to dissection of slivers. An extreme example of the changing theoretical and practical
● Thoughtful quality control can minimize damage to the aspects of the surgical technique is that I rarely use punches
follicle by careful monitoring of in vitro times and pa- now, as I did 8 years ago. I have abandoned them for two
rameters such as dehydration; time of tissue out of a reasons:
● Increased concern for the recipient area vasculature, slit grafts with a similar orientation. Although such peer opin-
whose compromise I suspect will ultimately affect ions concern me, I have not encountered this problem as would
growth rates of subsequent sessions. be indicated by perceptible poor hair growth, and I have used
● Aesthetic considerations, wherein a round punch does it in more than 100 procedures. I am fastidious with tumescence
not make the recipient site shape that best assists the and prefer incisions that are as shallow as possible. Perhaps
linear coupled FU to grow in a linear arrangement. these considerations account for our differing experiences and
Rather, the shape of the punch literally dictates the pro- opinions.
duction of a plug.
More recently, such concern for the recipient area vasculature Minigrafts vs. the ‘‘Silent Killer’’ of Invisible
culminated in Seager’s one-pass approach [see Addendum, Exogen Follicles
Chapter 12B]. He bases this approach on his opinion that the
best growth of a series of transplantations comes from the first Why not use a higher number of FU grafts? A prominent peer
procedure. He believes this is due to the adverse impact of a and a consumer advocate have said that comparing MM with
previous transplant procedure on the recipient area vasculature. Total FU grafting is equivalent to comparing ‘‘a Chevy with a
However, a confounding variable that seems impossible to cor- Cadillac.’’ There are at least two answers to the question:
rect in studies or observations that would support this theory
● Aesthetically, in my opinion, there is the appearance of
is the phenomenon of loss of random telogen phases in trans-
higher hair density with a pattern of intermixed FU grafts
planted hair, followed by the ‘‘re-randomization’’ of the hair
and coupled FU grafts (as they exist in modern double
cycle. Explaining this further, the post-transplant growth of both
FU [DFU] grafts) vs. the homogeneous pattern of total
the hairless and invisible telogen follicle (also called exogen
FUT and
or kenogen follicle) and the visible anagen hair is very likely
● It is extremely difficult, if not impossible, to be specific
the reason that so many hair survival studies have growths of
about any parameter of the hair cycle, including the per-
greater than 100%. Re-randomization (i.e., the re-establishment
centage of follicles in anagen, telogen, or exogen, or the
of a normal percentage of telogen follicles from a state in which
duration of any of these phases; accordingly, the rate of
there is zero percent of the follicles in exogen, and, therefore,
follicle turnover varies in any given individual at a spe-
higher initial numbers of hairs) would give lower apparent
cific point in time. All the foregoing considerations are
growth rates for the subsequent procedures. Further studies are
probably in a constant state of flux, rendering a scientifi-
needed to establish one way or the other whether the one-pass
cally valid assessment next to impossible, in my opinion.
approach is advantageous with respect to recipient area vascula-
Nevertheless, the view that most of the telogen follicles
ture and graft survival.
have lost their fibers is gaining a growing list of support-
ers, and such ‘‘exogen’’ phase hairs are essentially invis-
Graft Orientation
ible at 10x magnification (48,62). For example Rebora
Concern for the recipient area vasculature has also impacted and Guarrera reported, in an article published in 2002,
the thinking about graft orientation. Graft orientation is an ex- that in 12 men followed for 14 years, 80% of the follicles
ample of an aesthetically driven concept. Can both minigrafts in a delineated, specific area went through such a stage,
and micrografts produce a better appearance if aligned in a which they called a ‘‘kenogen’’ rather than an ‘‘exogen’’
particular way? Hasson and Wong suggest that such is the case phase (63). In those men, such a phase lasted 4 to 7
with follicular unit grafts (FUGs) and align them coronally and months. Two females, who were studied in the same
in high concentrations (40Ⳮ/cm2) (see Chapter 23E). A more way but for only 2 years, showed 22% of follicles going
expressive technique to emphasize this consideration is, in my through a kenogen phase that lasted 3 to 12 months.
opinion, the graft that consists of two FUs cut in a linear manner The more severe the androgenetic alopecia in women,
(a ‘‘small’’ slit graft in this text) and placed in a pattern that or female pattern hair loss (FPHL), the higher and longer
is parallel to the hairline or partline. The aesthetics of this ap- the frequency and duration of kenogen appeared to be.
pearance, when intermixed with FU grafts, gives a more hetero-
geneous pattern of growth than the homogeneous pattern of total Note
FUT and can, in some instances, result in a visual impression of
‘‘chords’’ of hair. This pattern of combination grafting requires ● The invisible follicles lost with graft preparation are in-
the judgment learned from the experience of working with dif- versely proportional to the size of the graft.
ferent types of grafts and combinations of donor hair character- ● Even the use of chubby FU grafts does not save the
istics, if one is to avoid these chords of hair that look pluggy. single-hair FU in exogen and cannot be assumed to save
Should the pluggy appearance occur, it is always correctable all exogen follicles in a multi-hair FU graft.
by increasing the density with a second procedure. It probably ● The double FU graft has a better chance of transplanta-
need not be said, but it is best to err toward the total FUT side tion the single-hair FU grafts in exogen because of the
of the spectrum of grafting options while honing this judgment. larger amount of apparently non–hair-bearing skin that
Further considerations of this issue are mentioned by Unger in is transplanted.
Chapter 12F and 12G. Parsley and Beehner have especially ● The magnitude of the potential decrease in hair survival
expressed concern about excessive injury to the recipient vascu- is related to the hair density—both the number of hairs/
lature with such alignment of grafts (William Parsley and Mi- FU as well as the number of FU/cm2. For example, as-
chael Beehner, personal communication). Frechet is said to have sume a patient has X number of one-hair FUs grafts; 2X
had difficulty and vascular compromise with his use of larger number of two-hair FUs; and X three-hair FU grafts.
434 Chapter 12
Remember also, that between 4% and 24% of scalp hairs and of smaller grafts in general to minimize the possibility of
are in telogen phase at any given time (62,64). If, for any transitional noticeability. I must admit to feeling somewhat
example, you happened to operate on a patient at a time more guilty about the use of higher numbers of FU grafts than
when 20% of his follicles were in telogen phase, up to I would otherwise deem necessary, and, therefore, about the
5% of the follicles would be at very high risk of not unnecessary sacrifice of transplantable exogen follicles. I feel
being transplanted with total follicular unit transplanta- this guilt because it is my observation that such plugginess is
tion (TFUT) because they are the single-hair FU (20% apparent only to the more sophisticated and motivated eye when
divided by 4X ⳱ 5%). (These percentages are even it is given the opportunity to closely inspect the scalp. My per-
higher unless one assumes that the chubby FU graft sonal impression is that, almost without exception, an individu-
blindly and fortuitously captures all exogen follicles in al’s hairstylist is oblivious to a transplant procedure that would,
the multihair FU.) However, the loss of exogen follicles nevertheless, be called too pluggy/heterogeneous by these so-
with small grafts is even worse in the patient with low phisticated observers. If the ‘‘hairstylist parameter’’ is used,
hair density (less than average number of hairs/FU and these observers must be called overly sophisticated and too criti-
a lower density of FUs). In this situation, for instance, cal. Nevertheless, I have not found it worthwhile to be too
if the patient has X number of one-hair FU grafts X two- dogmatic about defending and defining the upper limit of heter-
hair FU grafts, and only the rare three-hair FU graft, up ogeneity of the composition of combination graft procedures;
to 10% of the total follicles in the donor area are at risk after all, the patients are happy in spite of (or perhaps partly
if one is using TFUT. This patient also has the worst because of) the increased percentage of FU grafts that peer
minigrafts. The question then becomes which type of pressure has influenced me to use. By interspersing FU grafts
graft and pattern is more acceptable for the growth out- more liberally within the minigraft zone to minimize transi-
come and appearance needed for that area of the trans- tional plugginess’’, my average maximal harvest uses a larger
plant? number of FU grafts than in the past—approximately 1000
I am not sure where to draw the line between losing invisible (and the balance are ‘‘cherry-picked’’ minigrafts containing two
exogen hairs to make two FU grafts instead of using one mini- FUs). Nevertheless, the needless loss of exogen follicles still
graft containing two FUs. Historically, many have damned mul- bothers me.
tibladed harvesting for having less of an impact than is being
considered in the discussion. Should the physician be criticized Gradient of Graft Density
for choosing to use the FU graft when there had been an option The gradient of graft density is an aesthetic and practical devel-
to use a minigraft? Of course, the FU graft is necessary in low- opment that, in combination with the intermixed pattern of FU
density cases and, arguably, other situations, but I sometimes grafts and minigrafts, is the core of combined grafting. This
feel guilty about the ‘‘silent deaths’’ of the exogen follicles. gradient uses a spectrum, which at one end is the fine, single-
Some physicians dismiss the aforementioned concerns and haired FU graft and at the other is the doubled-up multihaired
say that the percentage of hairs in both telogen and exogen FU graft. At the middle of the spectrum is the ‘‘coupled FU
is low. We have already discussed the numbers suggested by graft.’’ This is more fully discussed in Chapter 16 I.
previous studies. To them must be added the observation that
if these percentages were lower, the length of anagen would Terminology
have to be correspondingly longer than the commonly accepted
(but admittedly still unproven) range of 3 years to replace the Peer pressure is most apparent when it comes to terminology.
entire scalp with new hair. I am appreciative of consumer advocates who have counseled
An interesting study by Kolasinski supports the loss of viable me that the terms ‘‘minigraft’’ and ‘‘micro-minigrafting’’ have
follicles in exogen with small graft use. He transplanted appar- fallen into disfavor, at least in the ‘‘cybercommunity’’. I have
ently hairless tissue and found that hair grew from some of no problem using the more acceptable terms ‘‘combination
these apparently hairless grafts (see Chapter 9A). This study grafting’’ and ‘‘coupled FU’’ because they more accurately
was not conclusively confirmed by a study designed by Cole describe the surgical technique that I use.
at the Orlando live surgical workshop; further confirmation with
use of larger numbers of samples and subjects is necessary. Ellipse vs. Multibladed Harvest
Transitional Plugginess With a developed staff of surgical technicians, I do not have a

preference regarding elliptical dissection and slivering of the
An example of a change in surgical technique that seems to have ellipse vs. harvesting the donor area with the multibladed knife
been influenced by peer pressure is an increased intolerance of to make 2-mm strips for further dissection under the micro-
what Marritt has called ‘‘transitional plugginess.’’ It refers to scope. Transection rates are generally comparable, as discussed
what is judged to be an insufficiently subtle and homogeneous earlier. Elliptical excision and slivering takes approximately
pattern of hair growth during the time required to reach the 50% more time. However, a well-developed staff of surgical
intended final density of transplanted hair. An example of this technicians includes the kind of excess capacity to accommo-
would be the presence of a four-hair or five-hair minigraft, not date the temporary or permanent departure of the individual
intermixed with FU grafts, which is growing in an area where members of the team. All of my technicians have now chosen
only one transplant procedure has been done. This appearance the microscope as their tool of choice for magnification. This
is transitional in the sense that multiple procedures and, there- fits well with popular peer sentiment.
fore, a higher density of transplanted hair, are the ultimate goals. Occasionally, staffing specifics arise when multibladed knife
Such intolerance by my peers influences my use of FU grafts harvest is very important for the health of the practice and for
provision of optimal service to the patient. Maternity leave from 12D. Follicular Unit Transplantation
a job is an example of a position that needs to be kept open
for several months to await the technician’s return. Therefore,
Alone or Follicular Units with
I think that the surgeon’s maintaining skill with the use of the Multi-FU Grafts: Why, When,
multibladed knife continues to be very important from the long- and How?
term perspective of practicing the hair transplant specialty.
Ron Shapiro
Summary INTRODUCTION
In my opinion, the significant trends of the last 2 years include In hair restoration surgery, we are trying to
the following: redistribute a limited amount of donor hair, with
● There are fewer physicians staking out the extremes of minimal waste and maximum survival, to a potentially
surgical technique: MM with large minigrafts and few expanding bald or thinning recipient area. We want to
FU grafts vs. TFUT. accomplish this redistribution in a manner that ensures
● All hair transplant surgeons are becoming more sensitive the patient will be satisfied with the results now and in
to process plugginess and are generally using smaller the future. Patients’ satisfaction is dependent on
grafts at all phases of the restoration plan. meeting their expectations of naturalness, density, and
● On the other hand, there seems to be a developing gen- amount of work needed (1).
eral acknowledgement that chubbier and larger grafts Ron Shapiro
are better for hair survival; therefore, there is, almost
certainly, a hidden ‘‘cost’’ with the use of FU grafts. Graft Terminology
● Minigrafts are becoming more refined. Such grafts are In this chapter I am using the graft terminology set forth in
no longer merely cut to size but are sculpted more care- Chapter 5a. The term minigraft has been replaced by the term
fully in a linear configuration containing FUs and their multi-FU graft. In accordance with this, term combination
intervening space of non–hair-bearing skin. However, micro-minigrafting (CMM) is now referred to as combination
minigrafts can still be larger than double FUs, when hair micro/multi-FU grafting, but still has the same abbreviation of
characteristics permit, such as when there is low hair/ CMM. As explained in Chapter 5a there are a number of sub-
skin color contrast, and certainly with a white-haired types of multi-FU grafts (i.e.-micro-slit grafts such as DFUs,
Caucasian patient. traditional slit grafts cut ‘‘to size’’, slot grafts, and or round
● Terminology has changed to reflect these refinements. grafts). When specifically discussing one of these sub-types
Combination grafting and double FU grafts more accu- of multi-FU grafts they will be identified specifically by their
rately describe the technique and grafts of what previ- specific name.
ously would have been included in the less specific term
micro-minigrafting. The Goal
● Follicular unit extraction (FUE), (discussed in Chapter
10), is in its early stages of development. If its high Meeting a patient’s expectations of both naturalness and density
transection rates can be overcome, it may prove to be a are, in my opinion, the two most important goals in hair restora-
useful technique. tion surgery. In the early days of hair transplantation, the only
● Surgeons’ opinions and techniques are evolving. A good graft available to the physician was the standard, punch graft.
example is that of physicians who emphasized the nega- When this was the only graft available, the risk of creating an
tives of strip harvesting with a multibladed knife and unnatural look was high. The desire to improve naturalness led
called it ‘‘the blind harvest’’ with unacceptable transec- to the development and use of smaller grafts in larger numbers.
tion rates. Some of them are now at the forefront of Over time, we have seen the introduction of large minigrafts,
developing FUE, wherein the exposure of the follicles small minigrafts, micrografts, and, ultimately, follicular unit
to a blind harvest is by their criteria 100%, and literally (FU) grafts. The most extreme form of small grafting is total
could not be more blind. The current transection rate of follicular unit transplantation (TFUT), which refers to the exclu-
FUE would be unthinkable with any other technique. In sive use of FUs.
the minds of proponents, the donor scar has become
more important than transection rates, at least at this The Controversy
stage of their thinking and at this stage of development
No one would argue that the general trend of using smaller
of the FUE technique.
grafts in larger numbers has led to a higher degree of naturalness
● Areas of anatomy and physiology that were rarely dis-
on a more consistent basis. But as the exclusive use of FUs
cussed previously—specifically, donor area scarring and
increased, reports of poor hair density surfaced. Concern arose
recipient area vasculature—are now receiving the atten-
over the ability of TFUT to produce adequate density in all
tion they have always deserved.
situations (Figs. 12D-1a and b).
Most of the developments of the last 2 years are based on incom- Proponents of TFUT freely admit that FUs have specific
plete studies and the opinions derived from them. Whether they properties that potentially create obstacles with respect to
will stand the test of further scrutiny and be corroborated by achieving density. These tiny grafts are fragile, and there is an
future studies remains to be determined. It is an exciting time to increased risk of trauma, transection, and waste. Special skills
be in the still young, evolving specialty of hair transplantation. are needed for graft cutting and graft placement to ensure good
436 Chapter 12
Figure 12D-1 Example of poor density with exclusive use of follicular units. (a), Before surgery (b), one year after one session of
1200 micrografts. Low density may be due to an insufficient number of grafts for the area as well as badly executed technique, which led
to poor hair survival.
survival. However, proponents also point out that over the years multi-follicular unit grafting (CMM) procedures that consist
many adjustments in technique have been made to address these primarily of multi-FU grafts with only a limited number (100
potential problems. These include microscopic graft prepara- to 200) of micrografts, which are used in the hairline transition
tion, chubbier FUs, improved placement techniques, more atten- zone. Both of these approaches are extremes, (Figs. 12D-3a and
tion to dehydration and trauma, etc. Skilled practitioners of b). In reality, procedures today have begun to vary tremendously
TFUT argue that many of the early poor results were due to with respect to the numbers, types, and combinations of grafts
lack of experience with this new technique. Today, with more used (Fig. 12D-4). A review of the sections of this chapter that
experience and improved technology, practitioners believe they were written by Walter Unger, for example, reveals that patients
can consistently produce high survival rates and density that with CMM whom he treats also typically now have 800 or more
satisfies their patients (Figs. 12D-2a and b). FUs transplanted per session—in addition to multi-FU grafts.
Opponents of TFUT do not totally agree with this position.
They do agree that there are benefits to using FUs with respect The Question and the Quest
to naturalness. They also admit that the density produced with
TFUT in skilled hands today is far better than in the past. How- The questions remains: Are we paying a price in the form of
ever, they do not believe that TFUT is appropriate for all cases. decreased density for the increased degree of naturalness of
They think that in properly selected patients, combining FUs FUT results? Is the addition of micro-slit, slit grafts, and mini-
with multi-FU grafts can achieve a higher ultimate degree of grafts better for the production of density in some situations
density than FUs alone and can do so without noticeably sacri- and specific regions of the recipient area? I call this struggle
ficing naturalness. between multi-FU grafts for density and FU grafts for natural-
ness the Yin and Yang of hair transplantation.
The Trend Our quest has been to find techniques that create the best
balance of both naturalness and density. We want to answer
At one extreme we have TFUT consisting exclusively of FUs. the question: What graft or combinations of grafts are best to
At the other end of the spectrum, we have combination micro- use in different situations? Most experienced practitioners of
Figure 12D-2 Example of good density with exclusive use of follicular units (FUs). (a), Before surgery and (b), after three sessions
totalling 4500 FUs in the frontal two thirds of the scalp. Better results may be due to improved technique and a greater number of FUs
for the area.
Figure 12D-3 Two procedures showing both ends of the spectrum with respect to graft selection. The area in front of the dotted line
is the transition zone of the hairline. (a), A combined micro-minigrafting procedure with (X) limited number of follicular units (FUs)
(approximately 200) in the transition zone and (Y) only large multi-FU grafts posterior to this zone. (b), Total follicular unit transplantation
procedure with (X) exclusively FUs in all regions.
438 Chapter 12
may take up to 3 or even 4 years to see the final results of a

specific technique. This is unlike other plastic surgery proce-
dures, where results are seen in a matter of weeks. This leads
to a longer learning curve because a greater length of time is
needed to see a sufficient number of results and to make the
required adjustments in technique.
Wide Variety of Patients and Hair Characteristics

We see many types of patients with widely varying, ages, de-
grees of baldness, expectations, etc. In addition, these patients
may possess numerous variations and combinations of hair
characteristics (color, curl, caliber). All these variables can im-
pact the relative benefits of different sizes of grafts. This creates
a multifactorial environment that is difficult to evaluate objec-
tively.
Limited Patient Follow-up

It is difficult to have every patient return for follow-up. We do
not know how many of our patients with less than optimal
results simply do not return. This limited follow-up adds to the
difficulty in evaluating results objectively.
Figure 12D-4 Example of a procedure demonstrating the more
recent trend of blending multi-follicular units (FU) grafts with FUs.
The large number (X) of FUs in the first 3 cm of the hairline and Heterogeneity of Follicular Unit Transplantation
frontal region and (Y) small multi-FU grafts in the central region.
Most physicians agree that the area in front of the dotted line should and Combination Micro-Multi Follicular Unit
be treated with micrografts. It is the less scrutinized area behind Grafting Techniques
this line that is the subject of controversy.
Although we often refer to a technique as either FUT or CMM,
in reality they are very heterogeneous entities. For example, an
FUT procedure could refer to 1500 FUs placed across both the
frontal and midscalp regions (which would produce a density
hair restoration surgery agree that only one-hair and two-hair of only 15 FUs/cm2, or less); or it could refer to 1500 FUs in
grafts should be used in the transition zone of the hairline. a smaller area such as the hairline and frontal tuft (which would
However, there continues to be active debate over the optimal produce a density of 30 FUs/cm2, or more). As for CMM proce-
method of hair transplantation in the less scrutinized area behind dures, they also refer to a very heterogeneous group of proce-
this zone, where undetectable appearance at all stages may be dures, with the total number of grafts as well as the relative
less important than the final appearance of density. proportion of different sizes of grafts varying tremendously.
In this chapter, I discuss when, why, and how I believe FUs For example: a 500-graft procedure (consisting of 300 2-mm
alone or FUs in combination with multi-FU grafts should be punch grafts and 200 micrografts) and a 900-graft procedure
used in hair restoration surgery. (consisting of 500 small slit grafts and 400 micrografts) would
both be termed CMM, but they are obviously two very different
procedures.
COMPARING TECHNIQUES: AN This lack of specificity about both the exact numbers and
INTRINSICALLY DIFFICULT TASK types of grafts being used, as well as the specific location and
size of the regions being transplanted, has partially contributed
A number of factors make it intrinsically difficult to objectively
to the difficulty of comparing techniques. This is one reason
compare different techniques in the field of hair restoration
why we encourage physicians to be more specific when
surgery. I believe an awareness of these factors is important
describing the procedure they are performing and to use the
and may help physicians to keep a more open mind when at-
specific graft terminology and nomenclature set forth in Chap-
tempting to evaluate the effects of using various techniques and
ter 5A.
grafts. Before proceeding with the discussion of my personal
views on the use of FUs and multi-FU grafts, I would like to
examine some of these factors: Different Levels of Skill and Experience
It is well known that different levels of skill and experience
Long Learning Curve
can dramatically influence the results achieved with various
It may take up to 1 year to see the final results of a single hair techniques. Those of us who see the less than optimum results
transplant procedure. When multiple procedures are needed, it of other hair restoration surgeons are for the most part seeing
the results of their worst work or the work of less experienced

practitioners. It is easy to conclude erroneously that what we
are seeing is typical of that particular technique.
Unreliability of Studies on Survival and Density

This has been discussed in Chapter 9A (Graft Survival Studies).
It bears repeating that studies of survival of different grafts in
small areas (1 cm to 4 cm) cannot automatically be extrapolated
to what occurs in the larger areas treated in actual clinical situa-
tions. In addition, the difficulty of manually counting hairs in
grafts before and after they have been planted adds to the unreli-
ability of studies (2). Furthermore, nobody is certain how many
hairs are going into or coming out of the telogen phase. This
does not mean that studies are not of value, but only that the
information should be evaluated with this in mind. The empiri-
cal experiences gained by doing a large number of procedures,
if evaluated truthfully and objectively, may be as valuable as
some of these studies, or even more valuable. We hope the
recent advances and greater availability of digital photography
and computer imaging to count hairs will lead to more reliable
survival studies in the future.
Different Opinions on the ‘‘Clinical Significance’’ of

Various Results
Opinions vary with respect to questions about the clinical signif-
Figure 12D-5 Schematic drawing of various recipient regions
icance of different ‘‘degrees’’ of naturalness and density. Exam- and their approximate sizes in square centimeters. The total frontal
ples of questions on which opinions vary include: How impor- region (approximately 70 cm2) is broken down into smaller sub-
tant is the difference between natural on casual inspection vs. zones. The anterior portion of the frontal region is approximately
undetectable under critical examination? How important is 30 cm2 and consists of the hairline zone and the frontal tuft. The
achieving this difference in naturalness in one session vs. multi- posterior portion of the frontal region is approximately 40 cm2. I
ple sessions? Is the appearance of density achieved with 50 call this region the frontal core.
FUs/cm2 always adequate, or are there regions of the recipient
area where a higher density is desirable?
The foregoing discussion elucidates some of the reasons why
it has been difficult for physicians to objectively compare the ● The posterior portion, which I call the frontal core, is
results of different techniques in the field of hair restoration approximately 40 cm2.
surgery. In spite of these difficulties, we have made great
progress in evaluating the relative advantages and disadvan- BASIC PRINCIPLES OF DENSITY
tages of using different grafts with respect to their effect on
naturalness and density. Some of this progress is owed to the Knowledge the basic principles of density is useful for acquiring
knowledge gained from clinical studies. However, a great deal an understanding of the relative benefits of FUs vs. larger multi-
of insight comes from the empirical observations of physicians FU grafts, with respect to achieving density. In hair restoration
skilled in multiple techniques, who have had the good fortune surgery, we are dealing with two intrinsic limitations on density
to observe a large number of procedures over a long period of objectives:
time. ● A limited total supply of donor hair
● A limited amount per session of donor hair that can be
moved in a single procedure
NOMENCLATURE OF THE RECIPIENT AREA
Implications of a Limited Total Donor Supply
In this chapter, I follow the nomenclature for recipient regions
set forth in Chapter 5A. Figure 12D-5 is a diagram that illus- The total supply of donor hair is significantly less than the
trates these regions and their approximate sizes in cm2. As can amount of hair that originally existed in a full male pattern
be seen from this diagram, I divided the total frontal region balding area (full male pattern balding area ⳱ frontal region
(approximately 70 cm2) into anterior and posterior portions. Ⳮ midscalp region Ⳮ crown). Therefore, even if we move
the entire donor supply, we simply cannot reproduce—hair for
● The anterior portion is approximately 30 cm2 and in- hair—the same mathematical density (mathematical density ⳱
cludes both the hairline zone and the frontal tuft. hairs or FUs/cm2) that existed before hair loss started.
440 Chapter 12
What practical effect does this basic tenet have on the ulti- entire recipient region is not only unwise but also not achievable
mate ability to create density with hair restoration surgery? The because it would rapidly outstrip the limited donor supply.
total available donor supply has been stated to range from 4000
to 8000 FUs, with the typical patient probably having approxi-
mately 6000 FUs available for transplantation (3). From a prac- Implications of a Limited Amount of Hair That Can
tical standpoint, I find that most patients seldom receive these Be Moved per Session
high numbers of FUs over the course of their surgical treatment. Controversy exists over the maximum densities that can safely
This may be due, in part, to financial and time constraints. be produced in a single session with different types of grafts
However, even when time and money are not obstacles, obtain- (see Chapters 9A, 12AA, and 12 F.) The actual number of grafts
ing every one of the theoretically available 6000 FUs seldom that can be safely placed per unit area in a single session has
occurs, because it assumes perfect donor harvesting techniques not been definitively established. For FUs, it is commonly stated
and does not take into consideration the adverse effects of tran- that in skilled hands, up to 30 FUs/cm2 can be safely placed
section, waste, scarring, and decreasing donor laxity. All these before survival decreases. There are some physicians who be-
factors limit the true number of FUs we are able to obtain with lieve that with extreme skill and proper technique densities of
multiple procedures. 40 FUs/cm2 or more can be achieved in a single session with
In my experience, three full procedures totaling approxi- good survival. Although the results of these physicians look
mately 5100 FUs, performed over 2 to 3 years, are fairly repre- quite impressive empirically, it does not necessarily mean that
sentative of a patient who has aggressively pursued hair restora- there is an acceptably high survival rate. For example, if FUs
tion. To put this in perspective, a patient undergoing these are placed at a density of 45 FUs/cm2 and the end result is a
procedures would receive approximately three sessions of 1700 density of 35 FUs/cm2, the result looks good, but the survival
FUs each. Chart 12D-1 illustrates the theoretical densities that rate is actually only 77%. True scientific studies that use digital
would be produced if 5100 FUs were moved to variously sized phototrichograms of survival rates at these higher densities are
recipient zones. One point that should be obvious from this lacking and sorely needed. To have greater clinical relevance,
chart is that in most patients, even if only the front two thirds these studies need to be done with one or more tattooed refer-
of the balding area (frontal region midscalp region) is treated, ence points, and with examination of full transplant procedures
surgeons are ultimately going to be limited to an average FU rather than isolated 1-cm2 areas.
density of less than 40 FUs/cm2. This limitation dictates that With respect to multi-FU grafts, most physicians report ap-
a major focus in hair restoration surgery should be to optimize proximately 12 small slit minigrafts/cm2 or approximately nine
the ability to create a greater illusion of fullness at lower densi- medium-slit minigrafts/cm2 as the typical densities they can
ties rather than concentrating only on increasing the absolute safely produce with these specific types of multi-FU grafts.
numbers of hairs that are able to be placed. One method of In some respects, the numbers just discussed are misleading.
dealing with the limitations of total donor hair is to attempt to They examine only the theoretical maximum densities that can
produce higher densities only in specific, limited regions of the be produced in small 1-cm to 2-cm2 areas. In actual clinical
recipient area, where the aesthetic impact of high density is of practice, where larger regions of the balding scalp are being
particular importance (i.e., the frontal tuft and the central re- treated, much lower densities are being produced. This is ob-
gions). An attempt to produce higher densities throughout the vious if one examines from a mathematical perspective the sin-
gle session densities produced when various numbers of grafts
are placed in differently sized recipient regions. The following
two examples demonstrate this point:
● Example 1—Actual single-session density produced
when 1800 FUs are placed in the frontal two thirds of
the balding scalp in clinical practice: With total FUT
the average number of FUs used to treat the frontal two
thirds of the scalp (frontal region Ⳮ midscalp region)
ranges from 1500 to 2000 FU grafts. We will use an
1800 FUG session as an example. The average combined
size of these regions is approximately 130 cm2. This
calculates to a density of only 14 FUs/cm2 if the grafts
are evenly distributed (1800 FUs ⳰ 130 cm2 ⳱ 14 FUs/
cm2). In reality, it would take more than 3000 FUs to
produce a density of 25 FUs/cm2 in an areas of this sized
Chart 12D-1 Actual densities produced with three sessions (130 cm2 ⳯ 25 FUs/cm2 ⳱ 3250 FUGs). Chart 12D-
(approximately 5100 follicular unit grafts) in various recipient 2, and Fig. 12D-6 further illustrate the actual densities
areas. *This number of FUs is thought to be fairly representative achieved when 1800 FUGs are placed in other recipient
of the quantity of FUs a patient would receive if he had three fairly regions.
large procedures. The majority of patients today probably will have ● Example 2—Actual single-session density produced
only three or fewer procedures within 3 years of starting hair resto- when a 1000-graft CMM procedure consisting of 200
ration. †See nomenclature of balding scalp in Chapter 5A (Planning micrografts and 800 small slit grafts is done in the fron-
and Organization) These are average areas and could be larger or tal two thirds of the balding scalp. With CMM, the size
smaller with larger heads and greater degrees of recession. of a session can vary dramatically. For our example,
Figure 12D-6 Actual densities produced by one session of 1800 follicular units placed in differently sized recipient zones: I find using
the front half useful when I consult with patients. It consists of the frontal region plus half of the midscalp region.
we will use what would be considered a larger CMM crografts ⳱ 1800 FUs). Once again, we treat the frontal
procedure consisting of 1000 grafts (800 small slit grafts two thirds of the scalp (frontal region Ⳮ midscalp re-
Ⳮ 200 micrografts). Because every small slit graft has gion), which is approximately 130cm2. After taking
approximately two FUs per graft, this size of a CMM away the 200 micrografts and 20 cm2 for the hairline
session has an equivalent number of FUs (approximately zone, we are left with 800 small slit grafts (which, as
1800), as in the previous example (800 small slit grafts calculated previously, contain 1600 FUs) for the remain-
⳯ 2 FUs/graft ⳱ 1600 FUs and 1600 FUs Ⳮ 200 mi- ing 110 cm2. This leads to an average density of 15 FUs/
cm2 (1600 ⳰ 110cm2 ⳱ 15 FUs/cm2) in the area behind
the hairline to be treated solely with small slit grafts. In
reality, it would take 1375 small slit grafts for this
110cm2 behind the hairline to produce an average den-
sity of 25 FUs/cm2 (110 cm2 ⳯ 25 FUs/cm2 ⳰ 2 FUs/
small slit grafts ⳱ 1375 small slit grafts).
A few conclusions are obvious from the previous examples:
● Although FUT and CMM procedures contain different
numbers of grafts, they can often move similar total
amounts of hairs (FUs). They are simply distributing the
FUs in a different way.
● A second point is that the numbers of grafts needed to
produce average first-session densities of 25 to 30 FUs/
cm2 or higher are simply not used in typical cases of
either CMM or FUT. Chart 12D-3 shows the actual num-
bers of FUs needed to obtain single-session densities of
approximately 25 follicular unit grafts (FUGs)/cm2 in
different regions.
Chart 12D-2 Actual densities produced by one session of 1800 ● When densities of 25 to 30 FUs/cm2, or higher, are pro-
follicular units in various recipient areas. duced in a single session, it is usually limited to smaller
442 Chapter 12
of grafts to the actual size of the regions being treated to get

a more accurate estimation of the densities we produce.
Our Challenge: Creating the Illusion of Density

As stated before, a major challenge in hair restoration surgery
is to create the illusion of density (or appearance of fullness)
at lower than normal mathematical densities. Fortunately, this
goal is achievable; otherwise, hair restoration surgery would
not be possible.
The major factor that allows us to achieve this goal is that
the appearance of fullness can be maintained until approxi-
mately 50% of the original hair volume is lost. This long-held
and widely accepted dermatologic concept was verified in a
study by Marritt, who demonstrated that parted hair in a 1-cm
area did not begin to appear thin or to widen until approximately
50% of the original hair was lost (4). This same principle can
Chart 12D-3 Follicular units (FUs) needed to produce a density be applied in reverse when replacing hair (i.e., we need to re-
of approximately 25 FUs/cm2 in various recipient areas in a single place hair only to approximately 50% of its original volume)
session. (Fig. 12D-7). In reality, the appearance of fullness is not only
determined by the quantity of hair in a given area but also by
the effectiveness of this hair in creating this illusion. Therefore,
the actual amount of hair needed may be higher or lower de-
pending on this capability. Stated another way, equivalent
areas where higher densities are aesthetically critical,
amounts of hair can appear thicker or thinner depending on
such as the frontal tuft and the central regions.
how effective this hair is in creating the illusion of density. The
Ongoing confusion regarding the true densities achievable with effectiveness of hairs’ ability to create an illusion of density in
different techniques is partially caused by the inappropriate as- turn is determined by the optical effects of a number of factors
sumption that densities achievable in the small areas used in including hair shaft characteristics, color contrasts, angle of
survival studies are the same as those created when larger replacement, orientation, and distribution (or spacing) between
gions are treated in actual practice. We need to relate the number individual FUs.
Figure 12D-7 A schematic drawing illustrating the change in the appearance of fullness as hair loss progresses. It also shows the effect
of replacing hair with one or two sessions of follicular unit transplantation at densities of approximately 25 FUs/cm2 per session.
To better appreciate how the aforementioned factors exert surface area of the hair lies between the scalp and the
their influence, it is useful to understand the basic optical mech- eye.
anism behind the creation of the illusion of fullness. ● Orientation of Hair—Grafts can be placed in the recipi-
ent area, with the incisions oriented either sagitally or
coronally (or somewhere in between). It has been pro-
Optical Mechanism Behind the Creation of the posed that when grafts are placed coronally, they create
Illusion of Fullness a greater illusion of density because the linear distribu-
tion of hairs in the grafts creates more of a wall between
● We perceive an individual as having thinning hair when
the scalp and the eye (see Chapters 12F and 23C). This,
we begin to see scalp appearing through the hair.
depends on the direction from which the patient is being
● In general, we see objects by means of the light waves
viewed, and is theoretically true from the front and top
that they emit and that reach our eye. Objects of different
views. In addition, it has been proposed that grafts placed
color send off (or reflect) different wavelengths of light.
in coronal incisions can be angled more acutely, which
● On the head, light waves can potentially reach our eye
in turn can create a greater shingling effect. One reason
from either the hair shaft or the scalp.
this technique is not used more frequently is the concern
● Before observed thinning occurs, the light waves from
that a large number of coronal incisions may interrupt the
the scalp are blocked by the surface area of the hair
blood supply to a greater degree than sagittaly oriented
shafts interposed between the observer’s eye and the
incisions. This was probably true when coronal incisions
scalp. Thus, before thinning becomes noticeable, we can
were used with the larger-sized blades needed for multi-
see only the light reflected from the hair shafts and not
FU grafts. However, for FUs, the introduction of very
that reflected from the scalp.
small, razor-sharp blades, combined with tumescence in
● At a certain critical point in the progression of hair loss,
the recipient area, may overcome this obstacle (see
light waves from the scalp are able to pass through the
Chapter 23C).
existing hair and our eye is now able to see the light
● Distribution (or spacing) between individual FUs—The
reflected from the scalp. The contrast that the eye picks
more space that exists between two individual FUs, the
up between the light reflecting off the hair and the light
more room exists, at that spot, for light to pass through
reflecting off the scalp is what we perceive as thinning.
and reach the eye. The less space that exists between
● Any factor that limits the amount of light passing be-
two FUs, the less room exists for light to pass between
tween the hairs increases the appearance of fullness.
them. Both Unger and I believe a clinically relevant
● Any factor that limits the difference in wave length (and
difference between FUs and multi-FU grafts, with re-
hence the contrast) between the light waves reflected
spect to their ability to create the illusion of density,
from the scalp and the light waves reflected from the
is related to differences between them with respect to
hair also increases the appearance of fullness.
distribution and spacing of FUs (see also Chapter 12F).
Applying these basic principles to hair loss helps elucidate how The following example illustrates this point:
different factors increase or decrease the illusion of density. For ● Assume that exactly the same amounts of donor tis-
example: sue (and therefore the same numbers of hairs or FUs)
have been harvested and placed in equivalent areas
● Intensity of Lighting—With bright lights there is a by either FUT and CMM. The same average mathe-
greater quantity of light that will reach the scalp and matical density would have been created, but the
subsequently will reflect off the scalp and reach the eye. relative distribution (or variation in spacing), be-
The opposite is true with lower lighting. tween the individual FUs in this area would be dif-
● Wet Hair—The reason why hair appears thinner when ferent.
wet is that individual strands of wet hair tend to cling ● If total FUT were used, the distance between any
together and therefore decrease the surface area of the two FUs would always be greater than that seen in
hair interposed between the scalp and the eye. the donor area scalp. Even when a density of 50
● Color Contrast—Products that are used to color the FUs/cm2 is created with multiple procedures, no two
scalp exert their effect by making the wavelength of light individual FUs are as close together as found in na-
reflected from the scalp similar to that reflected from ture. Light has the ability to find and pass through
the hair shaft, thereby eliminating the contrast between all these spaces.
the two entities. This is the also the mechanism by which ● When multi-FU grafts are used, the space between
a naturally low contrast between hair color and scalp the FUs within the multi-FU grafts is at normal den-
color increases the illusion of density. sity (or higher than normal density if a degree of
● Hair Curl and Caliber—Curly hair and high-caliber hair contraction occurs). Light has a more difficult time
are more effective at creating the appearance of fullness passing between the FUs within the multi-FU at
because these characteristics increase the amount of hair these specific points of higher density. Thus, multi-
surface area in the given volume of space that is inter- FU can create a greater perceived density despite
posed between the scalp and eye. the fact that an equivalent amount of hair may be
● Angle of Hair Leaving the Scalp—The shingling effect transferred as FUs.
that occurs when hair is placed at a more acute angle An analogy may help to illustrate how the two aforementioned
positions the hair in such a manner that more of the factors—orientation and distribution of spacing—can affect the
444 Chapter 12
Figure 12D-8 (a, b), Major components of a follicular unit transplant procedure: Graft type equals one-hair to four-hair follicular units
(FUs) at densities of 20 to 30 FUs/cm2. The session size can be large or small depending on the area being treated.
Figure 12D-9 Male hairline recreated exclusively with follicular units (FUs). (a), Before surgery (b), immediately after placement of
1500 FUs, and (c), results one year postoperatively.
illusion of density. Imagine three playing cards placed in front to 30 FUs/cm2 —and occasionally higher—(Figs. 12D-8a, b).
of you. If they are placed sideways, it is easy to see past them. What is meant by properly prepared is discussed elsewhere in
If they are placed broadside, they block the light completely this text. It is important to note that my definition of TFUT
and appear like a solid wall. One realizes that the exact same does not necessarily mean the use of extremely large numbers
quantity of cards can create a totally different illusion depending of FUs. The number of FUs used depends on the size of the
on their distribution and orientation. recipient area being treated. If a large area is being treated (i.e.,
In the following section, I discuss how the properties just both the frontal and midscalp regions), the number of FUs used
described influence my decision to use FUs or FUs and multi- may be high (1500 to 2000 or more grafts). If a smaller area
FU grafts in different situations. is being treated (e.g., early temporal and hairline recession) the
number of FUs used may be lower (1000 or less). It is the ability
to successfully place one-hair to four-hair FUs at densities of
WHY AND WHEN TOTAL FOLLICULAR UNIT 20 to 30 or more FUs/cm2 in large or small areas that gives
TRANSPLANTATION this procedure its power. This ability has enabled me to meet
the goals of selected patients and to treat certain regions of the
For many years, I have lectured and written about the benefits
recipient area in a way I simply could not do in the past. Exam-
of FUT, and I still believe it is one of the most powerful tools
ples of these types of cases are shown in Figs. 12D-9 through
in hair restoration surgery. It is the cornerstone of most of my
Fig. 12D-14.
procedures. For the sake of clarity, I would like to define the
context in which I use the term total FUT (TFUT) in this chap- Naturalness and Follicular Units
ter. My definition of TFUT refers to the exclusive use of prop-
erly prepared, one-hair to four-hair FUs in selected regions of Much of the value of FUT is the high degree of naturalness
the recipient area, placed at densities typically ranging from 20 that can consistently be produced in a single session. The impor-
Figure 12D-10 Lowering a naturally high female hairline exclusively with FUs. (a), Before surgery, (b), immediately after placement
of 1300 follicular units, and (c), results 1 year postoperatively.
446 Chapter 12
Figure 12D-11 Recreating the temporal points and hairline exclusively with follicular units (FUs). (a), Before treatment, (b), immediately
postoperatively after placement of 1500 grafts, and (c), 1 year after two sessions of approximately 1200 FUs. This patient had his hairline
lowered. His frontal-temporal angle (x) was shifted forward. His temporal points (y) were re-created with the hair pointing in a more
posterior direction.
Figure 12D-12 Recreating temporal points and hairline exclusively with follicular units (FUs) in a patient with dark, coarse hair. Hair
loss was due to traction alopecia (a), Before treatment, and (b), 1 year after two sessions of approximately 1200 FUs each.
Figure 12D-13 Recreating the lateral hump area exclusively with follicular units (FUs) (recession of the lateral fringe): The white line
represents the location of the lateral hump (a), before transplantation and (b), one year after two procedures (of approximately 1800 FUs
cach), parted through the fringe area; and (c), a close-up view.
tant terms used in the previous statement are degree, consis- is useful in, for creating nonlinear patterns and gradients
tency, and single session. It is this consistency of naturalness in density. However, it must be reiterated that simply
in the first session (and conversely, the decreased need to worry using FUs does not guarantee that these natural arrange-
about plugginess) that has led to much of its popularity. ments and distributions occur. Improper placement of
Naturalness is the absence of visual cues that draw the atten- FUs in a linear pattern can still lead to hairlines that are
tion of the eye. With respect to the grafts used in hair transplan- too abrupt, straight, or harsh (Fig. 12D-16). An unnatural
tation, naturalness can be addressed on two levels: the natural- appearance can also occur when FUs are not blended
ness of an individual graft standing alone and the naturalness of into adjacent areas that contain residual miniaturized na-
the patterns and distribution of multiple grafts placed together. tive hair. An example of this is a pattern of transplanation
in which only the lateral aspects of the hairline in early
● The naturalness of an individual FU graft standing temporal recessions were treated, without the grafts also
alone—A transplanted FU has the ability to be indistin- having been blended and connected across the middle
guishable from a naturally occuring FU. As noted earlier, hairline area. If blending is not done, we may create two
this allows FUs to be undetectable after only a single populations of hair with different characteristics, right
session. (Fig. 12D-15 a and b) It is, however, important next to one another. The higher caliber donor hair creates
to note that use of FUs does not automatically ensure contrast and appears unnatural when viewed next to the
naturalness. To ensure a high degree of individual natu- finer, miniaturized native hair. This same principle ne-
ralness, FUs still have to be chosen, cut, and placed prop- cessitates the blending of transplanted hair into other
erly. If FUs contain excess epithelium and are placed adjacent areas of miniaturized hair; for example, the
too deeply, they can potentially appear pitted. They may miniaturized hair posterior to the hairline. It is important
also appear unnatural if they are too coarse for the given to recognize the existence of the aforementioned poten-
region in which they have been placed. tial problems. However, with skillful use of FUs and
● The naturalness of the pattern and distribution of multi- knowledge of natural patterns (see Chapters 5A and 5C),
ple grafts placed together—The tininess of FUs makes the potential for the unnatural appearance of FUs is very
them useful, similar to the way in which a tiny paintbrush low, and a natural look can be consistently created.
448 Chapter 12
Figure 12D-14 Repair of third-degree burn scar in the temporal and hairline areas with exclusive use of follicular units (FUs). a),
Before transplantation, showing severe burn in the temporal hairline area with thin skin grafts; (b), after two sessions of 1500 FUs each;
and (c), close-up view.
It is important to arrange and distribute grafts in such a way 12D-17); and the ability to selectively concentrate these larger
that they mimic nature and do not attract attention. Placement FUs in localized areas (Fig. 12D-18). The use of ‘‘recombinant
and distribution should be nonlinear and create gradual changes FUT’’ also called ‘‘follicular unit pairing’’ adds to the ability
in density that do not cause the appearance of contrast. This is of FUs to produce single-session density, Figs. 12D-19a, b, and
discussed more fully in Chapters 12F and 12G. Contrast (or c and 12D-20 (see Chapter 12E). It is worthwhile noting that
two entities that visually clash when seen next to each other) even Unger agrees with this position (see Unger’s commentary
draws the attention of the eye and makes the observer realize on Chapters 12B and Chapter 12F).
there is something unnatural about the hair. A more importantly and clinically relevant point is that these
three-hair and four-hair FUs produce the highest degree of den-
Density and Follicular Units sity in a single session that is still undetectable. It is this unique
property of FUs that makes them the graft of choice for specific
In a single session, TFUT also has value with respect to the situations or regions of the recipient area that require the best
combination of naturalness and density that can be produced combination of naturalness (undetectability) and density in a
in localized areas. I believe that in skilled hands, the larger single session.
three-hair and four-hair FUs have the potential to produce a As stated elsewhere in the text, less than perfect technique
higher mathematical hair density, in a single session, than DFU, can potentially lead to lower survival and densities. The level
TFU, or slit grafts. This ability is owed to two factors: the low of skill necessary is achievable, but a physicians must be honest
tissue-to-hair ratio of three-hair to four-hair FUs compared with with themselves about their level of skill (as well as the skill
that of multi-FU grafts with an equivalent amount of hairs (Fig. level of skill of their staffs) and take this factor into considera-
Figure 12D-15 Follicular units (FUs) can be indistinguishable from native hair. (a), Macrophotography of FUs one day postoperatively;
(b), macrophotography of FUs after they have grown for approximately 1 year. They are indistinguishable from native FUs. The arrows
point to three-hair FUs.
Figure 12D-16 Example of too straight a hairline created ex-

clusively with follicular units (FUs). Use of FUs does not automati- Figure 12D-17 Follicular units (FUs) are smaller than slit
cally mean the appearance will be natural. Proper distribution and grafts with an equivalent amount of hair: Follicular units have a
placement are also necessary. smaller tissue to hair ratio than small and medium slit grafts. There-
fore, FUs are smaller than small and medium slit grafts with an
equivalent number of hairs. They can be put into smaller incisions
and packed closer together. Notice that the three-hair FUs (x) are
smaller than the three-hair small slit grafts (y) that are cut to size.
450 Chapter 12
Figure 12D-18 Selective distribution: Separating and selectively placing one-hair, two-hair, and three-hair follicular units (FUs) allows
the surgeon to have precise control over the distribution of hair density. The transition zone (TZ) should contain primarily one-hair FUs.
Two-hair to three-hair FUs are used in the Defined zone (DZ) and the Frontal Tuft area (FT). Density in the FT area has a high aesthetic
impact. The Central area can use FUs or multi-FU grafts. Multi-FU grafts were used in this case.
Figure 12D-19 (a, b, c), Follicular pairing: Sometimes, there are more one-hair grafts than needed, and more two-hair and three-hair
FUs are desired. With follicular pairing, a two-hair graft can be artificially created by combining two one-hair grafts (or a three-hair graft
can be created by combining a one-hair grafts and a two-hair graft).
Figure 12D-20 Follicular pairing to increase density: By using follicular pairing, the density can be increased in an area without
creation of more incisions. All incisions in this area were made with a 15-degree sharp-point blade. Examples are shown of two hairs,
three hairs, and four hairs placed in incisions either as a single graft or as a paired FU. A dotted line shows how density can be increased
by adding a one-hair graft to a two-hair graft to make it a three-hair graft.
tion when making decisions about use of TFUT, the number ● Very particular patients who tolerate no degree of detect-
of FUs per session, and the level of FUs density. ability at any stage of the surgery.
● Patients with a low donor-to-recipient area ratio, who
When to Use Follicular Units may not have enough reserves to create a natural look
without depleting the donor area if multi-FU grafts are
The following regions of the recipient area, in my opinion, used initially.
should always be treated with FUs: ● Patients who have depleted donor reserves from past
surgery and need titration of the smallest number of
● The hairline area (see Figs. 12D-9 and 12D-10). This grafts in an area that will produce the desired effect and
includes the transition zone of the hairline (approxi- thereby conserve donor tissue for other areas in the fu-
mately the anterior first centimeter of the hairline) and ture.
a variable area behind the transition zone that I consider ● Patients with very poor hair characteristics that increase
part of the hairline and call the defined zone. Together, the risk of plugginess (e.g., dark, coarse hair on light
the transition zone and the defined zone take up much skin).
of the frontal third of the balding area. My reasons and ● Patients who may not proceed with a second surgery
method of treating this area with FUs are discussed in either for financial reasons, time constraints, or the need
more detail later. to travel.
● The temporal points and sideburns (see Fig. 12D-12).
● Eyebrows, eyelashes, mustache, and beard (see Figs.
15A-2 and 15A-4). WHY, WHEN, AND HOW TO USE MULTIPLE
● The receding lateral fringe (or lateral hump area) (see FOLLICULAR UNIT GRAFTS
Fig. 12D-13).
● The most posterior portion of the crown. Naturalness and Multiple Follicular Unit Grafts
● Scar tissue (see Fig. 12D-14).
There is no question that after a single session, multi-FU grafts
The following situations also meet the requirements for the look less natural in an area than FUs. The questions are: How
exclusive use of FUs: clinically significant is this degree of unnaturalness in the less
452 Chapter 12
scrutinized central region of the recipient area? Does the unnat- Unger has noted, the more original hair that persists in the
ural appearance persist after multiple sessions? This is partially recipient area, the finer textured or curlier the hair, and the less
determined by the type of multi-FU graft used and the skill skin-to-hair color contrast, the less noticeable the difference.
with which it is used. If large multi-FU grafts with too many More importantly, after a second session of FUs (or the simul-
hairs are put into too small an incision, they will produce a taneous placement of FUs between the multi-FU grafts during
pluggy, pinched appearance. This is especially true for high- the same session), this contrast and abnormal spacing disap-
color contrast and coarse hair. However, if smaller multi-FU pears (4) (see Chapter 12F).
grafts such as linear slit grafts that contain from two to three
FUs lined up one behind each other are placed skillfully in Density and Multi-FU Grafts
appropriately sized incisions, they can look just like multiple For approximately 2 years, I have considered the possibility
individual FUs placed one behind each other. Compression is that, in selected patients, the addition of multi-FU grafts to the
limited owing to the linear distribution of the FUs behind each less scrutinized central recipient area may improve the final
other. A slit graft with two FUs (a DFU) is shown in Fig. 12D- illusion of density I can achieve without sacrificing naturalness
21a and b. This graft stands on its own, appearing as if two to a clinically significant extent. This central recipient area in-
natural FUs were emerging from the scalp, one behind the other. cludes the mid-scalp region and the posterior aspect of the fron-
After a single session, skillfully placed slit grafts of this type tal region (frontal core). A recurrent observation that led me to
still appear slightly unnatural. This is not due to the individual reconsider the use of multi-FU grafts in these locations was the
appearance of each graft but rather to the necessary amount of high degree of naturalness and sometimes better density that
space that has to exist between each such graft in a single ses- resulted when I performed a TFUT procedure on patients who
sion. This creates an initial contrast of two different densities: had undergone previous CMM procedures.
(1) the normal (or possibly slightly increased) density of the I asked myself the question: Are there some properties of
FUs within the slit graft, and (2) the wider spaces between multi-FU grafts that create a greater illusion of density than
these slit grafts themselves. It is the contrast between these two FUs used alone? My current answer to this question is yes. I
different densities that draws the attention of the eye and leads believe that at the lower than normal mathematical densities
to a slightly unnatural appearance. The difference in the degree created during hair transplantation, multi-FU grafts have the
of naturalness between FUs placed in the hairline area and small ability to create a greater illusion of density with the same
or medium slit grafts placed in the central region after one amount of hair than when FUGs are used alone.
session is shown in Fig. 12D-22a, b, c, and d. This difference The reason for this was explained earlier in this chapter
is not noticeable except when viewed from above with the hair under the section ‘‘Optical Mechanism Behind Creating the
parted and under relatively close examination. Moreover, as Illusion of Fullness’’. It is worth a brief review here:
Figure 12D-21 (a), Macrophotography of a small slit graft with two FUs, and (b), a small slit graft after growth appears like two FUs
lined up one behind the other.
Figure 12D-22 Clinical difference in degree of naturalness between small slit grafts and FUs after one session. (a), Before transplantation
FUs are shown in the hairline and in the anterior portion of the frontal region, and small slit grafts are shown in the central region. (b),
Frontal view after one session; small slit grafts are undetectable from this view. (c), Top view from a distance after one session; small slit
grafts are still undetectable. (d), Close-up top view after one session; small slit grafts are more noticeable than the follicular units (FUs)
in this situation. The question is: How clinically significant is noticeability in the less scrutinized central area if it disappears after a second
session of FUs or small slit grafts?
454 Chapter 12
● When multi-FU grafts are used, the space between the contrast hair—especially white hair—and preexisting
FUs within these grafts is at normal density (or higher hair in the recipient area).
than normal density if a degree of contraction occurs). ● I lean toward using multi-FU grafts if I know the patient
Light has a more difficult time passing between the FUs has enough donor hair for multiple sessions and that a
within the multi-FU grafts at these specific points of higher final illusion of density is an important considera-
higher density. Thus, an equivalent amount of hair tion.
placed as multi-FU grafts gives one the ability to create ● If I choose to employ multi-FU grafts, I primarily use
an optical effect that lends a greater illusion of density small or medium slit grafts that contain from two to three
than FUs alone. FUs. The FUs in these grafts are aligned linearly and,
as noted earlier, if this is done properly, it can appear
The thought process and logic that led me to reconsider the use
as if multiple natural FUs are lined up behind each other.
of multi-FU grafts in the central region of specific patients were
● I always place a large number of FUs (approximately
as follows:
800 to 1500 FUs) anterior to these grafts to minimize
● If the degree of unnaturalness created by skillfully their noticeability in the same session.
placed multi-FU grafts in the less scrutinized central ● I usually stick and place three-hair or four-hair FUs be-
region is minimal and clinically insignificant in the first tween the multi-FU grafts during the same session to
session minimize noticeability.
● If this degree of unnaturalness disappears after multiple
sessions when FUs are added between themulti-FU Although we have come from different starting points, the fore-
grafts; going approach has more similarities than differences to that
● If the use of multi-FU grafts enables us to create a currently being used by Unger (see Chapter 12F). He does,
greater final illusion of density in this central region however, employ multi-FU grafts in a higher percentage of his
than we could achieve with the same number of hairs patients than I do and also occasionally uses larger multi-FU
placed exclusively as FUs; grafts such as small slot grafts or small round grafts.
● It follows that the use ofmulti-FU grafts in the central
area may enable us to meet our patients’ goals of density
(without sacrificing naturalness) better than with use of HOW TO USE FOLLICULAR UNIT
FUs alone. TRANSPLANTATION IN THE HAIRLINE AND
OTHER APPROPRIATE AREAS
It is important to point out a key distinction between the ways
I use multi-FU grafts and the way I commonly see them used: Creating a natural hairline is one of the most important elements
● I still primarily do a TFUT procedure, with the majority of a successful hair transplant. Many of us promise undetectable
of my grafts being FUs. However, at the same time, in hairlines in our marketing materials and literature. As a result,
selected patients, I add a proportion of multi-FU grafts the degree of naturalness demanded by patients has dramatically
to the central area in the hope that they will enhance increased. Today, patients expect an undetectable hairline that
the final appearance of density. can stand on its own after one session. They no longer tolerate
● As stated earlier, many CMM procedures in the past an embarrassing ‘‘grafty’’ phase. This also holds true for other
used mostly multi-FU grafts use minigrafts with only a highly visible regions of the recipient area, such as the temporal
relatively small number of FUs. I believe that the prob- points, lateral fringe, and posterior aspect of the crown. To meet
lem with older CMM procedures is not that they use this expectation requires creation of the best combination of
some multi-FU grafts in the central area, but that they naturalness (undetectability) and illusion of density in the first
do not use enough FUs in the hairline zone at the same session. This can best be achieved by using FUT and the princi-
time. ples described in the following section.
When and How to Use Minigrafts An Extended Hairline Zone That Includes a
‘‘Transition Zone’’ and a Defined Zone (Figs. 12D-
The following are the situations and methods in which I add
(or do not add) multi-FU grafts to a an FUT procedure: 23 and 12D-24)
● I do not use multi-FU grafts if the patient meets the Most discussions about hairlines focus only on the most anterior
criteria for exclusive use of FUs (see earlier). border of the hairline, commonly referred to as the transition
● I only use multi-FU grafts in the central recipient area, zone. In contrast, I conceive of a larger extended hairline zone
which includes the midscalp and the posterior aspect of bridging the bald forehead to the area of central density. I divide
the midfrontal region (frontal core). This area is approxi- this extended hairline zone into two smaller zones:
mately 70 cm2 to 100 cm2, and I usually place anywhere ● the anterior portion called the transition zone and
from 200 to 400 multi-FU grafts in this area at one time. ● the posterior portion called the defined zone. The most
● I lean toward using multi-FU grafts in this central region central portion of the defined zone includes a small oval
if the potential for transection and waste with the exclu- area I have called the frontal tuft.
sive use of FUs is high (white hair, fine hair, or an un-
skilled staff). This extended hairline zone basically occupies the anterior por-
● I lean toward using multi-FU grafts if the potential for tion of the frontal region described by Beehner in Chapter 5A.
unnaturalness is low (fine hair, curly hair, low color- The transition zone should be soft and irregular, whereas the
Figure 12D-23 Hairline zones. I see the hairline as consisting of two zones: the anterior portion (transition zone) and the posterior
portion (defined zone). The transition zone should be soft and irregular, and the defined zone should be more defined and dense. Both
these zones are important to the overall appearance of the hairline.
Figure 12D-24 Properties of a natural hairline: This figure shows my own untransplanted normal hairline. The dotted line separates
the transition zone from the defined zone. Notice the areas of intermittent increased density (variable density) within the transition zone.
456 Chapter 12
defined zone and ‘‘frontal tuft’’ should be more defined and

dense. I think that both these zones make important contribu-
tions to the overall appearance of the hairline, and both should
be created exclusively with FUs.
Transition Zone
The transition zone consists of the first .5 cm to 1 cm of the
hairline. It should initially appear irregular and ill defined but
gradually take on more definition and substance as it reaches
the defined zone. The most common advice given about creating
the transition zone has been to make sure that the anterior
border of this zone is irregular and does not follow a straight
line. This is correct, but the following additional principles are
also important to keep in mind when attempting to recreate a
natural transition zone:
● It is important to vary the density along the transition
zone. Close observations of normal hairlines reveals that
intermittent areas of higher density contribute a great
deal to the appearance of irregularity (Fig. 12D-24).
● Only one-hair FUs should be used in the anterior portion
of this zone, with a shift to two-hair FUs toward the
posterior portion.
● One-hair FUs can vary in caliber. Having the assistants
specifically search for and separate approximately 75 to
100 of the finest one-hair grafts for use in the most ante-
rior portion of this zone adds to the surgeon’s ability to
produce naturalness. In addition, it has been postulated
that using some one-hair FUs with the bulb removed at Figure 12D-25 It is postulated that single-hair follicular units
the most anterior portion of the transition zone may be can have their bulbs removed in this area in an attempt to create
useful if hairs of especially fine caliber are needed (Fig. a hair of finer caliber.
12D-25) (5).
● There is a natural tendency to fill in the spaces in the
transition zone. This impulse must be overcome to pre-
vent the creation of a hairline that looks too straight or ‘‘Properly’’ Trimmed Follicular Unit Micrografts
too solid.
● It is also important to adjust the width of the transition Most physicians will state that only micrografts should be used
zone based on the severity of hair loss. The greater the in the hairline area. However, this statement is not specific
degree of hair loss, the wider and more diffuse this transi- enough, because all micrografts are not the same. Micrografts
tion zone should be, mimicking the pattern found when can vary significantly in size and shape depending on the skill
more severe hair loss occurs in nature. and technique used to create them. Properly trimmed FUs have
the advantage of being smaller than untrimmed micrografts with
similar numbers of hairs (Fig. 12D-27). This enables them to
The Defined Zone and the Frontal Tuft (see Fig. 12D-
be placed in smaller incisions that can be closer together. Addi-
23) tionally, the minimal amount of epithelium left on these FUs
The defined zone is the area 2 cm to 3 cm wide, that sits directly limits the potential for pitting, which can still occur when un-
posterior to the transition zone. The frontal tuft is an oval area trimmed micrografts are placed too deeply. If enough one-hair
that is located in the midline directly behind the transition zone. FUs can not be found naturally, they can be created by carefully
As noted earlier, the hairline in these areas should develop a dissecting away finer hairs from existing two-hair and three-
higher degree of definition and density yet still appear totally hair FUs. Careful division of hairs within an FU does not appear
natural (undetectable) under close examination. Concentrating to impair the viability of the resulting follicles (see Chapter 9).
two-hair to three-hair FUs in this area accomplishes both goals In the early years of FUT, as much epithelium and extra
nicely. Density in these zones creates a fuller looking hairline tissue as possible were trimmed from grafts. This may have
by limiting the distance that can be seen past the transition contributed to some of the poor densities seen with early TFUT.
zone. It creates this effect without placing hair directly in the This extensive trimming created very tiny, fragile grafts with
transition zone, thereby limiting the chance of creating a hairline unprotected hair shafts that were potentially more susceptible
that appears too straight or too solid. to graft trauma and especially dehydration. In addition, unseen
Figure 12D-26a, b, and c shows the author’s normal (un- telogen follicles were at risk of being discarded in this process
transplanted) hairline next to two hairlines recreated with trans- (2,6). An improvement in the technique has been the preparation
plantation. Notice how the intermittent density in the transition of chubby, pear-shaped FUs (see Fig. 12D-27), which includes
zone blends into the greater substance of the defined zone. trimming away excess epithelium but leaving more tissue
Figure 12D-26 Comparing normal untransplanted hairlines with transplanted hairlines. (a), My untransplanted hairline, (b and c),
Transplanted hairlines.
Figure 12D-27 Trimmed vs. untrimmed follicular units (FUs). (a), Untrimmed FUs and (b), trimmed FUs. The teardrop shape of FUs
has minimal surface epithelium but still has tissue around the sebaceous gland and root. If FUs are created this way, they are smaller than
untrimmed FUs, which enables them to be placed closer together by means of tinier, less traumatic incisions.
458 Chapter 12
around the inferior portion of the graft (see Chapter 11B). I

believe the term chubby is a misnomer, because these grafts,
especially the three-hair and four-hair FUs, are still smaller than
grafts with equivalent amounts of hair where deliberate shaping
and trimming of the graft does not occur.
Excising a Single Donor Strip and Slivering with

the Microscope to Prepare Large Numbers of
Follicular Units
Controversy exists as to whether the use of single-strip donor
harvesting and microscopic dissection should be included in
the definition of TFUT. There is a difference between including
a parameter in a definition vs. believing that the parameter
improves results. As stated earlier, my definition of FUT is
simply the use of one-hair to four-hair FUs at densities of 20 Figure 12D-28 Estimated area of the hairline zone: The total
to 30 or more FUs/cm2 I don’t believe that the use of the micros- hairline area is the combination of the transition zone (TZ) and the
cope should be included in the definition of FUT; however, I defined zone (DZ). The average size of the total hairline area ranges
do believe that single-strip donor harvesting and microscopic from 20 cm2 to 30 cm2. At 20 to 30 FUs/cm2, it takes about 400
slivering should be used to ensure the best results when creating to 900 FUs to fill this area.
large numbers of FUs. My belief in the need for single-strip
harvesting and microscopic slivering to limit transection and
waste, when large numbers of FUs are prepared is discussed
in Chapter 11C. ber of two-hair or three-hair FUs in the defined zone and frontal
tuft areas. In such circumstances, a technique called follicular
Early Graft Testing Ensures Ease of Placement pairing can be used. This is the process whereby artificially
Later in the Procedure larger FUs can be created by combining smaller FUs (see Chap-
ter 12E). A two-hair graft can be artificially created by combin-
The importance of testing the fit of FUs to the recipient site, ing a pair of one-hair FUs; a three-hair graft can be created by
for assurance of nontraumatic placement and higher survival, combining a one-hair and a two-hair FU; and a four-hair graft
is discussed in Chapter 13A. can be created by combining a pair of two-hair FUs. The mini-
mal extra tissue and small size of the FUs allows for the process
Use of Selective Separation and Distribution (see of follicular pairing.
Fig. 12D-18)
Separating and selectively placing one-hair, two-hair, and three-
Use of Enough Follicular Unit Micrografts in the
hair FUs allows precise control over the distribution of mathe- Extended Hairline Zone During the First Session to
matical hair density. There are some techniques of creating mi- Ensure Naturalness and Substance
crografts (such as the Automatic Impulsive Force graft cutter) Sufficient numbers of FUs should be placed in the extended
that do not allow the separation of different sizes of grafts. hairline zone (transition zone plus defined zone) during the first
When these techniques are used, one-hair, two-hair, and three- session to ensure that it will be natural as well as have enough
hair micrografts are lumped together and the benefit of selective substance to stand on its own independent of further sessions.
distribution is lost. To accomplish this a density of approximately 20 to 30 FUs/
The advantages of selective distribution cannot be over- cm2 is required. This area can range in size from 20 cm2 to 30
stated. As discussed earlier, the anterior portion of the transition cm2. This necessitates that a minimum of 400 to 900 FUs be
zone should contain only one-hair FUs with a shift to two-hair placed in these zones during the first session (Fig. 12D-28 and
FUs toward the posterior aspect of this zone. Larger two-hair Table 12D-1).
to three-hair FUs should be placed in the defined zone, concen- Many CMM procedures consist of only 100 to 300 FUs in
trating more three-hair FUs in the midline central portion of the hairline before the switch is made more posteriorly to multi-
this zone (the frontal tuft area). Creating density in this frontal
tuft area has a high aesthetic impact, contributing to a greater
illusion of overall density and mimicking a pattern commonly
found in nature. The distribution is possible only when FUs Table 12D–1 Follicular Units Needed to Create a Density of
can be and are methodically separated and used in the previ- 20 to 30 FUs/cm2 in an Extended Hairline Area of 30 cm2
ously noted fashion.
Hairline area 20 cm2 25 cm2 30 cm2
Use of Follicular Pairing (see Figs. 12D-19a, b, and FUs needed for 400 FUs 500 FUs 600 FUs
c and 12D-20) 20 FUs/cm2
FUs needed for 600 FUs 650 FUs 900 FUs
Sometimes more one-hair FUs are created than are needed. At 30 FUs/cm2
the same time, it may be more desirable to have a greater num-
FU grafts. In my opinion, it is not the use of multi-FU grafts more severe degrees of hair loss, raising the hairline by as much
posterior to the hairline area but the use of too few FUs within as 1 cm to 2 cm may be appropriate. Sometimes a properly
this extended hairline region that limits the natural appearance constructed widow’s peak can be used to create the illusion of
created by this method in the first session. A slight increase in a slightly lower hairline without actually lowering the hairline
the width of the hairline area and a substantial increase in the zone inappropriately. This subject is discussed at length in
number of FUs would overcome this problem. Chapter 5A.
This number of FUs (400 to 900) is based on a conservative
degree of dense packing (20 to 30 FUs/cm2), which I think
most physicians have accepted as safe for FU viability. Higher Proper Placement of the Lateral Border of the
degrees of dense packing, defined here as 30 to 40 FUs/cm2, Hairline and the Fronto Temporal Angle (Fig. 12D-
may produce good hair survival in skilled hands, but this is 30)
more controversial and usually not necessary to produce a good
Virtually all mature male hairlines have a frontotemporal angle
cosmetic result. I believe the temptation to place grafts at very
that is formed by the junction of the frontal and temporal hair-
high densities should be resisted in the hairline, except under
lines. The frontal hairline is the superior border of this angle
certain limited circumstances. Otherwise, the hairline could be-
and the temporal hairline is the inferior border. The apex of
come denser than the central region and would produce an ab-
this angle moves posteriorly as the frontal and temporal hair-
normal ringlike effect when viewed from above. In nature, the
lines thin and recede. Properly positioning this point and re-
hairline area is typically less dense than the central region.
creating a soft fronto temporal angle is one of the more difficult
aspects of hairline recreation. This task is particularly suitable
Proper Placement of the Anterior Border of the for FUs. Blunting this angle or placing it too low causes an
Hairline (Fig. 12D-29) unnatural look.
Some of the common rules for estimating where the frontal
One of the most important principles of hairline placement is:
hairline should meet the temporal hairline are the following:
Do not place the hairline too low. Common guidelines for locat-
ing the anterior border of the hairline include the following: ● Draw a line from the lateral epicanthus of the eye back
● Four finger widths above the glabella toward a point where it meets the remaining temporal
● 8 cm to 10 cm above the glabella hair (7) (see also Appendix A in Chapter 12C).
● Where the horizontal plane of the scalp meets the vertical ● Make sure the hairline created by this point does not
plane of the face slope downward toward the ear but looks parallel or
slopes upward when viewed from the side (7) (see also
These rules for determining hairline placement are only guide- Appendix A in Chapter 12C).
lines that have to be individualized depending on the size and
shape of the head and the degree of alopecia. In patients with In mild-to-moderate hair loss, where there is only a little loss
of the temporal hair, these rules work well. The existing tem-
poral hair usually becomes the inferior border of the angle,
whereas the future anterior hairline becomes the superior border
of the angle. The apex of the angle lies on the line that was
drawn superiorly from the lateral epicanthus of the eye.
In more severe degrees of hair loss, where the temporal hair
has receded and the lateral fringe has dropped, finding this point
can be more difficult. There is no temporal hair with which the
lateral epicanthal line can intersect. Visualizing and recreating
what I call the lateral hump can help in these situations (Fig
12D-31a and b). The lateral hump is located superior to the ear
and is a semicircular area of hair that bridges the lateral fringe
to the midscalp region. It is the last part of the lateral fringe to
recede. If you look at normal lateral profiles, you can see that
an individual can be very bald and still retain this natural lateral
hump (Fig. 12D-31c). Visualizing and recreating such a lateral
hump gives the lateral epicanthal line a target to intersect. They
usually meet near the top of the hump or approximately 1 cm
anterior to a line drawn vertically from the auditory meatus.
The lateral hump usually becomes the inferior border of the
frontotemporal triangle.
It is important to take into account the fact that many younger
Figure 12D-29 Proper placement of the anterior border of patients will eventually lose the hair within these lateral humps.
the hairline. Common guidelines for locating the anterior border The surgeon should plan for this eventuality by either (1) trans-
of the hairline include (1) a four-finger width above the glabella, planting grafts through these areas before hair loss occurs (7)
(2) 8 cm to 10 cm above the glabella, (3) the point where the (see also Appendix A in chapter 12c), or (2) reserving enough
horizontal plane of the scalp meets the vertical plane of the donor tissue to transplant into these areas as hair loss progresses
face. in the future.
460 Chapter 12
Figure 12D-30 Proper placement of the frontotemporal angle in mild-to-moderate hair loss. Common rules include (1) drawing a line
from the lateral epicanthus of the eye to a point where it meets the remaining temporal hair; and (2) making sure that the hairline does
not slope down toward the ear but appears parallel or slopes upward. The existing temporal hair becomes the inferior border of the angle.
Adjusting the Hairline Downward (Fig. 12D-32a, b, used to find the proper angle and direction of hair in this
and c) area as well as occasionally assist in recreating cowlicks.
● The hair along the temporal hairline is pointed more
Patients often want a lower hairline than would generally be inferiorly toward the ear and leaves the scalp at a very
considered wise. There are two methods of using FUs that safely acute angle (almost flat). As one moves around the fronto
accomplish this goal: temporal angle, there should be a gradual transition in
● Creating a small widow’s peak in the midline is a rela- direction from pointing anteriorly in the frontal arm to
tively graft-economical way to produce the illusion of pointing inferiorly (and, occasionally, posteriorly) in the
a lower hairline temporal arm of this angle. Simultaneous, gradual
● Some patients may ask the surgeon to fill in the temporal change in angle takes place; from approximately 10 to
recessions and move the lateral aspect of the hairline 15 degrees in the frontal component to almost flat in the
lower. As noted earlier, the surgeon must be careful temporal component. There are nearly always residual
about filling in or blunting the normal fronto temporal miniaturized hairs that can act as guides for finding this
angle. I find that one way for me to lower this area in transition
a relatively cosmetically safe and graft-efficient manner
is to visualize the current angle and imagine sliding it
A STEP-BY-STEP SYSTEMATIC APPROACH IN
slightly forward.
USING FOLLICULAR UNIT TO CREATE THE
EXTENDED HAIRLINE AREA
Proper Direction and Angle (Fig. 12D-33)
The following is a step-by-step systematic approach that I have
It is also important to pay attention to the change in direction
found useful when creating my hairlines. It is not meant to be
and the angle of the FUs positioned around the hairline.
dogmatic. I know there are other methods that work just as
● The hair along the frontal hairline is usually directed well. This approach helps me to consistently and systematically
anteriorly, leaving the scalp at an angle of approximately build the initial framework of a hairline that I can later fine-
a 10 to 15 degrees. Existing miniaturized hairs can be tune.
Figure 12D-31 Proper placement of the frontotemporal angle in severe hair loss. (a), It is difficult to know where to place the apex
of the frontotemporal angle in severe hair loss when the lateral fringe has dropped. There is no temporal hairline for the lateral epicanthal
line to intersect. (b), Visualizing and recreating the lateral hump provides a helpful landmark. (c), The lateral hump is the last part of the
lateral fringe to recede and exists as a natural pattern in early hair loss.
462 Chapter 12
Figure 12D-32 Creating a widow’s peak and lowering the frontotemporal angle. (a), Before surgery, with a relatively high and flat
hairline. (b), Immediately after surgery showing lowering of widow’s peak area (x) and the frontotemporal angle (y) with the angle
maintained (dotted arrow). (c), One year after surgery, showing the aesthetic change that a relatively small amount of hair in the widow’s
peak and temporal area can create [dotted arrow, ‘‘x’’ and ‘‘y’’].
Mark and Draw the Hairlines Zones (Transition

Zone, Defined Zone, and Frontal Tuft) by Using the
Previously Described Principles (Fig. 12D-34)
Make Initial Marking Incisions Along the Anterior

Border of the Transition Zone (Fig. 12D-35a and b)
These marking incisions should be about 1 cm apart and slightly
irregular. Placing some anterior and some posterior to the drawn
line helps to create the irregularity. These marking incisions
ensure the position of the hairline will not be lost if the drawing
is accidentally erased, and allows safe movement toward the
defined zone.
Make Initial Marking Incisions at the

Frontotemporal Angle (Fig. 12D-35a and b)
Figure 12D-33 The normal angle and direction of hair in
the hairline and around the frontotemporal angle in a male pa- Look for existing hairs on both sides of the apex of the fronto-
tient with a crew-cut hair style. temporal angle to help determine the change in direction of the
placed in a staggered pattern at a density of approximately 25

FUs/cm2, thereby creating ‘‘organized disorder.’’ (It is a minia-
turized form of the ‘‘organized disorganization’’ that Unger has
long recommended for slit grafting (8). When small grafts are
placed at this density, the eye has difficulty recognizing this as
a pattern. It is preferable to random placement, which can lead
to unintentional skipped areas and an uneven distribution of
hair density.
Create an Initial Framework for the Transition

Zone (Figs. 12D-36a and b)
After the defined zone has been established, incisions are made
that connect the aforementioned marking incisions to the de-
fined zone. This creates an initial framework of multiple trian-
gle-like bridges that connect the transition zone to the defined
Figure 12D-34 Drawing the hairline zones and bringing zone. (The tips of these triangle-like areas are the marking inci-
the hairline forward. (1) Lateral hump, (2) transition zone, (3) sions that were initially made on the anterior border of the
defined zone, and (4) frontal tuft areas. After the initial drawing transition zone). The shape of each bridge resembles an elon-
is made, a more aggressive and lower hairline can be created gated triangle and contains approximately 6 to 10 incisions.
relatively safely with minimal grafts by creation of a small wid- The base of these triangles extends into the defined zone. When
ow’s peak (dotted line) and by shifting the frontotemporal angle
this procedure is finished, a framework exists for an irregular
forward (dotted line).
pattern in the transition zone. These triangular areas later be-
come the areas of increased intermittent density that help to
make the transition zone look more random and natural.
incisions as movement takes place around this angle. Make Make Multiple Passes by Keeping the Basic
some marking incisions alongside these hairs. Framework and Ratio of Density
Once the Marking Incisions Are Made, Begin After this framework is created, multiple passes and artistic
Making Incisions in the Defined Zone First, Before skills are used for refinement. These passes are made through
Working in the Transition Zone (Fig. 12D-35a, b) the transition zone. They fill in obvious spaces but keep the
same general pattern and care is taken not to eliminate the irreg-
This is one of the key techniques that help me to avoid making ularity. We try to create more incisions within the triangles than
too straight a hairline. By starting the Defined zone first and between the triangles. This approach accentuates the areas of
then moving anteriorly into the transition zone in an organized intermittent higher density within the transition zone, promoting
manner, I have more control. Incisions in the defined zone are further irregularity and naturalness.
Figure 12D-35 Early steps in creating the hairline. (a), Diagrammatic representation. (b), Actual patient. Place marking incisions (x)
along the anterior border of the transition zone (TZ). Make marking incisions (y) at the frontotemporal angle. Incisions (z) in the defined
zone (DZ) are created before work is done in the transition zone.
464 Chapter 12
Figure 12D-36 Later steps in creating the hairline: (a), Diagrammatic representation. (b), Actual patient. Marking incisions (xx) at the
anterior border of the transition zone. Incisions that connect the marking incisions (yy) to the defined zone (DZ), creating an initial irregular
framework with intermittent density. Multiple passes are made in the transition zone (TZ) to fine-tune this initial framework. Incisions in
the frontotemporal area (zz) follow the pattern of the existing hair for clues on direction and angle.
Figure 12D-37 Stick-and-place technique at the end of the procedure for fine-tuning. Follicular units (x) can be placed in the transition
zone to increase irregularity or in the defined zone to increase density. Longer hair on the grafts (y) gives an early impression as to what
the hairline will look like and helps with fine-tuning the procedure.
Place Grafts by Using Selective Distribution of grafts and then placed in the defined zone. Once again, it is
Follicular Units That Contain Different Numbers of best to concentrate more grafts in the frontal tuft region because
Hairs, and Follicular Pairing (Figs. 12D-18 to 12D- density in this region is crucial to an aesthetically pleasing ef-
20) fects.
The results after one session in the patient whose photo-
This type of placement promotes a natural density gradient and graphs have been used throughout this section are shown in
has been described earlier. Fig. 12D-38a and b. The results of the exclusive use of FUs
after two sessions are shown in Fig. 12D-39. The results of two
Final Stick-and-Place Fine-Tuning (Fig. 12D-37) sessions that used FUs in the extended hairline and small slit
grafts in the central area are shown in two other patients by
About 100 to 300 grafts are usually saved to further fine-tune Figs. 12D-40 and 12D-41.
the hairline at the end of the procedure. This is the point at
which physicians use their artistic skills to look at the hairline CONCLUSION
and stick and place these extra grafts at points where they are
needed. The physician can get an aesthetic appreciation for the In medicine, we evaluate the appropriateness of a treatment by
way the hairline will look and for what is needed, because the looking at its relative advantages and disadvantages in different
hairs have been left 2 mm to 4 mm long. One-hair grafts are situations—the risk-benefit ratio so to speak. We realize that
put in the transition zone if needed. If the transition zone is the same treatment, which may be appropriate in one situation,
satisfactory, the one-hair grafts are paired to create two-hair may not be as appropriate in another. This same approach
Figure 12D-38 Results of one session that used follicular units (FUs) and small slit grafts: These are the before (A) and after photographs
of the patient whose photographs have been used in the previous diagrams (12D-34 through 12D-37). (B), Incisions and pattern created
during surgery (FUs in extended hairline and small grafts in the central area). (C), Eight months after single surgery of 2200 grafts (1800
FUs and 400 small slit grafts).
466 Chapter 12
Figure 12D-39 Results of two sessions using FUs exclusively. (a), Before surgery; (b), frontal view after two sessions with a total of
3800 FUs; (c), close-up of hairline.
should also be taken in the field of hair transplantation. We not using large numbers of FUs in a single session, they did
want to choose the technique that will create the best balance not have to worry about poor survival or poor density. I believe
of both naturalness and density in different situations. For many we are now beginning to reach a middle ground. We have
years, the question has been: What grafts or combinations of learned a great deal over the years about limiting the problems
grafts are best to use in different situations? that can occur with either FUs or multi-FU grafts. We are now
Overreacting to either positive or negative results is a natural better able to harness the benefits of each graft while minimiz-
human tendency. I believe this has occurred in the field of hair ing the risks. Rather than using one or the other exclusively,
restoration surgery with respect to the use of both FUs and we harness their relative advantages for specific situations.
multi-FU grafts. The potential for plugginess with use of multi- Note: I would like to thank my patient coordinator Matt
FU grafts led many physicians to totally abandon them in favor Zupan for discussing and helping me conceptualize many of
of FUs. With the exclusive use of FUs, they did not have to these complex concepts over the past 12 years.
worry about plugginess.
The potential poor density that can occur with the exclusive Editor’s Comment
use of FUs has led some physicians to limit their use and to As I have stated elsewhere in this text, my initial concerns about
stunt their achievement of proficiency with this technique. By FUT were occasioned by my observation of the relatively low
Figure 12D-40 Results of two sessions that used Follicular units (FUs) and small slit grafts. (a), Before surgery. (b), Pattern showing
FUs in extended hairline and small slit grafts in central area. (c), Frontal view after two sessions. (d), Close-up of hairline.
hair density that I saw in patients treated by FUT practitioners, transplantation of 30 to 50 FU/cm2 or more but with hair densi-
and which were also reported by proponents of FUT. It is impor- ties that were substantially less than 30 ⳯ 2.3 or 40 ⳯ 2.3 or
tant to remember that in 1997, even Limmer was reporting only 50 ⳯ 2.3 hairs (2). (It is generally accepted that each FU con-
50 hairs/cm2 after two sessions (1). These numbers are far lower tains an average of 2.3 hairs.) FUT has evolved just as micro-
than what has been routinely achievable for several years now; minigrafting has evolved, and techniques have been found to
therefore, my concern about hair density for most patients is produce high hair densities with FUs without resorting to FU
no longer an issue. Unfortunately, however, this increased den- densities of 40 to 50/cm2. Thus, hair survival with FUs has also
sity was initially produced by dense packing of FUs, and my improved.
attention was then turned to reduced hair survival because ‘‘the I am satisfied that we at last know what we can and cannot
numbers did not add up.’’ FUT proponents were reporting the do with FU densities. We have at the same time improved the
468 Chapter 12
Figure 12D-41 Results of two sessions using follicular units (FUs) and small slit grafts. (a), Before surgery; (b), frontal view after
two sessions; (c), close-up of hairline.
techniques used for their preparation, storage, and insertion; have now sifted through initial FUT techniques and have satis-
therefore, I am now using far greater numbers of them in my fied themselves as to what should or should nor be done with
procedures. Eight years ago, I typically used 150 to 200 mi- FUs. Megasessions of 3000 or more FUs and dense packing of
crografts per session. Five years ago that number had increased, 50 or more FUs/cm2, for example, are no longer done by the
becoming 200 to 300 micrografts per session, and as late as 3 vast majority of practitioners. (A small minority are increasing
years ago, I was typically using only 300 to 400 micrografts their FU numbers and densities, and I have already commented
per session. As Shapiro has observed, for those I have treated on this phenomenon in Chapter 12B).
with FUs, DFUs, or small slit grafts for approximately the last The photographs shown by Shapiro (Figs. 12D-38, 12D-40,
2 years, I am using essentially the same number of FUs (700 12D-41) speak volumes about what is possible for properly
to 850 micrografts per session) and DFUs or small slit grafts selected patients of skilled physicians who use a combination
as he does when he uses this combination of graft types (see of FUs and multi-FU grafts. Those who think that FUT is ‘‘the
Chapter 12F). I think he was surprised to see this when he end of the evolution’’ are as wrong as all those who have pre-
started visiting my office during the preparation of this text- ceded them with such claims for any medical or surgical tech-
book. However, I know that there are many micro-minigrafters nique. Each gold standard finds its rightful place with the pas-
who are doing the same thing. This does not mean that we are sage of time and becomes another tool—but not the only tool.
evolving into converts to exclusive FUT for everyone (although In Chapter 12F and G, I go several steps beyond combining
I do currently treat approximately 20% to 40% of my patients FUs with DFUs or small slit grafts. Such an approach is not
with FUT.) What it means is that many hair restoration surgeons for novices or the faint at heart, but it should be obvious that
I would not still be doing this if my results—again, in properly The immutable laws of supply and demand dictate that the
selected patients—were not better than what I can achieve with more hair a patient requires, the less he has to donate. Surgeons
FUT or FUs and micro-slit grafts. I believe that the same results have created various strategies to deal with this inverse relation-
that I can achieve are also possible for many other physicians. ship. Dr. Norman Orentreich noticed the apparent disparity of
All that is necessary is the will to spend the same amount of open space vs. available tissue several months after his initial
time and effort on learning the technique as they have expended forays into this field. In his textbook, Dr. Walter Unger was
in learning how to carry out FUT, micro-slit grafting, micro- perhaps the first to emphasize the obvious fact—that there must
minigrafting, or perhaps even the one-pass technique described be a balance between density and coverage. In his book, he
by Seager in Chapter 12B. (WU) clearly states that ‘‘… very few areas are, in fact, solidly filled
… only the obvious and cosmetically important areas receive
four sessions (5).’’ Dr. Unger’s statement emphasizes that not
12E. Recombinant Follicular Units: all areas of the scalp have equal cosmetic importance and that
Concept Formalization this discrepancy influences decisions regarding graft placement
and density requirements in specific areas. It also implies that
James A. Harris
all areas of the transplanted scalp in the extensively bald patient
INTRODUCTION cannot have equal density; therefore, surgical sleight of hand
is needed to give the appearance of a cosmetically acceptable
One theory regarding the method of hair transplantation claims density.
that follicular unit hair transplantation (FUT) is the logical evo- The act of placing a standard grafts or minigraft into a recipi-
lutionary end-point of hair transplantation. This technique, de- ent site sets the stage for two events. First, because the graft
scribed by Limmer (1) and formalized by Bernstein and Rass- has the hair density of the donor area, which is in stark contrast
man (2), is an accepted method of hair transplantation, and to the surrounding bald skin, the patient requires multiple ses-
although much debate surrounds the ideal transplantation sions to camouflage the initial plugginess in the alopecic recipi-
method, few argue that FUT provides patients with natural, ent area. Matching supply and demand requires meticulous
undetectable results. The proposed advantages of FUT are mini- planning by the surgeon. Second, tissue dynamics and healing
mal scarring, patient control over additional surgeries, conserv- almost always result in some compression of the graft, which
ative use of the donor area, and results that are undetectable as leads to an increase in hairs/cm2. These two consequences—the
transplants. The disadvantages are increases in overhead, staff need for multiple sessions and the need for increasing densi-
training requirements, staff numbers, capital outlay for equip- ties—co-exist with the need to conserve donor tissue. The inevi-
ment, and quality-control requirements. Because of the small table result is that creating more density in some areas means
size of follicular unit grafts (FUGs), critics claim that follicular creating less coverage or no coverage at all in other areas of
units (FUs) are inherently fragile and therefore at increased risk the recipient scalp. As Unger states, ‘‘… the relatively large
of demise after transplantation (3). Critics also cite the lack consumption of donor tissue … must be accepted as part of the
of studies proving the superiority of FUT over standard mini- price to be paid for higher density (6).’’
micrografting methods as another drawback of the procedure. This dilemma is not unique to surgeons employing standard
The difficulty of designing a study, however, that includes both grafts and minigrafts. When speaking to patients who are con-
subjective and objective proof of the superiority of one method sidering FUT, surgeons often state that the natural appearance
over another, introduces almost insurmountable technical hur- of FUT results from the implantation of grafts exactly as they
dles (i.e., hair survival after a 3000-FUT case vs. survival after occur in nature. For all intents and purposes, this is true. After
a 600-minigraft case). In addition, designating a degree of trans- growth, a two-hair FU graft does not appear any different from
plant detectability is a subjective method of judgment; there- a naturally occurring two-hair FU. However, the statement is
fore, debates still surround the significance of the detectability not entirely true, because surgeons rarely find in nature 1 cm2
of the results, and will continue to do so. of scalp that contains 100% of two-hair or three-hair FUs,
Another area of contention in FUT is hair density. Detractors whereas this phenomenon can be found in strategically chosen
of FUT argue that the vast majority of FUT practitioners cannot areas on a transplant patient. The FUT surgeon sorts the grafts
achieve a level of density per session that rivals that obtained and dictates their nonrandom placement to create gradients and
by mini-micrografters. Journalists and attendees at international areas of density at the expense of density in other areas. Bern-
meetings frequently debate this topic. However, if surgeons stein (7) previously described this concept, and he and Shapiro
could consistently achieve densities of approximately 100 to further discuss it elsewhere in this chapter. Basically, surgeons
120 hairs/cm2 —adequate for producing acceptable re- use the concepts of weighting and differential distribution to
sults—few would propose this argument against FUT. Bolster- create higher density in certain areas, such as the part side or
ing this assumption is Marritt’s paper (4), which suggests that the central forelock. They can also change the number of inci-
approximately 100 hairs/cm2 looks to the human eye as dense sions per unit area. In theory, this approach is similar to Unger’s
as 200 hairs/cm2. The results obtained on my patients and by practice of placing a proportionately larger number of grafts in
patients of other physicians support the contention that FUT areas that are more cosmetically advantageous. Each surgeon,
easily achieves densities on the order of 100 hairs/cm2 There- within the constructs of the particular technique employed, ac-
fore, FUT is a viable method of hair transplantation not only for knowledges the limits of supply and demand and recognizes
producing undetectable results but also for achieving acceptable the relative cosmetic importance of different areas of the scalp.
hair densities. If a surgeon can produce these densities in one In an article published in 1998 (8), 21 respected surgeons
session and on a regular basis, I believe proponents in both proposed the criteria for these techniques, including the harvest-
camps would agree that FUT is a significant achievement. ing technique, the method of graft dissection, and the standards
470 Chapter 12
for documentation. In their paper, the authors state that ‘‘…

large sessions should be an integral part of FUT …’’ for two
reasons. The first is the size of the average FU graft. Its small-
ness enables recipient sites to be small, thereby minimizing
trauma. Minimized trauma allows surgeons to transplant a large
number of grafts and this can result in fewer total sessions. The
second is the need to generate adequate numbers of differently
sized FUs. That is, a case of sufficient size allows the generation
of enough single-hair grafts for the hairline and enough three-
hair and four-hair grafts for areas in need of density. Areas
where increased density is desirable require grafts that increase
the number of hairs per unit area.
In general, all procedures require multiple sessions to
achieve density. The standard 4-mm plugs, mini-micrografting,
and FUT routinely require more than a single session to ap-
proach 100 hairs per hairs/cm2. Regardless of the technique
employed, concerns exist regarding trauma to the scalp and
its possible effect on subsequent hair growth. When FUs are
transplanted, the second FUT session requires more time and
effort than the first, even if the number of grafts is the same;
therefore, minimizing the number of sessions required is in the
best interest of the patient and of future hair growth. Figure 12E-1 The epidermal area of a four-hair follicular unit
(left) is not much larger than that of a two-hair unit.
Theoretical Framework for Recombinant Follicular
Unit Transplantation
Nature deals patients an uncertain ‘‘hand of cards’’ when sur- (Fig. 12E-2). Surgeons who practice FUT see this range in size
geons consider FUT as their only transplant method. That is, daily in operating rooms.
FUs contain one, two, three, and four hairs, and a lucky patient Cole (10) reminds us of Headington’s work (11), which de-
has a slightly higher percentage of three-hair and four-hair scribes the anatomy of an FU. Headington defines an FU as
grafts—for the overall density of the area covered is determined ‘‘the pilosebaceous unit structure as disclosed at the mid-dermis
by three related factors: the average number of hairs per FU, of the scalp.’’ At the level of the mid-dermis, the volume of a
the surgeon’s efforts at sorting, and the number of grafts per
unit area.
Notwithstanding nature’s provisions for hair density and the
surgeon’s efforts at weighting, the average hair density per unit
area depends on the number of grafts per unit area. The paradox
of transplanting is that the technique that delivers the highest
density of grafts may decrease the probability of hair growth
by adversely affecting blood supply to the transplanted area.
The trend in FUT today, for instance, keeps the number of
incisions from 25/cm2 to 35/cm2 to minimize trauma and to
optimize growth. A technique such as recombinant follicular
unit transplantation (RFUT), which maximizes hair density and
limits trauma, would be a valuable addition to the surgical arma-
mentarium.
To achieve the goals of maximizing density, limiting trauma,
and working with the hand that nature deals for FU distribution,
surgeons look at the anatomy of an FU to provide insight. Dr.
Rassman observes that the ‘‘footprint’’ of a four-hair FU at the
epidermis can be the same as that of a two-hair FU (Fig. 12E-
1). The surgeon may also encounter what Dr. David Seager
describes as a ‘‘follicular family unit (9).’’ Identifying two FUs
as a ‘‘follicular family’’ is a judgment made when ‘‘two sepa-
rate units … look close enough almost to belong together.’’
The surgeon infers from the preceding information that the size
of a four-hair FU can range from a tightly compact structure Figure 12E-2 The size of a four-hair follicular unit ranges
with the epidermal area barely larger than that of a two-hair widely. The unit on the left has the appearance of four single-hair
FU to a structure that resembles four single-hair FUs in a row units, whereas the unit on the far right has a very compact structure.
the density of a single session by using the follicular family

unit. As noted earlier, the surgeon creates these three-hair and
four-hair grafts by finding two FUs that ‘‘look close enough
almost to belong together.’’ The chosen family units are ‘‘mar-
ginally longer than naturally occurring’’ FUs and thus require
a larger incision site. Norwood also performs this technique to
increase hair density (13). No reliable data presently exist to
assess the outcome of this variation in technique.
In his article on the follicular family unit, Seager notes that
many indiscrete FUs are unclearly identified as a single FU or
as several FUs in close proximity. He states that a search must
be made for these indiscrete units. Seager also outlines the pa-
tients in whom the use of follicular families is beneficial.
Briefly, follicular families are useful for correcting the problems
of patients with hairlines composed of compressed minigrafts
or standard plugs; patients with diffuse thinning who want a
limited area of dense coverage; patients with fine, light-colored
hair and a low hair/FU ratio; and patients who want transplanta-
tion to build up the fringe area. Bernstein (13), however, com-
ments that, for several reasons, using FUs in these ways violates
the principles that make FUT successful. He states that the
results look unnatural because there are no ‘‘doubled-up’’ FUs
in nature, even though FUs are transplanted in a manner identi-
cal to natural occurrence.
Figure 12E-3 Varying sizes of four-hair follicular units com- The disadvantages of using the follicular family unit tech-
prise the upper row, and recombinant follicular unit grafts comprise nique include a slightly less natural appearance because of
the bottom row. The one on the left is a three-hair unit combined ‘‘larger than FU’’ grafts with more skin, larger recipient sites
with a single-hair unit; the one on the right is two adjacent two- that increase trauma, and a more rapid depletion of the donor
hair units. The total volume of tissue in the combined grafts is area. The search for these family units also takes time away
essentially the same as the native four-hair units. from the technician’s task at hand—dissecting grafts—and, in
addition, leaves the technician to decide subjectively what con-
stitutes a family. In my opinion, all of these problems, except
four-hair FU is essentially the same as that of two 2-hair FUs or rapid donor area depletion, can be overcome in selected patients
one single-hair FU and a three-hair FU (Fig. 12E-3). Attempts to through recombinant follicular unit transplantation (RFUT).
define and to dissect the FU based on its epidermal appearance Dr. Ron Shapiro also points out the need to have a greater
and structure are misguided efforts to isolate the ‘‘true’’ FU that number of two-hair and three-hair FUs in areas that require
Headington describes. Based on the anatomy at the epidermis, greater density (14). He was perhaps the first to suggest that in
however, it makes surgical sense to use the structure of the cases in which an excess number of single-hair FUs are gener-
closely associated follicles—‘‘clusters’’ in Coles terminol- ated, the FUs may be combined to create a two-hair graft. In
ogy—as transplantable units. Cole describes his grafts as ‘‘fol- a similar fashion, grafts containing one hair or two hairs may
licular groups,’’ in which ‘‘on the surface of the skin the dis- be combined to form a three-hair graft in a technique Shapiro
tance between the hairs of a group is usually less than the calls ‘‘follicular pairing.’’
distance between the clusters.’’ For the surgeon’s purposes, a
transplantable graft that fits this definition should have the same Recombinant Follicular Unit Transplantation
appearance as a naturally occurring FU.
The ‘‘sanctity’’ of the FU does not appear to be so much The basic RFUT technique involves combining discrete FUs
related to the physiologic unit as Headington suggests; instead, into ‘‘recombinant’’ units (RUs), thereby creating higher num-
defined histologically, the FU seems more closely related to the bers of hairs per recipient site and a minimal number of inci-
superficial anatomic structure that appears to be the ‘‘building sions. This procedure allows for a completely natural appear-
block’’ of the hairy scalp. In a previously unpublished study ance and maximal density in a single session. Unlike the family
(12), Dr. Michael Beehner investigated whether or not any unit, in RFUT there is no excessive epidermis, and the incision
‘‘ ‘inherent’ quality in the intact FU confers upon it an advan- site is the same for a four-hair recombinant graft as for a natu-
tage for hair growth’’ over divided FUs. Hair counts obtained rally occurring four-hair FU. The surgeon cuts the grafts in the
in the intact group and the nonintact group were essentially the same fashion as all other FU grafts are cut, with special attention
same: 82% and 86%, respectively. Beehner concluded, there- paid to the epidermis, where only a minimal amount is
fore, that there was no special advantage to keeping FUs intact. left—usually no more than exists in many natural four-hair
The studies of Beehner and Martinick explore the same question FUs. Because the spacing at the mid-dermal level is identical
and are described in more detail in Chapter 9 . for naturally occurring four-hair FUs and for four-hair RUs,
The quest for maximum density in as few sessions as possi- surgeons do not place any additional tissue into the scalp. The
ble has led surgeons to adopt numerous transplanting strategies. appearance of an RU at all skin levels is, therefore, essentially
For patients with sparse donor areas, Seager suggests increasing identical to that of a natural FU.
472 Chapter 12
In theory, the visual effect of this technique mirrors that To illustrate the maximum possible yield of four-hair RUs
achieved in a patient with an inordinately high percentage (ap- in a case of approximately 1000 grafts, the surgeon may assume
proaching 90%) of four-hair FUs. In this case, the surgeon does the following FU distribution based on an example case by
not necessarily want to transplant at a hair density greater than Bernstein (15):
100/cm2, although it is possible. In the case of a patient with
RUs, the majority of planted units are four-hair RUs, and the Natural Distribution of Follicular Units
surgeon stops planting at a hair density of 100/cm2. As long as Hairs/Graft % No. of Grafts
final hair densities are the same, the total depletion of donor
area hair and the total area covered is identical in RFUT and 1 20 200
standard FUT. 2 50 500
After careful deliberation with the patient about desired den- 3 25 250
sity and the limitations of coverage, the surgeon prepares FUs 4 5 50
by using all of the criteria that define FUT, including single- 100 1000
strip harvesting and stereomicroscopic dissection. As noted ear-
lier, the surgeon gives special attention to removing maximum
amounts of the epidermis. The objective is to create recombi- If the surgeon uses these grafts in a situation in which maxi-
nant grafts, thereby increasing the number of hairs per graft. In mal density is required and no single-hair units are needed,
most instances, the RU is a four-hair graft, but there are excep- maximal recombination would yield the following:
tions in which five-hair grafts are advantageous. Such excep- Distribution of Recombinant Follicular Units
tions are discussed later in ‘‘Patient Considerations.’’ The
method involves the combination of two two-hair FUs (2Ⳮ2) Hairs/RFUT Percent No./1000 FUs
to create a single four-hair RU. Similarly, single-hair units are
combined with three-hair units (1Ⳮ3) to create four-hair RUs. 1⫹3 36 200
2⫹2 46 250
The recipient sites accommodating both the 1Ⳮ3 and the
3 9 50
2Ⳮ2 combinations are the same as the surgeon uses for three-
4 9 50
hair and four-hair FUGs (Fig. 12E-4). I use both the 22.5
100 550
Sharpoint and the 1.5-mm Minde knives successfully. The sur-
geon’s ability to use the same size incision as employed in
standard FUG means that the principle of minimal trauma is Therefore, to achieve maximal recombination, the surgeon
not violated. creates approximately 550 recombinant grafts for every 1000
native FUs produced. In the foregoing example, the average
FU has 2.2 hairs. The 1000 grafts cover approximately 33 cm2
at a recipient site density of 30 grafts/cm2. If there is 100%
growth, the final average hair count density will be 66 hairs/
cm2. The RFUs will average 3.9 hairs/graft. If the surgeon plants
these RUs at 25 grafts/cm2, and there is 100 % growth, the
result will be 98 hairs/cm2 and the surgeon will produce a 48%
increase in density in a single session that involved a 17% de-
crease in linear incisional trauma.
It is important to emphasize this last effect. If the surgeon
compares the incisional trauma necessary to achieve a final hair
density of 100 hairs/cm2, traditional FUT requires 45 incisions,
whereas RFUT requires 25. This difference represents a 44%
decrease in incisional trauma to achieve the same hair density.
Put in perspective, covering a 100-cm2 area of scalp with the
incision densities noted and a 1.7-mm incision, RFUT results
in a decrease of 3.4 meters, or approximately 11 feet of linear
trauma. This decrease likely has a positive impact on graft and
hair survival.
A disadvantage of this method, however, is that the area
covered for a given number of FUs is less than that of standard
FUT. In this example, the area covered is 22 cm2, or 33% less
than if the surgeon performs standard FUT. At first glance, this
seems a significant disadvantage, but if the goal of standard
FUT is to achieve a density of 100 hairs/cm2, the surgeon simi-
larly accomplishes this density if the grafts are planted as 25
Figure 12E-4 A native four-hair follicular unit (FU) is on the four-hair RUs in a single session or as 43 naturally occurring
right; a three-hair unit combined with a single-hair unit forms the units with 2.3 hairs each in two sessions. Ultimately, the final
FU on the left (a 1Ⳮ3 RU). The appearance from the surface is area covered is the same with either method.
essentially the same. These grafts were placed into a site created Another advantage of RFUT is its flexibility. If the surgeon
with a 1.5-mm Minde knife. reconstructs the frontal hairline and adds RUs posterior to the
hairline zone, a large proportion of the single-hair FUs at the degree of loss. At that time, he wanted to maximize density
hairline are used, and the majority of the recombinant grafts and to limit trauma in an attempt to decrease the possible risk
are doubled two-hair FUs. The remaining grafts are native three- of effluvium. I performed his second session with use of RFUs. I
hair and four-hair FUs. Any number of combinations is theoreti- harvested a total of 1088 FUGs, placed 100 grafts in the anterior
cally possible depending on the patient’s requirements for cov- hairline, and recombined the remainder to give maximal density
erage and density. as described earlier. I placed approximately 400 recombinant
Figure 12E-5 illustrates the results of this technique. The four-hair grafts; the rest were native three-hair and four-hair
patient presented is 50 years old and has a Norwood type IV grafts. The results show an entirely natural-looking increase in
pattern. He initially had a single session of 1523 FUs added to density.
his hairline and forelock areas. Approximately 1 year later, he
decided to have an additional procedure to add density. I dis- Patient Considerations
cussed with him the possibility of postoperative effluvium and
the possible relationship between the amount of trauma and the Studies are currently in progress to assess the outcomes of
RFUT in terms of growth and complications. Gross clinical
assessment of the patients who have undergone this procedure
suggests that this technique is indeed valuable and can achieve
the intended goal of higher density in a single session. Until
studies are completed, however, I suggest a very conservative
approach to the procedure. This conservatism should begin with
patient selection. Because surgeons associate this technique
with a more rapid donor area depletion, they should consider
only patients with a low risk of excessive hair loss and a favora-
ble donor-to-recipient ratio. With this in mind, I believe the
procedure should be limited to men who are 50 years of age
or older with Norwood types III or IV male pattern baldness,
including type A variants. Furthermore, because of the risk that
the transplanted area will appear ‘‘grafty,’’ only patients with
light-colored hair (red, blonde, gray) or salt-and-pepper hair
should be considered. In special instances, RUs may consist of
up to five hairs. This may be advantageous, for example, in a
patient who has graying temporal hair and dark hair in the occip-
ital region. The surgeon may conceive of the grafts as paint on
an artist’s palette. By combining a three-hair dark hair unit with
a two-hair gray unit, the surgeon can create a five-hair RU,
adding significant density to the hair and minimizing the
chances of detection.
As stated earlier, while studies are pending, I urge practition-
ers to adhere to the patient candidacy recommendations cited
in this section.
Discussion
Although some practitioners have advocated the use of multiple
individual FUs in a single recipient site, neither the formaliza-
tion of the concept nor its indications and uses have been previ-
ously presented. As indicated earlier, however, studies regard-
ing certain aspects of this technique are currently in progress.
All aspects of this procedure adhere to the guidelines for stan-
dard FUT, except for the recombination technique.
Graft placement always threatens to introduce technical dif-
ficulties. Piggybacking is a concern in FUT, and it is also a
concern with RFUT. However, when a surgeon addresses a
particular recipient site, that site demands full attention. Once
the physician places the graft, it is easy to identify; and when
the second graft placed, the technician knows the particular hair
Figure 12E-5 Upper photograph: Preoperative representation count and, therefore, knows whether piggybacking has oc-
of a 50-year-old man, Norwood type IV. Middle photograph: One curred.
year after standard follicular unit transplantation of 1523 grafts. In my practice, I place multi-hair FUs into sites created with
Lower photograph: One year after second session consisting of 100 a 22.5 Sharpoint blade. The profile of the blade creates a tapered
single-hair grafts to the hairline and approximately 400 recombi- or wedge-shaped incision, which can create piggybacking if
nant grafts to the forelock. one graft slips into the depths of the wedge. The 1.5-mm Minde
474 Chapter 12
knife may also be used. The profile of its incision is square, area in a single session. This result is highly desirable for se-
allowing the grafts to sit side by side and eliminating any ten- lected patients.
dency toward piggybacking. With that said, I have used both Assuming growth rates are comparable for standard FUT
knives successfully without any apparent differences in compli- and RFUT, the ultimate criteria on which to judge RFUT is
cations such as cyst formation or altered growth. how well it produces natural-looking results. In patients with
The method of placing two discrete FUs into a single recipi- unfavorable hair and skin color combinations, there is the risk
ent site obviously creates the possibility for additional manipu- that the transplanted area will appear grafted. Careful patient
lation of the grafts. The care required in graft handling is no selection is, therefore, imperative.
different in this technique from that used in standard FUT. My Practitioners of the standard mini-micrografting technique
experience has been that individual technicians prefer planting raise the issue of using grafts with higher hair density per graft.
recombinant grafts. Some technicians hold the two grafts to- These proponents question whether or not a significant visual
gether, place them as a unit, and then adjust them for position difference exists if a four-hair recombinant graft is placed into
and to ensure that no piggybacking occurs. Others place them a 1.5-mm to 1.7-mm incision as opposed to placement of a graft
individually, preferring less manipulation. At this point, there of two adjacent FUs into a small slit measuring 2 mm. Although
has been no apparent difference in growth using of either tech- this is a difficult question , examining the results of the four-hair
nique. linear grafts of the Moser technique (16) may help to answer it.
Although it takes longer to transplant an RU than a standard The technique offers diffuse coverage, but it presents a slightly
FU, this time difference is not a clear deterrent for RFUT. In grafted appearance when these are the only grafts used.
general, the length of time it takes to transplant a 500 RFUT Another issue, which Dr. Bill Reed might pose, is graft sur-
case is slightly less than the time it takes for a standard 1000- vival. His studies suggest that FUs are generally more suscepti-
graft FUT case. Although surgeons save no time with this proce- ble than multi-FU grafts to desiccation and handling effects and
dure, they gain the ability to provide higher density in a smaller that any advantages gained in the area of natural appearance
Figure 12E-6 (a), Preoperative representation of Dr. Emanuel Marritt. (b), Postoperative representation after 1400 follicular units have
been transplanted to the frontal hairline and forelock areas. Please note the presence of a smile.
are lost in decreased hair survival. I suggest that the same care about my concerns. I believe that excellent hair survival is possi-
and attention to detail required in standard FUT are required ble with FUT. The problem is that because the grafts are so
in RFUT. small, the technique of all the participants in the surgery must
Recombinant grafts introduce no concerns about graft be nearer to perfection than when the grafts are larger. I remain
compression because the grafts appear the same size as naturally skeptical that such near perfection is consistently possible in
occurring FUs. Mini-micrografters argue that if a four-hair slit everyday practice in most hair transplant offices. This concern
graft should compress, it would look even more like a recombi- is partially addressed by creating high hair densities without
nant graft. One advantage a recombinant graft offers over the increasing the number of incisions/cm2. In fact, RFUT de-
small slit graft is that it includes minimal epidermal tissue, and, creases the number of incisions/cm2 for any given constant
therefore, volumetric change is not an issue. number of hairs, thereby limiting trauma and potential dehydra-
Many present-day practitioners of FUT have used a variation tion of grafts during their planting. However, the high-quality
of RFUT before now. At the end of an FUT case, a number of technique demands of FUG preparation, storage (potential de-
single-hair grafts often remain. The question then arises: Should hydration), and other aspects of handling are still serious con-
they be transplanted as single-hair grafts or combined to give cerns. They are not insurmountable dilemmas, but they are addi-
grafts of twice the density? Invariably, and quite independently tional problems inherent in FUT that are not addressed by
of one another, surgeons recombine the grafts to form two-hair RFUT.
grafts. The recombinant process described here presents the The second aspect of RFUT that concerns me is less analyti-
formalization of the technique of recombining FUs for specific cal. I am bothered by the concept of taking something apart
indications. only to have to put it back together again. Are microslit grafts
The inspiration for this technique arose from the wishes of containing two FUs that are closer together than average
a retired hair transplant surgeon who waited many years to have (‘‘cherry-picked’’) or the FU families of Seager insufficient to
the surgery performed on his own head. Dr. Emanuel Marritt, create good density in most patients? With RFUT, the surgeon
who at the age of 56 had a Norwood type IV pattern and salt- adds all of the potential dangers of FUT to the procedure in an
and-pepper hair-, decided to undergo standard FUT. After one attempt to outdo nature’s own proportion of FUs with three or
more hairs. Although very close inspection of some patients
session of 1400 FU grafts transplanted to the frontal hairline
reveals the greater noticeability of the safer microslit grafts
and forelock areas, he looked at the result and stated, ‘‘I love
(including those of the Moser technique), slot grafts, and round
it; my hair looks great. Why couldn’t it be thicker? Why do I
grafts, the same hair characteristics that Harris recommends
need two sessions?’’ Of course, I should have known this would
for choosing candidates for RFUT—for example, light-colored
be his response, because I had heard him say before that if he
hair—make such detectability far less likely. Also, what would
were ever to have a transplant, he wanted it to appear as if a
look more pluggy: four hairs in a bunch or two Ⳮ two hairs
‘‘pelt’’ had been sutured to his scalp. He received a transplanta-
placed 1 mm or less apart in a microslit graft? I suspect the
tion at the usual density of approximately 30 grafts/cm2. He bunch looks pluggier if the distance between the grafts is simi-
had an FU hair density of 2.2 hairs/FU. In spite of an excellent lar. The distance between microslit grafts and between FUs is
result (Fig. 12E-6) with a very natural appearance, which in no not similar after one session, however, thereby favoring RFUT.
way appeared ‘‘peltlike,’’ his desire for more density in a single But, as I discuss later in this chapter, with each subsequent
session led to thoughts of how to accomplish this feat, which session, the distances between adjacent microslit grafts, when
ultimately led to RFUT and the techniques described in this compared to the distances between FU—in a FUT or RFUT
chapter. session—become more similar, and the microslit grafting be-
comes less detectable. The presence of any hair frizz, curl, or
Editor’s Comment
persisting original hair in the recipient area also decreases any
The concept of RFUT is fascinating and exciting. It certainly initial or temporary differences in noticeability.
addresses any problems I personally have had with the density Notwithstanding these concerns, both FUT and RFUT are
achievable with FUT. As is discussed later in this chapter, cosmetically superior to any other type of grafting for first ses-
RFUT may not be able to create the same hair densities that sions in patients with sparse hair or total alopecia. The more
slot or round grafts produce, but, in my view, it reduces the color contrast between the hair and skin and the coarser the
number of patients who need to consider slot or round hair, the more accurate this statement is. RFUT appears to be
grafts—at least with regard to achieving great hair density in a fascinating compromise between FUT and transplanting with
limited areas. As I noted in the commentary for Chapter 12D, combinations of FUs and Multi-FU grafts. It provides the best
FUT has come a long way since my initial published reserva- aspects of both approaches and minimizes their worst draw-
tions about the hair density that could be produced with it. In backs. (WU)
1997, for example, Limmer reported only 41 hairs/cm2 after
one session, 50 hairs/cm2 after two sessions, and 84 hairs/cm2
after four sessions (1). Perfecting the preparation and insertion 12F. Why ‘‘Mixed’’ Grafting:
of FUs, reducing the size of the recipient sites, and increasing Follicular Units and Multi-
the densities of FUs/cm2 have all resulted in the production of Follicular Unit Grafts
far better hair densities. Recombinant follicular unit transplanta-
tion appears to be another, and probably safer, evolutionary Walter P. Unger
step in the pursuit of density with FUT. INTRODUCTION
Despite the foregoing, I have two concerns about FUT and
RFUT. The first is hair survival—a subject that I discuss at I employ Follicular Unit Transplanting (FUT) exclusively for
many points in this text. Once again let me, be perfectly clear the hairline zones in all patients and, currently, in the entire
476 Chapter 12
recipient area for 20% to 30% of patients. Those who fall into velop type VI or type VII MPB, or very sparse temporal areas,
this latter category are (1) individuals who examine photographs can have very natural-looking results and a reasonable amount
of patients whom I have treated with FUT and find the hair of hair density in the frontal area with one or two sessions of
density produced with this method satisfactory; (2) those who FUT while conserving more of the donor tissue for other areas,
are particularly concerned about even the slightest detectability than is possible when larger grafts are used. (2) Totally alopecic
of grafts—even if only on very close inspection—at any point recipient areas nearly always have a more natural appearance
during the course of their treatment; (3) those whom I believe after a single session if grafts no larger than single follicular
are destined to develop type VI or type VII male pattern bald- units (FUs) are employed.
ness (MPB) or very sparse temporal areas; and (4) most of my Although relatively few patients I see in consultation have
patients whose recipient areas are totally alopecic when we areas of total alopecia, some of my colleagues see relatively
begin treatment. In fact, I prefer to at least begin with FUT in few who have persisting hair in their potential recipient areas.
these latter two groups of patients (Figs. 5A-14 and 12F-1 and It has been said that patients tend to choose physicians whose
2). Why? (1) Patients whom I have reason to suspect will de- philosophy of practice seems to match their own philosophies
Figure 12F-1 (a) A patient before treatment. The black crayon mark denotes the limits of the area to be transplanted. (b) Six months
after a single session of follicular unit transplantation (FUT) to the frontal area. (1277 micrografts and 199 small slit grafts.) (c) A side
view of the same patient after a second session of FUT was carried out in the midscalp region. This patient had indicated that he was not
concerned with not having dense hair. He wanted only natural-looking, medium-to-light coverage and the option not to have further
transplantation once he saw the results. (total of 2572 micrografts and 199 small slit grafts.)
Figure 12F-2 (a) A patient before FUT. This individual had particularly good donor hair characteristics including substantial wave
and frizz. (b), The same patient 9 months after a single session of FUT. He had also lightened the color of his hair. The frizzy hair and
lighter color make the result look thicker than it does in the patient shown in Figure 12F-1. In addition, the time interval was 9 instead of
6 months, as was the case with the patient shown in Figure 12F-1. (c), The same patient, side view, 9 months after a single session of
FUT. This patient was chosen for FUT because of his limited density objectives and his advantageous hair characteristics. I thought the
latter property would produce a denser-than-average appearance and that I was likely to satisfy his objectives with a single session. (See
color insert.)
or needs. Over the years, I have developed the reputation of urged, at this point, to review Table 5A-1 so they can understand
being both capable and happy to treat patients with relatively the terminology that is used in this sometimes complicated dis-
early MPB and female pattern hair loss (FPHL). As a result, it cussion.)
seems that I see many more individuals in these categories than As implied earlier, some of my patients are looking for
those whose preference has been to decline them for treatment. greater-than-average, or maximum, hair density, and their objec-
Only 5% to 10% of my patients have totally alopecic recipient tives are, in my opinion reasonable, given their ultimate donor-
areas. This in turn has affected how frequently I use grafts with recipient area ratio and donor-hair density. These latter qualifi-
more than one FU, because such grafts are far less noticeable cations result in a relatively small percentage of people being
in hair-bearing areas than in alopecic ones. (As discussed later, suitable for the use of slot grafts and round grafts. They are
subsequent sessions in the same area will be carried out in pace told about the disadvantages of using such grafts but are also
with further hair loss there, so the multi-FU grafts will never shown photographs of the remarkable results that can be pro-
be left on a background of otherwise total alopecia). Thus, 70% duced when they are employed. Of course, the more persistent
or more of my patients are initially treated with a combination hair there is in the recipient area at the time treatment is started,
of FUs and double follicular units (DFU), triple follicular units and the better the hair characteristics—for example, the less
(TFU), or quadruple follicular units (QFU) (micro-slit grafting), skin/hair color contrast, the more frizz, and the more wave or
or FUs, micro-slit grafting, and micro-minigrafting—which in- curl—the fewer the disadvantages of these larger grafts. As has
cludes the use of slot grafts and round minigrafts. (Reader are already been noted, they are also shown photographs of what
478 Chapter 12
can be created with FUT and smaller grafts. The decision on is laborious; although these examples are, ‘‘old’’, they
which approach to take is then left to the patient and, not to are satisfactory in validating the stated opinion
me. Once again, however, my experience with larger grafts is 2. Using such photographs may help defuse some of the
far greater and therefore very different from that of most hair usual criticism directed at authors for showing only their
restoration surgeons. As a consequence, my results with these best rather than their typical results.
grafts and my philosophy regarding their use are also very dif- 3. The more controversial the statement, the more photos
ferent from those of many of my colleagues. Just as with FUT, are required to support it. As pointed out several times
one must spend a considerable amount of time perfecting the in this text, most of my patients begin treatment well
technique—most specifically, learning how, when, and where before they are completely alopecic. Thus, their treat-
in the recipient area to use the various types of grafts. ment often extends over several to many years—in pace
The downside of gaining experience with FUT is creating with their rate of hair loss. Given that situation, it is
low hair densities and/or experiencing high rates of follicle sometimes difficult to find a sufficient number of photo-
death. The downside during the learning process in using larger graphs demonstrating relatively current techniques to
grafts is the complexity of the approach and creation of a pluggy lend credence to the opinion. I hope that providing the
appearance until expertise is gained. Enough of this has been number of the various types of grafts listed in the leg-
seen and written in this text and elsewhere that I need not elabo- ends will be useful to readers by helping them to envi-
rate on it here. Novice physicians must choose their own learn- sion what can be expected from such quantities.
ing process ‘‘poison.’’ In my opinion, however, the disadvan-
tages of using multi-FU grafts have been grossly exaggerated
by some FUT enthusiasts, and their advantages have been mini- THE RATIONALE
mized. The theoretical rationale for using multi-FU grafts is
presented in the following paragraphs as a corollary to Reed’s As noted earlier, the two most compelling reasons for exclusive
contribution to this text. An explanation of the techniques used use of FUT are the exceptional naturalness that this approach
in employing multi-FU grafts follows in Chapter 12G. Much can accomplish and the relative simplicity of using a single
type of graft for all transplantion. Patients and those who see
of the initial discussion is excerpted from an article that was
them are always impressed with just how natural the results
published by the author (1).
appear. Their comments, as well as the certainty that such natu-
It should be pointed out that most of the photographs shown
ralness will always be accomplished, are extraordinarily seduc-
in this section and throughout the text were taken of my patients
tive for the practitioner, and I am no exception to this allure.
whose treatment was completed 2, 3, or more years ago. During
The simplicity of FUT is also particularly important for novices
the past few years, however, the number of FUs per session has
and relative novices in hair transplanting, because it is obviously
approximately quadrupled. A typical micro-slit graft or micro-
much more complicated to learn when and where to use differ-
minigraft session currently includes 800 or more FUs. This is
ent kinds of grafts when many different types are employed.
primarily because I became satisfied that the evolution of the Unfortunately for most practitioners, two counterbalancing
preparation, storage, and insertion techniques of FUs had problems have been associated with FUT. The first was produc-
reached the point where very high hair survival rates could be tion of lower hair densities than could be accomplished with a
consistently expected with densities of 20 to 25 FU/cm2. As mixture of grafts. The second was that less tissue insulation
discussed in Chapter 5 and later in this chapter, during the same was provided for follicles of FUs than for those in larger multi-
period of time, we altered the way we prepared slit grafts and FU grafts, leading to more exposure of the hair follicles to
most slot grafts so that the FUs in the grafts were essentially potentially lethal damage during preparation, storage, and inser-
left intact and there were, respectively, single or double (side tion. This in turn could produce lower survival rates. Both of
by side) rows of them within the grafts. How important the these problems can be addressed through an expert and highly
physical integrity of FUs is to hair survival is controversial (see controlled technique. Over the past several years, the hair densi-
Chapter 9), but we have made this change because it seems ties producible with FUT have increased dramatically, but, as
reasonable, even without compelling evidence that it is so. The shown here, they are unlikely to match those that can be pro-
single row of FUs in microslit grafts avoids any possibility of duced with a combination of FUs and multi-FU grafts. Hair
compression of grafted hair—an important cosmetic advantage. survival with FUT, at least in some offices, has similarly im-
Finally, the amount of donor tissue and the total number of proved. The technique, however, is not ‘‘user friendly.’’ In this
grafts transplanted per session have increased significantly over text, Seager and others have emphasized the need for extraordi-
the past several years. nary care in all stages of FUT, specifically because the follicles
Much of the preceding information is reflected in the legends of FUs are so much more exposed to danger than those in larger
accompanying the photographs, in which I include the numbers grafts. Concomitantly, as Reed and others have pointed out, a
of each type of graft employed in that individual’s treatment. major drawback of FUT is that many technicians are usually
In most cases, these numbers are smaller than those I would required to prepare a sufficient number of FUs in a reasonable
typically use in a similar patient today—especially with regard amount of time. In my office, for example, it is not uncommon
to the number of FUs. The results we can currently expect after for a session of 1500 to 2000 FUs to require 6 to 7 hours (and
any number of sessions are therefore often considerably better even longer for ‘‘bleeders’’), despite the use of 8 to 10 techni-
than those I have shown in the photographs in this book. I cians and/or nurses. In addition, placing the FUs close enough
include them all the same for the following reasons: together to produce good hair density per session without killing
follicles requires great skill and patience. The higher the hair
1. Finding photographs to demonstrate specific statements density objective per session, the higher the FU/cm2 per session
must be, and the more dangerous it becomes for the FUs. Main- in slightly greater hair densities than most FUT advocates pres-
taining good quality control of so many areas becomes, in many ently achieve (more about this later). Omitting the single FU
situations, an impossible task. Even in offices where very good would result in the same hair density (or less) as FUT after
FUT is carried out, one cannot help but believe there will always one session. Because most physicians who employ micro-slit
be tired, bored, or upset technicians, as well as technicians-in- grafting do not scatter single FUs between their DFUs and
training, who are doing less than optimal work and, therefore, TFUs, they may therefore produce less hair density after a sin-
lethally injuring some FUs. The larger the staff, the more such gle session than FUT practitioners who employ FU densities
individuals may be present. Each of the potential problems of of more than 20 FUs/cm2. This is one of the immediate attrac-
density and decreased hair yield are discussed separately in the tions that FUT has for those who previously used micro-slit
next sections. grafting (or alternatively, slit grafts not prepared to keep the
FUs intact) without inter-spacing FUs between them. More-
over, it is important to recognize that there would be a much
HAIR DENSITY more even distribution of FUs after a single session of FUT
than could be achieved with a combination of FUs and DFUs,
For comparative purposes, I use figures included in an article TFUs, or slit grafts that were not microscopically prepared (see
published by Manny Marritt in 1999, based on his observations Table 5A-1). Therefore, if one’s objective were to complete the
at the office of Dr. Robert Limmer (2). As noted at the beginning treatment of any given patient with only one session, FUT
of this chapter, Dr. Limmer is widely viewed (and, in my opin- would most often be the preferable technique.
ion, justifiably) as the ‘‘father’’ of FUT. In his 1999 article, Nevertheless, the FUs within each of the DFUs or TFUs are
Marritt examined hair density in a number of patients at Dr. three times closer together than the 76 FUs/cm2 achieved by
Limmer’s office and noted that after two to four sessions, 76 Limmer in 1999 after two sessions (and by a few practitioners
to 126 hairs per cm2 were growing. today in one session), because the FUs within each DFU or
One third of the average hair density in the donor area would TFU would exist in at least their original donor area density
be approximately 76 hairs/cm2. (If each FU has an average of of approximately 230 hairs/cm2. In actuality, the FUs are even
2.3 hairs, and there is approximately one FU/mm2, there should closer together than they were in the donor area because the
be 230 hairs/cm2.) Despite this, it has been convincingly shown donor tissue shrinks once it is removed from the scalp and the
at many medical meetings and in this text that 76-hairs/cm2 can FUs move closer together. The schematic drawings in Fig. 12F-
produce a very good cosmetic result in many patients. Further- 3a and b are somewhat deceptive in the light of the foregoing
more, since publication of that article, FUT proponents have information. However, the more important significance of Fig.
continued to perfect their technique. Today, many practitioners 12F-3a and b, and the preceding discussion, is that it should be
can routinely achieve almost as much density after one session obvious that it is relatively easy to go between the DFUs and
as was possible in 1999 after two sessions. Other practitioners TFUs in a second session. Put differently, it becomes relatively
have produced more than 100 hairs per cm2 in limited areas in easy to insert 20 to 35 or 36.75 FUs (with a combination of
a single session (3). However, to date, with the exception of DFUs [or TFUs] and FUs) into each square centimeter during
small test sites, none have reported densities greater than 126 a second or even third session. Most FUT practitioners would
hairs/cm2 after any number of sessions. In addition, aiming for have great difficulty in getting 70 FUs (2 ⳯ 35) into 1 cm2 of
100 or more hairs/cm2 in a single session (see Chapter 12B alopecic skin in two sessions, and few have even tried to insert
Addendum)—usually in order to complete the treatment for the 105 (35 ⳯ 3) FUs into 1 cm2 in three sessions to produce
patient in a commercially attractive single session—exposes approximately the same hair density as that present in the donor
FUs to considerably more danger than more modest objectives, area and within each slit graft. As good as techniques have
such as two sessions per area. As a result, few practitioners try become, we are still technically unable to match nature’s den-
to complete treatment in one session. sity. Instead, as has been noted earlier in this text, FUs with three
In Fig. 12F-3a, each small square represents 1 mm2 and the or more hairs have been used in areas where higher densities are
entire box is 4 cm2. The dot in each small square represents required. Unfortunately, in the average patient, it is often the
one FU (1 FU/mm2). One sees 35 TFUs (by definition, each case that only about 15% to 35% of FUs contain three or more
TFU is three FUs long and one FU wide) separated from each hairs. I agree with Reed who has also pointed out earlier in this
other laterally by 3 mm and anteroposteriorly by 1 mm. In chapter that using all or most of the FUs with three or more
addition, single FUs are scattered between the rows of TFUs, hairs in some areas has until now had the unavoidable effect
resulting in a density of 36.75 FUs/cm2. In Fig. 12F-3b, a similar of minimizing the density obtainable with FUT in other areas
pattern is shown, except that the DFUs shown are only two because the remaining FUs have only one or two hairs. Recom-
FUs long and one FU wide. This results in a density of 35 FUs/ binant FUT (RFUT), described earlier in this chapter by Harris,
cm2. (If FUs are not scattered between the DFUs and TFUs, is a fascinating innovation that addresses this problem, but thus
the density decreases to approximately 20 FUs/cm2.) Fig. 12F- far, it has been employed by only a few practitioners. I suspect
3c demonstrates that if by chance or design the FUs in a TFU it will be more widely adopted for its obvious advantages.
graft are not lined up perfectly, one behind the other, the graft It may be argued fairly, ‘‘Who would want to produce such
is less likely to look at all pluggy than if there is perfect align- a high number of FUs and such concentrated hair density? Isn’t
ment of the FUs. Most FUT proponents currently recommend it a waste of the limited number of available FUs?’’ Suppose,
a density of 20 to 30 FUs/cm2 in the first session because they however, one would want concentrated density in a limited por-
are concerned about hair survival with higher densities (4). tion of the recipient area to create the impression of more den-
Thus, if hair survival rates were equal, transplanting the above sity in the entire frontal area. For example, higher density could
combination of DFU or TFU grafts and single FUs would result be produced in the same midline oval area behind the hairline
480 Chapter 12
Figure 12F-3 (A) Each small square represents 1mm2 and the entire box is 4cm2. The dot in each small square represents one follicular
unit (FU) (one FU/mm2). The 35 triple follicular unit grafts, are each by definition three FUs long and one FU wide, separated from each
other laterally by 3 mm and anteroposteriorly by 1 mm. In addition, single FUs are scattered between the rows of microslit grafts, resulting
in a density of 36.75 FUs/cm2. (B) A pattern similar to that shown in Figure 12F-3a with the exception of the double follicular unit (DFU)
grafts that by definition are only two FUs long and one FU wide. This results in a density of 35 FUs/cm2. (C) If by chance or design the
FUs in a microslit graft are not lined up perfectly one behind each other, the graft will be less likely to look at all ‘‘pluggy’’ than if there
is a perfect alignment of the FUs.
zone as has been advocated for FUT in this text and by most If the hair density can be greater with the use of DFUs or
FUT practitioners in other publications. (5) (see Chapter 12D). TFUs combined with FUs, why should the FUs be put at risk
Even more density might be wanted than is possible to produce by dividing all of these microslit grafts into single FUs? (See
with FUs that have three or more hairs. Or, suppose higher later.) In addition, why should transplantation be prolonged and
densities in larger areas, such as those as shown in Fig. 5A- why should the patient pay more for the surgery? What is the
40e, would be needed to produce the effect the patient really disadvantage of using this combination of grafts? Obviously,
wants. there is a less even distribution of FUs and hair; therefore, the
Figure 12F-4 (a), A patient 18 months after his first treatment. His hair has been parted parallel to his hairline and through the
transplanted area, approximately 1.5 cm posterior to the hairline. The slit grafts that were transplanted into the more or less alopecic area
can be seen in those areas. The slight noticeability of the slit grafts in such areas was camouflaged easily when the hair was combed
because the micrografts anterior to the slit-grafted area provided sufficient cover. In the areas, closer to the midline, where there had been
more persistent (original) hair, it is very difficult to see these slit grafts. Theoretical concerns that slit grafts are always considerably more
noticeable than follicular units are more theoretical than real when slit grafting is carried out in a hair-bearing area. The finer the hair
texture, the frizzier or curlier the hair, and the lighter the hair color, the less likelihood there is of detectable slit grafts in such areas, except
on very close inspection. (b), A patient before treatment. (c), Eighteen months after a first session consisting of 400 micrografts, 200 small
slit grafts, and 123 medium slit grafts. This photograph again demonstrates that any cosmetically significant temporary detectability of slit
grafting in individuals with hair characteristics that are similar or better than those of the patients shown in these figures is purely theoretical.
(d), The same patient as shown in Figure 12F-4c, but 6 months after a second session of micrografts and slit grafts. (A total of 824
micrografts, 411 small slit grafts, and 252 medium slit grafts were transplanted) (e), A patient before treatment. (f), The same patient 18
months after a single session of 155 micrografts and 315 medium slit grafts.
482 Chapter 12
Figure 12F-5 (a), A patient 4 months after a first session to his frontal area of 97 micrografts, 207 small slit grafts, and 249 medium
slit grafts area. This was an area that had previously looked similar to the crown area as shown. (b), The same patient 1 year after his
procedure. In an area with any persistent hair, there can be minimal or no cosmetically significant difference between follicular unit
transplantation and a combination of follicular units (FUs) and slit grafts or microslit grafts—depending on how much persistent hair is
present and hair/skin characteristics. Even if the hair is black and the skin is pale, small slit grafts and medium slit grafts, especially when
combined with single FUs placed between them, can be difficult to see, except on very close inspection. (See color insert.)
appearance may sometimes be substantially ‘‘less natural’’ than had noticed the transplantation in that period, and therefore he
could be routinely expected with exclusive FUT. As has been was not pressed to return any earlier.
noted earlier, in a totally alopecic recipient site, this author often By using grafts containing more than one FU, greater density
prefers to begin with a session of FUT, or, at least to use a can ultimately be achieved for the reasons discussed earlier.
substantial majority of FUs. The cosmetic advantage of FUT With each subsequent session of DFU, TFU, slit grafts, or a
in alopecic areas, even if only 20 to 25 FUs/cm2 are trans- combination of FUs and such grafts (preferably keeping pace
planted, is so compelling that it is hard to resist in most in- with the rate at which the individual loses original hair), the
stances, despite any drawbacks noted elsewhere in this discus- grafts are placed closer together, and the likelihood of their
sion. However, when one is working in an area with persisting detection becomes less and less (even as original hair is lost).
hair, there can be minimal or no noticeable cosmetic difference Thus, the use of this combination of grafts produces greater
between FUT and a combination of FUs and DFUs (or TFUs) density without increased clinically significant noticeability
or other types of microslit grafts—depending on how much (Figs. 12F-6 to Figs. 12F-12). Other photographs that validate
persisting hair is present and hair/skin characteristics (Figs. this statement can be found in Chapter 5 of this text (Figs. 5A-
12F-4 and 5). Even if the hair is black and the skin pale, such 12, 5A-13, 5A-15, 5A-16, 5A-18, 5A-21, 5A-28, and 5A-38).
multi-FU grafts, especially combined with single FUs between Furthermore, this is accomplished with less danger to the folli-
them, can be difficult to see, except on very close inspection.
cles because they are surrounded by insulating tissue that mini-
The patient shown in Fig. 5A-18 is an example of just such a
mizes the likelihood of their being injured by handling or dehy-
patient. It is also noteworthy that if the recipient area had origi-
dration. In areas where one can be virtually certain that all of
nally been totally alopecic in this patient, a background of hair
the hair will never be lost, for example, in women with FPHL
as good or better than that shown in the ‘‘before’’ photographs
could have been produced (see Figs. 5A-18a and d) with a single future noticeability of multi-FU grafts is not a concern, even if
session of exclusive FUT—for example, at 20 to 30 FUs/cm2. additional sessions are not conducted.
A second session consisting of a combination of FUs plus DFUs It has also been argued that multi-FU grafts transfer more
or TFUs, as shown in Fig. 12F-3a and b, could then have been alopecic skin—the skin between the FUs—to the recipient area
used without any more noticeability than appears in the remain- than do properly prepared FUs. Despite this undeniable fact,
der of the photographs in Fig. 5A-18. In fact, the patient shown however, the FUs within areas treated more than once with FUs
in Fig. 5A-18 was given less sophisticated treatment with multi- and DFUs (or TFUs) end up being far closer together than they
FU slit grafts that were not microscopically prepared. This pa- would have been if only single FUs had been employed. (This
tient is an entertainer who performs under bright lights. Conse- has already been discussed.) Hair density depends not on the
quently, he was very sensitive to the possibility of any detecta- amount of alopecic skin in an area but on the concentration of
ble plugginess. Yet he did not return to my office until an entire hairs per surface area. If a combination of FUs and multi-FU
year had passed after his first session, claiming that nobody grafts ultimately produces a higher hair density, it becomes
Figure 12F-6 (a), A patient before treatment. (b), The same patient 5 months after the first session. The small slit grafts are not
significantly clinically detectable despite frequent claims to the contrary by some FUT theorists. (See color insert.)
Figure 12F-7 (a), A patient before treatment. (b), Frontal view, 7 months after a first session of 352 small slit grafts. (c), A side view
of the same patient, 7 months after the first session to the midscalp and 14 months after the first session to the frontal area.
484 Chapter 12
Figure 12F-8 (a), Before treatment. (b), Six months after the first procedure (a total of 200 micrografts, 200 small slit grafts, and 192
medium slit grafts). (c), A side view 6 months after the first treatment. (d), Six months after the first procedure, with the hair parted through
the transplanted area for critical evaluation. The slit grafts are minimally noticeable in this patient, even when (1) the hair is parted through
the transplanted area and (2) there is significant color contrast between color of hair and skin.
Figure 12F-9 (a), Before treatment. (b), Six months after a combination of 506 micrografts, 205 small slit grafts, and 244 medium
slit grafts. (c), A photograph taken at the same time as Fig. 12F-9b, with the hair combed back for critical evaluation. (d), A frontal view
of the same patient 9 months after a first session of a combination of follicular units and slit grafts.
Figure 12F-9 Continued.
Figure 12F-10 (a), Before first treatment. (b), One year after the first procedure with a combination of follicular units and slit grafts
(205 micrografts, 163 small slit grafts, and 222 medium slit grafts.) The hair is combed back for critical evaluation. (c), The same patient
as shown in Fig. 12F-10a 1 year after the second procedure, with the hair parted through the middle of the transplanted area showing that
the the slit grafts are minimally noticable. (d), One year after the second procedure frontal view (a total of 445 micrografts, 364 small slit
grafts, and 387 medium slit grafts).
486 Chapter 12
Figure 12F-11 (a) A patient before his first procedure. (b), Seven months after three sessions of a combination of follicular units (FUs)
and slit grafts (a total of 601 micrografts, 350 small slit grafts, and 408 medium slit grafts.) (c), Side view of the same patient shown in
Fig. 12F-11a seven months after the third transplant. This patient, like many of those shown in this section of the text, was treated
approximately six years ago when smaller numbers of FUs were being used in the hairline. If he were being treated today, the hairline
would look considerably thicker after three sessions. They are shown because of the nice density produced by this combination of grafts
and the naturalness of the result, despite the use of far fewer micrografts in the hairline than are currently being utilized.
inconsequential that more alopecic skin has been transplanted ent area incisions should be made coronally or sagittally. They
at the same time. are shown in Fig. 12F-13a and b. Bill Parsley revisited this
question in a lecture he gave to the European Society of Hair
Hair Direction Restoration Surgery on June 7, 2002, in London. The pros and
cons of each are summarized in Table 12F-1. He reached the
The difference between the appearance of density that can be following conclusions:
created with a combination of FUs and multi-FU grafts vs. that
which is created by FUT is not just due to the higher number
of FUs/cm2 that can be transplanted with the former procedure. Consider coronal (perpendicular to the anteroposterior
With the most commonly used hairstyles (combing hair from midline) if you (1) require an acute exit angle, (2) are
one side to the other or straight back), the effect of the high working over larger vessels or nerves, or (3) if the
hair density within multi-FU grafts is enhanced when hair is patient plans to brush his or her hair back in an
transplanted in the same direction as the original hair in that anterior to posterior fashion. As an example, the
area. In the third edition of this text, two schematic drawings temple is an area where an acute angle and a minimal
were used to demonstrate—among other things—the inclina- depth incision are desired. Because a coronally aligned
tions (at that time) of their sources with regard to whether recipi- graft gives more effective coverage in the frontal view,
Figure 12F-12 (a), A patient before treatment. (b), Six months after the second session, each of which consisted of FUs and slit grafts.
(A total of 320 micrografts, 558 small slit grafts, and 240 medium slit grafts.) (c), A side view of the same patient taken at the same time
as Fig. 12F-12b. This individual was treated within the last 2 years and demonstrates a significantly thicker frontal hairline zone compared
with the patient shown in Fig. 12F-11 (as well as others in this presentation) because more micrografts were used for the hairline zone
during each session.
patients who brush their hair back might be better (2) have new or inexperienced assistants, or (3) if the
served with the coronal orientation—however, this patient has significant existing hair. Whereas there
provides a more significant benefit when one is have been problems with coronally oriented slits and
employing minigrafts and slot grafts than with slots (with larger incisions 4 mm to 5 mm in length),
follicular unit grafts. there have been few, if any, reports of perfusion
Consider sagittal grafts (parallel to the problems with smaller incisions such as those used for
anteroposterior midline) if you: (1) plan to dense pack, follicular unit grafting.
Table 12F–1 Coronal vs. Sagittal
Probability of significance Perpendicular (coronal) Parallel (sagittal)
Strong evidence Decreases depth of incision. Holds acute Less collagen damage Better site visibility
exit angle better for assistants Less vessel damage
Probable Better frontal cosmetic coverage. Incision Less transection of existing hair
better fits natural follicular unit alignment
Questionable Easier placement by assistants
488 Chapter 12
Figure 12F-13 (top) (a), A staggered pattern (each no. 15 blade slit separated by 6.0 mm) based on horizontal reference lines. (b) A
second staggered session consists of no. 15 blade incisions placed 2.0 mm to the right of the first set of incisions performed 4 months
earlier. (c) The final session consists of no. 15-blade incisions placed 2.0 mm to the right of the second set of incisions performed 4 months
earlier. (Drawing courtesy of Dominic Brandy.) (bottom), Schematic diagram of graft site placement for first, second, and third transplant
sessions. Dots represent one-hair and two-hair micrografts, vertical marks represent quarter grafts, and concentric marks represent half
grafts. (Drawing Courtesy of Dowling B. Stough.)
Although Parsley directed his discussion primarily to the the magnifying effect, I neglected to sufficiently emphasize the
incisions made for FUs, this bit of seeming minutia may be far importance of the somewhat coronal direction of hair, which I
more significant than it at first appears to be—in particular if, try to create in large portions of the recipient area when I make
as he suggests—either DFUs, TFUs, QFUs, or slit or slot grafts recipient area incisions. I described this orientation of grafts
are used. It may be an important reason why such grafts produce in Chapter 5 in this edition and in the third edition of Hair
an effect on apparent density that is disproportionate to what Transplantation (Figs. 10 [p. 226] and 11 [p. 228] in that text).
might be expected by simply totaling the number of FUs trans- It is, however, the combination of more solid walls of FUs in
planted. I have often pondered this magnified effect and tried these multi-FU grafts, along with the somewhat coronal direc-
several times in lectures to explain the use of these grafts as a tion of many of the grafts, that produces the full impact of
mechanism for enhancing the ‘‘shingling effect’’ (see also shingling. Shapiro has described it as the different visual block-
Chapter 5). If the grafts are directed from posterior left to ante- ing effect that can be produced with a playing card. If it is held
rior right, for example, and the hair is combed from the left in front of you, with only the edge of the card facing you, it
frontal hairline across to the right side or posteriorly and toward blocks very little of your field of vision. If, instead, it is turned
the right side of the vertex, far greater coverage is achieved somewhat to the right or left, part of the face of the card is
than if the grafts were inserted sagittally instead of somewhat now blocking part of what you are seeing. In the case of hair
coronally. This is because, as noted earlier, the FUs within the transplanting, the alopecic area is posterior to the graft. Another
multi-FU grafts provide a more solid ‘‘wall’’ of hairs than is way of describing it is to think of the FUs as the bushes of a
produced by transplanting single FUs as part of FUT. This wall hedge in front of a sandy (alopecic) area. The closer together
of hair is combed over any alopecic areas, covering them more the ‘‘bushes’’ are, the less of the ‘‘sand’’ (alopecia) behind them
effectively than a less solid wall. In previous explanations of can be seen. In Chapter 23C, Hasson and Wong describe the
advantages of incising recipient sites in a coronal rather than lost and the FUs can be more easily discerned (see later). Al-
a saggital plane. They believe that hairs in their multi-hair FUs though longer intervals may be preferred by some patients, oth-
produce better coverage when planted this way. The rationale ers want to thicken their thinning hair or to finish all transplant-
that several very closely spaced hairs in an FU (aligned coro- ing in the area as quickly as possible. For many individuals
nally) provide a visual advantage can be thought of as a mini- with the latter two objectives, I find FUT a disadvantage. I am
form of several very closely spaced FUs in a multi-FU graft reluctant to do a second session in a hair-bearing area with FUs
(aligned somewhat coronally) that produce a visual advantage. until there is sufficient additional hair loss to make clear to me
I did not reason all of this out when I started making my where the FUs are and where more grafts are truly required.
recipient area incisions somewhat coronally. This awareness The more hair there is in the recipient area, the finer the hair
came about because I operated on patients with relatively early texture is and the less color contrast there is between hair and
MPB. Whereas, for many years, most of my colleagues pre- scalp, the more difficult it is to find these FUs. Fortunately,
ferred to wait until MPB was well advanced before starting these are the same hair characteristics that minimize the detecta-
treatment. I was simply attempting to follow the direction of bility of grafts containing more than one FU, and this makes
persisting recipient area hair. I became accustomed to directing the use of such multi-FU grafts more cosmetically acceptable.
my grafts somewhat coronally, because that is what I find in Because both techniques—FUT and a combination of FUs
much of the recipient area before all of the hair is lost (Fig. and microslit grafts—offer distinct advantages and disadvan-
12F-14) (see also Chapter 5). I continued to employ the hair tages, I have suggested that hair transplantation for the majority
directions I had seen in those patients when I operated on more of patients will eventually evolve into a procedure that consists
alopecic recipient areas. Even if I am using a hypodermic needle of a session of exclusive FUT and another session of combined
for FUs, I turn the needle so the long axis of the incision is FUs and micro-slit grafts or slit grafts (1). For those who worry
made in the direction I want the hair to fall. Whenever there about the noticeability of TFUs, for example, DFUs could be
is persisting hair in anterior portions of the frontal area or hair- used instead. I have further suggested that if areas are com-
line zone, the hair is parted parallel to the hairline and combed pletely alopecic the first session should be carried out exclu-
in various directions until I can sense the way in which it tends sively with FUs. Subsequently, one or two additional sessions
to fall (Figs. 12F-14a, b, and c). Posterior to the anterior frontal
can be done with use of a combination of FUs and DFUs, TFUs,
area, as well as in the midscalp and vertex areas, any existing
QFUs or slit grafts without the occurrence of any noticeable
hair is parted coronally or sagitally and, again, combed in var-
plugginess and with resultant greater density than could have
ious directions to detect the way it seems to naturally fall. Once
been created with exclusive FUT. Alternatively, if there is suffi-
the hair direction is ascertained, I often comb the hair in that
cient hair in the recipient area when transplanting begins—as
direction again. I then ask my assistant to apply a piece of gauze
shown in Figs. 5A-18a and c—the surgeon can begin with a
to the ends of the hair and to push it in the opposite direction
combination of FUs and micro-slit or slit grafts and can perform
so that the hair ‘‘buckles’’ a little (Fig. 12F-14d). Sometimes,
the second session with FUT (if only two sessions are contem-
the same technique is also used in the anterior frontal area if
there is a substantial amount of the original hair still present plated). If a third session in the same area is deemed necessary
there. This maneuver helps to clarify the hair direction as I for additional density, it can be carried out either as FUT or a
make a line of incisions within the parted area (Fig. 12F-14e). combination of FUs and micro-slit or slit grafts. The patient
The hair is parted again, anterior to (if I part it coronally) or shown in Fig. 5A-18 was chosen specifically because he had
slightly to the left or right (if I part it sagittally) of the line of dark hair and light-colored skin, which represents a worst case
incisions, and the process is repeated, usually many dozens of scenario.
times, until the entire recipient area has been prepared. It is
worth repeating that in areas of ‘‘total alopecia,’’ there is nearly Hair Survival
always some ‘‘fuzz’’—if you look hard enough—that can act
as a guide in the choice of hair direction. The reader is referred to Chapter 9 for a more detailed discus-
sion of hair survival studies with FUs. It seems reasonable to
assume, however, as noted by Reed earlier in this chapter, that
The Advantage of Graft Detectability the smaller the graft and the less tissue surrounding the follicles,
As is often the case in medicine—and life—what is initially the more susceptible they are to injury, including fatal injury.
thought to be something bad may contain the seeds of something To summarize his arguments in the case of individual FUs,
good, and what initially seems good may evolve into something there is far less insulating tissue around each follicle than is
bad. So it is with the ‘‘disadvantage’’ of multi-FU grafts being present in multi-FU grafts; therefore, both manual pressure on
slightly more detectible than FUs if one is transplanting into a the follicles and the more serious danger of dehydration of folli-
recipient site that still contains some of its original hair. Any cles is increased. Moreover, the smaller the recipient site and
detectibility of microslit grafts transplanted months earlier into higher the density of FUs/cm2, the more handling one can ex-
a recipient area with some persisting original hair aids in opti- pect when trying to get the graft into place. Under such circum-
mal placement of additional grafts during the next transplant stances, the follicles are subjected not only to more physical
session. Conversely, if only FUs have been used in the earlier trauma but also to a greater likelihood of dehydration as the
session(s), their relative undetectability makes it more difficult graft is maneuvered into place. Sometimes, the graft pops out
to find them and therefore to optimally place the next set of of the hole one or more times and must be put back in repeat-
grafts. Thus, in the latter case, one is sometimes obliged to wait edly. (This also occurs when there is more than usual bleeding
longer between sessions until more of the original hair has been at the recipient site, but introducing that factor unnecessarily
490 Chapter 12
Figure 12F-14 (a), In the anterior portion of the frontal area, or the hairline zone, the hair is parted parallel to the hairline and is
combed in various directions until I can sense the direction in which it wants to fall. In this photograph, I have done that and have inserted
needles to indicate both the slightly coronal hair direction as well as the direction in which the hair wanted to fall in this particular individual.
(b), This is a side view of the same patient shown in Fig. 12F-14a showing how the direction of the hair changed in this patient across
the frontal zone and into the temporal area. The direction of the hair shown is quite common in patients, but, as indicated elsewhere in
the text, hair direction is extremely variable and the surgeon should always follow the natural inclination of the particular patient. (c),
Another view of the same patient shown in Figs. 12F-14a and b, demonstrating the changing angle and direction of hair in this particular
patient. The reader is also referred to Figure 5A-39c to see how complex hair directions can be in the crown area. (d), I usually comb
existing hair in various directions to detect which way it wants to fall. I then comb the hair in that direction and ask my assistant to apply
a piece of gauze to the ends of those hairs and to push in the opposite direction so that the hair ‘‘buckles’’ slightly. This maneuver clarifies
the hair direction for me as I make the recipient area incisions. (e), An intraoperative photograph with needles in place to show the varying
hair directions in the midscalp of this particular patient.
complicates the present discussion). Recognizing these prob- posterior to that zone—though he was unsure of exactly where.
lems, most FUT practitioners have, over the past few years, Although, as stated above, I am absolutely certain Limmer’s
begun to leave a good cushion of tissue as protection around survival rates are far higher than implied by the data, it certainly
the FUs. Such grafts have come to be referred to as ‘‘chubby’’ makes many of us more nervous about hair survival with FUT,
FUs as opposed to the ‘‘skinny’’ ones that were used earlier in given the common sense view that in everyday practice, the
the evolution of FUT. At the same time, however, the recipient smaller the graft, the more susceptible follicles within it are to
sites began to be made with smaller and smaller bore needles lethal injury.
or blades. This was done to decrease the size of the incisions As noted earlier, other FUT practitioners use 30 FUs/cm2
and therefore minimize the interruption of recipient area blood (or more) and FUs with three or more hairs in areas where
supply. A second purpose of smaller needles/blades was to facil- maximum density is the goal. However, in such an area, one
itate the placement of more FUs/cm2 than would be possible if should obtain in a single session and with 100% survival, at
larger ones were used. The result was that chubbier FUs were least 90 hairs/cm2 (30 FUs/cm2 ⳯ three hairs/FU). With 113%
being inserted into smaller sites. Unfortunately, any dense pack- survival (Seager) or 133% survival (Beehner), these numbers
ing of these sites further increased the likelihood of lethal dam- should be even higher. Yet only a very few FUT practitioners
age to the chubby FUs during their insertion owing to the in- have claimed these numbers after a single session and then only
creased difficulty of placing the grafts into holes that were so by using 40 to 50 FUs/cm2. The high rates of hair death with
close together. In any case, going back to the beginning of this FUT suggested by the aforementioned figures, were pointed
discussion, it seems eminently logical to assume that the smaller out at the 1999 annual meeting of the International Society for
the graft and the less cushioning material around the follicle, Hair Restoration Surgery and elsewhere (3,11). Since that time,
the more susceptible it is to injury. Thus, Reed has suggested, more and more FUT practitioners seem to have adjusted their
in this chapter and elsewhere that a small graft containing two FUs/cm2 downward. As commented on earlier, most now refer
or three FUs may be the optimal chubby FU (6). to routine densities of 20 to 25 FUs/cm2/session—a density I
What actually occurs in practice? For several years, FUT also use for FUT. It is worth recalling, however, that in Mayer’s
practitioners were claiming that they routinely transplanted 35 study on hair survival with different densities of FUs/cm2, he
to 50 FUs/cm2 and were thus able to produce increasing hair found 97.5% regrowth when 10 FUs were transplanted/cm2,
densities per session (5,7,8). Even if one ignores the fact that 92.5% regrowth with 20 FUs/cm2 and only 72.5% survival with
FUs containing more than the average 2.3 hairs per FU are 30 FUs/cm2 (see Chapter 9). There is a small though growing
frequently used in the areas where maximum density is the goal, group of surgeons who suggest routine FU densities of 50 or
any area treated with even 40 FUs/cm2 should produce 92 hairs more FUs/cm2 and sessions of 3000 or more FUs. I find this
per cm2 (40 FUs/cm2 ⳯ 2.3 hairs per FU) in a single session. trend very worrisome with regard to hair survival and have
Moreover, if David Seager is correct in saying that 113% growth discussed this concern at length in my commentary on Chapter
can be expected in an isolated test circle of FUs (9), there should 12B.
be 104 hairs after a single session of FUs planted with a density In a perfect world, expert technicians would patiently and
of 40 FUs/cm2. In addition, Michael Beehner has reported 133% carefully dissect FUs and implant them with a minimum amount
growth of transplanted chubby FUs (10). How then, in 1999, of trauma and dehydration. However, as Reed has stated earlier
did Limmer (according to Marritt (2)), using 30 to 45 FUs/cm2 in this chapter, and I have reiterated, in the real world, large
(7), produce only 76 hairs per cm2 after two sessions instead numbers of FUs require large numbers of technicians, and it is
of 92 hairs/cm2 (or more) after one session? Limmer has stated extremely difficult to constantly supervise them in order to
that his figures are misleading, and I have no doubt that in some achive excellent quality control. I have had the experience of
way they are. They otherwise imply extraordinarily high follicle hiring a technician with 3 years’ experience at a large, nationally
death rates. I am absolutely certain that Limmer’s survival rates advertised clinic that ceased operating in our area, thinking that
must be far better, or he would have abandoned FUT. (In a the work of training a new technician had been done. That
similar fashion, if my experience with a combination of FUs technician turned out not only to be far from satisfactory in
and multi-FU grafts were not far better than those suggested graft preparation and insertion but also untrainable; after sev-
by some FUT enthusiasts, I would have abandoned grafts with eral frustrating months, the technician was fired. We are cur-
more than one FU). Yet the reason for the discrepancy between rently retraining another technician who worked for several
the number of FUs transplanted and the hair densities produced years in the office of another practitioner whose clinical results
is unclear. Even if 30 FUs/cm2 had been used instead of 40, are excellent. With FUT, one is working with grafts that are
there should have been at least 69 hairs/cm2 after one session. the smallest and therefore the easiest to injure. Moreover, many
And even if only 10 FUs/cm2 were transplanted in the same technicians are preparing the grafts, and some technicians are
area on the second occasion, there should have been 23Ⳮ69, inherently better than others. Injuring the grafts less or more
or 92, hairs/cm2 after two sessions instead of 76 hairs/cm2. After depends on the technician’s hand/eye co-ordination, mental and
Limmer suggested to me that perhaps Marritt had measured physical state, etc. The larger the number of FUs/session and
hair density in the hairline zone, where many one-haired FUs the more FUs/cm2, the worse the problem. This is the Achilles
had been used, and that a multiple of 1.5 hairs/FU would have heel of FUT that must be recognized. In brief, we do not work
been more appropriate, I contacted Marritt. It seemed more in a perfect world. If the chosen technique involves many indi-
likely to me that an observer such as Marritt, who in his article viduals in the preparation and insertion of grafts, more lethal
was clearly impressed with the hair density he had seen in Lim- damage to the follicles can be expected than if slightly larger
mer’s patients, would evaluate the densest areas he saw instead grafts are used, in which the follicles are more cushioned against
of the least dense – in the hairline zone. Marritt, in fact, was trauma and dehydration. It may be that in most offices higher
certain he had not studied the hairline zone but ‘‘somewhere’’ follicle death rates may be part of the price to be paid for the
492 Chapter 12
maximum naturalness produced by FUT. However, given the session, carried out between the first and second surgeries, does
limited donor supply in many patients, this price may be very not significantly impair hair regrowth.
significant. Subsequently, a study of 2-mm2 grafts was conducted on
two additional patients in the office of David Seager. This study
revealed a hair growth rate of 98% to 114% in one patient at
11 months (depending on which technician’s hair count was
THE RATIONALE FOR USING A used) and 78% to 80% in the second patient at 91⁄2 months.
COMBINATION OF FUs AND ROUND GRAFTS Although the percentage of growth in the second patient was
IN HAIR TRANSPLANTING less than would have been expected given what was found in
the other four patients, results might have been better if the
Although a combination of FUs and micro-slit or slit grafts can
count had been done at 11 months or later. I had noted that this
produce more hair density than the exclusive use of FUs, their
patient was an unsuitable candidate for round grafts even before
impact on density pales when it is compared to what is possible
the study was done. The 2-mm2 grafts were not placed in the
with round grafting. Generally, in round grafting, a strip ob-
location that I typically recommend (see Chapter 9 for more
tained with a multibladed scalpel (with blades that are 3 mm
details). It may be fairly argued that excluding this patient from
apart) is divided into sections that are approximately 2 mm
the discussion that follows provides a possible positive bias.
wide, thereby producing grafts that are approximately 2 mm
However, I believe that for the aforementioned reasons (and
⳯ 2 mm. Just as with slit grafts, the hair density in each of
others), inclusion of this patient would have produced a far
these grafts is greater than that present in the donor area from
more negative bias against the results that I would reasonably
which it was obtained, because the strip contracts slightly after
expect to see in the patients I choose to treat this way—which
it is excised.
is approximately 100% hair regrowth.
It is not unusual for round grafts to contain 13 or more hairs
In each of the four patients with the more typical grafts, an
(see Chapter 9 and later). These grafts are placed into holes
average of 13 or more hairs grew from each 2-mm graft. (This
produced by round punches with a 2-mm diameter. Because
number was confirmed as ‘‘possible’’ by the three patients in
the surface area of a 2-mm square is larger than that of a round
the first study and as ‘‘acceptable’’ by the one patient in the joint
hole with a 2-mm diameter (4 mm vs. 3.14 mm), and because of
Unger/Seager study). Why such a high number? The answer is
the remarkable pliability of the skin, these square grafts virtually
that 2-mm2 grafts have 127% of the surface area of round grafts
always completely fill the oval recipient site produced by an
with a 2-mm diameter, and therefore contain more hair. In addi-
angled punch with a 2-mm diameter.
tion, donor tissue, as noted earlier, shrinks after it is excised
In view of my preceding comments on hair survival in FUs,
from the donor area. Thus, the hair is compressed from a larger
a brief review of some of the hair survival studies in 2-mm2
surface area (usually a 3-mm wide strip) into a smaller one. It
grafts described in Chapter 9 seems advisable here.
is the strip with compressed hair that is sectioned into approxi-
Michael Beehner reported in 1999 on a study of hair survival
mately 2-mm2 grafts. What are the implications of this number?
in 13 patients who received 65, 1.8-mm to 2-mm round grafts
(12). The grafts were transplanted significantly posterior to the 1. Figure 12F-15, is a schematic drawing wherein each
hairline and as a component of a third transplant session in each small square is 1 mm2 and the large box is 1 cm2. The
of the studied patients. In total, 457 hairs were placed, and after numbers denote the session in which a given 2-mm2
5 months, 428 hairs were growing. This represented a 93.6% box was transplanted. For example, all the 1’s denote
growth rate. As was also pointed out in Chapter 9, it is very the 2-mm2 grafts transplanted during session no. 1, and
likely that if the hair count had been repeated at 9 or 12 months, all the 4’s denote the 2-mm2 grafts transplanted during
the hair growth rate would likely have been even better. I de- session no. 4. The numbers to the right of the box docu-
cided to do a similar study on three totally alopecic patients ment the number of hairs that would be produced after
who were undergoing transplanting with a combination of FUs, each session if each 2-mm2 graft had an average of at
DFUs, TFUs, and 2-mm2 grafts placed into holes prepared with least 13 hairs, as were found in these four patients. After
a 2-mm round punch (13). The round grafts were placed behind one session, there would be 117 hairs/cm2; after two,
the zone of DFU grafts in the posterior aspect of the hairline there would be 195/cm2; after three, 273; and after four,
zone (Fig. 5A-40e). They were organized as three rows, in there would be 325 hairs/cm2! This pattern is valid given
which each of the 2-mm round grafts were separated from the the assumption that hair survival would be as good in all
neighboring grafts by 2 mm laterally as well as anteroposter- sessions as it was in the first. Although this is unlikely
iorly. Posterior to the round grafted area, additional DFU and Beehner’s reported hair regrowth rate of 93.6% in the
TFU grafts were used. All patients who were studied were 2-mm grafts 5 months after a third session would only
undergoing their first session. Also, in the first patient, it was reduce the average number to 12 hairs/graft. Even—to
evident that fewer hairs had regrown after 4 months than after stretch a point—if the average were only 11 hairs/2
8 months. As a result, in the subsequent two patients, our hair mm2 (approximately 85% hair survival in the grafts with
counts were done 9 months postoperatively. According to 13 hairs each, the result could be 275/cm2 after four
counts made with use of the Mantis stereoscopic microscope, sessions (Fig. 12F-16). Such hair densities, if used in
a total of 229 hairs were planted. After 8 to 9 months, a total large areas, would waste a limited resource. However,
of 241 hairs were counted, representing a 105.2% yield. Further- if one produces, for example, only a 1-cm wide band of
more, in patient number one, a second session had been carried high-density hair in properly selected patients, it would
out 5 months after the first, in the same areas but between create the appearance of remarkable density for the en-
previously transplanted grafts. Thus, it appears that the second tire recipient area (see Figs. 12F-17, 12F-18). There are
Figure 12F-15 A schematic drawing on the left in which each small square is 1 mm2, each larger (and numbered) box is 2 mm2, and
boxes represent the session number in which transplantation will take place. If each 2 mm2 has an average of 13 hairs, the results are as
tabulated to the right of the schematic drawing.
more photographs that validate this statement in the next 3. Very few patients with 2 mm2 grafts actually undergo
section of this chapter (Chapter 12G). four transplantation sessions in such an area, although
2. Because round grafted areas result in such high hair patients are advised at the outset that four sessions will
density, a narrow zone immediately anterior to the be needed to fill the area solidly; that is, to such an
round grafts must also be transplanted more densely extent that no plugginess will be noticeable when the
than usual; otherwise, an abrupt change in hair density hair is wet and parted. Two reasons why patients might
becomes noticeable. This is accomplished by scattering not consider a fourth session cosmetically necessary are
grafts ranging from 1.3 mm to 2.0 mm, and by placing (1) the high density produced by even three sessions
slot grafts and FUs with three, four, or five hairs in a (231 hairs/cm2 even if only 85% hair survival in 2-mm2
band 1 cm to 1.5 cm wide just anterior to the round grafts containing 13 hairs) and (2) the fact that only
grafts. This approach is explained in more detail later four 2-mm2 boxes are left to be filled with a fourth
in this chapter. session (Figs. 12F-16 and 12F-17). Although some phy-
Figure 12F-16 A schematic drawing on the left, in which each small square is 1 mm2, each larger (and numbered) box is 2 mm2, and
the boxes represent the session number in which transplantation will take place. If each 2 mm2 has an average of 11 hairs, the results are
as tabulated to the right of the schematic drawing.
494 Chapter 12
Figure 12F-17 (a), An intraoperative photograph of a patient treated with a combination of 150 micrografts, 133 medium slit grafts,
and 133 2-mm round grafts. (b), A preoperative photograph of the patient shown in Fig. 12F-17a with the hair wetted down with Betadine
to reveal the true extent of his hair loss. (c), The same view of the same patient as shown, in Fig. 12F-17b; the exception is that the hair
is dry. (d), One year after the third session, using the same combination of grafts as shown in Fig. 12F-17a (a total of 504 micrografts,
419 small slit grafts, 487 medium slit grafts, and 253 2-mm grafts.) Despite the use of 2-mm grafts, this patient claimed that nobody noticed
his hair transplant or any plugginess at any stage during his course of treatment. He returned to the office yearly and would have returned
earlier if he had thought ‘‘for a moment’’ that anyone had in fact noticed anything. (e), A frontal view of the same patient before treatment.
(f), Frontal view of the same patient 1 year after his third session. Rather remarkably, nobody has noticed that he has substantially more
hair—at least according to him—because the change has been so gradual. Patients very commonly report this. People often notice they
‘‘look better,’’ but most often ascribe it to weight loss or gain, ‘‘working out,’’ or some other source. It is also remarkable that if one
produces, for example, only a 1-cm wide band of high-density hair in properly selected patients, it creates the appearance of very dense
hair in the entire recipient area.
sicians have postulated that the compressed hair in the skin color contrast is minimal, if there is significant hair
2-mm2 grafts virtually guarantees their noticeability, or curl or frizz, and if there is at least some persisting
plugginess, this has not occurred in my patients, for original hair in the recipient area, or a combination of
reasons discussed later. (If it did occur, it would be two or more of these characteristics. As a result of all
extremely foolish for me to continue to offer this op- of the preceding conditions only 10% to 15% of patients
tion.) The fact that only a minority of patients treated seen by me are considered to be acceptable candidates
this way think they need to have a fourth session only for this approach—and some of them may not need
emphasizes how theoretical rather than real is the postu- thick-looking hair to be satisfied. In other words, this
lated plugginess of 2 mm2 grafts with compressed hair. is a technique that is suitable for only a relatively small
4. Because solid filling of the round-grafted area is usually minority of hair transplant patients. The exception to
not deemed cosmetically necessary by most patients and these general rules might be an individual with thick
because a zone of FUs and micro-slit/slit grafts is al- temporal hair but with a poor long-term ratio in the
ways used anterior and posterior to this area, use of donor-to-recipient area, who has decided to have maxi-
round grafts in transplanting today is far more ‘‘forgiv- mum hair density created frontally and to leave the areas
ing’’ than it was in the days before FUT and microslit posterior to the frontal area untransplanted. One such
grafting. Hair restoration surgeons who use round patient, shown in Fig. 5A-17, is wearing a hairpiece
grafts, as described earlier, do not have to be nearly as posterior to the transplanted frontal area.
expert in creating excellent cosmetic results with round
In 2002, Bradley Wolf proposed 10 reasons why incisions were
grafts, as those who used them 10 or more years ago.
superior to round holes (15). His rationale was well thought
The grafts anterior and posterior to the round grafted
out and deserves a reply preceded by a paraphrase of his argu-
area effectively camouflage any plugginess that the
ments:
great hair density in the round grafted area does not
overcome (Fig. 12F-18 and 19). 1. With use of punches there is ‘‘net loss of scalp tissue’’
5. A substantial majority of FUT proponents produce less from the donor area (but not from the recipient area).
than 80 hairs/cm2 in one session. However, if one could This effectively is a ‘‘scalp reduction in the donor
achieve 100 hairs per cm2 with a single session of area’’ and ‘‘the net loss, especially experienced over
FUT—note that very few practitioners can do and over, theoretically causes disruption of the scalp
this—after one session, FUT would transfer more hair anatomy, (italicization mine). Incisions cause no net
than 2-mm2 grafts containing 9 or even 11 hairs. On loss and therefore are less disruptive.’’
the other hand, after two sessions with 9.0 hairs per 2 How is excising a strip from the donor area for
mm2, 135 hairs would have been transferred; with 10 microslit grafting or FUT any different from excising
hairs per 2 mm2, 150 hairs would have been transferred, the same size strip for the preparation of slot grafts
and with 11 hairs per 2 mm2 165 hairs would have been or round grafts? Many FUT practitioners typically
transferred. With the exception of small, 1-cm2 square excise a strip that is 10 mm wide or wider, and I
test areas, nobody has shown hair densities after two typically excise one for microslit grafting, slot graft-
sessions of FUT that are remotely comparable to these ing, or round grafting that is 8 to 10 mm wide (see
densities. After three sessions of 2-mm2 grafts, the num- Chapter 10). There is, therefore, no more—and often
bers become even more impressive: One hundred less—net loss of donor area tissue when a strip is
eighty-nine hairs would have been transferred if there taken for slot or round grafts instead of for microslit
were 9.0 hairs per 2 mm2, 210 hairs if there were 10 grafts or FUs.
hairs per 2 mm2, and 230 hairs if there were 11 hairs 2. There is greater ‘‘linear excision damage’’ with scalp
per 2 mm2. With more than 11 hairs per 2 mm2 (which tissue removal by punches than by blade incisions.
is common in the patients to whom I offer this ap- Wolf gives as an example, the use of a 1-mm punch
proach), or larger grafts, the numbers become so high vs. a 45-degree microsurgical scalpel, both of which
that some patients stop after two sessions (see Fig. 12F- produce sites for grafts containing three to four hairs.
20). It should be clear from these figures that unless The 1-mm punch produces 3.14 mm of linear incision
there is massive (and thus far unproved) death of hair damage versus ‘‘approximately 2 mm’’ for the 45-
in 2-mm round grafts, the density of hair achievable degree blade, representing 36% greater damage from
with FUT can never produce anything remotely ap- the punch. If one includes the horizontal base of the
proaching the density achievable with 2-mm round 1-mm punch site, the hole results in an even greater
grafts. difference of total linear healing surface, which he cal-
6. As I have repeatedly stated over the years, using up culates as 4.14 mm, or an additional 10% more than
so much donor hair in relatively small areas is only from the blade.
acceptable if the donor/recipient area ratio is expected Although the preceding calculations may be valid
to be very good in the long run and if temporal hair for 1-mm punches, as with many theoretical discus-
density is expected to be high in the long run; thus, sions involving numbers, this argument can be easily
the end result will not be dense-appearing frontal hair reversed. If, for example, a 2-mm punch is employed
adjacent to sparse, cosmetically inappropriate temporal instead of a 1-mm punch, as has been shown earlier
hair. In addition, noticeability of round grafts during in this discussion, the number of hairs transplanted
the course of treatment should, ideally, be minimal. As into the 2-mm site easily grows to 12 to 14 hairs. Even
has been noted earlier, this is most likely if the hair and with use of only 12 hairs for the punch site, one fin-
496 Chapter 12
Figure 12F-18 (a), This patient was originally treated by me with standard round grafts more than 20 years ago. This is an intraoperative
photo taken during his first session (28 micrografts and 90 standard grafts.) (b), A preoperative photograph of the same patient. Over the
ensuing years, he continued to lose more hair in his midscalp and vertex area and he came back every 1 to 3 years for further treatment.
(c), This is a photograph of the patient taken approximately 20 years after his first session. It shows his current results, the end product
not only of the transplantation in the frontal area but also in the midscalp and vertex areas. (d), A photograph taken at the same time as
the one shown in Fig. 12F-18c, with the hair parted through the midline for critical evaluation. (e), A side-view photograph taken at the
same time as that in Fig. 12F-18c. (f), A photograph of the patient’s transplanted hairline 20 years after his initial session, with the hair
combed back for critical evaluation. The remarkable density shown is the result of round grafting right up to the hairline. The naturalness
is the result of follicular units that were added to the hairline just anterior to the dense round grafts, as transplantation was being carried
out in the midscalp and vertex. Few patients have donor reserves sufficient to produce this kind of result. However, this series of photographs
is useful in demonstrating the sort of density and naturalness that can be accomplished with the use, in appropriately selected patients of
round grafts combined with micrografts.
Figure 12F-19 (a), A patient before treatment. He had worn a hairpiece for many years. Most of my patients do not wait until they
are totally alopecic, as this patient was, before coming to see me. Because he continued to wear the hairpiece during the course of treatment,
he was unconcerned with the possibility of any temporary ‘‘plugginess.’’ His objective was maximum density that would most closely
resemble the density he was accustomed to with the hairpiece. (b), After three and a half sessions in which a combination of micrografts,
slit grafts, and round grafts was used (a total of 541 micrografts, 100 small slit grafts, 631 medium slit grafts, 141 standard grafts, and 50
2-mm grafts). This patient was treated more than 8 years ago. If he were treated today, his hairline would be even denser because we
currently use many more micrografts per session in the hairline zone. Nevertheless, he has an excellent result.
ishes with 6.28 mm plus 2.0 mm or an 8.28-mm linear when circular sections of scalp are removed, leading
healing surface for the 12 hairs in that site. If each FU to more scarring compared with incisions made paral-
has an average of 2.3 hairs, 5.2 incisions would be lel to Langer’s lines.’’
needed to transplant the same number of hairs (12 di- As Wolf implies, even some incisions violate
vided by 2.3). Each incision made with a 45-degree Langer’s lines. More importantly, in the experience of
blade creates an approximately 2-mm linear healing many of us, no practical cosmetic difference results
surface. Therefore, 5.2 sites would create 10.4-mm from this theoretical disadvantage (see no. 3 in this
(5.2 ⳯ 2 mm) of linear healing surface for the blade section).
sites vs. the previously noted 8.28-mm linear healing 5. ‘‘Evascularization, denervation, and removal of other
surface for the punch site containing the same number vital components from the scalp by punches can lessen
of hairs. the growth of transplanted hair’’ (italicization mine).
Of course, what is really important is not the inci- There is no clinical proof of this theoretical differ-
sion site length per hair but proof that any such difference. Moreover, as has been pointed out repeatedly in
ence actually results in a different rate of hair survival this text, hair survival is affected by many factors other
for each of the two techniques. Such evidence has than recipient area wounding. The accumulated impact
never been presented by anyone. One could just as of these additional factors is likely to be far more im-
easily argue that 2-mm grafts may do better because portant with regard to hair survival than recipient area
they are much farther apart than FU sites, but that too wounding.
has never been demonstrated to be the case. 6. ‘‘Tissue removal is often cited as an advantage of cir-
3. ‘‘Even small punches create more scar tissue’’ than cular punches’’; however, ‘‘four hairs present in a cir-
incisions, with ‘‘altered light reflection causing an un- cular section of skin, 1 mm in diameter, will occupy
natural appearance of the scalp’’ and skin color 0.015 mm,’’ or ‘‘1.9% of the surface area of that piece
changes. of tissue. When this amount of non–hair-bearing skin
Although this may be theoretically correct, it has is removed, it is replaced with skin that is 98.8%
no practical cosmetic significance in my experience non–hair-bearing.’’
and in the experience of many other practitioners who The preceding statements sound as if they might
use small round and slot grafts. The many photographs be an important argument against circular punches
in this text and Fig. 12F-21 should illustrate this, as until one remembers the actual difference in hair den-
do the numerous unsolicited referrals to me from sity that can be produced by round grafts (that are
hairstylists and cosmetic surgeons who see my results larger than 1-mm diameter). This has been discussed
on our shared patients. (Forgive my immodesty, but earlier in this section and need not be repeated here.
this is a very important rebuttal to the theoretical disad- What is important is how many hairs/cm2 can be pro-
vantage that is used too often by FUT proponents.) duced by each technique. The difference is very
4. ‘‘Langer’s lines are violated to a much greater degree strongly in favor of 2-mm2 (or larger) grafts. Put differ-
498 Chapter 12
Figure 12F-20 (a), An intraoperative photograph of the first session of a patient. (b), The patient shown in Fig. 12F-20a before
treatment. (c), One year after the second session. Each session consisted of a combination of micrografts, slit grafts, and standard round
grafts (a total of 300 micrografts, 220 small slit grafts, 335 medium slit grafts, and 82 standard grafts). (d), A frontal view of the patient
taken at the same time as the photograph shown in Fig. 12F-20c. (e), A side-view photograph taken at the same time as the photograph
shown in Fig. 12F-20c and 20d. Despite only two sessions, the hair density and appearance produced was satisfactory for this individual,
who felt that no further treatment was necessary. If his hair were wet and parted through the middle of the transplanted area, the empty
spaces between the standard round grafts would be obvious. However, he discovered that if this occurred, he could simply run his fingers
through his hair and the cosmetic problem would be eliminated. Despite the fact that many patients can achieve high visual density after
two sessions—as this individual did—all patients who elect to have round grafting done are advised that they will need three and a half
sessions to fill the area solidly with round grafts. It is emphasized that this is the commitment they are actually making when they choose
to use this combination of grafts.
Figure 12F-21 (a), An intraoperative photograph of a patient showing his second session of transplanting with a combination of
micrografts, slit grafts, and standard round grafts 10 years ago. Much, although not all, of the hair present in the recipient area shown had
grown in from a session done 4 months earlier. Although the pattern of round grafting that I use is usually very regular, the pattern shown
here is somewhat irregular anteriorly. This was because I had difficulty discerning where the previous round grafts had been used 4 months
earlier. (b), A photograph of the patient 6 months after his second session, with the hair combed back for critical evaluation (a total of 322
micrografts, 367 small slit grafts, 113 medium slit grafts, and 102 standard grafts). ‘‘Plugginess’’ from the standard round grafts was not
evident because the micrografts and slit grafts were placed anterior to the area of round grafts. (c), A top view of the patient taken 6 months
after his third session. A combination of micrografts, slit grafts, and round grafts was used in that session (a total of 472 micrografts, 367
small slit grafts, 478 medium slit grafts, and 102 standard grafts). (d), One year after the patient’s fourth session (a total of 597 micrografts,
478 small slit grafts, 707 medium slit grafts, and 102 standard grafts). Although the results look very natural, this patient was treated
approximately 7 years ago. If he were treated today, he probably would have a somewhat denser frontal hairline zone because I would
have used more micrografts there in each session. Nevertheless, he shows the remarkable density and naturalness that can be produced
with this combination of grafting, despite the fact that his hair was dark and his skin color quite pale. He is a Hollywood producer who
has referred a significant number of actors and entertainment executives to my office over the years because they were looking for the sort
of density they were not accustomed to seeing on their friends and coworkers who had undergone hair transplantation.
500 Chapter 12
Figure 12F-22 (A), An intraoperative photograph of the first session on a patient treated with a combination of micrografts, slit grafts,
and slot grafts. The slots grafts can be seen as a dense band of somewhat larger recipient sites approximately 3 cm posterior to the hairline.
(B), A preoperative photograph of the patient shown in Fig. 12F-22a. (C), A photograph of the patient 6 months after his first session,
with the hair combed back for critical evaluation (426 micrografts, 216 small slit grafts, 287 medium slit grafts, and 111 slot grafts). (D),
A photograph taken at the same time as that shown in 12F–22c but with the hair styled as he normally wore it.
Figure 12F-24 (A), A patient before treatment. (B), The same

patient 9 months after his first session with a combination of 317
micrografts, 150 small slit grafts, 62 medium slit grafts, and 100
slot grafts. (C), The same patient with his hair parted through the
middle of the transplanted area for critical evaluation. Note the
virtual absence of any plugginess despite the use of slot grafts.
Patients with white hair, particularly if it is also fine-textured, look
Figure 12F-23 (A), A preoperative photograph of a patient. extraordinarily good with this combination of grafts. (See color
(B), One year after his first session with a combination of 355 insert.)
micrografts, 151 small slit grafts, 219 medium slit grafts, and 102
slot grafts (front view). (C), A photograph taken at the same time
as that shown in 12F–23b, showing a lateral view of the patient 1
year after his first session.
502 Chapter 12
Figure 12F-25 (a), An intraoperative photograph of a patient being treated with a combination of micrografts, slit grafts, and slot
grafts. (b), A preoperative view of the patient shown in Fig. 12F-25a. (c), A frontal view 6 months after his second session of the following
combination of grafts; a total of 610 micrografts, 327 small slit grafts, 452 medium slit grafts, and 200 slot grafts. (d), A side view of the
patient before surgery. (e), A side view of the patient 6 months after two sessions with a close-up of the hairline zone. He was treated
approximately 5 years ago. Today, more micrografts would be done in the hairline zone during each session and it would have been
substantially thicker. (f), A photograph of the transplanted area with the hair parted through the midline for critical evaluation. Note the
absence of plugginess in the frontal area, where slot grafts had been employed. Some of the original hair has persisted in that zone. When
it is lost, unless the patient’s hair has become white or a salt-and-pepper combination, the patient probably will need a third session to
prevent any detection of the slot grafts when the hair is parted and wet. On the other hand, he also will achieve considerably more density
with this third session if it is carried out.
ently, the round grafts may be ‘‘98.1% bald’’ (for 1-

mm grafts) or ‘‘99.4% bald’’ (for 4-mm grafts), but
the density they produce can be two times greater (or
more) than any number of sessions of FUT to date
(see earlier). This difference is not a ‘‘myth.’’ Also,
given that an area that is 100% bald is being removed
and none is removed with incisional transplants, the
removal of tissue remains an advantage in itself.
7. ‘‘Incongruent fit occurs when tissue that is not round
is inserted into a round hole created with a punch.’’
I can understand this argument very well because
I believed it years ago—before I actually tried the
round graft—and recommended against ‘‘square
grafts in round holes’’ for just this reason. Once again,
this is theoretically problematic, I have seen no practi-
cal cosmetic evidence that it is disadvantageous (see
no. 3 again). Figure 12F-26 The large box shown above is 2 cm ⳯ 2 cm.
8. ‘‘Rotation of a (round) graft is necessary to cause per- Each small square within the box represents a 1 mm2 area and the
fect fit’’. This necessitates ‘‘skilled placers.’’ dots within those small squares represent a follicular unit (FU).
In practice, it is far easier to train technicians to The slot grafts shown above are two FUs wide and three FUs long.
place round grafts properly than to train them in all Adjacent rows are separated from each other by 3 mm laterally
aspects of FUT. Ease of placement is one of the major and more than 3 mm anteroposteriorly, as an example of spacing.
In actual practice, the spaces usually vary between 2 mm and 3
advantages of multi-FU grafts. Moreover, the physi-
mm both laterally and anteroposteriorly. A total of 102 FUs have
cian can easily and quickly check the orientation of
been transplanted in this 2 cm2 box in a single session, representing
multi-FU grafts, whether round or slot. This is done a concentration of 50 FUs/cm2.
at the same time as all FU and multi-FU grafts are
being checked, and, in my experience, it represents
very little extra burden on the operator.
9. ‘‘Grafts larger than one follicular unit become com-
pressed, causing a micro-migration of partially liber-
ated follicular units (compression and an unnatural in- than that achieved with FUs if they are prepared with the same
terpretation of space).’’ degree of care. The schematic drawing shown in Fig. 12F-26
Compression of multi-FU graft hair can be dis- illustrates the FU density that can be achieved with slot grafts
advantageous in the aforementioned respect, but as has after a single session. It is, once again, easy to fit similar second
been pointed out earlier in this section of the text, it session of grafts between those of the first session and to double
can also be advantageous with regard to creating high the FU density.
hair density. If circumstances are correct, (hair color,
texture, curl, etc., and presence of some original hair),
no clinical cosmetic problems occur.
10. ‘‘When space is correctly (naturally) interpreted, 12G. How I Use Multi-FU Grafts
fewer hairs are needed to create adequate density (itali-
cization mine). With a limited number of available Walter P. Unger
donor follicles, their economical use is imperative.’’
I agree with this statement completely. This does
not, however, mean that all patients cannot afford to THE HAIRLINE ZONE
use more follicles in limited recipient areas. As I have As indicated on numerous occasions in this text, I now construct
discussed earlier, there are 10% to 15% of patients hairline zones exclusively with micrografts (FUs). Different
in my practice who have excellent long-term donor/ practitioners attempt to create irregular hairlines with irregular
recipient area ratios and can well afford to create maxi-
hair densities in different ways. Some of these approaches are
mum density in limited areas. ‘‘God lives in the de-
outlined in earlier chapters. I therefore do not dwell on my
tails’’ but certainly one of the more important ‘‘de-
method of constructing this extremely important zone. Suffice
tails’’ is trying to give patients what they want if they
have suitable characteristics. it to say that having tried numerous possibilities, I have found
it most helpful to begin by creating a straight line of recipient
Although hair density and survival in slot grafts has not been sites 2 mm to 3 mm superior to the place where I want the
studied yet, my experience with them suggests that (1) the den- ultimate hairline zone to appear to start. My job then becomes
sity effect lies somewhere between those seen with microslit one of simply making that line irregular by producing small
grafts and round grafts (Figs. 12F-22 to 12F-25) (see Chapter and large mounds or triangles anterior to the straight line at
12G for additional photographs), and (2) hair survival appears various points. Subsequently, I establish another four to six
to be quite high. It is certainly not unreasonable to expect hair rows of micrograft recipient sites posterior to the straight line.
survival of microslit and round grafts to be as good or better The end-product is a hairline zone that consists of approxi-
504 Chapter 12
Figure 12G-1 (a), After having tried numerous possibilities, I find it most helpful to create a hairline by starting with a straight line
of recipient sites 2 mm to 3 mm superior to where I decide the ultimate hairline zone should appear to be. The photograph shows this
relatively straight line that was produced with an 18-gauge needle. A small widow’s peak was also created in this individual in the anterior
midline. (b), Beginning at the lateral ends of the hairline, I create more or less triangular mounds of recipient sites anterior to the straight
line. My job is now to simply make the original straight line irregular, by producing, at various points, small and large mounds of triangles
anterior to the straight line. (c), The irregularities are complete along the entire straight line, and I now produce a wider hairline zone,
making five to six sites posterior to the original straight line. This process is shown beginning on the right side of the photograph. (d),
The hairline zone is now complete. It has an irregular anterior border and a depth of approximately 10 follicular unit sites.
mately 800 or more micrografts. The photographs in Fig. or ledges. It is also important to remember that during graft
12G-1 illustrate this process. preparation, DFU grafts are ‘‘cherry picked’’ only from those
areas of the donor strip where the FUs are relatively close to-
gether. FUs are inserted in the same area between the DFU
MICROSLIT GRAFTING grafts during the first and sometimes second sessions to mini-
The locations of the various types of slit grafts that I employ mize their subsequent noticeability (Fig. 12G-2). The more alo-
are shown in Chapter 5A Fig. 40e. In each of these areas, the pecic the area and the worse the hair characteristics for trans-
incisions are made with a 噛15 blade or a Beaver Mini ES blade planting—by the latter I mean the more skin/hair color contrast
or a blade made to suit the size of the graft using a custom there is; the coarser the hair caliber; and the less frizz, wave,
blade cutter (Fig. 22C-18). They are spaced approximately 3 or curl—the more FUs will be used between the DFU grafts.
mm apart laterally and 1 mm apart anteroposteriorly, regardless As indicated earlier in this chapter, in a totally alopecic recipient
of whether they are for double follicular unit (DFU), triple fol- site and/or for patients with poor hair characteristics, the lateral
licular unit (TFU), or quadruple follicular unit (QFU) grafts borders may even be treated exclusively with FUs. In those
and in which session they are employed. As can be seen in Fig. situations, I am also more likely to use nothing larger than a
5A-40e, DFU grafts are always used in the area just posterior DFU graft for the entire recipient area, except the hairline zone
to a hairline zone. They are created as described earlier and and creases, where FUT is employed (Fig. 12G-2). In addition,
placed in the lateral borders of the recipient area—the creases in women, who virtually never lose all of the original hair in
Figure 12G-2 (a), An intraoperative photograph of a patient who was essentially alopecic in the recipient area. A wider than usual
zone of micrograft recipient sites was prepared. Posterior to those sites, I have elected to use double follicular unit (DFU) grafts. The
micrograft sites that were placed between the microslit grafts as a component of the treatment can also be seen in the photograph. (b),
Frontal view of the patient before treatment. (c), The same patient, shown 4 months after his first session, which consisted of 1237
micrografts and 404 DFU grafts.
the thinning areas, FUs and DFU grafts are usually employed; The other advantage of a U-shaped pattern is that it allows the
TFU and QFU grafts are rarely used (see Chapter 12H). In patient to experience a transplant session before a final decision
many male patients, however, the recipient area, posterior and is made whether to include an alopecia reduction (AR) at some
medial to the zones treated with DFU grafts, is treated with point—during which some or all of the untransplanted midline
TFU and (sometimes) QFU grafts. The worse the hair character- section could be included in the excision. Once the fears of
istics for undetectable transplanting, the greater the likelihood transplanting are dispelled, the patient can make a more rational
of using DFU grafts in this area. The better the hair characteris- decision about how useful an AR might be. As has been noted
tics, the greater the likelihood that QFU grafts will be used. in Chapter 5, only a small minority of patients currently choose
Specifically, the less contrast in skin/hair color, the finer the to include AR in their treatment planning. Nevertheless, the
hair caliber; and the more frizz, wave, or curl, the less detectable pattern of transplanting described earlier leaves this option open
TFU and QFU grafts will be. until a second session is carried out.
Quite frequently, if the frontal recipient area is large, a U- During second and later sessions, microslit grafts are placed
shaped pattern of transplanting is used in the first session rather between those transplanted earlier. This may be done through-
than a hemispheric pattern (Fig. 12G-3). The blood supply to out the entire slit-grafted area or only in parts of it. As indicated
the grafts closest to the midline in a U-shaped transplant pattern before, the grafts not used to fill in some previously transplanted
is less compromised than if a more solid hemispheric pattern areas can be placed into new sites. In these and later sessions,
is used. The untransplanted midline peninsula between the the size of the grafts can either be the same as in the first session
‘‘arms’’ of the U can be treated in the second and third sessions or increased to augment the hair density; after the first session,
because the U is transplanted less densely on those occasions. there is less concern about the noticeability of the larger grafts.
506 Chapter 12
Figure 12G-3 (A), Session 1. (B), Session 2: option A includes a plan for future alopecia reductions (ARs). (C), Session 3: Option A
with ARs. (D), Option B: No ARs planned, and sessions two and three include transplanting in the frontal midline.
Areas previously treated with DFU grafts might, for example,

be filled with TFU or QFU grafts, slot grafts, or even small
round grafts may be transplanted between them, depending on
density objectives and hair characteristics (Fig. 12G-4). Once
again, the better the hair characteristics, the larger the graft can
be without producing noticeable plugginess.
In the vertex area, micrografts are always placed at the center
of the whorl(s), where hair directions change substantially
within a small area. Grafts that are larger than an FU could
cause injury to some adjacent but divergent follicles. Peripheral
to the center of the whorl(s), I continue using only FUs in
some patients, whereas in others I employ DFU grafts with
FUs scattered between them (Fig. 12G-5). The better the hair
characteristics and long-term donor/recipient area ratio, the
more likely I am to choose the latter, especially if the hair is
white (Figs. 12G-6 & 7).
Most of my patients who are destined to develop total alope-
cia in the recipient area want a total of three sessions carried
out in frontal areas and two sessions in the midscalp and vertex
areas, to produce a hair density that satisfies them. Many, how-
ever, do not have enough donor tissue to transplant all three
Figure 12G-4 Although I have a general preference for slit areas. They often must limit transplantation to approximately
grafts when less dense filling is sought, I often use round minigrafts the anterior two thirds of the area of male pattern baldness
in combination with slit grafts in later sessions (schematic (MPB), accept lower densities in each of the three areas, or
drawing). agree to add AR to the treatment plan. Others are truly satisfied
Figure 12G-5 (a), A vertex recipient area before treatment. (b), An intraoperative photograph of the same vertex. Note the use of
micrografts at the center of the whorl of the vertex area and double follicular unit (DFU) grafts throughout the rest of the vertex area with
micrograft recipient sites scattered between them.
Figure 12G-6 (a), Another patient before treatment. (b), One year after one session of a combination of micrografts and slit grafts.
Although in most patients I use FUs exclusively in the vertex area, if hair characteristics are particularly good, a combination of slit or
microslit grafts and micrografts may be used instead. This patient received only 60 micrografts, 300 small slit grafts, and 241 medium slit
grafts transplanted, because he had undergone transplantation approximately 6 years ago. Today, I would have used considerably more
micrografts. Nevertheless, the results are very natural looking because of the patient’s good hair characteristics. (c), Another patient, before
transplanting of the vertex area. (d), The same patient, 1 year after treatment, with the hair parted through the middle of the transplanted
area for critical evaluation (352 triple follicular unit grafts). (e), A photograph taken at the same time as that shown in (d) but with the
hair combed as normally worn. Once again, the patient’s excellent hair characteristics (fine-textured, light-colored hair) resulted in an
excellent result after only a single session. (See color insert.)
508 Chapter 12
Figure 12G-6 Continued.
Figure 12G-7 (a), A patient with white hair showing the vertex before treatment. (b), The same patient 9 months after a single session
consisting of 170 quadruple follicular unit grafts.
Figure 12G-8 (a), A patient before treatment. (b), Six months after the second session of a combination of 485 micrografts, 300 double
follicular unit grafts, 496 triple follicular unit grafts, 121 quadruple follicular unit grafts, and 37 2-mm grafts. Most of the patients whom
I treat choose to have three sessions in the frontal area, but some are truly satisfied with two sessions in the frontal area and one session
in the vertex area (shown earlier). The patient in this photograph had very little fine hair available for his hairline zone. His satisfaction
with only two sessions was all the more surprising because few fine-textured hairs were available to create the ‘‘softness’’ that I normally
look for in a hairline.
Figure 12G-9 (a), This patient had previously had some round grafting in the frontal area carried out by another practitioner. Some
plugginess can be seen in the photograph. On the other hand, the patient had excellent donor hair characteristics with very dense, fine-
textured hair. (b), The same patient after only two sessions at our office. The unusually high hair density shown in this individual was the
result of his excellent donor area and the presence of the previously transplanted round grafts in the recipient area (A total of 176 micrografts
and 741 TFUs). (See color insert.)
510 Chapter 12
Figure 12G-10 (a), A patient before treatment. (b), The same patient after his fourth session to the frontal area (a total of 84 micrografts,
1102 triple follicular unit grafts, 172 quadruple follicular unit grafts, and 19 standard grafts.) This individual had an excellent result after
his third session but wanted still denser hair. I spent approximately 30 minutes trying to talk him out of this unreasonable objective, but
he insisted that he wanted hair ‘‘like I had when I was a young man.’’ I reluctantly carried out the fourth procedure. This photograph
shows what I think is too thick a result, but the patient could not have been happier.
Figure 12G-11 (a), A patient 4 months after his first transplantation to a previously alopecic vertex area approximately 15 years ago.
(b), Six months after his third session for the vertex area, with the hair parted for critical evaluation. (c), The same patient as shown in
Fig. 12G 11a and 12G-11b with his hair combed as it is normally worn. Very few individuals want to have their vertex alopecia treated
three times, nor do they have sufficient donor area reserves to be able to do that. Most patients have one or two sessions in the vertex
area. This patient was treated with a total of 71 micrografts, 44 triple follicular unit grafts, 594 quadruple follicular unit grafts, and 139
standard grafts in five sessions that also included the frontal area.
with only one session in the vertex area (Fig. 12G-6 and 12G-
7) or two sessions in the frontal area (Figs. 12G-8 and 12G-9).
Finally, some patients are looking for the kind of density that
requires four sessions to the frontal area (Fig. 12G-10) or three
sessions to the vertex area (Fig. 12G-11). Some individuals, for
example, have three sessions done frontally: two to the mids-
calp, and one of FUT in the vertex. Any area that is to be treated
only once is always treated with FUT. Sessions are usually done
5 to 6 months apart in the same area but can be farther apart
if the recipient area is not totally alopecic and/or hair character-
istics are good. Different portions of the scalp, such as the fron-
tal and midscalp areas, can be transplanted as close as 4 weeks
apart—provided that more than one donor area can be used. If
the same donor site is being harvested, a minimum of 3 months
is necessary. This interval allows any temporarily lost hair in
that area to regrow and be visible during graft preparation.
SLOT GRAFTING Figure 12G-12 (Left), The second session of a slot or round
Slot grafts, which by definition are three FUs long and approxi- graft was incorrectly angled more steeply than the first-session
graft. If an attempt is made to prepare a recipient site for the third-
mately two FUs wide, produce more hair density than a DFU,
session graft at the same angle as the first graft, injury to follicles
TFU, or QFU graft. The location of slot grafts is shown in Fig.
in the second-session graft cannot be avoided. (Right), Grafts for
5A-40e and Figs. 12F-22a and 25a. As noted earlier, slot grafts first and second sessions have been angled similarly. The site for the
may sometimes be used between previously transplanted slit third-session graft can be made without any injury to the adjacent
grafts after hair transplanted during the first session(s) of slit follicles. The necessity of ‘‘consistent angling’’ also exists in the
grafts has grown. If there are good hair characteristics and/or third dimension, which is not possible to show here; that is, in
hair in the recipient area, temporary discernibility of the grafts relation to grafts anterior and posterior to it (schematic drawing)
is minimal. Moreover, their location (posterior to areas treated
with smaller grafts) is also important in that regard. They are
particularly useful when placed between previously trans-
planted microslit or slit grafts located anterior to a zone of I find a slot-grafted zone works well for patients who have
exclusive slot or round grafts that were transplanted in previous frizzy hair (Figs. 12F-25) or wavy hair (Figs. 12F-22 and 12F-
sessions. The difference in hair density between areas treated 23); it is especially effective for those with salt and pepper or
with slot and (especially) round grafted and the areas anterior white hair (Figs. 12F-24 and 12G-13). It is difficult to overstate
and posterior to them that were treated only with microslit or the remarkable transformation that can be accomplished in pa-
slit grafts and FUs, can be considerable and quite noticeable. tients with these hair characteristics. Slot grafts produce a hair
After hair from the first session has grown, scattering some slot density between that achieved by micro-slit grafts and round
grafts anterior to the area made up exclusively of slot-grafts or grafts; patients who want greater than usual density often seem
round-grafts blurs any differences in hair density in these sites. less afraid of them than of round grafts. I will nearly always
In areas that are treated with slot grafts in the first session, use a 2.5 mm slot punch to create the recipient sites.
the grafts are placed 2 mm to 3 mm apart laterally and approxi-
mately 2 mm to 3 mm apart anteroposteriorly (Fig. 12F-26). ROUND GRAFTING
Sometimes, when the second session of slot grafts is placed
between first-session grafts in the area, only a small space sepa- Why do I persist in using round grafts in some patients when
rates the grafts from each other. In such cases, it may not be nearly everyone has abandoned them? Figures 12F-18 and 12G-
possible, during a third session, to fit a third set of slot grafts 14 show two patients whom I treated approximately 20 years
between them; therefore, a TFU or QFU graft or FUs consisting ago. They were obviously ideal candidates for this type of trans-
of three or more hairs may be used instead. Consistent angling plantation. Nevertheless, they demonstrate what I was able to
is also important if injury to previously transplanted grafts is accomplish, after many years of practice, for patients with suita-
to be avoided. While this is true of all types of grafts, one must ble donor/recipient area ratios and hair characteristics. Many
be especially careful when larger recipient sites are being made, more similar results can be found in the third edition of this
for example, for slot and round grafts (Fig. 12G-12). The ante- text. In addition, the photographs that are shown in this section
rior border of the slot-grafted zone is constructed in an irregular illustrate what can be created today by using patterns that in-
fashion to help minimize any obvious hair density differences clude round grafts. Why should a technique that can produce
between the border and the micro–slit-grafted areas anterior to such results be completely abandoned? More importantly, why
it. In addition, as noted earlier, some slot grafts are used in later should others not attempt to learn to do the procedure as well?
sessions between the more anterior micro-slit or slit grafts to The location of the zone that I may treat with round grafts is
minimize noticeable density differences. In addition, FUs with shown in Chapter 5A Fig. 40e.
three or more hairs are often used anterior to the slot-grafted Today, round recipient sites are nearly always made with a
area to minimize density differences between the two zones. 2-mm diameter trephine. and the grafts are organized so that
512 Chapter 12
Figure 12G-13 (a), An intraoperative photograph of a patient with white hair who has been treated with a combination of micrografts,
slit grafts, and slot grafts. (b), The patient before treatment. (c), Six months after the first session, the patient returned for a second session
in which slot grafts were used in the midscalp. A small amount of grafting was also done to the area treated during the first session. The
hair growing from that first session can be seen in the frontal area. (d), Six months after the second session, with the hair parted through
the middle of the frontal area. Note the total absence of detectable plugginess despite the use of slot grafts. (e), The frontal appearance of
the patient. The growth shown is the result of approximately 11⁄4 sessions of grafting, using the above combination of graft types. (f), A
side view of the same patient taken at the same time as that shown in Fig. 12G-13e. The remarkable density is owed to the use of the slot
grafts. It is difficult to overstate the transformation that can be accomplished with use of slot grafts for those who have white hair. A total
of 374 micrografts, 184 DFUs, 188 TFUs, and 148 slot grafts were used to transplant the frontal and midscalp areas. (See color insert.)
Figure 12G-14 (a), A patient 20 years ago, before treatment with standard grafts. (b), Six months after his fourth session. (c), A close-
up of his hairline after four sessions. In the days before micrografting, the hairline was constructed with grafts taken from the inferior
occipital area, where the hair was fine-textured but deemed to likely be permanent. Many of these hairlines looked very natural, especially
if the hair color was advantageous.
solid filling can be accomplished in four sessions (Fig. 12G- plant session primarily directed to the midscalp or vertex rather
15). During each session, Grafts must be placed one graft apart than as part of a (usually unnecessary) full fourth session to
anteroposteriorly as well as laterally. Complete or solid filling the entire frontal area. Other practitioners who use round grafts,
of an area with round grafts causes no discernible plugginess, such as Beehner, do not use them in an organized pattern, as
even if the hair is wet and parted through it. However, as noted I do. Instead, they use 1.3-mm to 1.8-mm grafts to make them
earlier in this chapter, very few patients ask for solid filling of less noticeable than 2-mm round grafts and scatter them about,
this zone. The combination of high hair density and few spaces thereby avoiding a zone that is considerably denser than the
results in very little or no noticeable plugginess after three ses- rest of the recipient area (see Chapter 5). I continue to organize
sions. Slight noticeability (e.g., wet hair parted through the areas of round grafts in such a way that solid filling can be
transplanted zone) is nearly always eliminated by a casual accomplished in four sessions for two reasons: (1) Most of my
sweep of the fingers through that area. Many patients find that patients who use this mix of grafts are looking for maximum
round grafts are so undetectable, even after two sessions, that density, and (2) if they notice any plugginess after two or three
they stretch out the interval between the second and third ses- sessions, I want to maintain the option of having a fourth session
sions for a year or even much longer. If a fourth session of to complete solid filling of the area.
round grafts is done, it is usually carried out as part of a trans- As noted earlier, a significant drawback of round
514 Chapter 12
The use of round or slot punches in an area with some persis-

tent original hair always results in less hair in that area for
approximately the first 3 months after transplantation. The rea-
son for the sparsity is that hair is removed by the punch and
no hair is present in the transplanted graft during this time.
Patients must be forewarned of this temporary decreased den-
sity; the ideal candidate is one who even with less hair in the
round grafted or slot grafted areas has enough hair to camou-
flage any noticeable thinning or plugginess. This short-term
decrease in hair density is more than compensated for by the
creation of much greater hair density for the rest of the individu-
al’s life. This, too, should be pointed out to patients.
Fortunately, as I noted earlier in this chapter, the perfect
technique required by hair restoration surgeons in the past
(when only 4-mm grafts were used) is no longer necessary to
avoid a temporarily pluggy appearance. The zones anterior to
(and often posterior to) the round grafted areas grow earlier and
provide considerable camouflage for the round grafts until the
camouflage is no longer necessary (see Figs. 12F-17, 20, and
21). For the same reason, even if the round grafts ultimately
do not touch each other and small spaces remain between them,
noticeable plugginess is not a problem.—This is why (as previ-
ously noted) some practitioners are willing to use round grafts
without even aiming for solid filling. In addition, if necessary,
spaces between round grafts can be filled with FUs. It should
be emphasized that this combination of grafting is far more
‘‘forgiving’’ of a less-than-perfect technique than were the
round grafting techniques of the past.
An intriguing appearance of substantial frontal-hair density
Figure 12G-15 Any area of alopecia can be solidly filled in is created by a zone of round grafts that is usually slightly less
one of three different ways. The method shown in the superior part than 10 mm wide (Figs. 12F, 17, 19, 20, and 21; 12G-16 and
of this figure is the usual four-stage approach. Areas that are still 12G-17). Thus, enormous amounts of donor tissue do not have
hair bearing are treated as shown in the middle of the figure. The
to be used in the process. All the same, as noted several times
approach shown at the bottom of the figure is the three-stage filling
in this text, only a small group of patients seen in consultation
described by the Orentreichs (schematic drawing).
are offered this combination of grafts. The reasons are as fol-
lows:
1. Most patients are satisfied with less hair thickness than
grafts—and, to a lesser extent, of slot grafts and larger micro-
is created with this approach.
slit or slit grafts—is that the angle and direction of the trephine
2. Frontal thick-looking hair looks out of balance if adja-
or slot punch must correctly mimic those of existing or previ-
cent temporal hair is, or will likely become, relatively
ously transplanted hair, to prevent lethal damage to adjacent
sparse.
hairs (Fig. 12G-12). Few surgeons were skilled enough to do
3. Many patients do not have enough persistent hair or the
this when 4-mm round grafts were more commonly used. As
kind of hair characteristics to reassure me that there
a result, few could create hairlines without obvious gaps be-
will be no detectable plugginess during the course of
tween the grafts. The smaller the round graft, the greater propor-
tion of hairs that are near the periphery of the graft, and these are treatments. I therefore prefer not to treat them with
the hairs that are endangered by incorrect angling or direction of round grafts.
recipient holes made adjacent to them in later sessions. In addi- 4. The ultimate donor/recipient area ratios of most patients
tion, the spaces between these grafts are smaller and more nu- are such that any increase in frontal density must be
merous; therefore, more holes must be punched out and filled paid for by decreased density or no transplantation at
in during later sessions. Thus, the use of 2-mm round grafts for all in other areas.
solid filling in the round grafted area is more dangerous to the 5. Many patients are terrified by the thought of having a
follicles than if 3-mm or 4-mm round grafts were used instead. pluggy look if round grafts are used.
Inexperienced practitioners might choose to use larger round Although I use round grafts in approximately 10% to 15% of
grafts for the reasons outlined. Unfortunately, the larger the my patients, the percentage in most practices should probably
round grafts, the more noticeable they might be between ses- be even smaller. This is because, in most practices, it seems as
sions. It is wise to use larger grafts only in individuals with if fewer patients with relatively early MPB are treated than is
particularly good hair characteristics and/or some persisting hair the case in my practice. Moreover, I rarely encourage patients
in the recipient area; these characteristics help to minimize tem- to choose round grafts because they do use more donor tissue.
porary noticeability of the grafts. Various patterns and sizes of It is never 100% certain that in the long run the patient may
round grafts that I have used are shown in Figs. 12F-18, 12G- not need or prefer to use that donor tissue elsewhere. Notwith-
16, and 12G-17. standing these considerations, some patients are such excellent
Figure 12G-16 (A), An intraoperative photo of the 1st session in this patient showing recipient sites for 254 FUs, 150 DFUs, 265
TFUs, and 55 standard grafts. (B), The patient before surgery. (C), The patient one year after the last of 3 1/2 sessions similar to the first
one, to the frontal area. (D), Side view one year after the last of the 3 1/2 sessions to the frontal area (E), A photo taken at the same time
as that shown in Fig. 16c but with the hair parted through the midline for critical evaulation..
516 Chapter 12
Figure 12G-17 (a), An intraoperative photograph of the first session in a patient treated with 226 micrografts, 150 DFUs, 80 TFUs,
120 slot grafts and 41 2-mm2 grafts. (b), Before transplantation. This is the same patient shown in Fig. 12G-17a. (c), Nine months after a
second session. (A total of 469 micrografts, 300 DFU grafts, 220 slot grafts, and 61 2-mm2 grafts.) (d), Nine months after a second session,
with the hair parted down the middle for critical evaluation. The patient had some persisting original hair in the recipient area when
transplanting began. As this hair is lost, a third or even a fourth session may be done in pace with the loss. (See color insert.)
candidates for this approach, I believe that not offering it is the area of MPB may seem more reasonable to both physician
unfair to them. and patients. An alternative may be to carry out additional trans-
Finally, I must repeat that just as with the technique for slot planting with FUs if sufficient donor tissue is still available.
grafting, some 1.0 mm to 2.0 mm round grafts, slot grafts and Whatever occurs, another option is presented that has worked
closely spaced FUs with three or more hairs in them are used well in my hands. I am convinced that this approach will also
between the micro-slit or slit grafts immediately anterior to the work well for any practitioners who decide to spend as much
round-grafted zone. This is necessary to avoid a sharp line of time perfecting it as they may spend on perfecting the FUT
demarcation between different hair densities. technique.
It is unlikely that more than a few of the readers of this text
will ever attempt to use a combination of FUs, micro-slit or slit
grafts, slot grafts, and round grafts. Nevertheless, it seemed
12H. Hair Transplantation in Women
worthwhile to present a discussion of the procedure here as an
option more readers may want to consider later. With the pas- Walter P. Unger and Robin H. Unger
sage of time, all transplanted areas become somewhat sparser
in pace with the gradual thinning of the donor sites from which INTRODUCTION
the grafts were obtained (Fig. 5A-52). It may be that in 15 or
20 years or longer, the hair of patients treated only with FUs Women with scalp hair loss should always be screened with
will look unacceptably sparse again. At that point, the benefits an appropriate history and physical examination. If there are
of originally denser results in perhaps a smaller proportion of any signs and/or symptoms suggestive of an endocrine or der-
matologic cause, they should be investigated appropriately or

referred to someone for this purpose (1). It is also important
to rule out temporary hair loss caused by severe emotional or
physical stress. This is discussed elsewhere in the text by Eise-
nberg. The majority of women whom hair restoration surgeons
see have no apparent cause for their hair loss other than heredi-
tary factors. Such loss, referred to as female pattern hair loss
(FPHL), is far more common than is generally recognized. A
full discussion of its incidence and patterns can be found in
Chapter 3B, but they are summarized below. There are two
peaks of onset—the third and fifth decades. Those who have
earlier onset tend to develop more severe hair loss, and this fact
should be kept in mind when deciding on a plan for treatment
of younger women. There are three recognized general patterns
of FPHL:
1. A caudal and centrifugal pattern described by Ludwig
(2), in which hair in the hairline is maintained, although
it may thin to varying degrees (Fig. 3B-4b). In Venning
and Dawber’s study of 564 women, 87% of premeno-
pausal women showed some degree of this pattern of
hair loss (3) (Fig. 12H-1).
2. A ‘‘male’’ pattern of frontoparietal loss described by
Hamilton (Fig. 3B-4a). In his study of 214 women,
Hamilton found that 79% had at least Hamilton type II
male pattern baldness (MPB) after puberty, whereas
type IV MPB occurred in 25% by age 50 years and in
50% by age 60 years (4). Venning and Dawber found
lower percentages in their larger study, but even they
reported Norwood-Hamilton types II to IV MPB in 13%
of their premenopausal women and 37% of their post-
menopausal women (3) (Fig. 12H-2).
3. A ‘‘Christmas tree’’ pattern of loss described by Olsen,
which begins as a widened part but evolves into a zone
of hair loss that is widest anteriorly at the hairline with
gradual narrowing and ragged borders, more posteriorly
(Fig. 12H-3) (5). In her study of 163 women ‘‘with
obvious but not severe patterned alopecia,’’ she found
this pattern in 70% of them, and she believes it is more
common than the Ludwig pattern. (We agree with her.)
Common to all of these patterns is the frequent presence of
small (1 mm to 3 mm) lacunae of total alopecia that are scattered
in the areas of diffuse thinning (5) (Fig. 12H-4). One of us
(WU) first pointed these areas out in the 1987 edition of this
text (6), and their presence has now been confirmed by others
(5). Their significance is discussed later.
WHICH WOMEN ARE CANDIDATES FOR

HAIR TRANSPLANTATION?
The aforementioned studies indicate that if a woman looks for
Figure 12H-1 (a), A patient before hair transplanting shown
signs of thinning hair—and many women with a family history with hair dry. (b), The same patient with her hair wetted with
of female hair loss are particularly alert for such a develop- Betadine solution before transplantation. This photograph better
ment—approximately 80% of premenopausal women find it. demonstrates the extent of thinning present in this individual, corre-
Furthermore, postmenopausal women not only find signs of sponding most closely to a Ludwig type II pattern of loss. (c),
hair loss but also will find it more frequently and easily or Twenty-four months after a single session of hair transplanting.
notice it without even trying to find it. (Norwood believes that (The results would have probably appeared similar if the patient
hair loss in women is less common but that it still affects ‘‘al- had returned in follow-up at 12 months.)
most 30% of women [older than] 30 years of age.’’) (7) In
today’s image-conscious world, is it any wonder that we are
seeing increasing numbers of women complaining of hair loss
518 Chapter 12
Figure 12H-2 (a), A female patient with moderately severe

thinning in the frontotemporal triangle before treatment. (b), The
same patient 7 months after the first hair transplant session. For
the purpose of critical evaluation, the hair has been combed back
in both photographs.
and seeking medical or surgical remedies? Because most of

these women do not have severe hair loss and are not destined
to develop it, many women whom we see in consultation for
hair transplanting today have good long-term donor area/recipi-
ent area ratios. Given the preceding information, of course, the
question of whether or not they should even consider surgical
intervention is warranted. The answer, for better or worse, is a Figure 12H-3 (a), A ‘‘Christmas tree’’ pattern of hair loss
subjective one. It would appear from the growing demand by involving a broad area of the frontal hairline and the midline has
women for hair transplantation that many more of them are been described by Elise Olsen. In this patient, virtually all of the
choosing to be proactive. frontal hairline hair has been lost, with the area of thinning hair
As with men, deciding whether a female patient is a candi- narrowing as it extends posteriorly. (b), Another patient with a
date for hair transplantation depends most importantly on (1) smaller but otherwise more severe ‘‘Christmas tree’’ pattern of
whether or not there is a good long-term potential donor-recipi- loss. (c), The same patient shown in Fig. 12H-3b after two sessions
ent area ratio and (2) whether or not the patient has realistic of hair transplantation. Generally, the less contrast there is between
expectations. We have already commented on the former con- the color of the hair and the skin, the thicker the hair appears to be.
sideration. However, it is important to recognize that in some If the patient had left her hair colored blonde instead of darkening it,
women the hair in any one or all of the temporal, parietal, and the results would have looked even better.
occipital areas may be sparse or may eventually be affected by
example, women who say they ‘‘do not want to see their scalps’’
should clearly understand that this is an unrealistic goal—even
women without significant loss can see their scalps. Patients
who cannot be satisfied with this goal are better left untreated.
Nevertheless, we have been impressed by the realism exhibited
by most of the women we are currently interviewing. All of
them would obviously like thick hair, but most are willing to
accept a significant degree of thickening in cosmetically impor-
tant areas if that is all that is possible. They have exhausted all
the proposed medical and cosmetic solutions without satisfac-
tion, and transplantation is the only option left that is certain
to produce a positive outcome—even if it does not produce as
much improvement as they would prefer.
As with all patients who have persistent hair in the recipient
areas, it is wise to extensively document the amount of hair
present. This is best done by taking numerous photographs at
different angles, with the hair dry, wet, and parted through thin
Figure 12H-4 In this photograph, arrows point to smaller areas
areas. It is remarkable how many patients, on seeing their origi-
of alopecia scattered within the area of diffuse thinning. These
lacunae of atrichia are typical of patterned thinning in women.
nal photographs 6 to 12 months after a session, make a statement
the thinning process. Therefore, they may or may not be suitable

as donor areas for hair transplanting. Careful evaluation of both
family history and physical findings is important. Of course,
the sparser the hair in the donor area, the fewer the hairs that
are available to thicken the recipient area. Most women have
enough donor hair to receive one to three hair transplant ses-
sions of 800 to 1200 grafts each. But all the same, as is covered
later, even a less than dense donor area enables the surgeon to
produce at least some thickening of strategically chosen por-
tions of the recipient area. The only requirement is that whatever
improvement is achieved should be considered by the patient
to be worthwhile in relation to the inconvenience, discomfort,
and cost of the procedure.
Bernstein and Rassman have stated that in their experience,
a ‘‘large percentage’’ of women with FPHL have an entity
referred to as diffuse unpatterned alopecia (DUPA) (8). They
believe that individuals with this condition—which includes
both extensive thinning of hair over the entire scalp and minia-
turization of often 50% or more of the hairs—are poor candi-
dates for hair transplantation. Thus, a ‘‘large percentage’’ of
the women they see are deemed unacceptable for surgical treat-
ment. For some reason, such changes are present in a minority
of the women whom we see in consultation. Why our experi-
ences have been so different is not clear. What is beyond ques-
tion, however, is the fact that virtually all of our female patients
who are accepted for surgery are very satisfied with their results.
Furthermore, one of us (WU) has been operating on women
for more than 20 years, so any long-term consequences of this
approach should have become evident by now.
This brings us to the second major factor affecting the candi-
dacy of patients—their objectives. For a minority of women,
anything less than dense hair is unacceptable. Although such Figure 12H-5 (a), A patient before hair transplantation. The
results are sometimes possible in women (Fig. 12H-5), in most black line denotes the limits of the proposed pattern of transplant-
cases a more realistic goal is a significant increase in hair den- ing. (b), Nine months after a single session of hair transplantation
sity in carefully chosen areas (see also later). We emphasize to in the patient shown in Fig. 12H-5a. This remarkable result in a
all female patients whom we accept for surgery that although single session is not typical. In most cases, a more realistic goal
we are confident of creating more hair density, or thicker hair, is a significant increase in hair density but not hair that appears to
with each session, we are not going to produce thick hair. For be as dense as that shown. (See color insert.)
520 Chapter 12
similar to this: ‘‘I didn’t remember having so little hair.’’ Such shaped, FUs containing three or more hairs each may be used
photographs can save recriminations, self-doubt, and enormous instead or together with the larger ones. It cannot be overempha-
grief. It is also very wise to emphasize to premenopausal women sized that recipient sites must be incised at the same angle and
the likelihood that they will experience further hair loss in the direction as those of the existing hair. If this is not done, the
perimenopausal and postmenopausal periods. Thus, future ses- matrices of adjacent hairs may be lethally injured. Some hair
sions may be necessary to maintain the desired density, pro- restoration surgeons do not take enough time or have not accu-
vided the donor region can support them. mulated enough experience and skill to do this procedure well,
and their results have reinforced the generally negative impres-
sion physicians have about hair transplantation in women. But
Technique and Discussion skill can be, and has been, acquired by many of today’s trans-
Generally, the technique used for hair transplantation in women plant surgeons; therefore, it should not be an obstacle for most
is similar to that employed in men. Because their body mass prospective patients. The sites are made very slowly and care-
is usually less than that of men, somewhat more care is taken fully and the surgery is interrupted, usually hundreds of times,
with administering the anesthetic solutions to women. These by combing of the hair in various ways to ascertain the angle
are injected more superficially, slowly, and intermittently, to and direction in which it naturally falls. It is not uncommon to
avoid anesthetic toxicity. The donor area is chosen based on spend an hour or more just to incise the recipient sites, but it
is time well spent.
the texture and density of the hair in the various areas and the
When the aforementioned techniques are used, existing hair
effect the donor scar will have on future hairstyling objectives.
is neither injured nor removed from the recipient area, regard-
For example, some women occasionally like to sweep the hair
less of what type of recipient site is being made. This is one
in the occipital area up toward the top of their head, where it
of two major reasons why hair transplantation is a possibility
is pinned in place. A scar in the inferior-occipital or parietal area
for more women today than it was 20 years ago. Before the
might become noticeable with such a hairstyle. We routinely use
development of follicular unit transplanting (FUT) and slit
only a single donor strip, which runs from the left to the right
grafting, only round grafts were used. Donor tissue was ob-
postauricular area and through the densest occipital and parietal
tained with round punches, and the grafts were placed into round
hair. As implied earlier, an average session in our practices
holes made by marginally smaller trephines. Making the recipi-
usually yields 800 to 1200 grafts of varying sizes, with the
ent sites, however, inevitably resulted in the removal of some
number somewhat lower if a greater number of multi-FU grafts
hair, so there was always a temporary reduction of hair in an
are employed. Poor density in the donor area also obviously
area that the patient had already found problematic. Moreover,
decreases the number of grafts obtained in each surgery. The
almost always, some of the hairs excised during the preparation
strip excised is, per usual, limited in size by closing tensions
of the recipient sites were permanent. Thus, the ‘‘old’’ method
and blood supply. In contrast to what we do in most men, we
always resulted in three undesirable consequences: (1) a tempo-
never extend the donor area into the temporal area of women, rary thinning in the recipient area (until the transplanted hair
because, in our experience, this is the most likely potential grew again), (2) the removal of some hair that would not have
donor area to experience future thinning. Because we never been otherwise lost as the patterned loss progressed, and (3) a
harvest the temporal areas of women, their donor strips are net gain in hair that was equal only to the difference in the
shorter than those of most men. In addition, the zone of good number of hairs removed and the number contained in the graft.
density hair in the occipital and parietal areas is very often For example, if 6 hairs were lost as the recipient site hole was
narrower than that in most male patients. As a result, the supply prepared, and the graft contained 14 hairs, the net gain was
of good donor tissue in many women is smaller than that in only 8 hairs. In contrast, using today’s techniques, FUs and
most men, with sequelae that are discussed later. In all sessions microslit grafts can be placed between existing hairs in a thin-
after the first one, the donor scar is excised as part of the new ning area. None of the original hair is removed, and the increase
harvest. Thus, regardless of the number of sessions carried out, in hair density is equal to the total amount of hair trans-
only one donor area scar is ever created. This differs from the planted—in the example used earlier, the total is 14 hairs.
multiple rows of scars produced with the harvesting techniques A second and equally important reason why hair transplanta-
that were in general use until the early 1990s. The latter tech- tion is a feasible treatment option for FPHL today is that no
nique contributed in a major way to the disqualification of many matter how many sessions are carried out, only a single scar is
women as suitable candidates. produced in the donor area. As in men, when the donor area is
In the recipient area, the types of grafts used are primarily harvested properly, most patients have so fine a scar that it is
follicular units (FUs) and DFUs. These are inserted into recipi- hard to find, even when one looks for it. Thus, hair is added
ent sites made between the existing hairs. Small but slightly to the recipient area at no apparent cost to the hair density in
larger grafts are used for the irregular, or oval, lacunae of total the donor area. There is, of course, a slight decrease in hair
alopecia that were referred to earlier. These areas are usually density in the donor area as the skin is stretched slightly to
punched out with an appropriately sized trephine, and the holes close the donor wound, but there is rarely noticeably decreased
that are created are filled with grafts that are usually 1.5 mm2 density. It is worth remembering that normal hair density
to 2.0 mm2. The result of this procedure is, essentially, the usually has to be reduced by approximately 50% before any
complete removal of the alopecic sites and a denser final result thinning is actually noticed by others. Although some female
than would be possible if only FUs and microslit grafts were donor areas may have less than normal density, the decrease
employed. (see also later) Because of the surrounding hair, these caused by excision of an 8-mm wide strip from a 70-mm
somewhat bigger grafts are difficult or impossible to detect. If to 80-mm wide hair-bearing rim, for example, is only approxi-
the small areas of atrichia are small enough, or very irregularly mately 8%.
Limitations and Problems

Most female patients require only one or two sessions in an
area of thinning—for example, the frontal area and/or the fron-
totemporal areas (10–12). This, however, is obviously depen-
dent on the degree of hair loss and the patient’s density objec-
tives (Figs. 12H-1 and 12H-6 to 12H-10). It is also dependent
on the density of hair in the donor region. A minority of patients
ask for three or even more sessions. In addition, it is usually
wise to keep some donor hair in reserve for possible future hair
loss in the same or other areas, especially in the case of young
women. Usually, there are inadequate amounts of donor hair
to treat all the thinning areas that are present or likely to develop
with the passage of time. Thus, priorities are given to some
cosmetically more important areas such as the hairline zone,
part line, or central vertex area. The thickened hair from these
areas can subsequently be used to comb over untreated
areas—which, incidentally, are useful as ‘‘controls’’ for assess-
ing the efficacy of the procedure. Fortunately, women are able
Figure 12H-7 (a), A 41-year-old woman with marked thin-

ning of the frontotemporal areas. (b), Six months after a single
session of FU and small slit grafts.
to use many styling ‘‘tricks’’ that are not available or acceptable

to men. Thus, they can maximize the benefits of hair restoration
surgery, even if only limited areas can be treated. Once again,
most patients who are obligated to make these choices consider
‘‘half a cup’’ better than ‘‘an empty one.’’ The old concept
women prefer ‘‘all or nothing’’ does not seem to apply to those
whom we are currently seeing.
Postoperatively, many women experience a temporary loss
of some hair adjacent to the donor area and/or some existing
hair in the recipient area. As incisions are made in both areas,
the blood supply to the remaining hair at those sites is decreased.
The result is that 10% to 30% of hairs in these areas may fall out,
(sometimes more adjacent to the donor area) but they regrow
approximately 3 months later (Fig. 12H-11). Although such hair
loss occurs in approximately 10% to 20% of the men in our
Figure 12H-6 (a), A patient with pronounced thinning of practice, women seem to be significantly more susceptible to
the hairline zone and frontotemporal triangles before treatment. it, with 25% to 50% of them experiencing this phenomenon.
(b), The same patient 12 months after the second hair transplant We always stress this possibility to our patients, because, in
session. Despite the patient’s dark hair, pale skin, and preferred our opinion, it is the worst ‘‘price’’ women may have to pay
hairstyle with hair combed straight back, the result looks very for undergoing hair transplantation. Interestingly, areas trans-
natural. planted with FUs at a density of 30 FU/cm2 or greater (into 18-
522 Chapter 12
Figure 12H-8 (a), Moderately severe frontotemporal thinning in a 46-year-old woman. (b), Twenty-four months after a single session
of follicular units and small slit grafts. (The results probably would have appeared similar if she had been seen in follow-up at 12 months.)
Figure 12H-9 (a), A 51-year-old woman with moderate thinning of the frontotemporal areas. (b), Eleven months after a single session
of FUs and small slit grafts. This patient’s frizzy hair and minimal hair/skin color contrast produced an excellent result. (c), Another lady
with hair characteristics similar to those shown in (a) but with more severe thinning. (d), Nine months after the second hair transplant in
the patient shown in (c).
disagree with this suggestion, providing the surgeon is skilled,

takes great care to follow the direction and angle of existing
hair, and is not overly aggressive with regard to the number
and densities of grafts. If there is moderate hair density still
present at the onset of treatment, it is more likely that any
temporary hair loss can be camouflaged by the remaining hair.
For those with sparser hair, another alternative is to transplant
only the left or right side of the recipient area, allowing the
untreated side to be combed over the treated one, if any signifi-
cant hair loss occurs. The untreated side can be transplanted in
a second session or a second transplant can be carried out in
the area that was previously thickened if that is deemed to be
advantageous for styling purposes. Moreover, temporary hair
loss can often be effectively camouflaged with the use of a
skin-coloring agent such as Toppik (see Chapter 14B) or, if
necessary, a temporary hairpiece or pastiche.
Hair transplantation has also been used for the creation of
eyebrows and eyelashes, and for the treatment of scars second-
ary to disease processes and cosmetic surgery. These are dis-
cussed in more detail in Chapter 15. In particular, scars from
rhytidectomies and the replacement of hairs lost anterior to the
ears—a telltale sign of many rhytidectomies—are usually eas-
ily corrected with hair transplantation (13). Conversely, a num-
ber of hair restoration surgeons, including Barrera (14), Kabaker
(S. Kabaker, personal communication, 2003), Shiell (R. Shiell,
personal communication, 2003) and Vogel (J. Vogel, personal
communication, 2003) have carried out hair transplantation
concomitantly with rhytidectomy. The donor tissue is usually
removed as the first or one of the earliest components of the
procedure, so that it can be divided into grafts during the course
of the rhytidectomy. On completion of the rhytidectomy, the
anesthetist can stay while the recipient sites are made and the
grafts are inserted. Alternatively, the field blocks for the recipi-
ent area can be infiltrated at the end of the rhytidectomy while
Figure 12H-10 (a), Severe frontal ‘‘Christmas-tree’’ thinning
the patient is still unconscious, and the rest of the hair transplant
in a 62-year-old woman. (b), Six months after a single session of
can be done while the patient is resting in the recovery area.
FUs and small slit grafts. A second session is planned for this area.
gauge recipient sites) seem to be more frequently and more

severely affected than when they are treated with a combination
of DFU and FUs. This may explain the relative aversion some
FUT proponents have had to hair transplantation in women (Fig.
12H-12). It is, however, important to emphasize not only the
possible occurrence of some hair loss but also its temporary
nature. These effects can sometimes be prevented, and nearly
always mitigated, by the use of a specially prepared 3.5% solu-
tion of minoxidil applied to the recipient and potential donor
areas for one week before, and 5 weeks after surgery. (A 2%
solution was too weak to produce the desired benefits and 5%
produced too high an incidence of side effects in my patients
so we simply mix these stock strengths together in equal parts.)
This preoperative use of minoxidil has not been found to signifi-
cantly increase bleeding during surgery. Because some tempo-
rary hair loss nevertheless remains a possibility, it is generally Figure 12H-11 Moderately severe but temporary hair loss, just
ideal to begin transplanting before the recipient area hair is very superior and inferior to the donor area scar. The photo was taken
sparse. There are some hair transplant surgeons who fear that 6 weeks after this woman’s surgery. Her hairstylist had mistaken
early surgical intervention, both in men and women with pat- this loss as representing a wide scar and had alarmed her. The
terned hair loss, might accelerate or worsen the problem. This scar is, in fact, approximately 0.2 mm wide and can easily be
is discussed in Chapter 5. Suffice it to say here that we strongly camouflaged by hair superior to it.
524 Chapter 12
Figure 12H-12 (a), Before transplantation. After this photograph was taken, this woman was treated with 1159 FUs at a density of
30 FU/cm2 into 18-gauge needle holes and 85 small slit grafts. (b), Some hair loss in the recipient area began approximately 3 weeks after
surgery. The patient is shown 3 weeks after surgery, with the most severe telogen/anagen effluvium I have ever seen. Perhaps FUT
proponents, who tend to use denser packing of FUs, see something like this degree of temporary loss in more of their patients than I usually
do. (I usually treat my female patients with more DFUs and approximately 800 FUs.) If my colleagues see a significant number of patients
with temporary hair loss, this would explain their frequent aversion to using transplants in patients with FPHL. (c), Five months after first
session, the temporary hair loss shown in Fig. 12H-2b began to improve 2 to 3 weeks after the photograph was taken.
Needless to say, this approach can be used for both female MPB. It is time that this fact was more widely recognized in
and male patients, and none of the hair-bearing tissue removed the medical and hair transplant communities.
during the ryhtidectomy is simply thrown away.
CONCLUSION 12I. Lasers in Hair Restoration

Surgery
Medical doctors frequently forget that there are sometimes sur-
gical options available for their patient’s problem, just as sur- Carlos Oscar Uebel
geons frequently forget that there are sometimes medical op-
tions available. Possible medical solutions should nearly always METHOD
be tried before surgical ones. For women with patterned hair
loss, however, who frequently have very little success from We use a Derma 30 Erbium: YAG Laser (ESC Medical System,
medical treatment, the possibility of hair transplantation should Yorkneam, Israel), that emits a beam composed of 50% Erbium
not be overlooked. Many women can expect results that are at ions in a Yag matrix. This is a 30-watt device, with 3.0 j (joules)
least as good as those seen in transplantation for men with early of pulsed energy, and a 2.94-␮ wavelength. We use the same
Figure 12I-1 Thermal damage study of the Erbium: YAG

laser in the scalp. Holes with a depth of 3-mm and damage to Figure 12I-2 Erbium: YAG Laser handpiece with a depth of
the inside borders at 10 ␮ to 15 ␮. 3 mm scans approximately 0,8 mm from the surface of the scalp,
making incisions of 1-mm diameter and 3-mm to 4-mm depth.
Figure 12I-3 (a), Young patient with total baldness and a few thin hairs. (b), 18 months after surgery.
526 Chapter 12
Figure 12I-4 (a) MPB in middle aged patient. (b) Two years postoperatively. (c) In a close-up view we can observe some white spots
surrounding the hair shafts due to the skin resurfacing property of the Erbium Laser ‘‘cone’’ shadow.
Figure 12I-5 (a), Intra-operative photo. The Erbium laser was used to improve the hairline and the occipital area. (b), Preoperative
photo. (c), Seven months after surgery.
528 Chapter 12
surgical routine as employed in the cold steel system. The recip- ble tool for doing that—the slot punch. This does not mean
ient bald area is massively infiltrated with a saline solution of that there is no possible future role for lasers in hair transplanta-
1:160.000 epinephrine to produce ‘‘ballooning of the scalp’’ tion. The Erbium laser (or other lasers that may be developed
and to minimize bleeding. The Erbium laser does not coagulate in the future) produces little or no thermal damage. Such lasers
blood vessels; therefore, it is mandatory to produce tumescence could theoretically be attached to a scanner that would rapidly
at all scalp levels. With the 3.0-j Erbium laser, we use the and consistently produce large numbers of recipient sites at pre-
following parameters: energy 3.0 j, rate 10 pulses per second; programmed densities in different areas, angles, and directions.
power of 30 watts, with 1-second to 2-second pulses. The hand- I have been told that this would be possible even in hair-bearing
piece, which has a 3-mm spot, scans approximately 0.8 mm recipient areas. One of the developers of the computer-driven
from the surface, producing holes with a diameter of 1 mm and tools that are now used in brain surgery is currently working
a depth of 3 mm to 4 mm (see Fig. 12I-1 and 2). The distance on such a system and I have had several meetings with him
between each hole is approximately 1 mm to 1.5 mm. We create and his engineers. Will this, in fact, come to pass? Anything
all the holes first and then start to insert the grafts with microsur- is possible. At this point, I personally see no need to employ
gical forceps. The grafts are placed flush to the skin, and a a laser in hair transplanting. (WU)
bandage is applied for 2 days, as in our punctiform technique,
to protect the implants.
REFERENCES
The History of the Follicular Unit Micrografting
POSTOPERATIVE PHASE
Technique: A Personal View
Postoperatively, we see minimal erythema and inflammation.
1. Limmer BL. A tribute to our assistants—because you mean so
Edema is also minimal. Crusts fall off after approximately 15 much to our profession. H T Forum Int 2002; 12(4):134.
days, later than occurs with cold steel transplanting. Hair growth
is also delayed, starting after approximately 4 months. Cysts
The Rationale for Follicular Unit Transplantation
and granulomas rarely occur, and we have achieved a consistent
hair yield of approximately 90%. This rate is better than what 1. Bernstein RM, Rassman WR, Szaniawski W, Halperin A. Follic-
we experienced with a CO2 laser (approximately 75% to 80%) ular transplantation. Int J Aesth Restor Surg 1995; 3:119–132.
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3. Limmer BL. Elliptical donor stereoscopically assisted micro-
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9. Gandelman M. Light and electron microscopic analysis of con-
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My experience with CO2 lasers in hair transplanting was pub- in hair transplantation. H T Forum Int 1996; 6:16–18.
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the International Society for Hair Restoration Surgery scientific 27. Limmer B. Follicular holocaust. H T Forum Int 1998; 8(5):1.
assembly. Nashville, Sept. 1996. 28. Bernstein RM, Rassman W. Dissecting microscope versus mag-
3. Limmer B. The density issue. Presented at the International Soci- nifying loupes with transillumination in the preparation of follic-
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4. Seager D. Does the size of the graft matter. Presented at the 16.
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Nashville, Sept. 1996. survival rates of follicular unit grafts vs. the micrografts of the
6. Rassman W. Are megasessions/dense-packing always appropri- micro/minigrafting technique. Presented at the International
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15. Reed W. Rethinking some cornerstones of hair transplantation. 40. Kim JC. Regrowth of grafted human scalp hair after removal
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530 Chapter 12
41. Beehner M. Two research studies on follicular unit growth. In- 5. Swinehart J. Cloned hairlines: the use of bisected hair follicles
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21–24, 1998. H T Forum Int 1998; 8(5):19. 25:654–660.
56. Arnold J. Reporting results of studies performed at WAHRS 5. Unger W. Recipient area. In: Unger W, ed. Hair Transplantation.
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57. Beehner M, Barusco M. The Orlando workshop experiments and zation and planning. In Unger W, ed. Hair Transplantation. 3d
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School of Medicine, Kyungpook Univ 1996:135–139. grafting techniques. Dermatol Surg 1998; 24:957–963.
59. Knudsen R. Editor’s note on ‘‘A slot by any other name.’’. H 9. Seager D. Dense hair transplantation from sparse donor area
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23, 1999. 130–137.
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ed. Estetica Clinica & Cirurgica: Revinter, 2000.
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1. Olsen EA. Female pattern hair loss: clinical features and poten- eds. Rejuvenescimento Facial a Laser: Revinter, 1998.
tial hormonal factors. J Am Acad Dermatol 2001; 45(suppl pt 4. David LM, Lask GP, Glassberg E. CO2 laser abrasion for cos-
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women. J Am Acad Dermatol 1988; 18:1–77. Oncol 1991; 17:340–344.
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13
Graft Insertion and Placement
13A. Placing Grafts: An Overview of the placer’s hand or on another area until they are ready
to be picked up for insertion.
Basic Principles and Current
Controversies
Physical Trauma
Ron Shapiro
Direct physical trauma during placement potentially reduces
the graft survival rate. It commonly occurs due to one of the
INTRODUCTION following:
The ability to place grafts successfully is a critical step in the 1. Squeezing the graft between the tips of a forceps with
hair transplant procedure, and its importance grows as surgeons excessive force
increasingly use smaller grafts in larger numbers. Placing a 2. Crushing the graft between a placing instrument and
large number of tiny grafts into small incisions is technically the wall of an incision site
difficult and increases the likelihood of problems occurring dur-
ing this step of transplantation. The complications can lead to The amount of direct physical trauma increases when the diffi-
poor yield or decreased naturalness. The need to overcome culty of placement leads to multiple, failed attempts at insertion.
these difficulties has resulted in a variety of clinical innovations Inexperienced placers have higher numbers of failed attempts,
and modifications in the placement technique. and they also have a tendency to grab a graft with greater force.
In this chapter, I examine some of the more common prob- The clinical significance of direct physical trauma is some-
lems that occur during placement. I also discuss the basic princi- what controversial and deserves more discussion. An early
ples and methods used to combat these dilemmas. study by Greco shows that major microscopic change occurs
in the cell structure of the bulb when forceps severely crush it.
However, more recent studies by Gandelman suggest that crush
injuries do not show the same degree of microscopic change
BASIC PLACEMENT PROBLEMS when forces typical of those in the clinical setting are applied to
the graft (1). In addition, Gandelman finds that the microscopic
Dehydration
changes associated with dehydration are much more severe than
Prolonged exposure to air, especially the dry, dehumidified air those associated with direct physical trauma. Other studies, such
of a surgical room, leads to graft dehydration, which is one of as Kim’s, show a 70% survival rate of grafts when the surgeon
the major causes of decreased graft survival. The potential for or staff removes the bottom third (2). If such severe physical
dehydration is greatest during placement of a larger number of trauma still results in a 70% survival rate, it would suggest that
small grafts. Two reasons for this are the following: mere crush injury during graft insertion would have relatively
limited effects on graft survival.
1. Smaller grafts dehydrate more quickly than larger The clinical significance of these findings has practical im-
grafts. Smaller grafts have a greater surface area-to- plications when applied to the adage: ‘‘Do not grab a graft by
volume ratio than larger grafts and, therefore, are more the bulb.’’ In general, it is prudent to limit direct physical trauma
vulnerable to the dehydrating effects of air exposure. by grasping the graft either below or beside the bulb.’’ How-
2. Smaller grafts take more time to place, thus increasing ever, in specific situations, tissue around the bulb is either sparse
the potential for prolonged air exposure both during or friable. In these cases, attempting to avoid the bulb creates
insertion and while waiting ‘‘on deck’’ to be placed. a tenuous grip on the graft and often results in multiple failed
Grafts on deck refer to grafts that are either waiting on attempts at insertion, which indirectly increase the graft’s de-
533
534 Chapter 13
gree of trauma and its potential exposure to dehydration. In ingrown hairs and/or epithelial inclusion cysts (3). Piggy-
such cases, therefore, it is better to accept a small degree of backing occurs more often when it is difficult to determine
trauma by gently grasping the bulb than a greater degree of whether a graft has already been placed in the incision. Factors
damage by frequently attempting and failing to insert the graft. that limit visibility, such as poor hemostasis, not using magnifi-
cation, etc., increase the potential for piggybacking; further-
Prolonged Time Out of the Body more, when grafts are hidden below the surface, the chance of
piggybacking also increases. It is important, therefore, to check
Studies indicate that graft survival does not decrease in grafts all questionable sites before placing a graft into the incision.
that remain out of the body for up to 6 hours. Limmer, support- An attempt should be made to limit the depth of the recipient
ing this claim, shows a graft survival rate of about 92% for sites so that the initial grafts cannot sink beneath the surround-
follicular units (FUs) kept out of the body for up to 6 hours; ing skin surface.
but he also finds a decrease in graft survival rate of about 1%
per hour after 6 hours. At 24 hours, the survival rate is about
70%. Kim shows a survival rate of more than 90% for FUs Grafts Placed Too Deeply
kept in saline solution for up to 6 hours. In his study, there is As noted earlier, overly deep placement often occurs during the
no difference between the survival rate of grafts kept at room initial insertion or when the grafts are patted with gauze; it also
temperature and grafts kept at 4⬚C, as long as the grafts remain occurs spontaneously after the placer has situated the grafts and
moist. Placing a large number of small grafts can take longer moved on to other sites. Just as with piggybacking, when grafts
than 6 hours, especially when carried out by inexperienced sink below the epithelium, cysts can form and ingrown hairs
hands. Although most experienced physicians finish a proce- can develop. In addition, a pitted look can occur. During place-
dure of 1500 grafts in fewer than 6 hours, larger sessions or ment, it is important to check sites repeatedly and to adjust
sessions performed by less experienced surgeons not uncom- grafts so that they are positioned flush with, or slightly above,
monly take from 8 to 10 hours. Developing more efficient and the surface epithelium.
quicker methods of placement therefore, should be an ongoing
effort. No matter what techniques the physician uses, however,
experience and skill remain the two most important factors for Empty Sites or Missed Sites
expedient and successful placement. It is essential for practi-
tioners, especially novices, to be aware of their limitations and Sites can be left empty because the placer overlooks them or
not to take on a large procedure that is above their skill level. because a graft slips out unnoticed during the procedure. Persis-
The length of time needed by an inexperienced surgeon may tent bleeding in an area may be a sign that a site has been left
cause the grafts to remain out of the body too long. empty or that a graft has slipped out. Continual checking for
missed sites is, therefore, essential to the success of the proce-
dure.
Popping
Popping occurs when tissue adjacent to the incision transmits
Bent Grafts
enough of the lateral or inferior forces created during the inser-
tion of the graft to expel the adjacent graft; that is, the previously Occasionally, when a surgeon places a graft in an incision, the
inserted graft ‘‘pops out’’ of an incision when the surgeon at- graft bends with the root coming up toward the surface. Bent
tempts to insert another graft adjacent to it. Any increase in grafts occur more often if the site is shallow or if the placer
lateral or inferior force increases the potential for popping. grips the graft too high and pushes rather than pulls it into the
Causes for such increases include the following: site. The fate of these grafts is unknown; possibly, they do not
1. Grafts are too large for the incisions. survive. Some surgeons believe that inserting bent grafts leads
2. Incisions are shallow. to kinky hair growth.
3. Certain patients with stiffer recipient area tissue (e.g.,
members of the black race, in scar tissue, etc.) transmit Improper Direction or Orientation of Grafts
forces of insertion more efficiently.
4. Inexperience and/or rough placement techniques jeop- Hair normally exits the scalp at a specific angle and direction
ardize the procedure. Experienced assistants master the peculiar to that area. The angle and direction of the incision is
fine motor skills and mechanics of gentle insertion. The the predominant determining factor of hair orientation. How-
art of gentle insertion limits both popping and direct ever, grafts must be placed deliberately to ensure that the hair
physical trauma, and I describe this art in more detail is oriented properly and with minimal physical trauma to the
later in this chapter. follicles. The importance of this placement varies with the type
5. Extra bleeding in the recipient site can produce a force of graft. Regardless of the angle and direction of the incision,
below the graft that causes the graft to elevate and lift round grafts need to be rotated to face the right direction. Slit
out of its site. and slot grafts must face anteriorly or posteriorly. With FUs,
the benefit of graft orientation is more subtle. When the hair
Piggybacking is straight, there is no major benefit achieved by rotating an
FU in its incisional site. When hair has a curl, however, it is
Piggybacking occurs when the surgeon places a second graft beneficial to rotate the FUs so that all of the hairs exit with
on top of a graft previously placed in the incision. It leads to their curls pointing in the same direction.
Graft Insertion and Placement 535
BASIC FACTORS THAT INFLUENCE PLACING thies. They are described in detail in Chapters 7A, B,
and C.
Visualization 2. Anesthesia and patient comfort. Pain in the recipient or
Small incisions and tiny grafts are difficult to see, especially donor area indirectly leads to increased bleeding if the
in a bloody field or amid existing hair. A poor view exacerbates patient’s blood pressure and heart rate increase. During
many of the problems listed earlier (piggybacking, missed sites, longer procedures, a sudden increase in bleeding some-
increased placement time, difficult insertion, etc.). Proper visu- times indicates that the anesthesia is wearing off. In
alization of grafts and incisions, therefore, is a basic tenet of these cases, it is helpful to use a long-acting agent, such
successful placing. To improve graft visibility, use the follow- as bupivacaine (Marcaine). Here again, an ounce of pre-
ing recommendations: vention is worth a pound of cure. If the procedure is a
long one, consider repeating the field blocks or nerve
1. Wear magnification loupes. Although magnification blocks at regular intervals before any pain is experi-
loupes improve visibility, some assistants resist wearing enced—for example, if lidocaine is being used for a
them, claiming that their vision is ‘‘fine’’ without them. field block, repeat the field block in both donor and
In my experience, however, assistants who place well recipient areas 3 hours after the prior one was produced.
without magnification place better with magnification. Control of the patient’s level of anxiety with anxiolytics
2. Limit looking away from the recipient site and ‘‘losing and maintenance of a calm atmosphere play indirect
the place.’’ This tenet is similar to the adage: Keep your roles in limiting bleeding.
eye on the ball. Surgeons and assistants have a natural 3. Mechanical measures. With skill and experience, me-
tendency to lose their place during insertion if, when chanical methods can control most bleeding. Occasion-
picking up a graft, they look away from the recipient ally, there is poor hemostasis in an individual site that
site incisions. Losing the place increases the possibility bleeds heavily (‘‘a bleeder’’). Surgeons and staff con-
of piggybacking and/or missing sites. It also leads to trol these sites with point pressure or by plugging them
wasted time when the placer has to check and recheck with a slightly larger graft or dilator. A constant, low-
the site for grafts. The following suggestions help to grade oozing from multiple incisions that gradually ac-
minimize this problem: cumulates to obscure the surgical field occurs more
often, however, than individual bleeders. Frequently,
A. Keep grafts waiting to be placed ‘‘on deck’’ in the spraying the incisions with a saline solution helps to
same general field of vision as the recipient site. minimize any decreased visibility of these incisions due
Placers accomplish this by keeping grafts on the to constant, low-level oozing. Diluted hydrogen perox-
tips of their fingers or on moist gauze situated adja- ide solutions may also be used. Some concern exists
cent to the recipient site incisions. regarding whether or not hydrogen peroxide is slightly
B. Follow a pattern. Placing grafts in an organized toxic to grafts. Recent studies by Kim suggest that di-
pattern rather than skipping around decreases the luted concentrations of hydrogen peroxide solutions are
chances of losing the place. safe to use for cleaning (4). Chapter C discusses other
C. Leave the donor hair 3 mm to 4 mm long. Longer suggestions to control bleeding without use of epineph-
donor hair not only acts as a marker for filled inci- rine.
sions, but it also makes it easier for the placer to 4. Tumescent and epinephrine solutions. Surgeons hold a
grab and adjust grafts if necessary. variety of opinions regarding the use of tumescent and
D. Consider using a two-person-per-graft, or epinephrine solutions to control bleeding in the recipient
‘‘buddy’’ technique, for insertion. ‘‘Buddying’’ area.
eliminates the need for the primary placer to look
away from the incision site. I describe this tech- A. Low concentration epinephrine solutions—Some
nique in more detail later. physicians use tumescent solutions with a low con-
centration of epinephrine to control bleeding. The
concentrations range from 1:100,000 to 1:300,000
Hemostasis (Bleeding) Control epinephrine and produce both vasoconstriction of
Controlling hemostasis is one of the most important factors in superficial vessels and some protection of deeper
successful placing of grafts. Excessive bleeding not only limits vessels by distending the dermis and subcutaneous
visibility but also contributes to grafts’ popping and slipping tissues. A potential problem with this technique,
out of their incisions. Basic ways in which to control bleeding however, is that delayed refractoriness to epineph-
include the following: rine and reflex vasodilatation can occur later in the
procedure, after the epinephrine wears off. Other
1. Preoperative measures. The adage: ‘An ounce of pre- potential problems of using tumescence in the re-
vention is worth a pound of cure,’ applies here. Before cipient site are an increased degree of popping re-
surgery, determine and address any factors that increase sulting from tissue turgor and a higher incidence
the risk of bleeding. These factors include, but are not of postoperative edema.
limited to, medications, such as nonsteroidal anti-in- B. Highly concentrated epinephrine solutions—Sur-
flammatory drugs and Coumadin, or preexisting condi- geons may administer small amounts of a high-
tions, such as liver disease, hypertension, or coagulopa- dose epinephrine solution, which has earned the
536 Chapter 13
nickname ‘‘super juice (5)’’. Concentrations range Graft size varies from case to case depending on the caliber
from 1:10,000 to 1:50,000 epinephrine. Physicians of the hair, donor area hair density, and the skill of the cutters.
inject only small amounts of solution (1 mL to 5 Graft size also varies depending on the amount of tissue that
mL) into localized sites in a staged fashion. Some the physician instructs assistants to leave around the follicles
physicians reserve this solution for as-needed situ- (i.e., the degree of ‘chubbiness’ the physician desires). Incision
ations only; others use it by moving systematically size varies depending on the blade used or the angle and depth
from one small area to another. A number of opin- of the incision. It is prudent, therefore, to test graft size to see
ions co-exist concerning the safety of a higher dose how grafts fit early in the procedure, before making too many
epinephrine solution, especially with cardiac pa- incisions. If needed, either the size of the grafts or the size of
tients on beta blockers. Sound clinical judgment the incision may be adjusted. Sometimes a minimal adjustment
and adequate monitoring are essential to this tech- in size produces a major effect on the ease of placing.
nique (see chapter 8A).
Graft Spacing
Hydration Control
Graft spacing also influences placement, specifically with re-
As mentioned previously, dehydration is a major cause of poor spect to popping. As mentioned earlier, certain patients have
yield. Grafts are vulnerable to dehydration during the placement more trouble with popping than others. Increasing the spacing
process at the following specific times: between incisions decreases popping. Therefore, if the surgeon
1. While on deck and waiting to be placed suspects that popping will be a problem, a slight increase in
2. During insertion in protracted procedure spacing is helpful.
3. After insertion, if the graft unknowingly slips out of an
incision site. Incision Depth and Limited-Depth Incisions
To keep grafts hydrated, follow these recommendations: Incision depth also affects placing. Problems occur if incisions
1. Repeatedly spray or add cool saline solution to the are too deep or too shallow. Incisions that are too deep lead
grafts on deck waiting to be placed. to increased bleeding and increased pitting; therefore, many
2. Keep the on-deck grafts close together or touching. surgeons have recommended limited-depth incision and have
Spreading grafts out instead of grouping them together created instruments to help in making such incisions. If, how-
increases the probability that they will become dehy- ever, incisions are too shallow, insertion becomes difficult be-
drated, because spread-out grafts have a greater amount cause of increased popping. It is important to understand that
of surface area exposed to the drying effects of air expo- limited-depth incisions do not, in fact, mean incisions of a truly
sure. minimal depth. Put differently, the depth of an incision should
3. Limit the number of grafts waiting on deck to a quantity not be limited to exactly the same length as the graft; rather,
that can be placed in a time frame that does not threaten it should be slightly longer than the graft to allow for some
them with the risk of dehydration. This number varies ‘give’ during insertion. Shallow incisions also present more
depending on the skill and speed of the assistants and problems under certain conditions, such as thin skin resulting
on the ability to keep grafts that are waiting to be placed from burns or scalp reductions.
moist. Many surgeons believe that grafts should not be
left unprotected or exposed to air for more than 5 min- Removing the Epithelium
utes.
4. Appoint one assistant to serve as a ‘‘loader.’’ The load- Some hair transplant techniques involve complete removal of
er’s responsibility is to take grafts from the petri dishes the graft’s epithelium (6). The potential benefit of this step is
and to put them on the placer’s finger or on other on- limiting the degree of pitting that occurs when grafts are placed
deck areas, replenishing these areas with grafts as neces- too deeply. The technique’s potential disadvantage, however,
sary. The loader also monitors the grafts for dehydration is an increased chance of piggybacking and of missed sites
and rehydrates them as needed. The loader not only during placement because of the increased difficulty of differen-
helps to control hydration but also reduces the need for tiating between occupied and unoccupied sites. As a result, re-
the placer to stop placing, to reload with more grafts, moving the epithelium is not a popular tactic.
and to re-identify the present placing area. This helps
increase the speed of placing. Dilators
5. Frequently check the recipient site for grafts that have
slipped or popped out after placement. Dilators were created to assist with the placement of smaller
grafts. They dilate incisions, mark empty sites, and aid in the
Graft Sizing control of bleeding. However, dilators are bulky, time-consum-
ing, and awkward to use. They may also contribute to compres-
It is important for the size of the graft to fit the size of the sion by allowing the placer to insert grafts that ordinarily would
incisional site because problems occur when the grafts are either be too large for an incision site. As experience with smaller
too large or too small for the site. When grafts are too large, grafts grows, many assistants find they place just as well, if not
more forceful insertion, multiple failed attempts, and an in- better, without dilators, and, therefore, dilators are not as popu-
crease in popping can occur. When the grafts are too small, lar as they once were. Some physicians still use them, however,
they can either sink too deep or slip out later in the procedure. to plug and to control bleeding in individual incision sites.
The Mechanics of ‘‘Gentle’’ Graft Insertion of a mechanical device is to increase the speed and efficiency
of placement while simultaneously maintaining a consistently
Gentle graft insertion limits popping, trauma, and bleeding. The low level of graft trauma. Most devices, however, do not clearly
ability to insert grafts gently is a talent that comes with experi- exceed the efficacy or ability of an experienced assistant using
ence and the development of skill. Some of the specific steps a forceps. Currently, two devices may have some merit: the
and mechanical factors that lead to a gentler insertion are the Choi Implanter and the Hair Implanter Pen.
following:
1. Proper body and hand positioning. The body should be The Choi Implanter
positioned so that it is ergonomically easy to insert the The Choi Implanter is composed of a needle that is left open
forceps into the incision at the proper angle. Many assis- along one side. The placer loads a single FU into the needle
tants assume contorted positions, struggling to insert and then inserts the needle into the scalp, carrying the FU along
grafts. Simply turning the patient’s head or reposition- with it. After insertion, the instrument allows the placer to with-
ing the assistant’s hand to a more ergonomically draw the needle and, at the same time, to leave the hair behind
friendly position often dramatically increases the ease in the scalp. Doctors in Korea use this device extensively, and
of placing grafts. it works well for the very coarse hair of the native Korean
2. Finding the angle. All incisions are made at a specific population. It is unknown, however, whether the Choi Implanter
angle. When a forceps enters an incision at the proper works as well for finer hair. Drawbacks of this device are its
angle, its tip slides straight down the path of the incision expense, its inability to be reused, the need for at least one
without touching the lateral walls or causing/requiring extra person to place the graft in the implanter, and its minimal
undue force. It is helpful to get a feel for the angle by availability outside of Korea.
performing test insertions with an empty forceps before The following developments, however, may increase the use
placement begins. of this device in other countries: (1) the creation of a replaceable
3. Grasping the graft. Grasp the graft as proximally as needle that significantly reduces the cost and increases the avail-
possible, trying not to touch the bulb. However, if there ability of this device; (2) the modified use of this device so that
is minimal tissue around the bulb, gently grasp the graft it only inserts the graft instead of both making the incision
at the bulb rather than further up on the shaft. When and inserting the graft, thereby allowing practices that do not
grasped above the bulb, the graft is more difficult to currently use a stick-and-place approach to employ the Choi
insert and tends either to bend or to be compressed be- Implanter adeptly; and (3) Improved models of this device (i.e.,
tween the tip of the forceps and the skin. This is because the Knu implanter and the Hans implanter). These devices are
the graft is not firm enough to be pushed down from discussed in more detail in Chapters 22C and 16G.
above; instead it needs to be pulled into an incision
from the proximal (bulb) end. To visualize this, imagine The Hair Implanter Pen (HIP)
trying to push a piece of string instead of pulling it from The HIP is a pen-like instrument that contains a tiny, hollow
its end. needle attached to a suction device. The placer turns the suction
4. Preparing for insertion. Once the graft has been gripped on simply by touching a hole on the side of the device with a
with the forceps, align its tip with the angle of the inci- fingertip. The instrument’s premise is that it automatically picks
sion. up a graft with suction instead of squeezing it between the tips
5. Initial insertion. Focus attention not on the graft but on of a forceps. After inserting the graft, the placer releases their
the tip of the forceps. Concentrate on sliding the tip into fingertip from the hole, thereby aborting the suction, and with-
and along the path of the incision. The graft will follow. draws the pen, leaving the graft behind. The device is simple
Do not push the graft into the incision; it will be pulled to use, and studies show that beginners prefer it, finding it easier
into the incision behind the tip of the forceps. to employ than a forceps. However, the HIP offers no speed
6. Early release of the graft limits popping. When the graft advantage compared with experienced placers. In addition, it
is one half to three quarters of the way into the incision, is not clear that using this device actually decreases trauma.
release the graft and withdraw the forceps. Popping Other problems with the HIP are that its suction is very noisy
typically occurs here because of the combined mass of and that, at present, the instrument has some mechanical prob-
the forceps and the graft, which both occupy the site. lems. Although there was some initial enthusiasm over this de-
Once the placer releases the graft and it sits about one vice, it is seldom used today.
half to three quarters of the way into the incision, it can
be easily re-gripped gripped at the point where it exits ‘‘Stick and Place’’ versus ‘‘Making All the Incisions
the skin and can be adjusted downward so that it is either First’’
flush with, or slightly elevated above, the epithelium. In
this technique, the placer never has to insert the forceps Stick and place is the general placement approach of making
more than approximately halfway into the incision, an incision and inserting the graft immediately afterward. It is
thereby decreasing the amount of popping in difficult discussed in detail by Seager in the next section of this text
cases. (Chapter 13B). Conversely, ‘‘making all the incisions first’’
refers to creating all (or most) of the incisions initially and then
Mechanical Implanter Devices returning to them later to insert the grafts.
Most techniques today fall under one or the other of these
A number of mechanical implanter devices have been devel- broad categories. Consider the following when deciding on a
oped over the years in an effort to improve placement. The goal procedure technique:
538 Chapter 13
1. Potential Advantages of the Stick-and-Place Technique 2. The first assistant never has to turn away from the recip-
A. Homeostasis can be controlled because the inci- ient site, so there is less chance of losing the place, of
sion houses a graft immediately after it is made. piggybacking, or of missing sites.
There is less bleeding and more visibility. 3. Opening the site makes the mechanics of insertion eas-
B. No incisions are ‘‘missed’’ when grafts are being ier, decreasing the possibility of trauma or popping.
inserted. 4. Continuously minimizing bleeding after every incision
C. No piggybacking occurs. improves visibility.
D. Inserting a graft immediately after making an inci- 5. The buddy or two-person technique is a good method
sion takes advantage of the initial dilation of the for training a new assistant without losing quality con-
incision by the needle or blade. The blade makes trol.
insertion of the graft easier and less traumatic and 6. Although it is not necessary in all situations, it is a good
results in less popping. technique to have in reserve for difficult cases in which
patients are prone to bleeding and popping.
2. Potential Disadvantages of the Stick-and-Place Tech-
nique The disadvantages of this technique are the following:
A. There is a risk of ‘‘painting oneself into a corner.’’ 1. More staff are required.
When the placer sticks and places, the work area 2. Usually grafts can be placed on only one area of the
is small and sometimes the placer misses the big head at a time, and total placement time depends on
picture. It is possible, therefore, to run out of grafts the difficulty of the case with respect to bleeding and
before the desired distribution is achieved or for popping. In cases of bleeding and popping, it is faster
an area to be covered unevenly. and more effective to have two people work together
B. If the State Medical Board (or other local author- in one area than to have two people struggle separately
ity) requires surgeons to make all the incisions, the in different areas. When bleeding and popping are not
surgeon, must be in the room for the complete problems, however, it is more efficient to have two peo-
stick-and-placement process and the procedure ple placing grafts separately in different areas.
must stop if the physician leaves the operating
room for any reason. Experience and Quality Control
C. If the physician’s State Medical Board (or other Experience and skill are more important than the use of a partic-
local authority) allows delegation in the process ular technique to place grafts successfully. Although experi-
of making incisions, the physician can delegate enced placers achieve good results with a variety of techniques,
part or all of the placement process tasks. How- inexperienced placers can create poor results no matter which
ever, the more tasks delegated, the less control the technique they use. In many practices, assistants place all the
physician has over the distribution, pattern angle, grafts, and, therefore, it is important for the surgeon to maintain
and direction of graft placement, which means that quality control. In the past, when placers inserted only a few
the physician must trust the skill and judgment of hundred grafts at a time, it was easier for the physician to over-
the assistants. This is particularly important when see the placement process and to maintain quality control.
responsibility for creating the hairline is delegated Grafts were larger, less susceptible to trauma, and easily adjust-
or when less experienced assistants are performing able by the physician at the end of the surgery. Maintaining
the tasks. Supervision and methods of quality con- quality control is more difficult today for a variety of reasons,
trol are especially crucial in these situations. San- such as the following:
doval discusses his method of ensuring quality
control during stick-and-place in Chapter 16F. 1. Placement has become more complex and therefore
more prone to problems. It is no longer possible to sim-
Two People per Graft Insertion (Buddy Technique) ply check the grafts at the end of a procedure. A high
level of skill must be maintained throughout the entire
Most techniques employ a single person to insert grafts through- placement process.
out the entire placement process. Less commonly, two peo- 2. Many physicians today do not know how to place grafts
ple—‘‘buddies’’—divide the insertion. This approach proceeds and are totally dependent on their assistants.
as follows: 3. In small medical practices, it is hard for assistants to
1. The first assistant finds and opens the incision site. perform cases on a regular enough basis to increase their
2. The second assistant partially inserts the graft. skill levels.
3. Finally, the first assistant adjusts the graft to the proper 4. In larger practices, the combination of a high staff turn-
depth and then locates and opens the next site. over rate and the need for more assistants exposes pa-
Placers can use this approach when making all of the incisions tients to new and inexperienced assistants.
first or when employing the stick-and-place technique. When It is important for physicians to implement quality control and
they use the latter technique, the first assistant makes the inci- not to delude themselves into thinking that the staff naturally
sion rather than simply finding and opening the existing inci- places grafts well.
sions. Tykosinski discusses the two person stick-and-place tech-
nique in detail in Chapter 16B. The benefits of this approach
are the following: CONCLUSION
1. Opening the incision site permits gentler placement and We want to develop placing techniques that will ensure both
less popping. the maximum yield and the greatest degree of naturalness. To
ensure maximum yield, grafts must be placed gently and

promptly, thereby limiting the potential for physical trauma,
dehydration, and extended time out of the body. To ensure the
highest degree of naturalness, grafts must be placed at the de-
sired depth and direction. Many factors that influence the suc-
cess of placement have been covered in this discussion. The
most important factors, however, are always experience and
skill.
13B. ‘‘Stick and Place’’ Method of

Planting
David J. Seager
INTRODUCTION Figure 13B-1 Needle resting on the surface of the recipient

area skin. The needle has not yet been inserted into the skin but is
At the time of writing of this chapter, it is my belief and the positioned parallel to the rest of the hairs in the recipient area, both
opinion of others (B. Limmer, personal communication, 2001) transplanted and original. Other grafts nearby are held in place by
that there are fewer than a dozen hair transplant facilities the left hand with a piece of gauze while the needle is inserted into
throughout the world routinely using the technique described the recipient area skin.
here.
TECHNIQUE its dermal papilla end resting on the recipient skin immediately
What is different about ‘‘stick-and-place’’ transplantation of adjacent to, and usually touching, the needle (Fig. 13B-3a).
follicular unit micrografts? With stick-and-place planting of mi- Next, the needle is slowly lifted out of the skin by the opera-
crografts, each recipient site is made with a needle, and a graft is tor’s left hand. When the bevel is about three quarters of the
inserted into the site immediately after the needle is withdrawn, way out, the narrow point of the needle holds the orifice of the
before the next recipient site is made. This differs from the ‘‘tunnel’’ (which has been made and then kept dilated by the
usual method of graft placement in which a large number of needle) open (Fig. 13B-4) as the operator’s right hand maneu-
recipient sites (usually all) are made first, and then later the vers the graft down into the tunnel by means of the jeweler’s
grafts are planted into the numerous ‘‘premade’’ sites. forceps (Fig. 13B-5). The graft is inserted as deeply as possible
into the empty tunnel made by the needle (which has now been
completely withdrawn by the operator’s left hand). Usually,
How Is It Done? two or three gentle pushes (see Figs. 13B-5 and 13B-6) are
required to insert the graft all the way down to the bottom of
Needles of varying types and sizes are used to make the recipi- the needle tunnel (Fig. 13B-7). During these additional pushes
ent sites. Commonly employed needles for this process, in de- (and, indeed, in all handling of [follicular unit] 兵FU其 mi-
scending order, are an 18-gauge NoKor needle and 18-gauge,
19-gauge, and 20-gauge hypodermic or solid-core needles. The
19-gauge hypodermic needle is my staple. More than 95% of
sites are made with it.
The needle is held with the right hand (Fig. 13B-1) (or the
left hand, if the operator is left-handed) and inserted into the
recipient area skin (Fig. 13B-2) to a depth corresponding to the
length of the graft (i.e., the depth from the epidermis to about
1 mm deep to the dermal papilla, at an appropriate angle and
direction).
The needle is left in place to dilate the recipient site tunnel.
The operator then switches hands. The needle, which has been
inserted into the recipient area skin, is now held with the left
hand, and the right hand gently picks up a graft with a pair of
jeweler’s forceps. The operator holds the graft with the fine
tips of the jeweler’s forceps, grasping the fat pad around and
deep to the dermal papilla. Beginners find it easier to hold the
graft as shown in Fig. 13B-3a; that is, with the forceps vertical,
almost parallel to the long axis of the graft. More experienced
operators tend to hold the graft as in Fig. 13B-3b; that is, with
the graft held almost at right angles to the long axis of the graft. Figure 13B-2 The needle has been inserted into the recipient
The operator then positions the graft parallel to the needle with area skin to a depth corresponding to the length of the graft.
540 Chapter 13
a
Figure 13B-4 The needle is being withdrawn almost com-
pletely, but the very tip/point of the bevel is being used to hold
the orifice of the recipient tunnel open to facilitate insertion of the
graft. This photograph depicts the graft inserted halfway during the
first push with the jeweler’s forceps. The needle is now withdrawn
(while the graft is held in position with the jeweler’s forceps).
the need to switch hands for instrument implementation and is

therefore clearly advantageous.
After each FU has been inserted to the full depth of its recipi-
ent tunnel, the sharp point of the bevel of the needle is next
placed on the surface of the recipient skin, about 1 mm (more
or less) away from the previously planted graft(s), and held by
the operator’s right hand at the appropriate angle and direction
for the graft’s orientation (Fig. 13B-8). Up to and including this
b moment, no pressure is placed on the needle to pierce the skin.
With the left hand, the operator uses a piece of gauze to cover
Figure 13B-3 (a), The graft is being held roughly parallel to the surrounding and adjacent previously planted grafts, pushing
the needle, and the needle has been pulled slightly out of the skin. down on them to keep them in place (Fig. 13B-9). At the same
The graft is being held by the forceps in the ‘‘beginner’s posi- time, the right hand of the operator pushes the needle into the
tion’’—parallel to the long axis of the graft for ease of inser- skin to the appropriate depth. The grafts are placed so close
tion—but without crushing a dermal papilla, hair shaft or sebaceous
gland of the graft. (b), This photograph is similar to the previous
photograph (a) but depicts the graft held by the forceps in the
‘‘advanced planter’s position.’’ (The graft is held closer to a right
angle than in the beginner’s position shown in the photograph of
part a.) It is almost impossible to learn how to plant micrografts
held in this position, but most, if not all, experienced planters even-
tually use this method of holding the graft exclusively.
crografts), it is important that the operator hold the graft very

gently by its superficial dermis. (The grafts are deliberately
prepared to be ‘‘chubby’’; that is, when they are originally
dissected from the donor tissue, abundant protective dermis and
subcutaneous fat is left around the hair shafts and dermal papil-
lae so that the grafts may be handled during cutting and planting
without pressure on any of the components of the pilosebaceous
unit.)
Rarely, a planter is ambidextrous enough to be able to create Figure 13B-5 A second push inserts the graft almost com-
the recipient tunnel entirely with the left hand. This eliminates pletely into the recipient tunnel made by the needle.
Figure 13B-6 The third push, which inserts the graft com- Figure 13B-8 The needle is placed in position for dense pack-
pletely. ing immediately adjacent to and parallel to previously planted
grafts. It is held by the operator’s dominant hand.
together that with most patients (depending on their skin charac-

teristics), these neighboring, previously planted grafts without follicular unit hair transplantation (FUHT) without receiving
the counterpressure of the gauze would be pushed out of the adequate tuition and training.
skin by the pressure of the insertion of the needle. Occasionally, The most important and most common cause of incomplete
some of these neighboring grafts ‘‘pop’’ out anyway (Figs. 13B- growth in an FUHT, however, is drying out of grafts lying in
10 and 13B-11). The operator has to remain vigilant and push a petri dish or resting on a gloved hand, or even those that are
any popped grafts back down into their recipient sites before partially extruded (by popping) from their recipient site on the
they have a chance to dry. scalp. Follicular units are much smaller and more vulnerable
to drying than larger grafts. Because of their larger surface-to-
volume ratio, they have nowhere near the same leeway for error
Incomplete Growth for drying and trauma. Minigrafts and standard grafts can still
As can be seen in Figs. 13B-10 and 13B-11, these popped-out obtain more than 95% regrowth if they are placed in rows on
grafts—especially if the area is very vascular—can be ex- gauze or Telfa pads and kept moist in a petri dish with saline
tremely difficult to spot. Grafts that have been left partially
extruded, even for a brief period of time (usually, because they
are covered with blood and therefore not seen), are a major
cause of poor growth in the hands of operators who perform
Figure 13B-9 Immediately before and during insertion of the

needle into the skin. The left hand uses a sterile gauze pad to apply
downward pressure to the previously planted grafts, preventing
them from being pushed out by the pressure of the needle insertion.
In practice, the gauze would be positioned all around the needle,
Figure 13B-7 The graft inserted completely by the stick-and- but for reasons of photographic demonstrability, the gauze has been
place method. left on the far side of the needle.
542 Chapter 13
Figure 13B-10 The photograph shows numerous follicular unit micrografts that are popping, and partially extruded. Most of them,
however, are covered with blood and would only be noticed by an extremely perceptive, vigilant planter. (Photo 10 is repeated with example
grafts labeled on the overlay.)
Figure 13B-11 The photograph shows a follicular unit micrograft that is popping, and almost completely extruded. It also shows a
graft that is also popping, but this is obscured by blood and would only be noticed by an extremely perceptive, vigilant planter. (Photo 11
is repeated with example grafts labeled on the overlay.)
solution, whereas FU micrografts must actually be immersed transplant experts have stable, mature staffs who have the man-
in a deep dish of saline solution to remain moist enough for ual dexterity to cut and plant standard grafts and minigrafts
such complete regrowth. expertly, but they may not have the inherent manual dexterity,
The third major cause (not necessarily in order of frequency) vision, and ability to persevere expertly with such fine, intricate,
of incomplete growth is excessive manipulation of grafts during arduous work as FUHT. These original staffs may not have
the planting process. Remember that even an exceptionally tal- sufficient ability or patience to become skillful at planting FU
ented technician, who has received intensive one-to-one instruc- micrografts without excessive traumatization into 19-gauge to
tion and who has practiced almost daily, requires a year to 18 20-gauge hypodermic needle sites. I believe these are the rea-
months to become adept at planting 1500 grafts in 1 day. sons why many eminent traditional hair transplant surgeons are
Many experienced and eminent hair transplant surgeons, unable to obtain more than 70% regrowth of their FUHTs.
with outstanding expertise in working with larger grafts, try
their hand at FUHT and persevere for some time in the belief Summary of Technique
that they are using the perfect technique. However, many of
these practitioners report that they obtain regrowth rates that The important points about the stick-and-place technique are
are no greater than around 70%. The reasons are obvious to the following:
me. Reduced regrowth occurs partly as a result of their not 1. The needle is initially held with the right hand and in-
appreciating many of these (and many other) finer points, that serted into the skin with the right hand, while the left
are currently known to fewer than half a dozen practitioners hand, using a piece of gauze, keeps the previously
throughout the world. Additionally, many of these veteran hair planted grafts in place.
2. Once the needle tip is inserted, the operator switches transplant surgeons who try their hands at FUHT using the more
hands, and the left hand now controls the needle. The traditional, and necessarily larger, premade recipient sites.
right hand picks up and readies a graft for placement Of course this assumes that the expert hair transplant sur-
into the tunnel, which has been made and then kept geons are paying meticulous attention to avoiding transection
open by the needle left in the recipient skin until a split of hairs, desiccation of grafts, improper handling of grafts, and
second before graft insertion. a myriad of other details that apply strongly to FU hair but
3. The choice of the angle whereby the forceps hold the hardly at all to transplantation with bigger grafts.
graft depends on the experience, skill, and preference
of the operator. Lower Peak Doses of Local Anesthetic and
4. The bevel of the needle can be used as a ‘‘shoehorn’’ Epinephrine
to hold open the orifice of the recipient tunnel.
A second advantage of FUHT is that a hair transplant can be
performed with administration of much lower peak doses of
local anesthetic and epinephrine. This is because the graft place-
ADVANTAGES OF ‘‘STICK AND PLACE’’ ment, and therefore application of the local anesthetic, starts in
the hairline and works back. Once the hairline area has been
Smaller Recipient Sites
locally anesthetized over an area about the size of quarter, and
The main advantage is that the operator is able to place the after this area is almost completely planted, an area of approxi-
grafts into smaller recipient sites than could be achieved by mately the same size posterior to it is locally anesthetized and
making all of the sites first and then planting the grafts into infiltrated with local anesthetic and adrenaline solution. This is
them later. This is because the needle that is making the skin the next area to receive grafts. This second quarter-sized area
opening also keeps the tunnel dilated until a split second before is already largely numb from the ring-block effect of the
insertion of the graft. Furthermore, the empty bevel of a hypo- quarter-sized area in front that was previously locally anaesthe-
dermic needle (either 18-gauge, 19-gauge, or 20-gauge) can be tized and planted with grafts. Thus, the process may be termed
used as a shoehorn to pull the orifice of the tunnel open and ‘‘freeze as you go.’’ Once the initial hairline ring block has
facilitate the placement of the graft (see Fig. 13B-4). It could been performed, local anesthetic with adrenaline solution is sub-
be argued that a Marritt dilator or other dilator could be used sequently administered (working ‘‘backward’’) in small quan-
in the same way, but if the grafts are placed as close together tities spread out over the time it takes to perform the whole
as densely packed FUs in the stick-and-place technique, the hair transplant. This slow, gradual administration of local anaes-
skin of most patients would split. thetic with adrenaline solution thereby minimizes peak blood
The benefit of minimizing the size of the recipient sites can- levels.
not be overemphasized. The secret of success in performing
megasessions of densely packed FUs lies in causing only mini- Variation of Graft Density
mal wounding to the scalp and consequently its vasculature. A third advantage is that the operator can vary the density of
The importance of minimal damage to the vascularity of the graft placement as skin characteristics—elasticity, hardness,
scalp was well understood by practitioners of 4-mm standard ‘‘mushy dermis,’’ vascularity, and so on—vary. These charac-
graft hair transplantation. With the dawning of the era of all- teristics can and do vary tremendously from person to person
micrograft hair transplantation, it was generally thought that and from one location of the same scalp to another. This means
damage to the vasculature was no longer an important issue that in areas that pop more, or where bleeding seems profuse
because needle sites were so small. However, because of the and uncontrollable, the grafts can be more loosely, or sparsely,
enormous number of follicular unit grafts needed to provide packed. When local conditions of the scalp improve, the opera-
density (whether in one densely packed session or several more tor can increase the density of graft placement at the time.
sparsely packed sessions into the same area), minimal wounding
per graft or per hair is still of paramount importance. Variation of Recipient Site Size
Excessive damage to the vasculature of the scalp with mi-
crografts is as fundamental a cause of poor hair transplant The fourth advantage is that the operator can vary the size of
growth as it used to be with 4-mm standard graft hair transplan- the recipient site to suit the size of the graft he or she is about
tation. For example, the regrowth after the fourth session of to insert. The staple needle I use is a 19-gauge hypodermic
100 standard grafts planted into the front third of a stage-V needle. Rarely, there are a few grafts that need an 18-gauge
patient is not usually as good as the regrowth after the first needle (e.g., coarse-haired, 3-hair or 4-hair follicular units).
session. On a smaller but similar scale, the regrowth of the Some grafts, on the other hand, can fit into a 20-gauge needle
fourth session of micrografts may be compromised by the vas- site. Such grafts include very fine-haired 1-hair or 2-hair FUs,
cular damage and scarring caused by prior work in the same or, sometimes, if the hair is very fine, 3-hair or 4-hair FUs. The
area. These problems can be minimized by use of a smaller operator, having sensed the skin characteristic of the particular
recipient site for a graft of the same size. area of scalp, is able to choose a suitably sized needle to make
The reason why stick and place is the preferred method is a recipient site that perfectly accommodates the size of the next
that it enables the same size of micrograft to be planted into a graft to be planted.
smaller recipient site than is possible when the sites are pre- Elimination of Piggybacking
made. It is the main reason why practitioners of this stick-and-
place method of planting are able to achieve a higher regrowth The fifth advantage is the elimination of piggybacking. With
rate than other, often more established and experienced hair the stick-and-place method, it is impossible to plant two grafts
544 Chapter 13
in the same hole (i.e., one on top of another), a situation that ods that I advocate. A long and expensive training period is
is difficult to completely eliminate when many recipient sites required to prepare an operator to perform speedy stick-and-
are premade. place planting of FUs. Most new operators require 18 months
to learn how to stick and place 1,500 grafts in one day. During
No Missed Needle Sites the first few months of the training period, there is the double
cost of the trainee’s salary and the instructor’s salary. Many
The sixth advantage is that there are no missed needle sites. trainee operators initially seem to be talented and quick to learn,
Especially in cases with existing hair, it is easy to miss at least but after a few weeks to a few months of intensive training,
5% of premade needle sites. Even in completely bald skin, 19- their skills seem to plateau, and it becomes obvious that they
gauge needle holes often close after several minutes, to the will never possess the skills and ability necessary to become
extent of becoming undetectable. Missed recipient sites that do experts. Others may develop the necessary technical skills, but
not eventually get planted with a graft result in unnecessary over time, they reveal unsuitable personality traits. These un-
damage to the vasculature and create microscarring without the suitable traits include being unable to accept instruction and
benefit of new hair growth. Of course, as the recipient sites get direction; to work with a microscope or to plant into the same
smaller and smaller, this point becomes less important. It is scalp for at least 8 hours (with intermittent breaks); and to get
still, however, not good practice to leave recipient sites empty. along with the rest of the staff (i.e., inability to become a good
team player). These trainees, who have already taken up many
DISADVANTAGES OF ‘‘STICK AND PLACE’’ hours of instruction and have occasioned discounted patient
sessions, have to be let go.
Needlestick Injuries
One disadvantage of the stick-and-place method is a greater Minimal or No-Charge Training Sessions
likelihood of the operator’s receiving a needlestick injury and
thereby possibly becoming inoculated through the patient’s Patients attended by the trainee must be told of this fact. This
blood with an infectious disease such as HIV, hepatitis B, or is obvious in any case because of the verbal coaching that the
hepatitis C. This is a risk to the staff but not to the patient. This instructor continually gives to the trainee. At the best of times,
method, therefore, must not be used with patients known to stick-and-place planting is slow, but the speed with which a
be carrying such an infectious disease. Constant attention to novice operator can perform this procedure is extremely slow;
prevention of needlestick injuries is required, of course, with therefore, only a small area can be covered during a full day’s
all patients, whether or not they test positive for an infectious work. Hence, an area that could normally be covered in one
disease. session during one day takes several days to cover when trainees
are performing the planting. Obviously, not many patients
Increased Cost would prefer to have trainees cut their grafts and plant their
precious, nonrenewable donor hair. As an incentive, hair trans-
The main disadvantage of the stick-and-place method is in- plant sessions performed by novice staff have to be offered at
creased cost. The factors discussed in the following sections either no cost or minimal cost, depending on the skill and speed
all contribute to this problem. of the trainee staff. Should the patient have poor growth, the
transplant, which was originally done at less than cost price,
Slower Planting has to be repeated by the senior staff at no charge.
In my experience, planting takes longer with the stick-and-place
method than with use of premade needle hole sites. This is Larger Staff with Increased Management Costs
contrary to the findings of Dow Stough and colleagues (1) and
may be partly explained by the fact that one tends to use a Even when all the staff members are fully trained (which hardly
technically more difficult, smaller recipient site with this ever happens owing to various degrees of constant attrition),
method than with technically easier, larger premade sites. Addi- management of a large staff such as is needed to perform FUHT
tionally, the mechanics of making the site and then changing properly—that is, with stereoscopic microscope dissection and
hands adds to the time required to plant each graft. This method stick-and-place planting—is extremely time-consuming. The
allows closer placement of grafts, but closer placement in- extra management adds still more to the cost.
creases the amount of graft popping.
The slower and more tedious method of planting FU mi- Quality Control and Extra Physician Hours
crografts is typical of the other components of FU micrograft
megasessions. Stereoscopic microscope-aided dissection of Finally, FUHT with stereoscopic microscope dissection and
donor tissue into FU micrografts is similarly more time-con- stick-and-place planting makes more demands on the physi-
suming and exacting than naked eye dissection of donor tissue cian’s time than traditional micro-minigrafting. A more sophis-
into minigrafts. The increased number of grafts usually necessi- ticated and vigorous protocol for quality control is required.
tated by FUHT makes the extra time consumed by the stick- This monitoring of quality is carried out continuously by senior
and-place method of planting much more significant. nurses and technicians who have to be paid for their time. The
hair transplant surgeon, who is ultimately responsible, must also
Recruitment and Training Costs play an enormous role in frequent monitoring of the technical
aspects of the transplantation process. These aspects include
Recruitment, training, and quality control of the staff’s perfor- accurate graft cutting, performance of the stick-and-place pro-
mance are major increased expenses associated with the meth- cedure with minimal trauma to the grafts, and keeping the grafts
moist at every stage of the process. The hair transplant physician required for rapid, expert, atraumatic planting of micrografts.
also monitors the patient’s comfort and well-being and oversees Such physicians do exist, but they are few and far between. It is
the aesthetic development of the hair transplant. In my practice, also unlikely that either an established or aspiring hair transplant
it usually takes about 5 to 6 hours to complete a 1000-graft physician would be prepared to undergo the rigorous training
session, and about 7 to 12 hours to complete a 3000-graft meg- and hours of practice that are necessary to build up the extreme
asession. Managing three to four megasessions per day is hectic, skill required for rapid dense packing of the recipient area with
nonstop, full-time work for any hair transplant surgeon. There- micrografts.
fore, FUHT (performed with stereoscopic-microscope-aided If, however, one is prepared to recruit, temporarily employ,
dissection and stick-and-place planting) is much more costly in and partially train large numbers of prospective staff, it is possi-
both physician hours and nurse/operator hours than transplantable to pick ultimately successful employees who have the rare
tion of mini-micrografts. talents of exceptionally good manual dexterity and vision and
psychological profile necessary to become expert graft dissec-
tors and planters. After a few years of such recruiting and train-
DELEGATION ing, it is possible to build up a whole team of highly skilled
nursing and technical assistants.
Most physicians who use the stick-and-place method eventually
delegate most, if not all, of the combined site-making and plant-
ing procedures to their highly trained staffs. This is similar to Disadvantages of Delegation
the practice in most hair transplant facilities of having the staff
perform most, if not all, of the dissection of the donor area into The main disadvantages of delegating tasks to staff include the
grafts. lengthy and difficult staff recruitment and training process, as
The surgeons still create the design and the plan of the hair discussed earlier. At my facility, it takes a year and a half to
transplants, including all the finer points that they would design train a new employee to be able to plant 1500 of 3000 grafts
themselves if they were making the actual incisional sites. This (the maximum number of grafts one can expect to consistently
includes a sort of ‘‘blueprint’’ for the angle and direction at harvest from a virgin scalp of average density) in 1 day. Unfor-
which each graft will be planted. The physician records precise tunately, the vast majority of trainees never develop enough
instructions regarding hairline placement, starting with the skill and speed. I have trained a number of staff with great
front-row ‘‘stragglers.’’ The process continues with mapping trouble, length of time, and expense, and with no guarantee as
of how rapidly density is increased posterior to these stragglers to how long they would stay in my employment. Moreover, it
in the usual ‘‘feathering’’ zone and how densely each area is is difficult to monitor their performances continually and to
to be planted in terms of the approximate number of FUs/cm2. exhort them to improve without creating an overly stressful
In addition to creating this detailed design and plan of the working environment.
hair transplant, the physician also monitors the technical stan-
dard of the actual planting technique. That is, the surgeon ob-
serves the way the grafts are handled by the forceps, makes ETHICAL AND LEGAL IMPLICATIONS OF
sure that the grafts are subjected to absolutely minimal trauma DELEGATING THE STICK-AND-PLACE
during the planting process, assesses whether or not the grafts PROCEDURE
are left exposed and allowed to dry for an excessive period of
There has, unfortunately, been a certain amount of criticism
time, and so on. Thus, physicians still have total control of the
made by some of the more traditional hair transplant surgeons
design and planning of the transplant. They also maintain the
who do not fully understand the benefits of stick-and-place
technical standard of care of the entire planting process with
planting and its delegation. Remarks such as, ‘‘… They hire a
one exception: The physicians do not actually make the recipi-
large number of technicians who do the entire hair transplant
ent sites or do the planting themselves. This is very similar to
procedure with the exception of excising the donor area,’’ are
how physicians delegate graft cutting. The physician specifies
all too common. These remarks carry two false implications: (1)
how many grafts, and what sizes, shapes, and numbers of hairs,
that hair transplant surgeons who make all their own recipient
etc., are required from each part of the donor area and the staff
incision sites perform virtually the entire hair transplant surgery
follows the directions. During the graft cutting process, the sur-
themselves; and (2) equally fallacious, that hair transplant sur-
geon is also expected to monitor the level of skill and care in
geons who delegate ‘‘stick-and-place’’ planting to their staff
handling of the donor tissue and regularly examine the resulting
allow virtually the entire hair transplant surgery to be performed
grafts as the dissection takes place. The same principles are
by (less able) staff.
carried forward into planting, with one exception. Because of
My point is that large hair transplant sessions consisting of
the greater vulnerability of the FU micrograft (because of its
thousands of tiny, vulnerable FU micrografts are best performed
lower surface area-to-volume ratio), the technique has to be
by a team.
flawless; no room for error exists. Quality control has to be
This work requires an extremely high level of skill including
much more intensive and rigorous than with standard grafts or
the combination of excellent manual dexterity and the persever-
minigrafts.
ance to constantly practice this repetitious technique. With that
combination, assistants can develop and maintain the necessary
ADVANTAGES OF DELEGATION standard to ‘‘sliver’’ perfectly and to stick and place the grafts
atraumatically and densely. Because of its repetitive, mechani-
It is unlikely for either an established or aspiring hair transplant cal nature, this work is well suited to appropriately selected,
physician to have the extremely high level of manual dexterity highly trained, and dedicated technicians.
546 Chapter 13
Of specific relevance here is that no technicians undertake Legal Implications

any independent judgment. All the decision-making is done by
the hair transplant surgeons exactly as if they were making all Some hair transplant physicians and their staffs are concerned
the incisional sites themselves. The recipient site placement that if stick-and-place planting is delegated to technicians, these
(that is, density, angle, and depth of insertion) and hair orienta- technicians could be accused of ‘‘practicing medicine without
tion are all preplanned, and any modification to these plans a license.’’ They think that the hair transplant surgeons who
as the hair transplant progresses must be done only after the employ the technicians and delegate work to them could be
physician gives specific orders, whether or not the modifica- charged with aiding and abetting this ‘‘crime.’’ Medical prac-
tions are initially suggested by the technicians. Hence, the staff tice acts vary from state to state throughout the United States.
makes no judgment decisions. They simply can be regarded as A detailed account of these acts as they apply to procedural
extensions of the hair transplant surgeon’s hands. As can be delegation in every one of the United States and every province
seen from a macrophotograph of planted grafts (see Fig. 13B-8), of Canada is beyond the scope of this chapter. There has, how-
there are no artistic or other decisions to be made regarding the ever, been some controversy regarding the legality of delegating
tasks in hair transplant surgery, and so there follows a very
proper position of the grafts. They are planted approximately
brief summary of the medical acts of the States of Oklahoma and
equidistant from each other according to the density dictated
Texas and the province of Ontario as they pertain to delegated
by the physician in charge. However, they are planted in a
medical acts.
slightly random rather than a geometric pattern. Therefore,
In Ontario there is a ‘‘Regulated Health Professions Act’’
judgment on the part of the delegated technicians plays no part
(RHPA). An excerpt (2) of an official bulletin from the Ontario
in making the incisional sites.
Physician’s Licensing Board regarding delegated medical acts:
In fact, much more decision-making is required of techni-
cians during the stereoscopic dissection of donor material into Prior to the proclamation of the RHPA on December 31,
grafts. This is dealt with in the chapter on classic microscopic 1993, it was against the law for a person to engage in
dissection, but in that chapter it is in reference to the ‘‘cutter,’’ the practice of medicine unless that person was licensed
who, in borderline cases, decides, for example, whether a partic- by this College. Prior to that time, there was a defined
ular FU is a four-haired FU, or perhaps two two-haired FUs ‘‘scope of practice’’ for medical practitioners, which in-
growing very closely together. cluded such things as the practice of surgery and obstet-
Throughout hospitals these days, many medical and surgical rics.
procedures are delegated to highly trained technicians whose
ongoing work is totally unsupervised. For example, in cases in Under the RHPA, ‘‘scope of practice’’ no longer exists.
which respiratory technicians take blood samples for arterial Instead there are 13 ‘‘controlled acts.’’ While there is
blood gases, legs can and have been amputated as a result of no general prohibition against unlicensed persons prac-
complications of femoral artery puncturing; however, there is ticing medicine, the RHPA prohibits unlicensed persons
no physician hovering over the technicians in the background from performing a ‘‘controlled act,’’ unless:
while they perform their femoral artery punctures. Similarly, 1. that person is authorized to perform the act; or
midwives are allowed to administer controlled substances to 2. a person who is authorized to perform the act has dele-
patients during intrapartum or immediate postpartum care. Mid- gated its performance to another person.
wives are also left more and more to perform their trade without
a physician present or even nearby. Those who are knowledge- There are 13 controlled acts defined in subsection
able about such matters realize that if traction is placed on the 27(2) of the RHPA:
umbilical cord to deliver the placenta before contraction of the
uterus, catastrophic bleeding may occur as a direct result. (Controlled Act no. 2 is the only relevant one.)
The trend is for physicians to delegate more and more poten-
2. Performing a procedure on tissue below the dermis,
tially dangerous medical and surgical acts to individuals who
below the surface of a mucous membrane, in or below
are not physicians, with full endorsement of physician licensing the surface of the teeth, including the scaling of teeth.
boards. Concerned physicians might also bear in mind that it is
fully legal for totally untrained, unsupervised, and unregulated Two conclusions can be drawn from this regulation. One is that
personnel to perform body piercing, tattooing, and other poten- because the incisional sites are made at an angle and do not go
tially hazardous procedures in which the skin is deeply incised. below the depth of the dermis, making the incisional sites is not
It is difficult to see how any harm could result from delegat- regarded as a ‘‘controlled act’’ and therefore anyone, whether or
ing performance of stick-and-place planting on the scalp to not medically delegated, or medically or otherwise qualified,
highly competent technicians. Hair transplant physicians con- can perform it. Second, if the incisional sites are made below
tinuously maintain surveillance over their graft planters. There- the dermis (a controlled act) it is perfectly legal for a doctor to
fore, the hair transplant physician need have no ethical misgiv- delegate its performance to a suitably trained staff member. The
ings regarding delegation of stick-and-place planting—even act goes on to say, ‘‘It is not legally necessary for a physician
though it involves delegating to staff the task of making the to receive permission from, or even to contact, this college
incisional sites. The hair transplant is still performed by the (read: Licensing Board) before performing a controlled act. The
hair transplant surgeon, who creates the transplant and is re- delegation of a controlled act need not be in writing.’’ The act
sponsible for the final outcome. The technicians’ hands, used goes on further to say ‘‘even in the absence of specific regula-
as an extension of the surgeon’s hands, often become even more tions around the delegation of controlled acts, physicians are
skillful than the surgeon’s own hands! responsible for ensuring that the accepted standard of care is
maintained in all aspects of their practice, including those en- conflict with the provisions of any other healing arts
trusted to their staff.’’ licensure act or rules promulgated pursuant to such act.
Next, let us look at the general delegation clause of the
Medical Practice Act of Texas. Here is the relevant excerpt (3): These three jurisdictions were selected as examples because
three of the best-known and most experienced practitioners of
General Delegation Clause stick-and-place hair transplantation work in those jurisdictions;
The Medical Practice Act, V.T.C.A., Occupations namely, Dr. Bobby Limmer in Texas, Dr. David Seager in On-
Code 157.001, establishes the general parameters of tario, and Dr. O’Tar Norwood in Oklahoma.
physician delegation in Texas. For your information, In these three jurisdictions, the laws regarding delegation of
that section is as follows: medical/surgical acts seem very liberal, requiring only that the
a. A physician may delegate to a qualified and properly procedure take place in a licensed physician’s office, that the
trained person acting under the physician’s supervision licensed physician delegate it to appropriately trained, compe-
any medical act that a reasonable and prudent physi- tent staff, and that the physician remain responsible. This also
cian would find within the scope of a sound medical seems to be contingent on the premise that the person perform-
judgment to delegate if, in the opinion of the delegating ing the delegated act is not required to make any judgment or
physician: decisions regarding a delegated act itself.
In summary, it is perfectly legal in many areas for doctors
1. the act:
to delegate to highly trained technicians within their office both
A. can be properly and safely performed by the cutting and stick-and-place planting of grafts. Any licensed phy-
person to whom the medical act is delegated; sicians who are considering delegation of stick-and-place plant-
B. is performed in its customary manner; and ing should, however, ascertain the legal regulations pertaining
C. is not in violation of any other statute; and to the jurisdiction in which they practice.
2. the person to whom the delegation is made does
not represent to the public that the person is autho-
rized to practice acts.
b. The delegating physician remains responsible for the
SUMMARY
medical acts of the person performing the delegated The technique, method, and advantages and disadvantages of
medical acts. the stick-and-place method have been discussed.
c. The board may determine whether: The importance of stick-and-place planting is greater than
1. an act constitutes the practice of medicine, not in- most physicians realize. The overwhelming advantage of the
consistent with this chapter; and stick-and-place method is that it allows smaller recipient sites
2. a medical act may be properly or safely delegated for planting grafts of the same. This in turn allows more dense
by physicians. packing of grafts while minimizing damage to the vasculature.
This also ultimately allows higher regrowth.
Traditionally, the scope of what a physician may Other advantages include the minimization of peak local
delegate to a nonphysician, be that person an RN, anaesthetic and adrenaline concentrations, the ability to vary
LVN, physician’s assistant, or medical assistant is graft density and/or recipient size while planting, and the elimi-
governed by this general rule. It does not seem to nation of piggybacking grafts or missing needle sites.
matter what letters the person has after their name; The disadvantages include the risks of needlesticks and the
what does matter is that the person to whom the act is
higher financial and time costs. The costs are raised because
delegated is ‘‘qualified and properly trained.’’ The fact
(1) the planting process is slower (compared with use of pre-
that a person is an RN, LVN, or the like primarily
made holes) and (2) because the larger staff requires expensive
goes, as far as the physician is concerned, to the
training and management. Although hair transplant physicians
question of qualifications and training.
are able to delegate much of the repetitive work of graft prepara-
Thus, it is legal for a physician to delegate to tion and plantation, they must still face longer hours and are
nonphysicians the task of performing injections, taking responsible for the design, the actual surgery, the patient’s
blood pressure, checking temperature, and other tasks safety and comfort, the training of a larger staff and, most im-
that do not involve the exercise of independent portantly, the direct personal supervision and monitoring of the
medical judgment. Those persons need not be technicians to ensure the highest standards of quality control.
registered nurses when they are employed in a In my practice, the advantages of delegation far outweigh
physician’s private medical office. the disadvantages, and the stick-and-place technique is the
Let us also look at the medical act of the State of Oklahoma. method of choice for FUHT.
Here is an excerpt (4) of the relevant legislation:
Editor’s Comments
E. Nothing in the Oklahoma Allopathic Medical and Seager and Reed, as well as many others including myself, have
Surgical Licensure and Supervision shall prohibit: stressed the point that (1) the smaller the graft, (2) the less
1. The service rendered by a physician’s unlicensed tissue surrounding the follicles, and (3) the larger the surface-
trained assistant, if such service is rendered under the to-volume ratio of any graft, the greater the potential for follicle
supervision and control of a licensed physician pur- death. Thus, the smaller the graft, the closer to ‘‘perfection’’ all
suant to Board rules, provided such rules are not in aspects of a technique that uses only the smallest grafts—FUs –
548 Chapter 13
should be. In this chapter and in his other chapters in the text, certain advantages that can be achieved only if he or a
Seager has implored all those who would use exclusive FU hair single individual in his office is part of each and every
transplanting (FUT) to consider this fact in every aspect of the stick-and-place team (see later). Seager rightly points
procedure. Of course, it is easier to accomplish perfection if out that one of the advantages of the stick-and-place
graft sites are made with slightly larger needles and are not as method is ‘‘that the operator can vary hair direction and
densely packed—for example, 35 to 40 FUs/cm2 —as Dr. angle, choice of numbers of hairs per graft in any given
Seager typically uses. He has good reasons for his preferences, area, and a multitude of other small decisions that are
which have been outlined here and elsewhere, but, nevertheless, made as recipient sites are produced.’’ One can attempt
many FUT proponents prefer recipient sites made with 18- to teach technicians all of these factors and to closely
gauge needles, rather than 19-gauge or 20-gauge needles be- supervise them, but no matter how close the supervision,
cause, in their experience, it is less traumatic to insert FUs into nobody can ever mimic exactly what the supervisors
the slightly larger holes they produce. Similarly, most FUT would do if they were carrying out this part of the proce-
proponents prefer less dense packing of FUs for the same rea- dure. In addition, when prospective patients see before
son. Bernstein, for example, prefers honed 18-gauge NoKor and after photographs of previous patients, they cannot
needles (the equivalent of 19-gauge or 20-gauge needles) and be sure they will get the same skill and artistry in their
a density of 25 FUs/cm2, only for his hairlines. Elsewhere he results unless the leader of the stick-and-place team is
uses standard 18-gauge NoKor needles and a density of 20 to the same. The only way to be absolutely certain of that,
25 FUs/cm2 (see Chapter 12AA). He also finds the fit of FUs is that the leader is always the same physician or that
in such sites snug enough for his liking. few enough patients are treated per day that another
It is also worthwhile pointing out the following considera- single individual can be part of each stick-and-place
tions: team, and—here is the difficult part—that this person
has stayed in the physician’s employment.
1. When one has difficulty inserting a graft so that multiple Nonetheless, there are practical disadvantages to the physician’s
attempts must be made to accomplish the task, there is being part of the stick-and-place approach. A large, superbly
not only physical trauma to the graft but also greater trained team is necessary to carry out the type of procedures
likelihood of dehydration. that Seager prefers. A steady flow of patients is therefore neces-
2. The closer the recipients sites, the more difficulty there sary to ensure them of a steady job. Considerable and costly
is in preventing popping, which leads to more handling advertising is usually necessary to create this steady flow of
and possibly more dehydration of previously trans- patients. Thus, economic imperatives can potentially gradually
planted grafts. play a large role in accepting or rejecting patients. Moreover,
3. If there is an average of 2.3 hairs per FU (1), and one in the end, all the costs of this type of practice, which Seager
can achieve 100% hair survival using 20 FUs/cm2, one has so thoroughly described here, must eventually be paid by
can produce 92 hairs/cm2 in two sessions. (20 ⳯ 2.3) the patient. Am I now suggesting that more of the physician’s
⳯ 2. This can be done by most practitioners more easily time be added to these costs? Is this practical? In many circum-
and probably more safely than if they instead try to stances, probably not. Furthermore, Seager has correctly
accomplish the same hair survival using 40 FUs/cm2 in pointed out that some nurses or technicians are better and more
a single session, for the reasons noted in (1) and (2) artistic at graft placement than the doctors for whom they work.
earlier (see also Chapter 9). The question that remains is how do patients know their teams
4. The more grafts per session, the more trauma to the will be as good as those that worked on the patients in the
vascular bed and, therefore, the greater the need for before and after photographs? How do they know that some
perfection in all other aspects of the procedure. A of the team members have not left the doctor’s employment?
smaller number of sites, less densely packed almost cer- Whether the doctor is as skilled and artistic as his technicians
tainly provide a buffer for other aspects of the technique or not, most individuals would be reassured if he were one of
that are less than optimal. (Seager tries to minimize the members of the stick-and-place team, always there to make
this vascular trauma by using 19-gauge and 20-gauge all the decisions in this important part of the process. If the
needles instead of 18-gauge and larger bore needles, physician makes all the recipient sites before any grafts are
but, obviously, if he used his preferred needle gauge, planted, regardless of the type of graft, the aforementioned con-
and if the grafts were less densely packed the vascular cerns are addressed. However, if all of the FU sites are made
bed damage would be even less.) There must be good first, the advantages of stick-and-place are lost—especially the
reasons why most FUT proponents, who initially were ability to place FUs so close together, in such small sites—if
among the pioneers of megasessions of several thou- that is the goal.
sands of grafts per session, rarely (if ever) carry out There is, in brief, no single optimal approach to FUT. Each
such procedures today. has its advantages and disadvantages. The ‘‘best approach’’
5. Delegating the creation of recipient sites to technicians varies from doctor to doctor and team to team. What is neces-
has clear-cut advantages, especially for the type of sary is to look at the results of a number of practitioners and,
transplantation Seager prefers. However, no amount of if possible, in company with the surgical team, try to mimic—in
supervision of such technicians can mimic exactly what its entirety—the technique of the practitioner whose results are
physicians would do if they were the technicians and preferred. Those who choose to mimic Seager must be prepared
actually making the sites. If the stick-and-place method to yield the bulk of the procedure to their technicians and to
is optimal for the reasons Seager gives – (and I believe spend a great deal more time supervising them than would be
it is, in the context of his entire approach), there are required with other methods. (WU)
13C. Insertion of Multi-Follicular if the deepest portion is first inserted into the recipient site.
Once this has been done, the graft can then be angled so that
Unit Grafts the hairs within it are in alignment with the direction in which
Walter P. Unger the recipient site was cut. At this point, the graft can then be
eased into place. As with the insertion of follicular units (FUs),
aiming the forceps at the same angle and direction as used when
INSERTION OF SLIT AND SLOT GRAFTS
the recipient site was incised also minimizes the trauma to the
Equipment: 1 jeweler’s forceps (straight or curved), 4⳯4 gauze, grafts and accelerates the speed at which they can be planted.
a hydrogen peroxide solution consisting of hydrogen peroxide Do not let the grafts sink below the surrounding epidermis. As
mixed in equal parts with normal saline solution in a spray noted earlier, the epidermal edge of the graft must be either
bottle. The grafts, when inserted into the recipient sites, must flush with the surrounding tissue or raised slightly above it (Fig.
meet the following criteria: 13C-2). If a graft is inserted below the epidermal surface, it
heals with a depressed line. In addition, the site appears to be
1. The hairs in the grafts must be in alignment with the empty. This increases the chance that another graft may then
angle and direction in which the recipient site was cut. be placed in the same site, ‘‘burying’’ the first one. Inevitably,
2. The grafts must be flush with, or slightly elevated above, cysts and infection develop. The scenario in which two grafts
the surrounding tissue. are inserted into the same site is referred to as ‘‘piggybacking.’’
3. The grafts must not have any hairs from the surrounding It can be avoided by proceeding with planting in an orderly
tissue inadvertently trapped beneath them. fashion across the surface of the recipient area, by cleaning the
area frequently with the hydrogen peroxide solution, and by
Frequent rinsing of the recipient area with the hydrogen peroxide
making sure that grafts are not allowed to slip below the skin
solution, or spraying with saline solution, may be necessary dur- surface at any time. The use of dilators also eliminates ‘‘skip-
ing graft insertion, depending on the amount of bleeding during ping.’’ If there is no dilator present, the assistant knows that a
the procedure. It is obviously much easier to work in an area free graft has already been inserted. In our office, we have found
of sanguinous debris, where sites and previously placed grafts that dilators slow us down and are not necessary to prevent
may be easily recognized. For slot grafts, the alopecic tissue must piggybacking.
be pulled out and, if necessary, snipped off before the grafts are Once the graft is in place, check to see that no hair has
inserted. For slit grafts, this is not necessary. inadvertently been trapped below it, because this hair can act
Expose the individual recipient site into which the graft will as an irritant or can lift the graft from the recipient site should
be placed by parting and holding away from the site any hair it be entangled in a comb or brush during styling. Checking
that may be present in the immediate area. With the jeweler’s can be done by stroking the epidermal tissue around the circum-
forceps, select and remove the desired graft from the graft dish. ference of the graft with the jeweler’s forceps to see whether
After assessing the direction in which the hairs are growing the tip catches on a trapped hair and lifts the graft out of its
from the graft, gently grasp it (with the jeweler’s forceps) by site. (Note: Once all the grafts have been inserted, it is useful
the fatty tissue beneath the hair bulb or approximately 1 mm to comb the hair gently. This also causes hairs that are trapped
above the hair matrices. Align the direction of the hairs with under the grafts to be caught on the teeth of the comb. If this
the direction of the recipient site and ease the graft into the site entrapment is the case, the affected graft will again be lifted
(Fig. 13C-1). Sometimes, it is a little easier to insert the graft from its site.)
Figure 13C-1 Illustration of a technique by which the deepest portion of the graft is first inserted into the recipient site. This method
may facilitate slit graft insertion. (A) The deepest portion of the slit graft is first inserted into the recipient site. (B) The slit graft is then
tipped forward until the slit graft and the recipient site are in alignment. (C) The slit graft is eased into the recipient site until the epidermal
edge of the graft is either flush with the surrounding tissue or raised slightly above it.
550 Chapter 13
continue to bleed excessively, the recipient site may be too

shallow, or the grafts may act as if they have been dipped in
oil and keep sliding out of their respective sites. Steady pressure
usually bring things under control eventually, but, if this fails,
we turn to the use of cyanoacrylate glue. Before the glue is
applied, the grafts must be adjusted, the area must be clean and
dry, and the hair adjacent to the graft must be held away from
the area. Once the glue is applied, it seals the grafts in place
and prevents further popping. The use of glue is tricky. It easily
sticks to surrounding hair and to the gauze and grafts and can
result in the graft’s being pulled out as the gauze is removed
from the area. The glue also sticks to fingers, and if too much
is used, can create a visual mess (see also Chapter 14).
After all the grafts are inserted into the recipient sites, wash
the area with a dilute hydrogen peroxide or saline solution to
remove any sanguinous material that may have collected on the
grafts and surrounding tissue. At this time, the grafts must once
again be scrutinized to make certain that (1) the hairs contained
within them are in alignment with the direction in which the
recipient site was cut (2) the grafts are flush with or slightly
elevated above the surrounding epidermal tissue; and (3) no
hairs have inadvertently been trapped underneath the grafts
(Fig. 13C-2).
More than 10 years ago, we investigated slicing off the epi-
dermis and a portion of the dermis of slit grafts before their
insertion (Fig. 13C-3). (See also Chapter 15.) Such grafts were
transplanted into one side of a recipient area while intact grafts
were transplanted into the contralateral side. No significant cos-
metic difference was noted in most patients. If the hair was
particularly coarse or dark, we tried to limit the number of hairs
per graft to three or four. In such individuals, removal of the
epidermis was also advantageous because it eliminated the com-
ponent of the graft that prevented hairs from slipping more or
less behind each other in a single line. Both of these ‘‘tricks’’
Figure 13C-2 After insertion, the grafts are scrutinized to make made graft compression less problematic. In addition, depressed
certain that the hairs within them are in alignment with the direction grafts, which cause epidermal cysts, were less likely to occur.
in which the recipient site was cut. The grafts are flush with or Today, slit grafts are prepared so that they are only one FU
slightly elevated above the surrounding epidermal tissue and no wide and noticeable compression of hair is therefore impossible
hairs have inadvertently been trapped underneath them. This 10- to produce.
year-old photograph shows a planted recipient area with slit grafts How long before planting can a graft dry out on a glove
posterior to round grafts. (Only a few micrografts had been trans- without the yield falling off significantly? This depends on a
planted anterior to the round grafts.) number of factors, including the thickness of the graft, room
temperature and humidity, and whether there is any air blowing
over the grafts (e.g., from an air conditioner or fan). Isabel
Banucci has devised a multigraft dispenser that among other
Inserting the grafts in an organized fashion—for example, attributes holds FU grafts in channels filled with saline solution
in rows or sections—not only minimizes the likelihood of pig- until immediately before they are shoehorned into their recipient
gybacking but also has another advantage. Inserting the grafts sites (see Chapter 22). We have nothing similar for larger grafts.
in this manner enables the assistant to keep steady pressure with In our offices, we limit to 10 the number of grafts placed before
one hand on a folded 4⳯4 gauze placed over the previously insertion on an experienced technician’s finger. (The grafts also
inserted grafts while simultaneously inserting grafts with the sit on a moist strip on the gloved finger.) In general, it would
other hand. (Note: Use a minimum amount of pressure while seem wise to plant grafts within 1 or 2 minutes after they are
holding the grafts in place. Application of too much pressure removed from the storage solution.
on the area can cause previously inserted grafts to ‘‘pop’’ out
of their sites.) Always check the gauze before throwing it away
to make sure a graft has not come out of its site and become INSERTION OF ROUND GRAFTS
stuck to the gauze. For some reason, patients prefer grafts to
be inserted into their recipient sites and not thrown into the When round grafts are inserted into the recipient sites, they
garbage. Occasionally, grafts seem to refuse to stay flush in must satisfy the following criteria: (1) the grafts must be flush
their recipient sites for one of three reasons. The area may with or slightly raised above the surrounding tissue; (2) the hairs
Figure 13C-4 Each recipient site is exposed by parting and

Figure 13C-3 The epidermis and a portion of the dermis may holding away from the site any hair that may be present in the
be removed from slit grafts before their insertion. This is often immediate area. Any excess fatty tissue or blood clots are also
especially helpful if the hair is particularly coarse and dark and removed from the bottom of the site before the graft is inserted.
‘‘compression’’ is therefore more likely to be noticed. Removing
the epidermis allows hairs in the graft to slip more easily behind
each other in a single line and, consequently, makes noticeable
compression of hair less likely. If slit grafts are prepared so that
they are only one follicular unit wide, compression, of course, is grafts, better approximation of hair matrices to their new blood
impossible to produce. supply, and less likelihood of secondary infection.
The desired graft is selected and removed from the graft
dish with the jeweler’s forceps. The graft is held firmly at the
epidermal edge and eased into the prepared recipient site (Fig.
13C-5). If the graft is inserted at the same angle and direction
in the grafts must be in alignment with either the fine vellus in which the recipient site was prepared, it enters the site with
or terminal hair still present in the recipient area or the hair in much less resistance and trauma (Fig. 13C-6). Once the graft
the adjacent previously transplanted grafts; and (3) no hairs is inserted and flush with the adjacent tissue, pressure is applied
from the surrounding tissue can be trapped under the grafts. with a 4 ⳯ 4 gauze that has been folded in half; the pressure
Equipment required: 1 Adson forceps, 1 jeweler’s forceps, is maintained until the graft remains in the site without elevation
above the surrounding epidermis.
1 pair of 3-inch curved scissors, 4⳯4 gauze, and a hydrogen
When all the grafts have been inserted, the entire recipient
peroxide solution as described earlier. When the recipient sites
area should be given a final inspection to once more make
are cut, the punch merely incises the circumference of the site
certain that (1) the grafts are flush with, or slightly raised above,
without removing the tissue within it. Once all the recipient
the surrounding epidermal tissue; (2) the hairs in the graft are
sites have been cut, the tissue is removed from within the sites in alignment with the fine vellus hair or terminal hair still pres-
by grasping it and pulling it upward with the Adson forceps.
If the tissue does not separate easily, it is released by use of 3-
inch curved scissors that make a cut in the subcutaneous tissue
as close to the galea as possible. When all the tissue has been
removed from the recipient sites, the entire area is cleaned with
a saline solution. Frequent washing of the recipient site during
insertion of the grafts provides a clean work area free of sangui-
nous debris.
The grafts are always inserted in an orderly fashion in either
rows or sections. Inserting the grafts in this way enables the
assistant to use one hand to maintain steady pressure with a
folded 4⳯4 gauze over the previously transplanted grafts
while still being able to continue inserting grafts with the other
hand.
The individual recipient site into which the graft will be
placed is exposed by parting and holding away from the site
any hair that may be present in the immediate area (Fig. 13C-
4). The bottom of the site is checked with the Adson forceps,
and any excess fatty tissue or blood clot that may have formed Figure 13C-5 While being held securely with the Adson for-
are removed. Removing blood clots from the bottom of the ceps, the standard size of round graft is eased into the prepared
recipient holes before grafts are inserted results in flatter-lying site.
552 Chapter 13
ent in the area or the adjacent previously transplanted grafts;

and (3) no hairs have been trapped under the grafts (see Fig.
13C-2).
Credits
Much of the preceding discussion and most of the photographs
have been excerpted from a similar section, authored by Mau-
reen McKeown, in the third edition of this text. My head nurse,
Valerie Mitchell, assisted in the revision.
REFERENCES
Stick-and-Place Method of Planting
1. Bernstein R, Rassman W. The aesthetics of follicular transplanta-
tion. Dermatol Surg. Vol. 23, 1997:785–799.
2. Whitworth JM, Stough DB, Limmer B. A comparison of graft
implantation techniques for hair transplantation [review]. Semin
Cutan Med Surg. Vol. 18, 1999:177–183.
3. Members’ Dialogue. Ontario College of Physicians and Surgeons.
Figure 13C-6 If the graft is inserted at the same angle at which Vol. 6, March/April 1998:19–20.
4. The Medical Practice Act, V.T.C.A. Occupations Code 157.001.
the recipient site was prepared, the graft enters the site with much 5. Oklahoma Allopathic Medical and Surgical Licensure and Super-
less resistance and trauma. vision Act Title 59 O.S., Section 492E.
14
Postoperative Phase
14A. Bandaging bandaging’’, many physicians and patients prefer the security
of an overnight bandage if it is presented as an option. In our
Walter P. Unger offices, patients are given a choice of an overnight bandage or
staying in the office for 1 to 2 hours postoperatively. If they
More than 27 years ago, Pierre Pouteaux began sending his choose the latter alternative, surgery is scheduled for the earliest
patients home without a bandage. His routine, as described in morning appointment so that they can stay through part or most
the 1979 and 1988 editions of this textbook, consisted of 4 of the afternoon before leaving. Such patients are also warned
inches ⳯ 4 inches (10 cm ⳯ 10 cm) gauzes soaked in saline that should they bleed a more than average amount during the
solution and applied to the recipient area at the end of the proce- surgery or while they are waiting to leave the office, a bandage
dure. The gauzes were covered with a water-repellent barrier, may still have to be applied. They return to the office the morn-
and a temporary pressure bandage was applied (1,2). The patient ing after their surgery for a checkup and hair washing, just as
stayed in Dr. Pouteaux’s office for several hours; the bandage do patients who have bandages.
was periodically removed for a check of the recipient area and For those who have a bandage, we continue to employ the
then reapplied. Patients were sent home, at the latest, by late routine dressing similar to one that has been described previ-
afternoon. In all the years that he did this, Dr. Pouteaux claimed ously (5). The bandaging process consists of an application of
that he had never received any calls from his patients because bacitracin to both recipient and donor areas, followed by Telfa
of postoperative bleeding or graft displacement. sheets applied in the recipient area only. Gauzes sized 8 inches
Increasingly, over the years, other hair restoration surgeons ⳯ 4 inches are placed on top of the Telfa, sheet by sheet,
have been abandoning bandages. Some have used cyanoacrylate layered and spread out evenly on top of the donor area as well.
glues, as has been described elsewhere in this text, whereas Two Kerlix bandages are used to hold the gauzes in place.
others have tried using smaller sessions and suturing the grafts While the first is encircling the head, the second is passed anter-
in place (3,4). With the rising popularity of follicular unit trans- oposteriorly, from front to back and back to front—each pass
planting (FUT) and minigrafting, however, many more practi- of the first Kerlix bandage anchors the second one in place (Fig.
tioners have decided to send their patients home without having 14A-1). The dressing does not cover the ears as older versions
performed either of the foregoing measures and without any of it did. Instead, patients are given half a length of a Kerlix
bandaging. Negative sequelae of such a policy are extremely bandage to run over the top of the head and to tie under the
uncommon. chin when they go to sleep. This minimizes the likelihood that
Bandaging involves disadvantages for patients, physicians, the bandage will accidentally fall off or shift during a possible
and their staff. From the patient’s point of view, bandages are restless sleep.
clearly visible—‘‘marking’’ them as having had surgery. Band- Lebovitz has also described a ‘‘Russian bandage,’’ which
ages may also be uncomfortable to wear overnight, and their includes a tie under the chin to hold it in place (6) (Fig. 14A-
use ideally necessitates returning to the office the next morning 2).
for removal and cleansing of the area. From the physician’s The bandage is left in place only overnight. The patient re-
point of view, there is not only the additional work of putting turns early the next morning, at which time it is removed, the
the bandage on and taking it off but also the additional expense area is cleansed as described later in the text, and the hair is
and staffing that it involves. Yet, despite the advantages of ‘‘no gently shampooed.
553
554 Chapter 14
Figure 14A-1 (a), Bacitracin (Baciguent) ointment is spread onto Telfa pads and is then laid over the recipient area. A 4 inch ⳯ 8
inch gauze is placed over the Telfa pad and directly onto the donor area, which is being treated with bacitracin but not Telfa. (b), One
Kerlix strip is wrapped circumferentially around the head, trapping the donor area gauze. The second Kerlix strip is drawn alternately
forward and backward. Each pass of the circumferentially wrapped Kerlix strip goes over the end of the second Kerlix strip before the
latter is drawn back in the opposite direction (forward and backward). (c), The process is repeated with the second Kerlix strip, gradually
moving laterally and medially with each pass to cover the entire top of the head. The bandage ends are secured in place with tape. (d),
The bandage is complete.
Postoperative Phase 555
NATURAL COURSE OF HAIR GRAFTS

Transplanted grafts follow one of three general courses:
1. They shed between 2 to 4 weeks postoperatively and
regrow at 3 to 4 months (range 21⁄2 months to 8 months);
or
2. They remain inactive for 10 to 14 days and then resume
growth without shedding; or
3. They remain inactive for 3 to 4 months and then resume
growth without shedding.
Although the third course has not been clinically reported and
normally occurs in less than 5% of grafted hairs, I have observed
it in many of my patients. In options two and three, a constric-
tion of the hair shaft (Pohl-Pinkus mark) corresponds to the
time of the transplant, thereby indicating a temporary disruption
in growth. The reasons for the differences in the courses of
growth are unknown, but once all the grafted hair begins grow-
ing, it resumes the regular growth pattern of 2 to 6 years of
growth followed by shedding and regrowth. The grafted hairs
gradually regain their asynchronous growth cycles, but because
this establishment takes time, sometimes a brief decrease in
hair counts associated with noticeable ‘‘thinning’’ occurs 3 to
4 years after the last transplant. During this period, more than
the average number of hairs go into telogen phase relatively
synchronously and resume their growth after 12 weeks. When
Figure 14A-2 The ‘‘Russian bandage’’ described by Lebovitz such synchronous loss occurs, patients should be reassured that
and Dzubow (Courtesy of Dr. P. Lebovitz). the phenomenon is temporary.
During the healing process, crusts of coagulated blood and
serum also develop at the base of the grafts where they exit the
scalp. Unless this is managed appropriately, they remain around
micrografts for 5 to 7 days, around minigrafts for 8 to 12 days,
and around larger grafts for 2 to 3 weeks.
14B. Management of the
Postoperative Period
GENERAL
William M. Parsley
Limmer has suggested four basic methods of wound care after
hair transplantation (R. Limmer, personal communication,
INTRODUCTION 1999):
After patients experience hair transplantation, they are often 1. Dry method (open): Clean blood residue from grafts
apprehensive and wonder whether they made the right decision and allow them to remain open and dry. This method
by undergoing surgery. The postoperative manner in which the advantageously keeps the area cool (dressings retain
surgeons and staffs treat them and handle their discomfort helps heat) and maximizes clotting mechanisms. The dry
determine whether they ultimately perceive the procedure as method is particularly popular after micro-minigraft and
a pleasant or unpleasant experience. Patient reassurance, pain follicular unit (FU) graft transplants.
control, physician availability, and wound care are all essential 2. GraftCyte or saline compresses and sprays (open):
elements of successful care, and they often determine whether When using this method, apply wet compresses for 30
patients choose the same surgeons to perform their later ses- to 60 minutes twice daily for the first 3 days after the
sions. Most postoperative care is based on common sense, and procedure to keep grafts clean and to promote healing.
the different concepts probably have little to do with the final If using the GraftCyte program, simultaneously use a
outcome of hair growth; they do, however, have a major impact concentrated copper-peptide spray hourly during wak-
on the patients’ opinion of the procedure and of their operating ing hours for 7 days.
physicians. Patient education before, during, and after the pro- 3. Open application of ointments, emollients, or gels:
cedure is therefore vital. No discomfort, occurrence, or compli- Leave the grafts open and coat them with a topical
cation should ever come as a surprise to the hair restoration preparation to promote healing, to give slight occlusion,
surgeon. Although some pain is unavoidable, the more discom- and to decrease infection and scarring. Frequently used
fort patients feel the unhappier they become. This chapter de- applications include petrolatum, antibiotic ointments,
scribes some of the current concepts that maximize the results of vitamin E oil, K-Y jelly, and aloe vera gel. Some sur-
surgery and keep patients as comfortable and happy as possible geons also use Iamin gel, a copper-binding peptide gel
during the postoperative period. promoted for wound healing.
556 Chapter 14
4. Occlusive dressings (closed): Numerous studies show unnoticed and feel embarrassed wearing a bandage.
that occlusion speeds wound healing and decreases With today’s smaller grafts, transplants are not very
pain. Cover the grafts with occlusive dressings; sur- noticeable when uncovered.
geons usually combine these dressings with emollients 5. Discomfort: Attempts to create compression with a head
or ointments. The dressings are popular with larger bandage often meet with discomfort and limited suc-
grafts, because FUs and micrografts heal quickly with cess. With no deep drainage system, the attempts may
or without occlusion. also block the outflow of venous blood and lymphatics,
and the edema that usually develops during the first
hours after a transplant may cause compression band-
HEAD DRESSINGS ages to become constrictive and painful.
6. Moist compresses: A full head bandage prevents the
The previous section of this chapter discusses head dressings use of moist compresses the first evening after the trans-
in more detail along with instructions for their use. plant. At present, saline and copper peptide compresses
are popular.
Pros of Head Dressings Few transplant surgeons use full head dressings at present. If
they use a dressing at all, a light headband with minimal pres-
Dressings are a mainstay for the postoperative care of surgical sure covering the donor site is sufficient. First, the donor surgi-
wounds, and they have been an essential part of hair transplan- cal site should be coated either with petrolatum or a double
tation since its inception in 1959. Many articles claim that antibiotic ointment, for example, Polysporin. The site should
occlusion after a surgical procedure leads to faster and less then be covered with Telfa pads or Melolin pads (Smith and
painful wound healing. Head dressings have the following Nephew Company); and, finally, a moderately loose headband
advantages: should be made with rolled gauze.
1. Protection against trauma: Head dressings protect the If surgeons prefer a full-head dressing, they may use Second
head against accidental blunt traumas and/or inadvertent Skin (Spenco) pads, laying them gently over the recipient site.
scratches. They also protect against traumas that arise If desired, the pads may be taped to the headband, but this is
from tossing or turning during sleep on the first night not necessary. Telfa pads or Melolin pads may be substituted
after surgery. for Second Skin; the surgeon then covers the dressing with a
2. Occlusion: Occlusive dressings increase the speed of surgical cap that holds it in place or a large Kling dressing
wound re-epithelialization. In addition, with occlusion, rolled over the ‘‘cap’’ of the head that covers and pads the
healing is less painful and has a decreased infection recipient and donor sites.
rate, because occlusion forms a barrier against bacteria.
3. Absorption of blood and possibly better hemostasis and/
or absorption of blood: The compression of the bandage PAIN
undoubtedly provides hemostasis to the donor area and
possibly to the recipient area. If bleeding occurs, the Almost always, some pain and discomfort follow hair transplan-
bandage absorbs the blood. Some patients are quite ap- tation surgery, but they are rarely severe. Usually, discomfort
prehensive about encountering their own blood, and it begins about 1 to 3 hours after the surgery ends, and it peaks that
is helpful, therefore, to reduce the chances that they see evening before gradually declining. Commonly, acetaminophen
any blood. (or no analgesics at all) adequately eases pain. However, many
4. Prevention or reduction of crusting: Occlusive dressings patients experience substantial pain, and it is, therefore, conven-
reduce or prevent crusting, particularly if the patient ient to have all patients fill a prescription for a stronger pain
wears the dressing for 3 or 4 days, changing it daily. medication in advance of the transplant to keep them comforta-
ble in the initial postoperative phase. The following are the
most commonly used medications:
Cons of Head Dressings
With the advent of mini-micrografting and FU grafting, a major- Narcotics
ity of surgeons have stopped using head dressings. The follow-
ing are some of their reasons: 1. Schedule 2: (in most states, the patient needs a special
prescription in hand):
1. New, smaller grafts are more difficult to dislodge.
Whereas large round grafts (used almost exclusively a. Percocet (oxycodone, 5.0 mg, 7.5 mg, or 10 mg,
in the past) were fairly easy to dislodge, the micro- with acetaminophen, 325 mg) Dose: one tablet
minigrafts and follicular unit grafts (FUGs) are more every 4 to 6 hours as needed).
tightly bound to their sites. b. Demerol (meperidine hydrochloride, 50 mg or 100
2. Follicular units/micrografts heal so rapidly that the ad- mg). Dose: 50 mg to 150 mg every 3 to 4 hours
vantages of occlusion decrease. as needed.
3. Heat buildup: Dressings retain heat, which somewhat Percocet and Demerol commonly cause nausea
counters their compression benefits because heat in- and vomiting. Although it is not strictly necessary,
creases the chance of bleeding and edema. some physicians pretreat the patient with trimeth-
4. Cosmetic: Many patients want their transplants to go obenzamide HCl (Tigan) or Gravol 30 minutes
before the aforementioned medications are taken, doctors wait a week) before the patient resumes these
to prevent nausea. medications.
2. Schedule 3: (prescription may be called in to the phar- 5. Lidocaine and bupivacaine. After the initial anesthesia
macy—many states do not consider these drugs nar- wears off, some patients experience an unacceptable
cotics) degree of discomfort. Reinjection with lidocaine or bup-
ivacaine offers temporary relief through this difficult
a. Tylenol No. 3 (acetaminophen, 300 mg, with co-
period. The surgeon normally performs the reinjection
deine, 30 mg). Dose: 1 to 2 tablets every 3 to 4
before the patient leaves the office on the day of the
hours as needed.
surgery, but it may be administered at any later time.
b. Darvocet N 100 (acetaminophen, 650 mg, with pro-
poxyphene napsylate, 100 mg). Dose: 1 tablet every
4 hours as needed. DONOR SITE
Ointments
Non-Narcotics
1. Cox 2 (cyclooxygenase-2) inhibitors: These drugs irri- Petrolatum and antibiotic ointments are the most popular topicals
tate the stomach less than other nonsteroidal anti-in- applied to the donor site. Of the antibiotic ointments, surgeons
flammatory drugs (NSAIDs), and they do not affect use double or triple ointments most frequently. The double anti-
bleeding time. These medications should not be used biotic ointments (Polysporin) contain polymixin B sulfate and
with warfarin because they decrease its depletion, and bacitracin zinc, and the triple antibiotics (Neosporin) addition-
bleeding problems can occur. Use rofecoxib (Vioxx) as ally contain neomycin. Because neomycin has been associated
a single dose of 25 to 50 mg per day, for 1 to 4 days with a small but significant number of allergic reactions (1),
as an effective analgesic. Use celecoxib (Celebrex) as many physicians prefer using the double antibiotic ointment. It
a single dose of 200 mg per day. Surgeons should not should be noted, however, that topical bacitracin has been known
use these drugs in patients who are allergic to acetylsali- to cause anaphylactic reactions on rare occasions (2). Mupirocin
cylic acid or have severe renal impairment. Although ointment (Bactroban) is also popular; it is a more potent antibiotic
they are less irritating to the stomach than other with a slightly higher incidence of burning and irritation. Gener-
NSAIDs, these medications still cause some irritation ally, these ointments should be applied one to three times daily,
(celecoxib is slightly worse than rofecoxib) and should usually after shampooing. Some question exists as to whether
not be used in patients with gastric ulcers. petrolatum (without antibiotics) may be adequate for healing in
2. Ketorolac tromethamine (Toradol): an NSAID. A single the donor site. By itself, petrolatum provides hydration and some
dose of 30 mg to 60 mg administered intramuscularly occlusion; it also serves as a barrier to bacteria.
immediately after surgery gives 4 to 6 hours of excellent The largest disadvantage of ointments is that they are greasy
relief during the early, uncomfortable, postoperative and difficult to remove, and it sometimes takes several days to
phase. Ketorolac is a potent analgesic comparable with remove them adequately. Massaging mineral oil, peanut oil, or
opiates and is commonly used postsurgically. It may be baby oil into the scalp to cut the ointment and then shampooing
given orally, but it is not as effective as when given with a strong detergent cleanser (Dawn dishwashing detergent)
intramuscularly. Physicians normally recommend oral often helps, but this process may need to be repeated twice
administration only to sustain the effect of an initial daily. The surgeon and staff must emphasize that the patient
intramuscular or intravenous dose. After hair transplan- not rub on the grafts or pull on the hair while applying the oils
tation, it is usually not worth the risk to use anything and shampooing.
beyond a single intramuscular dose. This medication
should not be given to patients with a history of gastric Gels
ulcers or renal impairment. Ketorolac inhibits platelet Although surgeons use gels infrequently on the donor area, gels
function, but in Unger’s experience in thousands of pa- maintain some popular support. Gels dry on exposure to the
tients—it has never induced a post–hair-transplant air and form a sticky film that offers some occlusive benefit.
hemorrhage after a single intramuscular dose (W. Advantageously, they dissolve in water and are easily removed
Unger, personal communication, 2002). without leaving hair greasy. K-Y jelly, aloe vera gel, and Iamin
3. Acetaminophen (i.e., Tylenol Extra Strength). Over- gel are the most popular. Iamin gel (Procyte Company, Red-
the-counter drug. Acetaminophen is mild and safe, and mond, WA) was approved in 1996 and contains copper-binding
it adequately comforts many patients. It does not, how- peptides. It is an anti-inflammatory agent that successfully treats
ever, sufficiently ease moderate to severe pain. Advan- slowly healing wounds. One disadvantage of Iamin gel, how-
tageously, it does not prolong bleeding and it causes ever, is its expense. For normal use of these gels, apply them
minimal gastric irritation. The standard dose is two tab- once or twice daily.
lets, ⳮ500 mg, every 4 to 6 hours. Patients should avoid
alcohol while taking this drug, because the combination Dressings
can cause liver damage.
4. Acetylsalicylic acid and other NSAIDs: Ibuprofen, na- See earlier discussion of dressings. At present, because the com-
proxen, fenoprofen, etc. Surgeons should administer mon postoperative practice includes excising and suturing of the
these medications with caution during the immediate donor area, bleeding is less problematic and dressings are less
postoperative period because they prolong bleeding. necessary than in the past. Overnight, a light headband with mini-
Many physicians recommend waiting 2 to 3 days (some mal pressure should be used to catch the small amount of blood
558 Chapter 14
that may ooze between the sutures. Ointment-coated Telfa pads of after 6 or 7 days with ointment alone or after 7 to
placed underneath the headband prevent the dressings from stick- 10 days with no dressing or ointment at all (R. Limmer,
ing to the wound, and, usually, no significant bleeding occurs. personal communication, 1999): Because they are non-
The dressing should be removed 18 to 24 hours later and not re- adherent, hydrogel dressings often need to be taped to
placed except in the rare case of excessive bleeding. a headband or secured with a surgical cap. The pads are
more effective if the patient is relatively bald, because
Cold Applications significant hair does not allow contact with the scalp.
If using Second Skin, the nonsterile (but clean) 3 inch
Following the general principles of injury, it is wise to consider ⳯ 6 inch pads work well.
the time-tested principle of ‘‘RICE’’ (R-rest, I-ice, C-compres- 2. Telfa pads (Kendall Co., Mansfield, MA) are nonadher-
sion, E-elevation). As stated earlier, compression is somewhat ent, absorbable, permeable pads that are the most com-
risky if it encircles the head, but point compression over the monly used dressings for the recipient area. They are
donor area works well. Many physicians suggest that patients opaque and absorb only small amounts of blood, so they
administer cold applications to the donor area during the first require a more absorbent overlying pad such as Reston
night. This process prevents bleeding, gives point compression, foam (3M HealthCare, St Paul, MN) or 4 inch ⳯ 4
and decreases pain; and patients can achieve it with bags of inch gauze pads if bleeding is a concern. An antibiotic
frozen peas, corn, or crushed ice, or with flexible cold packs. ointment coating may be used under the Telfa pads, and
Flex-i-Cold packs (Cramer Products, Inc., Gardner, KS) that the pads should be removed the next day.
are 6 inches ⳯ 71⁄2 inches are convenient and may be refrozen 3. Cellophane wrap (Saran wrap). This is an inexpensive
many times. The patient may apply the cold packs repeatedly, but effective occlusive dressing composed of regener-
alternating an hour on and an hour off. While resting the head ated cellulose film to which glycerin or glycerol is
back on the pack or bag, the patient experiences point pressure. added. It is relatively impermeable and transparent, and
it is generally coated with an antibiotic ointment and
Suture Removal removed the next day. Absorbent pads are often used
at the periphery of the Saran sheets.
Most surgeons remove sutures, or staples, 6 to 10 days after 4. Hydrocolloid dressings (Duoderm) and alginate dress-
surgery. If the wound closes under tension, the removal can be ings (Sorbsan and Kaltostat) are rarely used dressings
done as late as 14 days after surgery. If absorbable sutures are for the recipient site. They are nonadherent and absor-
used by the physician, they do not need to be removed even if bent. Both have the slight disadvantage of containing a
specific sections absorb slowly. Removal, however, may offer foul-smelling gel (3).
the patient relief and may alleviate irritation. Even though
Monocryl is an excellent absorbable suture, some physicians
Ointments
have removed unabsorbed sutures as late as 2 months after
surgery. Surgeons generally use petrolatum antibiotic ointments under
dressings, but they also, though infrequently, use the ointments
alone. The ointments are helpful in minimizing crusting, but
RECIPIENT SITE their infection prevention is questionable. Infections in the post-
Dressings vs. No Dressings operative period are relatively rare in hair transplanting; thus,
it is difficult to evaluate the benefit of antibiotic ointments.
As noted earlier, the current medical trend is to not use dressings. One disadvantage of the ointments is that they make the grafts
More than half of the experienced hair transplant surgeons with slightly less secure in their sites, so more care is required to
whom I have communicated do not use dressings. There are sev- avoid their being accidental dislodged.
eral good options, however, for those who wish to use dressings:
1. Hydrogel dressings (Vigilon–Bard HomeHealth, Mur- Gels
ray Hill, NJ: Spencer 2nd Skin, Spencer Medical Corp, As noted earlier, some physicians use K-Y jelly, aloe vera gel,
Waco, TX): Hydrogel dressings are water suspensions and Iamin gel, lubricants that are water soluble and dry to a
with a small amount of polyethylene oxide between two sticky film. Their advantages are that they do not leave the hair
layers of either polyethylene or polyvinyl alcohol on a greasy and they are easily removed.
polyester mesh (3). One layer of the mesh, which rests
against the skin, is removed, whereas the other, outer GraftCyte
mesh layer remains on the head. These dressings are
nonadherent and semipermeable both to gases and water Procyte Corporation (Redmond, WA, 888–966–1010) has de-
vapor, and they are semitransparent, which increases veloped a postoperative program that uses superoxide dismu-
the visibility of the surgical site. The dressings are tases (copper-binding peptides). Their premise is that copper
soothing to the skin and effective in decreasing discom- peptide products provide micronutrients that speed healing of
fort. Often, they are lightly coated with an antibiotic the hair follicles. With the use of GraftCyte, it is claimed that
ointment. Patients use the hydrogel dressings for the patients shed fewer hairs after their transplantation, and the ones
first night and then frequently discontinue use, because that do shed regrow more quickly. Additionally, less erythema
they are messy when combined with ointment. How- and crusting occur. The treatment is reported to have the double
ever, if patients use hydrogel dressings constantly with advantage of providing moisture in addition to micronutrition.
ointment, they heal without crusts after 4 days instead The procedure is as follows:
1. GraftCyte moist dressings: Beginning immediately after numbers of grafts in the patients’ previous cases or in the study
surgery, the patient places moist dressings—individ- cases; nor did it mention the location of the grafts. The reader,
ually packaged, sterile gauze pads moistened with puri- therefore, assumes that the study relied on the patients’ memo-
fied water, sodium chloride, and copper peptide acetate ries of their earlier transplants.
(PCA)—over the recipient site for 30 to 60 minutes Larger and better-controlled studies need to be completed
twice daily for three days. Occasionally, gentle pressure to establish the true value of the GraftCyte system. The most
should be applied to keep the scalp saturated. compelling reason to consider this regimen is the number of
2. GraftCyte concentrated spray: The patient also begins experienced transplant surgeons who are convinced of its value
using the spray immediately after surgery, spraying it based on its use and results in their practices. Unfortunately,
onto the recipient area hourly during the waking hours there are a number of equally experienced surgeons who remain
for 7 days or until finished. Fifteen to twenty sprays skeptical of its worth.
should be used with each application.
3. GraftCyte Postsurgical shampoo: The patient uses this Vitamin E (alpha-tocopherol) Oil
formulation of copper peptide and aloe vera gel as a
daily shampoo for 3 to 4 weeks after surgery. The physi- Numerous surgeons use Vitamin E oil on the recipient area to
cian determines the time of the initial use of this product, lubricate it, to help prevent crusting, and to promote healing.
and most patients begin shampooing within the first 72 Most commonly, physicians obtain the oil by pricking natural
hours after surgery. First, patients use and rinse their vitamin E capsules and squeezing the oil onto the recipient skin.
regular shampoo; second, they gently shampoo with the Patients apply it twice daily for 7 to 10 days. Its disadvantages
GraftCyte shampoo for 2 to 3 minutes before rinsing. are that it is sticky and frequently associated with allergic contact
The first study of GraftCyte, in 1998, consisted of 12 patients dermatitis and occasionally with contact urticaria (6). One study
who postoperatively used copper peptide saturated saline compared vitamin E ointment with Aquaphor on separate sides
gauzes (concentration not mentioned) on one side of the scalp of the same sutured wound. Physicians and patients both pre-
and compared them with plain saline compresses used on the ferred the final cosmetic appearance of the Aquaphor side (7).
other side of the scalp (4). The study was double-blinded, so
neither the patient nor the investigator knew which side of the Minoxidil
scalp contained the placebo. Patients used compresses for 60
A few small studies exist indicating that shedding decreases
minutes per application and continued for 5 days after surgery:
when the patient uses topical minoxidil during the hair transplant
Day 1 (one application); Days 2 to 4 (four applications per day);
postoperative period. In the first study, published in 1987, 12 pa-
Day 5 (three applications). This progression represented a total
tients used minoxidil, 3%, twice daily postoperatively beginning
of 16 applications, and the patients received no further treat-
2 to 3 days after surgery. Two patients, both of whom had round
ment. The study then followed the patients for 12 weeks. On
grafts placed on the vertex, did not experience shedding (8). In a
the sides treated with copper peptide, the study reported: less
later study, Bouhanna pretreated 16 patients with minoxidil, 2%,
erythema and edema, better hair growth and hair quality, less
twice daily for the 4 weeks preceding surgery; he discontinued
effluvium, and more hairs continuing to grow without shedding.
the treatment for 3 weeks and then restarted and continued it for
The study data, however, revealed no difference in shedding
3 months. He used 4-mm grafts, and at 30 days, 71% of the grafts
of grafted hairs in 7 of the 12 patients, less shedding on the
had partial continued hair growth, and 31% of the grafts had over
GraftCyte side in 3 of the 12 patients, and less shedding on the
50% retention of hair without shedding (9). More studies are re-
placebo side in 2 of the 12 patients. Therefore, a net gain of 1
quired to clarify the effect and proper dosage of minoxidil.
patient in 12 benefited with regard to shedding.
In June 2000, Dr. Gary Hitzig reported the only other study
regarding GraftCyte of which this author is aware (5). The study GENERAL CARE
involved 30 patients, 20 of whom used their previous transplant
procedures as controls. The study divided patients into 3 groups Elevation
of 10 each: (1) previous older plug transplants; (2) previous
recent transplants with saline compresses as aftercare; and (3) Although many of the postoperative medications used by sur-
no prior surgery and, therefore, no ‘‘control’’ session. The pa- geons are debatable, basic physical care is a cornerstone of opti-
tients’ treatments proceeded as follows: mal postoperative care. Elevating the head is an extremely impor-
tant component in that care. In the first hours after the transplant,
1. GraftCyte topical pads containing 0.5% PCA immedi- edema forms and must be controlled. Elevation reduces venous
ately postoperatively then twice daily ⳯ 2 days (20 and lymphatic pressure and is, therefore, advantageous. Most
minutes each) surgeons recommend that the patient elevate the upper body at
2. GraftCyte spray hourly while awake ⳯ 14 days least 45 degrees for the first 24 hours after the transplant. A recli-
3. GraftCyte shampoo daily starting at day 2 ner chair or a couch, with pillows for support, easily achieves the
In the best target group (prior HT with only saline aftercare), proper elevation. After the first 24 hours, there is a difference of
the time it took the transplant to become undetectable decreased opinion regarding the required level of elevation. At that time, if
by 60% to 70%, and patient satisfaction increased from 80% much edema has developed, many surgeons instruct the patient
to 95%. In all groups, an impressive 90% of the grafts continued to lower the upper body somewhat from the original 45-degree
to grow without shedding, compared with only 30% in controls angle by sleeping on two or three pillows in bed. Because gravity
with prior plugs and 70% with recent, prior transplants in which affects the fluid bolus, when the patient lays the head back, the
patients used saline compresses. This study did not state the fluid ‘‘gravitates’’ toward the temple and parietal scalp rather
560 Chapter 14
than down over the forehead and eyes. Others physicians, how- clined 15 degrees to 25 degrees to encourage the gravi-
ever, believe that the 45-degree elevation remains important, and tational pull on the fluid, which moves the fluid toward
they ask their patients to maintain it for 72 hours after the proce- the temples rather than inferiorly over the orbits.
dure. 5. Acetylsalicylic acid or NSAIDs should be avoided for 2
Only rarely does significant swelling occur in patients who to 3 days after surgery (some surgeons suggest avoiding
experience minimal swelling after the first night. It is reasona- these medications for up to 10 days) to prevent bleeding.
ble, therefore, for the surgeon to request that the patient main-
Corticosteroids before and/or after surgery are the most com-
tain the 45-degree angle for the first night only, because the
monly used medications for preventing edema, but no conclusive
position causes discomfort during sleep and is unnecessary for
evidence establishes that corticosteroids prevent or control
a longer period of time.
edema after hair transplant surgery (10). Several reports indicate
that they reduce swelling after facial plastic surgery, such as rhi-
Avoidance of Trauma noplasty, 24 hours after the procedure but not 6 days after it
(11–13). In another study, patients started prednisolone, at 60 mg
Direct trauma is one of the main causes of graft loss after trans-
daily, after surgery and tapered it over 5 days (14). A difference
plantation, so surgeons should instruct patients to be extremely
in the occurrence of edema existed between the study group and
careful to avoid bumping or inadvertently scratching their heads
the control group. Dr. Norwood claims to have reduced his inci-
after the procedure. Patients should be particularly careful for
dence of postoperative swelling from 20% to less than 5% by
a few days when entering and exiting automobiles and when
using systemic corticosteroids and adding 50 mg of triamcino-
performing any work. To prevent inadvertent scratching, pa-
lone acetonide to 50 mL of lidocaine (l mg/mL) for operative an-
tients should cut their nails short and occasionally wear a surgi-
esthesia (15). In the second edition of this text, Nordstrom re-
cal cap, particularly while sleeping.
ported on 44 patients treated preoperatively with two mL of
prednisolone acetate (Depo-Medrol) administered intramuscu-
Rest larly. Fifty percent of the patients took the drug on the first trans-
plant but not the second, and the other 50% on the opposite sched-
Rest is essential to the treatment of traumatic injuries. In hair
ule (16). Thirteen patients benefited from the drug. The duration
transplantation, this means severely reducing the patient’s ac-
of edema decreased by 1.5 days (3.54 days vs. 2.07 days), and
tivities, particularly for the first 24 hours after surgery. Cuta-
periorbital ecchymosis decreased by half (63% vs. 34%). Nords-
neous vasodilatation is a mechanism the body uses to speed
trom performed the study at a time when placing large, round
cooling from the heat buildup of exercise. Relative inactivity
grafts into holes was the common practice. At present, edema is
reduces vasodilatation in the skin and decreases the possibility
far less prevalent with the newer, smaller grafts.
of trauma. After the first 24 hours, activity may be increased
gradually over the next week. Most surgeons permit vigorous
exercise 6 to 7 days after the procedure, but most suggest post- Bleeding
poning swimming for 2 weeks. Commonly, some bleeding occurs at the donor site after trans-
plantation, but, fortunately, it is often minimal. The patient’s pil-
low should be covered with an old, clean towel or a barrier pad for
POSTOPERATIVE ROBLEMS AND THEIR 3 to 4 days to prevent staining of the pillowcases. If the bleeding is
CARE: COMMON PROBLEMS active, the patient should apply mild to moderate pressure, keep
the head elevated, and use a cold compress. Nearly always, the
Edema
bleeding stops within a few minutes. If the bleeding persists,
Edema, or swelling, caused by the retention of normal amounts however, the patient should notify the physician. If it is arterial,
of tissue and fluid, begins almost immediately at the time of the surgeon may use additional sutures or—far less often—re-
the surgery, and its development continues for a short but vari- open the wound and tie off or cauterize the artery.
able time. In many instances, it goes unnoticed until 3 to 5 days
after surgery when it moves down over the forehead and reaches Pruritus
the orbits. Prevention is its best treatment. If edema develops,
however, possibilities for accelerating its resolution include: Mild pruritus in both the donor and the recipient areas com-
monly begins several days after transplantation. Usually, a topi-
1. The fluid is massaged away from the forehead and back cal corticosteroid solution or ointment controls this problem.
into the temple region. The patient presses one hand Clobetasol, 0.05% solution (50 mL), applied twice daily, or as
against the mid-forehead to stabilize the forehead and needed, eases discomfort. If the problem persists, oral antihista-
uses the other hand to rub the fluid back toward the mines and/or cold compresses also offer relief.
temple; the stabilizing hand is moved laterally as the
fluid moves. Crusting
2. A cool pack is placed over the forehead for 15 minutes
or more three to four times daily. Crusts are coagulated serum and blood that seep from around the
3. After 2 to 3 days, when edema no longer develops, using grafts in the first 24 to 48 hours after surgery and that give a straw
an ACE wrap as a headband just above the eyebrows colored or a blackish-red color, respectively, to the wound. As
blocks the fluid drop and allows the fluid to absorb from noted earlier, once formed, they remain on micro-mini grafts for
the skin superior to the headband. 7 to 10 days and on larger slot or round grafts for 10 to 20 days.
4. The patient should sleep with the upper body semire- Usually, they cause more embarrassment than damage to the pa-
tient, but sometimes they dislodge a graft if caught on a fingernail 1. Scratching the recipient site: Physicians should warn
or comb. Crusts can be difficult to remove; therefore, as with patients about this problem and advise them to cut their
edema, their prevention should be the surgeon’s main goal. After nails short.
completing the transplant, the head should be cleaned so that it 2. Bumping their heads: Patients should stoop, not bend,
is free of blood before the patient goes home, and if the patient to pick up objects, and they should be extremely careful
returns the next day for a postoperative checkup, the head should getting in and out of vehicles.
again be cleaned with saline solution or diluted hydrogen perox- 3. Rubbing the grafts or pulling on the hair: This can occur
ide (1:4) and the hair should be shampooed to remove crusting. while the patient is shampooing.
Wet compresses, occlusive dressings, and topical ointments and 4. Brushing or combing dry hair: Hair often dries against
gels help prevent crust formation. As previously discussed, the a crust, and brushes and combs easily pull it out, so
most popular topicals are antibiotic ointments, plain petrolatum, physicians should advise patients to comb their hair only
K-Y jelly, Iamin gel, and aloe vera gel used twice daily. Sham- after shampooing, while it is still wet.
pooing the hair one to two times daily also aids in the prevention
of crusting. If the surgeon and patient prevent crust formation for
the first 3 days after surgery, the patient usually remains clear for
UNCOMMON PROBLEMS
the remainder of the healing process.
After 10 days, if any crusts remain, the patient may begin Neuralgia
soaking the scalp with a wet tap water compress for 10 minutes
before taking a long shower. While shampooing, the patient Neuralgia, or persistent pain associated with a sensory nerve in
may gently remove the crusts with the fingernails. Usually, the the donor region, is uncommon, but when it occurs, it may present
crusts can be removed with 2 to 3 days of this protocol. a difficult problem. Physicians assume it arises from transection,
partial transection (16), irritation, or stretching of a nerve. There
is frequently a ‘‘trigger point’’ in the postauricular region, which
Hypoesthesia
elicits pain with even slight direct pressure or manipulation. On
Patients should be forewarned that some degree of sensation loss rare occasions, neuralgia lasts for several years and is associated
occurs after every session of transplantation, particularly after with a neuroma. Some physicians believe it occurs more fre-
strip harvesting, which is the current method of obtaining donor quently in emotionally unstable patients. The best ‘‘treatment’’
grafts. Hypoesthesia is most noticeable on the midscalp and the is prevention by carefully removing the donor strip, minimizing
vertex. Normally, it disappears within a few weeks to 5 months, cautery, avoiding nerve entrapment by a suture, and avoiding ex-
but occasionally it lasts up to 18 months. Fortunately, permanent cisions that are too wide. Many surgeons think that removing the
sensation loss is rare, but it remains important for the surgeon to cut strip from the subcutaneous tissue with blunt scissors instead
prevent damage to the nerve bundles during donor harvesting. If of a scalpel blade is much gentler to the underlying vessels and
patients understand that temporary sensory loss often occurs, nerves. Despite using good technique, neuralgia occasionally de-
they usually evince little anxiety or concern regarding hypoesthe- velops. Usually, it is mild and only a minor aggravation to the
sia. Once they experience the condition, however, many patients patient; occasionally, however, it becomes severe. If so, there are
benefit from reassurance that it is only temporary (16). several treatments to consider:
1. Inject a local anesthetic with or without corticosteroids

Dislodging Grafts
(17): Good results have been reported after injection
Dislodging a very small number of grafts during the first 3 days of of 2 mL of 0.5% bupivacaine with 4 mg (2 mg/mL)
the postoperative period is relatively common. With FU grafting, triamcinolone acetonide (R. Shiell, personal communi-
the grafts dry quickly once they are dislodged and do not survive cation, 2000).
long enough to be reimplanted. Patients must understand, there- 2. TENS (transcutaneous electrical nerve stimulation):
fore, that the surgeon places a large number of grafts and those This apparatus transmits electrical impulses through the
one or two lost ones—losses that the surgeon expects—have lit- skin into the underlying peripheral nerve, blocking the
tle impact on the overall transplant appearance. Larger grafts, if pain signal to the brain and releasing beta-endorphins,
not desiccated, may be saved. The patient should immediately both of which prevent the feeling of pain (M. Gandel-
place the dislodged graft in a cup of water with a quarter teaspoon man, personal communication, 2000).
of salt and then call the doctor. Dr. Shiell states that contact lens 3. Analgesics: If the pain is not too severe, these may
rinsing solution is excellent for supporting grafts until the patient adequately ease the patient’s discomfort. Before narcot-
returns to the office for graft reimplantation (R. Shiell, personal ics are used, NSAIDs should be considered. Surgeons
communication, 2000). Furthermore, if vital grafts are lost on the may also consider other medications, such as tricyclic
frontal hairline, he ‘‘steals’’ more posteriorly placed grafts to re- antidepressants (amitriptyline), anticonvulsants (phe-
place them. nytoin and carbamazepine), and membrane stabilizers
During FU grafting, a number of miniaturized, or telogen, (mexiletine) (18).
hairs are always present. It is a good idea to plant them all, even 4. ‘‘Tincture of time’’: Surgeons need to reassure patients
though some may not survive because of the short length of their that it is rare for nerve-associated pain to remain over
grafts, which dislodge easily. If surgeons explain this possibility time.
to patients in advance, patients rarely experience much concern, 5. Occasionally, if the aforementioned measures are un-
and the grafts are usually too small to be noticed anyway. productive, surgeons excise the painful trigger point or
The main causes of dislodged grafts are the following: neuroma (R. Shiell, personal communication, 2000).
562 Chapter 14
Central Necrosis natural, miniaturized hairs of the region, because previously

transplanted hairs are more vigorous and less susceptible to
Central necrosis is the death and ulceration of tissue usually, but shedding. Cosmetically significant effluvium occurs more fre-
not always, in the center of the frontal scalp at the junction of the quently in women, and, for this reason, many surgeons prefer
midscalp. Central necrosis initially arose as a problem associated not to perform transplantation in women unless their alopecia
with the past, aggressive use of large, round grafts, but presently, is advanced. The degree of effluvium is somewhat unpredicta-
with megasessions, dense packing, and slot grafts, it has resur- ble, and if the patient understands this in advance, distress is
faced as a problem. It commonly occurs within 1 to 2 days after minimized.
surgery and appears as an adherent crust over the midfrontal In the usual postoperative course, shedding begins 2 to 4
scalp. It also may appear after an uneventful healing period of 2 weeks after surgery; regrowth occurs slightly before or at the
to 3 weeks, at which time a black blister or crust of variable size same time as the transplanted hair begins to grow. A small
develops in the central frontal scalp. Occasionally, it occurs in percentage of the hairs, however, may not return. There are
the donor area, particularly in the postauricular area, when the several ways to reduce shedding. First, extra time should be
donor strip has been closed under tension. In a few days, an ulcer given during site creation to avoid transecting existing follicles.
replaces the crust or blister; it heals over a variable amount of time Second, overly aggressive dense packing should be avoided in
but leaves a depressed scar. An unidentified surgeon reported the areas that contain large numbers of existing hairs, even if the
following case to the Hair Transplant Forum International in hairs are miniaturized. Third, consideration should be given to
1999: a nonsmoking female patient with an unknown number of treating the patient postoperatively with topical minoxidil, twice
micro-minigrafts developed a 2.0 cm ⳯ 2.8 cm area of necrosis in daily, starting 4 to 7 days after surgery. Fourth, GraftCyte and/
the frontal central scalp 3 weeks postoperatively (19). A personal or topical minoxidil may be useful in the postoperative period.
experience includes one case that occurred in a 48-year-old dia-
betic patient; the individual had (150) 3.5-mm slot grafts and 800 Syncope
FUGs placed in the frontal half of the scalp. Two and a half weeks
postoperatively, an ulcer 1.0 cm in diameter developed and Although postoperative syncope is uncommon, it generally oc-
healed within 10 days, leaving a slightly depressed scar. Dr. curs the day after surgery during the dressing change. It is not
David Seager observes that a large, more adherent than normal associated with discomfort but is rather psychological in nature.
crust in the frontal scalp signals that an area of necrosis lies be- Episodes decrease if the surgeon and staff distract the patient
neath. Additionally, he notes that adjacent to the necrosis, the with conversation, music, or television. The assistant should not
physician often finds an area of patchy, poor hair growth that pos- overmanipulate the surgical site. If syncope occurs, the patient
sibly indicates ischemia (D. J. Seager, personal communication, should lie prone on a table with a cool, moist compress over
2000). the forehead. It is a good idea to keep cold, wet compresses in
Central necrosis is an under-reported problem, possibly be- Saran wrap (to prevent water evaporation) in the office refriger-
cause of concerns over the reporting surgeon’s reputation. For ator at all times for just these occasions. Vital signs should be
this reason, it is difficult to determine the condition’s incidence taken and basic support given. Usually, the patient responds
and proper treatment. Fortunately, the few reported cases have within 1 to 2 minutes.
healed quickly with wet compresses and antibiotics. Applying
Iamin gel to the cleaned ulcer bed twice daily after compresses Nausea and Vomiting
helps to accelerate healing.
Nausea and vomiting sometimes occur as side effects of some
pain medications. They are best treated with promethazine HCl
Graft Shedding (Phenergan) suppositories, 25 mg to 50 mg, used every 6 hours
Patients need to be forewarned that much of the newly grafted as needed.
hair will temporarily shed at about 2 to 3 weeks after surgery. If
patients are not warned of this, they may mistakenly think their Infection
grafts are falling out. Usually, patients are told that most of the Infection is extremely rare in transplantation. The pustules,
time the newly planted grafts are expected to go into a resting which occur with new growth at 3 months, are often confused
stage, at which time the hair shaft separates from the root but that with infection. If an infection does occur, culture and systemic
the root is still firmly imbedded in the skin. They are told that the antibiotics are necessary, and any significant infection should
hair is continuing to grow under the skin and that by about the be taken seriously. Consider having the patient evaluated for
third month, it will reach the surface. As stated earlier, there have a possible immune deficiency and review the sterility of the
been reports of a certain percentage of grafted hair that did not operating technique. Shampooing the scalp with chlorhexidine
shed but continued to grow after a brief rest phase. gluconate (Hibiclens) the night before and the morning of sur-
gery is very helpful in preventing infection. Also important is
Postsurgical Effluvium of Preexisting Hair a good surgical technique that ensures a reasonable level of
sterility, the prevention of hematomas, and a minimized number
Some postsurgical effluvium, or hair loss, of preexisting, non- of implanted hair particles and fibers.
grafted hair occurs in nearly every transplant patient. Significant
effluvium, however, is far less common. It usually occurs when Arteriovenous Anastomosis (fistula)
placers situate numerous grafts in a region that contains many
miniaturized hairs, such as cases of diffuse patterned alopecia Arteriovenous (AV) fistulas, abscesses, or hematomas that pul-
and female pattern alopecia. The shed hairs are generally the sate on palpation are very uncommon, occurring in one of every
5000 cases (20). Often, the patient complains of feeling or hear- Cysts and Pustules
ing the pulsations. Usually, AV fistulas develop in the donor
area, but they also occur on the temple region. They disappear A variable number of pustules occur in the postoperative period
naturally and spontaneously within a few months. If treatment of most hair transplant surgeries. The discussion here is con-
is necessary because the patient fears rupture, the surgeon care- fined to the occasions when they become clinical problems.
fully dissects and ligates the entry and exit vessels. If the vessels There are several causes for these cysts and pustules:
rupture, bleeding is surprisingly strong and difficult to control. 1. Implanted hair spicules: Care should be taken by both
the cutters and the planters to remove all spicules from
Hiccups the grafts before implanting, because the spicules act
as foreign bodies.
Hiccups occur uncommonly in transplantation and appear to be 2. Transected hairs in the grafts: This is more significant
related to preoperative intravenous diazepam (Valium). In pa- when the lower part of the hair shafts remains, because
tients given intravenous diazepam, Shiell estimates the incidence the transection interrupts its pathway to the surface.
of hiccups is 5%. Diluting the diazepam and injecting it slowly Normally, transected hairs remain with the graft, and
is said to aid in its prevention. His cases are usually transient, but surgeons transplant them because they remain viable.
some last 2 to 3 days. Onset varies from during the operation to 12 3. Epidermal tissue deposited during site preparation:
hours postoperatively. After switching to midazolam (Versed), This occurs with hypodermic needles when tissue enters
Shiell stopped observing the delayed onset of hiccups (21). Dr. the ‘‘core,’’ and the stick then deposits it. Solid core
Arnold postulates that scalp surgery stimulates hiccups, because needles (Mediquip Surgical) help prevent this problem,
a sensory branch of the phrenic nerve innervates the postauricular because they have no core that collects tissue. Also,
area. Because some individuals have aberrant extensions to the tissue may be deposited by slot or round punches, partic-
posterior scalp, irritating these pathways stimulates the phrenic ularly if the punch is dull and causes the skin to be
nerves and produces hiccups. To support his claim, he finds that pushed in deeply. Dr. Michael Beehner suggests a
four of five patients with hiccups after transplant surgery cease method to remove buried plugs of tissue. He takes a
hiccuping within 2 minutes of reanesthetization of the donor area scalpel handle and uses it like a ‘‘squeegee’’ over the
with lidocaine (22). Treatment is usually successful with chlor- recipient scalp, forcing out buried tissue. This process
promazine (Thorazine) at a dose of 25 mg every 4 hours until the obviously must be completed before graft planting be-
hiccups cease. Side effects of chlorpromazine include drowsi- gins to avoid forcing out new grafts (25).
ness, orthostatic hypotension, and, rarely, neuroleptic malignant 4. Buried grafts: They occur when the surgeon places a
syndrome (NMS). graft so deeply that it loses contact with the epidermis.
Traquina, in a retrospective review, reported on 20 patients Buried grafts also occur with ‘‘piggybacking’’—plac-
who had hiccups after hair transplant surgery (HTS) or scalp re- ing a graft on top of a previously placed graft and thus
duction (SR) over a 10-year period from 1989 to 1999. Nine had forcing the first graft deeply into the skin. In both cases,
HTS; six had SR; and five had both HTS and SR surgery (23). placing the first graft too deeply creates the problem.
Nine of these patients were seen 1 day postoperatively and re- Several techniques minimize this problem: (1) leaving
ceived phrenic nerve massages; eight experienced immediate re- the hair long enough on the graft so the placer can iden-
lief. Left phrenic nerve massage entails the up and down massage tify whether the graft has been placed too deeply and
of the lateral side of the midportion of the sternocleidomastoid can pull it back out if necessary; (2) once the grafts
muscle for 1 minute during which the patient does not breathe. have been inserted properly, cutting the hair shaft flush
Ten other patients treated with simethicone (150 mg to 160 with the skin, because if the hair is coarse, it pushes the
mg every 2 hours until resolution of symptoms) experienced graft deeply every time pressure occurs over it; (3) not
relief within several hours (one of these patients also received making the site too big for the graft, because the discrep-
chlorpromazine). This treatment is based on an assumption by ancy allows the graft to be buried more easily; and (4)
many physicians that apprehensive patients swallow air and leaving the graft slightly elevated above the skin be-
subsequently experience gastric distention. cause it will settle down flush with healing, whereas
sunken grafts nearly always leave ‘‘pits’’ or cysts.
5. Miscellaneous: If transected during site creation, ‘‘resi-
Sweating dent’’ (preexisting) hair in the recipient region can cause
cysts. Some physicians feel that the transection of seba-
Sweating in the recipient site is a newly reported phenomenon
ceous glands in the bald scalp at the time of site creation
in transplantation. Dr. Ron Shapiro offered the first report of
also creates cysts.
sweating. He noted a case in which a Norwood VI male patient
received a total of 2500 FUs and micro-minigrafts over two Once a cyst forms, the surgeon can treat it by lancing it with
sessions (24). Approximately 18 months after his last session, a no. 11 blade, draining it, and covering it with wet compresses
the patient reported excessive sweating in the recipient area, and antibiotics if necessary. After the surgeon drains the cyst,
which did not affect the surrounding scalp. Personal experience a search is conducted for hair or other evidence of buried grafts.
includes two patients with similar sweating patterns. The pa- If found, the buried grafts must be removed. Often, the debris
tients were asymptomatic and unaware of the sweating, but I emerges with the purulent fluid, and, once drained, the cyst
observed it on follow-up examinations. Sweating is relatively heals rapidly. The cysts that form in hair transplant surgery
rare, but surgeons may report it more frequently as awareness differ from common epidermal inclusion cysts because they
of its existence grows. No cause has yet been determined. rarely form an epidermal sac that requires surgical excision.
564 Chapter 14
SYSTEMIC MEDICATIONS 3. Tylenol PM (acetaminophen 500 mg and diphenhydra-

mine 25 mg in each tablet): Normal dose is 2 tablets at
Corticosteroids (see earlier under Edema) bedtime. This is an over-the-counter product that is
There is essentially only one reason why surgeons use cortico- quite effective but produces a slight hangover.
steroids in hair transplanting; that is, to prevent edema. Under
the discussion of edema, it is noted that there is no compelling Antibiotics
evidence that demands the use of corticosteroids, but there are Although widely used, antibiotics are generally not required
many excellent hair transplant surgeons who are convinced of in the postoperative period except in patients with the risk of
their value and use them routinely. Although it is difficult to endocarditis or those with prosthetic joints. Infections after
determine the best treatment procedure for a drug whose bene- transplantation are rare if the surgeon follows sterile techniques
fits are somewhat questionable, the following are some of the for donor harvesting and clean/sterile techniques for graft place-
regimens used by the more experienced surgeons: ment. If antibiotics are used, most surgeons administer a cepha-
1. Oral: Prednisone is by far the most widely used oral losporin, such as cefadroxil (Duricef), 1000 mg to 1500 mg, in
corticosteroid in the postoperative period. Most physi- a single, preoperative dose (26). If the surgeon uses it postopera-
cians give the patient a single dose, daily, starting with tively, however, a dose of 500 mg twice daily for 5 days should
40 mg to 60 mg on the morning of the transplant and suffice, keeping in mind that it is difficult to establish the correct
then tapering the dose over a 5-day period (keep in dose of a drug that may not be required.
mind that most edema disappears in 3 to 5 days without
medication). The disadvantages of this method are pa- Analgesics (see earlier under Pain)
tient noncompliance and increased stomach irritation.
The advantage is the ability to stop the drug quickly if
problems arise. Dr. Richard Shiell (R. Shiell, personal
communication, 2000) believes that controlling edema ACTIVITIES
through steroids is dose related. He notes that he has
equivocal results when administrating prednisolone at Work
a dose of 30 mg per day, but he experiences clearly
evident edema control with doses of 60 mg per day. The time at which work may be resumed depends on the pa-
2. Intramuscular: tient’s job. If it is a desk job without client contact, the patient
may return the next day. If there is client contact, the patient will
a. Celestone Soluspan (mixture of betamethasone so- not want to return until the transplanted scalp is cosmetically
dium phosphate, 3.0 mg, and betamethasone ace- acceptable. If the patient has had previous grafting or has signif-
tate, 3.0 mg, in each milliliter): 1 mL to 2 mL ad- icant hair in the recipient area, return to work can generally
ministered at the start of the procedure gives an take place in 3 to 4 days without notice. A patient with little
effective blood level for 5 to 7 days. hair and no hair to brush over the recipient area, may want to
b. Triamcinolone acetonide (40 mg/mL): 30 mg to 50 wait longer. Patients with advanced baldness can return in a
mg (0.75 mL to 1.25 mL) administered the morning week if they prevent crusting and have little eythema, assuming
of the procedure offers a moderately quick and ef- FUs or micro-minigrafts are exclusively used. Occasionally,
fective level that tapers slowly for 3 weeks. FUGs are undetectable at 2 to 3 days, but the patient should
c. Methylprednisolone acetate (Depo-Medrol, 40 mg/ not plan on this timeframe. With round or slot grafts, it takes
mL): 1 mL to 2 mL given the morning of the sur- 11⁄2 to 3 weeks before the grafts are cosmetically acceptable.
gery is the usual dose. It provides effective blood Of course, if a patient can wear a hat at work, return can take
levels for 7 or more days. place almost immediately if the work is not physical. A patient
3. Intralesional (not systemic but mentioned for complete- who does heavy physical work should take off at least 1 week
ness): As mentioned previously, Dr. Norwood reports from work.
successful reduction of edema by adding 1 mg of triam-
cinolone acetonide to each mL of lidocaine during oper- Exercise and Sports
ative anesthesia (15).
Most surgeons advise patients to avoid exercise for at least 3
Sedatives days after surgery. At that point, they may begin light, upright
exercise and gradually increase their workout level daily if they
1. Diazepam (Valium), 2 mg, 5 mg, and 10 mg tablets: do not experience any problems. After 1 week, they may resume
Usually given at bedtime to relieve anxiety and aid sleep heavy exercise that does not risk a blow to the head. After 2
for the first 3 or 4 nights after surgery. Standard dose weeks, they are free to resume all activities.
is 5 mg to 10 mg at night. Use during the day can induce
drowsiness and ataxia. There is a slight ‘‘hangover’’ Shampooing
effect the next morning.
2. Zolpidem tartrate (Ambien). 5 mg and 10 mg tablets: Some surgeons advise patients to wait at least 3 days before
Given at bedtime to aid sleep for the first 3 or 4 nights. shampooing, whereas others shampoo the patient’s hair imme-
Standard dose is 5 mg to 10 mg at night. This drug has diately after surgery. Generally, 48 hours is recommended be-
the advantage of fewer hangover effects and is one of fore shampooing. If the shampooing is reasonably gentle, there
the most widely used sleeping pills. is little risk of dislodging grafts.
Now that most shampoos are pH-balanced, the type of sham-

poo the patient uses is unimportant. GraftCyte makes a copper
peptide shampoo, but no proof of its effectiveness in aiding hair
growth or decreasing shedding is available. Shampooing early
aids the cosmetic appearance of the hair and reduces crusting.
The patient may allow the full force of the shower to hit the
donor area, but this pressure can be too strong on the recipient
site for the first 4 days. If the patient can control the force of the
shower stream, it should be reduced to one third of flow strength
for shampooing the recipient site. Otherwise, a plastic pitcher can
be taken into the shower and used to pour water over the recipient
site while the patient is shampooing. To prevent excessively
rough shampooing, Dr. Joe Greco suggests that patients initially
lather shampoo in their hands with a soft shaving brush that can
then be used to apply the lather gently to their scalps.
HAIRPIECES
Hairpieces may be worn starting 3 days after surgery provided
that the patient does not apply tape to the recipient area and Figure 14B-1 Camouflage Products. These are some of the
does not clip the hairpiece to hair in the recipient area. Usually, commonly used camouflage products for alopecia.
patients can place the tape just below the grafts or use hair
outside the recipient area for clipping. Patients should keep the
mesh or plastic that contacts the scalp as clean as possible. It
should also be mentioned that many surgeons have occasionally
a. Toppik (Spencer Forrest, Inc.): These widely adver-
noticed poor regrowth in patients who wear hairpieces during
tised fibers are made from wool keratin. They come
their recovery period. The reasons are unknown, but some phy-
in eight colors and give a fairly natural appearance
sicians speculate that humidity and traction are possible causes.
to the hair. The company also makes a holding spray.
Dr. Seager believes that overwearing of a hairpiece can be a
b. Super Million Hair (Japan): This is the original
problem; therefore, he recommends that his patients wear their
fiber camouflage for hair. It was produced in Japan
hairpieces for no longer than 12 hours a day (D. J. Seager,
in 1992 from rice keratin as a by-product of sake
personal communication, 2000).
distillation and is not available in the United States.
c. Hair Magic (Lookwell, Inc.): Rayon fibers consti-
CAMOUFLAGE AGENTS tute this product, which comes in eight colors.
2. Powder cakes (DermMatch—DermMatch, Inc.): The
General patient applies DermMatch with a wet sponge applicator
that has been rubbed on the powder cake to pick up the
Camouflage agents are topicals applied to the scalp to give hair material. It is advertised as water resistant, and is found
a fuller, thicker appearance. They generally cover both the hair to be true. In practical situations, such as light rain, it
and the scalp with a color that matches the patient’s hair. Even works well. DermMatch is excellent for focal work, and
though their main use is to camouflage natural balding, they it is the least messy and the most economical of all
helpfully hide crusts and compensate for effluvium during the the camouflage agents. Its disadvantage is that it takes
postoperative period. Most physicians underuse these agents longer to apply than most of the other products. It comes
because they are unfamiliar with them. Their effects are instant in eight colors, and although some physicians recom-
and can be dramatic. Some experience with repeat usage is mend using it 2 to 3 days after transplantation, patients
necessary to obtain optimal results (Fig. 14B-1). should wait at least 6 to 7 days, because of the manipula-
tion it requires during application.
Types 3. Lotions (COUVRe—Spencer Forrest, Inc.): This ses-
ame seed emulsion comes in a tube and was one of the
1. Fibers: The patient sprinkles fibers onto the hair and
first camouflage agents available in the United States.
scalp and then lightly brushes them. The fibers attach
Unlike the other agents, which the patient applies to
to the hair by magnetic pull and styling hair spray holds
the hair, COUVRe requires direct application onto the
them in place. A disadvantage of fibers is that they
scalp. It is relatively resistant to water. Some physicians
easily come off on pillows and are slightly messy during
recommend waiting 2 to 3 days after transplantation
application. Fibers require some expertise in application
before using it, but, once again, patients should wait 7
to prevent clumping. They survive light moisture but
days after the transplant. It has the consistency of cream
not heavy rain. Patients may apply them beginning 1
shoe polish; nevertheless, some patients love it.
to 3 days after the transplant, the shortest waiting period
4. Sprays: These are the most maligned of the camouflage
of all the products, because the fibers remove easily.
agents, but personal experience suggests that many of
The following are commonly used fibers:
the criticisms are unfair. After applying all of the prod-
566 Chapter 14
Figure 14B-2 Fifty-year-old white man. Fullmore spray was used to camouflage his vertex alopecia. The photograph on the left was
taken before the spray was used and the photograph on the right was taken after the spray was used.
ucts on hair in a side-by-side comparison, it is found ● Spencer Forrest, Inc.

that the sprays are the most popular (Fig. 14B-2). They 64 Post Road West
are water-resistant and the fastest to apply. Unfortu- Westport, CT 06880
nately, some users report problems with sprays coming Phone 800-416-3325
off on pillows and getting onto clothes and furniture http://toppik.com
during application. With experience, patients learn to COUVRe Toppik Fullmore
control the latter problem. Also, because sprays are ● DermMatch, Inc.
aerosol, slight inhalation occurs. It helps to follow the 9812 Fall Road, 噛ll4-222
application with an ordinary hair spray, but this is not Potomac, MD 20854
absolutely necessary. Two of the most commonly used Phone 800-826-2824
sprays are the following: www.dermatch.com
DermMatch
a. ProTHIK (Aquilia International Ltd) comes in five
● Lookwell, Inc.
colors.
23505 Crenshaw Blvd. Dept. 135
b. Fullmore (Spencer Forrest, Inc.) comes in six colors.
Torrance, CA 90505
Even though the products are similar, ProTHIK advises waiting Phone 888-456-6593
2 to 3 days after transplantation before use, whereas Fullmore http://hairmagic.com
advises 7 days. It is recommended that patients wait 7 days ● Hair Magic
before using either product because sprays come out of hair only Aquila International Ltd.
moderately easily with shampooing. ProTHIK sells a remover Box 500, 3049 Las Vegas Blvd South
shampoo (proClean), but any good, high-seducing shampoo re- Las Vegas, NV 89109-1980
moves either product. Phone 800-710-8445
If speed of application is important, the fibers or sprays may www.prothik.com
be a good choice. If focal application is important, DermMatch ProTHIK
or COUVRe may be appropriate. If water resistance is a consider-
ation, a spray or DermMatch is a good choice. If cost is important,
DermMatch is easily the most economical. In practical applica- SUMMARY
tion for hair transplantation, a fiber (Toppik) should be consid-
ered for the first 10 to 14 days after transplantation to conceal the In general, properly performed hair transplantation is a safe pro-
surgery. Later, to mask effluvium, the fibers, DermMatch, or the cedure that has few significant surgical complications. Most
sprays (Fullmore or ProThik) may be effective—the choice de- problems are minor and easily manageable. The patient must un-
pends on the patient’s activities and preferences. These products derstand the proper postsurgical care, what to expect, and possi-
offer considerable comfort to patients who want their procedure ble complications. If problems or questions arise, the physician
to go unnoticed. At the time of this writing, a good place to inves- needs to be available. A call to the patient 5 to 7 hours after the
tigate these products is folica.com under cosmetic remedies. surgery often provides great comfort. Patients who are confident
in their care and reasonably comfortable in the first days after for the same reason—especially before washing the hair. Pa-
their transplant tend to be satisfied and happily refer others to tients are also encouraged to apply a 3.5% solution of minoxidil,
their hair restoration surgeon. Table 14B-1 summarizes my post- twice daily, (a mixture of equal parts of 2% and 5% solutions),
operative instructions to patients. beginning the morning after surgery and continuing for 5 weeks.
(Female patients start this 1 week before surgery as well.) The
solution has the side effect of dilating intact vessels to compen-
sate somewhat for any decrease in circulation caused by the
severing of numerous vessels in the recipient area. It accelerates
Editor’s Comment healing and decreases the likelihood of any temporary loss of
As usual, different physicians have different protocols for the existing recipient area hair (1,2). Application of the same solu-
postoperative management of their hair transplant patients. Ap- tion may also be carried out, twice daily, in the donor area and
pendix A is the postoperative instruction information given to is especially recommended for female patients, who seem to
our patients. The reader may note that we wash the scalp the be more prone to temporary hair loss adjacent to donor area
morning after surgery and instruct the patient to wash the hair incisions, as well as for patients who have extensive scarring
twice daily, beginning the next morning. This is done after the in the donor area or greater than usual closing tension. An article
scalp is soaked in a tub of warm water for 15 to 20 minutes, by Eremia and Umar (3) reviewed the effect of 2% and 5%
to soften the crusts and facilitate their removal. We encourage topical minoxidil used for 2 weeks before primary cervicofacial
swimming in clean water, as soon as 48 hours after surgery, rhytidectomy and 4 weeks after surgery (with a 5-day break
Table 14B–1 Pain Meds
Sutures Shampoo Sleep Pain meds Work Exercise
Day 1 1st Coat with antibiotic Do not shampoo Sleep in recliner Tylenol No. 3(or Take off from No exercise
24 hours ointment chair; head Darvocet); one work
after HT 1–2 times daily elevated at least every 4 hrs for
45 degrees pain as needed
Day 2 Coat with antibiotic Do not shampoo (if Sleep in bed with Tylenol No. 3(or Take off from No exercise
ointment not cleaned in head on 2–3 Darvocet); one work
1–2 times daily our office, may pillows every 4 hr for
shampoo gently) pain as needed
Day 3 Coat with antibiotic Shampoo gently; Sleep in bed with Tylenol No. 3(or May resume Easy walking
ointment rinse with water head on 2–3 Darvocet); one desk work,
1–2 times daily at low stream on pillows every 4 hr for but no public
grafts pain as needed contact
Day 4 Coat with antibiotic Shampoo gently; Sleep in bed with Tylenol No. 3(or May resume Regular walking
ointment rinse with water head on 2–3 Darvocet); one light upright Light upright
1–2 times daily at low stream on pillows every 4 hr for work; no exercise
grafts pain as needed blows to head
Day 5 Coat with antibiotic Shampoo gently; Sleep normally Normal OTC May resume Light jogging
ointment rinse with water products should light upright Light upright
1–2 times daily at low stream on be adequate work; no exercise
grafts blows to head
Day 6 Coat with antibiotic Shampoo gently; Sleep normally Normal OTC May resume Light jogging
ointment rinse with full products should light upright Light upright
1–2 times daily stream be adequate work; no weights and
blows to head calisthenics
Day 7 Coat with antibiotic Shampoo gently; Sleep normally Normal OTC May resume Resume regular
ointment rinse with full products should light upright exercise
1–2 times daily stream be adequate work; no
blows to head
Day 8 Coat with antibiotic Shampoo Sleep normally Normal OTC May resume Resume regular
ointment normally; rinse products should normal work exercise
1–2 times daily with full stream be adequate
1–2 times daily with full stream be adequate
Have sutures with full stream be adequate
removed
568 Chapter 14
period beginning on the day of surgery). They concluded that CLASSIFICATION AND INCIDENCE
‘‘minoxidil plays a role in effectively preventing the temporal
hair loss’’ that usually occurs after that type of surgery. They Fortunately, complications of any significance are unusual with
did not find any increase in usual postoperative complications modern transplant techniques. Because there is no well-ac-
or problematic side effects. Avram and colleagues also reported cepted method for anonymously reporting complications, their
that the consensus of ‘‘11 international experts on hair loss and review necessarily relies on anecdotal information and scattered
hair transplantation’’ was that such treatment can ‘‘increase hair case reports. Complications can arise either (1) intraoperatively,
density and speed regrowth of transplanted follicles’’ (4). (2) during the early and late postoperative periods, and, in some
Our patients are asked to not wear a hairpiece at all for the cases, (3) years after the procedure’s completion. Intraoperative
first postoperative week and as little as possible during the next complications are not discussed because they are covered else-
week—for example, during the day but not evening or night- where in this text.
time. After 2 weeks, they may resume normal use. There is For the sake of convenience, the list of potential problems
considerable debate as to whether these instructions are overly associated with transplantation can be arbitrarily divided into
conservative. Most other practitioners, including myself, re- aesthetic and medical complications (Table 14C-1).
main concerned that the warmth and moisture under the hair-
piece, as well as its variable cleanliness, are conducive to infec-
AESTHETIC COMPLICATIONS
tion (5). Others have reported that their patients resume usual
hairpiece use as soon as the day after surgery without any nega- From a practical standpoint aesthetic complications can be di-
tive consequences. vided into those that cause (1) an unnatural appearance and
I am not aware of any good evidence to suggest, as Parsley (2) those that cause a lower than expected final appearance of
does, that there is less postoperative edema after sessions of density. With the increased use of larger numbers of smaller
small grafts compared with those that include larger grafts. I use grafts, unnatural results are much less common than in the past.
all types of grafting from follicular unit transplantation (FUT) to However, even small grafts can produce unnatural results if
combinations of FUs and many sizes of multi-FU grafts and they are not placed and distributed properly. A patient’s satis-
have never noticed any consistent difference in postoperative faction with density is a function of both expectations and the
edema. actual amount of hair that exists after the procedure. Poor
As for persistent pain in the donor areas—specifically neu- growth, effluviums, and natural progression of the patient’s un-
romas or presumed neuromas—I have long recommended two derlying androgenic alopecia are a few of the factors that can
options: lead to poorer density than was desired.
Patients must be adequately informed about these potential
1. Injecting 0.5 mL to 1 mL of a solution of 3.33 mg or
problems. The surgeon must be willing to acknowledge the
5.0 mg/mL of triamcinolone acetonide (Kenalog) in 2%
possibility of suboptimal aesthetic results when evaluating pa-
lidocaine with 1/100,000 epinephrine into each problem
tients. The physician’s humility and open-mindedness are pre-
area along the donor area scar (6). Usually, two or three
requisites for successful transplantation.
treatments, with 3-week intervals between them, elimi-
nate the problem.
2. Excising any pinpoint areas of tenderness or recurring Poor Growth
foci of radiating pain. (I have only once had to excise In general, transplantation of undamaged, small grafts into
one.) (WU) healthy skin produces excellent growth. Some surgeons claim
to achieve 100% growth; however, it is unrealistic to expect
that they can determine a patient’s exact percentage of hair
14C. Complications of Hair growth. Accurately determining growth rate requires precise
hair counts that the surgeon must perform in a blinded fashion
Transplantation to ensure unbiased results. Scientifically accurate counting re-
Jerry E. Cooley quires tattooing grids of skin and using macrophotography. Few
surgeons are willing to take these steps, and they cannot always
depend on accurate accounts from patients because of the role
INTRODUCTION
the patient’s expectations play in perceiving the results. Patients
Webster’s dictionary defines complication as ‘‘a difficult factor who experience excellent growth may feel dissatisfied because
or issue often appearing unexpectedly and changing existing of their unrealistic expectations , whereas patients who achieve
plans, methods, or attitudes.’’ Using this broad definition, sur- relatively poor growth may feel satisfied if any new hair appears
geons and staff consider a number of issues when reviewing on their previously bald scalps. Surgeons, therefore, rely on
the possible complications of modern hair restoration surgery.
This section does not consider complications associated with
outdated techniques, such as punch harvesting the donor area,
nor does it discuss complications associated with other types Table 14C–1 Frequency of Headache Before Punch Hair
of surgical procedures, such as alopecia reductions (AR) and Grafting
flaps, which are discussed elsewhere in this book (see Chapters
19, 20, and 21). Instead, it examines complications related to Frequency group 1 2 3 4 Total
contemporary hair transplant procedures and their postoperative Number of patients 16 22 59 32 129
periods.
their experience and intuition to estimate the patient’s graft Postsurgical Effluvium
growth.
To explore the problem of poor growth, I sent questionnaires Another complication associated with transplantation is post-
to 12 experienced hair restoration surgeons (unpublished re- surgical effluvium, or shedding of preexisting, nontransplanted
sults). The combined experience of the surgeons includes over hairs from the recipient area. Shedding typically occurs in the
160 years of performing transplants and more than 65,000 treated first 2 to 3 weeks after the procedure and can continue for
patients. Although surgeons disagree about the definition of poor another 3 to 6 weeks. This often cause tremendous concern to
growth, most would agree that a very reasonable assessment of the patient. However, the effluvium is usually temporary, and
poor results would be less than 90% growth, evaluated at least 8 the patient should be reassured that most of the hair usually
months after the procedure. In this anonymous survey, the sur- regrows in a few months. Unfortunately, in some instances, a
geons estimated that the prevalence of poor hair growth in their portion of the hairs grow back with a finer caliber or not at all.
own practices averaged 6%, with a range from 0% to 25%. The It is believed that these particular hairs were probably already
extent of this range suggests that although some surgeons will- significantly affected by the ongoing androgenic alopecia and
ingly acknowledge poor growth in their patients, others do not. were ultimately destined to be lost permanently. The trauma of
When asked to identify the leading cause of poor growth, the surgery simply moved these hairs one step further along the
most surgeons answered that injury to hair follicles during the cycle toward becoming vellous hairs. It is best to forewarn
procedure produced the most damage. They placed equal em- patients of the possibility of effluvium because they are better
phasis on the importance of avoiding damage to the follicles able to accept it if they have a prior understanding of it.
during the harvesting, dissection, and placement phases of the The postsurgical effluvium of preexisting hair may be either
procedure. an anagen or telogen effluvium. If the preexisting hair falls out
Follicle trauma is accepted as a major cause of poor growth, fairly quickly after a hair transplant (i.e., after 2 to 3 weeks),
and it can occur at any point during the procedure. For example, it may indicate that the mechanism is an anagen effluvium trig-
during harvesting, the hair follicles can be transected, whether gered by the cumulative trauma of interrupted blood supply,
the surgeon uses a single or a multibladed knife. During the edema, and chemotactic factors. On the other hand, if the hair
dissection and preparation of the grafts, there is ample opportu- does not fall out until approximately 6 to 10 weeks after the
nity for assistants to transect or damage hair follicles, and, dur- surgery, it may indicate that the mechanism is a telogen efflu-
ing placement, forceps can easily crush grafts (1). Desiccation, vium. For unknown reasons, women seem more prone to posts-
or drying, of the grafts can also occur at any time, and it pro- urgical effluvium than men do, and this should be discussed
duces morphological changes in the hair follicle that may corre- with women patients before surgery.
late to poor growth (2). Avoiding follicular injury requires that To minimize postgraft effluvium in a recipient area that has
both the surgeon and the assistants use a meticulous surgical significant preexisting hair, some surgeons reduce the overall
technique. To avoid damaging follicles, many physicians stress number of incisions, their size, and the relative spacing between
the importance of adequate magnification during graft dissec- them. Others physicians, however, do the opposite and suggest
tion. As part of the same study cited previously, I found that using large numbers of grafts, which are by necessity closely
grafts produced by surgeons who use the dissecting microscope spaced, to ‘‘overwhelm’’ the expected effluvium so that the pa-
for graft preparation contain half as much follicular transection tient perceives a net benefit (6). Brandy and Shapiro stress the
as grafts of those who do not use a microscope (3). Although importance of using magnification loupes and adequate lighting
transected hair follicles can regenerate and produce hair (4), as the surgeon creates the recipient sites to avoid damaging exist-
their regrowth never equals the growth rate of undamaged ing hairs with the blade (7,8). Some physicians advocate the use
grafts. If surgeons experience problems with poor growth, they of minoxidil (Rogaine) or finasteride (Propecia) to limit postop-
must evaluate all aspects of their surgical procedure and deter- erative surgical effluviums (see Chapters 14C and 5B)
mine whether their technique damages follicles.
In some patients, the surgeon can predict the possibility of Delayed Temporary Marked Thinning
poor growth before performing the transplant. Conditions that (synchronization)
reduce the vascularity of the recipient skin can lead to less than
expected growth. For example, when surgeons transplant grafts Occasionally, 3 to 7 years after transplanting has been completed,
into scars, they expect good growth, but the decreased vascular- a patient may return to the office complaining of a rapid decrease
ity occasionally causes poor growth. If the patient smokes, vas- in the density of transplanted hair. The cause is nearly always a
cularity may be further impaired. Previous transplant proce- more or less synchronous conversion of the transplanted hairs
dures also diminish the vascular support in a given area. from anagen to telogen phase. Normally, an average of only 1 of
Although surgeons generally accept that previous punch graft- every 10 scalp hairs goes into telogen phase at any given time.
ing lowers recipient circulation, others suggest that even micro- Thus, there is a slow, steady, barely noticeable turnover of scalp
grafted recipient incisions made with hypodermic needles de- hair. However, when an area is transplanted, for example over a
crease the vascular support in subsequent procedures and result period of 1 year, all of the hair in all of the transplanted grafts has
in less than expected growth (see Chapter 12B). gone into telogen phase that single year. The cycles of these hairs,
Rarely, experienced surgeons also note inexplicable poor therefore, become more synchronized than usual, so that 3 to 7
growth, and Shiell coined the term ‘‘X-factor’’ to denote its years later instead of 1 of 10 hairs entering telogen phase, 6, or
unidentified cause (5). Surgeons identify the X-factor as the 7, or 8 do so within a period of 1 year. The result is a fairly rapid
source of poor growth only after ruling out all other possible depletion of hair density, but only a temporary one. No treatment
causes such as follicular trauma. Physicians believe X factor is necessary other than providing reassurance to the patient.
cases are unavoidable. Gradually, over the years, the transplanted hairs revert to asyn-
570 Chapter 14
chronous telogen phases and the problem resolves itself sponta- area is the last to lose its pigment and turn gray or white. As a
neously result, some surgeons deliberately take grafts from the temporal
A similar but milder form of this phenomenon can occur area, which they expect to gray sooner, and which, when scat-
approximately 2 years after a single large hair transplant proce- tered within the recipient area, mimics the natural graying pro-
dure. A patient may come to the physician and saying that the cess in that area (see Chapter 10)
results were great at the 1-year mark but later the hair began
to appear slightly sparser. The explanation for this may be that, Cobblestoning or Tenting
at first, approximately 100% of the transplanted hair is in the The skin surrounding grafted hair can have an unnatural appear-
anagen phase; however, after 1 or 2 years, some of those hairs ance as it exits the scalp. When surgeons use larger round grafts,
enter a telogen phase. (This would be a component of the hair they can accidentally create a ‘‘cobblestone’’ effect in which the
cycles of different hairs becoming asynchronous.) elevation of the graft is higher than the surface of the surrounding
skin. They can avoid this problem by ensuring that the grafts are
Unnatural Appearance placed at, or only slightly above, the skin surface. When ‘‘cob-
Unnatural or noticeable results can be considered a complica- blestoning’’ occurs, however, surgeons treat it by shaving off or
tion of hair transplantation. Results can appear unnatural be- electrodesiccating the excess skin. Elevated skin can also sur-
cause of improper distribution (placement) of multiple follicles round micrografts or follicular units (FUs), causing the skin to be
that create patterns not found in nature. An individual follicle slightly tented. Fortunately, patients rarely notice this effect.
itself can also contribute to an unnatural appearance owing to
problems related to color, curl, and caliber, as well as to the Pitting
appearance of a follicle as it exits the skin. The opposite of cobblestoning and tenting is pitting, which oc-
curs when the skin immediately adjacent to the graft has a lower
Kinkiness elevation than its surrounding skin. This results in an unnatural
In some cases, transplanted hair takes on an unwanted curly or ‘‘delling’’ or pit around the hair that is noticeable because of
kinky appearance, a problem that decreases over time. Physi- shadows. Pitting is a difficult problem to correct and usually
cians have studied this effect (9,10) with electronic microscopy requires punch excision, electrodessication, or dermabrasion of
and found that it is associated with disruption of the cuticular the grafts or the skin peripheral to the pit. To avoid pitting,
pattern and large areas devoid of cuticular ridging. Others spec- surgeons and assistants should take care not to place the grafts
ulate a transient decrease in sebaceous gland activity. ‘‘Body- below the surface of the skin and to minimize the amount of
building’’ conditioners that fill in the cuticular fractures and epidermis left on the grafts during graft preparation.
defects may be helpful.
Decreased Caliber MEDICAL COMPLICATIONS

In some cases, the diameter of transplanted hair is diminished. Bleeding
This obviously leads to an appearance of decreased fullness.
The exact mechanism and incidence of this phenomenon are Although bleeding complicates placement of grafts in the recipi-
not known but they are thought to be caused by the cumulative ent sites, it has never been reported to be severe enough to
effects of the various traumas that occur to the graft during the require a blood transfusion. As discussed elsewhere in this text,
transplanting process. Kim has shown that the upper hird of a patients should be asked to discontinue the use of medications
transected hair regrows with a decreased diameter, and it is that increase bleeding (e.g., acetylsalicylic acid, nonsteroidal
speculated that this is related to the decreased diameter of the anti-inflammatory agents, vitamin E) for appropriate periods of
new dermal papilla that has to be regenerated (11). time (see Chapters 7 and 8) Also, surgeons should question
patients regarding personal and family histories of bleeding
Increased Caliber problems. In particular, von Willebrand’s disease is the most
commonly inherited bleeding disorder; it may occur in as many
If the transplanted donor hair is of greater caliber than the preex- as 1 in 1000 people. People inherit most forms of this disease
isting hair in the recipient area, it can lead to either a positive as autosomal dominant traits; therefore, asking the patient for a
or a negative aesthetic effect, depending on its location and on family history of easy bleeding is helpful in identifying possible
the patient’s specific hair characteristics. The higher caliber is cases. Some cases, however, are mild and go unnoticed, becom-
more effective in creating the illusion of density. On the other ing apparent only during the transplant.
hand, hairs of increased caliber may appear unnatural and be Although bleeding can occur in either the donor or recipient
more noticeable if juxtaposed against finer hairs in certain areas. area in the days after the procedure, it hardly ever creates a signifi-
On occasion, a few hairs from the donor site may regrow with cant problem. Bleeding in the recipient area may indicate that a
a much higher caliber. Cole has nicknamed these hairs ‘‘Super graft has become dislodged. Patients should avoid touching the
Hairs.’’ The cause is not known but it has been postulated that recipient site after the procedure and keep in mind that for several
it may be caused by the effect of certain growth factors. It seems hours after surgery, the scalp is numb and they are more prone to
to occur more often in donor hair found in scar tissue. accidentally bumping the head. This is especially important for
patients to remember when getting in and out of cars. If bleeding
Hair Color occurs from the recipient site, the patient should apply direct
If surgeons use only donor hair from the occipital area, this can pressure to the site with a sterile gauze pad or a clean cloth for at
create an unnatural appearance as the patient ages because this least 10 minutes. If in the unlikely event it that it should continue,
the patient should contact the operating physician. Bleeding in other foreign body reactions, and epidermal cysts. Most of the
the donor area is virtually always controlled with additional su- time, pathogens cannot be cultured from these lesions; however,
tures. Rarely, the donor area has to be opened and a bleeding ves- secondary bacterial infection or an infectious agent that cannot
sel cauterized. Delayed bleeding in the donor area may also result be cultured may theoretically be involved in some cases.
in development of a hematoma, which appears as localized swell-
ing with tenderness, and, in some instances, inflammation. Most Epidermoid Cysts and Ingrown Hairs
hair restoration surgeons have never encountered hematomas in
Epidermoid cysts and ingrown hairs can occur when grafts are
their careers. This needs to be distinguished from a wound infec-
planted below the skin, especially when grafts are ‘‘piggy-
tion and may require opening up the wound, evacuating the he-
backed.’’ Some think that small punches or hypodermic needles
matoma, and then resuturing it. However, most hematoma forma-
can sometimes push small amounts of epithelium below the sur-
tion resolves uneventfully with conservative care.
face and that these later develop into epidermoid cysts. Usually,
epidermoid cysts and ingrown hairs appear as a few localized ery-
Arteriovenous Fistula thematous pustules, a few weeks to months after surgery. Con-
Rarely, an arteriovenous fistula may form in the recipient or servative treatment consists of washing the hair daily with an
donor area after transplantation. It results from the accidental antiseptic shampoo, for example, chlorhexidine gluconate
juncture of a severed vein and artery and manifests as a pulsat- (Hibiclens), moist warm soaks, and topical antibiotics. Some-
ing nodule. It is unknown whether surgeons can prevent this times, a cyst spontaneously extrudes its contents. If not, the cyst
unusual event, but it nearly always resolves spontaneously over should be incised and all contents expelled. After the surgeon in-
a period of 3 to 6 months. A more rapid elimination of the fistula cises the cyst, it typically heals quickly, but, usually, topical or
can be produced by ligating the afferent vessel, but, usually, this systemic antibiotics (e.g., tetracyclines) hasten healing.
is done only if the fistula is unusually large and/or superficial
and surgeon is concerned about the possibility of its rupturing. Chronic Folliculitis
Some surgeons, including Unger (12), have noted what is proba- Occasionally, hair transplant patients develop a persistent mild
bly a variant of this complication in the form of a serpentine, folliculitis scattered throughout the recipient area. It usually
gently pulsating, enlarged vessel in the temporal area after trans- begins several months after a transplant. As stated before, true
plantation of the frontal area (Fig. 14C-1). Unger found in one pathogens are rarely cultured from these lesions. Some believe
of his patients that three sutures were required to collapse the that this condition may occasionally be due to foreign body
vessel, one at each of its ends and one at its midpoint. The reactions triggered by powder from surgical gloves or by small,
sutures were removed 2 weeks later, ‘‘with more than 80% nonviable spicules of hair. Spicules of hair that consist of less
improvement in appearance.’’ than the distal one third of the follicle have little chance of
growing (11). Because of the theoretical chance of foreign body
Cysts, Pustules, and Papules reactions, these spicules should ideally be removed from grafts
before their insertion. On the other hand, if a follicle contains
A variety of cysts, pustules, and papules can occur either within more than the distal one third of the shaft, there is a greater
the first few weeks or as late as 2 to 4 months after a hair transplant chance of its being viable (11), and it should probably be left
procedure. They can appear as a few isolated sites or as multiple within the graft. If a patient develops chronic folliculitis, it
diffuse lesions. Possible etiologies include ‘‘ingrown’’ hairs, is important to rule out underlying predisposing habits—for
example, infrequent washing, dirty work or hobbies, and dirty
hats or helmets, as well as predisposing medical conditions such
as diabetes mellitus. Conservative treatment consists of hair
washing and warm soaks at least once daily with chlorhexidine
gluconate shampoo povidone-iodine (Betadine) shampoo. The
areas should be cleansed two or three times a day with alcohol
swipe pads, and topical antibiotics, such as bacitracin or Pol-
ysporin, should also be applied to infected sites three times a
day. Occasionally, systemic antibiotics, such as erythromycin,
cephalosporin (Keflex), or tetracycline must be used. In resis-
tant cases, longer term treatment may be needed, much like the
treatment given to patients with chronic acne vulgaris. On rare
occasions, short-term systemic or topical steroids are used in
an attempt to treat any underlying foreign body reaction.
Infection
True infections in the recipient area after transplantation are
Figure 14C-1 A serpentine dilated, pulsating vein was noted uncommon, generally occurring in less than 0.1% of patients
by the patient within 10 days of his third transplant session (6 (12). Unfortunately, it may also be clinically difficult to distin-
weeks before this photograph). The latter consisted entirely of slit guish a true infection from the small cysts or pustules due to
grafts and micrografts. Unger believes this complication is a variant ingrown hairs, foreign body reactions, or epidermal cysts, as
of an arteriovenous fistula. discussed earlier. When doubt exists, a swab for culture and
572 Chapter 14
sensitivity should always be taken. Osteomyelitis of the skull secondary to the galeotomy was presumed to be responsible
is a rare complication of scalp infections subsequent to hair for this improvement. In the second edition of this textbook
transplantation (13). Nordstrom reported, on a study involving 129 patients with
Infection of the donor site manifests as pain, erythema, and male pattern baldness (MPB) who were treated with punch
purulent drainage. If the surgeon suspects infection, exudates grafting and interviewed relative to the frequency and severity
from the area should be cultured to identify the causative patho- of their headaches before and 24 to 50 months after the proce-
gen and its sensitivities. Topical care consists of applying warm dures were carried out (16). The patients were divided into
saline compresses for 15 minutes three times daily, removing four groups: (1) headaches more often than once a week, (2)
pus, debris, and crusts, and applying topical antibiotics. If the headaches less often than once a week but more often than once
infection does not respond promptly to local care or is judged a month, (3) headaches less often than once a month, and (4)
to be serious, systemic antibiotics should also be pre- headaches never. Tables 14C-1 and 14C-2, respectively, outline
scribed—usually cephalosporins, tetracyclines, erythromycin, (1) the frequency of headaches before punch hair transplanting
or penicillin. and (b) the frequency of headaches in the four pain groups
When infection occurs and is treated properly and promptly, before and after transplanting in 18 patients. As can be seen
it generally has a negligible effect on the ultimate growth of from the numbers in Table 14C-2, patients seemed to have
the hair. Some surgeons even theorize that the associated in- headaches less frequently after transplantation.
flammation results in better than expected hair growth! To avoid
infection, the surgeon should adequately cleanse the patient’s Neuralgias and Neuroma
skin preoperatively with an appropriate antiseptic, use clean
surgical techniques, and emphasize patient compliance with The occasional patient may experience either a sharp, shooting
postoperative instructions regarding cleansing and care of the pain or an uncomfortable burning or tingling sensation that trav-
skin. Surgeons disagree about the usefulness of routine periop- els up the back of the head superior to the donor area. Often,
erative antibiotics, and there are no well-accepted standards of pressure at a specific site along the donor site triggers this pain.
care (see Chapter 7E) It has been postulated that this is due to nerve injury in the
donor area followed by abnormal traction or healing of the nerve
Postoperative Frontal Central Necrosis (12). Occasionally, a true neuroma develops in the donor area.
Unger has reported that injecting dilute corticosteroids (for ex-
There have been infrequent reports of unexpected skin necrosis ample, a 3.33 mg/mL solution of triamcinolone acetonide in
in the recipient area after seemingly routine transplant proce- 2% lidocaine with 1:100,000 epinephrine) into the area, once
dures. In one reported case (14), a healthy, nonsmoking female or twice, with a 6-week interval, has nearly always eliminated
patient underwent a single transplant procedure by an experi- the problem (12), but, occasionally, excision of the precipitating
enced surgeon. The procedure itself was normal, with a rela- focal site is necessary.
tively conservative number of grafts placed into small incisions
in the anterior scalp, and the surgeon did not use excessive
Hypoesthesia
epinephrine. Approximately 3 weeks postoperatively, the pa-
tient developed a blister followed by an area of necrosis 2 cm Many patients complain of decreased sensitivity of their scalps
⳯ 2.8 cm in the frontal recipient area. Cultures revealed rare after hair transplantation; this experience is normal and tempo-
organisms, and a biopsy showed normal granulation tissue. The rary and usually disappears in a matter of weeks or months
area healed uneventfully. There have been a few reports of after the surgery. Occasionally, it is permanent, but it is rarely
similar cases, but the cause for this phenomenon remains un- bothersome to those who have this occur. To avoid hypoesthe-
known. It has been suggested that a small subset of patients sia, the surgeon should be careful during donor harvesting to
may have a subclinical problem with the vascularity of their incise only as deeply as necessary. Use of tumescent anesthesia
scalps that makes them more susceptible to necrosis and that aids the surgeon in dissecting just below the hair bulbs, thereby
becomes apparent only when a transplant is carried out. decreasing the chance of transecting nerves.
Pain Scarring
Surgeons expect patients to experience a certain amount of post- With modern transplantation techniques, surgeons excise the
operative discomfort, especially in the donor area. For most donor area and close the wound with sutures, staples, and, more
patients, this pain is only mild and can be controlled adequately
by over-the-counter analgesics. Occasionally, patients experi-
ence severe pain and require prescription analgesics such as Table 14C–2 Frequency of Headache in the Four Pain Groups
narcotics. Rarely, some patients report chronic pain or an in- Before and After Operation in 18 Patients
crease in the frequency or severity of headache after transplanta-
tion. The latter phenomenon is so uncommon that a causative Tension headache Migraine Total
relationship to hair transplantation has never been established, Group (before/after) (before/after) (before/after)
and some have suggested a psychiatric rather than a physical
etiology. There is, in fact, evidence to suggest that hair trans- 1 10/0 3/0 13/0
2 4/1 1/1 5/2
plantation (and AR) may decrease the frequency and severity
3 0/7 0/3 0/10
of headaches. Ponten, for example, recorded decreased fre-
4 0/6 0/0 0/6
quency of headaches in one of every three patients who had
Total 14/14 4/4 18/18
undergone a frontal galeotomy (15). A decrease in scalp tension
recently, cyanoacrylate glue. Typically, scars are merely fine bulbs have a sharp, outward angle that make graft dissection
lines that are covered easily by the surrounding hair. and placement extremely difficult (18). With a mushy dermis,
transection rates are high and growth is often unexpectedly
Wide Scars poor. Stough proposes that a variation in the collagen structure
Occasionally, scarring may be wider than expected. This subject of these patients causes this condition.
is dealt with in Chapters 10 and 17.
Keloid or Hypertrophic Scars

CONCLUSION
Some patients are prone to keloid or hypertrophic scarring. These
are benign, proliferative growths that histologically consist of Complications associated with hair transplantation are, fortu-
thick, hyalinized collagen bands. They tend to occur in whorls nately, uncommon. Avoiding aesthetic complications requires
surrounding clusters of cells (i.e., macrophages, myofibroblasts, skill, experience, and an artistic eye. Preventing medical com-
and fibroblasts). The similarity, however, ends there. Hypertro- plications requires choice of a proper surgical technique, judi-
phic scars, by definition, remain well within the boundary of the cious use of medications, and continued availability to patients
original wound and usually begin soon after injury. Most impor- in the postoperative period. Some complications, nevertheless,
tantly, they often improve with time and are easily ameliorated occur; surgeons should advise all patients of this fact as part
with additional surgery, because avoidable factors such as ten- of the informed consent before the procedure.
sion, motion, and infection play a role in their formation and can
be minimized. Keloids, on the other hand, characteristically ov- Editor’s Comment
ergrow the boundary of the original wound and often may not
In more than 36 years, I have encountered only three or four
begin until many months after injury. Minor injuries may cause
patients who developed what appeared to be a chronic folliculi-
keloids in predisposed individuals (blacks, Asians, and pregnant
tis in the recipient area; the onset occurred years after their hair
women). If the surgeon is concerned that a keloid may form in
transplantation had been completed. No pathogenic organism or
the patient, a test graft should be performed and then observed
systemic or local cause was found, and the folliculitis followed a
for 3 months to see if one might appear (12). If keloidal scarring
occurs in the donor or recipient area, it should be treated with a chronic course of varying severity not just for weeks or months
series of injections of intralesional corticosteroids (e.g., triamcin- but also sometimes for several years. Cooley briefly mentions
olone acetonide 5 mg/mL to 20 mg/mL). Re-excising a keloid is chronic folliculitis in the preceding chapter, but the entity I am
not recommended because of its high recurrence rate. describing here generally occurs later and persists far longer
than usual. Because of these differences, I believe it deserves
Wound Dehiscence separate recognition and emphasis. Low-dose prolonged sys-
True wound dehiscence of the donor site is rare. It is more likely temic antibiotics, such as tetracycline, erythromycin, or ci-
to occur if the wound has been closed with excessive tension, if profloxacin (Cipro), daily hair washing with chlorhexidine glu-
it becomes infected, or if there is an unusual amount of bleeding conate or povidone-iodine shampoo, alcohol wipes two to three
postoperatively (12). If excessive bleeding does occur, the pa- times daily, and topical antibiotics such as baciguent, Pol-
tient should be treated for the underlying cause, and, whenever ysporin, or garamycin were often helpful in controlling the se-
reasonable, the site should be resutured within 8 hours, with the verity of the problem, but they failed to completely eradicate
sutures left in for 2 weeks. If such bleeding occurs 12 hours or it—until one day it disappears for no apparent new reason.
more after surgery, or if there is residual tension or significant Fortunately, as indicated, this type of chronic folliculitis is rare.
infection present, the wound should be left open to heal by sec- Physicians who are presented with this problem should be sym-
ondary intention and repaired at a later date (12). pathetic and supportive of the patient rather than allowing this
persistent problem to make them feel frustrated and impatient.
Hyperfibrotic Scarring Second and third professional opinions should also be sought
Hyperfribrotic scarring refers to thick, firm skin that rarely de- to reassure the patient that everything that can be done is, in
velops in the recipient area and that characteristically has a fact, being done.
distinct ridge at the junction of the forehead and that area (17). A single instance of septic pulmonary emboli from an in-
Its cause and treatment are discussed, in detail in Chapter 17. fected hair transplant was recently reported (1). Interestingly,
This entity was more common in the past, when large slit grafts this diagnosis was originally suggested by my daughter, Robin
or round grafts were, used in the frontal area. It has not yet Unger, who, as an intern assigned to the patient, persisted in
been reported with pure FU grafting. Unger took biopsies of this suggesting it to her supervisory staff. The report was published
type of lesion and found focal chronic inflammatory infiltrate in after she had left the service. A variety of treatments have been
the dermis and, more significantly, ectopic hair shafts devoid suggested for keloids (2–6). Keloids may be present on the
of follicular tissue in the subcutaneous tissue. He believed the trunk but not on the scalp after hair transplantation. In a similar
findings strongly suggested that the etiology of this disorder fashion, I have seen a keloid develop in the postauricular donor
was the trapping of hair shaft spicules and a secondary foreign
area of an Asian patient, whereas other (relatively nearby) donor
body reaction in susceptible individuals (12).
sites in the same individual healed beautifully. In brief, it would
appear that keloid formation, like hypertrophic scarring, is not
Mushy Dermis
due simply to an underlying inherent propensity to this kind of
Stough coined the term ‘‘mushy dermis’’ to describe patients healing but is also related to other factors such as location,
whose donor tissue has a soft, mushy quality and whose hair tension, type of injury, and infection. (WU)
574 Chapter 14
APPENDIX 14A POSTOPERATIVE Bandage

INSTRUCTIONS
Do not attempt to lift the bandage or check under it. It is impor-
Scheduled Date/Time of BANDAGE REMOVAL: tant that the bandage maintains firm, even pressure on the donor
Scheduled Date/Time of SUTURE REMOVAL: and recipient areas and does not shift overnight. You will have
been given a long piece of gauze. Before you go to sleep for
the evening, please wrap it over the top of the bandage and tie
PAIN MANAGEMENT
it underneath your chin to hold the bandage down firmly.
Before leaving the office, you will be given an envelope con-
taining the postoperative instructions, a roll of gauze, and a Bleeding
small envelope containing the following postoperative medica-
tions. Envelopes numbered 1, 2 and 3 are your pain medications. Significant bleeding rarely occurs after surgery. If it does, you
will notice a blood spot on the bandage.
1. Tylenol 噛3: Contains codeine, which may cause consti- If bleeding should occur:
pation.
2. Percocet: (Stronger than Tylenol 噛3) Must be taken ● Apply firm, steady pressure over the bleeding area for
with Gravol or Compazine to avoid nausea. 10–15 minutes without lifting the bandage. If the blood
3. Demerol: (Stronger than Percocet). Must be taken with spot on the bandage continues to spread, call Dr. Unger
Gravol or Compazine to avoid nausea. (See instructions at 416–944–9393 or 212–249–9393. You will hear the
below.) ‘‘after-hours’’ tape that will give the emergency phone
number you are to call. Leave a message to have the
GRAVOL IS FOR TORONTO PATIENTS; doctor or nurse return your call.
● If you experience bleeding in the days after the bandage
COMPAZINE IS FOR NEW YORK PATIENTS
has been removed, apply pressure as described above.
As soon as you experience any discomfort (do not wait for If at any time you are unable to stop the bleeding, call
pain), begin taking your pain medication. Take Tylenol 噛3 as our office.
directed on the package. If your discomfort does not subside
within 30–45 minutes after taking Tylenol, take the Percocet Bandage Removal
(preceded by Gravol/Compazine) as directed on the package.
If you are still having discomfort 30–45 minutes after taking the We have given you an appointment for the day after surgery
Percocet, take the Demerol as directed on the package. Continue to have your bandage removed. PLEASE EAT A GOOD
taking the pain medications at 3–4 hour intervals because they BREAKFAST BEFORE YOUR APPOINTMENT. You
will help control the discomfort. must be on time. Baseball caps are provided for all patients to
GRAVOL or COMPAZINE: To avoid nausea that may be wear on ‘‘bandage day.’’ Female patients may like to bring a
caused by either the Percocet or the Demerol, you must take scarf to use after the bandage is removed.
these 15 minutes before taking either of those medications. Gra- We suggest taking one Tylenol 噛3 for your comfort, 1 hour
vol should not be taken more than once every 4–6 hours. before your scheduled appointment time.
If you have to drive, please take two extra-strength Tylenol
instead of the Tylenol 噛3.
SERAX IS FOR TORONTO PATIENTS; AMBIEN Do not exert yourself for the first few hours after bandage
IS FOR NEW YORK PATIENTS removal.
SERAX or AMBIEN: To help you sleep comfortably the first We will give you some gauze to take with you after bandage
few nights after the surgery, you may take one or two of the removal. There occasionally is a small amount of bleeding from
Serax tablets or one-half to one of the Ambien sleeping pills the recipient and donor areas. Use the gauze to apply very gentle
approximately 30 minutes before going to sleep. pressure to the bleeding area for 5–10 minutes.
ANTIBIOTICS: You have already taken your first dose of The night of bandage removal, DO NOT soak, massage, or
two antibiotic pills. You must take two more antibiotic pills 6 shampoo your head. Just apply minoxidil and Surgilube, both
hours after the first dose, unless instructed otherwise. Please of which are provided.
eat before you take these pills.
DO NOT drive a car while taking any of the above pain or Swelling
sleep medications. Your reflexes will be impaired and driving
could be dangerous. Most people will experience some degree of forehead swelling.
DO NOT take any aspirin or medications containing aspirin Swelling is usually worst after the first session. To help prevent
for 2 days after surgery. swelling and bruising, follow the instructions below:
DO NOT drink any alcohol while on medication. You may You will be given two reusable ice packs on bandage-re-
want to have some extra-strength Tylenol on hand to take for moval day. Apply the ice packs to your forehead and to your
any discomfort you may have during the week after surgery. temporal and eye areas. DO NOT PLACE COLD PACKS
DIRECTLY ON THE GRAFTS. We recommend using the
Nourishment packs 10 minutes on and 20 minutes off, as often as possible
for the first few days after surgery.
It is very important to eat well and drink plenty of fluids, espe- Sleep with your head elevated at a 45-degree angle by using
cially water, on the night of the day you have surgery. three or four pillows, or sleep on a reclining chair for 1–5 nights
after surgery. In general, try to keep your head elevated for the DO NOT PICK AT OR OTHERWISE TRY TO REMOVE
first 5 days. THE CRUSTS. They will begin to fall off between 1–3 weeks
Note: If swelling should occur, we are sorry for any inconve- after surgery. Do not expect any hair growth for at least 3
nience or embarrassment it may cause you. Unfortunately, if months. This is perfectly normal. By 5 months, all grafts will
you call the office, there is no further treatment or medication have started to grow. However, the full cosmetic benefit is not
available. Nature must take its course. The swelling will gradu- reached until 9–12 months after surgery.
ally subside over 3–7 days.
Shampooing Infection
Beginning on the second day after surgery (the day after band- Infection is rare. The most important thing is to follow the
age removal), and for 1 week, or until your sutures are removed postoperative shampooing instructions. If you are going to be in
from the donor area, you should wash your hair TWICE daily, an area where there are environmental pollutants (construction
in the following manner: sites, dust, etc.), you should wear a hat. If you experience any
● Fill the bathtub with warm water; lie back in until the redness, swelling, tenderness, or ‘‘pus pimples’’ in the donor
water covers the donor areas (sutures). We recommend or recipient areas, call Dr. Unger’s office.
that you add Epsom salts to the bathwater to aid the
healing process.
● Soak the donor areas for 10 minutes. Numbness
● After soaking for 10 minutes, continue to soak while Many fine nerve endings are cut during each procedure, result-
gently massaging the donor areas with the pads of your ing in decreased sensitivity either in the donor or recipient areas
fingertips for another 10 minutes. or both. This decreased sensitivity is nearly always temporary
● After you have been soaking and massaging for 20min- and will resolve in 6 to 18 months.
utes, apply a wet face cloth to the recipient area, continu-
ously wetting it with bathwater. This helps dissolve the
Surgilube. Vitamins
● Gently shampoo your whole head with a mild shampoo
that contains no medications. Do not be afraid to get a There may be some benefit in taking vitamin supplements post-
good lather. Bring a cup into the bath and rinse off the operatively. You may take vitamin E, 800 I.U. per day, beginning
shampoo with clean, warm tap water,. 24 hours after surgery and continuing for at least 14 days. You
● Continue washing your hair in this way for the first 7 days. may also take vitamin C, 2000 mg per day, immediately after sur-
● Gently towel dry your hair. Apply minoxidil to the grafts gery and continuing for at least 14 days. A vitamin-mineral sup-
to assist the healing process. A prescription will have plement may also be taken beginning 24 hours after surgery.
been sent to you.
● Next, apply the water-based Surgilube to the recipient
area. As you heal…
Depression
Suture Removal
Some patients experience a brief period of ‘‘let-down’’ or
You have been given an appointment approximately 7–10 days depression the first few days after their hair transplantation.
after surgery to have the sutures removed. You may want to take This is, in some part, due to the Valium given preoperatively,
one or two extra-strength Tylenol one hour before you come to as well as the pain medications and the sleeping pills taken
the office to alleviate any slight discomfort that you may experi- during the postoperative night. Some patients may subcon-
ence. sciously have expected to feel and look better ‘‘instantly,’’ even
After your sutures have been removed, wash your hair daily
though they rationally understand that this will not be the case.
in the shower until all the crusts falloff.
During the first few postoperative days, patients sometimes
Exercise question whether they should have decided to have the surgery.
As healing occurs, these thoughts usually disappear quickly. If
We recommend that you do not exercise for 1 week. If you do you feel depressed, the understanding that this is a ‘‘natural’’
begin exercising after 7 days, or otherwise engage in activities phase of the healing process may help you.
that cause you to perspire, please wash your hair as soon as possi-
ble after the activity. This is to prevent infection. Maximum
weight lifting or any kind of heavy lifting must be avoided for 14 Healing
days after surgery. You may swim in a clean lake or a clean non- Another major factor in the course of healing is whether you fol-
public pool beginning the third day after surgery. Wait 2 weeks low the instructions given by the doctor verbally and the recom-
before swimming in a public pool or lake of uncertain cleanliness. mendations in these pages. Such guidelines are designed to pro-
mote the healing process and to prevent the occurrence of
ADDITIONAL INFORMATION anything that may interfere with recovery. It is imperative that
you recognize that you are a partner in this process and that you
Transplanted Hair Growth
have the responsibility to follow instructions carefully. Our in-
A few days after surgery, crusts will begin to form on the recipi- structions, based on broad experience, are designed to give the
ent site. These crusts are part of the normal healing process. best opportunity for healing without delay or surprise.
576 Chapter 14
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Forum Int 2000; 10:182–183.
1. Pouteaux P. Other alternatives. In: Unger W, Nordstrom R, eds. 24. Shapiro R. Sweating question. H T Forum Int 2000; 10:51.
Hair Transplantation. 2d ed.. New York: Marcel Dekker, 1979: 25. Beehner M. A technique for preventing cysts. H T Forum Int
581–589. 1995; 5:20.
2. Pouteaux P. Alternative approaches to transplantation. In: Unger 26. Randall JK. Surgical microbiology and antibiotic prophylaxis for
W, ed. Hair Transplantation. 3d ed.. New York: Marcel Dekker, hair restoration surgery. In: Stough DB, Haber RS, eds. Hair Re-
1995:436–442. placement. St. Louis: Mosby, 1996:68–76.
3. Morrison J. Tissue adhesives in hair transplant surgery. Plast Re-
constr Surg 1981; 68:491–497.
4. Orentreich N, Orentreich DS. ‘‘Cross-stitch’’: suture technique Editor’s Comments
for hair transplantation. J Dermatol Surg Oncol 1984; 10:970.
5. Unger W. Bandaging. In: Unger W, Nordstrom R, eds. Hair 1. Unger WP. Hair transplantation in early male pattern baldness.
Transplantation. 2d ed.. New York: Marcel Dekker, 1988: J Dermatol Surg Oncol 1984; 10:945–952.
375–380. 2. Unger WP. Postoperative course. In: Unger WP, ed. Hair Trans-
6. Lebovitz PJ. J Dermatol Surg Oncol 1980; 6:259–263. plantation. New York: Marcel Dekker, 1995:355.
3. Uremia S, Umar SH, Li CY. Prevention of temporal alopecia
following rhytidectomy:the prophylactic use of minoxidil. A
Management of the Postoperative Period study of 60 patients. Dermatol Surg 2002; 28:66–74.
4. Avram CY. The potential role of minoxidil in the hair transplanta-
1. Patrick J, Panzer JD, Derbes VJ. Neomycin sensitivity in the tion setting. J Dermatol Surg 2002; 28:894–900.
normal (nonatopic) individual. Arch Dermatol 1970; 102:32. 5. Unger W. The interview. In: Unger W, ed. Hair Transplantation.
2. Roupe G, Strannegard O. Anaphylactic shock elicited by topical 3d ed.. New York: Marcel Dekker, 1995:95.
administration of bacitracin. Arch Dermatol 1969; 100:450. 6. Unger W. Complications of hair transplantation. In: Unger W,
3. Kannon GA, Garrett AB. Moist wound healing with occlusive ed. Hair Transplantation. 3d ed.. New York: Marcel Dekker,
dressings. Dermatol Surg 1995; 21:583–590. 1995:366.
4. Perez-Meza D, Leavitt ML, Trachy RE. Clinical evaluation of
GraftCyte moist dressings on hair graft viability and quality of
healing. Int J Cosm Surg 1998; 6:80–84. Complications of Hair Transplantation
5. Hitzig GS. Enhanced healing and growth in hair transplantation
using copper peptides. Cosm Dermatol 2000; 13:18–22. 1. Greco JF, Kramer RD, Reynolds GD. A ‘‘crush study’’ review
6. Rietschel RL, Fowler JF. Reactions to selected topical medica- of micrograft survival. Dermatol Surg 1997; 23:752–755.
tions. In: Rietschel RL, Fowler JF, eds. Contact Dermatitis. Vol. 2. Gandelman M. Light and electron microscopic analysis of con-
10. Baltimore: Williams & Wilkins, 1995:152. trolled injury to follicular unit grafts. Dermatol Surg 2000; 26:
7. Spencer JM. Vitamin E could hinder wound healing, not help. 25–31.
Dermatol Times l999; 20:8. 3. Cooley J, Avram M. Follicle trauma and the role of the dissecting
8. Kassimir JJ. Use of topical minoxidil as a possible adjunct to hair microscope in hair transplantation: a multicenter study. Dermatol
transplant surgery. J Am Acad Dermatol 1987; 3:685–687. Clin April:307–313.
9. Bouhanna P. Topical minoxidil used before and after hair trans- 4. Kim YC, Choi YC. Regrowth of grafted human hair after removal
plantation. J Dermatol Surg Oncol 1989; 15:50–53. of the bulb. Dermatol Surg 1995; 21:312–313.
10. Langtry JAA, Maddin WS, Carruthers JA, Rivers JK. Is there a 5. Shiell S. X-factor: unexpected, unexplained reduced hair growth.
rationale for the drugs used in hair transplantation surgery. Der- In: Norwood O, Shiell S, eds. Hair Transplant Surgery. Spring-
matol Surg 1998; 24:967–71. field. IL: Charles C. Thomas, 1984:134.
11. Griffies WS, Kennedy K, Gasser C, Frankhauser C, Taylor R. 6. Bernstein RM, Rassman WR. The logic of follicular unit trans-
Steroids in rhinoplasty. Larygoscope 1989; 99:1161–1164. plantation. Dermatol Clin 1999; 17:277–295.
12. Hoffman DF, Cook TA, Quatela VC. Steroids and rhinoplasty. 7. Shapiro R. Look before you leap—an approach to megagraft hair
Arch Otolaryngol Head Neck Surg 1991; 117:1137–1141. transplantation, Annual scientific meeting of the American Acad-
13. Schaberg SJ, Stuller CB, Edwards SM. Effect of methylpredniso- emy of Cosmetic Surgery, January 1996, Orlando, FL.
lone on swelling after orthognathic surgery. J Oral Maxillofac 8. Brandy D. A technique for hair grafting in between existing folli-
Surg 1984; 42:356–361. cles in patients with early pattern baldness. Dermatol Surg 2000;
14. Echarvez MI, Mangat DS. Effects of steroids on mood, edema, 26:801–805.
and ecchymosis in facial plastic surgery. Arch Otolaryngol Head 9. Nelson B, Griffiths C, Stough D. Curly lusterless hair: anatomic
Neck Surg 1994; 120:1137–1141. surface changes of transplanted hair shafts [letter to editor]. J
15. Norwood OT. Say goodbye to postoperative swelling. H T Forum Dermatol Surg Oncol 1993; 19:1129–1130.
Int 1992; 3:13. 10. Sadick NS, Hashimoto K. Acquired post transplantation hair
16. Nordstrom RE, Nordstrom RM. The effect of corticosteroids on kinking. Dermatol Surg 1995; 21:261–262.
postoperative edema. In: Unger W, Nordstrom R, eds. Hair Trans- 11. Kim JC. Regeneration of the human scalp hair follicle after hori-
plantation. New York: Marcel Dekker, 1988:391–394. zontal sectioning: implication for pluripotent cells and melano-
17. Unger WP. Postoperative course. In: Unger W, Nordstrom R, cyte reservoir. In: Van Neste DJ, Randall VA, eds. Hair Research
eds. Hair Transplantation. Marcel Dekker: New York, 1995:356. for the Next Millennium: Science BV, 1996:136.
18. Seager DJ. Pain control and management of the postoperative 12. Unger WP. Hair Transplantation. 3d ed.. New York: Marcel Dek-
period. In Stough DB, ed. Hair replacement. St. Louis: Mosby, ker, 1995:363–374.
1996:105–110. 13. Jones WJ. Osteomyelitis of the skull following scalp reduction
19. Stough DB. Postoperative frontal central necrosis. Hair Trans- and hair plug transplantation. Ann Plast Surg 1980; 5:480–482.
plant Forum International. Vol. 9, 1999:56–57. 14. Stough DB. Post-operative frontal central necrosis. H T Forum
20. Unger WP. Complications. In: Unger WP, ed. Hair Transplanta- Int 1999; 9:56–57.
tion. 3d ed.. New York: Marcel Dekker, 1995:370. 15. Ponten B. The result of frontal galeotomies for loss of hair, a
21. Shiell RC. Hiccups. H T Forum Int 1995; 5:16–17. preliminary report. Acta Chir Scand 1963; 126:406.
16. Nordstrom R. Change of rate of headache after punch grafting. 2. Gold M. Topical silicone gel sheeting on the treatment of hypertro-
In: Unger W, Nordstrom R, eds. Hair Transplantation. 2d ed.. phic scars and keloids. J Dermatol Surg Oncol 1993; 19:912–916.
New York: Marcel Dekker, 1988:395–397. 3. Larabee WF, East CA. Intralesional interferon gamma treatment
17. Unger M. Hyperfibrotic transplants. H T Forum Int 1993; 3:8–9. for keloids and hypertrophic scars. Arch Otolarnygol Head Neck
18. Stough DB. Mushy dermis. H T Forum Int 1998; 8:23. Surg 1990; 116:1159–1162.
4. Craig DPD, Pearson D. Early postoperative irradiation of keloid
scars. Br J Plast Surg 1965; 18:369–376.
Editor’s Comment 5. Ollstein RN, Siegel HW, Cillooley JF. Treatment of keloids by
combined surgical excision and immediate postoperative x-ray
1. Hirsch BE, Salibian MS, Arunabh, Roethel M, and Kagan E. therapy. Ann Plast Surg 1981; 7:281–285.
Staphylococcus Aureus Sepsis Complicating Hair Transplant. In- 6. Brody GS. Keloids and hypertrophic scars. Plast Reconstr Surg
fectious Diseases in Clinical Practice 2001; 10(2):101–2. 1990; 6:804–808.
15
Transplanting Areas That Need Special
Consideration
15A. Eyebrow, Eyelash, Mustache, split into single-hair grafts. The operator takes great care to cut
between the FUs and at the same angle as the hair follicles grow.
and Pubic Area Hair The operator closely trims the grafts to eliminate all unneeded
Transplantation dermis and subcutaneous tissue and, therefore, provides clean
and neatly trimmed grafts that fit into the 21-gauge needle of
Yung-Chul Choi and Jung-Chul Kim
the Choi implanter. Grafts that are clean and closely trimmed
allow for implantation with a greater density than grafts that
INTRODUCTION have the surrounding dermis attached. This method of creating
If the naked eye can identify a hair transplant, the transplant single-hair FUGs is different from that used in many other parts
has not achieved its greatest capability: an absolute and artificial of the world because it does not employ the use of ‘‘slivering’’
naturalness. Single-hair transplantation restores hair to eye- or a microscope. We are able to use this method because the
brows, eyelashes, mustaches, and pubic areas in an elegant, combination of high hair-shaft caliber and low follicular unit
natural manner that is indistinguishable from the original hair density (FUD) in the typical Asian patient allows one to more
that occupied these areas (1). The process of single-hair trans- easily dissect in between individual FUs without transection. In
plantation involves the joint efforts of physician and highly Caucasian patients, microscopic dissection of FUs is commonly
trained and experienced assistants. The following is a descrip- employed (see Chapter 11A, B, and C).
tion of the technique we use in our office to perform these We typically use a mechanical hair transplantation device
procedures. called the ‘‘Choi’’ Implanter to simultaneously make the inci-
sion and plant the graft. The operator inserts hair grafts into
the needle of the Choi implanter by means of jeweler’s forceps
GENERAL TECHNIQUE (Fig. 15A-1). The needle is then inserted into the skin at the
desired angle and the plunger is pushed. The needle automati-
The surgeon and assistants perform each of the aforementioned cally withdraws, leaving the hair follicle neatly tucked under
procedures with the patient under local anesthesia: 2% lidocaine the skin, and the ring around the needle holds the single-hair
with 1:100,000 epinephrine and diazepam for mild sedation. graft in place while the needle is withdrawn. Once the graft is
The surgeon uses the lateral aspect of the occipital region as in place, an assistant applies gentle pressure with a swab while
the selected donor site because this area contains the greatest the operator inserts adjacent hair grafts. The grafts require nei-
number of single-hair follicular units (FUs) as well as hairs ther dressings nor bandages.
with the finest diameter.The surgeon excises a donor strip from Throughout the cutting and grafting process, the staff main-
the occipital scalp after clipping hair in the donor area to a tains all grafts and donor tissue in sterile petri dishes holding
length of 1 cm to 1.5 cm. The surgeon then closes the donor chilled saline solution, and the dishes are supported on frozen
area with sutures, which are generally removed 10 days postop- packs.
eratively.
The next step is to produce single-hair follicular unit grafts
(FUGs) from the harvested donor tissue. After placing the ex- EYEBROW
cised strip on a block of birch wood, the operator divides it
into smaller segments using a No. 20 scalpel blade carefully The cause of an eyebrow defect may be a burn, trauma, alopecia
positioned between the visible hair follicles. With the same areata, or leprosy. Many patients who need eyebrow transplan-
blade, the operator cuts each segment into FUs, which are then tation, especially Asians, have patchy or thin (low-density) eye-
579
580 Chapter 15
Figure 15A-1 Single-hair graft being loaded into a Choi im-

a
planter.
brows. Successfully reconstructing the eyebrow depends on the

surgeon’s ability to reproduce the direction and angle of a nor-
mal eyebrow with the use of single-hair grafts.
While observing the normal eyebrow, one notices the flat
angle of the hairs against the skin, the upward direction of
growth in the medial part of the brow, and the convergence of
hairs in the lateral part. Surgeons usually reconstruct the medial
part of the brow with a convergent and more lateral direction,
however, because the transplanted hair is thicker than normal
eyebrow hair (Fig. 15A-2a, b, and c).
EYELASH
The eyelid is anesthetized with 2% lidocaine and the cornea
is anesthetized with a topical ophthalmic lidocaine solution. b
Afterward, the operator places an eye shield under the patient’s
eyelid to protect the cornea.
1. ‘‘Sewing’’ technique: In 1994, Caputy and Flowers (2)
reported the ‘‘pluck- and-sew’’ technique of individual
hair follicle placement. We have modified this method
to reconstruct eyelashes. The surgeon and assistants pre-
pare single hair grafts with long hair, using the same
technique described earlier (we do not use the pluck
technique for isolating single-hair grafts). The hair end
loops through the eye of the curved needle. The surgeon
inserts the needle into the skin of the anesthetized eyelid
and brings it out through the edge of the eyelid at the
exact site and correct angle for an eyelash. The hair is
then pulled through until the follicle enters the tunnel
created by the needle (Fig. 15A-3). The surgeon inserts
approximately 50 single-hair grafts to reconstruct both
eyelashes in a single session. c
2. Choi implanter technique: The surgeon inserts the
needle of the Choi implanter into the edge of the eyelid
and pushes the plunger as the left finger steadies the Figure 15A-2 (a), Hair direction of a reconstructed eyebrow.
eyelid. The hair follicle remains in the eyelid while the (b), Preoperative view showing little or no hair on the eyebrow.
needle is withdrawn. (c), Postoperative view of the reconstructed eyebrow.
MUSTACHE
The single-hair transplantation technique as described can be
applied to reconstruct mustaches in cases in which the surgeon
Transplanting Areas That Need Special Consideration 581
a
a
Figure 15A-3 (a), The hair is pulled through the edge of the b
eyelash in the tunnel created by the needle. (b), Early postoperative
view of a reconstructed eyelash.
camouflages a scarred upper lip as a result of cleft lip sequelae,

burn, trauma, or cancer (Figs. 15 A-4a, b, and c). The physician
must take care to avoid damaging the mandibular or facial
nerves during graft insertion. A few grafts are usually dislodged
in the early postoperative days because of the high mobility of
the skin in this area. Once again, the angle at which the hair
exits the epidermis is acutely flat against the skin. Hair direction
of the mustache is primarily directed downward on the medial
part of the mustache near the philtrum. As one moves away
from the philtrum, a slight lateral trend may develop in the
direction of the hair. The density of hair on the philtrum may
be slightly less than that of the rest of the mustache.
Pubic Hair
Hypotrichosis of the pubis, or hairless mons pubis, is a heteroge- c
neous group of diseases (3). Although genetic abnormality, hor-
monal or receptor defects, and ectodermal defects are present Figure 15A-4 (a), Early postoperative view of a reconstructed
in some patients, the majority of causes are idiopathic. This mustache. (b), Before photo (close-up) of a cleft-lip deformity (x)
condition is common in Mongolian women (4). Besides the (c), One year after repair of a cleft-lip deformity.
582 Chapter 15
aesthetic problem, this condition may cause the patient to expe-

rience low self-esteem, social embarrassment, and psychologi-
cal problems. Therefore, rapid and precise reconstruction aids
the patient’s mental health.
The transplantation methods (primarily with single-hair
grafting) and the need for orientation of hair growth in the
proper direction are also important. Additionally, it is essential
to discuss carefully the patient’s desires and expectations and
to outline in detail the area to be transplanted before performing a b
the procedure.
Dupertius (5) describes pubic hair patterns according to their
distribution and density. The horizontal type is the most com- Figure E15A-1 (a), Photograph of a male patient before eye-
mon pattern in young females, and it looks like an inverted brow transplant. (b), Photograph of the same patient indicating the
triangular extending to the medial surface of the thighs. The pattern of the transplanted eyebrow.
sagittal type, the second most common pattern in women, mim-
ics a diamond shape, pointing upward toward the umbilicus.
Our experience shows that most patients who want pubic hair
transplantation favor the horizontal-type design (Fig.15A-5). ters to transplant these areas, other, more traditional methods
of graft insertion have also been used successfully. Some physi-
Editor’s Comment cians use a 19-gauge to 21-gauge needle with the stick-and-
place method describe by Seager in Chapter 13B. Others make
In transplantation of eyelashes, only well trimmed one-hair FUs all the incisions first with a tiny microblade, such as a 15-degree
should be used. The same is generally true for mustaches, Sharpoint, and place the grafts afterward. Whatever technique is
beards, and eyebrows. However, for these areas of transplanta- used, the physician must be prepared to deal with the increased
tion in patients with fine hair, some physicians have found the vascularity, bleeding, and mobility of these areas. Controlling
selected use of a small percentage of two-hair FUs acceptable. the bleeding and stabilizing the tissue takes an increased level
Remember that even apparently ‘‘straight’’ scalp hair fre- of skill.
quently has a slight curl or curve to it that must be taken into Optimal aesthetic results depend on using the right size and
account when the grafts are planted. For eyelashes, the curve caliber of hair as well as mimicking the pattern, direction, and
on the scalp should obviously be directed upward, whereas for angles found in nature.
mustaches, beards, and eyebrows, a downward direction should
be used. Eyelashes can also be transplanted using long-clipped
rather than short-clipped donor area hair and a French needle
as described briefly in this section. A longer, well-illustrated
discussion of this approach can be found in Hair Transplanta-
tion, the Art of Micrografting and Minigrafting (1).
As stated in this discussion, Dr. Choi and Dr. Kim use a
Choi implanter for procedures in these areas. Since this chapter
was written, Dr. Kim has started using a slightly modified ver-
sion of the Choi implanter called the Knu implanter (see Chapter
13A). Although Dr. Choi and Dr. Kim use mechanical implan-
Figure 15A-5 Postoperative view of a horizontal-type repair Figure E15A-2 Photograph of a woman showing the natural
of the pubic region. hair direction in a normal eyebrow.
When transplanting eyebrows, I have found it advantageous the eyebrow vary considerably as shown in five individuals
to have the patient lie on the left or right side rather than in in Figs. E15A-1 to E15A-3. We nearly always glue the hairs
the supine position that I use in most transplanting sessions. I very carefully into place with cyanoacrylate glue. Extreme
am better able to insert the needle consistently at a sufficiently care must be taken not to accidentally get the glue in the
acute angle with the patient in this position. It is also important eye. Needless to say, the patient’s eyelids are kept closed
to search for an appropriate donor area containing hair with a during the gluing process.
caliber as close as possible to that of the original eyebrows and All of the aforementioned recommendations also apply to
to seek out areas where the hair is least likely to turn gray or hair transplantation in the temporal areas, except that FUs con-
white. (Eyebrows often remain pigmented long after most of taining more than two hairs may be used in the temporal area.
the scalp hair has become white.) Sometimes, it is not possible (Its anterior border is, of course, still produced with single-
to find a donor site where the desired hair coloring and caliber haired FUs.)
prerequisites are both present; in such cases, compromises must
be made. Unless the hair caliber is significantly greater, I prefer
to choose areas that are more likely to maintain their dark color-
ing than areas where the caliber is ideal.
As implied by the foregoing, the angle at which the hair
exits the skin is particularly acute in the eyebrows. In addition,
the borders of the eyebrow hair must be irregular—just as in
the hairline. I use partial hair follicles and FUs containing single
hairs in the peripheral areas of the eyebrows, and I never use
anything larger than a two-hair FU. Follicular units that contain
more than two hairs are longitudinally sectioned into one-hair
and two-hair units. Patients are forewarned that they will likely
need a second session and, occasionally, even a third session.
Although one session is often satisfactory, it is best to plan
for the worst rather than the best possible scenario; moreover,
patients’ density objectives can vary significantly. The width
of the eyebrow hair should be consistent bilaterally and should
taper gradually as in a normal eyebrow. Hair directions in
b Figure E15A-4 Photograph of pubic area before transplanta-

tion. (Photograph of pubic area after transplantation. (a and b, Cour-
tesy of Catello Balsamo, MD. From Balsamo C. 2002. Axillary
Figure E15A-3 A photograph of a man showing the natural hair as an alternative to scalp hair in pubic transplant, H T Forum
hair direction in a normal eyebrow. Int 12:4:149, with permission.)
584 Chapter 15
Catello Balsamo has published an article on the use of the P ⳱ Recession is parallel to the anterior sideburn line (Fig.
axilla as a donor site for hair to be transplanted into the pubic 15B-2c)
area (2) (Fig. 15A-4). The advantages of this donor site are that R ⳱ Recession has caused a reversed angle that is usually
‘‘axillary hair is very similar to pubic hair and, importantly, anteriorly convex but is now concave (Fig. 15B-2d)
the patient does not suffer the inconvenience of having continu-
ously to cut back excess growth, as is the case when scalp hair This straightforward classification, which uses capital letters N,
is used.’’ Balsamo was surprised by the relatively small number T, P, and R, can be added in brackets after the usual Norwood
of FUs that could be obtained from a 3.5 cm ⳯ 1.8 cm axillary classification to further define the patient’s current hair loss
strip—59 FUs—and the relatively longer period between the status (e.g. VI (T) or VI (P)).
transplant and the onset of hair growth in the recipient area. In Patients in classes N and T usually require no augmentation.
all other respects, he found the procedure quite similar to the These patients should be encouraged to use finasteride (Pro-
more conventional transplantation of scalp hair. (WU) pecia) and/or topical minoxidil (Rogaine)to prevent further thin-
ning. Classes P and R should be considered for surgical aug-
mentation. Of course, the patient’s objective is most important,
but the physician’s advice is also of great value in helping the
15B. Transplantation of Temporal patient to understand the options.
Points After evaluating scores of ‘‘normal’’ anterior temporal
points, it was noted that the usual balance of the point with the
Melvin L. Mayer and David Perez-Meza
frontal hairline is to place it where the following two lines
intersect (Fig. 15B-3):
INTRODUCTION
Line 1 is drawn from the tip of the nose, over the center of
Hair transplant surgeons have continued to refine and produce the pupil.
increased naturalness with the use of follicular units (FUs). Line 2 is drawn from the proposed most anterior point of
However, many have been reluctant to rebuild temporal points the frontal hairline to the tip of the ear lobe.
because of prior warnings about doing this and because they
were afraid of producing unnatural results. Nordström, for ex- The point where the two lines intersect is an excellent reference
ample, encouraged hair transplant surgeons to avoid rebuilding for placement of the anterior tip of the temporal point. However,
the temporal points in the era of larger grafts (1). This was surgeons should never allow the above rule of thumb to override
excellent advice in the past, and, certainly, the inexperienced their own artistic judgment. They must learn to look at the shape
surgeon should not attempt augmenting the temporal points. It of the patient’s head while balancing the aesthetics of the eye,
was very difficult to get a natural result with grafts containing ear, and nose and, at the same time, remembering the patient’s
more than three hairs. Unger also suggested that patients should restoration goals. Also, remembering always that hair loss is
not generally be encouraged to have transplantation into the progressive; surgeons must use ‘‘time-machine’’ tactic and en-
temporal area, because, ultimately, increasing the size of the vision the patient 30 to 40 years later.
recipient area would decrease the likelihood of having the op-
tion to restore the entire area of male pattern baldness (MPB).
He also pointed out that it could be difficult to match the texture SURGICAL TECHNIQUE
and caliber of hair in the temporal recipient area with hair taken
from the usual donor sites (2). Khan and Stough suggested that Surgical techniques are similar to those employed in transplant-
temporal peaks should not be reconstructed (3). Unfortunately, ing eyebrows, with exclusive use of FUs. After the design is
for most practitioners, the result of all this advice has been a drawn with a black grease pen, a surgical marker is used to
delay in confident rebuilding of the temporal points. place irregular dots that outline the proposed temporal point.
Lack of emphasis on reconstructing temporal points is also These do not rub off when the anesthesia is introduced or when
reflected in the fact that the problems of hair loss and recession the area is cleansed with an antiseptic agent such as chlorhexi-
of the points are not addressed in Hamilton’s classification (4) dine gluconate with alcohol (Hibiclens).
or in the later, more widely accepted Norwood Classification The best match of hair color and caliber is usually found in
(5). Examination of this classification reveals that all examples the supra auricular or the supra-postauricular area (Fig. 15B-
on the chart from types I to VII have exactly the same well- 4). To avoid creating a very unnatural appearance, it is impera-
developed temporal points (Fig. 15B-1). What needs to be tive to match the color of the transplanted hair to that of the
added to this most popular classification is an easily understood hair in the receding temporal point. It is better not to build out
description that stages the temporal point hair loss, which is, the point if no matching hair color is available. Because the
in fact, a component of virtually all stages of advancing MPB. best match of hair color and caliber is found in the supra-auricu-
lar area, the planned incision should be extended to include hair
from this area when the donor strip is taken. The hair should
CLASSIFICATION OF TEMPORAL POINT always be left at least 1 cm long (Fig. 15B-5). This ensures an
RECESSION easier determination of curl and hair direction when the FUs
are placed into the recipient area (Fig. 15B-6).
To describe the temporal point status, it is useful to define the
The decision about the amount of donor hair to be used for
following four classes:
the points is made based on the calculation in square centimeters
N ⳱ No thinning or recession of temporal point hair (Fig. of the area to be restored. Twenty FUs/cm is a reasonable goal.
15B-2a) Usually, about 200 to 250 FUs are required per side. Only the
T ⳱ Thinning and mild recession (Fig. 15B-2b) one-hair and two-hair grafts should be used and, of course, only
Figure 15B-1 Standard Norwood classification. Notice that all are falsely shown with well-developed temporal points.
a Class N b Class T
Figure 15B-2 (a), Temporal point recession classification. (b), Temporal point recession classification. with mild recession. (c),Temporal
point recession classification. (d), Temporal point recession classification. N ⳱ Normal; P ⳱ parallel to anterior sideburn line; R ⳱
reversal of temporal angle; T ⳱ thinning.
586 Chapter 15
c Class P d Class R
Figure 15B-2
the naturally occurring single FUs should be placed at the edge To reproduce nature, observe that the hair in the points not
(Fig. 15B-7). only grows at a very acute angle but also inferiorly and poste-
When the sites are made, the bevel of the blade should al- riorly. There are usually a few miniaturized or vellus hairs that
ways be placed almost flat to the surface of the epidermis. The can be used as a template to duplicate the correct angle and
recipient sites in the edge are best made with an 18-gauge direction. As already noted, the needle or blade should be kept
needle. Single-hair FUs fit well into these sites. More central as flat as possible to create these acute angles. The skin must
to the point, posterior to the single-hair FUs, an SP 89 blade also be kept tight by the surgeon’s index finger and thumb as
that is laid almost flat to the skin surface creates an excellent the sites are made with the other hand. (Fig. 15B-9).
site for two-haired FUs (Figs. 15B-8a,b). A more natural result
is obtained by using three-hair FUs in other areas of the trans-
plant, unless the patient has extremely fine, blond, or grey hair, POSTOPERATIVE CARE
or is of the black race. A very useful dressing can be made from a 4-inch square piece
of Vigilon, cut diagonally corner to corner, which creates two
triangles that fit perfectly over the temporal points. Gauze topped
Figure 15B-3 Anterior point of the temporal point is located

at the intersection of two lines: Line 噛1 (solid) is through the tip
of the nose, pupil, and temporal point. Line 噛2 (dotted) is through
the midpoint of the anterior frontal hairline and the tip of the ear-
lobe. These are guidelines, but artistic judgment should also be Figure 15B-4 The supra-auricular area has the best match of
used. donor hair color and caliber.
Figure 15B-5 Keeping the hair 1 cm long helps determine

angle and direction of the hair during insertion. a
Figure 15B-6 The hair should be inserted so that it curls inferi- Figure 15B-8 (a), Solid core, 18-gauge needle with bevel vir-
orly and toward the skin. tually flat to the skin. (b), SP 89 blade positioned virtually flat to
the skin.
with a Kerlex wrap keeps the patient from rubbing the grafts out
as a result of friction of the head against a pillow (Fig. 15B-10a,b).
The patient must always be informed that despite postoperative
use of glucocorticosteroids, there is an increased risk of periorbi-
tal and nasal bridge edema (30% to 40%) when temporal points
are built out. Also, when the temporal points are reconstructed,
the surgery is anatomically close to the orbits, which entails an
increased risk of infraorbital ecchymosis. Neither edema or ec-
chymosis is likely to occur until the third to fifth postoperative
day.
CONCLUSION
Use of the classification described herein, combined with pa-
tient evaluation, artistic considerations, surgical techniques, and
postoperative care, enables the transplant surgeon to augment
the temporal points with confidence and assurance of obtaining
Figure 15B-7 Only single-hair follicular units (FUs) should a natural-looking result (Fig. 15B-11a, and b), (Fig. 15B-12a
be used at the anterior border of the temporal points. Two-hair FUs and b) (15B-13a, b, and c), (Fig. 15B-14a, b, c, and d), (Fig.
can be used in the central and posterior portion. 15B-15a, and b).
588 Chapter 15
Figure 15B-9 Skin should be kept taut to assist with insertion of the bevel of a solid core 18-gauge needle at a very acute flat angle.
a b
Figure 15B-10 (a), Triangular piece of Vigilon used as a dressing. (b), Temporal point bandage using Kling over a triangular piece
of Vigilon.
a b
Figure 15B-11 (a), Preoperative photograph of patient no. 1. He is a class III (P). (b), Postoperative photograph of patient no. 1 after
two surgeries that used follicular units at each temporal point. P ⳱ Parallel temporal thinning.
a b
Figure 15B-12 (a), Preoperative photograph of patient no. 2. He is a class V (P). (b), Postoperative photograph of patient no. 2 after
two procedures with follicular units transplanted to the temporal points.
590 Chapter 15
a b
Figure 15B-13 (a), Preoperative photograph of patient no. 3. He is a class IV (P) patient. (b), Postoperative photograph of patient
no. 3. (c), Close-up postoperative photograph of patient no. 3.
a b
Figure 15B-14 (a), Preoperative photograph of patient no. 4. He is a Class III (R) (b), Postoperative photograph of patient no. 4
immediately after surgery. Notice the pattern of the grafts. (c), Postoperative photograph of patient no. 4 after two surgeries, totaling
approximately 250 FUs in each point, have matured. (d), Close-up postoperative photograph of patient no. 4 after two surgeries. (R) ⳱
reversal of temporal points.
c d
a b
Figure 15B-15 (a), Preoperative photograph of female patient no. 5 with alopecia of the temporal area. (b), Close-up postoperative
photograph of female patient no. 5 after transplantation of 200 follicular units into the temporal areas.
15C. Hair Transplantation in Asian ern cultures, MPB was once a sign of wealth and virtue. In
Japan, before the Tokugawa Shogunate collapsed in 1868, the
Patients unique hairstyles of the age obscured baldness. Differences in
Kenichiro Imagawa style corresponded to differences in rank and class—Samurai,
merchant, farmer—but all men shaved the frontoparietal por-
INTRODUCTION tion of their heads throughout their lives, so baldness proceeded
invisibly (Fig. 15C-1). In modern times, however, the Japanese
and other Asians have become more concerned about hair loss
Asians include a wide variety of people distributed geographi- and baldness.
cally from the Middle East to the Far East, but in this chapter,
the word ‘‘Asian’’ is used specifically to identify ethnic groups
composed of individuals who have Mongolian blood, such as ETHNIC CONSIDERATIONS
the Japanese, the Koreans, and the Chinese.
Historically, Asians have been less concerned with male pat- It is extremely important to consider the differences in hair
tern baldness (MPB) than Caucasians, perhaps because in East- characteristics that exist between Asians and Caucasians.
592 Chapter 15
pale color of the scalp very clearly shows through the straight
black hair.
Conversely, the larger caliber of Asian hair shafts contrib-
utes to a greater appearance of density. The average diameter
of hair shafts in Asians is more than 100 ␮, which is much
larger than the usual 70-␮ diameters found in Caucasians. Con-
sequently, the same amount of hair produces more coverage in
Asians than in Caucasians. At the same time, it is more difficult
to find the fine hairs that are needed to make a hairline and
part line look natural. (See also Chapter 23B.)
Hairline
The typical Asian scalp is round and wide compared with the
relatively long and narrow scalp of the average Caucasian. Per-
haps motivated by this difference, most Japanese men prefer
a low, straight hairline and a round, temporal angle. Stated
differently, noticeable frontal recessions are generally unac-
cepted by Japanese men, even though the surgeon occasionally
advises this type of hairline. Furthermore, because of their
round, wide foreheads, Asian patients require more hair to cre-
ate the hairline than Caucasian patients (Fig. 15C-2). Several
reports classify Asian hairlines, but most of these hairlines are
not unique to Asians (4,5). One common hairline design created
in Japan is the widow’s peak, also called Fujibitai (‘‘the peak
of Mt. Fuji’’). As stated previously, the other difficulty in
achieving a natural hairline is the large caliber of Asian hair
shafts. Every effort should be made to search for and use the
finest hair in the most anterior lines of grafts.
Figure 15C-1 Kabuki actor, Sojuro Sawamura, who had the Excessive Scar Formation
typical hairstyle of Samurai. This Ukiyoe painting was produced
by Tokokuni Utagawa between 1789 and 1801. The Asian scalp is thicker and less elastic than the Caucasian
scalp and suffers a higher incidence of keloid or hypertrophic
scarring at the donor site. Excessive tension causes scarring,
and, therefore, surgeons should avoid creating donor resections
that are wider than 1.5 cm. Of course, multiple sessions increase
Hair Density the risk of hypertrophic scarring. In my experience, however,
Ezaki estimates that the average hair density in Japanese men Asian patients have not experienced excessive scar formation
is 130 hairs/cm2 (1), and Pathomvanich reports that Thai men at the recipient site.
have a hair density of fewer than 20 hairs/4 mm2 (equal to
100–200 hairs/cm2) (2). I have counted donor density using
5-mm field dermatoscopy and found an average density of 160
hairs/cm2 (80 follicular units [FUs]/cm2), which is higher than
that reported in previous research. Nevertheless, the hair density
of Asians is undoubtedly lower than that of Caucasians, who
average 200 hairs/cm2 (3).
Asians have a predominately large proportion of two-hair
follicles. They form, on average, 50% to 55% of the total hair
follicles; single-hair follicles compose 30%, and three-hair folli-
cles compose 10% to 15%. Asians rarely possess four-hair folli-
cles. (See also Chapter 23B.)
Hair Character
Most Asian patients have straight black hair and light skin color,
both of which make it difficult to achieve the appearance of
density. Straight hair appears less dense than curly hair, and
black hair creates a strong contrast with the usually pale Asian Figure 15C-2 Comparative anatomy of the scalp and hairline.
skin color. This high skin/hair color contrast also makes it very A typical Asian scalp is round and wide and the hairline is flatter
difficult to achieve the illusion of fullness. This is because the than that of a typical Caucasian.
TECHNIQUES OF HAIR RESTORATION IN number of FUs seen through the dermatoscope are counted and
ASIAN PATIENTS then the number of hairs/1 cm2 are estimated by multiplying
the number of FUs by 8. The patient is sedated and a tumescent
Alopecia Reduction technique is employed to anesthetize the donor area. To mini-
mize the number of transected follicles, I perform a new ap-
Alopecia reductions (ARs) are not common in Japan. Only a
proach called the open technique or donor dissection (6). A
few doctors are skilled AR practitioners, and that number has
噛15 scalpel is used to make a superficial incision in the donor
declined because wide scars in the thinning areas are extremely
area, and then a small skin hook is used to assist cutting more
obvious in Asians patients. Additionally, many Japanese pa-
deeply until the hair follicles can be viewed directly. Cotton
tients are intolerant of the pain and other potential problems
swabs keep the field clear of blood. The surgeon excises 1-cm
associated with AR surgery, such as stretch-back, stretch-atro-
long blocks at a time and closes the final wound with intrader-
phy, slots, etc.
mal Maxon 3–0 sutures and 4–0 nylon skin sutures. All proce-
dures are performed 2.5⳯ magnification.
Hair-Bearing Flap
Japanese surgeons still employ several kinds of flaps for hair Graft Dissection
restoration surgery, and many physicians believe flaps work To aid the dissection process, the surgeon uses stereomicro-
better than grafts for the coarse, straight hair characteristic of scopes when dissecting FUs and loupe magnifiers with transillu-
Asian patients. Currently, I use flaps in the following situation: minators when dissecting minigrafts. A Ringer lactate solution,
kept cool on ice and monitored by a thermostat, holds the grafts
1. Patient preference for a flap until they are ready for implantation.
2. To treat patients with complications of artificial hair
implantation, such as infection or scar formation Recipient Site
3. For other reconstruction cases, such as burns, nevi, etc.
At the recipient site, the surgeon makes a microslit for a one-
The high incidence of smoking in Asians patients (55% of Japa- hair follicle with a 19-gauge solid-core needle, and, for two and
nese men smoke) increases the risks of telogen effluvium and three-hair follicles, uses an 18-gauge NoKor needle. A Swann
necrosis during flap procedures. These complications and im- Morton SP90 miniblade is employed to create sites for mini-
provements in hair transplantation have decreased the use of grafts. For cases in which artificial hairs need to be removed,
flaps for cosmetic purposes. the surgeon uses a 0.75-mm punch to make a microhole for
one-hair follicles, a 1-mm punch for two-hair follicles, and a
Hair Transplantation 1.3-mm punch for three-hair follicles and for minigrafts. All
recipient sites are created first and then the grafts are inserted
The cornerstone of successful hair transplantation in Asian pa- with use of jeweler’s forceps.
tients is similar to that in Caucasian patients: the surgery re-
quires meticulous procedural planning. Bigger grafts are more Postoperative Course
conspicuous in Asian patients compared with those used in Cau- Shampooing is resumed 48 hours postoperatively, and the donor
casians because of the strong contrast between generally black sutures are removed on the 10th postoperative day. One trans-
hair and light skin of Asian patients’ and their large hair caliber. plant session achieves 25% to 30% (20 to 25 grafts/cm2) of
Thus, surgeons must develop and hone their techniques, guided the original donor area density, and most patients experience
by the demands of this specific consideration, to become knowl- satisfaction with two or three sessions in the same alopecic area.
edgeable in creating a favorable transplantation plan for Asian Sessions are generally spaced approximately 6 months apart
patients. (Figs. 15C-3 to 15C–6).
The Current Combination Transplantation

Technique
Follicular unit transplantation (FUT) has come into worldwide
use; sometimes, however, patients are dissatisfied with the low
density and high cost of this technique. Therefore, I perform a
combination method using FUs and small minigrafts (average
size: two FUs or four hairs per minigraft) that work more practi-
cally and effectively in Asian patients. This method achieves
a natural, dense appearance and is affordable because it reduces
operative time as well as equipment and labor costs.
Donor Harvesting
The surgeon photographs the patient and designs the hairline;
the hair is then trimmed in the donor area, which is located in
the midocciput, extending slightly into the temporal region. The
hair is trimmed to approximately 2 mm in length. I then evaluate
density using a dermatoscope with a 5-mm window. First, the Figure 15C-3 Preoperative view.
594 Chapter 15
Historical Perspective
A leading Japanese newspaper reported that 9.7 million Japa-
nese men (21%) have MPB, and, although the percentage of
Asian men who experience baldness appears lower than that of
Caucasian men (i.e., United States 34%, Germany 41%, Eng-
land 36%), Asian baldness has been increasing (7). According
to Inaba, an advocate of the sebaceous gland hypothesis, the
main cause of increasing baldness relates to dietary factors,
such as the increased intake of fats, but the proven etiology is
unknown (8).
Hairpieces and artificial hair grafts remain the most popular
forms of hair restoration in Asians. Surgical solutions are not
as popular as other methods because few public reports exist
in Japan about the improvements surgeons have made and con-
tinue to make in micrograft, minigraft, and follicular unit graft
(FUG) transplantation. Many people are surprised to learn that
Figure 15C-4 Fifteen weeks after one session of 700 mi-
surgeons practice specific techniques of transplantation in peo-
crografts and minigrafts.
ple of different races, all of which have distinct hair characteris-
tics. Specifically, many Asians are surprised that surgeons study
and work with characteristics specific to their hair and skin to
create successful, natural-looking transplants. For years, how-
ever, Western surgeons have performed successful micrograft,
minigraft, and FUG procedures for Asian patients.
Okuda was a pioneer of the standard graft (9), but many
surgeons have ceased to perform this kind of procedure in Japan.
Artificial hair techniques replaced the standard graft in the
1970s, because as noted earlier, the corn-row appearance of
poorly done transplants is especially conspicuous in Asian pa-
tients. In the 1990s, surgeons refined minigrafts, micrografts,
and FUGs, which became the standard techniques. Single-hair
transplantation for small, limited areas is another technique em-
ployed in Japan. Sasakawa first reported this procedure in 1930
(10). Tamura then reported its use for pubic atrichia (11), and
Fujita reported its capabilities in transplanting eyebrows (12).
No one attempted to use these techniques for generalized MPB,
however, until Choi in Korea invented the single hair ‘‘Choi
implanter’’ in 1992 (13). Later, Choi and Kim made a Choi
Figure 15C-5 Six months after first session before the perfor- implanter for larger two-hair and three-hair FUGs (14). They
mance of the second session. use the term ‘bundle hair,’ which is synonymous with the more
standardized phrase ‘follicular unit’ (FU). At present, the use
of the Choi implanter is considered one of the basic methods
of micrografting in Japan (Fig. 15C-7).
Figure 15C-6 Postoperative view. Two sessions were per-

formed. This view was obtained 1 year after the first session. Figure 15C-7 Two techniques in hair transplantation in Japan.
Mini/Micrografting vs. the Choi Implanter in Asian posed of biracial and multiracial individuals of African descent.
Patients For the purpose of this book, when this discussion refers to the
hair of black people, it defines that hair as having more black
Mini-micrografts and the Choi implanter are emblems of two than white or Asian characteristics. Hair characteristics of black
factions of FUT current in Japan, and, until now, no comparative patients present a special set of challenges and opportunities to
study has ever been completed, although Stough and Whitworth the hair restoration surgeon. If surgeons work skillfully with
performed comparative studies of all FU techniques (15). The these specific characteristics, they produce excellent results for
Choi implantation method is particularly effective for the the patient. Any prospective hair restoration patient, and partic-
coarse, larger caliber hair of Asians and reduces the total treat- ularly the black patient , requires careful evaluation and screen-
ment time needed for highly trained technicians to support the ing with a proper medical history and examination before
surgeon. Kim and Choi use the unaided or naked eye to dissect undergoing hair restoration surgery.
grafts. They believe they do not need magnification because of The surgeon must pay particular attention to histories of
the combination of low density and high caliber found in Asian keloid formation, hypopigmentation, hyperpigmentation, or any
patients, which makes it easier to cut between FUs. However, tendency toward psuedofolliculitis barbae. A search for previ-
not using magnification may increase the risk of transection. ous scars or injuries aids in identifying such characteristics. If
Several other disadvantages should also be mentioned regarding none are found but the history is questionable, the surgeon may
the use of mechanical implanters. want to perform one or more test grafts in an obscure area, such
Surgeons who use the Choi implanter have sometimes expe- as the parietal hair margin, and observe these grafts for 3 to 6
rienced poorer than expected hair growth in their patients, which months. If a tendency for keloid formation is found, the surgeon
may be related to technique or mechanical factors. Seager and should prudently advise the patient against transplantation.
Beehner report that excessively trimmed FUs with little protec-
tive dermis, subcutaneous fat, or sebaceous glands may have
an increased risk of poor growth (16,17). To fit into a Choi HAIR AND SKIN CHARACTERISTICS
implanter, FUs must be cut very ‘‘skinny’’. This may account
Curl
for poorer than expected growth, especially in patients with
very fine hair. The Choi implanter results in the poorest growth Black individuals have an unparalleled degree of curl in their
when surgeons use it to correct traumatic alopecia or scalp dam- hair. The hair develops this marked curl within the dermis,
age caused by artificial hair grafts. When the surgeon pushes where the follicle has an acute curve (Fig. 15D-1). The elliptical
the plungers, the high pressure applied to the grafts causes crush cross section and, tightly coiled helical nature of the hair shafts
injuries. Comparable instruments with the same automatic also influences the degree of curl (1) (Fig. 15D-2). It is my
mechanism also have similar drawbacks. Another relative dis- observation that an inverse relationship exists between the de-
advantage of the implanter is that the instrument requires that gree of curl and the white genetic characteristics that the black
donor hairs be at least 2 cm long for the surgeon to place them patient may have. The advantage of such an acute curl is that,
into the plunger. This makes it more difficult to accurately deter- compared with straight hair, each hair covers a significantly
mine donor density with the dermatoscope. greater amount of surface area in a given volume of space.
Each technique has advantages and disadvantages, and no Extremely curly hair, therefore, creates the illusion of density
method is clearly superior for transplanting in Asian patients, more effectively. Another advantage is that extremely curly
but further comparative studies of the techniques should be hair more effectively hides the point of insertion of grafts and
carried out to create new and better techniques in the future. therefore allows grafted hair to appear less noticeable than if
the hair was straight. A disadvantage of this type of hair in
transplantation is that it is more difficult to prepare grafts with-
CONCLUSION out transecting the follicles.
Hair transplantation technique should always be adjusted for
the individual being treated. Hair characteristics, head shape,
Minimal Hair/Skin Color Contrast
hair and skin color, and other unique features specific to Asians Skin color and hair color both depend on the amount of melanin
necessitate certain modifications in the treatment that has been they contain. In patients with both dark skin and dark hair, there
discussed. The perfecting of FUT and minigrafting in particular is little skin/hair color contrast, and this characteristic creates
has been very beneficial for Asians, who can now expect excel- a greater illusion of density and naturalness than is found with
lent results. a high skin/hair color contrast (2). (Chapter 12D)
Owing to both these characteristics—increased curl and low
skin/hair color contrast—the surgeon may be able to use larger
15D. Hair Restoration in Black minigrafts and still avoid creating a ‘‘grafty’’ appearance. This
may be useful because moving more hairs per graft decreases
Patients the risk of transection.
Melvin L. Mayer
DECREASED HAIR DENSITY AND POOR
INTRODUCTION DONOR-RECIPIENT RATIO
No ethnic group remains entirely homogeneous and uniracial. It is well documented that blacks have significantly less hair
The ‘‘black’’ community is actually, to a large extent, com- density than whites, in both donor and recipient areas (3). The
596 Chapter 15
in these patients also tend to have a smaller number of follicular

units (FUs) per graft than similar sizes and shapes of minigrafts
in whites. This reflects the natural low intrinsic density of the
donor area.
Patients’ hair can be transplanted using follicular unit grafts
(FUGs) exclusively or by combining FUGs with minigrafts.
For all the reasons discussed earlier, when working with black
patients, some surgeons prefer minigrafts instead of exclusive
FUs (4). On the other hand, there are proponents of total FU
grafting who argue that the surgeon can place the FUs as densely
as necessary to produce good coverage. I have seen both meth-
ods create excellent results. The key to success is to use the
type and/or combination of grafts with which the surgeon and
staff have the most experience and expertise.
DONOR HARVESTING
Before donor harvesting, it is helpful to use generous amounts
of saline solution for tissue tumescence. This prepares the donor
area for excision. As noted earlier, donor harvesting is more
difficult in black than in white patients because of the extreme
Figure 15D-1 Marked intradermal hair curl in a black patient. follicular curl in the former, which can lead to more hair-shaft
transections. By using generous amounts of tumescence, the
surgeon creates extra firm turgor and is potentially able to par-
tially straighten the curved hair follicle, which results in fewer
surgeon must account for this lower density when evaluating transections and, therefore, a better harvest.
and planning a patient’s transplant. Close examination reveals that the curl in the donor area
However, even though the density may be only 5 to 10 hairs generally curves inferiorly in the vertical plane. One must com-
per 4-mm diameter circle, these patients exhibit an excellent pensate for this curl when harvesting donor tissue. One method
appearance of fullness because of the characteristics described of doing this consists of using a single no. 10 or no.15 blade
earlier. Therefore, when restoring an alopecic area in black pa- bent with a needle holder to produce a blade whose curve ap-
tients, one does not have to achieve as high a mathematical proximates that of the curl of the follicles (Fig. 15D-3 and Fig.
density as in whites to have a successful result. As a result of 15D-4). Arnold demonstrated this technique at one of the live
the low donor hair density found in black patients, minigrafts surgery workshops in Orlando as a way of reducing the follicle
transection rate in such patients. Using the two outer blades of
a multibladed knife, one can achieve a similar advantage by
bending both blades to match the curl. Such a ‘‘modified’’
method may have an advantage over use of a single blade,
because it simultaneously makes the upper and lower incisions
while holding the skin stable. In contrast, when the surgeon
uses the single-blade method, the second cut occurs in tissue
that has less stability and, therefore, contains a higher risk of
follicle transection. However, a multibladed knife with all of
its interior blades in place should not be used in patients with
marked follicle curl, because this method produces unaccepta-
ble transection rates.
Some surgeons have, in the past, contended that they can
excise black donor tissue with fewer follicle transections by
using a power-driven punch and employing an arcing motion
(4). In this text, Leonard also advocates such an approach. In
my hands, the punch creates a higher transection rate per graft
than a curved single or double-bladed knife.
GRAFT PREPARATION
The harvested donor ellipse needs to be further dissected into
the final grafts. The first step in this process is to produce ‘‘sliv-
ers’’ by using the technique described in detail by Seager in
Figure 15D-2 Tightly coiled nature of hair shown in a black Chapter 11B. It is imperative to use magnification with a ster-
patient. eomicroscope or loupes, with close attention to the marked curl.
Figure 15D-5 Donor strip from a black patient; hairs appear

straight because the curl is in the vertical axis.
Figure 15D-3 A bent no. 15 blade can approximate the curl RECIPIENT AREA PREPARATION
in black patients.
Most authors agree that larger grafts can be used in black pa-
tients (2,4). Minigrafts of one and a half millimeters success-
fully move two or even three FUs per graft. On the other hand,
minigrafts larger than 2.0 mm, or ‘‘standard’’ grafts, may in-
The surgeon should perform slivering with a straight blade be- crease the risk of producing both hypopigmented halos at the
cause, as noted earlier, the curl has a vertical axis (Fig. 15D- outer edge of the grafts and an irregular skin surface. I typically
5). However, when the final micrografts and minigrafts are pro- use approximately 300 minigrafts and 400 micrografts (for the
duced from the slivers, a blade bent to match the curve of the frontal hairline) to graft the anterior half of a patient with a
curl in the hair shaft is often more effective. This technique class V male pattern baldness (Fig. 15D-7a, b, and c). Usually,
creates fewer transections because the curved angle of the blade two surgical procedures, 6 months apart, achieve the patient’s
matches that of the hair shaft (Fig. 15D-6). However, to avoid density objective. If surgeons exclusively use FUs, they require
follicle transection, if the surgical technician does not use a three times as many grafts to achieve similar results. Figure
curved blade, multiple, small cuts must be made during the 15D-8a to 15D-8e show the results after two procedures of
preparation of each graft. mixed grafting using 1.5-mm minigrafts, 2.0-mm minigrafts,
and one-hair to three-hair FUGs in a Hamilton class VI black
man.
Figure 15D-4 The curl curves inferiorly in the vertical plane Figure 15D-6 A bent razor or scalpel blade is helpful in prepar-
in black patients. A no.15 blade illustrates the position for incision. ing micrografts or minigrafts with less transection.
598 Chapter 15
a b c
Figure 15D-7 (a), Combination grafting preoperatively marked with a grease pencil; the surgeon anticipates transplanting 300 minigrafts
and 400 micrografts. (b), Combination grafts immediately after incisions have been made for 403 micrografts and 325 minigrafts (Hitzig
minislots). (c), Combination grafts immediately after placement in a black patient.
SPECIAL CASES by tight braiding can lead to alopecia and, over a long period
of time, permanent hair loss (7–9). Female patients with traction
Scarring with or Without Hypopigmentation alopecia resulting from tightly braided ‘‘corn rows,’’ a currently
Scarring with hypopigmentation has several etiologies, includ- popular hairstyle among young women, frequently consult hair
ing severe dermatitis, dermatoses such as lichen planus and restoration surgeons for advice (Fig. 15D-11).
lupus erythematosus, and physical trauma. In particular, exces-
sive exposure or sensitivity to chemicals used to straighten Pseudofolliculitis Barbae
curly hair destroys the hair follicle and produces hypopig-
mented scarring (5) (Fig. 15D-9a). One method of correcting Pseudofolliculitis barbae, commonly referred to as ‘‘razor
this problem is by excising the scarred area with extensive bumps’’ or ‘‘ingrown hairs,’’ occurs in patients who shave
undermining between the galea and the periostium and em- their very curly hair. This practice produces a foreign–body-
ploying advancement flaps as if performing a scalp reduction type inflammatory reaction on the face, which appears as a
(SR) procedure (Fig. 15D-9b) (6). The surgeon may also papular, pustular, and sometimes scarring condition (10,11).
consider grafting into a scarred area if test grafts are healthy The surgeon must consider and discuss this problem with a
or if a test of the area with an 18-gauge needle reveals an black patient who is considering a beard or mustache trans-
adequate blood supply. After sticking the recipient site with plant. If ingrown hairs are not pricked open with a sterile
an 18-gauge needle, the surgeon should observe blood within needle and treated with an appropriate antibiotic, they occa-
a few seconds. If the blood supply appears marginal, test sionally lead to an abscess and the ultimate death of the hair
grafts should be done before a full transplant session is follicle.
attempted or a recommendation should be made for surgical
reductions with an advancement flap. It is worth repeating
that, in my experience, if surgeons use circular punches SCALP REDUCTION
greater than 2.0 mm in diameter, they increase the risk of If the standard evaluation for a tendency to form keloid scars
producing ‘‘halo’’ hypopigmentation around the outer margin is satisfactory, an SR in a black patient can produce excellent
of the graft. ‘‘Cobblestoning’’ or ‘‘delling’’ may also occur results. Although hypopigmentation of the surgical incision oc-
with larger graft sizes. casionally occurs in some individuals, SRs are extremely effec-
tive in most black patients for the following reasons:
Hot Comb and Traction Alopecia
1. The skin has superior tensile strength but also maintains
Black female patients commonly experience hot comb and trac- significant elasticity. The thickness of the dermis in
tion alopecia (Fig. 15D-10a and b). Continuous traction caused blacks is greater than in whites.
a b
c d
Figure 15D-8 (a), Preoperative photographs of a black patient (top view). (b), Preoperative photograph of a black patient: posterior
view. Views of post-operative of results after two surgical procedures First surgery: (218) 2.0-mm minigrafts; 216 mini-slit grafts; and 275
micrografts; total ⳱ 709 grafts. Second surgery: (400) 1.5-mm minigrafts; 200 mini-slit grafts; and 250micrografts; total ⳱ 850 grafts.
(c ), Lateral view ; (d), top view; (e), posterior view.
600 Chapter 15
2. Because of the extreme hair curl, the SR scar is more

easily hidden and, therefore, requires fewer grafts to be
cosmetically camouflaged (6,12).
CREATING THE MALE HAIRLINE

Generally, the male hairline of a black patient is flatter than
that of a white patient (Figs. 15D-12 and 15D-13a and b). How- b
ever, as with any consultation, the surgeon must take into ac-
count the patient’s objectives when drawing the hairline. I find
Figure 15D-9 (a), Preoperative photograph of chemical burn
it useful to ask patients to bring earlier photos of themselves
from straightener solution. (b), Postoperative photograph of repair
or pictures from magazines that show their desired hairlines.
using scalp reduction with flap advancements and no grafting.
SUMMARY
Several particular hair and skin characteristics make hair resto- scars compared with whites and Asians. Bernstein is
ration surgery both easier and more challenging in black pa- correct in noting that surgeons can be easily ‘‘fooled’’
tients. With a careful history, knowledgeable patient selection, by the apparent pre-operative scalp laxity of black
appropriate expectations, and supportive adjustments in surgical individuals. At the time of suturing, the donor wound
technique—including graft sizes and numbers—surgeons can tension is often greater than was anticipated on the
achieve excellent hair transplant results for black patients. basis of the pre-operative examination(1). Per usual,
the less closing tension, the less likely the production
Editor’s Comment of unsatisfactory scars.
There is general agreement among hair restoration surgeons 2. Although donor area hair and FU density are less than
that the treatment of black patients requires some unique altera- those in whites—typically 0.6 FUs/mm2 —expected
tions in planning and technique that can be summarized as fol- coverage of the recipient area is almost always substan-
lows: tially better than could be anticipated on the basis of
hair counts. This is a mirror image of the apparent great
1. Black patients are more prone to develop keloids, hair density in the donor area despite the reality of low
hypertrophic scarring, and wider than usual donor area hair density revealed by close inspection. As Mayer has
Figure 15D-11 Tightly braided style of ‘‘corn rows,’’ which

can lead to alopecia, is currently popular with young people.
3. If strip harvesting is used, I have already advised bend-

ing no. 15 blades to accommodate the natural curvature
of the hair. Jim Arnold, whom I quoted, has counseled
that when bending the blades, one should ‘‘bend them
as much as you can . . . until they break . . . only then
will you discover their limits. If you don’t end up with
as many snapped and broken blades as intact, bent ones,
Figure 15D-10 (a), Preoperative view of traction alopecia. (b),

Postoperative view of traction alopecia.
noted, the appearance of greater than actual density is

due to the ‘‘crispy’’ or ‘‘kinky’’ nature of hair in blacks,
usually minimal hair/skin color contrast, and hair curl.
Thus, one should be less deterred by low donor area
hair density in black patients than in others. Unfortu-
nately, the opportunity for ‘‘comb-over’’ of untrans-
planted areas is also reduced by tight curliness. All of
the preceding information should be taken into account
when coverage objectives are initially discussed with Figure 15D-12 The flatter hairline is popular among black
patients. male patients.
602 Chapter 15
hard’’ tumescence in the donor area is far more impor-

tant in patients with curved follicles for all inci-
sions—including the first. If the blade cannot pass eas-
ily through the tissue without encountering a gritty
feeling (which indicates follicle transection), the incis-
ing angle should be altered and more tumescent solution
added. If necessary, a power punch should be used to
bore out round grafts with an arcing hand motion(4).
The resultant Swiss–cheese-like area can subsequently
be excised with an encompassing single-blade elliptical
harvest (after high tumescence of the edges is obtained).
All the tissue—both round grafts and the elliptical seg-
ment—can then be dissected into whatever type of graft
are needed.
4. Preparation of FU grafts is more challenging in black
patients. As noted earlier, horizontal cuts for strip exci-
sions must be made with curved blades, but vertical
cuts for slivering can be made with straight blades. The
division of the slivers into single FUs with a straight
blade or preferably, a curved blade, as I have recom-
a mended, requires as much or more care as the initial
horizontal incisions.
5. Because of the follicle curvature, FUs must be larger
than usual; thus, recipient sites must also be larger than
usual. The number of sites and their density should be
adjusted accordingly. Also, because of the hair crispin-
ess and curl, multi-FU grafts are less pluggy looking
than they otherwise would be. In my opinion, large slit
grafts, slot grafts, and yes—even round grafts—are,
therefore, very acceptable and often superior options
for black individuals. The number of hairs per FU is
also generally lower than in whites, so multi-FU grafts
are, in addition, more effective in producing higher re-
cipient area hair densities than FUs alone—especially
FUs that must be spaced farther apart for the previously
noted reasons. (WU)
See also the Epilogue, Sec. L.
15E. Hair Transplantation in the

Transsexual Male
Richard C. Shiell
b
INTRODUCTION
Figure 15D-13 (a), Preoperative photograph of Hamilton class
V patient. (b), Postoperative photograph of patient after a transplant From the start, I wish to make it clear that I am referring
with 800 2 2.0-mm minigrafts and 300 micrografts; total ⳱ 1100 here to the genetically male individual who wishes to dress
grafts. and perhaps live as a female, whether or not he has had
gender reassignment surgery.
Transsexualism has been defined as ‘‘The adoption of a so-
cial role opposite to that of the biological sex. It is characterized
by a persistent and irreversible conviction that one does not
you are holding back (2)’’. Cole advises using a single belong to one’s biological sex but rather to the opposite sex
blade rather than double or multiblade knives. He has (1).’’
emphasized that even in whites, follicle transection rates The incidence is estimated to be somewhere between 1: 5000
are higher when the second (superior) incision is made. and 1:50,000. Most transsexual individuals who come for hair
Thus, one should always inject more tumescent fluid transplantation are male, but Swedish studies suggest that the
just before the second incision (3). Of course, ‘‘rock- sex incidence may, in fact, be equal (2).
Hair transplantation for female-to-male transsexuals is most estly sized sessions of less costly minigrafts combined with
uncommon, and I have not had such a case. Under the influence follicular units (FUs) may be a more economical way to manage
of additional androgens, genetic females who are carrying the to the patient’s situation than a single, relatively large session
genes for baldness will lose some hair and may develop bald- of closely packed FUs.
ness. They are usually proud of the hair loss, however, as they
see it as an enhancement of their masculine appearance and
thus are unlikely to seek hair restoration surgery. However, Hairline Design
it is inevitable that such a case may arise someday, and the
Transsexual patients are usually beautifully groomed and mani-
management would be as described for genetic males elsewhere
in this book. cured and the surgeon must design a female hairline to match
When a genetically male transsexual individual comes to their gender choice (see Hair Transplantation in Females in
a hair restoration surgeon, the patient has already provided Chapter 5A) This design generally involves the use of a much
the diagnosis, and medical management is nearly always more rounded temple infill and a lower hairline than that de-
well under way. Patients are generally taking estrogens and signed for most males. (Figs. 15E-1a, and b) If there is a poor
antiandrogen medication. Sometimes gender reassignment sur- donor/recipient area ratio, the surgeon may suggest the use of
gery has been performed, and the patient is at this point a higher than normal female hairline. Such a hairline should
concerned only about a residual male baldness that is spoiling only be considered after careful discussion with the patient,
the feminine appearance. Many of these individuals have who may prefer to achieve greater frontal density and leave the
advanced androgenetic alopecia and have worn wigs for years crown alopecic. Alternatively, the patient may prefer to use a
but wish to present a more feminine appearance when the small switch or toupee in this region rather than skimp on the
wig is removed at home. hairline region.
When the patient is insistent on exceptional density at the
Approach to the Patient hairline, it may be advisable to perform Juri flap surgery or to
provide a reference to a surgeon experienced in this technique
Empathy is essential, and if the surgeon cannot be nonjudgmen- (Fig. 15E-2a, b, and c). Most patients seem to be happy with
tal about these patients, they should be referred to another sur- a modest improvement in hair cover, however, and hair trans-
geon who has no such difficulty. Some patients are openly ho- plantation with plugs, minigrafts, micrografts, or FUs, generally
mosexual and single and live with male partners, but a produces a high rate of patient satisfaction.
surprising number are married and still living with their female
partners and children at the time of their presentation for assess-
ment. Most give a fairly uniform history of having felt like ‘‘a Donor Site
woman trapped inside a male body’’ since childhood. In some
cases they are even accepted into their household as another As in biological females, it is important that the donor site is
‘‘Mommy’’ to their children after gender reassignment. In most not located too inferiorly in the occipital area. This is because
instances, however, an irreversible rift occurs in the family unit, the patient may wish to wear the hair up at times. In addition,
which places an increased psychological and financial burden in my experience, donor tissue taken from relatively inferior
on the patient. occipital areas more commonly results in wide scars, possibly
The patient’s self-identification is female, and the surgeon due to a stretching effect of the neck muscles.
should regard the patient as such. The patient should be treated
with dignity, and the surgeon and staff should always use the
words ‘‘she’’ and ‘‘her’’ when discussing the patient, whether Future Progression of Baldness
the individual is present or not. If this is not done, the patient As all of these patients are undergoing hormonal treatment,
may experience great personal distress by overhearing the sur- male pattern baldness develops only very slowly, if at all, partic-
geon or a staff member inadvertently use the word ‘‘he’’ or ularly after orchidectomy. In some cases, where donor hair is
‘‘him.’’ in short supply, it is useful to alert the patient to the fact that
good donor hair can be obtained during a future rhytidectomy.
Financial Considerations Hair-bearing skin, which would normally be discarded, is re-
moved from either or both the preauricular and postauricular
The financial aspects of gender reassignment cannot be under-
regions. After discussion with the cosmetic surgeon, the hair
estimated. To enhance the feminine appearance, the patient may
require breast augmentation, liposuction, cheek implants, chin transplant specialist can time the arrival of the hair transplant
reduction, cricoidectomy (to minimize the telltale Adam’s team quite precisely. After changing into scrub suits, the team
apple), and hair removal from the back, shoulders, abdomen, dissect this tissue into minigrafts or FUs while the facial surgery
and face. In older patients, there may be additional procedures proceeds. As soon as access to the recipient area is gained, the
desired to help eliminate wrinkles of the face, eyelids, and neck. grafts may be implanted. The patient’s scalp is then cleaned,
All of these procedures are in addition to hair restoration and and dressings are applied if required (3).
gender reassignment surgery. One great advantage in working with transsexuals is that
The need for ongoing surgery and the patient’s possible lack they are usually exceptionally skilled at hair care and styling
of financial resources may modify the type of hair restoration so they have a great ability to make the surgical work look as
procedure that the surgeon suggests. For instance, annual mod- good as possible (Fig. 15E-3a, b).
604 Chapter 15
Figure 15E-1 (a), Preoperative photograph of patient no.1 showing planning of the hairline in a transsexual male, with more rounded
temple infill and a lower hairline than that designed for most male patients. (b), Photograph of patient no. 1 showing results after transplanta-
tion. (a and b, Courtesy of Dr. M. Beehner.)
a b
Figure 15E-2 (a), Preoperative photograph of transsexual male patient no. 2. This patient wanted a strong hairline, so a flap was
planned. (b), Preoperative photograph of transsexual male patient no. 2 with lines drawn that show the planned location of the flaps.
(c), Postoperative photograph of transsexual male patient no. 2 showing the results of a single-flap procedure. Follicular units can be put
in front of the flap to cover the scar and make a more irregular hairline. (a–c, Courtesy of Dr. M. Marzola.)
606 Chapter 15
fibrous tissue (1).’’ Historically, dermatologists have used the

term cicatricial alopecia to refer to scarring alopecia caused
by inflammatory disease processes such as discoid lupus erythe-
matosus, lichen planopilaris, pseudopalade, etc. In the field of
hair transplantation, the term is often used more broadly to
include scarring alopecias caused by various forms of trauma
(burns, accidental injury, cosmetic surgery, radiation, etc.).
Chapter 4 categorizes and discusses the various causes of scar-
ring alopecia, and it is not the purpose of this chapter to repeat
this information. However, at times, the hair transplant surgeon
may be called on to consider grafting into scar tissue. The pur-
pose of this chapter is to discuss the various factors and tech-
niques that need to be considered when contemplating hair
transplantation into an area of scarring.
FACTORS TO CONSIDER BEFORE

TRANSPLANTING
Although there is often initial concern about viability, our expe-
rience has shown that hair can often be implanted successfully
in scar tissue (2–7). The physician should, however, carefully
a evaluate a number of factors before deciding to perform such
a procedure, and alter the technique to accommodate those fac-
tors.
Optimal Procedure: Surgical Revision vs. Hair

Transplantation
If the area of scarring is relatively small, or if the surgeon
is confident that the scar can be removed by an excision and
subsequent repair, such an alternative should be presented to
the patient. In some situations, when larger areas of alopecia
exist, a portion of the area can be excised, leaving a small area
that requires fewer grafts. The use of expanders and flaps should
also be considered for such cases (2). Physicians who are not
skilled in these more aggressive types of procedures should
consider an appropriate referral. It may be that after partially
removing a larger area of scarring, a smaller scar may remain
that can be more easily and more aesthetically enhanced by
transplantation.
Although many types of grafts currently exist in the field of
hair restoration surgery, we believe that smaller grafts, and in
particular follicular unit (FU) grafts, are better than larger ones
for transplantation into scar tissue. It is our opinion that FUs
b
have the greatest chance of survival and the least chance of
causing ischemic injury when they are transplanted into what
Figure 15E-3 (a), Preoperative photograph of transsexual male may be less vascular areas of scar tissue. It should be noted,
patient no. 3. (b), Postoperative photograph of transsexual patient however, that in the past, other types of small graft procedures
no. 3 after full growth and the use of new styling to improve the were successfully performed in areas of scarring (3–6).
look.
Etiology of Scarring
Scarring Caused by an Inflammatory Disease Process
The caveat in transplanting patients whose scarring is the result
15F. Transplanting Into Scar Tissue of inflammatory disease processes (lichen planopilaris, discoid
and Areas of Cicatricial lupus erythematosus, etc), is to be certain that the disease process
Alopecia has ‘‘burned out’’ before undertaking the procedure. It may be
appropriate to consult with a dermatologist and/or obtain a biopsy
Paul T. Rose and Ron Shapiro from the area to be transplanted to ascertain whether the inflam-
matory or infectious process has subsided. A general rule of
INTRODUCTION thumb has been to wait until there are no signs of active disease
for approximately 1 year (2). Unfortunately, owing to the vari-
The term cicatricial contains the Latin root cicatrix, which able clinical course of these processes, we cannot be certain that
means, ‘‘scar resulting from the formation and contraction of the disease will not reactivate at a later time.
There are apparently no scientific studies that discuss sur- are legitimate concerns, experience has shown that the blood
vival rates of grafts in patients with various types of scarring supply in scar tissue is often sufficient to accommodate the
alopecias. There is concern that the survival rate may be some- appropriate placement of FU grafts. However, certain precau-
what diminished in some cases compared with that of grafts tions and modifications should be taken. Some physicians have
placed in normal tissue. In spite of these concerns, as noted recommended assessing the blood supply by sticking the tissue
earlier, experience has shown that grafts can often be success- with an 18-gauge needle and waiting for the appearance of
fully transplanted, and patients are grateful for the cosmetic blood. If none appears after a few minutes, the surgeon should
improvement. It may be that these patients sometimes accept be extremely cautious and consider performing test grafts in
less than full growth because the transplant surgeons improve the area before committing to a larger procedure. Generally, in
an unnatural deformity rather than try to reverse the natural areas of scar tissue, the first transplant should always be per-
balding process. However, it is important to educate these pa- formed with smaller numbers of grafts placed at lower densities
tients before the procedure and warn them about the possibility than are typically used in normal skin. It is also prudent to wait
of disease recurrence and a decreased hair survival rate. longer between sessions (e.g., 8 months to 1 year). In these
In examining the patient, it is also important to be certain circumstances, it is better to plan to do multiple smaller sessions
that the apparent scar is indeed a scar. For example, in rare that succeed rather than one large session that might fail. As
instances, a basal cell carcinoma of the sclerosing type can stated earlier, it is our opinion that FU grafts, with their associ-
mimic a scar. If there is any question about the diagnosis, the ated small recipient sites, have the greatest chance of survival
area should be biopsied. and the least chance of causing further injury in tissue with
decreased blood supply. Although not a proven fact, some phy-
Scarring Caused by Physical Trauma sicians suggest that the use of a 2% to 5% solution of minoxidil
(Rogaine) for 1 week preoperatively and 5 weeks postopera-
With scars caused by physical trauma or cosmetic procedures, tively may improve the blood supply and the odds of a success-
the surgeon should inquire as to the nature of the injury or ful transplant. Theoretically, the use of pentoxyfylline (Trental),
procedure. It may be important to know how the surgery was 400 mg, three times daily with meals, for at least 2 weeks before
performed. Although this occurs rarely, a patient may have a surgery, may also provide greater oxygenation to the tissue.
history of neurosurgery or maxillofacial surgery, and there is
a possibility that there may be a contraindication to performing Scalp Thickness
the hair replacement procedure. For instance, there may be a
fixation device lying underneath the area of surgery that could The thickness of the scalp in areas of scarring can vary signifi-
be compromised or subject to infection. In this situation, it may cantly depending on whether the scar is hypertrophic or atrophic.
be prudent to speak with the surgeon who performed the opera- Some scar tissue is thick and tough, whereas other scar tissue is
tion to determine whether the patient is cleared for hair trans- thin and friable. With hypertrophic scars, there is concern that
plant surgery or other scalp surgery and whether perioperative the incisions will not gain access to the blood supply. Minimum-
antibiotics are recommended. depth incisions should probably not be used in these situations;
rather, the surgeon should err on the side of making the incisions
We are increasingly called on to provide hair transplants to
slightly deeper. Simple hypertrophic scars must also be differen-
mask scarring resulting from aesthetic surgery. Most com-
tiated from true keloid scars, because transplanting into true ke-
monly, these scars are from rhytidectomies and brow lifts. In
loid scar tissue may stimulate further keloid formation.
both instances, there may be significant hair loss surrounding
Transplanting into atrophic scar tissue, such as that created
the scar in addition to the scar itself. To provide a natural ap- by postradiation injury, creates a different, and in our opinion,
pearance, the area surrounding the scar may also need to be a more difficult problem (9). The recipient area in this thin,
transplanted. Although this type of surgery is rarely performed poorly vascularized tissue is more prone to ischemia. In addi-
today, there are some patients who have undergone direct brow tion, the shallow skin makes it difficult to create incisions deep
lifts. These lifts can leave scars that extend into the eyebrow. enough to house even tiny FUs. Placing grafts into shallow
When this occurs, the techniques for transplanting eyebrows incisions is also more difficult and may lead to greater graft
(see Chapter15A) can be used. trauma and poor survival. Making the incisions at a more acute
Some patients who have previously undergone hair trans- angle can increase the length of the incisions and create a poste-
plantation may have scars in the donor area. In many cases, a rior ‘‘pocket’’ to house the graft. Careful use of tumescent solu-
simple scar revision can take care of the problem. There are, tion (without epinephrine) can temporarily distend the skin,
however, cases in which the donor area has been heavily har- making it easier to create these more acutely angled incisions.
vested and the remaining hair-bearing area adjacent to the scars Others have recommended turning the blade 90 degrees (so the
is quite sparse. In such cases, it may be reasonable to obtain cutting surface is parallel to the skin) to facilitate making an
grafts from other, less heavily harvested portions of the donor incision at a more acute angle (2,4,5).
area (e.g., taking hair from the parietal areas to place in the On several occasions, we have noticed that after the first
donor area). Follicular unit extraction (FUE) is another method conservative transplant into an area of atrophic scarring, the
of obtaining hair to transplant into scarred donor area. tissue characteristics improve and become more favorable for
a second transplant procedure. The tissue becomes thicker and
Blood Supply more supple. It may be that the FU grafts act like multiple tiny
skin grafts, and the FUs also may stimulate angiogenesis. Figure
The issue of adequacy of the blood supply to the scar tissue 15F-1a through 15F-1f shows the progression of a patient
often arises. In addition to leading to poor graft survival, this through two procedures of FU grafting into a large area of scar
limited blood supply can potentially leave the recipient area tissue that was secondary to burns. The scar tissue in this patient
more vulnerable to infection, further ischemia, and necrosis, as was more vascular, thicker, and easier to transplant at the time
more vascular injury from the grafting occurs. Although these of the second procedure.
608 Chapter 15
a b
c d
e f
Figure 15F-1 (a), ‘‘Before’’ photograph of a patient who suffered severe burns to the scalp as a child. The scalp skin was thin and
adherent to the skull in the area of the burn. (b), Three days after surgery showing 1200 follicular unit grafts (FUGs) (600 to each side).
Healing is good except for one small area of scabbing at the anterior border of the temporal hairline (x), which may represent a small area
of ischemia. (c), Five months after initial surgery, early growth has occurred in all areas including the initial area of ischemia. (d), One
year after surgery even growth and moderate cosmetic improvement have taken place. In our opinion, the underlying tissue appeared thicker
and more supple at this time. (e), One hour after the second surgery with 1600 FUGs. (800 to each side). It was easier to place grafts
during this procedure because of the increased thickness of the skin. (f), One year after the second procedure, significant improvement is
seen.
SUMMARY OF TECHNICAL TIPS 2. Balsamo C. Axillary hair as an alternative to scalp hair in pubic
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1. In cicatricial alopecia, caused by an inflammatory
process, make sure the disease is dormant before pro-
Transplantation of Temporal Points
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2. Pathomvanich D. Hair Replacement, Special Categories, Mosby
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3. Cole J. Hair transplanting in African Americans. H T Forum Int 331.
2002; 12(4):153. 8. Burke JW. Surgical treatment of cicatricial baldness. South Med
4. Unger W. Hair transplanting in blacks. In: Unger W, ed. Hair J 1966; 59:662.
Transplantation. 3d ed.. New York: Marcel Dekker, 1995: 9. Nordstrom RE, Holsti LR. Hair transplantation in alopecia due
281–285. to radiation. Plast Reconstr Surg. 1966; 72:454–458.
16
Personal Techniques
16A. Microstrip Grafting The size of all the grafts should be uniform, with an
average of 0.66 mm ⳯ 3.0 mm.
Patrick Frechet 2. The microstrip graft is inserted into slits created at the
same angle and parallel to the hair direction of the pa-
INTRODUCTION tient’s original hair.
3. The ergonomics of each step, from cutting the first graft
The goal of modern hair transplantation is to offer patients to inserting the last graft, is made as simple, gentle, and
a natural-looking final result. There are three main factors that fast as possible.
contribute to the degree of naturalness that can be achieved:
In a previous article, I introduced an earlier version of the
1. Proper framing of the face with the grafts microstrip grafting technique, which had two characteristics
2. Undetectability of the individual grafts distinct from the current method: (1) the microstrip was longer
3. Closely matched density in the grafted and nongrafted (6 mm to 8 mm) and, (2) the slits in the recipient area were
areas created at an angle perpendicular to the original hair (14).
Aesthetically, the grafts looked very natural, even with 10
The only general consensus among hair transplant surgeons
to 15 hairs per graft, because they were, at most, only one
is that the first few millimeters of the frontal ‘‘feathering
FU wide. With these narrow grafts there was no problem
zone’’ should be transplanted with micrografts. This area
with the tuftiness and compression that are sometimes seen
makes up only 5% to 10% of the total number of hairs that
with small minigrafts that are two FUs wide. Unfortunately,
are transplanted. The other 90% to 95% of the hairs may be
there were two major complications that occasionally oc-
grafted using a number of approaches: (1) total micrografting
curred:
(follicular unit hair transplantation [FUT]) (1–6); (2) micro-
grafting and minigrafting (1,2,7,8); (3) blended grafts (10–13); 1. Excessive vascular damage led to poor growth and even
(4) linear grafts with slot punches (9). Each surgeon has necrosis in the exceptional cases. This was caused by
personal opinions as to the approach that works best to the angle and direction of the recipient incisions, which
achieve the desired results. I currently use a ‘‘microstrip’’ severed more blood vessels than usual, and the length of
grafting technique that I have been performing for several the sites (up to 8 mm) further contributed to the damage.
years. Since 2001, I have been exclusively using the improved 2. The scalp was sometimes visibly ‘‘wavy.’’ This was
version of this method. likely secondary to the fact that the incisions were made
As previously mentioned, the microstrip grafting technique against ‘‘Langer’s lines.’’
offers patients undetectable grafts, density closely matched
It is important to stress that this technique is acceptable only
to that of the nongrafted areas, and a natural final result after
if one believes that there is no significant negative conse-
two or three sessions. Furthermore, the technique allows the
quence with respect to long-term regrowth of the grafts.
surgeon to perform a session of up to 3000 hairs without
There is significant preliminary research that indicates that
any additional assistants. There are three major components
transected hair follicles regrow (15,16) (see Chapters 9A and
in the surgery:
9C). A comparative study presented at the Fifth Congress of
1. The microstrip graft is prepared by making slivers from the World Hair Society compared 50 intact single-hair grafts
the harvested strip. The cutting is done in one motion with 100 bisected single-hair grafts. The study concluded that
to minimize both the trauma to the grafts and the time there were no significant differences at 4, 6, and 9 months
needed for their production. The grafts are at most one in terms of density, naturalness, and the number of hairs
follicular unit (FU) wide and two to three units long. that had regrown. A previous study by Dr. Melvin Mayer
611
612 Chapter 16
documented an excellent rate of regrowth of transected folli- each approximately 3 mm wide. To determine the length of
cles—in fact, the numbers were better than expected. donor strip necessary, one needs to know that a strip 3 mm
If, as these studies have indicated, follicular transection wide and 6.6 cm long produces 100 microstrip grafts. Thus,
has no significant consequence with respect to graft survival, to produce 700 microstrip grafts, one needs to cut a donor
nor does it result in changes in the major hair characteristics strip that is 23 cm long (each 3-mm-wide strip yields 350
(such as caliber, color, texture, etc.,), it becomes possible to microstrip grafts). With an average of 4.4 hairs per graft
significantly reduce graft preparation time. I cut grafts one (based on an estimate of 220 hairs/cm2 in the donor area),
by one from the strips, using a magnifying loupe (8x). Seven the number of hairs harvested averages 3000 hairs.
hundred microstrip grafts, averaging 0.66 ⳯ 3.0 mm, are Once the strips are harvested and the wound is closed,
usually prepared in less than 40 minutes. In preliminary the surgeon turns the seat 90 degrees and places each strip
investigations, the number of follicles transected averaged in a bowl of saline solution before cutting. Using magnifying
approximately 30% of the total strip. After 1 year, hair counts loops (8x), each strip is trimmed, with as much adipose tissue
indicated that the actual and expected rates of regrowth closely as possible removed. The cutting edges of the scissors should
corresponded to one another. A controlled, scientific study be aligned as closely as possible with the extreme base of the
has not yet been completed on a large enough group of follicle. This step, which eliminates as much fat as possible, is
patients to confirm this observation. essential because fat significantly increases the volume of
It is my belief that factors other than transection play a far the graft and makes its insertion into the recipient slit difficult
greater role in graft survival, and this view is supported by and traumatic. However, no other tissue (apart from the fat)
various articles on the subject (17–21). These influences in- is discarded. I believe that this retention of tissue helps to
clude the following: achieve better graft survival after transplantation, compared
with that observed in other techniques.
Good hydration of the grafts
Minimal cutting and gentle handling during preparation
Second Step: Cutting the Strips into Microstrip
Limited trimming of the grafts
Use of all tissue except some fat Grafts
Gentle insertion of the grafts into the recipient area The full-length of the strip is divided into smaller sections,
Correct storage temperature each of which yields an average of 100 microstrip grafts.
Thorough cleaning and disinfection of the surgical field This division is carried out on a 7-cm-long tongue blade that
Short time lapse between excision and implantation has been soaked in saline solution for a period of time before
Minimal contact with foreign bodies and foreign liquids use, to help keep the strip well hydrated during cutting. If
Limited vascular damage in the recipient area the tongue blade is dry, the wood acts as a sponge and
Operator alertness absorbs the saline from the strips, increasing the risk of
Given the fact that this technique is superior with respect to dehydration of the grafts.
many of these listed variables, perhaps the rate of hair survival To cut the strip, I use thin razorblades (approximately
is comparable with, or even better than, the rate achieved by 0.12 mm wide), which have a cutting edge that is slightly
other methods of hair transplantation, with a lower incidence superior to the usual medical blades. The grafts are cut one
of follicular transection. by one, in a single motion, with the surgeon’s forearms
resting on the table. The extreme edge of the strip is held
with fine forceps to keep the strip steady while the grafts
are being dissected. It is critical that the forearm remain steady
THE PROCEDURE ITSELF
and rest on a hard surface. For a more detailed discussion of
To limit the length of the procedure, the surgeon performs all these ergonomic parameters, the reader is directed to an
stages of the surgery seated behind the head of the patient. To excellent article on the subject (22). Only the wrist and the
transfer the harvested strips from the patient’s head during fingers should move to maximize precision and speed and
donor excision and to be positioned correctly for graft prepara- minimize fatigue. At the end of the cutting stage, all the
tion, the surgeon turns the seat 90 degrees. After cutting of the microstrip grafts should be lined up in a row on the tongue
microstrip grafts, the seat is rotated back to the initial position blade (Fig. 16A-1).
to start the frontal anesthesia, create the recipient sites, and Each tongue blade is then placed in cool saline solution in
insert the grafts. a rectangular dish—not a round petri dish. This way, the tongue
blades remain stationary and submerged, and the grafts stay
very well hydrated on the tongue blades until they are ready
First Step: The Donor Area
for insertion.
The width of the strip should be consistent to ensure that
the microstrip grafts will be of equal length. A double or Characteristics of Microstrip Grafts
multibladed knife is used to achieve this end. The exact Once the 3-mm-wide strips are dissected, they produce grafts
length of the strips and the exact number of grafts can be that are 3 mm long. Each graft usually contains two FUs, or
evaluated easily. For example, two 3-mm-wide strips can be fractions of FUs. If the strips are cut more than 3 mm wide, the
obtained by means of three no.10 blades and two spacers; grafts contain more FUs, and this can result in the appearance of
a 2.5-mm spacer for the inferior strip and a 2.25-mm spacer a linear line of hair, producing an ‘‘Indian-line’’ effect. Further-
for the superior one. When the three-bladed knife is angled more, it is technically much more difficult to produce grafts
properly to excise the donor area, the resulting strips are from a wider strip.
Personal Techniques 613
Figure 16A-1 A 3-mm-wide strip that has been cut into 100 microstrip grafts and placed on a tongue blade. The grafts are ready for
insertion.
The width of the microslit grafts is the most critical aspect usual manner and the surgeon then proceeds to make the recipi-
of this type of minigraft, with respect to both aesthetics and ent sites. The micrograft sites are generally created in the frontal
noticeability. In addition, grafts that are 0.66 mm wide can be hairline, in the usual fashion, if they are to be used. There are,
eased gently and without difficulty into their recipient sites, however, procedures that I believe can be performed without
regardless of the scalp elasticity of the patient. If the width of any micrografts, because the microstrip grafts can be perfectly
grafts is larger, even 0.80 mm, the graft may become difficult undetectable even in the feathering zone.
to insert in certain cases. More importantly, a wider graft is Slit graft recipient sites are generally chosen rather than slot
more detectable and can negatively influence the final aesthetic graft sites for several reasons: (1) they result in less vascular
result. A graft 1.0 mm to 1.2 mm wide, for example, may con- damage, (2) they are faster to produce and, (3) the sites can be
tain two FUs side by side (or two fractions of FUs). If there is created closer together. This said, slot grafts are a good alterna-
any compression, these FUs may appear closer to one another tive in some patients, and they are subject to less follicular
than usual and be noticeable to the eye. Even somewhat nar- trauma on insertion.
rower grafts that are perhaps 0.80 mm to 1.0 mm wide may be The slit sites are directed in the manner used by most hair
more visible in patients who have very coarse hair or very dense transplant surgeons today. Specifically, they are created in a
hair or a strong color contrast between hair and scalp. This may direction that lies parallel to that of the original hairs. It is also
happen despite the avoidance of technical errors such as pitting necessary to angle the blade to match the angle of the hair; this
or compression of grafts in sites that are too small for them. generally lies between 30 degrees and 40 degrees. The depth
Interestingly enough, microstrip grafts that are 0.66 mm wide
of the sites varies between 4 mm and 5 mm. The distance be-
cannot produce an FU that contains three or four large-caliber
tween slits should allow for easy graft insertion and be as narrow
hairs, because the width of the microstrip graft is such that this
as possible; the average distance between sites is 2 mm or less.
FU would be automatically vertically transected. Thus, transec-
This results in approximately 12 slits/cm2, which represents
tion may be regarded as beneficial in such cases because it
approximately 52 hairs/cm2 in patients with average hair density
enhances the aesthetics of the final result.
Microstrip grafts that are narrower than 0.60 mm are not (220 hairs/cm2).
highly effective because the grafts contain less hair, take much To ensure undetectability of the microstrip grafts, the spac-
more time to prepare and plant, and produce no significant aes- ing between them is also critical. Generally, FUs are spaced
thetic benefit when compared with slightly wider grafts. about 1mm apart in nature. Therefore, when microstrip grafts
are placed too far apart, they appear too sparse in contrast to
the non grafted area. Thus, using the approach described here,
Third Step: The Recipient Area
it is necessary to complete a minimum of two sessions in any
Once all the grafts are cut and lying on the tongue blades in given area. I usually test graft insertion after a few sites have
saline solution, the surgeon returns to the original position fac- been completed to determine whether the spacing is appropriate.
ing the head of the patient. The anesthesia is performed in the This helps to make sure that the insertion is easy and non trau-
614 Chapter 16
matic and allows the physician to adjust for variability in scalp A natural appearance can be created only with the proper
elasticity. If the slits are made too close to one another, the combination of all these factors rather than any single one
graft insertion becomes difficult. The grafts can repeatedly of them.
‘‘pop’’ out of the slits, and the increased handling, which be-
comes necessary, increases trauma to the follicles and lengthens
planting time. Detectability of the Graft
It may seem as if the detectability of a graft is directly related
The Blade Knife to Create the Slits to the number of hairs in the graft. By that reasoning, a one-
The preferred instrument used to create the slits is a chisel hair graft would be less detectable than a two-hair or three-hair
blade, which has a rectangular shape that closely approximates FU. However, it is my belief that both DFUs and five-hair round
the shape of the microstrip graft. Earlier procedures were minigrafts can look more obvious than 12-hair microstrip
performed with a Minde knife or a razorblade cut to size. grafts. This is because of the issue of compression. Grafts other
Better results were obtained with the SM 62 blade, which than microstrip grafts are more prone to this complication. If
created a more open site because of the width of the blades the distance between two FUs is significantly smaller than
(0.50 mm [SM 62]vs. 0.12 mm [Minde knife]). With more usual, the eye is drawn to this unusual pattern. This holds true
experience, I found that still thicker blades were even more even if there are no compounding influences such as large hair
beneficial. The Rosati needle, with a thickness averaging 1 caliber, significant color contrast between hair and scalp, or
mm, was used for some time. However, a blade that is 0.125 pitting. The compressed appearance can be caused either by
mm thick is now the instrument used to create recipient slit intrinsic contractile forces of the collagen fibers within a graft
sites. This blade acts not only as a cutter but its modified or by extrinsic forces of the surrounding tissues (which become
Ellis handle tip also instantly dilates the sites to a 1–2 mm
significant when the graft does not fit perfectly into the recipient
opening (Dr. Blugerman helped to make improvements on
site). In the nonfeathering zone, the only grafts that look natural
this device) (Figs. 16A-2a and b). All the slits can be made,
are those not susceptible to intrinsic or extrinsic compression
one after the other, with the same blade, and the sites allow
for easy, nontraumatic insertion of the microstrip grafts. The forces.
blade length is always slightly smaller than the length of the To my knowledge, only the three following varieties of
microstrip graft. For example, a blade that is 2.75 mm long grafts have these properties:
is used to produce sites for grafts that have been cut from
1. One-hair or two-hair micrograft
3-mm-wide strips.
2. One-hair to four-hair FUs
3. Three-hair to eight-hair (or more) microstrip grafts
Ergonomics of Graft Insertion
Once all the slit sites are made, insertion begins immediately.
The tongue blade is held with a needle holder, with the 100 Spacing Between Grafts and Density
microstrip grafts lined up on its surface at an angle that Spacing between grafts can be more variable, and still look
directs the roots of the grafts toward the slits. A right-handed natural if one of the three varieties of grafts just mentioned
surgeon holds the tongue blade with the left hand and moves is used. However, the closer the grafts are, the better. There-
as insertion proceeds, so that the graft to be inserted next fore, the result of one session of FU grafts placed slightly
is only 1 cm away from the slit (Fig. 16A-3a). The forearm closer to one another (1 mm to 2 mm apart) may look better
of the surgeon rests on the right side of the patient’s head than the result of a microstrip graft session in which the
pillow. Only the wrist and the fingers move, and the range
grafts are approximately 2 mm apart. For this reason, at least
of motion is only 1 cm to 2 cm upward and 1 cm to 2
two microstrip grafting sessions are generally needed (Fig.
cm downward (Fig. 16A-3b). Therefore, there is exceptional
16A-4); more than two, however, can produce excellent results
economy in motion and precision. Obviously, as long as
homeostasis is very good, the procedure can be completed (Fig. 16A-5 and 16A-6).
very rapidly. Density is visually important because it fosters the impres-
The total surgical time is usually 3 hours or less for a session sion that the patient is not losing hair. Particularly when hairs
that transplants 3000 hairs (or 700 grafts), and only one opera- are short, and the volume of hair is thus decreased, barely ade-
tor—the surgeon—is required for all stages. quate hair density in the grafted area continues to give the
impression of matching the nonbalding area. A previous study
showed that 50% of the normal hair density is enough to fool
AESTHETICS OF HAIR the eye. However, I doubt that this is true in an area, such as
TRANSPLANTATION—A SUMMARY the whorl, where density should be greater.
The production of an aesthetically satisfactory hair transplant
depends on the following conditions: The Natural Framing of the Head with the
Transplanted Hair
1. Detectability of the graft itself
2. Spacing between grafts Equilibrium must be achieved for naturalness. The height of
3. Volume, density, and distribution of hairs in the grafted the frontal feathering zone and the degree of temporal recession
area compared with the nongrafted zones are crucial. This topic is discussed fully in other sections of the
4. Framing of the face text.
Figure 16A-2 (a), The cutting-dilating knives, or ‘‘iconoclast’’ knives. Here, three different widths of tips and a 2.75-mm-wide blade,
in the upper right corner. The blade incises, while the tip of the Ellis handle, which has been modified to have a considerably smaller than
usual diameter, follows the blade as it penetrates the recipient area skin, thus dilating the recipient site to a 1 to 2 mm width. (b), Slits
made with these knives. Note the ‘‘open’’ wound that allows the microstrip graft to slide easily and quickly into the slit. Usually, no
compression or popping of grafts is observed when an iconoclast knife is used.
616 Chapter 16
Figure 16A-3 (a), The tongue blade is held with a needle holder, with the 100 microstrip grafts lined up on its surface at an angle that
directs the roots of the grafts toward the slits. A right-handed surgeon holds the tongue blade with the left hand and moves as insertion
proceeds, so that the graft to be inserted next is only 1 cm away from the slit. (b), The surgeon is seated behind the patient’s forehead.
Both of the surgeon’s elbows are lying on the bed. Only the fingers move to insert the grafts. (I use 8x magnifying loupes throughout the
entire procedure.)
Figure 16A-4 (a), Caudal view. The patient is seen immediately after production of 650 long slits (2.75 mm) and 50 slightly shorter
slits. The grafts have not yet been inserted. (b), Result after two sessions totaling 1300 microstrip grafts and 100 micrografts (6000 hairs).
618 Chapter 16
Figure 16A-5 (a), Caudal view. Results are shown in a patient after four sessions of microstrip grafts (a total of 10,000 hairs). (b), A
close-up of the caudal view of the same patient with the hair parted for critical evaluation. Note the absence of any cosmetically significant
degree of ‘‘compression’’ or ‘‘plugginess’’. (c), An even closer view of the recipient area shown in Fig. 16A-5a and b. Note the complete
absence of compression.
a b
Figure 16A-6 (a), Frontal view before treatment. (b), After three sessions. A total of 1800 microstrip grafts and approximately 8300
hairs were transplanted. No micrografts were used.
620 Chapter 16
16B. A Personal Hair Restoration Finishing a procedure within a reasonable amount of time
is important to ensure good survival. I found that my maximum
Technique from Brazil rate of placement into multiple premade incisions peaked at
Arthur Tykocinski and Ron Shapiro about 400 FUGs per hour. In a 2000 FUG procedure, if it takes
only 2 seconds more to insert each graft, this represents an
increase of more than 1 hour in the overall procedure. Thus,
INTRODUCTION
when large procedures are being performed, even a small
Follicular unit transplantation (FUT) (1) is not an easy tech- amount of time loss during each placement can add up to a
nique to master. I have been trying to perfect the technique great deal of total wasted time. For these reasons, I instituted
since I first learned it from Shapiro (2) in 1996. My earliest the modifications in my technique, which are described later.
procedures took longer than 6 hours and consisted of less than I believe these changes have helped to improve my speed (up
1000 follicular unit grafts (FUGs). As I became more proficient, to 500–600 FUs per hour) and, at the same time, reduce assistant
numbers and speed increased. My staff and I now do sessions fatigue and allow for more gentle graft insertion.
that average 2200 FU grafts and typically take 5 to 6 hours. In
this chapter, I discuss some of the specific modifications I have
made in my technique to improve results. In particular, I de- TECHNIQUE
scribe, (1) how I employ the two-person stick-and-place (S& Graft Type and Preparation
P) technique and, (2) how I have added the use of four-hair to
five-hair follicular groupings (FGs) or ‘‘follicular families’’ to My grafts are prepared with use of the classic single strip and
the traditional use of one-hair to three-hair FUGs. microscopic slivering technique described by Seager in Chapter
11B. To prevent dehydration during graft preparation, I use a
Evolution of My Procedure plastic dispenser (originally used for small ice cubes) filled with
saline solution to hold the grafts (Fig. 16B-1).
Initially, like many hair restoration surgeons, I performed the I use one-hair to three-hair FUGs as well as slightly larger
procedure by first making all the incisions in the recipient area four-hair to five-hair FGs (Fig. 16B-2). Follicular groups are
and then placing the FUGs into these premade incisions. Later, similar to the follicular family units described in the past by
I started to save a small percentage of FUGs grafts to S&P at Seager (10). Follicular units in the donor area are generally
the end of the procedure. I found this final S&P phase very spaced approximately 1 mm apart. It is usually fairly obvious,
useful for fine-tuning our hairlines and selectively increasing on casual observation, that each FU is an individual entity.
density in specific areas. Over time, I found that using the S& Follicular groupings, on the other hand, consist of two individ-
P technique was quicker, easier, and more precise than placing ual FUs that are spaced so close together (.2 mm or less) that
FUGs into premade incisions. Therefore, in 1997, I started to they appear to be a single unit (Fig. 16B-3). The logic of using
use the S&P technique exclusively for the entire procedure. FGs (or families) is discussed in more detail at the end of this
I used a specific two-person S&P technique shown to me chapter.
by Shapiro. This two-person S&P technique is slightly different
from the one-person S&P technique described by Seager (Chap- Graft Organization
ter 13B). With the one-person S&P technique, a single assistant
is required to first make the incision and then insert the FUG Keeping the grafts organized also helps speed up the process.
directly afterwards. With the two-person method of S&P, two I start by separating the grafts into FUGs with one, two, three,
people work in unison; the first person (the ‘‘sticker’’) makes or more hairs. I keep these grafts very well organized in a petri
the incision, and the second person (the ‘‘placer’’) inserts the
FUG immediately afterward. I believe the two-person S&P
technique is faster and less fatiguing than the one-person S&
P technique. In addition, in my office, the physician is the sticker
and therefore makes all the incisions and decides the angle,
direction, and distribution of the grafts. The mechanics of this
technique are described in greater detail later in this chapter.
In 1999, I presented my technique in Paris, at the Second
European Meeting of Hair Restoration (3). I called it ‘‘the Bra-
zilian style’’ because another Brazilian surgeon, Dr. Carlos
Uebel, had previously introduced a similar technique in 1986,
which is still popular in Brazil today (4) (see Chapter 16E). Dr.
Uebel’s technique was used for the placement of both minigrafts
and micrografts. My technique differs in that it is specifically
tailored for the placement of larger numbers of microscopically
prepared FUGs and FGs.
Placement of large numbers of small FUGs into many pre-
made incisions is difficult. The stick and place method helps
eliminate some of its potential problems, as is discussed later.
It is worth mentioning here, however, that one of the significant Figure 16B-1 A plastic container is used to hold, separate, and
advantages of my method is reduced operating time. keep grafts moist during cutting.
Figure 16B-2 We use one-hair to three-hair follicular unit graft

(FG) and slightly larger four-hair to five-hair FGs. As seen in this
photograph, a three-hair FUG and a four-hair to five-hair FUG are Figure 16B-4 Grafts organized in piles of 15 with all the hairs
about the same size and can therefore fit into the same small recipi- pointing in the same direction and converging at the same point.
ent site. This increases the speed of placement.
dish filled with a saline solution, in groups of 15, disposed like Preparing the Recipient Site
a fan, with the hairs converging at the same point (5) (Fig. 16B-
4). This disposition enables the placer to easily pick up a group Vasoconstriction is obtained with regular adrenaline tumescent
of grafts by their converged hairs and quickly move them to solution (1:30,000). Like Seager and Limmer, I only use a small
the fingertip. Because the grafts are all pointed in the same amount at a time (2 mL to 5 mL) in the immediate area that
direction, they do not have to be rotated or turned toward the we are about to treat. I also inject a small amount of normal
graft before placement because it is already in position. saline solution (4 Ml to 10 mL) into the deep dermis and subcu-
taneous tissue of the recipient area just before I start making
new incisions. This helps prevent vascular trauma to the deeper
vascular bundles (6) (Fig. 16B-5).
Figure 16B-3 Magnified photograph of donor area showing

follicular units (FUs) (solid circle) and follicular groups (FGs) (dot-
ted circle). An FU is fairly obvious as a one-hair to three-hair
natural grouping that appears to emerge from a single orifice. An
FG occurs when two FUs are so close together that they appear to
be a single larger unit, but on closer examination, they are recogniz- Figure 16B-5 Deep vascular bundles are protected by tumes-
able as two individual FUs situated extremely close together. cence with normal saline solution.
622 Chapter 16
Loading the Grafts onto the Placer’s Finger Density and Pattern
If the grafts on the placer’s hand are kept far from the recipient I prefer to create incisions using the ‘‘regular irregularity’’ de-
sites, the assistant is forced to change the field of view every scribed by Walter Unger (7). I usually work in one area and
time a new graft is picked up. This wastes precious time. I try to create the final density desired before moving to the next
prefer to keep grafts that are waiting to be placed in the same area. However, if popping occurs, I move to a different area
field of vision as the recipient sites. I do this by loading the and later return to the area where the popping occurred to com-
grafts onto the tip of the index finger and then moving this plete the coverage.
finger as close as possible to the recipient sites (Fig. 16B-6).
This increases the speed of placement. Advantages (5)
Two-Person Stick-and-Place (S&P) Technique Faster Procedure

The technique described herein has decreased the time required
In my office, we usually follow a four-stage approach and work to insert each graft. Using this technique, I am able to increase
in pairs of two (one sticker and one placer): the rate of graft placement from 400 to 650 grafts per hour.
1. The ‘‘sticker’’ makes the incision using a 15-degree
Sharpoint microblade for one-hair or two-hair FUGs, Less Bleeding
and a 22.5-degree Sharpoint microblade for three-hair If a graft is placed immediately after an incision is made, it
and four-hair FUGs (Fig. 16B-7a). When the tip of the stops the bleeding and eliminates the need for continuous clean-
blade reaches the desired depth, it is twisted slightly, ing. This saves time and increases visibility in the remaining
creating a small ‘‘real’’ aperture in the recipient site. work area.
This slight opening assists the placer with the initial
insertion of the graft (Fig. 16B-7b).
Less Follicular Trauma
2. The placer gently inserts the graft into the tiny aperture
created by the blade and then slides it down the incision, With S&P, the fibrin does not have sufficient time to accumulate
keeping it parallel to the blade but trying to avoid touch- and harden within the incision. Incisions are at their largest
ing the cutting surface of the blade. Once two thirds of immediately after they are made. In contrast, after a short period
the graft is inside the incision, the placer stops. of time, premade incisions contract slightly, making it more
3. The sticker at this point removes the blade and, using difficult to place the graft. In addition, I twist the blade slightly
the tip of the blade, ‘‘hooks’’ the top of the graft (Fig. to create more of an opening in the site, thereby making it easier
16B-7c). When the placer feels that the graft is hooked to slide the graft down the wall of the incisions.
by the blade, the graft is released and the forceps re-
moved (Fig. 16B-7d). Less Vascular Trauma
4. Using the tip of the Sharpoint blade, the sticker now I can use smaller incisions than would otherwise be necessary
adjusts the graft downward to the desired level (Figs. to place the same size grafts. This benefit is also due to the
16B-7e and 7f). reasons described earlier. Smaller incisions produce less vascu-
With time and practice, two people can develop a rhythm with lar trauma.
this technique and move smoothly between the stages.
A More Relaxed Procedure for the Surgeon
The doctor does not have to cope with the stress of trying to
predict the total number of grafts that will be produced nor to
estimate the number of incisions that will be made. The doctor
has to concentrate attention only on making incisions.
A More Relaxed Procedure for the Assistant

The assistant has to concentrate only on watching the physi-
cian’s microblade and gently inserting the graft after the physi-
cian makes each incision. There is no need to search continually
for empty incisions in a bloody field. This makes the procedure
less stressful and less ‘‘eye-fatiguing’’ for the assistant.
Stick and Place Eliminates Missed Sites and

Piggybacking
The S&P technique decreases the risk of inclusion cysts and
ingrown hairs.
Figure 16B-6 Proper placement of grafts on the tip of a finger
that remains very close to the recipient sites ensures that the grafts
Avoid Errors of Planning
stay in the placer’s field of vision at all times. Thus, no time is One never has to worry about making the right number of inci-
wasted in trying to find the place when new grafts are picked up. sions. If incisions are premade, one can mistakenly create too
Figure 16B-7 (a), The ‘‘sticker’’ makes an initial incision with the Sharpoint blade. (b), The sticker twists the blade slightly (x) to
create a small opening between the blade and the incision, which eases placement of the graft. (c), The placer inserts the graft by sliding
it along the blade (y) and stopping about two-thirds of the way into the incision. The white dotted line shows the direction of the forceps
at this stage. (d), The graft is ‘‘hooked’’ with the point of the blade (z) after the placer has inserted it about two-thirds of the way into the
incision. The placer removes the forceps as soon the graft is hooked. The (white dotted line) direction of the forceps is shown at this stage.
(e, f), The sticker adjusts the graft to the proper level with the tip of the blade.
624 Chapter 16
many or too few incisions and have to return to make more of Chubby Grafts
them at the end of the procedure. When confronted with chubby grafts, the surgeon can use the
A Greater Ability to Adjust the Different Angles and side of the blade as a shoehorn, increasing the aperture and
Directions of Incisions facilitating the insertion.
When making incisions, the physician often changes the direc-
tion and angle of the incision to follow the direction and angle Number of Blades
of existing hair in the area being treated. With the S&P tech- I use a total of three to six Sharpoint blades for each procedure
nique, the placer can see and follow the changing angle and of 2000 FUs. If care is taken to avoid touching the cutting
the direction of the blade incision. When placing into premade surface of the blade with the forceps, the blade lasts longer.
incisions, there is no guide to help placers adjust for these
changes. Rhythm
A Greater Ability to Adjust for Variation in the Size of An attempt should be made to maintain a consistent speed.
Grafts Initially, the pace should be slow; speed can be increased as
The size of FUs that contain the same number of hairs can confidence grows. Often, with experience, a certain rhythm de-
vary depending on hair caliber, degree of trimming, and space velops between the sticker and the placer, and this increases
between the hairs in the FU. With premade incisions, it can be speed.
difficult to adjust for these variations. With S&P, one can easily
adjust the angle or depth of the blade to create a larger or smaller
incision, if necessary. FOLLICULAR GROUPINGS
Additional Tips for Sticking and Placing All hair transplant surgeons seek to satisfy their patients.
Achieving a satisfied patient requires that the physician succeed
Forceps in meeting the patient’s goals for both naturalness and density.
I recommend a fine-tip forceps with diamond dust inside the Today, patients want to accomplish as much as possible with
grip to hold the graft firmly. I believe a straight, 45-degree each session. No one doubts that natural results can be produced
angled tip makes it easier to insert the graft and follow the with the exclusive use of FUGs. However, meeting the patient’s
incision’s angle and direction. expectations of density after a single session is a more difficult
task to accomplish, especially if only FUGs are used. To create
Graft Insertion
greater density, we have traditionally used one of the following
I recommend picking up the graft at the bottom while avoiding options:
the papilla. The graft should not be held by its fatty (yellow)
tissue, because this tissue easily detaches from the graft. It is 1. Use larger minigrafts (7) to increase hair density. How-
best to try to hold the graft by the (white) collagen fibers, adja- ever, in the initial session, the hair density that can be
cent to the papilla. It is not necessary to grab the entire width created is still limited because of the need to use larger
of the graft (Fig. 16B-8). The tip of the forceps should not pass incisions placed further apart. In addition, minigrafts
over the entire width of the graft because its sharp point could have the potential to be more noticeable than FUGs after
hook into the tissue of the recipient site and become stuck during the first session.
placement. The graft should be inserted by following the same 2. Use a greater degree of dense packing: Ultimately, a
direction and angle as that of the incision. density of 40 FUs/cm2 or more is needed, to satisfy
the average patient’s expectation of hair density. Most
physicians place FUGs at densities averaging 25 FU/
cm2 to 30 FU/cm2. Higher densities are possible, but
they require a process that is both more tiring and more
technically difficult (see Chapter 12B). In addition,
dense packing, at greater than 30 FUs/cm2, is believed
to lead to lower survival rates. This is especially true
in the central area, in older patients, and in smokers. In
extreme cases, tissue necrosis can occur (8,9).
3. Doing multiple sessions: The problem with multiple ses-
sions is that patients would obviously like to have more
density as soon as possible.
So what other options are there? In my opinion, the use of FGs
provides a possible solution.
The Logic of Using Follicular Groupings

The usual distance between naturally occurring FUs in the scalp
can range from as low as 0.2 mm to as high as 1.5 mm. As
Figure 16B-8 Proper grasp of the bottom of the graft is shown stated earlier, FGs consist of FUs in the donor area that are
before insertion. spaced so close together (less than .2 mm), that they can easily
Figure 16B-11 Close-up of follicular group in the recipient

area after it has been planted and grown out (dotted circle). Notice
Figure 16B-9 High-power photograph of donor area showing that it contains two follicular units (FUs) very close together, but
a population of follicular groups (FGs) with four to six hairs dotted they do not appear compressed. It is next to a three-hair FU for
circles). Spacing between follicular units (FUs) within the FG is comparison (solid circle).
less than .2 mm. Spacing between normal FUs is about 1mm.
do not require larger incisions than those typically used for a

be mistaken for one unit (see Fig. 16B-2 and 16B-3). In a normal three-hair FUG because they are approximately equal in size
donor scalp, a significant number of FUs may be close enough and thus can be placed in sites of the same size (see earlier in
together to be considered FGs (Fig. 16B-9). I have found this Fig. 16B-2). With typical small slit minigrafts, a larger size site
number to be about 14% of the total number of grafts. When must be used because of the spacing between the FUs within
I split apart the FUs that exist within a naturally occurring FG, the minigraft. Therefore, small slit minigrafts cannot be placed
I can only reinsert them back into the recipient area at a distance as close together as FGs. Table 16B-1 compares the differences
of about 1 mm to 2 mm from one another. Therefore, the density between FGs and minigrafts.
that these naturally occurring FGs produce in nature is signifi-
cantly decreased when they are split apart (Figs. 16B-10a and
b and 16B-11.
Table 16B–1 Comparison of Small Slit Minigrafts and
On the other hand, if they are together as an intact FG, the Follicular Grouping
combination of small size and greater number of hairs can be
used to advantage and produce greater density than with a sim-
ple FU alone. A significant characteristic of FGs is that they
Small Slit Minigraft Follicular grouping

(2 FU) (2 FU)
• Two to three FUs • Two FUs found to naturally

(follicular unit) in a graft be spaced about 0.2 mm to
cut to size .5 mm apart
• Space between FUs is • Closer spacing creates
usually ⬃ 1 mm smaller grafts with higher
number of hairs.
• Space between FUs greater • Smaller graft fits into same
in mingraft than in FG small microblade incision
that three-hair FUGs fit into.
• Greater space means larger • Small incisions can be placed
graft and larger incision at higher density
Figure 16B-10 (a), Intact follicular group (FG) containing six • Larger incision means • This is a naturally found
hairs. Close examination reveals that this FG consists of two follic- more space between spacing and grouping and
ular units (FUs) approximated very close together. (b), The same incisions and less densitiy. does not appear compressed
FG has been cut into two individual FUGs. If they are separated when replaced in this manner
like this, when they are put back into the recipient area, they will
be further apart than they were in nature. FU ⫽ follicular unit; FUG ⫽ follicular unit graft.
626 Chapter 16
Safe Density
Most hair restoration surgeons agree that placing FUGs in inci-
sions spaced at 20–30 FUs/cm2 is safe. However, many patients
require 40 FUs/cm2 to 50 FU/cm2 to achieve the appearance of
adequate density. With FGs, this higher density can be achieved
without creation of more recipient sites. If FGs (11) are used,
25 incisions per cm2can be created with microblades (Sharpoint
15 degrees or 22.5 degrees). However, because each FG holds
two FUs, 50 FUs/cm2 can actually be created in one single
session. Thus, it is possible to increase hair density and volume
without increasing the number of incisions. This procedure does
not need to be done in all parts of the recipient area. It is,
however, desirable to have this density in specific, aesthetically
important parts of the recipient area such as the frontal tuft.
In 2002, we did a study (12) to demonstrate that it is possible
to increase the hair density in a specific area using FGs, at the
same time keeping the incisions at 25 to 30 micro incisions per Figure 16B-12 (a), ‘‘Before’’ photograph of patient A. (b),
cm2. In a 1-year period, we selected 102 male patients with ‘‘After’’ photograph of patient A.
androgenetic alopecia. The two-person S&P Brazilian tech-
nique was used for the entire procedure. On average, we placed
2385 grafts per session, with the breakdown of grafts as follows:
one-hair FUGs ⳱ 327 (16.34%); two-hair FUGs ⳱ 832
(41.58%); three-hair FUGs ⳱ 459 (22.94%) and FGs ⳱ 383
(19.14%). We averaged 2.09 hairs/FU and 4.18 hairs/FG be-
cause each FG contained two FUs. In the center of the frontal
area (frontal tuft), we placed only FGs. We used the 15-degree
Sharpoint blade and, sometimes, the 22.5-degree Sharpoint
blade. The latter is the same size as the blade we often use for
three-hair FUGs. In this central area, we made incisions at the
usual density of 20 to 30 incisions/cm2. Because only FGs were
used in this area, we were able to place almost 40% more hairs
than if we had used FUs exclusively.
CONCLUSION Figure 16B-13 (a), ‘‘Before’’ photograph of patient B. (b),

‘‘After’’ photograph of patient B.
Using FGs, in addition to FUG, during FUT is an effective and
safe method to increase hair density and volume (we can safely
double the number of FUs in an area). Vascular trauma is not
increased because the incisions are kept safely at 25 incisions/
cm2. In addition, by using the two-person S&P technique, it is discussion, using FGs certainly seems to be a very elegant way
possible to increase both the speed and control of the procedure. of increasing hair density in limited areas without increasing
The results of this technique in two patients are shown in Figs. the number or length of recipient area incision sites.
16B-12a and b and 16B-13 a and b.
Editor’s Comment 16C. Optimal Strategies in Hair
The more hairs that are present in a small surface area, the
Transplantation
greater the likelihood of some noticeable ‘‘plugginess.’’ Min-
islit grafts that include two FUs that are farther apart could Jörg Hugeneck and Claudia Moser-Prawetz
therefore be expected to be less likely to produce a pluggy
appearance than an FG. I have not yet tried FGs as described INTRODUCTION
by Tykocinski, but Harris describes a similar type of graft in
Chapter 12E, which he refers to as a ‘‘recombinant FU.’’ In By the year 2000, the micro/minigraft method of hair transplan-
that chapter, he cautions that finer hair with less skin to hair tation was optimized to such an extent that excellent results
color contrast produces a better effect than that seen with could be achieved, particularly with the use of the three to
coarser hair and higher color contrast. four hair small slit grafts described in the third edition of this
There are approximately only 14% of FUs growing as FGs textbook. Indeed, the results today look so natural that we have
according to Tykocinski, therefore, the area to be treated with made embarrassing mistakes with several patients coming for
them has to be limited. Minigrafts allow larger areas to be a checkup. In the rush of routine work, we thought our own
treated more densely as the number of minigrafts is not as lim- result from the operation was natural hair growth! One could
ited. On the other hand, as I note in my comment after Harris’ hardly make a better mistake.
Yet perfect operation technology is not enough to satisfy

patients for the rest of their lives. The real challenge for the
modern hair transplant surgeon is not just to strive for a good
result in the short term. In an age when more people are living
to between 80 and 90 years old, we have to plan a design that
will satisfy patients for up to 50 years. Because predicting
changes in hair loss for a period of more than 50 years is diffi-
cult—if not impossible—, and because it often is not known
precisely when hair loss stops, one must plan conservatively.
A result that appears optimal over a 5-year period can look
unnatural and unattractive when rapid hair loss develops; the
signs of the treatment can be seen and the patient becomes
understandably dissatisfied. Corrective measures are often diffi-
cult, or even impossible, if the donor hair has already been
completely used. Thus, there are a few rules that should always
be observed in hair transplantation. The guiding principle on
the road to success should be to produce a high hair density.
This objective is easier to achieve if the hair problem is re-
stricted to a small area.
For large alopecic patches, an aesthetically acceptable solu-
tion can be achieved by observing the following rules: 1) maxi-
mum usage of donor hair and 2) reduction of the treatment area.
Figure 16C-1 Frontal design for patients with Norwood types
IV to VI.
Maximum Usage of Donor Hair
A large area of male pattern baldness (MPB) necessarily means
a narrow fringe. No more than approximately 40% to 50% of
being able to see it in the mirror every day. O’Tar Norwood
donor hairs should be removed, if one is to avoid over depletion
once said, ‘‘Forget the back,’’ and we agree.
of the donor area and, consequently, an obviously thin fringe
It is absolutely essential that the highest possible percentage
of permanent hair.
of transplanted follicles survive. It is our opinion that even when
The following problems may occur if this rule of thumb is
exercising extreme care, it is not possible to achieve 100%
not followed: (1) unattractive scarring and (2) sparse hair den-
growth from the donor follicles. Follicles can be damaged at a
sity in the fringe, which only worsens with age.
To prevent both of these negative outcomes, the donor hair
should be excised without concentrating the removal in any one
area of the donor rim.
Removing hairs in a long, narrow strip has certain advan-
tages. If the hair roots are removed in an even fashion over the
whole fringe area, there are more follicles available in total. In
addition, during closure of the wound, less tension is introduced
around the wound edges compared with the amount of tension
that results after the excision of a wide strip. This approach
results in narrow, unobtrusive scars and also likely produces
less postoperative pain in the donor area.
Reduction of the Treatment Area

Young patients in particular, even Norwood types IV to VI
patients, would like complete hair coverage of the entire alope-
cic area. Although this is technically feasible, we believe the
doctor performing the treatment should very strongly dissuade
the patient from pursuing this objective. It is better to replace
either the anterior or posterior area of MPB to ensure good
results and satisfied patients. Generally, there is enough donor
hair available for sufficient coverage of approximately one half
to two thirds of the area of MPB (Figs. 16C-1 and 16C-2).
Which area(s) the patient chooses is a subjective decision. We
always prefer and recommend that the frontal area be treated. Figure 16C-2 Occipital design for patients with Norwood
This allows the patient to fully enjoy the successful result by types IV to VI.
628 Chapter 16
number of points during the treatment: (1) at the time of excision Our specific method of dissection creates very small grafts
of the donor strip(s) (in particular, we believe the use of mul- that are the same shape as the recipient site and includes trim-
tiblades is potentially harmful), (2) during preparation of the ming off the epidermis. We believe this limits hair compression,
grafts, and, (3) during implantation of the grafts. tufting, scarring, and any ‘‘gooseflesh effect.’’ The latter refers
Well-trained staff and careful handling of the implants is to transplants in which there is depigmentation around grafts
imperative. Yet even if the transplantation has been performed that are not completely flush with the skin.
under optimal conditions, the graft will thrive only if there is
sufficient blood supply. The blood supply is much better if two
guidelines are followed: (1) the grafts are as small as possible PRE-ANESTHESIA
and (2) as few blood vessels as possible are damaged when
making the recipient sites. Half an hour before the treatment, the patient is given one dose
of diazepam (Valium), 10 mg, as a relaxant. The patient either
Graft Size dozes or sleeps peacefully throughout the operation, which is
accompanied by soft background music. We are often told at
Large grafts with more than four follicles should generally be the end of the transplantation that the procedure was far more
avoided, because we believe that the resultant tufting effect pleasant than a visit to the dentist. Immediately before the treat-
gives unattractive results. Moreover, large implants not only ment, we also administer an intramuscular injection of beta-
contain a large number of hair roots, but also a sizable amount methasone (Celestan Biphase), 2mL, which we have found pre-
of skin tissue. This interfollicular skin, which adds no additional vents significant postoperative swelling in approximately 95%
camouflage, does, however, consume oxygen that might other- of all cases.
wise be available for the follicles. In the minislit graft method,
which we perform, we take particular care to remove as much
non–hair-bearing tissue from the graft as possible. By arranging DONOR AREA
the follicles in a longitudinal direction, one can remove even
more oxygen-consuming tissue. We choose a single elliptical donor area that is outlined and
There are, of course, cases in which the distance between then anesthetized, using lidocaine 2% with epinephrine 1:
follicles in the donor area is larger than average, and it is not 100,000. The size of the area removed depends on the number
possible to remove the tissue between the individual hair roots. of grafts needed, the quality of donor hair, and the overall hair
In these cases, grafts with just one or two follicles should be density. For a patient with average donor area hair density, 1400
produced. Depending on the requirement, two grafts may then grafts (approximately 60 micrografts and 1340 three-hair grafts)
be placed in one recipient-slit site. Thus, one can still create usually can be obtained from a strip that is approximately 30
slit sites that contain three-hair or four-hair roots while minimiz- cm ⳯ 1.2 cm. We would generally use 8 mL to 10 mL of
ing the amount of alopecic tissue that is transplanted. lidocaine to anesthetize this area. Normal saline solution is infil-
trated into the donor site, just before excision, to create donor
Damage to Blood Vessels tissue that is firm and thus easier to dissect. For a 10 cm ⳯ 1
cm large excision, for example, we use approximately 30 mL
We believe the minigraft method, which uses round recipient of saline solution. The ellipsoidal donor area is incised and
holes between 1 mm and 2 mm, damages more blood vessels removed by means of a no. 10 blade. This is done freehand
than the slit-based method. A further reduction in the risk of with two parallel incisions, with great care taken to follow the
damage to the blood vessels can be achieved if the slits are angle of the hair and to stay superficial to the galea. After the
created so that they follow the direction of the vessels in the ellipse is removed, larger bleeding vessels are cauterized and
skin. Another advantage of slit incisions is that the grafts can the donor area is sutured. Double-layer closure is used in every
be placed closer together, and a higher hair density produces a case. We use Dexon 3–0 for subcutaneous suturing (Fig. 16C-
better appearance. 3) and a continuous 3–0 Resolon suture for skin closure. Scars
Based on these benefits, as well as clinical observations, from preceding operations are excised as part of any subsequent
we believe that the best results can be achieved with the slit harvesting.
incisions.
TECHNIQUE GRAFT PREPARATION AND STORAGE

One of the initial problems with slit grafting was that the ‘‘pie- The excised ellipse is placed, with the hair-bearing surface visi-
shaped’’ grafts produced from quadrisected round grafts did ble, on a cutting surface Telfa pad (Kendall Health Care Prod-
not match the shape of the linear slits. Compression and scar- ucts Company, Mansfield, MA 02048), which is also well suited
ring, which resulted in a ‘‘tufted’’ look, were quite common. for dissecting grafts. For major operations, approximately 10
Another difficulty encountered with these grafts was the ‘‘pop- of these pads are needed. With a no. 11 blade, the ellipse is
ping’’ and bleeding that occurred when an attempt was made divided into secondary slivers by cutting perpendicular to the
to place a large number of these grafts in close proximity. longitudinal plane Fig. 16C-4. The width of these secondary
Our technique can be used to transplant up to 1400 small strips varies, depending on the donor hair density and preferred
grafts in one session, with very little bleeding or popping. Trans- graft size. For example, the width is approximately 1 mm if
planting these large numbers of small grafts improves the distri- grafts with three hairs are the goal.
bution of donor hair, which produces an aesthetically pleasing These secondary strips, or slivers, are placed on their sides
result in just one session. and again cut with a no. 11 or no. 10 blade into thin, flat
Figure 16C-3 The donor area is sutured subcutaneously with 3/0 Dexon.
slit grafts that approximate the shape of the recipient incisional linear distribution of hair in the graft, and the removal of
sites (Fig. 16C-5). When cut in this manner, most of the all excess tissue and fat limit the possibility of compression
hairs in the graft line up one behind the other so that there of the hairs within the grafts and lead to a more natural final
is only one vertical line of hair. These grafts are further result. Close observation reveals that the epidermal surface
reduced in size by meticulous trimming away of all surround- of these grafts can contain excess tissue that expands out
ing excess fat and tissue. We believe that the flat shape, the into a mushroom-like shape (Fig. 16C-6a). This, along with
Figure 16C-4 The ellipse is cut into 1 mm-wide to 2-mm-wide

secondary strips. Figure 16C-5 The secondary strips are cut into thin, flat grafts.
630 Chapter 16
Figure 16C-6 (a), Schematic drawing showing grafts before trimming with epidermal surface expanding into a mushroom-like shape.
(b), Schematic drawing showing the trimming of this excess tissue.
excess dermis from the sides, is trimmed away (Figs. 16C- We believe that both the ‘‘gooseflesh effect’’ and scarring
b and 16C-7). We then trim the epidermis from each graft can be limited by practice of these techniques of graft harvesting
with a single cut at an oblique angle, thereby reducing the and preparation. The slit grafts produced have several special
surface area and creating a uniform shape at the upper end properties:
of each graft (Fig. 16C-8).
1. They are thin and flat, matching the shape of the recipi-
ent incisions.
2. The hairs are distributed in a linear fashion within the
grafts, thus helping to create a more natural final appear-
ance (Fig. 16C-9).
3. The grafts are shorter and more uniform in shape, with
less surface area because of trimming and removal of
the epidermis.
As described later, these properties help to minimize bleeding,
ease graft placement, and limit scarring and compression.
Conventional slit grafts with a larger surface area are sub-
jected to more pressure laterally and on the skin surface
when placed into narrow recipient incisions. This causes the
so-called ‘‘tufting’’ and ‘‘gooseflesh’’ effect sometimes seen
in the recipient areas of patients treated in this fashion.
As grafts are being prepared, they are transferred directly to
a storage solution until they are ready for placement. We have
been investigating a number of solutions to determine which
medium can best enhance micrograft viability. Currently, most
offices use a chilled, buffered saline solution (PBS). We com-
pared hair shaft elongation and morphology of grafts after 5
hours of immersion in various solutions (Fig. 16C-10a, b, c).
The results of our study, although limited in scope, indicate
that Dulbecco’s modified Eagle’s medium (DMEM)—a com-
mon cell-culture medium—significantly improves follicular vi-
ability in vitro (1). Hair shaft elongation was found to be 25%
to 28% better when stored in DMEM compared with PBS (Fig.
16C-11a). Furthermore, when growth factors (insulin and
aminoguanid [AMG]) were added to DMEM, a further im-
provement in growth in vitro was noted (Fig. 16C-11b). The
study was extended to compare viability of grafts in DMEM
with the addition of various inhibitors of cell apoptosis (catalase
and 14, 15-epoxy-eicosatrienoic acid); again, these molecules
Figure 16C-7 Actual photograph of the schematic shown in improved in vitro cell growth (Fig. 16C-11c). Obviously, fur-
Fig 16C-6 demonstrating trimming of extra tissue. ther studies with a larger cohort need to be examined. Moreover
Figure 16C-8 Close-up view of a graft with the epidermis removed.
Figure 16C-9 Close-up-view of one growing graft. Hairs in the graft line up one behind the other.
632 Chapter 16
Figure 16C-10 Morphology of micrografts after 5 days in culture: (a), buffered saline solution (PBS), (b), Dulbecco’s modified Eagle’s
medium (DMEM) (c), DMEM/insulin (INS)/ aminoguanid (AMG).
Figure 16C-11 (a), Chart showing effect of patient serum in storage solution. (b), Chart showing effect of insulin and aminoguanid
(AMG) on in vitro hair shaft elongation. (c), Chart showing effect of catalase, 14, 15-epoxy-eicosatrienoic acid in vitro hair shaft elongation.
Figure 16C-12 The 22.5-degree omnitome is used for the mi-

Figure 16C-11 crografts (right). The 45-degree omnitome is used for the
three–four hair small slit grafts.
three to five hairs. For patients with dark hair and light skin,
we need to determine the effect of different storage solutions
it is more appropriate to use grafts containing only one to three
in vivo; perhaps graft viability will improve and/or growth will
hairs.
occur more rapidly after transplantation.
The Sharptome Microsurgical Knife (15 degrees or 22.5 de-
grees), is generally well suited for creating one to two hair
micrograft incisions. When the skin of the scalp is very elastic,
RECIPIENT INCISIONS the 15-degree knife can be used; in other cases, it is preferable
to use the 22.5-degree knife. For three-hair grafts, we use the
While the grafts are being dissected, the patient is placed on 45-degree microsurgical knife, and for four-hair or five-hair
his back and given bilateral supraorbital nerve blocks; marcaine grafts, the Sharptome Microsurgical Blade 74–1000. We begin
0.5% with epinephrine 1:200,000 is used. The recipient area creating the recipient sites posteriorly and gradually progress
is then infiltrated with a special saline-lidocaine-epinephrine anteriorly, in order to make the surgery both cleaner and easier.
solution (saline, 100 mL; lidocaine 2% with epinephrine 1: The recipient area incisions are completed before any graft
100,000, 19 mL; and epinephrine 1:100, 1 mL). Enough solu- placement begins.
tion—usually 100 mL when 1000 grafts are done—is infiltrated All incisions are directed anteriorly when the frontal area is
to anesthetize, minimize bleeding, and distend the recipient area being treated. We also direct most of the grafts anteriorly in
by approximately 1 cm. the occipital area, gradually changing the direction as we ap-
Incisions are made with a variety of sizes of ultrasharp mi- proach the fringe to follow the direction of the existing hair.
croblades, known as Sharptomes (Robbins Instruments, Inc., For Norwood-Hamilton type VI patients (3), we use approxi-
Chatham, NJ). The size of the blades is carefully chosen to mately 1000 to 1400 grafts of various sizes, per session, when
match the size and shape of the different grafts (Fig. 16C-12). transplanting both the anterior scalp and the vertex. We use
Because we remove the epidermis, our grafts are shorter approximately 600 to 700 grafts per session, when only the
and, therefore, our incisions are not as deep as those required anterior scalp is transplanted, and the posterior border of the
for conventional slit grafts (3mm to 4 mm). This, in addition grafting is designed to create a normal circular vertex shape.
to skin distention with the tumescent solution, allows us to One reason that this technique produces a more natural result
create recipient sites above the vascular plexus and helps to is the ability to transplant very large numbers of very small
minimize bleeding. The hairline zone is 1 cm to 5 cm wide and grafts. This produces a more natural distribution of hair. For
is created with only one or two-hair micrografts, placed 1 mm example, 350 six-hair grafts and 700 three-hair grafts both pro-
to 3 mm apart in an irregular, staggered pattern. We put more duce 2100 hairs. But the 700 three-hair grafts produce a more
one-hair grafts in the anterior aspect of this zone and more two- even distribution of this hair over the same area (Figs. 16C-13
hair grafts in its posterior aspect. Behind this zone, we use three- and 16-14).
hair or four-hair small slit grafts, placed 2 mm to 4 mm apart,
also in an irregular, staggered fashion. This pattern is followed
PLACEMENT
for patients with average hair quality and light-brown hair of
average density. In every case, the graft size must be catered For planting the grafts, we use special surgical forceps—Du-
to the patient’s particular graft and hair characteristics. For a mont & Fils forceps 5/45 that have been developed for eye
patient with fine, blond hair and light skin we use grafts with surgery and have very fine tips (available from Reiner Inc.,
634 Chapter 16
Figure 16C-13 (A), Patient A with large area of male pattern baldness. (B), Patient A after three treatments. (C), Close-up of the
hairline of patient A.
Figure 16C-14 (A), Patient B, 55 years old, with frontal baldness. (B), Patient B after three sessions. (C), Frontal hairline view of
patient B.
Marianneng. 17, 1090 Vienna, Austria). We do not find it neces- times, the graft sites heal so fast that they are barely visible 10
sary to use dilators. When placing the grafts, it is important to days after insertion.
make sure that they are either flush to, or slightly higher than, There are several theories that might explain this:
the scalp. If they are placed below the surface, they are hard
to see and piggybacking and cyst formation may occur. Because 1. Careful attention is given to creating grafts that are the
the grafts absorb some of the saline solution while they are in same size and shape as the slits. The hairs have a rela-
the petri dishes, they are slightly larger at the time of insertion tively linear distribution within the graft, and all excess
than they are a few hours later. As they shrink, the grafts that fat and tissue around the graft is removed. This limits
are slightly elevated tend to become flush with the skin. the effect of lateral compression on the graft.
Popping and piggybacking can cause problems when an at- 2. The depth of our incisional sites is just a little more than
tempt is made to place very large numbers of grafts closer to- that of the graft. This, combined with careful attention in
gether. Popping refers to one graft elevating as its neighbouring placing the grafts flush with the skin, keeps the grafts
graft is being placed in the next site. We feel that this problem from falling deep to the skin surface, and thus prevents
becomes significant when grafts are either too large or have cyst formation and pitting.
the wrong shape for the recipient site. As noted earlier, our 3. Healing takes place between the edges of the recipient
dissection technique produces very small, flat grafts that are sites and the surface of the grafts. The edges match up
the same shape as the recipient slits. We also carefully choose perfectly and there is essentially no gap between them
the size of our microblade to match the size of our grafts, which and the grafts. The result is easy migration of cells from
change according to the density in the donor tissue. Therefore, the recipient area to the dermal surface of the grafts with
we have little problem with popping. minimal scarring, cobblestoning, or gooseflesh effect
Piggybacking refers to the placement of one graft on top of being produced.
another in the same site. Usually, this occurs because of diffi-
culty in visualizing the site. We rarely encounter this problem
for the following reasons: STAFF REQUIREMENTS
1. We have minimal bleeding, our field is very clean, and For 1000 to 1400 grafts we use 10 technicians. The grafts are
the sites are easily visualized. prepared while the recipient incisions are being created. When
2. We carefully place all our grafts either flush to, or all the recipient incisions are finished, two of the technicians
slightly higher than, the surface of the scalp; they are, start placing grafts while the others continue to cut the grafts.
therefore, difficult to miss. A session of 1400 grafts, performed by our staff, takes approxi-
3. To keep the recipient area clean, we periodically spray it mately 4 hours.
with hydrogen peroxide 1.5% during the transplantation
process.
BANDAGING
An overnight bandage is always used for the donor area. A
BLEEDING
neomycin-bacitracin (Neobacitracin) spray is applied to the
Excessive bleeding limits visibility and makes graft placement wound before bandaging. The recipient area is left without a
more difficult. This can hinder the placement of a large number bandage.
of grafts. The three following interventions are part of our tech- The patient may wait in the office for approximately 1 hour
nique to help control bleeding: and then leave without a bandage if no significant bleeding
has occurred during that time. We have had no postoperative
1. Administration of a sedative (diazepam [Valium], 10 bleeding in the last 1500 patients treated this way.
mg, or sleeping pill) before the procedure relaxes the
patient. This, along with good pain control during the
procedure, helps control the blood pressure and thus
bleeding. 16D. Surgical Refinements and
2. The epinephrine solution we use causes very good vaso- Artistic Creativity in Hair
constriction.
3. Because we remove the epidermis, our grafts are shorter Restoration
and, therefore, the depth of our incisions can be shal- Shagufta Khan and Sajjad Khan
lower to accommodate the graft (3 cm to 4 mm). This,
combined with the distention of the skin achieved with
our epinephrine solution, keeps the incision superficial It is difficult, if not impossible, to tell the difference between
to the deeper vascular plexus and helps minimize transplanted and nontransplanted hair if the follicular unit grafts
bleeding. (FUGs) are transplanted artistically. However, if the FUGs are
transplanted in the wrong place, they can still produce unnatural
results. In addition, graft survival and density may suffer if
SCARRING, COMPRESSION, TUFTING skillful technique is not used in donor harvesting, graft prepara-
tion, recipient site creation, and placement. In this chapter, we
Since we have been using the technique described herein as a describe some of the surgical refinements we have developed
rule, we have seen no tufting—or goosebump effect. Many in our practice to improve our results.
636 Chapter 16
Table 16D–1 Estimation of FUGs with the Graded Density Table 16D–3 Percentage of One-Hair to Four-Hair FUGs in
Approach Different Density Types
Recipient Density 4-Hair 3-Hair 2-Hair 1-Hair

Norwood type surface area FUGS needed type FUG FUG FUG FUG
II 20 cm2 1000 A 5% 65% 25% 5%

III 40 cm2 2000 B — 50% 40% 10%
IV 80 cm2 3000 C — 20% 60% 20%
V 120 cm2 4000 D — — 50% 50%
VI 160 cm2 5000
VII 200 cm2 6000
ference influences the final outcome by affecting the final

distribution and the total number of hairs transplanted to each
SURGICAL REFINEMENTS area.
Using the aforementioned numbers, we created a table to
Estimating the Number of Grafts Needed assist us with estimating the number of hairs and different sizes
of FUGs obtained from a donor strip 10 cm long and 1 cm
Proper planning is essential for the success of any surgical pro- wide. (Table 16D-4).
cedure. The progressive nature of hair loss makes the planning If the strip length is extended from 10 cm long to 15 cm or
more difficult in hair restoration. Hair restoration deals with 20 cm long, we add the figures together to calculate the number
the existing baldness while keeping in mind future hair loss. of FUGs. The same is true if the width of the strip is enlarged.
The progression of hair loss is dependent on genetics and age.
If patients start losing hair in their early 20s and have a strong
Selecting the Donor Area
family history of hair loss, the hair loss is almost certainly going
to be faster than average. If the onset of hair loss begins later, We use the level of the external occipital protuberance to indi-
when patients are in their 50s or older, the hair loss is usually cate the middle of the safe donor zone in the occipital area. We
more gradual. try to make sure that there is 2 cm to 3 cm of terminal hair-
The numbers of FUGs we think are needed to treat an exist- bearing area superior to and inferior to the selected zone. The
ing pattern of baldness are shown in Table 16D-1. With small donor area can be extended into the temporal area with the same
areas of hair loss, we can recreate higher densities; for example, approach, if needed (Fig. 16D-1).
1000 FUGs placed in the 20cm2 area of a Norwood type II Hair in the temporal area is finer than hair in the occipital
patient, produce a final density of 50 FUs/cm2. With greater area. Temporal hair is used for the hairline, eyebrows, and eye-
degrees of hair loss, we are limited to recreating lower densities; lashes because of its finer nature. The difference in dermal
for example, 6000 FUGs placed in a 200cm2 area of a Norwood thickness and, consequently, the length of FUs below the skin
type VI patient create a final average density of only 30 FUGs/ may explain this difference. The dermis is approximately 3 mm
cm2. to 5 mm thick in the temporal area and 4 mm to 5 mm thick
in the occipital area. This means the thickness of the dermis is,
Evaluating the Donor Area Density on average, 1 mm less in the temporal area than in the occipital
area (Fig. 16D-2).
Evaluating the donor area density is important for estimating The subcutaneous layer thickness in both these areas is the
the number of FUGs that are safely available for the procedure. same, about 2 mm to 3 mm. In both these areas, the terminal
In our practice, we use the Kahn densitometer, which has 8x hair transverses the dermis and is embedded approximately 1
magnification and allows us to count the hairs in a 16mm2 mm into the subcutaneous tissue (Fig. 16D-3). This makes the
surface area. We translate that figure into hairs/cm2 and use it temporal hair follicular depth, on average, 1 mm less than occip-
to classify the donor area density into four density types (Table ital hair.
16D-2). The selected donor area hair is trimmed to 2 mm in length.
The average number of hairs per FUG varies with the differ- The donor area hair density is evaluated by means of the Khan
ent density types. The higher the density, the greater the propor-
tion of three-hair and four-hair FUGs (Table 16D-3). This dif-
Table 16D–4 Calculating the Number of FUGs in a Donor Strip

10 cm Long and 1 cm Wide (10 cm2)
Table 16D–2 Classification of Donor Area Density
Density Total No. 4-Hair 3-Hair 2-Hair 1-Hair Total No.
Density type Average hair/cm2 Range of hair/cm2 Type of Hairs FUGs FUGs FUGs FUGs of FUGs
A 200 (175–225) A 2000 25 433 250 100 808

B 150 (125–175) B 1500 — 250 300 150 700
C 100 (75–125) C 1000 — 66 300 200 566
D 50 (25–75) D 500 — — 125 250 375
Figure 16D-3 Anagen hair bulbs in both the occipital and tem-
poral area are embedded approximately 1 mm into the subcutaneous
fat.
Figure 16D-1 Selecting and anesthetizing the donor area.
tion of lidocaine with epinephrine provides better hemostasis

densitometer and assigned one of the density types listed in than ‘‘stock’’ solutions. The epinephrine concentration is fur-
Table 16D-2. If a patient has type A density, and we plan to ther diluted from 1:100,000 to 1:150,000 for patients younger
perform a session of 1000 FUGs, according to Table 16D-4, than 25 years of age and patients older than 60 years of age.
we would need a donor strip that is 12.5 cm long and 1 cm wide. A point is marked in the center of the donor area (point A),
This strip would yield 1000 FUGs with 31 four-hair FUGs, 544 and two points are marked 3 cm lateral to this center point
three-hair FUGs, 312 two-hair FUGs and 125 one-hair FUGs, (point B1 and point B2) (Fig. 16D-1). Two milliliters of the
for a total of 2500 hairs. The length and width of the strip is local anesthetic solution are injected 1 mm to 2 mm deep into
marked before the area is anesthetized. the superficial dermis with a 30-gauge needle at points A, B,
and B1, to raise a wheal (approximately 2 cm2) at each site.
Donor Area Anesthesia Injections into the superficial dermis are repeated through the
lateral margins of the initial wheals to extend the initial wheal,
Diazepam (Valium), 10mg, is given orally to the patient 30 without causing further pain or discomfort, until a field block
minutes to 1 hour before injecting the local anesthesia. Lido- of the donor area is completed. Anesthetic and hemostasis ef-
caine, 0.5%, 100mL is mixed with 1 mg of epinephrine 1:1,000 fects last longer owing to slow reabsorption of the local anes-
strength. This solution creates a concentration of lidocaine, thetic solution in the dermal plane. Injecting local anesthetics
0.5%, with epinephrine, 1:100,000. The freshly prepared solu- in this plane also lifts the dermal plane away from the neurovas-
cular plane. Tumescence in the donor area is achieved, by inject-
ing normal saline solution 1 mm to 2 mm deep into the superfi-
cial dermis with a 30-gauge needle. This technique lifts the
dermal plane further away from the neurovascular plane (Fig.
16D-4). Enough normal saline solution is injected to achieve
supertumescence and make the skin ‘‘rock hard’’. The dermal
supertumescence minimizes bleeding and reduces incisional
damage to the follicles during ellipse harvesting.
Donor Area Harvesting

The depth of the neurovascular plane in different areas of the
scalp varies depending on the thickness of the dermal and sub-
cutaneous layers in those areas. The depth of the neurovascular
plane in the occipital area is 6 mm to 7 mm. The depth of the
neurovascular plane in the temporoparietal area is 3 mm to 5
mm deep. We use the Khan depth-control blade handle on a
single blade to harvest our donor strip. The depth guard is ad-
justed to 5 mm in the occipital area and 4 mm in the temporopa-
rietal area (Fig 16D-5).
Figure 16D-2 The width of the dermis and hence the length A very shallow incision is made and angled in the same
of the follicle is about 1 cm longer in the occipital region than in direction that the hair grows. After this, the skin edges are sepa-
the temporal region. rated by the skin hooks and further incision is carried out by
638 Chapter 16
Figure 16D-4 Supertumescence in the superficial dermal layer

lifts it away from the neurovascular plane
use of a dissecting microscope mounted on a special rotating

support. We believe that using a microscope during donor har-
vesting reduces the follicular damage in the surgical margins
of the ellipse to 1% (Figs. 16D-6 and 16D-7). In our experience,
if the patient has perfectly straight hair and has not had any
previous surgeries, the average surgical margin of follicular
damage is 5% without use of magnification. If the patient has
curly hair or previous scarring in the donor area, the average
surgical margin of follicular damage without the microscope is
10%. The donor area is closed with staples. Figure 16D-6 An initial shallow incision is made, skin hooks
are applied, and the rest of the harvesting is done with a dissecting
Graft Preparation microscope on a mechanical arm.
In graft preparation, the dissecting surface averages three times

the total surface of the harvested area. Without assisted magnifi-
cation, there is an average of 5% damage to the FUs. This can
be reduced to 1% with the use of a stereomicroscope. However,
Figure 16D-7 The surgical margin of the ellipse, obtained with

Figure 16D-5 A depth-control blade handle is used to help the dissecting microscope, shows minimal transection. We believe
monitor the depth of the incision and keep it above the neruovascu- the transection rate of the elliptical margins can be decreased to
lar plane. 1%.
the use of the stereomicroscope reduces the graft preparation

speed and may put too much strain on the neck and back of
the technicians. We use the Keller & Khan system, which con-
sists of a camera connected to a high-resolution flat monitor.
The camera is mounted above the dissecting area. It has a wide
field depth and projects a 10⳯ image onto the high-resolution,
flat-screen monitor. The FU graft preparation is carried out by
looking at the screen. This system allows flexibility of posture
and reduces the strain on the neck and back of the technicians
(Fig 16D-8).
Recipient Area Anesthesia

A local anesthetic cream is applied in the supraorbital area, just
superior to the eyebrows, 30 minutes before the supra-orbital
block is performed. Three fingers are placed in the center of
the forehead (Fig. 16D-9) and the needle is passed lateral to the
fingers at eyebrow level until it slightly touches the supraorbital Figure 16D-9 Supraorbital nerve block with the three-finger
ridge. lidocaine, 0.5%, 2 mL, with epinephrine, 1:100,000 is rule for recipient area anesthesia.
injected with a 30-gauge needle. The block takes effect in 1 to
2 minutes. After the supraorbital block is completed, a local
anesthetic solution of lidocaine, 0.5%, with epinephrine, 1:
100,000, is injected with a 30-gauge needle 1 mm to 2mm deep recipient sites, a recipient area 3 cm2 is injected with normal
into the dermis along the proposed hairline of the recipient area. saline solution. This solution is injected 1 mm to 2 mm deep
After this has been done, the whole recipient area is injected into the dermis and enough saline solution is injected to expand
with the same solution and in the same manner. An average of the area by 50% to 100%, depending on the skin type of the
1.50 mL of local anesthetic is injected per cm2. A 0.5% solution, patient. The average expansion in African Americans, Hispan-
1 mL, contains 5 mg of lidocaine For a procedure of 1500 FUs ics, and Asians is 50%. The average expansion in white patients
in a 4500-mm2 surface area, approximately 70 mL of lidocaine, varies from 50% to 100%. The recipient sites are created in
0.5%, is therefore injected (350 mg of lidocaine is far below the 3 cm2 expanded area. The process is repeated serially, in
the toxic level). The anesthetic effect lasts 5 to 6 hours because additional 3 cm2 areas until the whole recipient area has been
of slow reabsorption of the lidocaine and epinephrine in the covered. The expansion process lifts the dermal plane away
dermal plane. In our opinion, slow administration in the dermal from the neurovascular plane, provides an increased surface
plane of up to 700 mg of lidocaine with epinephrine is safe area during site preparation, and helps to create sites that will
(see also Chapter 8). be much closer to each other once the infiltrated saline solution
disperses. In areas of thinning hair, the expansion spreads apart
Recipient Site Incisions
the existing hairs, thereby facilitating site production in between
Expansion Technique the hairs and reducing the risk of trauma to the existing hair.
We use an expansion technique that we believe enables us to The expanded area shrinks back to normal after the completion
create greater densities in selected areas. Before preparing the of planting, along with the recipient sites. The latter shrinkage
reduces the incisional damage of the sites and allows faster
healing. Finally, the shrunken sites also hold the grafts more
firmly (Fig. 16D-10a).
Slits Versus Holes

Currently, there are three main approaches for preparing the
recipient sites for FUGs: microslits, micropunches (1 mm or
less), or needles.
The survival of grafts in all type of sites appears to be very
similar, with an average of 95%. Once the hair starts to grow
after the transplant, it is impossible to tell which types of sites
have been used. In our opinion, none of the small site techniques
produce aesthetically superior results compared with each other;
the best guideline is for surgeons to use the technique they have
perfectly mastered. However, we think that micropunches may
help to a small degree to increase hair density.
Recipient Site Study on Micropunches

Figure 16D-8 Graft preparation is carried out with magnifica- Ten patients participated in a Recipient Site Study that we car-
tion using the Keller & Khan system. This system consists of a ried out. In each patient, two areas that measured 1 cm2 were
camera connected to a high-resolution flat monitor. marked. Forty 1-mm punch sites were made in each marked
640 Chapter 16
the tattooed recipient surface area was measured. The area had
shrunk from 140 cm2 to 125 cm2. The tattooed darkness also
decreased as a result of the punch technique (Fig. 16D-10b).
Graded-Site Preparation for Recipient Incisions

We use the graded-site preparation approach. This approach
divides the recipient area into the following three zones (Fig.
16D-11):
1. Feathering zone (Hairline)
2. Frontal density zone (area behind hairline)
3. Vertex zone
Feathering Zone
a This is a 1-cm transition zone in which single-hair FUGs are
used. The first 0.5 cm are planted with 20 to 25 single FU/cm2;
the second 0.5 cm with 25 to 30 single-hair FUs/cm2. The whole
zone is restored in an irregular but symmetrical way.
Frontal Density Zone

This area starts where the transition zone ends and is 4 cm deep.
In the first cm, two-hair FUGs are used, and in the remaining
3 cm, a combination of two-hair and three-hair FUGs is used.
A total of 35-hair to 40-hair FUs/cm2 are planted.
Vertex Zone
This zone is posterior to the frontal density zone and extends
through the rest of the recipient area. The area is planted with
25 to 30 two-hair to three-hair FUs/cm2.
Microslits are used for the feathering zone. In the frontal
b density zone, we use 1-mm punch sites. We return to microslits
Figure 16D-10 (a), Schematic demonstrating principle of ‘‘ex-

pansion technique.’’ (b), Interesting case in which an area that had
been tattooed was measured before and after transplantation with
5600 FUGs in 1-mm punches. The area shrank from 140 cm2 to
125 cm, indicating that the use of punches decreases the size of
the recipient area and increases density.
area. One area was planted with 40 FUGs, whereas the 1-mm
holes in the other area were left empty. After 6 months, the
areas where the sites were made were measured. The area with-
out grafts had shrunk to 80 mm from the original size of 100
mm2. The area where the grafts had been planted had shrunk
to 90 mm2. The study indicates that the punch technique reduced
the recipient area by 10% and provided a higher density per
mm2.
Interesting Case Study

A 40-year-old patient with class V1 baldness had his whole
recipient area tattooed; he thought that the tattoo would look
like hair. The patient’s tattooed surface area measured 140 cm2.
Three procedures were performed with use of a 1-mm punch
technique rather with slits in the hope that the darkness of the
tattoos would fade as well. After three procedures, the patient Figure 16D-11 Graded site preparation showing feathered
had a total of 5600 FUGs. Six months after the last procedure, zone (1 cm), frontal density (4-cm) zone, and vertex zone.
Figure 16E-1 Frontal and oblique (right and left) side views.
Figure 16D-12 Follicular unit extraction (FUE) technique.
posterior to this in the vertex zone. In the second procedure,

nothing is planted in the anteriormost 0.5 cm of the feathering hairline of the temporo-parieto-occipital(TPO) flaps. In 1986
zone. In the next 0.5 cm of the feathering zone, 25 to 30 single- (4), I introduced posterior megasessions with micrografts and
hair FUs/cm2 are planted. In the frontal density zone, 25 to 30 minigrafts. At that point, I created my own surgical routine,
two-hair to three-hair FUs/cm2 are planted. In the vertex zone, introducing a ‘‘stick–and-place’’ method, named the puncti-
20 to 25 two-hair to three hair FUs/cm2 are planted. form technique, which was published in several magazines, an-
nals of congresses, and books (5–7). The use of TPO flaps
Follicular Unit Extraction gradually declined, and, at present, surgeons use micrografting
in 99% of hair replacement patients. Micrografting is a simple
The donor area is divided into 2.5-cm2 areas located 1 cm apart standby technique that requires three assistants and lasts 2 to
from each other. Hair shafts are trimmed to a 2-mm length. A 3 hours; the result is a natural-looking transplant with little
local anesthetic solution of lidocaine, 0.5%, with epinephrine incidence of risk or postoperative complications.
1:100,000, is injected with a 30-gauge needle into the dermis
1 mm to 2 mm deep. Immediately before the follicular extrac-
tion, a normal saline solution is injected 1 mm to 2 mm deep PREOPERATIVE PROCEDURE, HAIRLINE
into the dermis to achieve supertumescence. Supertumescence CREATION, AND ANESTHESIA
spreads the FUs apart,which reduces the chances of trauma to
the adjacent hair follicles during incisions. Preoperatively, the physician documents all patients by means
For follicular unit extraction (FUE), a 1-mm titanium end- of digital images of frontal and oblique views from both the
punch, mounted on a depth-controlled punch handle, and a dis- left and right sides of the head (Fig. 16E-1a). If the patient has
secting microscope are used. Dissecting microscope magnifica-
tion allows the trimmed hair shaft to pass into the punch and
precisely follow the direction of the hair for extraction. The
punch is passed 2.5 mm to 3 mm into the dermis. Each 2.5-
cm2 area is harvested completely before the next one is used.
Extraction is performed with the FU held gently by fine jeweler
forceps while the dermis is pressed down with another forceps.
The dissecting microscope allows us a better chance to follow
the precise direction of the hair. Follicular damage is 10% with
the dissecting microscope and 20% with out it. When a limited
number of FUs is required (Fig 16D-12), such as in hairline,
eyebrow, eyelashe, mustache, sideburn, and beard reconstruc-
tion, FUE is useful.
16E. The Punctiform Technique

Carlos Oscar Uebel
INTRODUCTION
I first presented micrografts for hair restoration surgery in l982 Figure 16E-2 Drawing of the hair-bearing ellipse that the sur-
(1), and Juri (2) and Chajchir (3) taught me to hide the anterior geon will harvest from the neck.
642 Chapter 16
occipital baldness, a posterior view is also included. The sur-

geon harvests follicular units (FUs) from the neck, which con-
tains the best density and quality of histological hair layers, and
removes a hair-bearing flap ellipse, usually 6 cm to 8 cm from
its base (Fig. 16E-2). The size of the ellipse depends on the
number of FUs the surgeon will implant and varies from l0 cm
to 15 cm in length and 2 cm to 3 cm in width. In specific cases,
if the scalp has limited laxity, the ellipse is sometimes extended
into the retroauricular area. It is important to preserve the galea
aponeurotica and the occipital neurovascular branches in the
donor area; therefore, only the skin and the subcutaneous fat
with the capillary bulbs are removed. The frontal hairline is
drawn with the patient standing in front of a mirror, thus, the
patient is able to see the surgeon’s plan and articulate personal
desires and expectations. This line should be irregular and
asymmetrical and should preserve the temporal recesses (Fig.
16E-3). The patient is then taken to the surgical center, where
sedation is given in the form of midazolam, 5 mg, and fentanyl Figure 16E-4 Blockage of the supraorbital and trochlear nerve
citrate, 2 mL. The surgeon blockades the supraorbitary and branches.
trochlear nerve branches and the coronal area with bupivacaine,
0.5% with epinephrine, 1:200.000 (Figs. 16E-4 and 16E-5).
This anesthetizing solution also enters the occipital area, the
region from which the surgeon has removed the ellipse. The
achieve (Fig. 16E-6a and b). Creating ‘‘scalp balooning’’ with
next step is scalp ballooning, which I described in l991 (7). The
‘‘white marbles’’ allows the surgeon to implant micrografts
surgeon infiltrates tumescence in the recipient area, entering all
without significant bleeding.
levels of the scalp up to the dermis, to obtain a ‘‘white marble,’’
the maximum blood vessel constriction that the surgeon can
HARVESTING THE HAIR-BEARING ELLIPSE
From the occipital region, the surgeon takes an ellipse whose
size is determined by the number of FUs to be implanted. The
physician excises the donor area with a surgical blade held at
an oblique level to avoid both destroying the capillary bulbs
and reaching the neurovascular branches found in the lateral
extremities of the ellipse. The galea is not divided into sections
and the fat is left intact. The small blood vessels are cauterized,
and the superior and inferior edges of the wound are undermined
to prevent excess tension at closure. The surgeon uses repair
stitches and a subdermal running suture with 4–0 nylon. Wound
closure is an extremely important stage in the procedure, and
Figure 16E-3 Irregular and asymmetrical anterior line de-

sign with temporal recesses. Figure 16E-5 Coronal blockage 1 cm beyond the hairline.
a Figure 16E-7 Residual scars formed by punches and drills. At

present, surgeons prefer a horizontal scar to achieve a second har-
vest more easily and without follicular damage.
Figure 16E-6 a, b, Massive infiltration of all scalp levels with

supertumescence to obtain the ‘‘scalp balooning’’ with ‘‘white
marble.’’
Figure 16E-8 Follicular units, described by Headington,

are surrounded by fibroconjunctive tissue.
the surgeon always takes care to ensure that the quality of the
scar is as good as possible. This is especially important during
the second session when the same area is harvested for new
grafts. Harvesting is not performed with punches or drills be-
cause these methods can cause scar fibrosis and damage the
per unit. Headington’s study radically improved microcapillary
remaining capillaries (Fig. 16E-7).
surgery in the 1990s, and surgeons began separating these units
with a three-dimensional microscope (Fig. 16E-11). Over a hard
PREPARING THE FOLLICULAR UNITS surface, such as wood or acrylic, the slightly turgid, hair-bearing
ellipse is cut into multiple slices, approximately 1 cm wide (Fig.
Nordstrom (8) and Marritt (9) first invented micrografts, and 16E-12). The subcutaneous fat is discarded except for a small
Headington (10), who had the brilliant idea of making trans- amount that is left for the nutrition of the capillary bulbs and
verse histological studies of scalp, identified FUs for the first for the protection of the bulbs against any micro trauma that
time in l984. He identified ‘‘nests’’ with one to three capillary they might suffer before or during implantation (Fig. 16E-13).
follicles, one to two vellus hairs, sebaceous glands, and a pillus In my office, the FUs are separated from one another and from
erectus muscle, all surrounded by fibroconjunctive tissue (Fig. the entire surrounding fibroconjunctive tissue by a sharp surgi-
16E-8). On the surface of the scalp, these nests are clearly visi- cal blade (Fig. 16E-14). The accompanying microscopic images
ble, but the densities vary from patient to patient (Fig. 16E-9). show the area from which the FUs have been harvested; the
In Fig. 16E-10, the nest contains a density of 65 FUs/cm2, or sebaceous glands usually exist in the medium third, and fatty
approximately l30 hair shafts, with FUs averaging two shafts tissue surrounds the capillary bulbs (Fig. 16E-15a and b).
644 Chapter 16
Figure 16E-9 Follicular units observed on the surface of

the scalp. Figure 16E-12 Cutting the ellipse slices to a 1-cm width.
Figure 16E-13 Trimming the subcutaneous fat.

Figure 16E-10 Density of 65 follicular units/cm2 (about
130 hair shafts).
Figure 16E-11 Preparation of the follicular units with a Figure 16E-14 Separating follicular units and preparing
three-dimensional, magnifying optical viewer. them for implantation.
Figure 16E-16 (a and b), ‘‘Stick-and-place’’ procedure

with follicular units. The surgeon makes the incision and the
assistant simultaneously introduces the graft with a microfor-
ceps. This is the goal of our technique.
Figure 16E-15 (a and b), Microscopic vision of the follicu-

lar units with their sebaceous glands and capillary bulbs sur-
rounded by adipose tissue.
646 Chapter 16
IMPLANTATION
We use our punctiform implantation method like ‘‘stick-and-
place’’. A microincision of 3 mm to 4 mm in depth is created
in the tumescent skin and intense blood vessel constriction is
maintained. In a continuous movement, the assistant uses the
forceps to bring the FU by its bulbar extremity to the slit where
the blade is, and both the surgeon and the assistant smoothly
push the graft into its definitive bed (see Fig. 16E-16a and b).
In the crown area, I generally use a no. 11 blade to replace
minigrafts (Fig. 16E-17), and, in the front hairline, microblades
are used to create sites for single-hair FUs that help camouflage
and compensate for the degraded area (Fig. 16E-18). On the
top and on the crown of the head, perpendicular incisions are
made, but, in the frontal region, the cut is changed to an oblique
angle that will allow normal, forward hair growth (Fig. 16E-
19). At the end of surgery, moist gauze with saline solution is
applied as well as a bandage that the patient wears for 48-hours Figure 16E-18 Microblade used to create a degraded area in
postoperatively (Fig. 16E-20a, b, and c). the front hairline.
COMPLICATIONS
I have seen very few complications with my hair transplant
procedures. Given that only small areas are undermined and no
muscle tissue is disturbed, surgeons do not encounter hemato-
Figure 16E-17 Number 11 blade used in the crown area for Figure 16E-19 Oblique incision with a microblade used in the
minigrafts frontal region to allow normal forward hair growth.
Figure 16E-20 (a, b, and c), Moist gauze with saline solution and an elastic bandage applied for 24 to 48 hours postoperatively.
648 Chapter 16
Figure 16E-21 Inclusion cyst that normally appears in the

third postoperative month and that the surgeon ruptures and cleans
with antiseptic solution.
mas or abundant bleeding. Because of use of the epinephrine

solution, only rarely is excessive bleeding in the recipient area
seen. Edema often occurs in the forehead and glabellar regions
and sometimes reaches the superior eyelids. This complication
arises on the second or third postoperative day and disappears
without the use of any anti-inflammatory medications or corti- Figure 16E-23 (a, b, and c), Incipient baldness with an im-
sone therapy. If the operative wound is closed under great ten- proved density and a new hairline.
Figure 16E-22 (a), A young patient with anterior baldness. (b), the same patient 2 years postoperatively.
Figure 16E-23 Continued.

650 Chapter 16
a b
Figure 16E-24 (a), Patient submitted to a megasession. (b), The final results in the same patient 1 year postoperatively.
sion, it can develop large or hypertrophic scars; therefore, we rec- which we can perform hair restoration surgery. Today, we pri-
ommend harvesting a thinner scalp ellipse when scalp tissue marily perform follicular unit transplantation (FUT), but, if indi-
lacks good elasticity and the surgical borders are undermined. By cated, we occasionally use larger minigrafts and scalp reduc-
the third postoperative month, patients commonly develop some tions. In this chapter, we share some of the specific methods
cysts, although these are seen most frequently in patients with and modifications of technique that we have adopted to help
oily skin. These cysts are easily lanced with a needle or forceps us with our procedure.
and an antiseptic solution is applied to them (Fig. 16E-21).
RESULTS SEDATION AND ANESTHESIA

Final results are clearly seen after 8 months. The hair begins Oral Sedation
to grow in the third month. At this time, I advise patients, to
begin applying minoxidil, 5%, twice a day on the scalp and As we strive to meet our patients’ higher demands, the number
shampooing daily with Aloe Vera and Jaborandi (both made by of grafts we transplant per session and the time required for the
Amazon Herbal Medicine ). Hair transplantation is a treatment hair transplant procedure have increased. Maintaining patient
suitable for both young and old patients and is especially benefi- tranquility over such a long period of time traditionally required
cial for patients with incipient baldness. The surgeon can im- increasing the total dosage of intravenous (IV) sedative drugs
prove their hair density without damaging their remaining hair (Fentanest, Versed, etc.). To reduce, and in some cases elimi-
and they need never live with baldness. The final results in nate, the need for IV sedatives and their associated risk, we
female patients are generally only appreciated l2 to l4 months combine oral benzodiazepines and first-generation antihista-
postoperatively (Figs. 16E-22 to 16E-24). mines to produce conscious sedation.
Patient consultation with the physician before the surgery,
is key in determining the amount of grafts needed. Equally
16F. The Hair Transplant Procedure important is the evaluation of the patient’s psychological pro-
in My Office file. The interview should reveal previous sedative drug use,
previous procedures with a vasovagal reflex, and the patient’s
Arturo Sandoval-Camarena overall anxiety level. These questions determine our approach
INTRODUCTION to the patient’s sedation and anesthesia requirements. If a high
anxiety level or hyperkinetic personality is observed, and a ses-
In my office, we have used many different techniques over the sion of more than 1500 follicular unit grafts (FUGs) is planned,
past 10 years to improve our results as well as the ease with an oral dose of hydroxyzine (Atarax), 10mg, and of lorazepam
(Ativan), 1mg or 2mg, is given. First-generation antihistamines

and oral benzodiazepines produce a consistent somnolent effect
ranging from 45 minutes to 2 hours after administration. This
type of sedation is very safe, and the patient maintains a calm,
comfortable, and anxiety-free state, which, we believe, is essen-
tial for any session extending longer than 5 hours. Patients with
a previous sedative drug use history may have tolerance of
lorazepam, but such patients usually respond well to antihista-
mines. The patient’s level of tranquility during the first hour
of the procedure indicates whether a second dose is necessary.
Intravenous Sedation
When IV sedation is necessary, midazolam (Versed, Dormi-
cum) is given at an average initial dose of 0.03 mg/kg –to
0.05mg/kg. I commonly use midazolam in combination with
Figure 16F-2 Follicular units inside a 5 ⳯ 5 mm2 are counted
fentanyl (1 g to 1.5 g/kg—initial dosage only). Low oxygen
in four different areas. The sum of all four gives a fairly precise
saturation is encountered in less than 3% of our patients. Gener-
densitometry.
ally, this difficulty is resolved with verbal stimulation and only
rarely by painful stimulation and/or oxygen.
THE DONOR AREA

Rassman densitometer, or, as in my clinic, with a small strip
Safe Area of x-ray film with a 5 ⳯ 5 mm square that is used to calculate
donor density (Fig. 16F-2). Assistants can quickly count the
I select my donor area by finding the occipital protuberance. number of follicular units (FUs)/cm2 in four different points of
Immediately inferior to this reference point is where I outline the patient’s donor area. The sum of the four measurements,
the inferior border of the donor strip. The hair inferior to the divided by four, provides a very accurate average of donor area
protuberance will eventually become thin or fall out; moreover, hair density. The width of the strips may measure 10 mm to
this area is a common location for unsightly, wide scars. The 15 mm at the midline, 8 mm to 10 mm superior to the mastoid
‘‘refined donor area’’ is an anterior extension of the midline process, and 10 mm to 12 mm in the parietal area. The ends
donor strip. It also has definable limits. Four centimeters, or a of the strip are tapered to avoid a ‘‘dog-ear’’ closure. The total
two-finger width, must separate the lateral strip from the supra- length varies, depending on the number of grafts desired. Strips
auricular fringe to prevent wide scars (Fig. 6F-1). I never extend going from ear to ear may measure 22 cm to 25 cm.
the strip past the tragus, because cosmetic concealment of an After the donor strip has been outlined, my assistants trim the
unsightly scar is troublesome in this area. donor hair to an approximately 4-mm length. This is important
because these hairs will serve as guides, indicating the angle
Donor Strip Dimensions the blade must have in order to slide parallel to the hair shaft.
Every centimeter of donor strip is marked (see Fig. 16F-1);
The width and length of the donor strip depend on the elasticity the total number of centimeters is multiplied by the results of
of the patient’s scalp. Densitometry can be measured with the densitometry to reach an approximate yield. For example, if
18 cm of donor area have been marked and the densitometry
averaged 90 FUs/cm2, we would estimate obtaining (18cm2 ⳯
90 FU/cm2 ⳱ 1620 FU grafts).
A 3-mm border is shaved around the donor strip to prevent
ingrown hairs. Immediately peripheral to this border, small dots
are made with a marker to indicate where the local anesthesia
must be injected. This is useful, because it ensures that the
anesthesia will fully cover the outside border, sparing the patient
discomfort during harvesting or suturing.
The donor strip is divided and harvested in multiple sections.
Harvesting in this fashion minimizes the time hair follicles are
away from a blood supply. Depending on the size of the strip,
I may harvest it in two, three, or even four fragments. I divide
the strip with diagonal lines carefully drawn in between hairs
to prevent follicular transection.
The refined donor area is colored to remind technicians that
only FUGs (one–hair and two-hair) produced from this section
Figure 16F-1 A ‘‘safe’’ refined donor area is found 4 cm above of the donor strip are to be planted in the most anterior centime-
the supra-auricular fringe. Strips in this area usually do not exceed ter of the hairline. The hair in this area is usually finer, the
a width of 1.0 cm to 1.2 cm. follicular groups are smaller, and the hair becomes gray sooner.
652 Chapter 16
Local Anesthesia of the Donor Area

Anesthetizing the donor area is accomplished with lidocaine,
1%. This concentration applied superficially slows absorption
and reduces the risk of toxicity. Immediately following this, I
reinfiltrate the inferior border with a solution containing equal
parts of longer acting bupivicaine (Marcaine), 0.5%, and lido-
caine, 2%, with epinephrine 1:200,000. Vasoconstriction helps
slow absorption of the bupivicaine.
Instrumentation
In my hands, the multiblade knife results in excessive transec-
tion of the hair follicles. I prefer a no.10 single scalpel blade
to any other strip-harvesting instrument. Figure 16F-4 Gentle traction is applied to the strip that has
been grasped at the end is with a towel clamp. Dissection of the
Strip Harvesting subcutaneous plane is performed with supercut Metzenbaum scis-
sor or a no. 10 scalpel blade.
When the strip is removed, the ideal position for the surgeon is
sitting with the donor area at eye level. Physicians should use
some type of magnification; I prefer 2x or 2.5x magnification.
The scalpel should be held with support from both hands, giving
from the fascia help to avoid cutting important vascular struc-
the physician a better feel of the necessary depth. The initial inci-
tures.
sion should be made from right to left, creating the inferior bor-
der. The physician and one assistant should check for transection
as the incision is being made. The blade should glide continu- Hemostasis and Closure
ously. However, the blade should slide slowly enough for the as- In my procedures, cautery is rarely used. In most cases, I pack
sistant to grasp and turn the emerging border to verify correct the wound with compressed gauze, which is held in place with
angulations of the blade (Fig. 16F-3). Using tissue forceps, the towel clamps. Usually, this measure provides adequate hemos-
assistant should check for transection while using the other hand tasis.
to keep the surgical field dry. The superior border is incised in After the first strip segment is removed, the area is sutured
practically the same manner; however, on occasion, tissue for- with a 3-0 nylon continuous suture. The suture should grasp
ceps are required to create tension by pulling on the inferior bor- the smallest portion of tissue possible by taking ‘‘small bites.’’
der of the strip. I rarely employ staples, despite the time efficiency in placing
The first step in freeing the strip from its bed is to grasp them, because the postoperative discomfort is a common com-
one end with towel clamps. Pulling on the strip should create plaint for most patients. I have seen equally acceptable cosmetic
light-to-moderate tension; in some cases, the tension is enough results with both methods.
to literally pull the strip from the subcutaneous plane. When
this is not the case, dissection at the subcutaneous plane is
achieved with supercut Metzenbaum scissors or a simple no. THE RECIPIENT AREA
10 scalpel blade (Fig. 16F-4). In my opinion, using a scissors
offers excellent sharpness and cutting with the curved tips away Hairline Placement and Design
The hairline placement depends on several factors. The first is
the rule of thirds, used at present by most doctors when choosing
the anterior point of the hairline. In some cases (Norwood I to
V), I may place the hairline approximately 1 cm superior to
this point. Adding the additional centimeter to the height of the
hairline gives me the opportunity to modify the hairline in the
future if the patient wants that.
In other cases, I place four fingers (which together are approx-
imately 9 cm wide) flat on the patient’s forehead (Fig. 16F-5),
beginning superior to his eyebrows. I place most of the anterior
aspect of the hairline at that level. I then follow my index finger
with an eyeliner pencil to give the hairline an oval look in the
frontal and horizontal views of the profile. I corroborate the hair-
line design and height by placing my hand over the proposed hair-
line and stepping away from the patient (Fig. 16F-6). With my
hand in this position, I can easily imagine what the final hairline
Figure 16F-3 The blade should slide continuously but slowly will look like in relation to the rest of the patient’s physiognomy.
enough for the assistant to turn the emerging border and verify the When the patient and I have come to an agreement on the design,
correct angulation of the blade. I draw the hairline with a permanent marker.
Hairline Design for Norwood Class VI and VII

Certain rules can be followed for creating a hairline in most
patients; however, temporal hairline recession may require al-
teration of existing guidelines. When the temporal border and
lateral fringe have receded excessively, such as in a class VI
or VII on the Norwood scale, a ‘‘hump,’’ or lateral fringe,
should be recreated (Fig. 16F-7a and b) to help determine the
height of the hairline and the placement of the frontotemporal
triangles. Significant recession indicates that the hairline, and
especially the apex of the frontotemporal triangle, needs to be
placed more superiorly.
Each individual’s particular characteristics must always be
considered. Age, for example, is an important factor in deciding
the hairline height. Underestimating future hair loss in a young
patient is a common mistake. On occasion, a patient retains a
low hairline or a widow’s peak. I do not recommend incorporat-
ing the new hairline into the widow’s peak; rather, the hairline
should be structured more superiorly (Fig. 16F-8). As with any
Figure 16F-5 In most cases, four fingers (about 9 cm) are a

safe rule to follow for hairline placement.
Figure 16F-7 In some cases, reconstrction of the ‘‘hump,’’ or

Figure 16F-6 Confirm the hairline placement by placing a lateral fringe, is necessary for correct hairline placement. (a),
hand over the proposed hairline and stepping away from the patient Planned recreation of lateral hump (solid line). (b) After recreation
for an overall glance at the general physiognomy. of hump (solid line). (a and b, Courtesy of Ron Shapiro, MD.)
654 Chapter 16
ence of more hair on one side of the scalp than on the other or
areas of uneven density. Patients insisted that grafts did not
grow in these areas, and some even demanded their money back
or wanted more grafts free of charge. This difficulty originated
with the stick-and-place method, a technique that offers impor-
tant advantages, but, nonetheless, a method that delegates the
task of making recipient sites to the technicians. The problem
arises when two or more technicians are involved in the planting
phase of the procedure. In this situation, the density (FU ⳯
cm2) is determined by the technician; hence, the technician’s
inability to plant grafts close together could result in uneven
density, resulting in patient dissatisfaction.
I have resolved this problem of unevenness by dividing the
recipient area into 1-cm boxes (Fig. 16F-9a). First, I outline
the recipient area and have my assistants mark every square
centimeter with a ruler and a thin marker. This grid of 1-cm2
boxes offers several advantages. The first is estimation of the
number of grafts needed for a determined area. Matching the
number of sites to the number of grafts is now precise and
requires simple mathematics). I can control the density in prede-
termined areas and prevent areas of uneven growth. This is very
useful in my practice, because density may be tapered from 30
to 45 grafts per box in the anterior 2 cm of the frontal hairline
and from 20 to 30 FUs in other areas. It is common for recipient
sites to be created hurriedly and with uneven density in many
Figure 16F-8 The new hairline often needs to be placed poste- offices where time efficiency is paramount, or when blood flow
rior to the residual widow’s peak and the frontal tuft for a natural from fresh sites causes poor visibility in the area.
and mature hairline aspect (dotted line). This task can be comfortably delegated to experienced tech-
nicians who are instructed on how many grafts must be planted
per cm2. The boxes may be color-coded, indicating, for exam-
ple, that blue boxes require 40 FUs/cm2, whereas black boxes
hairline, minimal asymmetry should always be sought for natu- need only 30 FUs/cm2. The boxes allow us to take better advan-
ralness. The widow’s peak and lateral mounds (described by tage of the stick-and-place method. In a busy office setting, one
Ronald Shapiro and William Parsley elsewhere in this text) can confidently move on to the next case without worrying
erase the visual impression that the hairline was designed with whether the technicians will decide on their own how dense the
a compass and make the forehead look smaller; however, the planting should be. It is important to note that only I create the
patient ultimately decides on what is or is not to be done. pattern and incisions in the first centimeter of the hairline and
The donor hair reserve is probably the most important factor I only use the stick-and-place technique with this grid behind
to consider when one is determining the hairline height and the immediate hairline zone (Fig 16F-9b).
design in Norwood VI or VII patients. Patients with poor donor The boxes are also useful when I make long-term follow-
density must consider even more superior hairlines and/or alo- up evaluations of graft survival in my patients. Furthermore,
pecia reduction surgery with tissue extenders (Frechet exten- the grid also allows me to measure the performance of my
der), and/or simply accepting a frontal forelock. Patient phy- technicians. In any office, it is important to recognize the techni-
siognomy many times causes these rules to be bent. When a cians who plant quickly and/or those who injure the grafts.
hairline is chosen, consideration should be given to whether the Finally, it is important to avoid harvesting more than the patient
shape of the face is wide, narrow, long, short, triangular or needs or can afford. Use of 1-cm2 boxes (or cm2) is the easiest
square. I also consider the patient’s height when placing a hair- method of estimating an almost exact number of grafts and the
line. Shorter patients can more easily accept a more inferior size of the donor area.
hairline, whereas taller patients require a more conservative
hairline placement.
Finally, when the fronto-temporal triangle is designed, con- GRAFT PREPARATION AND PLANTING
sideration should be given to future temporal hair loss. In a
young male patient, creating a triangle rather than rounding out Follicular Unit Transplantation
the apex of the triangle, such as might be done in a female Currently, all our hair transplant procedures are done with
hairline, is precisely what ensures that the hairline will remain FUGs. My technicians prepare the FUs with stereoscopic micro-
aesthetic, even in the event of future loss in the temporal area. scopes with 10x magnification. One or two technicians divide
the strip into slivers, also under magnification, while two to four
Using and Marking Centimeter Boxes for Quality other technicians dissect the slivers into FUGs. Donor tissue is
Control kept refrigerated or in an iced saline solution and is placed
Common complaints that have been made over a period of many according to the number of hairs per FUG. As noted earlier,
years during patient follow-up visits have focused on the pres- the lateral ends of the donor strip have been marked or colored,
Figure 16F-9 (a), The 1-cm grid can be used to control density in different areas behind the hairline when the stick-and-place method
is used. (b), The actual hairline pattern is created by the physician and not by stick and placing on the part of the assistants.
indicating that one-hair or two-hair FUs produced from this part with black hair and white skin requires a wider feathered zone
of the strip are to be planted in the most anterior centimeter of of 1 cm to 1.5 cm. Patients with gray or blond hair need only
the hairline. 0.5 cm of irregularly placed grafts to achieve a natural-looking
hairline.
Local Anesthesia
Lidocaine, 1%, with epinephrine, 1:200,000, is injected intra- Recipient Sites
dermally into the recipient site. When anesthetizing, one should Sites for one-hair or two-hair FUGs are made with 19-gauge
never slide the needle through unanesthetized skin but rather and 20-gauge needles, depending on the thickness of the hair
advance it through areas that have been previously anesthetized. and the elasticity of the recipient’s scalp.
Areas to be planted are infiltrated 8 to 12 minutes before the We routinely bend the tips of our needles for the recipient
recipient site incisions are made, thereby taking advantage of holes at a 90-degree angle (Fig. 16F-10). The angle acts as a
the maximal vasoconstriction effect afforded by this timing. stop, preventing unnecessary vascular damage to deeper ves-
Planting from ‘‘back to front’’ (crown to forehead) is also sels. Usually, two technicians plant simultaneously, and a third
helpful in reducing the popping situation. Another advantage
of this stick-and-place technique is that the grafts are quickly
positioned in a still-dilated hole, which has been proposed to
facilitate easier and less traumatic placing. With an inexperi-
enced staff, one drawback of the stick-and-place method is that
orifice angle and direction are delegated to the planting techni-
cians. By leaving several needles or dilators inserted in the skin,
one can guide the technicians to the correct direction of the
incisions.
As stated earlier, the recipient sites for the anterior-most
centimeter (also known as the feathered zone) of the hairline
are strictly done by me (Fig 16F-9b). This is a task that only
the physician should undertake. Allowing assistants or techni-
cians to do this part of the transplant inevitably results in hair-
lines that may be too curvilinear on one side and too straight
on the other. The width of the feathered zone varies, depending Figure 16F-10 Needles can be altered to ensure a minimum
on the color contrast that exists between hair and skin. A patient depth of recipient sites.
656 Chapter 16
a c
Figure 16F-11 (a, b, and c), The end result in this patient, achieved 6 months after surgery, was produced by transplantation of 2514
FUGs. A physician and eight assistants performed the procedure in one session that lasted 7-hours. (a), Patient A before treatment. (b),
Patient A 3 days after surgery with crusts still showing. (c), Patient A showing growth after 6 months.
a b
Figure 16F-12 Patient B had 4388 FUGs placed in one session that was 9 1⁄2 hours long. The services of the physician and 10 assistants
were required. (a), Patient B before treatment. (b), Patient B after 11 months.
may also plant on a patient with a large bald area. Figs. 16F-
11 and 16F-12 show typical results of patients treated in my
office.
16G. The No-Touch Technique

Konstantinos J. Minotakis and Ron Shapiro
INTRODUCTION
Two common approaches used today to create recipient sites
and place grafts are (1) making the incisions first (MIF) and
later placing grafts into these premade incisions, and (2)
sticking and placing (S&P), whereby an incision is made and
the graft is immediately placed into the site (see Chapter
13B).
One of the advantages of MIF is that the physician has con-
trol over the angle, direction, pattern, and distribution of the
hair. However, it is difficult, even with fine jeweler’s forceps,
to place a large number of follicular unit grafts (FUGs) into
tiny, closely spaced, premade incisions. Some of the difficulties
that need to be overcome include missed sites, popping, multi-
ple failed attempts, and forceful handling of the grafts. When
bleeding occurs and obscures the field, these problems are mag-
nified (see Chapter 13A) Figure 16G-1 Choi implanter device. Newer devices, such as
With S&P, a number of these problems can be overcome. the Hann implanter or the Knu implanter, have replaceable needles,
Because the grafts are placed immediately after the incision is a feature that significantly decreases the cost of using these instru-
made, bleeding is minimal and there is much less chance of ments.
missed sites and/or piggybacking. Some believe that with S&P,
grafts can be inserted less forcefully and into smaller incisions
because the wound has no time to contract. However, some
degree of graft handling and potential graft trauma still occurs.
The process is also very time-consuming. Therefore, the task while minimizing their disadvantages. We make the incisions
is usually delegated to technicians, and the physician thus loses first, as with MIF. We then use the Choi implanter, as an
a significant degree of control over the aesthetic aspect of the implantation device only, to place the grafts into the premade
procedure. In particular, the physician longer has direct control incisions. We call this method the no-touch technique because,
over the angle, direction, or distribution of hair. if it is done properly, the grafts can be inserted gently without
The Choi implanter is a device used in Korea to make the any manipulation or ‘‘touching’’ of the delicate structures of
incision and implant the hair simultaneously (Fig. 16G-1). It the follicles. In the following discussion, we describe the
consists of a hollow needle that is open along one side. When steps of this technique and how we use it in our practice.
used in the way it was originally intended, the graft is loaded
and kept protected in this hollow as the needle is inserted into
the skin (Figs. 16G-2a and b and 16G-3a). After insertion, the
device allows the needle to be withdrawn while leaving the DONOR HARVESTING AND GRAFT
graft behind in the incision (Fig. 16G-3b). This technique can PREPARATION
be described as an S&P approach that employs the aid of a Donor harvesting and graft preparation is basically the same as
mechanical device. Typically, the physician makes the incisions the procedures described by Seager and Limmer (see Chapter
with this device and thereby maintains aesthetic control over 13B). However, one important difference is that we leave the
the procedure. However, a number of other problems exist. The hair shaft approximately 2 cm long. This hair length is necessary
device is ‘‘heavy’’, and there is a lot of popping if FUGs are to load the Choi implanter device properly. We also use this
placed less than 1.8 mm apart. The needle on the end of the added hair length for all manipulations of the graft; therefore,
device becomes dull after a few incisions and this dulling of we never touch the shaft (see Figs. 16G-2a and b). The added
the needle further precipitates popping. This problem also hair length has some additional benefits. It identifies filled sites,
means that a moderately expensive device has to be changed making it easier to identify empty sites. It also has a positve
frequently, which increases costs significantly. pschcological effect on the patient at the end of the procedure,
because this longer hair gives the patient a preview of how the
THE NO-TOUCH TECHNIQUE results will look. The grafts are kept in chilled saline solution
and are separated into groups of one-hair FUGs, two-hair FUGs,
The no-touch technique is a new approach that we believe and three-hair FUGs for easy differential loading of the Choi
combines the benefits of the previously described techniques implanter at a later time.
658 Chapter 16
a b
Figure 16G-2 (a), Schematic drawing showing the loading of hair into the Choi implanter. Notice that hair is left relatively long. Also,
with this technique, the graft is manipulated only by a grasp on the hair shaft. (b), Loading the Choi implanter by threading it through the
needle and holding the long hair shaft.
RECIPIENT INCISIONS was 45cm2. To produce an average density of 28 FUGs/cm2

for the total area, we needed 1280 FUGs.
We use 19-gauge needles for one-hair FU grafts and 18-gauge
needles for two-hair and three-hair FUGs. More recently, we
have been using 21-gauge needles for ‘‘dense packing’’ of one- NO-TOUCH PLACING: ACTUAL TECHNIQUE
hair FUGs.
We measure the actual size of the areas that we are going We use a team of three assistants with the no-touch technique.
to treat to determine the number of FUGs we will use. In the This team consists of two ‘‘loaders’’ and one ‘‘placer’’ working
patient shown in Fig. 16G-4, for example, the area to be treated together in a circular assembly line approach (Figs. 16G-5a and
b) as described in the following list:
1. The ‘‘loaders’’ fill the Choi implanter. They grasp the
Figure 16G-3 Schematic drawing showing the mechanism of Figure 16G-4 Patient A’s area of alopecia was measured and
inserting the Choi implanter (a). The needle is withdrawn, leaving found to be 45cm2. It therefore required 1280 FUGs to create an
the graft behind (b). average density of 28 FUs/cm2.
a b
Figure 16G-5 (a), We use a three-assistant team for the no-touch technique—two ‘‘loaders’’ (on the left) and one ‘‘placer.’’ The
loaders place the follicular unit into the implanter pen, which is then put into bowls of chilled saline solution. Implanters with one, two,
and three hairs are placed into separate bowls. (b), The placer keeps an eye on the recipient area and simply reaches over for the appropriately
sized implanter for the area that is currently being placed.
graft by the hair shaft that has been left long and thread
it into the implanter without touching the body of the
graft (see Fig. 16G-2). Different, color-coded sizes of
implanter are used for one-hair, two-hair, and three-hair
grafts.
2. The loaders place the prepared implanters into a bowl
of chilled saline solution, with the graft end inside the
bowl and the handle facing out. The bowl is in close
proximity to the placer, providing an easy reach for the
placer.
3. The one-hair, two-hair, and three-hair implanters are
placed in separate bowls so that the placer may easily
distinguish between the different sizes.
4. The placer keeps an eye on the recipient area and simply
reaches over for the appropriately sized implanter for
the area currently under placement. The placer knows
the location of the different-sized implanters; thus, there
is no need to look away from the recipient site. This
increases the speed of placement.
5. The placer gently inserts the tip of the Choi instrument
partially into the incision, depressing the mechanism to
deposit the graft. Used in this manner, the Choi implan-
ter makes placement very easy, with little popping. As-
sistants also appear to learn the process very quickly.
6. The ‘‘placer’’ gives the empty Choi implanter back to
the loaders.
7. The two loaders continually reload the empty Choi im-
planters and put them back into the bowls.
8. About seven implanters are kept circulating at all times. Figure 16G-6 Using the Choi implanter, follicular unit (FU0
9. With time, a rhythm develops, and the process becomes densities of 50 FUs/cm2 or more can be planted with no occurrence
quite fast. We find that our speed has continually in- of popping.
creased and we can now place approximately 2000 FU
grafts in 4 to 5 hours.
660 Chapter 16
a b c
Figure 16G-7 (a), Patient B, with temporal alopecia before treatment. (b), The same patient 7 months after transplantation of 50 FUs/
cm2 into the alopecic area. (c), Close-up photograph of Patient B, 7 months after transplanting.
Figure 16G-9 (a), Patient before transplantation. (b), Same pa-

tient immediately after transplantation of 2300 follicular units. (c),
Figure 16G-8 (a), Patient with minimal eyebrow hair before Twelve months after the photographs shown in Figs. 16G-9 and
surgery. (b), Nine months after one surgery consisting of 215 follic- 16G-10. (d), Frontal view photograph taken at the same time as
ular units (FUs) (approximately 107 FUs per eyebrow). the photograph shown in Fig. 16G-9c.
Figure 16G-9 Continued.
SUMMARY OF ADVANTAGES AND 5. Only small teams (three assistants and one physician)
MISCELLANEOUS POINTS are needed to do a procedure.
6. Separating the tasks of placement and loading makes
In summary, we think the no-touch technique offers the follow- the procedure less stressful for the assistants.
ing advantages: 7. The training is much simpler. Newcomers can actually
1. The graft can be placed with little or no trauma help as loaders after only a few hours in the surgical
because the body of the hair follicle is not touched suite.
throughout the entire process. With MIF and S&P, the 8. The cost of using the Choi implanter is much reduced
graft has to be handled to some degree. Anecdotally, with this method. The implanter mechanism is made of
we have found that our patients are experiencing earlier aluminum and therefore has the potential to break quite
regrowth, with final results being reached as early as 6 frequently if it is used to make incisions. When it is
to 8 months. used only as a placing instrument, it can last for as many
2. Unlike the S&P technique, the control of the procedure as 2500 grafts. Because it is used simply for placement,
is in the hands of the physician. it can be sterilized and reused. Newer models have re-
3. The Choi implanter makes placing FUGs into small in- placeable needles.
cisions very easy. We can reach densities of 50 FUGs/
cm2 without any occurrence of popping (Fig. 16G-6). CONCLUSION
4. The no-touch technique provides a faster method of
placement. We can now place as many as 2000 to 2500 The no-touch technique consists of making all the incisions first
grafts in 4 to 5 hours. (as with MIF), with 18-gauge and 19-gauge needles (as in S&
662 Chapter 16
P,) but unlike MIF and S&P, the former technique uses the A Personal Hair Restoration Technique from Brazil
Choi implanter to fill these premade incisions. We believe this
technique harnesses all the advantages of the other two tech- 1. Bernstein RM. Standardizing the classification and description of
niques while minimizing their disadvantages. Figs. 16G-7, 16G- follicular unit transplantation and mini-micrografting techniques.
Dermatol Surg 1998; 24:957–963.
8, and 16G-9 show the ‘‘before’’ and ‘‘after’’ photographs of 2. Shapiro R. Follicular hair transplant. Visit to his office. Tampa,
three patients who have been treated with this technique. Examination under Anesthesia (EUA), March 1996.
3. Tykocinski A. Follicular hair transplant—the Brazilian style. II
Annual meeting of European Society of Hair Restoration Surgery.
REFERENCES Paris, 1999.
Microstrip Grafting 4. Uebel CO. Punctiform technique with micrografts. Presented at
Jornnda Carioca Cir Plast. Rio de Janeiro, 1986.
1. Unger WP, ed. Hair Transplantation. 3d ed. New York: Marcel 5. Tykocinski A. Follicular hair transplant—the Brazilian style. 7th
Dekker, 1995. Annual Meeting of the International Society of Hair Restoration
2. Stough DB, Haber RS, eds. Hair Replacement: Surgical and Med- Surgery. San Francisco, 1999.
ical. St. Louis: Mosby, 1996. 6. Arnold J. Minimal depth. Sixth Annual Meeting of the Interna-
3. Inaba M, Inaba Y. Androgenetic Alopecia, Modern Lancett of tional Society of Hair Restoration Surgery. Washington, 1999.
Pathogenesis and Treatment. Tokyo: Springer-Verlag, 1996. 7. Unger W, Coterril P. Mini micrografting—visit to their office
4. Stough DB. The single hair graft technique for advanced male 1995.
pattern alopecia. In: Stough DB, Haber RS, eds. Hair Replace- 8. Camarena-Sandoval A. Planting both sides evenly. H T Forum
ment: Surgical and Medical. St. Louis: Mosby, 1996. Int 2001; 11:19–20.
5. Limmer BL. Elliptical donor harvesting. In Stough DB, Haber RS, 9. Seager D. Doctors and their patients. 7th Annual Meeting of the
eds. Hair Replacement: Surgical and Medical. St. Louis: Mosby, International Society of Hair Restoration Surgery. San Francisco,
1996. 1999.
6. Bernstein RM, Rassman W. The art of follicular transplantation, 10. Seager D. Dense hair transplantation from sparse donor area—in-
5th Annual Congress of the, Barcelona, 1997. troducing the ‘‘follicular family unit.’’. H T Forum Int 1998; 8:
7. Lucas M. Alternative approaches to transplantation. In: Unger 21–22.
WP, ed. Hair Transplantation. 3d ed. New York: Marcel Dekker, 11. Tykocinski A. Combining follicular grouping and follicular units
1995. to increase hair volume and density. 9th Annual Meeting of the
8. Marritt E. Alternative approaches to transplantation. In: Unger International Society of Hair Restoration Surgery. Puerto Val-
WP, ed. Hair Transplantation. 3d ed. New York: Marcel Dekker, larta. México, 2001.
1995. 12. Tykocinski A. A one-year study of using exclusively ‘‘follicular
9. Hitzig G, Shwinning JP. Linear punch, my fifteen-dollar laser. grouping’’ in specific areas to increase hair density and volume
5th Annual Congress of the International Society of Hair Replace- during FUT 10th Annual Meeting of the ISHRS. Chicago, 2002.
ment Surgery. Barcelona. Spain, 1997.
10. Knudsen R. General principles of recipient site organization and
planning. In: Unger WP, ed. Hair Transplantation. 3d ed. New
Optimal Strategies in Hair Transplantation
York: Marcel Dekker, 1995. 1. Hugeneck Joerg, Krugluger Walter. Development of storage solu-
11. Unger WP. Hair grafting. 5th Annual Congress of the Interna- tion for isolated hair follicle micrografts. 10th annual meeting of
tional Society of Hair Replacement Surgery. Barcelona. Spain, the International Society of Hair Restoration Surgery, October
1997. 9–12, 2002. Chicago.
12. Beehner ML. Preserving the possibility of a later forelock in hair
transplant patients. Fifth Annual Congress of the International
Society of Hair Replacement Surgery. Barcelona. Spain, 1997. The Punctiform Technique
13. Straub P. Alternative approaches to transplantation. In Unger WP,
ed. Hair Transplantation. 3d ed. New York: Marcel Dekker, 1995. 1. Uebel CO. Improvement of the frontal hairline with the angular
14. Frechet P. Microstrip grafting. Int J Aesth Restor Surg 1998; 6: flap and micrografts. Transactions of the International Advanced
7–18. Hair Replacement Symposium. (AAFPRS) Birmingham. AL,
15. Kim JC. Regrowth of grafted human scalp hair after removal of February 1982.
the bulb. H T Forum Int 1993; 3:14–15. 2. Juri J. Use of parieto-occipital flaps in the surgical treatment of
16. Oliver RF. Histologic studies of whisker regeneration in the baldness. Plast Reconstr Surg 1975; 55:456.
hooded rat. J Embryol Exp Morph 1996; 16:231–244. 3. Chajchir A. A new scalp flap for baldness surgery. Aesth Plast
17. Cooley J, Vogel J. Follicle trauma in hair transplantation. preva- Surg 1991; 15:271.
lence and prevention. 5th Annual Congress of the International 4. Uebel CO. Punctiform technique with micrografts—a new
Society of Hair Restoration Surgery. Barcelona, 1997. method for pattern baldness surgery. Presented at Jornada Carioca
18. Shapiro R. Controversies with total micrograft megasessions. the Cir Plast. Rio de Janeiro, August 1986.
issues of low graft yield and low density. Fifth Annual Congress 5. Uebel CO. Baldness surgery—flaps and microtransplants. 1st In-
of the International Society of Hair Restoration Surgery. Barce- ternational Congress of Hair Replacement Surgery. California:
lona. Spain, 1997. American Academy of Cosmetic Surgery, May 1987.
19. Mangubat EA. Impulsive force: a new method to cut grafts. Int 6. Uebel CO. Micrograft—a new approach for pattern baldness sur-
J Aesth Restor Surg 1988; 6:19–23. gery. Transactions of the Tenth Intl Congress ISAPS. Zurich.
20. Seager D. Advantages and disadvantages of graft preparation Switzerland, Sept. 1989.
using the binocular stereoscopic dissecting microscope. Int J 7. Uebel CO. Micrografts and minigrafts—a new approach for bald-
Aesth Restor Surg 1998; 6:27–31. ness surgery. Ann Plast Surg 1991; 27:476.
21. Shapiro R. The cosmetic significance of ‘‘follicular units’’ vs. 8. Nordstrom REA. Micrografts for the improvement of the frontal
small minigrafts in hair transplantation. Int J Aesth Restor Surg hairline after hair transplantation. Aesth Plast Surg 1981; 5:97.
1998; 6:46–49. 9. Marritt E. Single hair transplantation of hairline refinement: A
22. Arnold J. Pursuing the perfect strip: harvesting donor strips with practical solution. J Dermatol 1984; 10:962.
minimal hair transection. Int J Aesth Restor Surg 1995; 3: 10. Headington JT. Transverse microscopic anatomy of the human
148–153. scalp. Arch Dermatol 1984; 120:449–456.
17
Correction of Cosmetic Problems in Hair
Transplanting
Walter P. Unger
INTRODUCTION nique appears to show greater hair densities than they create
with FUT alone. In portions of this chapter, I have utilized an
The widespread adoption of micro-minigrafting (MM) and fol- organization of the discussion that is similar to B & R’s, in order
licular unit transplanting (FUT) has resulted in a sharp decline to facilitate an understanding of the differences and rationales
in the number of new patients with cosmetically unsatisfactory behind our philosophies. In brief, I use FUT and B & R’s general
results of hair transplanting. Nevertheless, individuals treated approach in some cases ( Figs. 17-1 & 17-2), but prefer a
recently with poor hair transplanting designs, as well as those mixture of FU and variously sized multi-FU grafts in other
transplanted 10 or more years ago, continue to arrive in our patients. The major difference between our grafting philoso-
offices exhibiting the signs of old and poor techniques and un- phies would seem to be that I am prepared to add multi-FU
satisfactory long-term planning. In addition, relatively early on grafts in some of these individuals, whereas B & R are only
in the development of MM, far fewer grafts were being em- willing to excise such grafts—entirely or in part. I also use
ployed per session and physicians sometimes produced results alopecia reduction (AR) in some of my patients. In most re-
that, by today’s standards, are less than optimal. Most of us—if spects, therefore, I agree with B & R and have liberally bor-
not all of us—who have been in practice for 7 to 10 years, or rowed from their excellent paper.
more, periodically see some of our own patients whom we This discussion on the management of problem results is
treated prior to that period. Thankfully, they return to us for divided into two broad categories: 1) The recipient area and 2)
updating with current techniques or for additional transplanting The donor area. Each area is subdivided into errors of a technical
in areas of male pattern baldness (MPB) that have developed nature and errors that are related to poor planning—immediate
since we carried out their first hair transplants. and long-term. Some preliminary comments are warranted.
Bernstein and Rassman (B & R)(1) have written an extensive
description of their approach to repair cases, which recommends 1. Repair patients have often not understood, or occasion-
the exclusive use of follicular units (FUs)(1). This approach ally have been intentionally misled, as to what they can
can be utilized by physicians who prefer to restrict their practice accomplish with hair transplanting. An important com-
to FUT, but I find this philosophy unnecessarily limits one’s ponent of repair work is making sure that there is no
options. Whenever one is obliged to excise at least part of many misunderstanding of what can and cannot be accom-
(or all) previous multi-FU grafts, (and their approach frequently plished by each procedure, as well as the sequence and
requires this), it usually entails more sessions, because it will goals of each session. These patients are frequently
otherwise produce less dense results than a combination of FU angry and/or depressed about what has happened to
and multi-FU grafts will. (See later.) It also always results in them. Trust must be established and there is no better
the loss of some hairs as the excised portions of old grafts are way of doing that than being totally frank about these
transferred to new areas. A review of the photos in part II of matters. The physician should emphasize that although
B & R’s article reveals that despite their recommendation to each procedure will improve the patient’s appearance,
use only FU in repair cases, (and in other publications, never optimal results will be seen only after multiple ses-
to use anything other than FUT in new patients), they are able to sions—usually two or three sessions, but sometimes
achieve excellent cosmetic results in some individuals without more. It is therefore important to create the hope of a
removing any pre-existing round grafts. Put differently, a mix- normal appearance, whenever that can be reasonably
ture of FU and multi-FU grafts can produce very acceptable anticipated after a course of treatment. This will encour-
results in specific patients. Even in their photos, this latter tech- age the patient to complete their treatment.
663
664 Chapter 17
2. The donor/recipient area ratio in patients seen for cor- quence of this recommendation (1). That, in fact, does not occur
rective procedures is frequently insufficient to correct unless one proceeds without regard to the number and density
all the presenting problems. Thus, goals should be prior- of grafts being utilized per session. Put differently, B & R’s
itized so that if all objectives cannot be met, at least the concept may work well in some instances—perhaps even most
most important ones, hopefully, will be achieved. The instances—but in my experience, it is not optimal in all situa-
patient should then clearly understand that the final re- tions, as B & R suggest. Interestingly, Shapiro has told me that
sult will be a significant improvement but will never the main reason he started experimenting with multi-FU grafts
be perfect. again, was that he noticed how thick and natural the repair
3. The bulk of corrective work in the recipient area is based patients he was treating looked when he added FUs to their
on three strategies: 1) camouflaging any cosmetic flaws prior grafting. Once the repair was completed, they frequently
by adding grafts to the recipient area. 2) Excising old looked better than many of the patients he had treated exclu-
grafts that cannot be camouflaged and/or would be bet- sively with FU—at least with regard to hair density. (I have
ter utilized elsewhere in the recipient area and 3) elimi- already commented on B & R’s patients who seemed to show
nating any new areas of alopecia that were originally the same effect.) If the reader is a FUT dogmatist, but has
unanticipated. These strategies are discussed subse- noticed the same phenomenon in some repair cases, you would
quently. do well to reconsider adding multi-FU grafts to some of your
virgin patients, who are looking for greater-than the average
Camouflage density that you can achieve with FUT.
Usually, two or three repair sessions are required to produce
The most effective way to camouflage old grafts is by a) creat- optimal results, but as indicated earlier, each session produces
ing a new, properly constructed hairline zone anterior to the some improvement. The number of sessions will vary with the
previous grafting, and b) filling any alopecic spaces between chosen width of the new hairline zone, hair characteristics, and
the old grafts. Creating a new hairline zone, anterior to the hair density in the previously transplanted grafts. Very fine, or
hairline grafts, is usually the more important of these two objec- very coarse hair, and hair with high color contrast relative to
tives. It has two major advantages over filling the empty gaps the skin will require more sessions. Old grafts containing dense
between the old grafts. 1) It allows transplanting into normal hair may also require more sessions, anterior to them, to ade-
skin and 2) It provides maximum effect with the fewest possible quately camouflage them—but this also has an advantage in
hairs. In essence, it corrects the cosmetically important hairline that it results in a denser final result (see Figs. 17-2 to 4). If
zone of the poor transplant and uses the existing grafts to pro- the old grafts contain dense hair and the new hairline is only
vide density and coverage—especially in areas that could not 3 mm to 4 mm wide, it can be produced exclusively with FUs
be covered when the hairline was unsatisfactory and the hair (see later), although multi-FU grafts may be required within
had to be combed forward for camouflage. B & R describe their the old transplanted areas.If the new hairline zone is wider than
concept of camouflage with an analogy: ‘‘If one wants to hide 3 mm or 4 mm, but less than approximately 3 cm, and the hair in
a picket fence, boarding it up will only create a solid wall and the round grafted area is dense, a zone of micrografts, microslit
make it obvious. It would be preferable to plant bushes and grafts, slot grafts, or scattered small round grafts (1.3 mm to 2
shrubs in front of it. The fence would still be in the same posi- mm2) must be produced anterior to the solidly round grafted
tion, but not as noticeable (1).’’ They also note that the deeper area. The micrografts that are in close proximity to the dense
the new hairline zone can be made, the better the camouflage round grafts (anterior to and between them) should also each
and the fewer the sessions that will be necessary to eliminate contain three or more hairs. In my experience, in these circum-
any apparent plugginess. Their analogy holds true in many cir- stances, if only FUs are utilized to create a new hairline zone,
cumstances, however, if the so called picket fence is composed the change in hair density from that new zone to the old round
of wide planks painted bright orange, a very dense and wide grafted dense area will be too great and noticeably too abrupt.
zone of bushes would be necessary to accomplish sufficient The reason for this will be discussed later.
camouflage. Given that we are very often dealing with limited If you choose to use only FUs in the new hairline zone, the
donor tissue reserves, as well as an existing hairline that should new softening zone usually has to be at least 1.5 cm wide, and
not be lowered much farther than it already is, a wide zone of part of each dense round graft must be excised to lower the
bushes may not be ideal. In more concrete terms, this analogy hair density within the round grafted area (1). In cases where
works well provided that previously transplanted grafts do not the adequate camouflage of prior transplanting requires a new
have any one of, or an unfortunate combination of, hair that is hairline that would be too low, then one is once again usually
too dense, too coarse, or has high color contrast with the skin. obliged to excise some of the old grafts. Alternately, an AR
In the latter instances, if there are adequate donor hair reserves, can be carried out to raise the hairline, but that is a more invasive
filling in the spaces between these strong planks (old dense procedure and is usually not necessary. If there are inadequate
haired round grafts), with round grafts containing hair of similar donor reserves to fill the empty spaces with round grafts, while
density and texture—combined with softening of the hairline at the same time correcting other problems, then excision of
with a relatively narrow zone of FUs and sometimes multi- old grafts and FUT remain preferable to filling the spaces be-
FU grafts— produces better results, and more quickly. This tween the dense round grafts with other round grafts. However,
approach produces maximum density in the area and can often there are disadvantages associated with the excision of previ-
effectively eliminate the pluggy look in one to three sessions ously transplanted hair that will be discussed later.
(Figs. 17-3 & 17-4). Poor hair survival in the new round grafts, Ironically, it is often easier to improve a bad transplant with
because of scar tissue, has been suggested as a likely conse- relatively sparse hair than one that has grafts with good hair
Correction of Cosmetic Problems in Hair Transplanting 665
Figure 17-1 This patient with fine-textured, medium brown hair, presented with a pluggy-looking hairline zone and obvious extending
of his male pattern baldness (MPB) into the adjacent temporoparietal areas. Most of the round grafts within the pluggy area did not contain
particularly dense hair. I felt that only approximately 20 old grafts had to be excised (in part or completely). These grafts were excised
and the sites sutured. b) A total of 2417 follicular units (FUs) were transplanted, in two sessions separated by a 6-month interval. The
photo shows the results 9 months after the second session.
666 Chapter 17
Figure 17-2 This 29-year-old patient presented with a pluggy-looking transplant, but with hair growing, for the most part, in the correct
direction and at an appropriate angle. The hairline was also in acceptable position. His hair had a slight frizz to it and was medium-brown
colored. I elected to treat him exclusively with follicular units (FUs). Nine months after a second session of follicular unit transplantation
(FUT), with a total of 1682 grafts having been transplanted.
survival and density. The former can often be treated with FUs area, as well as the potential effect of this on any grafts that
alone and requires less donor tissue to eliminate noticeable might be transplanted during the same session.
plugginess and gaps between the grafts. The latter situation When larger grafts are well posterior to the hairline zone they
requires expertise in round grafting, which most of today’s hair can often be left intact—especially if the hair characteristics are
restoration surgeons lack and as noted above, requires the utili- advantageous—for example, if the hair is fine-textured or curly
zation of more of the already depleted donor tissue. Rather or if there is little skin to hair color contrast. Alternately, if hair
fortunately, poor transplants very often have poor hair density characteristics are less advantageous, or the patient’s objectives
and are best treated by FUT alone—with all its inherent advan- are more demanding, a portion of each graft can be removed
tages (Fig. 17-5). (laterally or centrally) so that only three to six hairs are left to
grow at each site (the numbers of hairs will again depend on
hair characteristics). The need for partial graft removal will also
Excising Cosmetically Inappropriate Old Grafts be affected by how much hair will eventually be available to
treat the recipient area. The less hair available for the camou-
Old grafts may have too much, too little, too coarse, or too fine flage of relatively large grafts, the smaller the original grafts
hair for their location. Others contain hair that is angled or must be made. Fortunately, when larger grafts lie within the
directed improperly or, as just discussed, the old grafts may proposed new hairline zone, if you use a punch that appears to
complicate the creation of a cosmetically satisfactory new hair- remove the entire graft, frequently one to three hairs will regrow
line zone. In addition, the grafts may be in an inappropriate at the site (as noted earlier). This is an acceptable outcome in
location or may be depressed below the surrounding skin or most instances. Elsewhere, for example in the midscalp or ver-
elevated above it. (Graft elevation can be corrected with electro- tex areas, leaving a few surviving hairs is also often helpful
cautery as well as by excision—see below.) Removing part (see Fig. 17-6).
of an old graft, rather than the entire one, has the following One should use sharp hand, or, preferably, power punches.
advantages: 1) it preserves some of the hair in the original graft Power punches require less pressure and avoid the necessity of
while providing hair for transplanting in other areas, and 2) it twisting or rotating that is required of the hand punch. The latter
creates immediate cosmetic improvement. Any hair contained can result in small changes of the angle of incision and follicle
in excised grafts, or portions of grafts, should, of course, always injury. If the holes are made with a 2 mm or smaller punch,
be reused (Fig. 17-6) and the patient should be warned that he and are not located in the hairline zone, they may be left to
or she will have less hair immediately after the procedure. heal by secondary intention. By the time the scars from these
If the objective is the removal of all the hair in a graft, then holes contract and additional hair is transplanted into the area,
both the surgeon and the patient should be aware that more than the tiny scars are cosmetically inconsequential at such sites.
one excision of a graft is sometimes necessary to accomplish Otherwise, they should be sutured perpendicular to Langer’s
that goal. Unsatisfactory old grafts sometimes contain follicles lines to produce the smallest possible scar. I typically use 5–0
that splay proximally due to surrounding scar tissue. Thus, the silk on an ophthalmic needle or undyed Poliglecaprone 25, 4-0
advancing punch may not capture the entire follicle at the deep on a PS1 cutting needle, if the hair and/or skin is light-colored.
periphery of the graft. The physician should also keep in mind Sutures are removed in 5 to 7 days. B & R have suggested
the effect the excisions will have on the blood supply to the the interesting idea of stretching the skin perpendicular to the
Figure 17-3 a) This 38-year-old patient demonstrates a number of problems: (1) obvious spaces between previously transplanted round
grafts with dense dark hair, (2) progression of his male pattern baldness (MPB) beyond the originally treated area, and (3) varying textures
and densities of hair within the old grafts. Fortunately, most of the old transplanting was done in an area well posterior to where a hairline
zone could have been placed, so it was easy to produce a new and more natural-looking hairline zone anterior to the old grafts. b) The
grafts at the midline anterior border of the transplanted area were excised and moved further posteriorly, as were those containing hair that
was excessively coarse or dense. During the same sessions, a new hairline zone was created, grafts were added to previously untreated
areas in the lateral frontal areas and to the previously treated ones. The anterior aspect of the midscalp was also transplanted during two
of the three repair sessions. A total of 623 micrografts, 203 small slit grafts, 837 medium slit grafts, 268 – 2 mm round grafts and 23
standard grafts were utilized in three sessions. The photo shows natural looking and dense-appearing results, 12 months after the third
session. c) Frontal view, 12 months after the third repair session. d) Caudal view, with the hair parted for critical evaluation. e) Caudal
view, with the hair combed as he normally wears it. Note the effective coverage of the vertex area. Often the best way to provide coverage
in the vertex area is to do additional grafting in the midscalp and to comb it over the vertex. f) Frontal view. This photo was taken at the
same time as those shown in b to e. The patient had returned for additional transplanting posterior to previously treated areas. The black
crayon marks end at two grafts that I felt were too coarse and that I intended to excise. Not uncommonly, an otherwise excellent hairline
zone may be marred by the presence of only one or few inappropriate grafts. It is most often best to excise such grafts in the hairline,
rather than to attempt to camouflage them by surrounding them with micrografts.
668 Chapter 17
Figure 17-5 a) A patient before his first repair session. The

black lines denote the areas to be treated. Rather fortunately, poor
transplants very often have poor hair density as one of their compo-
nents. They are, therefore, best treated by follicular unit transplanta-
tion (FUT) alone—the most economic method—with regard to
donor hair—of executing repairs. Few (if any) grafts, with dense
hair, need to be excised. Excisions cause delays in adding hair and
thus prolong the treatment period. In addition, no hair is lost during
the movement of previously transplanted hair from one area to
another. b) Five months after a single session of 1287 follicular
units (FUs) to the frontal area, with the hair parted for critical
evaluation. He had returned for a first session of transplanting to
the midscalp and I took the opportunity to add some grafts to the
anterior midline of the frontal area at the same time. The recipient
Figure 17-4 a) A 46-year-old patient before his first repair ses- sites for the latter can be seen. His fine-textured, medium brown
sion. He wanted to not only eliminate his pluggy appearance, but to hair was ideal for producing a light-to-medium dense, natural cov-
have a final result that would be dense enough to properly match his erage, with single sessions of FUT, in any area. He preferred a
dense temporal hair. His donor/recipient area ratio was excellent. b) sparser coverage in the largest area that could be treated, rather
A close-up of the right side of his frontal area, before his first repair than treating smaller areas more densely.
session. The small, dense grafts in his transplanted hairline were the
result of 1.3 mm to 1.5 mm round grafting. Farther posteriorly, larger
round grafts had been utilized. c) Nine months after his third repair
session. A total of 1024 follicular units (FUs), 481 small slit grafts,
422 medium slit grafts, 101 slot grafts, 24 1.5 mm and 1.3 mm round
grafts and 20 standard round grafts had been utilized.
between the excision sites concomitantly, because making the

recipient site may sever previously placed sutures; c) requiring
a separate patient visit for the removal of the sutures; and d)
acting as a nidus for potential infection (patients are advised to
use bacitracin (Baciguent) ointment, twice daily, on all sutured
sites). On the other hand, not using sutures results in a more
unsightly and troublesome postoperative period. On balance, I
prefer not to suture sites posterior to the hairline zone, unless
the temporary small holes are cosmetically unacceptable.
If the excision of an old graft is necessary, it is best to do
this concomitant with additional grafting because it avoids delay
in completing the repair. However, if one is exclusively using
FUs, it is usually better to excise and replant excised hair, in
Figure 17-6 a) The vertex area of the patient shown above, separate sessions, before any new donor area hair is harvested
had been transplanted with standard round grafts. He had originally and used for camouflage purposes. B & R have written that
come for correction of poor transplanting in the frontal and mids- one to four sessions, with an average of two sessions, are typi-
calp areas and was so happy with the progress there, that he decided cally carried out before any camouflage grafting is started (in
to also try to correct the vertex problem. Because I was concerned most of their patients). Excision and reimplantation of hair from
about running out of donor tissue, he had an alopecia reduction
previous grafts always results in some hair being lost in the
(AR) performed on the right and posterior aspects of the vertex, 3
process. As indicated above, it usually requires additional pro-
months prior to the above photo. The hair in the standard grafts
had been cut short to facilitate the excision of a portion of each of
cedures, and therefore delays completion of the repair process.
them. b) An intraoperative photo showing the holes where a 2 mm Whenever possible, camouflage, rather than excision, should
punch had been used to excise a portion of each of the standard be the major, or sometimes the sole, method of correction.
grafts. At the same time 129 follicular units (FUs), 398 small slit Because of the previously noted problems associated with
grafts, and 15 1.5 mm round grafts were scattered throughout the excision of isolated grafts, if unwanted grafts are closely spaced,
vertex area—some of them obtained from the excised portions of relatively long elliptical excisions of groups of them can be
the old grafts. c) Nine months later, a light but very natural looking used, instead of trying to remove all of them by punching them
coverage of hair was present in the vertex, and the results of the out and suturing them individually. In such cases, the skin thick-
transplanting in the midscalp and frontal areas can also be appreci- ness and color on both sides of the wound should be similar.
ated. The hair in the vertex has been parted for critical evaluation Once again, one must be careful not to endanger the blood
with regard to both hair density and the minimal noticeability of supply to the recipient area while doing this. Elliptical excisions
the multi-FU grafts. are generally better for cosmetically less important areas. In
most areas, the laborious, time-consuming punching out and
suturing of grafts will produce a superior cosmetic result. Linear
excisions are best closed in two layers, 5-0 Vicryl for deep
Langer’s lines prior to punching out the graft. This results in dermis and a running 5-0 silk or Poliglecaprone 25, 4-0 suture
the circular wound relaxing into an oval shape when the stretch superficially. Sutures are typically removed in 7 days.
is removed, and an easier closure(1). Suturing has the disadvan- As an alternate to excising hair in unwanted places, such
tages of: a) limiting the number of grafts that can be removed hair can be removed with electrolysis or lasers. Effective elec-
per session, because each suture uses up some of the limited trolysis is more difficult in scarred areas because of distorted
scalp laxity in the area; b) reducing the ability to transplant hair angles, so laser removal is more suitable if there is signifi-
670 Chapter 17
cant scarring present. Destroying hair by either method, how- is the middle of the permanent zone—usually overlying the
ever, wastes hair that could be used elsewhere and is therefore occipital protuberance and the superior nuchal ridge in the
rarely done in our office. donor area (2). Superior to this line, there is an increased
likelihood of wider than average scars. Inferior to it, the
chance of wider than average scars increases even further.
Eliminating Originally Unexpected New Areas of
This is because neck muscles attach onto the inferior portion
Alopecia
of this ridge and neck muscle activity will have a negative
Eliminating any new areas of alopecia that were originally not affect on scar formation. Scarring from previous procedures
anticipated, and that have developed since the original trans- in the area will also severely limit scalp mobility. B & R
plants were done, can be accomplished by adding grafts to the have suggested follicular unit extraction (FUE) as a method
new areas or by excising them. This subject will be covered in of circumventing the problem of tight scalps (3). Unfortu-
detail later. nately, if there is extensive donor area scarring, the follicle
directions are often distorted substantially by the scar tissue
and the chances for follicle transection with FUE increases.
Spacing of Repair Sessions
(See Chapter 10)
I usually space repair sessions at least 6 months apart so I can Scarring Despite needing the maximum amount of hair
better assess the effects of each session before another is carried you can get in order to repair the recipient area, one is very
out in the same general area. This, in turn, allows me to avoid
often obliged to revise donor area scars during repair sessions.
using any of the limited amounts of donor tissue in an area that
New donor strips usually must include a maximum amount
doesn’t absolutely need more coverage. I am, therefore, left
of scar tissue and correspondingly fewer hairs. One also has
with more donor tissue to use as weighting in specific cosmeti-
cally more important areas. For example, after choosing an area to leave enough hair in the donor area to cover any remaining
that I want to treat more densely for styling purposes, I can scars. As noted above, however, scarring decreases mobility
transplant donor area expensive round grafts into the alopecic and decreases the blood supply to the area. The latter results
gaps between previously transplanted dense-haired round in an increased propensity to embarrassing temporary hair
grafts. loss adjacent to new donor areas, infection, delayed healing,
wound dehiscence, or frank necrosis at one or more points
along the line of closure. One must, therefore, limit donor
Limitations strip widths so as to avoid any closing tension. Other preven-
The physical factors, which limit what can be accomplished tive measures in the donor area are reviewed later in this
during a repair of cosmetically unsatisfactory hair transplanting discussion.
include: low donor hair caliber, low hair density, poor scalp
mobility, and scarring.
Low Hair Caliber Hair caliber plays a very important role FUT VS. COMBINATION GRAFTING FOR
in hair transplant repair procedures. Fine hair texture produces REPAIRS
less coverage, but more natural looking hairlines. You will need
more fine hairs per session, or more sessions, to get the same At this point it is useful to summarize the advantages and disad-
coverage as can be created with hair of higher caliber. B & R vantages of limiting oneself to FUT in repair cases. The perfect-
explain it this way: ‘‘The range in terminal hair shaft diameter ing of FUT has given us the ability to produce natural-looking,
is approximately 2.3 fold (.06 mm to .14 mm). The range in light-to-medium coverage of untreated areas anterior to, poste-
cross–sectional area (Pi R2) is approximately 5.4-fold. The rior to, and between previously transplanted grafts in many pa-
range in hair density is only approximately two-fold (150 to tients. It also requires the use of the least possible amount of
300 hairs/cm2). As a result, hair caliber is 2.7 times as important donor tissue. It, cannot be over emphasized that nearly always
as hair density (5.4 times vs. 2 times) with regard to coverage whenever the correction can be done by FUT alone, repairs
(1).’’ (See Chapter 10.) should be done that way. Nevertheless, there are some patients
Low Donor Area Hair Density When a donor strip is who, despite previously poor hair transplanting, still have a
excised and the defect is sutured, the surrounding skin is satisfactory donor to recipient ratio, hair characteristics that are
stretched and the distance between adjacent FUs is increased. suitable for larger multi-FU grafts and who prefer the densest
In general, just as in an area of advancing MPB, this concen- possible ultimate result. These individuals are treated with mul-
tration can be reduced by 50% (or to 0.5 FU/mm2) before tiple types of grafts and results can be impressive (Figs. 17-3,
the hair density appears to be decreased from its original 17-4, 17-7 to 17-10). These patients typically present with many
state. In repair cases, however, it is sometimes preferable to round and multi-FU grafts with high hair density, natural hair
reduce hair density in the donor area by more than 50%, in angle and direction, and hair caliber that is appropriate for its
order to obtain a sufficient number of grafts to create a location. Their main (or only) problem is that they look
satisfactory appearance in the recipient area—as long as scar- ‘‘pluggy’’.
ring in the donor area is not, and will not in your judgment, As noted earlier, if the surgeon limits himself exclusively
be visible in the future. to FUT, he is often left with no option but to excise all, or
Scalp Mobility The location of the donor site greatly af- nearly all, of the round and multi-FU grafts in part or, more
fects the likelihood of wide scars occurring. The ideal location often, in their entirety (1,4,5). This is often done in single or
Figure 17-7 a) Before this patient’s first repair session. The

black crayon mark indicates where the new hairline was to be
placed. Round grafts had been used in a previous session, by an-
other physician. Because 1) those grafts had been placed well poste-
rior to his then receding hairline, 2) the hair survival had been
relatively poor, and 3) his hair was quite fine-textured, the pluggi-
ness had not originally been very noticeable until he started losing
additional hair and his hair was wet. He still wanted a relatively
thick result and had an excellent donor/recipient area ratio, so we
elected to use a mixture of micrografts and slit grafts. b) A photo
taken at the same time as that shown in a, but with his hair wet,
revealing more clearly the plugginess he was concerned about. c)
Nine months after a single repair session, consisting of 469 FUs,
465 small slit grafts, and 50 medium slit grafts.
6. Excision will result in scars that may be noticeable—al-

multiple sessions, in which transplanting is totally limited to though this is presumably temporary.
FUs that are prepared from the excised grafts. It also serves the
Creating denser hair is advantageous if donor reserves are ade-
added purpose of limiting the amount of donor tissue that must
quate, but, of course, it is not wise if reserves are limited—as
be used in these areas to produce cosmetically acceptable re-
they often are. In the latter case, ‘‘breaking down a wall of
sults. But if donor reserves are adequate, it is not the ideal way
hair’’, is preferable to consuming large amounts of donor re-
to deal with the cosmetically most important frontal area in
serves in order to both soften or create a new hairline zone, as
many patients. Why?
well as to fill all empty spaces between round grafts that contain
1. As noted earlier, while the hair in the punched out seg- dense hair in the anterior 2.5 cm to 3.0 cm of the hairline zone.
ments is always used in other areas, some of it is always More moderate FUT proponents might accept leaving some
lost in the process of excising, preparing, and re-trans- larger and round grafts alone for one or a combination of the
planting it. following reasons If the hair within these larger grafts is: a)
2. The holes made during the excising of tissue, add vascu- fine-textured, b) curly, c) located in a cosmetically less impor-
lar damage to the area, and therefore the physician must tant area, or d) if there is minimal hair to skin color contrast,
limit whatever transplanting is to be carried out in the or e) if the hair density within the larger grafts is relatively
same area—especially if the latter is to be done con- low—either naturally or due to poor growth and, f) if the spaces
comitantly with the excisions. between the older grafts are relatively small. I would agree
3. While the patient will look better after each treatment, that all of the aforementioned characteristics should encourage
there will be less hair initially in the recipient area than surgeons to leave multi-FU grafts in place, provided that they
if the excisions had not been necessary. are located in an appropriate area and are angled and directed
4. The long-term hair density, in the area in which portions properly. It is, of course, always necessary to remove grafts
of grafts are excised, is also usually substantially less that are not located properly and often necessary to remove
than it could have been if there had been a cosmetically those that are angled or directed inappropriately. Similarly,
acceptable way of leaving it intact. grafts that contain hair with a texture or density that does
5. The bulk of the grafting will be delayed, thus prolonging not blend in well with its neighboring grafts also must be
the cosmetically unsatisfactory appearance. replaced.
672 Chapter 17
Figure 17-8 a) Before his first repair session, this patient also Figure 17-9 a) This patient had been treated by me, 24 years
had round grafts placed into a central area in the frontal area and had ago, before the above photo was taken. He had started treatment
many unsatisfactory multi-follicular unit grafts anterior to that zone. while he still had a moderate amount of his original hair present,
All these grafts were becoming more and more noticeable with his and had not returned for additional sessions as he had lost more
advancing hair loss. He had an excellent donor/recipient area ratio, of that hair. He now wanted to complete the frontal area as densely
very good hair characteristics, and wanted relatively dense frontal as possible. b) A photo of the patient shown in a, 12 months after
hair. b) A frontal view of the same patient, 9 months after his third his third retrofit session. A total of 523 micrografts, 531 small slit
repair session. A total of 453 micrografts, 50 small slits, and 1170 grafts, and 303 medium slit grafts had been utilized. c) A side-
medium slit grafts had been utilized. c) A side-view photo of the pa- view photo taken at the same time as that shown in b.
tient taken at the same time as the photo shown in b.
Figure 17-10 a) This 43-year-old man had undergone hair transplanting 15 years prior to seeing me. He had fine-textured brown
colored hair. The transplanted area was moderately pluggy-looking and would have appeared much worse had his hair not been so fine or
if there had been more color contrast between his hair and scalp colors. Subsequent to his original transplanting, his MPB had extended
further laterally and he had also lost all hair posterior to the transplanted zone. He was basically left with a pluggy-looking, unsatisfactory
isolated frontal forelock (IFF) as is shown above. I designed lateral ‘‘humps’’ for completion of the frontal-third of the area of the MPB
and a new hairline zone anterior to the old one. The black crayon line delineates these objectives. b) The same patient five months after
a second repair session. The first session—done 15 months prior to this photo—consisted of 809 FUs, 266 DFUs, 30 TFUs, and twenty-
six 2 mm round grafts that had been placed strategically between the old round grafts. The second session consisted of 1109 FUs, 220
DFUs, and 20 slot grafts. c) A frontal view of the patient pre-operatively. d) A frontal view taken at the same time as the photo shown in
Fig. 17-10b. The central midline hair density demonstrates the density advantages of using multi-FU grafts in combination with FUs, as
well as the absence of noticeability of multi-FU grafts with this approach.
The dilemma for those who concur with the more moderate some of these patients (Fig. 17-11); it may actually be even
approach described earlier, is that many patients seen for repair greater because of graft contraction (see Chapter 12F). The best
of hair transplanting do not fit neatly into groups with these char- one can hope for, if one is using only FUs, is alternating areas of
acteristics. For example, some patients may have dense, coarse, dense (round grafts) and less dense (FUs) hair—unless one be-
dark hair within quite large round grafts (see Fig. 17-3). If they gins by totally excising the multi-FU grafts.
appear pluggy in the transplanted areas, how does one deal with For the same reason, if you were presented with a dense,
the spaces between such grafts? If the spaces are small, FUs may solid line of hair that was created, for example, with round
suffice. However, exclusively using FUs for filling larger spaces grafts or a flap (Fig. 12F-18 and Fig. 17-12), and if you were
between such grafts will result only in the lessening of the pluggy determined to use only FUs, the area treated with FUs must be
appearance, rather than its total elimination. This is because FUs quite narrow. As noted earlier, if you attempt to make it more
can never produce hair density comparable to that present in the than 3 mm to 4 mm wide—that is, if you attempt to do anything
original donor area (generally 180 to 240 hairs/cm2)—and such more than to blur the straightness or abruptness of the old
hair density may, in fact, be present in the large round grafts in line—you will create a zone of hair that is considerably, and
674 Chapter 17
hairline zone, part-side ‘‘crease,’’ and an anterior midline egg-

shaped area (see Chapter 12D). Usually, combing the hair from
one side to the other, diagonally and posteriorly, will provide
the best coverage of the frontal and midscalp areas. In the vertex
area, however, the greatest density should be produced in the
center of the whorl of the vertex, where the hair naturally parts
in many different directions. At that site, FUs should contain
a minimum of two hairs, and as many three and four-hair FUs
as possible—the latter, as long as the hair caliber and color
contrast is not too great. As discussed earlier, in many cases
the exclusive use of larger FUs will produce the most rapid
cosmetic improvement, but with lower hair density than that
which can be created with a mixture of graft types. Each case
must be judged on its own merit as to whether FUT or mixed
grafting would be better for that particular patient.
With the above generalities in mind, the discussion will now
Figure 17-10 Continued. e) An intra-operative photo showing turn to the management of specific problems in recipient and
the distribution of the various grafts used during the patient’s first donor areas.
corrective procedure. This series of photos demonstrates that re-
moving all or most of the multi-FU grafts is not necessary in some
repair cases. Prior removal of multi-FU grafts may not only delay RECIPIENT AREA
the transplanting of substantive amounts of hair but may also ulti-
mately result in lower final hair density. Technical Errors
Cobblestoning
Most patients with grafts that are elevated above the surround-
ing recipient area surface can be adequately treated with light
electrocautery (6). I use a Hyfrecator, set at unipolar delivery
noticeably, less dense than the previously densely transplanted
and approximately 50. Light cautery is applied to each graft to
hairline. Once again, this is because FUT cannot create anything
completely flatten it. Nearly always, this is done at the same
approaching the hair density that is present in round grafts with
time as additional grafting is being carried out, but before any
good hair survival—no matter how many sessions of FUT are
incisions are made in the recipient area, so that the field is
carried out. This presents no dilemma for the FUT practitioner
entirely clear of blood during the cautery. If it is not overdone,
if the old hairline is solid, and more or less where it should
there are no negative effects on existing hair growth in the area,
be—one simply softens that line with FUs. Unfortunately, this
or on the grafts being transplanted. In Blacks and Asians, there
is a relatively unusual situation. It presents no problem when
is a slightly greater chance of causing pigmentary changes, but
the hair growth in the old round grafts is not dense—which is
I have not yet seen that as a consequence.
fortunately often the case. One simply fills the spaces around
An alternative method of treating cobblestoning is shaving
these sparse grafts with FUs. Additionally, it presents a lesser
off the elevated part of the grafts with a no. 15 scalpel blade.
dilemma if the hair in the old grafts is fine-textured, or curly,
Light electrocautery is employed to stop any bleeding. If graft
or has little color contrast with the recipient area skin because
elevation is particularly severe, dermabrasion may be used in-
alopecic spaces between such grafts are less noticeable and are,
stead. Unfortunately, the latter has the usual possible negative
therefore, easily corrected with FU. It does, however, become
sequelae such as pigmentary changes, long-lasting erythema,
problematic in most other situations.
etc. Shaving off the graft with a blade or dermabrasion requires
removal of hair in the area being treated—most patients would
normally object to both. Rather fortunately, in the many repairs
THE VERTEX that I have carried out, I have never had to use anything more
than electrocautery for cobblestoning.
Often the best way to provide coverage in the vertex area is to
do additional grafting in the midscalp and to comb this new
hair over the vertex. This requires fewer grafts than would any Compression and Dimpling
attempt to satisfactorily transplant a sparse or pluggy-looking If round, slot, or old slit grafting has been employed, compres-
vertex. As has been noted previously, removal of a portion of sion of hair into unsightly dense clumps or lines may occur.
each larger graft in the vertex is also helpful in minimizing the Depression of the graft, causing a dimpling of the skin, may
number of grafts necessary to produce a natural-looking result, or may not be associated with compression (Fig. 17-13). Mi-
if you choose to utilize grafts within the vertex area. This may crografts that have been implanted too deeply, especially if not
often be done at the same time as FUs and microslit grafts are enough of their epidermis has been trimmed away, will also
transplanted between the larger, partially excised ones (see Fig. produce dimpling. As noted in Chapter 14C, these problems
17-6). are best corrected by punching out the offending grafts, suturing
When one is doing corrective work in the frontal and mid- the site, and later replacing them with more appropriate ones.
scalp area, because donor reserves are always limited, it is im- The excised grafts, of course, can be retransplanted elsewhere
portant to more densely transplant strategic areas, such as the at the same time. If dimpled micrografts are very numerous,
Figure 17-11 a) This 56-year-old gentleman had undergone hair transplanting 15 years prior to seeing me. He had fine-textured, reddish-
to-blonde colored hair. The transplanted area was moderately pluggy-looking and would have appeared much worse had his hair not been so
fine and relatively light-colored. The density in the transplanted area was also relatively low. In addition to the preceding, his MPB was obviously
extending further laterally and he had lost all of the hair posterior to the transplanted zone. He was basically left with a pluggy-looking, unsatisfac-
tory isolated frontal forelock, as is shown above. I designed lateral ‘‘humps’’ for completion of the frontal third of the area of MPB and a new
hairline zone anterior to the old one. The black crayon line delineates these objectives. b) The above photo shows a slightly different view of
the same patient, with his hair dry, but after the boundaries of the area to be transplanted had been drawn in. c) A mixture of different types of
grafts was employed for the corrective procedure. The FUs were used to create the new ‘‘humps’’ and the bulk of the hairline zone, as well as
to fill small spaces between the old round grafts in the hairline zone. The most-posterior border of the newly transplanted area was also treated
with a zone of micrografts. Small, round grafts were inserted into larger alopecic spaces between round grafts in the old hairline zone. The
DFUs were employed primarily posterior to previous transplanting. d) The above photo shows the new frontal hairline constructed primarily
with FUs. As can be seen, some of the old round grafts contained relatively dense hair. Because of the fine texture of the hair and the
advantageous coloring, I felt I could get additional density by filling in the spaces between these round grafts with new 2 mm2 grafts. e)
Nine months after first repair session that consisted of 1270 FUs, 105 DFUs, and 21, 2 mm2 grafts. (See color insert.)
676 Chapter 17
Figure 17-12 a) The patient shown in the above photo had undergone flap surgery. Note the abrupt dense hairline and white, clearly
visible, scar line anterior to it. b) In 1992, after 221 micrografts in two sessions. The scar line has been improved dramatically and the
hairline softened. This patient was treated 10 years ago. Similar results could probably be produced in one session today.
the operator can try excising only the worst ones, while adding If hair dispersal is irregular in a cosmetically important stan-
new FUs between and anterior to the old ones. dard graft, hairless areas may be removed by overlapping the
graft with additional adjacent round grafting. Small round mini-
Poor Hair Yield grafts, or micrografts may also be placed into the bare
If hair density in a cosmetically important section of the recipi- areas—grafting into the graft (6). If there are very few hairs
ent area is inadequate, additional grafting should obviously be present in the standard graft, it may be excised entirely, sutured,
carried out. Micrografts and microslit grafts are particularly and replaced with smaller grafts in later sessions.
useful, not only for increasing the density over a wider area
than would be possible if round grafts were being used—given Inappropriate Grafts
a limited amount of donor reserves—but also to minimize any Consistent quality and quantity of hair in grafts in the same
plugginess by providing a more even background of hair and general area is an important component of good transplanting.
color between existing grafts. In addition, mini alopecia reduc- Quite commonly in repair cases, a graft with a particularly dense
tions (MAR) and AR can be very helpful in excising hairless growth of hair or with coarse hair is located in an area in which
gaps in recipient areas, if one is trying to conserve grafts or the hair is considerably less dense or less coarse (or vice versa).
does not have enough donor material left (6). (See later.) Such a graft sticks out like a ‘‘sore thumb’’. The best way to
Figure 17-13 Compression of minigrafts that contain too many hairs or overly coarse hairs, and dimpling of FU and minigrafts. The
grafts appear to be sitting in slight depressions.
handle this problem is to excise such grafts and to re-use the a 15⬚ to 30⬚ angle as long as this is consistent with the angle
hair in a more suitable area where the hair texture is more of other hairs in the area. Such angling ensures that the bulbs
similar (Fig. 17-14). of the transplanted hairs will not end up resting in the middle
Another way of dealing with this problem is to try to camou- of the scar tissue, which is inherently less vascular than normal
flage the graft in question by inserting micrografts, microslit skin. These patients should also be prewarned that hair yield
grafts, slot grafts, or round minigrafts around it. In general, if in scars is often somewhat less than in normal tissue.
the offending grafts are in or near the hairline, this approach In some patients with previous hair transplanting, a distinct
requires too much hair and repeated sessions. Cosmetic results increased skin thickness develops in the transplanted area. The
are also usually less satisfactory. Notwithstanding the preced- result is a ridge where the normal forehead skin thickness meets
ing, if a new hairline is being established far enough anterior the thickened transplanted area (7). This complication has been
to the inappropriate grafts, their replacement is less important referred to as hyper-fibrotic healing or hyper-fibrotic ridging be-
(Figs. 17-14 & 17-15). cause on biopsy, extensive fibrosis and foreign body giant cells
are found (8). This is discussed in more detail in Chapter 14C.
Scarring and Hyperfibrotic Healing The view that hyper-fibrotic ridging is more likely when
Grafts with peripheral scarring can be ignored in cosmetically grafts that are larger than an FU are utilized (1) is based on the
unimportant areas. However, if such scars are easily seen, the rather short period in which FUT has been utilized. Hyper-
graft and its scar should be punched out and the hole sutured. fibrotic ridging is either secondary to a foreign body reaction
If a multi-FU graft is being used to replace a round graft, an to spicules of hair on the graft being accidentally inserted during
appropriate-sized graft should be used for the new recipient previous sessions (8), an idiosyncratic reaction to grafted tissue,
site. The new hole should be slightly smaller than the graft or a combination of both. The size of the graft is probably
being moved into it, so that there are no gaps between the graft inconsequential. Time will tell if FUT really leaves one free of
and the wall of the recipient site. This is especially important any possibility of this complication. Meanwhile, the correction
when correcting peripheral scarring, which is usually caused of ridging is best treated by the excision of the elevated area
by what was an originally inadequate donor graft/recipient site as a strip or series of strips.
size differential. As indicated in the introduction to this section,
if there is extensive scarring in the anterior aspects of the recipi- Incorrect Hair Direction or Angle
ent area, I have nearly always found it best to create a new Transplanted hair that is improperly directed or angled may be
hairline zone slightly more anteriorly, as long as the new line left alone in cosmetically unimportant areas, unless the direction
is not too low. or angle is markedly wrong. If the problem is obvious or the
Micrografting directly into scars is also often a very satisfac- hair direction or angle is significantly inappropriate, the offend-
tory way of dealing with this problem. The linear scars that ing grafts should be excised. As noted earlier, if the sites are
may be present in front of flaps, for example, can be effectively larger than 2 mm or if they are in a cosmetically obvious area,
treated with micrografts. However, two or sometimes three ses- they should usually be sutured. In other instances, the sites can
sions are usually necessary to produce good aesthetic results often be left unsutured. The small resultant scars will become
(see Fig. 17-12). It is generally wise to transplant the grafts at less noticeable as more hair is transplanted into the area, and
Figure 17-14 a) Before correction: irregularly sized spaces, coarse-haired grafts scattered with fine-haired ones, and varying hair
directions. b) After repair session. Coarser-haired grafts were replaced with more appropriate ones. Round minigrafts, standard round grafts,
and micrografts were used. Sometimes, incorrectly directed grafts must be excised during a separate session before grafts can be added
adjacent to them. Fortunately, that was not necessary for this patient, as most of the very poorly directed grafts were well posterior to the
hairline zone, in less cosmetically important areas.
678 Chapter 17
Figure 17-15 a) Before first repair session: This patient demonstrates the classic ‘‘Barbie-doll’’ appearance, poor hairline design, failure
to anticipate further hair loss, too coarse hair in hairline grafts, too dense hair in hairline grafts, and irregular spacing of grafts, making
filling of remaining spaces more difficult. The grease pencil line denotes the suggested new hairline. b) Eight months after a single repair
session, consisting of 55 standard grafts, 48 round minigrafts, 175 slit grafts, and only 77 micrografts. Areas anterior to the old transplant
were treated with micrografts and small and large slit grafts. The spaces between previously transplanted round grafts were filled with
round grafts of various sizes to completely eliminate any plugginess in the anterior-most rows. Because the misdirected grafts were well
posterior to the new hairline zone, it was not necessary to excise them.
if they remain noticeable, hair can be transplanted directly into diately after transplanting and sometimes it has been noticed
them. Often you cannot immediately replace the excised graft only after a number of years have passed. Most involved pa-
with another correctly directed one, as any sutures you have tients say the stubble was seen the day after surgery along with
used may be cut by the recipient tool, and the recipient tunnel all the other donor hairs, however, they never fell out nor did
itself will be angled or directed incorrectly. For the same reason, they grow. Rassman has transplanted hair into such areas as
you usually cannot transplant in proximity to that site. There- well as into the surrounding scalp at the same time and the
fore, it is, unfortunately, sometimes best to remove inappro- grafts in the involved areas always failed to grow normally
priately directed grafts during one or more separate sessions, while grafts in the surrounding normal areas grew well (9).
during which new grafts will not be used in the same area. New Arnold, who has seen similar cases, has reported that topical
grafts, especially micrografts and microslit grafts can often be minoxidil (Rogaine) solutions and injections of triamcinolone
used, however, at the same time, anterior to, posterior, or lateral acetonide did not stimulate growth, nor did plucking the hairs
to the area in question. stimulate new growth (10). He found that, in second and third
surgeries in the area, some of the transplanted hairs grew while
‘‘Barbie-Doll’’ Appearance an equal number of hairs remained as stubble. He reported that
Plugginess or the so-called Barbie-doll effect is usually the biopsies he carried out at several sites showed intact bulbs with
result of multiple factors (see Fig. 17-15) including one or more a normal mature pigmented hair in place—the original donor
of: grafts with compressed dense hair, unsightly spaces between hair. Whereas a normal anagen bulb shows two to three mitotic
grafts, and adjacent grafts that contain hairs with different densi- figures per high-powered field, these bulbs had no mitotic fig-
ties or textures. The ideal method of correcting plugginess not ures whatsoever. The cause of this disorder is unknown and the
only depends on which of these components are present, but only known treatment would appear to be excision of the areas
also on where the plugginess occurs and hair characteristics, rather than transplanting into them.
such as hair texture, caliber, color, contrast with skin, wave,
and curl. There is, therefore, no single approach that is ideal Planning Errors
for all patients. The correction of each of these problems has
been dealt with previously, as has the importance of creating ‘‘The first region to bald is the area where you should
new areas of hair that can be combed over the cosmetically be most hesitant to transplant’’ (1).
problematic ones.
Hairline Too Low
Stubble Trouble If the hairline zone has been placed too far anteriorly, especially
A growing number of hair transplant surgeons have reported if many grafts have been used for its construction, the treatment
small, circumscribed areas in which transplanted hair is present of choice, in most instances, is a U-shaped AR posterior to the
but has failed to grow normally. The hair within these zones hairline. Extensive undermining is carried out anterior to the
exists only as stubble and continues to look this way, showing AR incision. Closure of the excision site results in an elevation
neither loss nor growth. Sometimes such stubble is noted imme- of the entire hairline (5,6). When one is more concerned with
the lateral aspects of the hairline, an AR with its greatest width hair density and scalp laxity on the one hand, while increasing
posterior to the lateral hairline is utilized. Soft-tissue expansion the demand for hair in the recipient area ‘‘by producing scars
before any AR and scalp extension, have revolutionized the in the top and the crown that must be camouflaged.’’ ARs are
efficacy of this approach. also said to ‘‘alter patterns and change hair direction (1).’’ All
As indicated earlier, if the unwanted, most anterior grafts are of these disadvantages are, ‘‘acorns that have been turned into
not too numerous or too low, yet are anterior to a cosmetically oak trees.’’ All occur to a minor degree or not at all if ARs
acceptable hairline, they can be punched out individually or are appropriately planned and skillfully carried out in properly
excised as a strip in a single session or staged ones. Punched- selected patients (see Chapter 19). B & R have, no doubt, seen
out graft sites in this location are always sutured with 5–0 silk some examples of poorly planned and/or poorly executed ARs
or poliglecaprone 25, 4-0, taking advantage of Langer’s lines and have generalized their experience. An AR can immediately
to create minimally noticeable scars. Low density scattered FUs remove a 2.5 cm to 6.0 cm zone of alopecia, leaving only a
can be used in later sessions to camouflage the scars that may fine scar in its place. The latter can be transplanted with FUs
result from these excisions. or minigrafts if it is at all noticeable. Thus one has saved vir-
tually all of the grafts that would have been necessary to trans-
Hairline Too High plant that alopecic area. Those grafts are still in reserve for
The problem of the too-high hairline is one of the easiest to the treatment of other areas. Although there is obviously some
correct. The obvious solution is to lower it with a new and decrease in hair density and laxity in adjacent rim hair, the
properly constructed hairline zone. (See Chapter 12.) decrease in the number of grafts that can be harvested from the
rim is always substantially less than the number of grafts that
would have otherwise been necessary to transplant the excised
Incorrect Filling of Frontotemporal Recessions
alopecic strip. Additionally, the hair distribution within the ele-
Such an error may or may not be a component of a hairline vated rim hair is perfectly natural. As indicated, the effect of
that is too low (Fig. 17-16). Any grafts in unwanted locations AR, in eliminating the alopecic area, is immediate and does not
can be treated with one of the following options: require two or more transplant sessions and months of waiting
1. They may be removed with a punch or strip-method of for the transplanted hair to grow. I urge the reader to review
excision, or ‘‘V’’-shaped excision. Chapter 19, and the commentaries by Seery and myself, for
2. They may be punched out and replaced with appropri- further elaboration on these opinions.
ately sized non-hair-bearing grafts obtained from areas Mini-ARs (MARs) are extremely useful in areas that are
of MPB. transplanted with insufficient density, but are not suitable for
3. Hairs within such grafts may be removed with electroly- other types of treatment—especially additional grafting. Wher-
sis or lasers. As noted earlier, laser removal is preferable ever one would have used grafts, one simply punches out
if there is considerable scarring in the area, which may holes—singly, in rows, or in groups, with the holes almost
distort follicle direction and render electrolysis less ef- touching each other (11). The size of the holes can vary accord-
fective. Dermabrasion may or may not also be neces- ing to the width of the hairless spaces. For example, they may
sary. be 2 mm to 5 mm in diameter at various points along a line
(Fig. 17-18). The configuration of a line of such holes can vary
according to what is required. They may, for example, be linear,
Anterior and Posterior Scalp Transplanted When an
S-shaped, L-shaped, Y-shaped, etc. The MAR may also be per-
Insufficient Number of Grafts Were Available to Join formed concomitantly with additional transplanting, as long as
and Treat the Entire Area the blood supply to the new grafts is not compromised by the
A variety of AR shapes should be employed to reduce the size of MAR patterns employed.
the alopecic recipient areas as much as possible. Grafts present
within any sections that will eventually be excised, may be Lateral and Posterior Extension of Male Pattern
reused elsewhere. The transfer of such grafts should ideally be
Baldness Beyond the Original Estimate
done during prior hair transplanting sessions in other areas (Fig.
17-17). It can also be carried out at the time of the AR, but The problem of extension of MPB, beyond the physician’s orig-
before the actual excision of the area because it will be easier inal estimate, accompanies virtually every repair case I see. It is
to accurately excise the grafts before the section is removed a variation of the lack of long-term planning already discussed.
from the scalp. This approach allows one to entirely remove Perfect foresight, in 100% of cases, is no doubt impossible to
sparsely transplanted areas, while increasing the hair density in achieve. However, it often appears that no attempt was ever
areas that one intends to later transplant more densely. Alterna- made to transplant into future areas of loss, thereby condemning
tively, it can result in the complete removal of previously un- the patient to a seemingly never-ending catch-up game with
transplanted areas, thereby saving the grafts that would have the progression of MPB. Careful inspection of the scalp hair,
been necessary to transplant such areas. Of course, transplanting especially if the hair is wet, is the best way to anticipate and
grafts at the same time as an AR is being performed should be treat future hair loss at the same time as more obviously balding
done in such a way that it does not compromise the blood supply areas are being transplanted (see Chapter 5).
to either surgical site. Extension of MPB, beyond the areas originally transplanted,
I have never understood the aversion by some practitioners results in a hairless strip of skin or alley between the transplanted
to AR in the above-noted circumstances. B & R have opined area and the narrowed rim of permanent hair (Fig. 17-19). This
that ARs negatively ‘‘alter the balance between supply and de- gap should either be excised with an AR or ARs, or treated with
mand.’’ They claim that ARs do this by decreasing donor area additional grafting, or both. In general, the second option is not
680 Chapter 17
Figure 17-16 a) Before corrective transplanting: Results of prior poor transplantation are obvious just anterior to temporal hair. The
frontotemporal area into which these grafts were placed should rarely be transplanted because persistent hair in this triangle, beyond the
age of 30 years, is extremely uncommon. b) Caudal view, before corrective transplanting. c) After five sessions, totaling 500 standard
round grafts in frontal and midscalp areas. Grafts that were improperly placed in the frontotemporal triangle had been excised and the
holes sutured. This patient was treated 24 years ago. d) Caudal view, with the hair combed in a natural left-to-right direction. This degree
of hair density cannot be achieved without using round grafts, but should rarely be aimed for today, because an inordinate amount of donor
tissue is expended in doing so.
the best, especially for wide or potentially wide alleys. It is better months later, as happens when grafts are used—and no grafts
to conserve the grafts that would be required to transplant a wide have been consumed. Alleys on the left and right sides of the
alopecic alley for other areas; this is best achieved by excision of scalp should generally be excised at different times. An interval
all (or most of) the area of unanticipated MPB. The hair in the of at least 6 months should separate the two procedures and
superior temporal area usually is somewhat sparse, and if the pre- their design should avoid embarrassment of the blood supply
viously transplanted areas contain dense hair, then a narrow tran- to the central scalp (6).
sition zone with intermediate-density hair should be created be-
tween these two areas. The intermediate zone can be produced Summary of the Preceding and Other Tactics
with FUs or, if hair characteristics are particularly good, a combi- Employed for the Correction of Poor Planning in the
nation of FUs and DFU. Recipient Area
The above approach produces cosmetically acceptable re-
sults, with a minimal expenditure of donor tissue. Once again, 1. Construct an entirely new hairline zone whenever this
I am perplexed by the reluctance of some practitioners to use is practical. The texture and density of hair in this zone
AR in this situation. The alley is often totally gone after a single should ideally be fine and uniform. Grafts that are
excision and is replaced by an even, natural growth of temporal not appropriate, or are angled or directed improperly,
hair. The effect is immediate, rather than occurring 3 or more should be removed, and re-used elsewhere. Excision
and replacing them with FUT or M/M in that zone.

Alternatively, the spaces between the round grafts that
have high hair density—especially if the hair is coarse
or has high color contrast with the skin—can be filled
with additional round grafts of appropriate sizes. The
advantages and disadvantages of both of these options
have been described above. Micrografts, with or with-
out microslit and slot grafts, are always used anterior
to any zone of high-density hair that is produced by
using this approach.
3. Consider elevating the hairline by using AR to accom-
plish tactic no. 1, in order to avoid producing a new
hairline that is too low.
4. Use as many ARs as practical. Poor planning, when
it occurs, is usually paired with poor technique in all
Figure 17-17 A patient in whom insufficient donor reserves aspects of hair transplantation, including donor hair
were available to join and complete transplanting of areas started wastage, and other problems in the donor area (that
anteriorly and in the vertex. Pattern of proposed future alopecia will be discussed later). These ARs may be done be-
reduction (AR) marked in black crayon. Twenty grafts were excised fore, or at the same time as, additional transplanting,
from the site of the future AR at the same time, as I was transplant- or may be interspersed between transplanting sessions.
ing in the frontal area. Smaller grafts, created from these larger In some patients, at least one and often two ARs are
ones, were used in the areas being transplanted that day. Another carried out before any repair transplanting is started.
similarly designed AR will probably have to be carried out lateral Replacement and retransplantation of inappropriate
to the one shown, as that area loses more hair in the future. grafts, in clearly visible sites, may be done at the same
time as AR.
5. Soft-tissue expansion before AR, or scalp extension
(which obviates the need for soft tissue expansion),
sites can usually be left to heal by secondary intention, dramatically increases the effectiveness of AR.
if less than 2 mm in diameter. Alternatively, they can 6. In most patients, it is best to complete the repair of
be sutured or filled with replacement grafts taken from the part-side hairline zone, the part-side ‘‘ledge’’ or
areas of MPB, depending on circumstances that have ‘‘crease’’, and anterior midline scalp, in that order,
already been discussed. Adequate cosmetic correction before doing much on the non--part-side, the midscalp,
is often difficult to achieve when grafts are added here and the vertex area. This will ensure that areas of prior-
and there to an existing poor hairline zone. ity are completed first, in case you exhaust the donor
2. Areas previously treated with round grafts in the ante- area before expected. Remember that hair transplanted
rior 2.5 cm to – 4.0 cm of the hairline zone can be to the midscalp can frequently be successfully styled
dealt with by excising them completely or partially, to cover all, or much of, the vertex area.
Figure 17-18 a) A single line of holes is shown. It has been punched out with whatever size of punch was necessary to completely
remove the alopecic tissue between previously transplanted round grafts. This individual was running out of potential donor grafts. The
configuration shown is a somewhat distorted S-shape, but in fact, could be any pattern, as long as the blood supply to the concomitant
grafting is not compromised. b) The bridges between the holes shown in a) were cut and the edges inter-digitated, before the wound was
stapled closed. Although stainless steel staples were used in this particular patient, I usually use sutures.
682 Chapter 17
Figure 17-19 a) Before repair sessions 10 years ago: This 56-year-old man had started having the vertex area transplanted many years
earlier. His MPB had advanced leaving an island of pluggy-looking grafts in the central vertex. Photo shows pattern of proposed alopecia
reduction (AR) on right and left side, as well as a proposed new hairline. b) Immediately after first AR. c) Proposed second AR, on the
left side, has been marked. d) Immediately after second AR on left (at this point, two sessions of grafts were growing more anteriorly).
Figure 17-19 Continued. e) Right side of area of MPB, before ARs: Left side had been the same width and had been completely
removed with two ARs. f) Immediately after second AR on the right side: Three sessions of micrografts and slit grafts are now growing
in the frontal area. Two of the latter had been done 6 weeks apart—4 weeks before the first AR on the left side, and one 4 months later.g)
After three transplant sessions to the frontal area, one to the vertex, and four ARs. Another transplant session to the vertex was carried
out immediately after this photograph was taken. One of the reasons the vertex looks substantially less pluggy after only one session is
that a portion of many of the previously transplanted standard-sized grafts had been punched out and used as slit grafts. The holes in these
grafts were not sutured and healed without noticeable scars. h) Before repair: front view.
684 Chapter 17
Figure 17-19 i) Two sessions of slit grafts growing anteriorly. Pattern of proposed second AR on the left is shown. j) Side view after
three transplant sessions to the frontal area, one to the vertex, and four ARs. The ARs were done by Dr. Martin Unger; grafting by me.
7. Space sessions farther apart than usual. To begin with, Below, for example, is an excerpt from the negative
you are dealing with a depleted supply of donor grafts. ruling on a 2001 application to the FDA, on behalf
Grafts should not be placed into areas where they are of one of the manufacturers of AH, which asked for
not absolutely necessary. Intervals of at least 6 months revocation of the ban on prosthetic hair fibers in that
between sessions are usually wise. This allows for an country. Alternative manufacturers of AH would ap-
accurate assessment of the effects of prior repair ses- pear to feel that their applications would be viewed
sions, and avoids the use of additional grafts in areas similarly; to my knowledge, no others have even ap-
that may not need them. plied for evaluation of their fibers in the last few years.
8. Lightening the hair color or coloring the scalp to more
‘‘The histology data from both clinical and pre-clinical
closely match the color of the hair, and permanent
studies is unsatisfactory. Your submission does not
waves are useful adjuncts to repair sessions. Take ad-
adequately explain such basic issues as from which
vantage of them whenever possible. (See Chapter 14B)
subjects the samples were obtained, how those subjects
9. Sometimes the best course to follow is to try to produce
were selected, what the particular sites of the biopsies
a natural-looking frontal fringe of hair, behind which
were and how they were chosen, how deep the
a hairpiece can be used. This approach is usually the
biopsies were, and how much of the implant and
only one possible whenever the donor area has been
surrounding tissue was removed. Histology protocols
severely depleted or scarred by previous surgery.
to assess the tissue response should have included
10. Consider the implantation of artificial hair (AH) when
methodology (such as plastic embedding) to ensure
there are insufficient donor reserves. If the patient is
that the fibers were not removed in the sectioning of
unwilling to wear a hairpiece, tattooing (see later) and
the tissue. Without identification of the fiber-tissue
AH seem to be the only other options for the treatment
interface, the histology data are inconclusive.
of unsatisfactory recipient areas and scarring in the
Moreover, your studies are insufficient to evaluate the
donor area. The quality of AH fibers has improved
long-term consequences of prosthetic hair implants.’’
substantially over the last 5 to 10 years. They are less
problematic with regard to tissue reaction and infec- ‘‘To ensure the success of the procedure and reduce compli-
tion rates than they once were, but none have, as yet, cations, your clinical studies relied on strict patient selection,
been approved by the FDA in the United States. strict surgical technique adherence, close patient follow-up, and
other burdensome requirements for patients, including pre- trophic scars, or wide scars. The latter are especially prone to
scribed pre- and post-implant use of topical antibiotics and topi- occur if the scalp is more lax than average, or if the patient has
cal steroids, daily use of particular shampoos, and avoidance Ehlers-Danlos syndrome. Patients who bleed more than average
of such common conditions as exposure to heat, sunlight, and postoperatively, because they are bleeders, or have taken medi-
acidic conditions (which may include sweat). But even among cation that causes them to bleed, or who routinely engage in
patients adhering to these measures, the published studies you strenuous exercise, can also develop excessive scarring. Ob-
provided demonstrate serious infection rates of 1.0% in the 196- viously, patients who develop donor area infections, also tend
patient prospective study and 3.8% in the 503-patient retrospec- to have scars that are wider than usual.
tive study. A further 11.2% of the participants in the 196-patient Problematic scars can be excised as strips containing only
study experienced inflammation reactions and mild infections, scar tissue, or a combination of scar and graft tissue. Excision
which researchers attributed to poor post-procedure care. The of donor strips, in repair cases, is nearly always designed to
percentages of total unspecified adverse events were 13.8% in include more scar than hair. In a large majority of the repair
the 196-patient prospective study and 20.1% in the 503-patient cases I see—even those with sparse donor areas—some grafts
retrospective study. These data suggest that despite the elabo- containing one, two, three, or more hairs can be produced from
rate care protocol specified by your labeling, as well as the strips excised from the donor area, without making it look spar-
other restrictions on use, a significant risk of adverse events, ser. For example, if alternating rows of hair and scar are present,
particularly infection, remains. Moreover, the adverse events I usually use a double-bladed knife to excise the strip, with the
patients experienced under a very vigorous compliance regime objective of removing two rows of scars and only one interven-
suggest that if there is less vigilance outside the controlled envi- ing row of hair (see Fig. 17-20). A single blade may be em-
ronment of the study, even more serious adverse events, similar ployed when necessary to facilitate that objective. The hair in
to those experienced in the years before the ban, may result.’’ the donor area will appear thicker, despite the removal of addi-
All AH are eventually rejected by the body and, as indicated tional hair because more scar tissue is removed than hair, and
in the foregoing FDA response, are prone to developing inflam- because one often ends up with two intact rows of hair abutting
mation, infection, and sebum plugs around their points of inser- each other after the excision is completed. If you feel that com-
tion. Between 10% and 25% of the fibers usually have to be plete excision of a scar may result in an unacceptable amount
replaced yearly, requiring continuing treatment and costs. The of scalp tension in the area, it can be removed in staged proce-
reactivity and frequency of serious problems with different fi- dures. At the minimum, the superior or inferior incision should
bers, and in different individuals, varies tremendously. While always pass through healthy hair-bearing tissue, so that at least
some patients have few problems, severe infection and scarring, one border of the excision site will have the most optimal blood
secondary to AH, continues to be reported. Richard Shiell, who supply possible. Whenever there is a decrease in hair density
has studied the use of AH in a group of his patients, over the that will result from such new strips being taken and sutured,
past three years, has stated that close follow-up of patients (reas long as it is more than offset by a decrease in visible scar,
gardless of the type of AH used) is mandatory. Most hair resto- then excising a strip containing hair and scar remains warranted.
ration surgeons have not used AH and appear to be hesitant to As was noted earlier, this is usually true even if—in order to
do so. At this point in time, virtually all would agree that AH obtain a sufficient number of grafts to produce a satisfactory
should be considered a last resort solution, only suitable for appearance in the recipient area—it reduces the hair density in
correction of disfiguring results of prior hair transplanting and the donor area to less than 50% of its original density.
when insufficient donor hair is available. In addition, it should In a private communication on November 27, 2002, Gandel-
be reserved for patients who fully understand the need for regu- man suggested using two parallel zigzag incisions with the ob-
lar check-ups by a physician and the potential for serious infec- jective of removing, as much as possible, a wider than average
tion. Nevertheless, such individuals might prefer this alternative
to doing nothing, tattooing, or wearing a hairpiece. There is
a small group of physicians who are studying the results of
implantation of the newer types of AH. Hopefully, a satisfactory
fiber will be developed that can pass the requirements for FDA
approval, and this option will then become a more acceptable
one.
DONOR AREA
Technical Errors
Excessive Scarring
Prior to scar revision in the donor area, try to find out exactly
why the excessive scarring developed. Speaking to the previous Figure 17-20 The shaded area represents zone excised from a
hair restoration surgeon(s) is often a good idea. Poor scars can previously harvested donor area consisting of alternating bands of
be due to faulty planning or technique by the physician who hair (H) and scar (S). Note: (1) As much or more scar tissue is
carried out the procedure, but can also be caused by improper excised as hair-bearing tissue. (2) Two hair-bearing strips are left
postoperative care by the patient. Unacceptable scars can, of adjacent to each other after the excision. The result is that the hair
course, be secondary to a genetic predisposition to poor heal- will appear to be denser in that general area, despite the removal
ing—for example, an inherent tendency to form keloids, hyper- of additional hair from it.
686 Chapter 17
scar. He interposes hair scalp triangles with triangles of scar 2. As a last resort, donor material may be obtained imme-
tissue. ‘‘The result resembles the shotgun scars caused by hand diately superior to the most superior previously har-
engine harvesting and can be concealed with shorter occipital vested donor areas. These grafts may or may not contain
hair. Patients accept these scars more readily than wide linear permanent hair, but should provide some interim help
ones.’’ He has used this technique for approximately 30 patients until such time as those hairs are lost. By then, perhaps,
in the last 5 years. the hair color will have become gray or white, and the
It is wise to take a somewhat narrower strip than you think area will have the appearance of sufficient density, de-
you can remove without creating undue tension on closing. spite some thinning that has occurred. One must be very
Often scar tissue elsewhere in the donor area will result in more careful to place such grafts in areas where the cosmetic
closing tension than you might have expected. Also, as noted impact will be minimal if the hair is, in fact, not perma-
in Chapter 10, each added millimeter of strip width increases nent. It is more common than usual to have temporary
closing tension disproportionately. Undermining, two-layer clo- hair loss adjacent to donor areas that are taken superior
sure, and interrupted sutures or staples should be used whenever to multiple rows of scars. As a result, the preventative
you encounter more than the expected amount of closing tension measures discussed earlier, such as low closing tension,
(despite having taken the earlier-noted precautions). Undermin- applications of 3.5% minoxidil and topical antibiotics
ing, if it is done, should be done beneath the superior rather are also recommended in these donor regions.
than the inferior flap for two reasons: 1) inferior undermining 3. Follicular unit extraction. See Chapter 10.
will result in stretch forces on the suture line whenever the neck Producing adequate anesthesia in an extensively scarred donor
is flexed and, 2) most of the blood supply to the wound comes area is sometimes difficult, not only because it requires more
from the inferior region and undermining the inferior flap com- pressure to inject the solution, but also because diffusion of the
promises this supply. If there is particularly great closing ten- anesthetic is impaired by the scar tissue. Try to infiltrate through
sion, a small area can be left without sutures to heal by second- a zone of normal tissue inferior to the strip that will be ex-
ary intention (see Chapter 10). cised—even if this needs to be 5 mm or more inferior to the
A variable amount of tissue edema will occur at the donor intended donor strip.
site over a 3 to 5 day period after the surgery. Sutures, that One can successfully transplant hair into scar tissue in the
were originally associated with absolutely no tension, can be- donor area, but this should be a last-resort tactic, because it
come very tight owing to the postoperative edema. (See later.) consumes donor tissue that is usually better employed in the
As a result, blood supply to the area may become compromised recipient area and scars can nearly always be excised instead.
and temporary hair loss, areas of necrosis, or infection may Notwithstanding the preceding, there are some wide scars
occur. In view of the preceding, as noted earlier, one should that seem to be impossible to improve, even when one tries to
always aim to remove less, rather than more, scar tissue at any take them out in a staged fashion. There are multiple factors
one time. To improve vasodilation and healing, I also recom- involved in these cases and we clearly do not know all of them.
mend that the patient apply a 3.5% solution of minoxidil (mix I suspect the most common factor, however, is the tendency of
equal parts of 2% and 5% minoxidil solutions), twice daily to physicians to take a little bit more scar tissue than is really
the donor area until the sutures are removed (for its vasodilating possible without tension developing at the wound site—either
effect). This should be followed with the application of Baci- at the time of closing or postoperatively. I have followed two
guent ointment, 10 to 15 minutes later. A systemic antibiotic patients whose scars would not improve, despite very conserva-
is nearly always prescribed (usually cefdinir [Omnicef] 300 mg tive partial excisions. I observed these patients over the course
or [Duricef] 500 mg twice daily]; it is taken one hour before of several days. Postoperatively, tension changed from being
surgery and is continued until the sutures are removed. Unless nonexistent to severe, due to the accumulation of edema devel-
contraindicated, in an effort to minimize edema, besides the oping in that area. I suspect many of the patients who developed
routinely given Depomedrol 80 mg at the start of surgery, I wide scars, but who have had proper technique used in the
also prescribe 60 mg of prednisone to be taken each morning donor area, are individuals who develop more than the average
for 3 postoperative days. In addition, I remove the sutures at amount of edema postoperatively (see Chapter 10). The only
10 days, rather than at my usual 7 days. Patients are advised way such patients have been successfully managed in my prac-
to call the office at the first sign of increasing erythema, increas- tice, is by utilizing soft-tissue expansion prior to the scar exci-
ing pain, or purulence. sion, so that there is an extraordinary amount of laxity of the
If one of the primary purposes of the session is to obtain scalp before the scar is excised. It is best to take a conservative
grafts for additional transplanting, rather than to simply maxi- approach and remove less scar than you think may be possible.
mize scar excision, one side of the head can be used as the Even then, complete resolution of the problem may remain im-
primary source for new grafts, while the contralateral side has possible. In such cases, transplanting of hair or AH into the
a maximum amount of scar tissue removed. In a subsequent scar, or tattooing of the scar (see later) must be considered.
session the objectives for each side can be reversed.
Additional grafts for repair cases can often be obtained in Planning Errors
three other ways:
Planning errors in the donor area can be subdivided into three
1. Temporal areas have frequently not been harvested. broad categories: 1) taking donor tissue from areas that are too
Grafts from these sites are usually perfectly acceptable, superior. This results in scars that can be easily seen or in grafts
but many hair restoration surgeons prefer not to use with only temporary hair growth; 2) taking donor tissue from
them for a variety of reasons. This can often provide areas that are too inferior, with the same results as in 1) and
an untapped reserve of donor tissue in such individuals. 3) over-harvesting. Even if harvesting is not excessive, one can
make the mistake of trying to remove more hair than should (12). He reported on 82 procedures done in 62 patients. The
wisely have been harvested in the long run; one must always patients were unanimously highly pleased, even when the re-
take into account the gradual thinning of hair in the donor area sults were less than perfect. Only 20% of them returned for
that naturally occurs with the passage of time. Although scars additional procedures. Unfortunately, although expert tattooing
may not be noticeable in a young man, by the time he is older can be very effective, most hair transplant surgeons are unlikely
and the rim hair has thinned out somewhat, they may become to have the dedication or the patient volume to ever achieve
more obvious—especially when the hair is wet. the necessary expertise. Cooperating with a tattoo artist may
The best defense against such occurrences is to begin hair be the ideal solution for those who feel that pigmentation is
transplantation in your patients by taking a single donor strip their only resort.
from the middle of the thickest area of hair growth in the donor It is worthwhile remembering that once the scalp is tattooed
area. Subsequently, harvest a single strip with the scar from with a dye that contains iron, MRIs may become inaccessible
any previous session(s) in the middle of the new donor strip. to them; the iron in the dye heats up in the MRI unit and the
Thus, only a single scar is produced in the thickest portion of procedure must be stopped. The older dyes apparently contained
the donor area—no matter how many sessions have been car- more iron than newer ones and therefore are more problematic.
ried out. Using two donor areas, but harvesting them in a similar Most MRI facilities try to do the MRI but warn the patient of
fashion, is the second best method. The excision of multiple what may happen. CAT scans present no problem for patients
virgin donor areas, for each session, is the technique that pro- with tattoos.
duces the most scars and is least safe from the ravages of time.
The pros and cons of each approach are discussed in Chapter REFERENCES
10.
The best treatment, for any of the three planning problems 1. Bernstein R, Rassman W, Rashid N, Ascione S, Shiell R. The
noted above is re-excision of scar tissue and closure under mini- art of repair in surgical hair restoration. Dermatol. Surg 2002;
28(10):873–893.
mal tension. The objective is to transplant permanent hair in 2. Seery G. Hair transplantation: Management of donor area. Der-
the recipient area and to produce a scar, which will be as fine matol. Surg 2002; 28(2):136–142.
as possible and the least noticeable in both the short and long- 3. Rassman W. Follicular unit extraction: Minimally invasive sur-
term. Hair transplanting into scar tissue may be undertaken if gery for hair transplantation. Dermatol. Surg 2002; 28(8):
sufficient donor material is available and once again AH can 720–728, and 28(10):873–893.
4. Swinehart JM. Hair repair surgery. Dermatol. Surg 1999; 25:
be considered as a last resort. Tattooing scar tissue has also
523–529.
been suggested. Jerry Cooley recommends combining FUs with 5. Vogel JE. Article correction of the corn-row hair transplant &
the tattooing of ‘‘fine curved lines, the same or finer than the other common problems in surgical hair restoration. Plast. Re-
actual hair’’ instead of ‘‘dots’’ of tattoo pigment, in bad donor constr. Surg Aril:1528–1536.
area scars. However, it should be kept in mind that although 6. Unger W. Correction of poor transplanting. In. Hair Transplanta-
an individual’s hair may, for example, be black or brown when tion Unger W, ed. New York.: Marcel Dekker, 1995:375–388.
7. Unger M. Hyperfibrotic transplants. Hair Transplant Forum Intl
he is relatively young, as he gets older and his hair begins to 1993; 3(4):8–9.
gray, darker tattoo pigments could become starkly evident. 8. Unger W. Hyperfibrotic ridging, Complication in hair transplant-
Thus, the patient may be forced to dye his hair on a continual ing. In. Hair Transplantation Unger W, ed. New York: Marcel
basis or live with an unacceptable appearance. Fortunately, tat- Dekker, 1995:368–369.
toos do tend to fade with the passage of time, but it still may 9. Rassman W. ‘‘Stubble’’ Trouble, private communication. 1995.
10. Arnold J. ‘‘Stubble’’ Trouble, private communication. 1995.
be many years before a tattoo is faint enough to make hair
11. Unger W. Mini-alopecia reductions. In. Hair Transplantation
coloring unnecessary in an individual whose hair has become Unger W, ed. New York: Marcel Dekker, 1995:615–620.
white. Dr. Alvaro Traquina has published a paper on micropig- 12. Traquina A. Micro-pigmentation as an adjuvant in cosmetic sur-
mentation for scars subsequent to cosmetic surgery of the scalp gery of the scalp. Dermatol. Surg 2001; 27(2):123–128.
18
Basic Science and Principles of Reductions and
Flaps
18A. Scalp Surgery: Mechanical and longitudinal in the limbs and scalp and circumferential in the
neck and trunk (Fig. 18A-1).
Biomechanical Considerations The lines of minimum tension are surgically important for
Gerard E. Seery two main reasons.
1. Elliptical excisions achieve greatest width of tissue re-

INTRODUCTION moval when made parallel to the lines.
2. Incisions made along or parallel to the lines heal with
The purpose of surgery is to effect functional and/or cosmetic
a minimum of scar, whereas incisions made across them
improvement while causing as few adverse consequences as
heal less well.
possible. At its core are three basic modalities: namely, incision/
excision, mobilization, and reconstruction. The above findings led to the concept of collagen transection
Scalp is made up of collagen, elastin, blood vessels, nerve scarring, which is the unsatisfactory scarring that results when
fibers, and lymphatics with mucopolysaccharide ground sub- incisions are made across collagen bundles. Consequently,
stance, tissue fluid, hair follicles, sebaceous and sweat glands. knowledge of the orientation of collagen in the skin is clearly
The purpose of this chapter is to describe a rational approach
to the surgeon’s advantage. It is, however, likely that present
for complication-free scalp surgery by observing the anatomical
knowledge of collagen orientation may still be rudimentary. In
and biomechanical effects of the three basic modalities of sur-
the light of the above, the argument is made that, where possi-
gery on scalp tissue.
ble, surgical incisions in scalp tissues should ideally be made
Modern scalp surgery was born out of experience gained in
the first and second World Wars (1,2)—times when saving lives in a vertical axis other than in the occipital hair transplantation
was paramount and niceties of cosmesis and preservation of donor area where horizontal axis paralleling crease lines is pre-
sensation of secondary or no importance. Progress was mea- ferred.
sured in terms of scalp flaps designed to address some specific While much has been made of the problems of collagen
reconstructive problem or need. A new chapter in the history transection, it is probably as important not to transect elastic
of scalp surgery began in 1977, when the operation of scalp fibers. Fortunately, as collagen and elastin generally run in par-
reduction for male pattern baldness was described (3,4).This allel, incisions that spare one spare the other. The importance
contributed a wealth of information about scalp surgery and it of elastin is detailed later in this paper.
is on this and data derived from clinical research (detailed later) It may be argued that the scalp is in some way protected
that the following observations and conclusions are based. from collagen transection scarring by galea aponeurotica that
bears the tension of closure. It is, however unlikely that scalp
incisions that transect collagen and elastin would result in scars
Incision/Excisions of comparable quality to those that do not (Fig. 18A-2).
Lines of cleavage in the skin were first described by Langer in Incisions should also parallel the directional orientation or
1881, and reinvestigated by Cox in 1941 (5). The lines are drape of hair in order to avoid transecting hair follicles. Depend-
believed due to collagen bundles arranged in parallel in the ing on the surgery contemplated it may not be possible to make
dermis, although this has not been confirmed by electron mi- incisions that simultaneously parallel both lines of minimum
croscopy (6). Where crease lines exist, their direction generally tension and directional orientation of hair but it remains a coun-
coincides with the lines of minimum tension. These tend to be sel of perfection nonetheless (Figs. 18A-3 & 4).
689
690 Chapter 18
Figure 18A-1 Diagrammatic representation of lines of minimum tension.
Vascular Considerations periphery of the scalp has dire consequences for the vascularity
of tissues both adjacent and distant from the transection site.
The scalp is supplied by a system of anastomoses between In all likelihood, the scalp also derives at least some minimal
branches of the external and internal carotid arteries (Fig. 18A- blood supply from bone perforators deriving from meningeal
5). The blood supply is centripetal i.e. the larger trunks in the vessels. This would explain the survival of surgically circum-
periphery run medially and centrally, becoming smaller as they scribed scalp.
enter a system of free anastomosis with their fellow trunks. The belief that the scalp has a superabundant blood supply
This and their spatial or depth location are of critical importance and consequently, is very forgiving of surgical indiscretions,
to the surgeon. The arteries are cutaneous and are classically may benefit from reconsideration. This is particularly so, with
described as being in the subcutaneous tissues with attachments respect to hair transplantation for male pattern baldness.
to the deep layers of the dermis (7). Dissection in subgaleal Klemp (9) in 1980, evaluated scalp subcutaneous blood sup-
and subpericranial planes spares vasculature and allows large ply in subjects with male pattern baldness (MPB) and concluded
flaps to be raised in safety (Fig. 18A-6). blood supply to be reduced relative to controls. Toshitani (10)
The fact that scalp is not supplied by perforators (8) is of enor- in 1990, using Doppler flowmeter and thermography studies,
mous practical import for surgeons, as surgical transection of demonstrated relatively reduced flow in the central scalp of
subcutaneous vasculature and particularly of larger trunks in the MPB patients.
Basic Science and Principles of Reductions and Flaps 691
Figure 18A-2 Z-plasty reconstruction of central scalp. Note barely discernible anterior midline scar compared with posterior component
that transects collagen and elastin.
Goldman, in 1996 (11) reported details of a study that mea- tomical location of the major neurovascular trunks is imperative
sured scalp transcutaneous PO2 in subjects with MPB. Signifi- (as is magnification) if these structures are to be spared during
cant microvascular insufficiency in regions of the scalp that surgery.
lose hair and an associated relative tissue hypoxia was found. A corollary of the above is that incisions in the central scalp
Goldman speculated that, contrary to the theory of donor area are associated with minimal neurovascular trauma making their
dominance, hair follicles in the frontal and crown regions may use the preferred choice, when a choice exists. It should be
not be genetically different from those in the non-MPB areas remembered, however, that more than two midline scalp reduc-
and that it is the relative local hypoxia in bald areas that may tions might produce a slot scar.
be the underlying pathophysiology by which age, genetics, and
androgens interact to cause male pattern baldness. Mobilization and Reconstruction
Goldman’s study has many practical implications not the
least being that transplanted hair may never regain the caliber Tension-free surgery, long the holy grail of surgeons, remains
of its pretransplantation state. The relative hypoxia in MPB elusive. Significant tension causes necrosis: lesser degrees of
subjects suggests that smaller numbers of grafts per session tension predispose to atrophic changes, the extent of which var-
may be conducive to relatively improved growth and better ies with the intensity and duration of the stretching force and
quality hair than larger sessions. the capacity of the tissue to withstand it.
The surgeon’s first weapon in the battle for tension-free clo-
Neurological Considerations sure is the undermining and advancing of local tissue. If the
defect is small and the tissues are flexible and well vascularized,
The sensory nerve supply of the scalp is similar to the vascular this is usually successful but if the defect is extensive and/or
anatomy in that it is centripetal, subcutaneous, and of a similar the tissues are tight, undermining alone may not suffice.
distribution. Should undermining not result in optimal closure, other mo-
Incisions in the peripheral scalp that transect vital larger dalities are available, whereby immediately adjacent tissue can
vascular and nerve trunks result in extensive, hyposthenic, be used to literally bridge the gap. These include volumetric
poorly vascularized tissues and should be avoided. Where and nonvolumetric expansion, intraoperative extension, delayed
avoidance is not possible because of the specific goals of the extension, intraoperative volumetric expansion, and delayed
contemplated surgery, a specific knowledge of the exact ana- volumetric expansion. Should these measures fail or be inappli-
692 Chapter 18
Figure 18A-3 Note relatively unsightly horizontal collagen transecting component of scar.
cable, local and/or distant transposition flaps and free flaps Materials and Methods
round out an extensive menu of reconstructive alternatives.
However impressive this array of reconstructive choices may Work commenced on cadaver scalp followed by clinical investi-
seem, all have difficulties and fall short in that none address gation of over 700 consenting patients undergoing alopecia re-
moval.
the root of the problem, i.e., tension vectors generated at wound
closure. Pericranium
In 1994, Frechet’s Extender research (12) demonstrated the
possibility of controlling tension-vectors in the tissues and It was believed that pericranium and galea aponeurotica might
prompted the surgical research project described herein. be suitable tissues on which to construct a deep plane suture
It was believed that if there were some method of channeling fixation designed to reduce the adverse impact of wound clo-
tension-vector forces from the superficial (skin) to deep plane sure-induced tension-vector forces on the tissues. As pericra-
tissues, then enhanced tissues excision and tension-reduced clo- nium is not well described in anatomy textbooks, the following
sure might be possible. Consequently, the finding of an alterna- description is believed relevant.
Pericranium is a dense membranous or fibrous sheet (Fig.
tive transmission route from that naturally occurring at the time
18A-7) loosely fused on its outer aspect to the galea aponeuro-
of wound closure became the objective. It was believed, should
tica from which it is readily separable via the subgaleal space.
this be possible in scalp reduction surgery, the relevant method- It is usually of similar thickness to galea and easily bluntly
ologies for so doing, might be applicable to surgery of the inte- dissected from the outer table of the skull as an intact sheet
gument in general. (contrary to descriptions in textbooks, which describe it as
Scalp surgery, was chosen as the experimental testing bound down and densely adherent at skull suture lines).
ground, using the operation of scalp reduction as a test model Pericranial dissection from bone is bloodless other than the
(13). occasional, easily controlled, minimal bleeding from the rare
What follows is an account of a clinical research project bone perforator. Subperiosteal stripping is simple, easily ac-
designed to complished, and safe.
Over the course of the work, multiple periosteal flaps of
1. study the tissue responses to mobilization and recon- various sizes were raised in different locations thereby denuding
struction and the outer table of the skull of periosteal cover. On re-exploration
2. determine surgical modalities that limit tension-in- months later, the denuded areas were covered with tissue indis-
duced, adverse biomechanical effects. tinguishable from pericranium.
Figure 18A-4 a) Preoperative galea fixation. b) Postoperative. Note significant bald area reduction, excellent scar, and no topographical
distortion of tissues.
694 Chapter 18
Figure 18A-7 Pericranium raised as intact membranous sheet.

Note the comparative thickness of galea aponeurotica.
Pericranial thickness varied from one individual to another

Figure 18A-5 Neurovascular anatomy. Arteries on patient’s and from one skull location to another in the same individual
right. Nerves on patient’s left. but the impression is that periosteum in the frontal areas may
be slightly thinner than in the crown.
Pericranium was capable of retaining sutures even when sub-
jected to significant tension.
Wound Anchorage to Median Pericranial Flap

In this (and all other scalp exposures described in this chapter)
a sagittal subgaleal approach was used. Undermining was done
for about 15 cm bilaterally. A midline pericranial flap, about
1.5 cm in height, was raised with a periosteal elevator, from the
anterior to the posterior limit of the wound. This was included in
the deep galeal wound closure with a continuous 2-0 Vicryl
suture (Fig. 18A-8). In this and all other procedures detailed,
two indelible tattoo marks each 10 mm from the midpoint of
the sutured wound, were made for purposes of measuring
stretch-back.
One hundred operations were done without noteworthy com-
plication. The first 25 procedures with 12 weeks or more follow-
up were analyzed. These included 11 first time reductions and
14 others with two or more conventional subgaleal procedures
done previously. In the combined group, the average bald area
removal measurement was 3.1 cm with an average stretch-back
of 13%. In the first-time cases, the average bald area removal
was 3.3 cm, with a stretch-back of 13%. Fine linear scars were
consistently achieved.
Figure 18A-6 Cross-section of scalp. Note location of subcuta- The extent of bald area removal and a stretch-back of 13%
neous vascular plexus. was consistent with that found by others and is discussed later
in this chapter.
The study’s main benefits were: 1) establishment of param-
eters of comparison for data analyzed and detailed below, and
2) the anecdotal impression that incorporating a pericranial flap
Figure 18A-8 Diagram showing sagittal pericranial flap incor-

porated into the galeal wound closure.
Figure 18A-9 Four, offset pericranial flaps constructed in cen-
tral scalp and sutured to deep lateral galeal surface.
in the deep-wound closure seemingly contributed to the produc-

tion of fine linear scars.
This latter impression formed the basis for subsequently in- is consistent with suturing without undue tension to the relevant
cluding a small periosteal flap in all scalp wound repairs (and pericranial flap (see Fig. 18A-9).
scar revision in particular) in my personal practice. This simple
innovation is highly recommended. Results
Scalp Reduction with Deep Plane Fixation Over 200 operations were done without noteworthy complica-
tion. The first 50 with a postoperative follow-up of 12 weeks
The term Deep plane fixation applies to a surgical technique or more were reviewed. All cases were first-time deep plane
that employs the strategic bilateral placement of several approx- fixation procedures with 27 having had one or more conven-
imation sutures in the undermined deep tissues, lateral to the tional scalp reductions and the remaining 23 no previous scalp
wound margins, in order to direct harmful tension vector forces surgery. In the combined group, the average bald area removal
from the superficial tissues to deeper planes, where they are was a 3.5 cm with a stretch-back of 13%. In the 23 who had
harmlessly dissipated. The term and definitive concept of deep no previous surgery, the average bald area removal was 3.9 cm
plane fixation is new to medical literature but isolated descrip- with an average stretch-back of 13%.
tions of the technique are in print (14). In this chapter the tech- Fine linear scars were consistently achieved and a further
nique of deep plane fixation, as applied to scalp surgery, is bonus was minimal postoperative pain. In all cases, a reduced-
described. Deep plane fixation is believed relevant to all surgery tension, easily closed wound was possible.
of the integument.
Stimulated by experience with the Frechet extender, but cog- Analysis
nizant of its problems associated with biological incompatibil-
ity, it was postulated that if by using endogenous tissues, the The cases chosen for comparison were first-time scalp reduc-
tension-vector forces could be directed away from areas most tions only. In those cases with the median pericranial flap proce-
susceptible to tension (i.e., tissues at and adjacent to the wound), dure and no Deep plane fixation, the bald area removal measure-
it might be possible to effect a more comprehensive bald area ment was 33 mm while those with Deep plane fixation had a
removal and a tension-reduced closure. bald area removal of 39 mm. As the only noteworthy variable
between the two groups was the Deep plane fixation in the latter
Procedure group, it was concluded that the increased bald area removal
measurement from one group to the other of 6 mm (18.2%)
The conventional sagittal excision was done together with an was due to deep plane fixation.
exclusively subgaleal dissection of about 15 cm bilaterally.
Four medially based, offset pericranial flaps were raised in Modifications
the central scalp. (Fig. 18A-9) Four individually placed 3-0
nylon sutures were placed in the deep galea, two on each side, As experience was gained, the following modifications were
as far laterally (usually about 6 cm) from the wound margin as made in an attempt to improve on the procedure just detailed.
696 Chapter 18
1. Undermining was confined to about 5 cm (instead of Discussion

about 15 cm) from the wound margin bilaterally, i.e.,
sufficient to facilitate deep plane fixation sutures. It is believed that modest judicious undermining is indispensa-
2. Deep aspect of galea, about 5 cm from the wound marble for optimal wound closure. Extensive undermining may be
gin, was sutured to pericranium without recourse to ineffectual and associated with problems (15). Undermining,
pericranial flaps (although these can be usefully em- particularly when extensive and blind, is potentially harmful
ployed in rare cases when the percranium is not well- because it
developed). 1. opens tissue planes to infection
3. Three or more 2-0 nylon sutures were placed bilaterally 2. has the potential for traumatizing blood vessels and
and under considerably more tension (but not excessive) nerves
than that was done originally, i.e., more and stronger 3. results in extensive scar formation throughout the un-
sutures under greater tension were used. dermined area
These modifications made the operation more efficient, simpler, 4. allows tension forces to be conducted into areas remote
and safer by virtue of the relatively reduced undermining. The from the wound
operation, originally named anchor scalp reduction was re-
It is also ineffectual, as explained below.
named galea fixation.
It had been personally observed, in very lax scalps, that it
Only eight cases with the modification detailed here were
was possible to remove a 5 cm width at the midsagittal ellipse
personally available to follow-up. However, a further 35 cases
level and yet easily close the wound without any undermining
using an identical technique, as described earlier, were pre-
whatsoever. Conversely, in tight scalps, removing 5 cm and
sented by Donald Hause (14a).
achieving closure would be impossible, regardless of the extent
In these combined 43 cases, the average central scalp re-
of undermining. This led to the conclusion that the more impor-
moval measurement was 3.9 cm with an average stretch-back
tant factor, by far, in determining the extent of tissue amenable
of 10%.
to excision is not the extent of undermining, but scalp laxity.
No linear relationship seems to exist between the extent of tissue
Comparative Statistics amenable to removal and the extent of tissue undermined.
Scalp reduction results are reviewed by Richard Shiell (14B). Under the heading of Materials and Methods earlier, two
A 35-mm reduction is quoted as an average for first reductions groupings of similar operations were described, one with under-
by surgeons using central or paramedian approaches and closing mining of 15 cm and deep plane fixation and the other with
under moderate tension. Allowing for Nordstrom’s 40% stretch- only 5 cm of undermining and deep plane fixation. The excision
back this reduces the worthwhile benefit to 21 mm. widths in each group were identical at 39 mm. There was no
Martin Unger, M.D., reports stretch-back to be around 10% significant difference in stretch-back. This suggested the extra
with an average excision of 24 mm in his modified major proce- undermining of 10 cm bilaterally contributed nothing in terms
dure. Dr. Nordstrom’s own figures for first time central reduc- of increase of tissue excision amounts.
tions are quoted as 36 mm with an average stretch-back of 40%, This conclusion is scientifically supported by Raposio (16)
a net gain of 22 mm. who, in an excellent paper on tensiometric measurements in
The galea fixation operation has a 39 mm reduction with a serial scalp reduction, reported ‘‘the benefits of an extensive
13% stretch-back or 34 mm gain as detailed earlier. This repre- (15 cm) undermining were minimal as compared with those
sents a net gain of over 50% compared with the scalp reduction obtained with 5 cm undermining.’’
procedures in Dr. Shiell’s analysis. Extensive undermining may also have detrimental biome-
It was concluded that deep plane fixation allowed increased chanical effects. Skin is made up of collagen, elastin, blood
tissue excision and tension-reduced closure. vessels, nerve fibers, and lymphatics with mucopolysaccharide
ground substance and tissue fluid. All these elements are af-
Addendum fected by undermining and stretching.
The ability of skin to recover from stretch resides in its
When the early phases of this work were presented at an Interna- elastin component. When skin stretches, the elastic fibers elon-
tional Society of Hair Restoration Surgery meeting some years gate in the direction of the stretching force, allowing the convo-
ago, some skepticism was expressed regarding the feasibility lutions in collagen to straighten out. The resultant elongation
of suturing galea to periosteum. Since that time several thou- is a function of progressive displacement of ground substance
sands of such sutures have been personally placed and variations and tissue fluid, which accompanies collagen realignment. This
on the technique have been used by surgeons including Bluford continues until there is a structure of parallel collagen fibers
Stough (Cosmetic Surgery Times, March 1999), Patrick Frechet that resists further extension and complies with Hooke’s Law
(personal communication) and in the series presented by Hause of Physics, which states that stress (stretch) is directly propor-
(14a). tional to the strain (elongation), provided the elastic limit is not
Even if the skepticism expressed was well founded, it does exceeded (17).
not invalidate the operation of the deep plane fixation concept, The elastic limit of skin (or any substance) is that point at
if indeed it were not possible to suture galea to pericranium, which the components commence to rupture and the stress/
an alternate fixation methodology, e.g., a small screw or some strain ratios no longer apply. It is accompanied by adverse tis-
such placed in the outer table of the skull would suffice. How- sues changes. The elastic limit for skin elastin is generally about
ever, this has never been found to be necessary in my personal 10% and that for collagen 100%. Stated differently—when skin
experience. elongates more than 10% of its resting length—the elastic fibers
rupture. The impaired elastin is now no longer able to return Summary

the collagen to its normal resting state even when stress is re-
moved. This results in permanent irremediable adverse conse- Complication-free scalp surgery is most likely when incisions
quences for the tissues called plasticization, better known to spare neurovascular structures and do not transect collagen,
surgeons as stretch-atrophy (thin, dry, brittle, poorly vascu- elastin, or hair follicles.
larized skin) commonly seen following midscalp serial scalp Deep plane fixation allows for relatively increased tissue
reduction using traction closure. Stretch-atrophied tissues are excision and reduced tension closure. As much as 50% of in-
relatively unsatisfactory for subsequent hair transplantation creased scalp tissue excision may be possible (relative to similar
(17a). procedures that do not utilize deep plane fixation).
Skin stretching also attenuates blood vessels, thereby de- Undermining beyond a certain conservative limit is ineffec-
creasing tissue perfusion, which, if allowed to continue un- tual and, if extensive, has potential for deleterious conse-
checked, will ultimately exceed the critical closing pressure and quences.
perfusion stops. Lesser degrees of stretch will reduce circula- The above conclusions were derived from studies in scalp
tion. Elongation of nerves and lymphatics causes pain and surgery but are believed relevant to all surgery of the integu-
edema, respectively (18). ment.
Non-undermined skin is better able to withstand the ill ef-
fects of tension stretching than undermined skin (19).
18B. Classification of Scalp Laxity
Practical Considerations
Rolf E. A. Nordström
In order that skin be advanced for purposes of wound closure,
the tethering structures at the wound margin should be divided. Alopecia reductions (ARs) can play a very important role in the
This, accompanied by judicious limited undermining and gentle correction of male pattern baldness (MPB). Younger patients, in
skin stretching, is the time-honored method for optimal wound particular, are a special problem in surgical hair replacement
closure. Increased undermining and stretching makes tissue because one cannot be certain how extensive the final area of
components more susceptible to the deleterious effects of stress alopecia will be. As will be noted in Chapter 19, it is, therefore,
as described earlier. With skin elongation comes loss of tissue often wise to include AR as part of the planning for the correc-
fluid, decreased tissue perfusion and adverse tissue changes. tion of vertex alopecia in young men. When planning the total
The more undermining and stretching, the greater the likelihood surgical program, it is of great value to have as accurate a
of adverse tissue consequence and, in extreme cases, necrosis. preoperative idea as possible concerning the amount of bald
Lesser degrees of stretching are conducive to stretch-atrophic area that can be removed with AR. A few patients with very
change. tight scalps are not suitable candidates for AR because only a
In order to achieve optimal tension-reduced wound closure, minimal benefit can be expected. On the opposite end of the
the following progressive steps are recommended: spectrum is an equally small group of patients with extremely
1. Divide only the tissue attachments immediately adja- lax scalps, who can have a bald area with a width of up to 14
cent to the wound. This results in a sewing edge that cm totally removed with three or four modified major ARs.
allows physical advancement of tissue and a small Most patients fall between these two extremes.
amount of skin amenable to gentle stretching. (The After performing many modified major ARs, one gains a
wound margins are physically lifted into the defect feeling for the amount that can be excised in each patient by
rather than stretch-advanced into it). This alone may pinching the bald area between the fingers to see how much it
allow easy closure if the tissues are reasonably elastic can be compressed. It is very difficult to give the beginner very
and the defect is not too large. exact advice on this estimation. As a rough guide, if one uses
2. Progressively undermine small increments of tissue at a sagittal-midline excision, an experienced surgeon can expect
the wound periphery while testing for closure after each to remove an average of 3.5 cm in the first AR, about 3.0 cm
increment of undermining. After a few centimeters of in the second, and 2.5 cm in the third. Substantially better results
undermining (about 5 cm in the case of scalp reduction, can be expected if you employ scalp extenders (see Chapter
much less in donor area closure) have been done, further 20).
undermining is not recommended and is likely to be Bosley has advised a system of placing two small dots with
nonproductive and/or harmful. It is necessary to resist a marking pen on the scalp 10 cm apart, spanning the width of
the temptation to engage in extensive, ineffectual, and the area to be excised (1). The skin between the dots is com-
potentially dangerous undermining. pressed medially from the sides with both thumbs and both
3. Should Step 2 still not allow for tension-reduced wound index fingers. The reduced distance is then measured. As a
closure, a simple deep plane fixation technique may be general rule, he found that when using a midline sagittal AR
used to divert tension away from the superficial tissues pattern, he could expect to obtain a reduction of twice that width
and allow tension-reduced closure. This technique is at its widest point.
described earlier as galea fixation and a variation of this He also divided patient scalp laxity into five classes. Class
can be done in most cases with a little ingenuity on the I has a scalp that was compressible between the dots by less
part of the surgeon. See deep plane fixation donor area than 0.5 cm. This type of scalp was so tight that it was usually
closure in Chapter 10. thought to be a contraindication to AR. Class II has a scalp that
4. Tissue expansion, etc., skin grafts, and flaps are proce- was compressible by 0.5 cm to 1.0 cm. This was still somewhat
dures of last resort. less than the average. Class III was compressible by 1.0 cm to
698 Chapter 18
1.5 cm. This is the most common class. During compression,

the skin forms a gentle double-wavelike pattern. The sides of
the two wavelike folds do not touch. In this group of patients,
he usually obtained a reduction of approximately 3.0 cm. Class
IV was compressible by 1.5 cm to 2.0 cm. Class V was com-
pressible by more than 2.0 cm. In this class, up to 5.0 cm could
sometimes be excised with a single procedure.
AR can be performed in a variety of patterns, with or without
prior tissue expansion or extension. In addition, the skill of the
surgeon and the time interval between the AR is important.
Most of the remodeling of the scalp takes place within 6 weeks.
18C. The Science of Skin Stretch and

Tissue Expansion
James E. Vogel Figure 18C-1 An electron micrograph of an arteriole in the
dermis. When the surrounding collagen fiber network is deformed,
the lumen may become obliterated, producing ischemia, skin
INTRODUCTION blanching, and possibly necrosis. (From Ref. 17.)
As physicians performing hair replacement surgery, in particu-
lar using the techniques of tissue expansion and scalp advance-
ment, it is incumbent on us to critically review the anatomical larly, nerve constriction, transections, or scar entrapment may
basis and scientific data available on these techniques. This is cause pain or anesthesia. Interruption of lymphatics or oblitera-
necessary so that traditional modalities and new advances in tion results in edema. In addition, the fibrous networks of the
tissue expansion can be used both effectively and with maxi- scalp are transfixed by hair shafts (Fig. 18C-2). This partly
mum safety. explains the relative immobility of scalp dermis compared with
The concept of expanding skin was used for the first time other areas of the body. Hair shafts are surrounded by follicles
in medicine by Neumann (26). Little attention was focused on and sebaceous glands, which are attached to the main collagen
the applications of tissue expansion until Radovan, in 1976, network by fine fibrils. The elastin fibers and collagen network
reintroduced the concept and began using it successfully in are the principal elements responsible for skin stretch.
breast reconstruction (33,34). Austad, Cherry, Sasaki, and oth-
ers in the 1980s, pioneered applications of conventional tissue
expanders and described the histology of expanded tissue LONG-TERM (TRADITIONAL) TISSUE
(3–5,12,35). Until 1984, most reports on the use of tissue expan- EXPANSION
sion employed two operative procedures and an inflation time
Epidermis
ranging from 4 to 10 weeks (13). In 1987, Sasaki and others
demonstrated that, for selected cases, intraoperative tissue ex- Analysis of multiple sites of skin overlying an expander reveals
pansion was a variable alternative to conventional expansion no significant variation in epidermal thickness during tissue
techniques (25,29,35). Recently, a variety of skin-stretching de-
vices and clinical applications have been developed to immedi-
ately harness the viscoelastic properties of skin (6,14,19,22,24)
Other new techniques have been developed to dramatically re-
duce the time needed for skin expansion or to monitor the effects
of expansion (7,10,18,28) The concepts of rapidly expanding
skin for surgical maneuvers are currently of worldwide interest
(21).
ANATOMY AND PATHOPHYSIOLOGY OF

STRETCHED SKIN
To appreciate what is accomplished in the operating room using
tissue stretch and expansion techniques, it is crucial to under-
stand the induced anatomical and histological changes. These
have practical and critical everyday implications to clinical
practice. As seen in Figure 18C-1, a small arteriole is coursing
through the dermis. When the fibrous network is deformed Figure 18C-2 An electron micrograph of a hair shaft sur-
through stretch or excessive tension, the lumen may become rounded by its follicle and sebaceous gland. They are shown at-
compressed and lead to telogen effluvium. If the lumen is oblit- tached to the main collagen network by fine fibrils. (From. Ref.
erated, there will be blanching and, ultimately, necrosis. Simi- 17.)
expansion (2,8,32). One week after placement of the prosthesis, of the expander and subsequent weight gain. Significant atro-
some thickening may occur in the epidermis, but this also occurs phy of muscles also occurs during the process of tissue
in sham-operated controls. The increased thickness probably expansion (see Fig. 18C-3). This effect is evident whether
represents postoperative and localized edema. By 4 weeks after the expander is placed above or below the muscle. Muscle
placement of the prosthesis, epidermal thickness decreases to its function, however, remains active, and after removal of the
normal baseline and essentially remains unchanged throughout expander muscle mass is diminished but maintains the ability
expansion (Fig. 18C-3). Accessory skin structures, such as hair to hypertrophy with use.
follicles, show some degree of compression in the anteroposter-
ior plane. The interfollicular distance increases as the tissue is
expanded. It has been estimated that a twofold expansion in Capsule
average hair-bearing scalp is necessary before a clinically no-
A distinct capsule forms around the expander (see Fig. 18C-3)
ticeable thinning of the hair begins.
and an increased vascular network develops in the area adjacent
Dermis to the capsule. The augmented blood supply around the peri-
prosthetic capsule is a physiological and anatomical change in
In contrast with the epidermis, there is rapid decrease in dermal the tissue induced by the expander and the expansion process.
thickness over the entire implant during the expansion process The presence of a foreign body, increased tissue tension, and
(2,8,33). This effect is most pronounced during the first few ischemia are thought to bring about this physiological increase
weeks after implant placement and persists throughout the entire in blood supply. The increased blood supply in the capsule
period of tissue expansion. Restoration of preexpansion dermal supports the surgical dogma of including this layer with the
thickness occurs after the implant is removed. This can take up scalp flaps. An x-ray of barium injected into the blood vessels
to 2 years. of an expanded and nonexpanded flap reveals the dramatic in-
crease in vascularity of the tissue-expanded flaps (Fig. 18C-4).
Muscle and Fat
Although injection studies have not been performed on the scalp
Considerable compression and some obliteration of fat occur above the tissue extender (see Chapter 20), it is likely that a
with tissue expansion. This is quickly restored after removal capsule, rich in neovascularization, also develops here as well.
Figure 18C-3 A low-power view of tissue over an implant at 4 weeks demonstrating (1) intact, normal stratified squamous epithelium,
(2) slight compression of hair follicles, (3) moderate atrophy of the panniculus carnosus muscle, and (4) a well-formed fibrous connective
tissue capsule. Normal nonexpanded tissue. Note the thickness of the panniculus carnosus muscle compared with that of the treated animal
on the left (200 X). (From Ref. 2.)
700 Chapter 18
Figure 18C-4 An x-ray of barium-injected vessels of (A) a nonexpanded random pattern, pigskin flap and (B) a matched skin flap
that underwent tissue expansion. Note the dramatic increase in vascularity of the expanded flap. (From Ref. 2.)
Electron Microscopy classic work entitled Tissue Expansion: Dividend or Loan (5) ?
Research was first performed using guinea pigs, in which tissue
In 1982, Pasyk and Austad performed electron microscopic expanders were inflated on a daily basis for 4 weeks. By using
studies of expanded tissue in the guinea pig (31). Their work light microscopy and autoradiography with tritiated thymidine,
has described skin expansion at the electron microscopic level. they showed a threefold increase in mitotic activity within 24-
Active fibroblasts, with prominent rough endoplasmic reticu- hours after tissue expansion, compared with unoperated con-
lum and mitochondria, are identified in the expanded dermis trols. This was the first conclusive evidence to document the
(Fig. 18C-5). New immature collagen fibers of differing size biological origin of expanded tissue. This origin was from a
are present as well. The presence of active fibroblasts in the net increase in cellular proliferation, a true tissue dividend (Fig.
expanded dermis is important. They are believed to be directly 18C-6).
related to the origin of the immature collagen fibers that are The first conclusive evidence that this phenomenon of cellu-
present. lar proliferation existed in humans was only recently demon-
strated. In 1993, workers from Sweden documented an in vivo
increase in DNA synthesis in expanded human epidermal cells
ORIGIN OF SURPLUS SKIN (TRADITIONAL (31). The light micrografts shown in Fig. 18C-7 reveal the sig-
EXPANSION AND SKIN STRETCH) nificant milestone achieved by these workers defining the
A fundamental question in a discussion of stretched or expanded human response to tissue expansion. Although this analysis has
skin is ‘‘Where does this skin actually come from?’’ never been performed on a human scalp, there is no reason to
believe that the pathophysiology of expanded scalp would be
different from other areas of the body skin.
A Biological Origin
Proliferation A Mechanical Origin
The presence of active fibroblasts and other histological clues
were available to suggest the origin of expanded skin during Recruitment of Tissue-Expanded Skin
the early 1980s. However, the evidence remained circumstantial The tissue dividend, as a result of expansion over time, explains
until 1986, when Austad, Thomas, and Pasyk published the only one component of the added availability of chronically
Figure 18C-5 Electron micrograph of eight-month-old guinea pig expanded skin. Note the following: (1) part of a fibroblast with
prominent rough endoplastic reticulum (er), (2) numerous mitochondria (m), (3) Golgi (g), (4) pinocytotic vesicles (arrows), (5) nucleus
(n), and (6) collagen fibers (c). The presence of active fibroblasts in the expanded dermis is significant. They are believed to be directly
related to the origin of new collagen. (From Ref. 31.)
stretched skin. The other component is tissue recruitment. The

contribution of tissue recruitment to the overall expansion pro-
cess is best understood diagrammatically (Fig. 18C-8). Sur-
rounding loose skin is recruited by two processes. These are
the undermining needed to place the implant and the dissection
of the advancing expander itself as the implant volume in-
creases. Thus, recruitment (mobilized tissue) and increased mi-
tosis are the two primary mechanisms to provide increased
availability of tissue with expansion of tissue over time. Me-
chanical creep (defined later) also contributes to the recruitment
of available tissue with traditional methods of tissue expansion.
INTRAOPERATIVE TISSUE STRETCH (OR

EXPANSION)
Mechanical Origin
The Viscoelastic and Other Biomechanical Properties
of Skin
In the past several years, a popular method for obtaining addi-
tional transferable hair-bearing scalp is to apply intraoperative
stretch of the tissues or immediate tissue expansion. The acute
gain in tissue availability through these maneuvers is possible
because of the physical properties of skin. The viscoelastic
properties of skin are the biomechanical elements primarily re-
sponsible for intraoperative expansion and rapid stretch of skin.
These dynamic and physical properties of skin have direct clini-
cal applicability to every flap or advancement procedure that
has been performed on, or designed for, the scalp. Anatomically,
the ability of skin to stretch rapidly depends primarily on the
fibrous networks and architecture of collagen and elastin. The
scanning electron micrograph (Fig. 18C-9) clearly defines the
structure of collagen fibers in the dermis. The fibers are long,
compared with their diameter, and they appear to be randomly
oriented.
When skin is stretched in any direction, an increasing num-
Figure 18C-6 First documentation of the biological origin of ber of collagen fibers become aligned in the direction of the
traditionally expanded skin (guinea pig). Tritiated thymidine label- stretching force. When increasing stretch, the collagen fibers
ing of unexpanded (a) and expanded (b) epidermis (H&E X 400). align in a parallel fashion (Fig. 18C-10). Once the collagen
Note the dramatic increase in the uptake of thymidine, indicating fibers have fully realigned themselves parallel to the forces of
an increased rate of mitosis in expanded epidermis. (From Ref. 2.) pull, the skin is said to have reached its maximum degree of
702 Chapter 18
Figure 18C-7 The first documented human response to tissue expansion reveals increased numbers of cells incorporating tritiated
thymidine (b) compared with nonexpanded skin (a). (From Ref. 30.)
elastic stretch. At this point, the skin is highly resistant to further

extension. This is an irreversible process called creep (see later).
If the stretched tissue is not pulled to the degree seen in the
electron micrograph, the skin is said to have been stretched
within the range of its elasticity. Here, maximum stretch has
not been achieved (i.e., creep has not occurred), and the change
is reversible, since stretch-back or recoil of the collagen can
occur. The amount of recoil or stretch-back that occurs will
depend on a host of factors. These include tension on the suture
line, methods of closure, the presence or absence of wound
healing problems, and so on. The return of the deformed colla-
gen to its relaxed position after sudden stretch is the job of the
much finer elastin fibers. If the skin is stretched further than
its maximum degree of elastic stretch, the collagen ruptures
and, clinically, stria will result. It is well known from clinical
and daily observation that the existence of stria is an irreversible
phenomenon.
Figure 18C-9 An electron micrograph of the collagen fibers
Physical Properties of Creep, Stress Relaxation, in human dermis. Note the fiber length, compared with their diame-
Tissue Dehydration, and Load Cycling ter, and the random orientation. (From Ref. 17.)
Creep and stress relaxation were first described by Gibson in
1967. Creep occurs when a piece of skin is stretched and the
stretching force is held constant. Stress relaxation is the biome-
chanical reaction to creep. When skin is stretched for a given
Figure 18C-8 The contribution of tissue recruitment to the

overall process of tissue expansion is seen diagrammatically. The
dotted area represents the region in which the expander exerts its Figure 18C-10 An electron micrograph of collagen fibers in
influence through cellular proliferation. The hatched area repre- stretched skin. Note their straight alignment in the direction of
sents the phenomenon of the enlarging expander itself contributing stretch. This orientation places a limit on the skin extensibility in
to the recruitment process. (From Ref. 36.) the direction of pull. (From Ref. 17.)
distance and that distance is held constant, the force required

to keep it stretched gradually decreases. The decrease in force
needed to maintain the increased length of stretched tissue is
the definition of stress relaxation (Figs. 18C-11 & 18C-12).
The mobile micro-architecture of skin and scalp that favors
the phenomenon of creep requires an internal lubricant. This
lubricant is provided by the mucopolysaccharide ground sub-
stance and the tissue fluid lying between the collagen fibers.
As the tissues are stretched, the tissue fluid and ground sub-
stance are progressively displaced from the fibrous collagen
network. This dehydration process is another mechanism re-
sponsible for increasing skin length with acute (e.g., immediate)
stretch.
Creep and stress relaxation have traditionally been important
in the operating room while closing donor scalp defects and
advancing wound edges when one is faced with a wound that
just will not close easily. The usual technique for employing
these viscoelastic properties of skin is familiar to most surgeons
and is referred to as load cycling. The procedure of load cycling
involves placing the sharp hook of a retractor under the dermis
of each flap to be advanced, and these flaps are then pulled in
opposite directions. The pull usually lasts for at least a minute
and is frequently cycled several times. On a microscopic level,
the technique aligns the dermal collagen fibers. The tissue fluid
and ground substance lying between the collagen fibers are
progressively displaced from the fibrous network. This tissue
dehydration process and realignment of the collagen fibers is Figure 18C-12 Stress relaxation is a natural sequela of creep.
maximized by performing the procedure three or four times. When skin is stretched for a given distance and that stress is held
The scientific rationale for the technique of load cycling has constant, the force required to maintain that stress gradually de-
creases. Clinically, this is seen in scalp flaps that initially seem too
tightly sutured and later seem to have ‘‘relaxed.’’ (From Ref. 17.)
been substantiated in the laboratory and is based on the princi-

ples of creep and stress relaxation. As seen in the strain (creep)
vs. stress graft (see Fig. 18C-11), by the third or fourth stress
application (e.g., pull) more tissue length (e.g., creep) is ob-
tained given a constant stress. The process of stress relaxation
and load cycling are the fundamental scientific elements on
which a recently described skin-stretching device is based (19).
Stretch-Back
Although the immediate stretch of scalp can produce dramatic
intraoperative reduction in alopecia, the long-term gain can be
reversed if stretch-back of advanced flaps occurs. A seemingly
endless clinical debate over the existence of stretch-back has
occurred during the past 10 to 15 years. Studies by Nordström
and others have addressed this issue and report significant loss
of gained tissue advancement with rapid skin stretch. (29).
However, reports by Unger have sharply refuted the finding of
major stretch-back after flap advancement with scalp reduction
(37,38). Stretch-back is a clinical term, and no one scientific
Figure 18C-11 Tissue creep occurs when a piece of skin is element defines this phenomenon or measures it. Clearly, the
stretched and the stretching force is held constant; the skin contin- degree of collagen fiber realignment, degree of skin stretch
ues to extend. The scientific basis of tissue creep explains the ra- within its range of elasticity, extent of tissue dehydration, local
tionale for the technique of load cycling. As skin pull (stress) is scar widening, and final wound tension, all contribute to the
cyclically applied to the same or greater degree, additional length tendency toward stretch-back of advanced flaps. The most im-
(strain, creep) is obtained. (From Ref. 17.) portant component to the equation determining the extent of
predicted stretch-back has not yet been scientifically scruti-
704 Chapter 18
nized. However, clinically reduced intraoperative wound clos-

ing tension seems to be a crucial factor.
To minimize stretch-back of extensively advanced scalp
flaps, one author has employed a retaining strip of Alloplast to
connect the two leading edges of the flaps (19). However, it
remains to be shown whether higher wound-closing tensions
seen with extensive flap advancement supported with Alloplast
can counter the unrelenting forces of recoil over time.
The concept of stretch-back in permanently expanded skin
has been studied recently in laboratory experiments (11). The
presence of fibroblasts and their contribution to collagen syn-
thesis in expanded skin is significant. This observation led
Chang and others to ask: ‘‘Does tissue expansion alter dermal
fibroblast function, and does the duration of tissue expansion
alter the degree of fibroblast contractility and anticipated
stretch-back?’’ Their findings in a rat model showed what clini-
cal surgeons have observed for years, namely, that tissue expan-
sion inhibits the in vitro contractile function of dermal fibro-
blasts in a time-related fashion. This is the first scientific study
that provides support, on a cellular level, for the clinical impres-
sion that a longer duration of skin expansion may result in less
stretch-back.
ANALYSIS OF SKIN STRETCH AND

EXPANSION TECHNIQUES
Techniques for stretch in skin or scalp are most logically ana-
lyzed based on the length of time needed to accomplish the
procedure.
Prolonged (Traditional) Tissue Expansion

In clinical practice, the greatest deterrent to the use of traditional
methods of tissue expansion is the poor patient acceptance of Figure 18C-13 An increase in the mitotic rate of epidermal
the time required and the deformity of the procedure. From a cells occurs 12 to 24 hours after tissue expansion (arrows). With
purely reconstructive standpoint, traditional methods of scalp deflation of the implant, a significant decline in the rate of epider-
mal mitosis below baseline is also noted. The mechanism of action
expansion over time offer unparalleled flap mobility, improved
for increased proliferation is not defined. (From Ref. 2.)
vascularity, and decreased donor site complications, when com-
pared with the techniques of immediate tissue stretch. However,
given the realities of what most patients are willing to go
through, workers have investigated these questions: 1) How
long does tissue need to be expanded, in order to develop addi- cians (including Nordström) had observed in their practice for
tional new skin? 2) What techniques improve the efficiency of years (36). Schmidt noted that rapid expansion over 2 weeks
expansion? 3) What is more important, wide undermining or could duplicate the results of traditional expansion over 6
intraoperative expansion? weeks. This research was significant because it scientifically
Experimentally, it appears that the peak of cell multiplication documented, for the first time, the ability to gain new tissue
following expansion occurs between 12 and 24 hours after the using a shortened expansion time span.
expansion process (1,2,4,5,26) (Fig. 18C-13). This is an impor- In a later study, Wee et al. used a new concept of tissue
tant laboratory finding when one is trying to determine clinically expansion, which is still experimental, but may find clinical
how fast tissue expansion can be performed and still obtain a applicability (Fig. 18C-14). They used an implantable, continu-
true increased cellular proliferative response to expansion. ous tissue expander pump to demonstrate expansion in 3 days
In 1986, Nordström and Pietila demonstrated clinically that equal to that obtained in their earlier experiments over 2 weeks
a 59% increase in the filling volume per filling session could (30). This new concept of tissue expansion employs a micropro-
be achieved by a temporary over-inflation of the expander in cessor controller with a feedback loop to adjust the pressure in
each session to a point at which the overlying tissues were the expander on a continuous basis to maintain expander pres-
blanching, or the patient could not stand any higher pressure sure just below capillary-filling pressure. Most intriguing was
due to pain (32). This resulted in a corresponding increase in that collagen synthesis (and cellular proliferation) and other
the speed of total expansion. Other workers have made this biological characteristics of the skin were equal over a 3-day
same observation (21). Experimental, histological, and labora- expansion period to those occurring over the more traditional
tory data have been published to substantiate what many clini- 6-week period of expansion. In theory, this technique might
provided by tissue recruitment from the mechanical dissection

and immediate tissue stretch of the expander. It is not known
whether this increase in obtainable surface area by massive
hyper-expansion is a reversible (i.e., temporary) phenomenon
(i.e., loan), or whether, in fact, this is a durable gain in tissue.
Another relevant issue for the practitioner is whether massive
and rapid tissue expansion would be tolerated by the patient.
Immediate Expansion and Stretch

It has been shown experimentally that intra-operative expansion
and stretch provide a more efficient immediate gain in tissue
length than load cycling or unidirectional stretching techniques
(35). This does not negate the validity of load cycling as a
technique but merely elucidates the improved three-dimen-
sional efficiency of intraoperative tissue expansion. Investiga-
tors in Israel have developed a skin-stretching device that can
be used preoperatively or intraoperatively to presumably har-
ness the viscoelastic properties of skin (19). Frechet has used
an elastic extender to harnesses the biological properties of skin
to internally advance scalp flaps (15). The prime advantage of
internal, unidirectional scalp stretch over time is the absence
of the cosmetic deformity of tissue expanders. At this time, the
principal appeal of his technique rests in high patient accep-
tance, early reports of substantial tissue stretch, and low morbid-
ity (Chapter 20a).
A controversy exists over the relative importance of under-
mining vs. the direct benefit of the intraoperative expansion
process. Different centers have independently evaluated this
question and suggest that extensive undermining of tissue
equals the benefit of reducing wound tension as a result of
intraoperative expansion (20,23). These scientific findings sup-
Figure 18C-14 An experimental continuous tissue expander port the clinical experience that extensive undermining of the
pump that has dramatically shortened the time needed for tissue scalp has significant value in gaining flap. Undermining ad-
expansion. This technique employs a microprocessor controller to vancement flaps or stretching them with an expander are two
maintain a constant infusion pressure over a period of days. (From techniques that can be used by the hair and scalp surgeon, ac-
Ref. 36.) cording to the clinical situation and location of the tissue to be
advanced. The surgeon’s experience, the nature of the alopecia
reduction, and the patient’s desires should be the guide to the
preferred method of tissue advancement and stretch.
allow hair and scalp surgeons to harness the benefits of tradi-
tional expansion in only 3 days and, thereby gain greater patient
CONCLUSION
acceptance. Other methods for improving the efficiency of tis-
sue expansion have been attempted experimentally or in clinical The fundamental ability for skin to stretch is witnessed on a
practice. daily basis. Consider the expanding abdominal skin during
One of the fundamental questions concerning tissue expan- pregnancy or the expansion of female breast skin during adoles-
sion that still remains is the relative contribution of the various cence. Surgeons of many disciplines have used this ability of
mechanisms to the overall expansion process. It will be recalled skin to care for their patients’ needs. Most likely there is a larger
that two primary mechanisms are involved with traditional tis- role for scalp advancement and reduction. Scalp techniques on
sue expansion techniques. These are cellular proliferation and tissue expansion and scalp stretch have far exceeded the number
tissue recruitment. By using traditional expansion techniques, of scientific reports on this topic.
it has been estimated that new tissue proliferation contributes As hair replacement surgeons employing techniques of tis-
40% to expanded skin, whereas recruitment (undermining and sue expansion and other forms of scalp stretch, it is incumbent
mechanical tissue creep) constitutes 60%. on us to fully understand the rationale and proven scientific
The increasingly important role of undermining and tissue basis for the techniques we use. This will allow us to safely
recruitment with traditional expansion was emphasized in 1993 employ the technology and develop a scientific basis for future
by Fukuta et al (16). Fukuta and his co-workers used a dog advances and improved patient care.
model to show a more efficient and rapid expansion of available
tissue over time but found that no increase in tissue proliferation Editor’s Comment
occurred in the hyper-expanded animals. All additional surface Vogel reviews Nordström’s and Pietila’s studies with soft tissue
area that was gained by rapid and massive hyper-expansion was expanders that found that a 59% increase in the filling volume
706 Chapter 18
per session—a point at which the overlying skin blanched or 18. Gibson T. Physical properties of skin. In Reconstructive Plastic
pain was excessive—resulted in a substantially faster expansion Surgery Converse JM, ed. Philadelphia: WB Saunders, 1977:70.
19. Gibson T. Physical properties of skin. In Reconstructive Plastic
(1). Using this approach, Schmidt et al. have accomplished in
Surgery Converse JM, ed. Philadelphia: WB Saunders, 1977:74.
2 weeks what traditional expansion techniques can achieve only
after 6 weeks (2). What is even more impressive is their experi-
mental use of an implantable continuous tissue expander pump Classification of Scalp Laxity
that can achieve the same results in 3 days! Collagen synthesis,
1. Bosley LL. Reduction of male pattern baldness in multiple stages:
cellular proliferation, and other biological characteristics of the
A retrospective study. J. Dermatol. Surg. Oncol 1980; 6:498.
skin were also equal to that seen after 6 weeks of traditional
expansion. If 3 days of expansion—even if it requires hospitali-
zation and/or moderate amounts of analgesic—can consistently The Science of Skin Stretch and Tissue Expansion
produce results as good as that previously seen after 6 weeks
of traditional treatment, much of patient and physician reluc- 1. Argenta L. Controlled tissue expansion. Surg. Rounds Feb 1986:
65–86.
tance to utilize tissue expansion and AR for male pattern bald- 2. Argenta L, Austad E. Principles and techniques of tissue expan-
ness will have been eliminated. This is an extremely important sion, in Plastic Surgery McCarthy J, ed. Philadelphia: WB Saun-
yet, thus far, inadequately explored area for additional clinical ders, 1990:475–507.
studies. (WU) 3. Austad E. Complications of tissue expansion. Clin. Plast. Surg
1987; 3:549–550.
4. Austad E, Pasyk K, McClatchey K, Cherry G. Histomorphologic
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10. Toshitani S. A new apparatus for hair growth in male pattern 72:680–685.
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11. Goldman B. Transcutaneous PO2 of the scalp in male pattern structive surgery. Contemp. Surg 1987; 30:21–31.
baldness: A new piece of the puzzle. Plast. Reconstr. Surg 1996; 14. Ehlert T, Thomas J. Rapid intraoperative tissue expansion for
97:1109. closure of facial defects. Arch. Otolaryngol. Head Neck Surg
12. Frechet P. Scalp extension. J. Dermatol. Surg. Oncol 1993; 10: 1991; 117:1043–1049.
616–622. 15. Frechet P. Scalp extension. J. Dermatol. Surg. Oncol 1993; 19:
13. Seery GE. Anchor scalp reduction. Dermatol. Surg 1996; 22: 616–622.
1009–1013. 16. Fukuta K, Jackson I, Noreldin A, Pieper D. Efficacy of cycled
14. Millard DR. Scar repair by double-breasted principle. Plast. Re- hyperinflation for rapid tissue expansion. Plast. Reconstr. Surg
constr. Surg 1970; 45:616. 1993; 91:846–852.
14a. Hause D. Anchor scalp reduction revisited. International Society 17. Gibson T. Physical properties of skin. In Plastic Surgery McCar-
of Hair Restoration Surgery: Hawaii, 2000. thy J, ed, W B Saunders 1990:207–220.
14b. Shiell R. Alopecia reduction revisited. Hair Transplant Forum 18. Hallock G, Rice D. Increased sensitivity in objective monitoring
International 1996; 6:2. of tissue expansion. Plast. Reconstr. Surg 1993; 84:561–569.
15. Field LM. Regarding tissue expansion and limited or wide under- 19. Hirschowitz B, Lindenbaum E, Har-Shai Y. A skin stretching
mining. J. Dermatol. Surg 2001; 27:323. device for the harnessing of the viscoelastic properties of skin.
16. Raposio R, Santi L, Nordström REA. Serial scalp reductions: a Plast. Reconstr. Surg 1993; 92:260–270.
biomedical approach. Dermatol. Surg 1999; 25:210–214. 20. Hochman M, Branham G, Thomas R. Relative effects of intraop-
17. Edsberg LE. Mechancial Properties of human skin subjected to erative tissue expansion and undermining on wound closing ten-
static versus cyclical normal pressure. J. Rehab. Res. Dev 1999; sions. Arch. Otolaryngol. Head Neck Surg 1992; 118:1185–1187.
36:2. 21. Machina B, Shindo M, Sasaki G, Rice D, Chandrasoma M. Imme-
17a. Starnes W. Hair growth in scalp reduction scars. Hair Transplant diate versus chronic tissue expansion. Ann. Plast. Surg 1991; 26:
Forum 1994; 4:1. 227–232.
22. Mackay D, Saggers G, Kotwal N, Manders E. Stretching skin: 33. Radovan C. Breast reconstruction after mastectomy using the
Undermining is more important than intraoperative expansion. temporary expander. Plast. Reconstr. Surg 1982; 69:195–208.
Plast. Reconstr. Surg 1990; 86:722–730. 34. Radovan C. Tissue expansion in soft tissue reconstruction. Plast.
23. Man D. Stretching and tissue expansion for rhytidectomy: An Reconstr. Surg 1984; 74:482–492.
improved approach. Plast. Reconstr. Surg 1989; 84:561–569. 35. Sasaki GH. Intraoperative sustained limited expansion (ISLE) as
24. McCauley R, Oliphant J, Robson M. Tissue expansion in the an immediate reconstructive technique. Clin. Plast. Surg 1978;
correction of burn alopecia: Classification and methods of correc- 14:563.
tion. Ann. Plast. Surg 1990; 25:103–115. 36. Schmidt S, Logan S, Hayden J, Ahns N, Mustoe T. Continuous
25. Mustoe T, Bartell T, Garner W. Physical, biomechanical, histo- versus conventional tissue expansion: Experimental verification
logic and biochemical effects of rapid versus conventional tissue
of a new technique. Plast. Reconstr. Surg 1991; 87:10–15.
expansion. Plast. Reconstr. Surg 1989; 83:687–691.
26. Neumann CG. The expansion of an area of skin by progressive 37. Unger MG, Unger WP. Allopecia reduction. In Hair Transplanta-
distension of subcutaneous balloon. Plast. Reconstr. Surg 1957; tion Unger WP, ed. New York: Marcel Dekker, 1979:102–108.
19:124. 38. Unger MG. 1979.
27. Netscher D, Spira M, Peterson R. Adjunctive agents to facilitate 39. Kolk C, McCann J, Knight K, O’Brian B. Some further character-
rapid tissue expansion. Ann. Plast. Surg 1989; 23:412–416. istics of expanded tissue. Clin. Plast. Surg 1987; 14:447–453.
28. Nordström R, Devine J. Scalp stretching with a tissue expander 40. Wee SS, Logan SE, Mustoe T. Continuous versus intraoperative
for closure of scalp defects. Plast. Reconstr. Surg 1985; 75: expansion in the pig model. Plast. Reconstr. Surg 1992; 90:
587–591. 808–814.
29. Nordström R. ‘‘Stretch-back’’ in scalp reductions for male pattern
baldness. Plast. Reconstr. Surg 1984; 73:422–426.
30. Olenius M, Dalsgaard C, Wickman M. Mitotic activity in ex- Editor’s Comment
panded human skin. Plast. Reconstr. Surg 1993; 91:213–216.
31. Pasyk K, Austad E, McClatchey K, Cherry G. Electron micro-
scopic evaluation of guinea pig skin and soft tissues ‘‘expanded’’ 1. Pietila J, Nordström R, Virkkunen P, Voutilainen P, Rintala A.
with a self inflating silicone implant. Plast. Reconstr. Surg 1982; Accelerated tissue expansion with the ‘‘overfilling’’ technique.
70:37–45. Plast. Reconstr. Surg 1986; 81:204–207.
32. Pietila J, Nordström R, Virkkunen P, Voutilainen P, Rintala A. 2. Schmidt S, Logan S, Hayden J, Ahns N, Mustoe T. Continuous
Accelerated tissue expansion with the ‘‘overfilling’’ technique. versus conventional tissue expansion: Experimental verification
Plast. Reconstr. Surg 1986; 81:204–207. of a new technique. Plast. Reconstr. Surg 1991; 87:10–15.
19
Alopecia Reduction Procedures
Introduction to Alopecia Reduction viability and sensation. The longer and more peripheral the inci-
sion, the more damage inflicted. Major reductions or scalp lift-
Gerard E. Seery ing procedures are particularly culpable in this regard.
Compound incisions (Mercedes star, Y, T, etc.) are poorly
The goal of maximum tissue removal, although unquestionably compatible with the criteria. The central lazy-S incision, while
important, must be tempered by the realization that an overly more acceptable than compound incisions, produces more scar-
aggressive approach may result in irremediable adverse conse- ring than the simple vertical incision because of its relatively
quences to scalp viability. An alopecia reduction (AR), for ex- increased length and a degree of directional incompatibility with
ample, that successfully removes a generous amount of bald- skin-tension lines.
ness, but leaves in its wake a poorly sensate, partially
devascularized, stretch-atrophied and/or badly scarred scalp, is
a poor trade-off for a mere reduction in the size of the bald MOBILIZATION
area. AR, a cosmetic procedure, should be accomplished with- Mobilization is, essentially, a synonym for tissue undermining.
out significant complications or none at all. All excisional surgery creates a defect that is normally recon-
Four chapter sections, (19A, B, C, and D), have been contrib- structed by advancing and/or stretching adjacent tissue. Modest
uted by four different surgeons, each of whom discusses his undermining safely and efficaciously facilitates this. Extensive
own individual approach to AR. The procedures described have undermining, however, is associated with a multitude of prob-
in common the three basic modalities of surgery, namely, inci- lems—particularly in scalp surgery. Undermining, in general,
sion/excision, mobilization, and wound closure, but differ sig- opens up tissue planes to infection; predisposes to nerve, as
nificantly in the details of how these modalities are applied. well as blood vessel damage and bleeding and produces scar
Rather than attempt to influence the reader with regard to the tissue throughout the area undermined. Moreover, there is com-
relative merits of the various approaches, a set of criteria be- pelling experimental and clinical data to suggest that extensive
lieved to be generally compatible with the most optimal out- undermining is an ineffectual modality for maximal excision
come, is detailed in this commentary. It is hoped that, by using of tissue (1–3). The scalp is especially adversely affected by
these criteria, practitioners may be better able to evaluate for extensive undermining. Scalp has, throughout its greater extent,
themselves the data set forth in each of those sections. a subgaleal space which houses a layer of fibro-areolar tissue
that allows the scalp to slide or glide in all directions on the
INCISIONS underlying periosteum. This gliding phenomenon allows
wounds to be reconstructed with negligible trauma or distortion
Incisions should be few, short, directionally compatible with to scalp tissues via simple non-traumatic tissue movement.
both skin tension (Langer’s lines), and hair orientation patterns Gliding, coupled with gentle stretching, is the standard surgical
and also transect as little neurovascular architecture as possible. modality with which scalp defects are reconstructed.
The midline or sagittal incision comes closest to compati- Scalp undermining is effected in the subgaleal layer. Signifi-
bility with these criteria. The advisability of making few and cant and uncomplicated undermining can also be carried out in
short incisions requires no explanation. Incisions that cut across the subpericranial plane but this is seldom done. Unfortunately,
collagen bundles and elastin result in collagen transection scar- undermining defiles the subgaleal plane by producing a layer
ring. Incisions that follow hair orientation patterns avoid follicu- of scar tissue in this hitherto virginal space, thereby limiting
lar transection. Scalp neurovascular anatomy is comprehen- or eliminating the scalp’s subsequent ability to glide on the
sively detailed in Chapter 2. Incisions in the peripheral scalp pericranium. Extensive undermining severely limits this vital
transect major structures and are associated with impaired tissue modality of scalp biomechanics.
709
710 Chapter 19
The deleterious effects of tissue stretching are discussed in with larger defects, serial excisions have been successfully em-
Chapter 18. For the reasons stated, it would seem that the less ployed to remove areas that could not be excised in a single
extensive the stretching (and undermining), the better. This, operation (3). Although the field of scalp surgery continued to
again, applies particularly in scalp surgery. The reader is invited progress, including the development and design of transposition
to compare the extent of undermining and stretching, in the flaps, it was not until the mid-1970s that the same techniques
modalities described in the chapters under discussion, in order became incorporated into the treatment of male pattern baldness
to arrive at conclusions. The advisability of not incising or un- (MPB).
dermining the occipital (donor) area will not be discussed here In the spring of 1976, I began excising areas of MPB to
because the problems resulting from this are now generally improve the donor/receptor ratio in patients being treated with
understood and accepted. the Orentreich punch graft technique of hair transplantation (4).
The concept came to me and my brother, Dr. Walter Unger, as
we were reviewing photographs for use in an upcoming text,
CLOSURE and happened on a photograph showing the ‘‘before’’ of an
Wound closure should be effected with as little tension as possi- area of cicatricial alopecia that had been treated with excision,
ble. Few would dispute this statement—but it is not always rather than punch grafting, and an ‘‘after’’ photograph that
respected. Closure is inextricably linked with undermining, the showed its almost complete removal. The before print could
purpose of the latter being to facilitate tissue excision and ten- have easily been mistaken for an area of baldness in the crown
sion-free wound closure. As noted earlier, an operation that region, and we decided to try it on our next patient with vertex
employs extensive undermining eliminates the scalp’s ability MPB. After completion of the first 60 cases, we decided to
to glide and, therefore, depends exclusively on traction ad- publish a paper on what was clearly an important new concept
vancement of undermined tissue to effect closure. Traction ad- for the treatment of MPB. The paper was originally submitted
vancement is not compatible with low-tension or no-tension to the Journal of Plastic and Reconstructive Surgery, in October
closure. It is unlikely that a surgeon who extensively under- 1977, and arrangements were made to present it at the 1978
mines and stretches tissue will then refrain from maximal exci- meeting of the American Society of Dermatological Surgery.
sion. Much to our surprise and disappointment, our paper was re-
Stretch-back is a biological phenomenon that invariably ac- turned with the comment that its reviewers felt the concept was
companies excision and suturing in elasticized tissue. Tension ‘‘nothing new or important.’’ Subsequently, the same paper
vector forces, generated at closure, produce a recoil effect, was submitted to the Journal of Dermatological Surgery and
which manifests maximally at the wound edge and tends to Oncology and was published in September 1978 (2). It has been
spread the wound/scar. As time goes on, the tissues undergo credited with ‘‘the introduction of scalp reduction to a large
what Gibson calls stretch relaxation and Nordström calls segment of the surgical community (5).’’
stretch-back. This is described in detail in Chapter 18. Stretch- We were not alone in happening on this concept for which
back can be minimized or eliminated if causative tension forces the time had obviously come. The Blanchard brothers, in fact,
are diverted or channeled away from at risk undermined tissues had apparently thought of the same idea at approximately the
into areas where the adverse effects harmlessly dissipate. This same time, and the publication of their paper preceded our own
is as classically seen with the Frechet Extender and in the deep by 1 year (6). This was largely because of the delays that re-
plane fixation (DPF) techniques. These techniques allow maxi- sulted from the submission of our paper to the Journal of Plastic
mal removal of tissue, a low tension or no-tension closure with and Reconstructive Surgery and subsequent communications
minimal stretch-back, avoidance of stretch-atrophic change, and with them. Sparkuhl and Kim had also been using the same
produce the least scarring. approach, but had neglected to publish the results (7). At the
AR surgery has come a long way in recent years. A typical International Hair Transplant Symposium at Lucerne, Switzer-
reduction is the equivalent of a 4000-hair transplantation. The land, in February 1978, presentations on this subject were made
operation requires no particular surgical expertise and is well by Sparkuhl as well as Stough and Webster (8).
within the ability of many hair restoration practitioners. In my A large series on scalp reduction was published by Bosley
opinion, the newer innovations described in this textbook allow et al. in February 1979 (9), and in December 1980, Alt published
for complication-free results with no adverse impact on the his first paper, making us aware that larger areas of alopecia
donor area. could be removed, provided that extensive undermining, in-
creased tension on closure, and galeotomies were employed
(10). Significant contributions to this field have also been made
19A. My Approach to Alopecia by Norwood and Shiell (11), Fleming and Mayer (12), Nords-
tröm (13), and Marzola (14), as well as others who have publi-
Reduction cized and continued to modify and refine the procedure.
Martin G. Unger Although hair lifting and alopecia reduction have been used
to describe this operation, the term scalp reduction, first used
by Sparkuhl in 1978 (15), now seems to have gained widespread
HISTORY
acceptance for this procedure. Incorporation of one or more
For many years plastic surgeons have used advancement or scalp reduction operations with hair transplantation has become
rotation flaps to reconstruct scalp defects after areas of malig- increasingly used over the years, and today is carried out on
nancy or cicatricial alopecia have been excised (1,2). In cases almost every patient having extensive hair transplantation.
Alopecia Reduction Procedures 711
USEFULNESS OF SCALP REDUCTION

One must always assume that a patient with MPB is going to
progress to a Norwood class VI or VII (16) at some time during
his lifetime and plan ahead for this. In keeping with this philoso-
phy, the approach I most frequently use for hair restoration is
as follows: Hair transplantation to the U-shaped area anteriorly
(Fig. 19A-1), elimination of 60% to 70% of the remaining area
of alopecia on the dorsum by scalp reduction (Fig. 19A-2) or
scalp extension, and then hair transplantation to the remaining
30% to 40% of the dorsum to bring about a normal transition
in hair direction from one side to the other, as well as to recreate
the whorl formation in the crown region. If the initial hair loss
is confined to only the midscalp and crown areas, then only
alopecia-reducing procedures are carried out, following which
the patient is observed for at least 6 months to try to determine
whether his hair loss will progress rapidly or slowly. If rapid
progression is noted, an additional reduction is carried out and
then a further waiting period repeated. If the hair loss is rela-
tively stable for at least a 6-month period, the area is trans-
planted, knowing full well that we might have to excise a hair-
less gap on each side between the lateral fringe and transplants
at some time in the future (Fig. 19A-3).
Some patients prefer only micrografting and minigrafting to
the entire dorsum. These individuals are a small minority in
my own practice, and more than 90% of my patients have reduc- Figure 19A-2 Same patient as Figure 19A-1 after 65% of the
tions, regardless of whether their transplanting is done in a more midscalp and crown area have been removed by two S-shaped
traditional form together with micro- and minigrafts or, alterna- Unger-modified major scalp reductions.
tively, with only micrografts. The important point here is that,
from day 1, we anticipate extensive baldness and plan for it,
Figure 19A-3 Crown area demonstrating the area to be excised

Figure 19A-1 The patient has had hair transplantation to the between the region of previous transplantation and the lateral
U-shaped area anteriorly. fringe.
712 Chapter 19
regardless of the stage of baldness that the patient has reached

when he first presents for hair restoration. In general, scalp
reduction reduces the area of alopecia in size and simultane-
ously brings excellent hair density to previous areas of alopecia
(see Figs. 19A-1 and 19A-2).
By performing a surgical reduction of an area of alopecia
combined with hair transplantation in the treatment of patients
with MPB, several useful benefits can be achieved.
1. If the same number of donor grafts are used, the reduced
area of alopecia can be covered more densely.
2. A greater proportion of the original bald area can be
covered with the same number of grafts if the density
of the grafts remains the same.
3. In younger patients with less fully developed male pat-
tern baldness, a reduction of the area of most advanced
baldness can act as a stopgap before a final decision is
made to proceed with hair transplanting; it also effec-
tively conserves a significant donor area for future use.
4. In some cases, where the donor/recipient site ratio may
initially be inadequate for hair transplantation, reduction
of the area of alopecia may result in a satisfactory ratio
for at least partial treatment.
5. When the remaining number of donor grafts is very
limited and a portion of the bald crown is still present,
this area can be surgically reduced or removed entirely. Figure 19A-4 Preoperative view of the dorsum of the scalp
6. Scalp reduction may be employed to elevate the superior demonstrating an area to the right of the midline of poor transplanta-
border of the lateral fringe of normal hair on one or tion.
both sides (17); thus, the part alone can be moved to a
cosmetically more pleasing and more medial position
or, in addition, when both sides are raised before hair
transplanting, a more normal frontal hairline position
can be designed.
Scalp reduction has also proved extremely useful in the repair treatment of patients with postinflammatory or cicatricial alope-
of areas of previous hair transplantation. cia. This includes patients with lichen planopolaris, or burn
patients, regardless of whether the cause of the burn is thermal,
1. Scalp reduction can be used to remove the hairless gap chemical, or radiation. In addition, areas of permanent traction
between previous grafts and the lateral fringe when pro- alopecia can also be treated and significantly improved by scalp
gressive hair loss has occurred (see Fig. 19A-3). reduction.
2. Minireductions can be used to excise areas of alopecia
between rows of previously transplanted grafts (18).
3. Areas of poor graft survival or improper hair direction PATIENT SELECTION
from previous hair transplantation can be surgically ex-
cised to eliminate this area. If desired, satisfactory grafts As with any operative procedure, certain clinical factors must
can be removed from the area before or (less preferably) be taken into account, such as the general health of the patient,
after it is excised, and implanted for a second time into the degree of alopecia, the laxity of the scalp, the ultimate objec-
the remaining area to be transplanted. tive or goal of the patient, the age of the patient, and the psycho-
4. When there is good hair survival in the grafts, but the logical ability to accept the scalp reduction procedure.
grafts have been spread too far apart or are too notice-
able in general, a portion of this area can be similarly General Health
excised and the grafts from within the area removed
Scalp reduction surgery is an elective cosmetic procedure. The
and transplanted for a second time (Fig. 19A-8).
physician should ensure that the general health of the patient
5. In situations when the normal donor area has been ex-
is satisfactory before the surgery is undertaken. As with any
hausted, a portion of the previously transplanted area
elective operation, the patient should have a general history
can be used as a donor site by punching out the grafts
taken and a physical examination performed before the proce-
in that area and then excising the area itself.
dure. Coexisting medical conditions, such as hypertension, dia-
6. When an area of alopecia occurs in the donor area of
betes, and thyroid disease, should be controlled as well as possi-
the patient, a scalp reduction in the donor area can be
ble. If a blood dyscrasia is present, all factors relating to that
carried out to remove the area of alopecia.
patient would have to be considered before a decision is made
Although scalp reduction is mainly used to treat or repair pa- about whether the risks of elective surgery are justified. Special
tients with androgenetic alopecia, it can also be used for the consideration also must be given to patients with a history of
Figure 19A-5 Same patient as Fig. 19A-4, with staining of

blood to the left of the scalp reduction incision to indicate the Figure 19A-7 Same patient as Fig. 19A-6 after worthwhile
amount of redundant scalp tissue present. The staining was pro- grafts within the region have been cut out in a circular fashion.
duced by overlapping the right flap on top of the left flap with a
skin hook.
Figure 19A-8 Postoperative view of a second patient. The

Figure 19A-6 Same area as Fig. 19A-5. The hair has been scalp reduction has been closed in two layers and the circular grafts
clipped from the blood-stained area, and a superficial incision made have been transplanted (for a second time) from the excised scalp
to demarcate the redundant scalp tissue (blood-stained area). to an area to the right of the incision.
714 Chapter 19
hepatitis. The type and communicability of the hepatitis and Age

whether the surgeon and his staff have been vaccinated are
important factors. Acquired immune deficiency syndrome The older the patient, the more accurate is the estimate of the
(AIDS) has become increasingly worrisome to the profession. ultimate extent of male pattern baldness. When the end stage
All patients, or at least those in a high-risk group, should be is more certain, the need and number of scalp reductions can
screened for the presence of human immunodeficiency virus be more fully appreciated. In younger persons, it is wise to
(HIV) antigen if possible. incorporate scalp reductions, because the full extent of baldness
will be known only at some future time. It is always wise to
Degree of Alopecia assume the worst possibility will occur.
The reduction operation is most useful in individuals with alo-

pecia, classes 3 to 6, according to the classification of Norwood Psychological Factors
(16) and Hamilton (19). It is important when classifying a pa- Not all patients can psychologically accept having a portion of
tient to take into account the potential for future hair loss. In their scalp excised. Others are frightened by often unfounded
general, the larger the area of alopecia, the more useful scalp rumors about hair transplantation and are hardly able to cope
reductions are and the more important it is to include the prog- with yet another unknown procedure. For both reasons, scalp
nosis for additional loss in your overall planning. reduction in our offices is usually carried out after one or two
Raising the part or adding hair to previous areas of MPB is transplanting sessions have been performed. In this way, pa-
as important a function of reductions, in individuals with large tients learn firsthand whether their fears concerning transplanta-
areas of present or future alopecia, as is the removal of alopecia tion are founded and can evaluate how well they would be able
areas. This aspect of the procedure cannot be overly empha- to tolerate a scalp reduction. Other pros and cons of doing scalp
sized. reductions before hair graft transplantation will be discussed
later.
Scalp Laxity If the patient can accept the idea of the operation, but not
The patients who benefit most from scalp reduction are, as the actual procedure while awake, a general anesthetic can be
expected, those whose scalps have the greatest degree of laxity. used. In addition, a general anesthetic can also be used with
This is not to say, however, that this procedure cannot be done patients who require higher concentrations of local anesthetic.
on anyone who does not have substantial scalp laxity. It is not Fortunately, the patients in each of these groups represent a
unusual at the time of surgery to obtain results as good as, or small minority, and the added risks of a general anesthetic are
better than, average on patients who preoperatively have only best avoided if possible.
borderline scalp laxity. The degree of undermining and whether
one is going to carry out galeotomies are also important addi-
tional factors to be taken into account. TIMING OF SCALP REDUCTION AND HAIR
A few patients have so little scalp laxity that scalp reduction TRANSPLANTATION PROCEDURES
is pointless. Fortunately, they represent a small minority. An-
other small group of individuals seem to benefit very little from Most Common Sequence
even repeated scalp reductions. About the same area of alopecia Usually, two graft procedures, spaced 6 weeks apart, are per-
quickly returns after each procedure and is accompanied by formed on the anterior scalp using a U-shaped pattern. In addi-
progressive thinning of the bald skin. This latter phenomenon tion, an ‘‘island’’ of grafts is occasionally placed posteriorly
suggests that most of the new laxity is primarily because of and is separated from the anterior portion of the U by a gap of
stretching of the alopecia site, rather than the laxity of the entire alopecia 4 to 6 cm wide (20). More frequently, the U-shaped
scalp increasing, which occurs in most patients. Accurate before area may be extended posteriorly on one (usually the left) or
and after measurements should identify members of this small on both sides. A 3-month to 4-month interval is left between
group and will prevent nonproductive repeated scalp reductions. the second and third transplantation sessions as well as the third
and fourth sessions. With most reduction patterns, I prefer to
Objectives delay excision for 6 weeks after any transplanting and to use
A patient who is certain of his present and future objectives the same interval before any further transplanting is performed
and who has adequate donor grafts to accomplish this end may in the same general area. Thus, the first scalp reduction is most
have little use for a scalp reduction. When making an estimate often carried out 6 weeks after the second and subsequent trans-
of the available donor grafts, however, the age of the individual planting sessions. Midline, S-pattern, and Y-shaped reductions,
and possible future advancement of male pattern baldness on the other hand, may be done as soon as 1 day before a
should be considered. transplant session, because these patterns do not compromise
Scalp reductions are most valuable in those who intend to the blood supply to the anterior U-shaped area to be grafted.
employ all, or virtually all, available donor grafts for as large
and dense a coverage as possible, or in those who require raising Scalp Reduction Before or During Hair
the sides to a cosmetically better position. Patients whose ulti- Transplantation
mate objectives are not yet fully established should also con-
sider scalp reduction. In such persons, the individual retains the There are advantages and disadvantages to doing scalp reduc-
option of more extensive or denser punch transplanting in the tions before, instead of between, grafting sessions. Alopecia
future. reductions before transplanting have the following advantages:
1. Undermining is easier to carry out in areas that have tions. An alternative in some of these patients might be only
not been transplanted. transplanting the forelock area, in which case, reduction would
2. Grafting patterns do not have to take into account future become optional.
ideal patterns of scalp reductions.
3. Estimates of how much skin can be removed by scalp ‘‘Early’’ Scalp Reductions
reductions and, therefore, how large an area can reason-
ably be attempted with the available number of donor Some controversy surrounds the question of whether one should
grafts, are made more easily if scalp reductions are done perform a scalp reduction through an area of hair-bearing skin
first. that is in the early stages of androgenic alopecia. No single
4. No special care is needed to avoid injury to previously answer is satisfactory for all individuals. In general, however,
transplanted grafts. the presence of hair in an area that will be removed by a scalp
reduction is not an absolute contraindication. Other factors must
Transplanting hair before scalp reduction does not appreciably also be taken into account:
affect the amount of tissue that can be removed in subsequent
scalp reductions, provided the area of transplantation is under- 1. The patient’s desire to complete the entire hair replace-
mined during the reduction operation. ment and scalp reduction program as quickly as pos-
Disadvantages of scalp reduction before transplantation in- sible.
clude the following: 2. The patient’s preference to carry out all operations on
hair-bearing skin to avoid the embarrassment that might
1. If scalp reductions are done first, the patient must wait be produced later by similar operations when the scalp
longer before he sees hair growing on previously bald would have no hair left to camouflage the procedures.
sites. The more reductions done, the longer this delay 3. The desirability of moving the part to a more medial
becomes. position.
2. Each scalp reduction may cause some stretching of the 4. The patient’s willingness to accept a temporary telogen
scalp tissue in both the bald and hair-bearing lateral effluvium, which may occur after a scalp reduction, in
fringe areas. The latter supplies the donor grafts for later an area of hair-bearing skin. Telogen effluvium is an
transplantation. Any stretching of the hair-bearing skin inconvenience that may, in fact, be tolerated better in
would cause a lower density of hair per unit surface the early stages of male pattern baldness when remain-
area, fewer hairs per graft, and correspondingly less ing hair can still camouflage the region.
satisfactory results from transplanting such grafts. Clini- Some physicians believe that early scalp reductions might has-
cally, this is usually not a problem if only the redundant ten the rate of hair loss in any predisposed area. This has not
skin is removed in carrying out the scalp reductions. been noted clinically in any of the many hundreds of patients
3. It is usually psychologically preferable to start with the at this stage of hair loss on whom I have operated. It is possible
better-known hair-transplanting procedure. that other physicians who use significantly more tension in clos-
There is usually no absolute answer to the question of whether to ing their wounds might cause this or a permanent hair loss on
perform scalp reductions before or between transplant sessions. either side of the incision line similar to that which occurs in
With most patients, the previously described sequence of opera- some patients after a facelift operation. Obviously, the best solu-
tions is carried out. However, exceptions are made in specific tion to this problem is prevention by avoiding excessive tension
instances—most often in younger individuals who are con- and, in my opinion, by doing so there is no exacerbation of the
cerned about vertex alopecia, but who also want to increase the rate of hair loss.
possibility that they will have sufficient donor grafts left to
transplant the anterior aspect of their scalp if hair loss occurs PATTERNS OF SCALP REDUCTION
there later. In these patients, usually one or more scalp reduc-
tions are carried out before any transplantation, as related ear- Originally, six basic patterns of scalp reductions were described
lier. as examples of the many possible variations (2). The sagittal
In addition, a scalp reduction may be performed in a younger midline ellipse was incorporated in the original ‘‘star’’ pattern
person in the central scalp region to intentionally delay the start and the lateral crescent shape or lazy-S has been described by
of hair transplantation. The reason for this delay might be to Alt (5,10,15). In recent years, Marzola has described a pattern
allow the physician to make certain that the patient will become that consists of an anterior incision in the temple hair as well
a good candidate for transplanting or, alternatively, to allow as along the margin of the lateral fringe (14) and, since 1986,
the patient some time to prepare psychologically or financially Dr. Dominic Brandy of Pittsburgh, has been carrying out a
for hair transplantation. This interval may also result in a psy- Marzola type reduction on each side in one operation instead
chological accommodation of the patient to male pattern bald- of two (21). This latter procedure, referred to as scalp-lifting,
ness so that transplantation may no longer be necessary, and has been even more effective in reducing the area of alopecia,
in this instance, only a fine scalp reduction scar would remain. but does have some disadvantages.
Another exception to the most common sequence is patients From the beginning, it has been stressed and should be em-
who want to the anterior U-shaped area transplanted, but have phasized again that, even after performing several thousand op-
unacceptably low lateral fringes when they present. In these erations, no one pattern is optimal for all patients. With each
patients, one or more reductions must be done before the trans- patient, the operation should be tailored specifically for that
planting to elevate the sides and have a normal frontal hairline. patient with consideration of his ultimate goal, area of alopecia,
Usually an S-shaped or Y-shaped pattern is used for these reduc- pattern of previous hair transplantation, and so on.
716 Chapter 19
Sagittal Midline Ellipse

The sagittal midline ellipse pattern of excision has enjoyed
widespread popularity over the years for the following reasons
(22):
1. It is effective in removing large areas of alopecia owing
to lateral mobility of the scalp.
2. It is the safest and, technically, the easiest pattern of
excision to perform for the beginner.
3. There is no postoperative anesthesia or hypoesthesia of
the scalp.
4. For the more experienced practitioner, this pattern can
be used most easily concomitantly with grafting.
In comparison with other designs, the principal disadvantages
of this pattern are:
1. A central scar through the crown region almost always
necessitates hair transplantation of that area.
2. In comparison with some patterns (e.g., the U-shaped
pattern), less scalp tissue is removed anteriorly.
3. The most serious problem with this pattern is that re-
peated reductions produce a change in hair direction on
each side of the scar that is difficult to camouflage. The
bald area is also distorted by being slightly elongated
(Fig. 19A-9). Nordström has described one method to Figure 19A-10 Posterior view of patient demonstrating that
the occipital end of the reduction incision has been curved to the
improve this change in hair direction (13), but a better
patient’s right to prevent an axelike scar.
option is to leave a small zone of alopecia between the
two sides and then create a normal transition from one
side to the other using hair transplantation grafts. Be-
cause of this alteration in hair direction, the sagittal mid-

line ellipse does not lend itself well to the creation of
a whorl pattern in the crown, unless a zone of alopecia is
left or Frechet transposition flaps are carried out (23,24).
4. When the pattern is extended into the occipital region,
an axelike scar can be produced there. The best solution
of this problem is prevention, which can be achieved
by using an alternative pattern, such as a Y pattern, by
stopping the excision at the margin of the occipital
fringe, or by curving the end of the scar in the occipital
region to one side (Fig. 19A-10). Alternatively, if one
is planning to use Frechet transposition flaps, the axe-
like scar is created on purpose, and then removed by
the Frechet flaps (23,24).
Y Pattern
The Y-pattern excision design has gained increasing popularity
over the past few years. The principal advantages over the mid-
line pattern are as follows:
1. A larger area can be excised with the Y pattern as com-
pared with a midline operation, given the same area of
alopecia. This is true for two reasons: First, the laxity
of the scalp is usually greatest in the crown region; and,
second, the increased total length of the incision allows
more scalp tissue to be removed in that area. This holds
true even with the double-convex contour of the
Figure 19A-9 After three midline reductions, the bald area is cranium.
elongated and the hair direction in the midline distorted. A whorl 2. The Y-shaped scalp reduction allows the greatest area
pattern in the crown would be impossible. of alopecia to be removed if one is not transplanting
the crown or crown and vertex regions, and no scar is

left in those areas. For example, by positioning the lat-
eral arms of the pattern to follow the anterior margin
of the crown area, one can reduce the area of alopecia
anterior to the crown, without creating a scar in the
crown region itself. This is particularly useful when the
patient is uncertain about the total area to be trans-
planted, when there is a paucity of donor area, or when
the crown transplantation is significantly delayed.
3. In many patients, the Y-pattern scalp reduction con-
forms to the area of alopecia much better. This is partic-
ularly true of patients who have pear-shaped bald areas
or persistent hair extending anteriorly from the occipital
region (Fig. 19A-11).
4. Hair direction in the crown region is preserved much
better by a Y-shaped scalp reduction (Fig. 19A-12). This
is a significant advantage and most useful if a whorl
pattern is planned for the crown region. Maintaining the
normal hair direction is also particularly important in
younger patients who are balding more rapidly in the
crown and vertex than in the frontal area. By carrying
out a reduction, transplantation of the crown can often
be delayed several years and the donor area saved for
the frontal region.
5. With the Y-shaped scalp reduction, a greater number Figure 19A-12 A Y-shaped reduction has been performed. The
of pattern variations are possible. The Y shape can in- hair direction in the crown region is less distorted and a whorl
volve the entire dorsum or any other desired area. The pattern can be made.
vertical component may be short or almost the entire
length of the area of alopecia. The lateral components
may be short or long, straight or curved, and be angled
as most appropriate (25). ear, forms posteriorly with closure of the wound. The
6. The Y-shaped scalp reduction allows an elevation of Y-shaped incision allows the posterior dog-eared tissue
the occipital region, impossible with a midline opera- to be dispersed over two areas, instead of one.
tion. By detaching the galea from the central part of 8. With the Y-pattern scalp reduction, no axelike scar is
the nuchal ridge of the occipital bone, an even greater produced in the occipital region.
advancement of the occipital hair can be achieved in
The principal disadvantages of the Y pattern are
some patients.
7. When large areas of scalp are removed with midline 1. The Y-shaped scalp reduction is technically more diffi-
scalp reductions, a certain redundancy of tissue, or dog- cult than the midline incision. Six wound edges must
be approximated with the former, as opposed to two
with the latter. Nonetheless, if one deals with each com-
ponent of the Y excision at a time, the complexity is
dramatically reduced. Basically, each component is
treated similarly to a midline ellipse.
2. Although necrosis of the tip of the posterior flap has
been reported (10,15), not a single case has occurred in
my experience with well over 1500 cases using the Y
pattern. This specific topic was discussed at the Sixth
National Symposium on Hair Replacement Surgery (12)
and the conclusion was that tip necrosis is extremely
rare and virtually totally avoidable.
3. If the lateral components are initially placed at the ante-
rior margin of the crown and then a Y-shaped reduction
for the crown itself is desired later, a fairly complicated
situation develops. The second reduction can be carried
out, if a 1-in. bridge of tissue can be left between the
two lateral component scars on each side of the midline
and if at least 3 months have passed since the last exci-
sion. If these conditions cannot be met, a midline scalp
Figure 19A-11 The Y pattern is best suited for areas of alope- reduction of the crown is indicated, even though the
cia shaped like a three-leaf clover, or pear. area removed will be smaller. This situation occurred
718 Chapter 19
only once in my practice when a young man changed Although the vertical component is usually placed in the
his mind about having a crown transplantation. Ob- midline, it can be positioned to either side, and the lateral arms
viously, this type of problem cannot occur if only mid- made of unequal length. This is most useful for patients who
line scalp reductions are repeated. have had previous grafting on one side up to the midline, but
4. There is more interruption of the neurovascular supply none on the opposite side and the crown.
of the scalp with a Y-shaped scalp reduction. Because The lateral components of the Y are usually directed poste-
each of the three flaps created with a Y has an excellent riorly. However, they can be positioned anteriorly or both ante-
nerve and blood supply, this is not clinically important. riorly and posteriorly (25). By positioning the arms forward
5. Because the total length of the incisions is longer with toward each temple, the anterior transplated U-shaped area can
the Y-shaped scalp reduction, more time and effort is be preserved unchanged while the remaining area of alopecia
required for closure. is reduced in size. One’s imagination is the only restriction to
the number of variations of the Y pattern possible.
Y-Pattern Variations
The Lateral Patterns
By varying the length of the vertical component, the pattern
can encompass the area desired, such as the anterior one-third In the lateral patterns, part or all of the scar is placed at the
or two-thirds of the area of alopecia. When the vertical compo- periphery of the bald area. Included in this group are the S, J,
nent is very long and the lateral arms short, the pattern resembles and C types, described by Unger and Unger (2,20), as well as
a rocket. Other variations include changing the angle at which the lateral crescent-shaped (lazy-S) pattern described by Alt
the lateral arms meet the anterior element (a 45⬚ angle is the (10,15). The principal advantages of these patterns are as fol-
most common, although the usual range is 30⬚ to 90⬚), asymmet- lows:
ric angles on each side, a midline excision with one lateral arm,
and creating straight or curved lateral components (anteriorly 1. All or a portion of the resultant scar is positioned at a
or posteriorly or both). By curving posteriorly-directed arms to more cosmetically favorable area (the periphery of the
form a semicircle around the crown (Fig. 19A-13), a very useful bald area).
pattern is created. With this variation, the vertical component 2. As with the Y pattern, there is no elongation of the
is first reduced in size; the vertical galea is closed; and then original area of alopecia or significant distortion of the
the posterior semicircle is reduced. This pattern is particularly hair direction.
useful to reduce the size of the crown when transplantation to 3. Elevation of hair occurs in the occipital region. This is
that area is doubtful or significantly delayed. a distinct advantage over the midline pattern, but not
as effective as the elevation of the occipital region with
the Y pattern.
4. Because of the lateral position of the scar, undermining
and galeotomies in the hair-bearing region on the side
of the incision are technically easier to perform than
with the midline or Y pattern. Related to this advantage
is the usefulness of this pattern to elevate the lateral
fringe to a more medial position or, alternatively, to
excise an area of alopecia between a previously trans-
planted zone and a receding lateral fringe.
5. This pattern preserves the possibility of creating a whorl
pattern in the crown region that is intermediate in de-
gree; significantly better than the midline pattern, but
less satisfactory than the Y pattern.
The disadvantages of lateral patterns are:
1. The operation is technically slightly more difficult than
the midline pattern.
2. Usually, some hypoesthesia or anesthesia is caused by
transection of neurovascular bundles. This is nearly al-
ways of a temporary nature and located within the area
of baldness itself.
3. One side of the scalp may be elevated more than the
other until surgery is carried out on the contralateral
side. Usually this is totally preventable if desired or not
clinically significant.
4. If an intermediate zone of diminished hair growth exists
between the dense lateral fringe and a sparse, more cen-
tral region, excision of the intermediate zone could
Figure 19A-13 Y-pattern variation with the lateral components cause an asymmetric appearance if the hair is not
forming a semicircle around the crown. combed over the area of alopecia.
5. After a lateral pattern has been carried out on each side,

the circulation in the remaining central scalp might be
significantly impaired and, consequently, result in less
successful growth from grafts placed within that region.
6. Because the total length of the incision is usually mid-
way between that of a midline and a Y pattern, the bald
area removed is always more than a midline excision,
but often slightly less than a Y pattern, which involves
the entire dorsum of the scalp.
I have used the modified S pattern, as shown in Fig. 19A-14,
with increasing frequency over the past few years. This pattern
is slightly different from the modified S pattern described by
Schauder et al. (26). However, both variations enable excellent
bilateral elevation of the lateral fringes anteriorly and, at the
same time, concealment of the scar at the edge of the hair fringe
posteriorly.
The Marzola modification of the lateral pattern (14), in gen-
eral, has the same advantages and disadvantages as just previ-
ously noted. Because the incision extends just inside the anterior
margin of the temple hair, an added advantage is created by
allowing the lateral portion of the scalp to be rotated anteriorly
as well as medially. However, the disadvantage of this operation
is a scar at the anterior margin of the temple hair. As there
is little tension along this temple incision, usually the scar is
aesthetically quite good.
Scalp lifting involves carrying out bilateral Marzola lateral Figure 19A-15 Preoperative view of Fig. 19A-22.
patterns during the same operation. The Marzola pattern is dis-
cussed in detail in his section of this chapter, p. 570, and the
Brandy procedures will be elaborated on slightly more later in
this chapter, as well as by Dr. Brandy in his section.
U Pattern
Since first described in 1978, the original pattern has been modi-
fied so that more tissue is removed along the lateral components
on each side and less is removed anteriorly (27). The overall
effect ensures that the anterior hairline is not moved superiorly
to any significant degree while simultaneously taking greater
advantage of the lateral mobility of the scalp. As the trans-
planted U is usually fixed to the periosteum by grafts, care is
taken not to undermine the anterior area, to further ensure mini-
mal change in the distance from the nose to the hairline.
The principal advantages of this design are:
1. The scar is located immediately posterior to the anterior
U-shaped area of transplanation (Figs. 19A-15 and 19A-
16).
2. The lateral hairline areas can be raised for correction
of previously faulty location.
3. Because of the length of the incision, a considerable
area can be removed.
On the other hand, the most significant disadvantage of this
design is the postoperative anesthesia present within the U-
shaped flap created.
Miscellaneous Patterns
The miscellaneous group includes the T pattern (Figs. 17, 18),
the I pattern, the transverse or horizontal ellipse, and the cres-
cent-shaped pattern of the crown (Figs. 19 and 20). The I pat-
Figure 19A-14 Modified S-shaped pattern for scalp reduction tern, although one of the first described, has rarely been used.
(posterior view). Usually, some alternative design is more suitable and conforms
720 Chapter 19
Figure 19A-16 Postoperative photo of patient seen in Fig.

19A-5. U-pattern reduction demonstrating the position of the scar Figure 19A-18 T-pattern reduction of crown region.
immediately posterior to the anterior transplanted area.
Figure 19A-19 Preoperative view of Fig. 19A-20, with mark-

ings for the crescent-shaped excision.
Figure 19A-17 Preoperative view of Fig. 19A-18.

ital area. Alternatively, if the bald area is an elongated oval, a

midline sagittal ellipse or one of the lateral patterns can be used
with equal success. For specific purposes, such as raising the
hairline on one side, a lateral-type pattern is always used. When
hair transplantation is going to be confined to the anterior half
of the dorsum of the scalp, a Y-shaped or U-shaped pattern is
usually performed. With the crown and vertex areas, the Y
pattern is usually the procedure of choice, although the T pat-
tern, the horizontal ellipse, and the crescent-shaped ellipse are
still frequently employed, if they conform best to the shape of
the area of alopecia.
THE STANDARD REDUCTION

The standard scalp reduction is characterized by undermining
limited to approximately 10 cm from the incision itself. This
undermining may be restricted to the dorsum of the scalp for
certain patterns or, optionally, carried out to more than one
area, including the occipital or lateral regions, depending on
the location of the incision. With the major reduction (scalp
lifting) and the Unger modified major scalp reduction, all of
the aforementioned areas are always undermined with each op-
Figure 19A-20 Crescent-shaped reduction has been com- erative procedure.
pleted. (Same patient as Fig. 19A-19.)
Preoperative Information
In the consultation before surgery, I initially discuss with
to the shape of the area of alopecia in a more natural fashion. the patient what the purpose of the scalp reduction will be
The other patterns are still regularly used on selected patients. for that particular patient. Specifically, the goal is estab-
lished—whether it is to achieve a greater density in a limited
area, to provide coverage of a larger area with the same density,
Combined Patterns
to preserve donor site grafts for the future, or to convert an
Although usually only one pattern is used, in rare cases, I have unsatisfactory candidate for hair transplantation into a satisfac-
employed two patterns during the same procedure. On one occa- tory one. The patient is told that the operation will remove as
sion, for example, I carried out a U-shaped pattern in the anterior much tissue as the laxity of the scalp will allow. In explaining
half of the dorsum of the scalp and a sagittal midline ellipse this, it is often useful to refer to the removal of extra skin in
pattern in the posterior half. The purpose of this combination the bald area, rather than referring to the scalp. Somehow, the
was to maximize the amount of tissue that could be removed word skin seems to be more psychologically acceptable to most
from the anterior half of the area of alopecia. In another case, patients. The reduction pattern to be used is then described to
after punch graft transplants, a patient applied hot compresses the patient. A diagram is often useful.
that destroyed tissue in the midline area. In addition, this same It is important to describe the nature and location of the
patient had a remaining area of alopecia along the posterior and incisions and resultant scars as accurately as possible. If one is
right side of the crown between the grafts and his lateral fringe. going to employ prophylactic antibiotics, the patient should be
In this patient, the lateral pattern was used to remove the gap informed of this and given appropriate instructions. It is my
in the crown region, and then it was combined with a sagittal practice to prescribe erythromycin, 333-mg tablets three times
midline ellipse more anteriorly to excise the area destroyed by a day, which is started 2 hours before surgery and continued
the hot compresses. for 5 days. If one is going to use corticosteroids to minimize
The possibility of combining patterns is included in this postoperative edema, this should also be reviewed. I use 5-mg
chapter for completeness. In general, it should be carried out tablets of prednisone. The daily dosage is as follows: day 1, 30
only in extreme situations and only by a surgeon who has had mg; day 2, 25 mg; day 3, 20 mg; day 4, 15 mg; day 5, 10 mg;
years of experience with scalp reductions. In each of the two days 6 and 7, 5 mg.
patients previously noted, one reduction pattern was carried out If diazepam or other medication is to be used, the patient is
and completely closed before the other pattern was initiated. informed of this as well. In addition, when diazepam is used
on the day of surgery, the patient is given a test of two 5-mg
Summary tablets, which he takes, one at a time, 30 min apart, on an
evening about 1 week before the surgery to rule out idiosyn-
In general, pattern selection varies with each patient. If the cratic reactions to the drug. Patients must specifically be in-
reduction involves the entire dorsum of the scalp, a Y-shaped formed not to drive after taking this medication, both after the
pattern will be used if the area of alopecia is pear-shaped or if test tablets and on the day of surgery. The expected post-opera-
there is a persistence of hair extending anteriorly from the occip- tive course is fully explained as well as the possible side effects,
722 Chapter 19
such as a mild tightness of the scalp for 1 to 4 weeks, telogen tation anteriorly. A judgment is then made about the width that
effluvium developing adjacent to the incision in some patients can be excised, after which the proposed area for removal is
who have hair remaining in the area of surgery, and that a small marked and suitable tapering is carried out at each end.
seroma might occur, creating a small temporary bump at each
end of the incision. Anesthesia
Postoperative discomfort and edema in most patients is com-
parable with that experienced by them after hair transplantation. As in the past, a general anesthetic is used only for those patients
A few find it worse or better. With the U- and J-shaped patterns, who cannot psychologically accept being awake during the op-
there is always some temporary postoperative hypoesthesia or eration or for those who are extremely difficult to anesthetize
anesthesia of the tissue within the arms of the U or J. If de- with local anesthesia. When a greater concentration of local
creased sensation is usually expected following the particular anesthesia is required, the risk of toxicity increases proportion-
pattern used, the patient should always be told before surgery. ately. As noted earlier in this chapter, such patients represent
For medicolegal reasons, one must also discuss possible a small minority. If a general anesthetic is used, local anesthetic
complications. It is important that once the patient has been with epinephrine should still be used along the proposed exci-
informed of them that they be put in the proper perspective. sion lines to minimize blood loss.
Usually, the best way of doing this is to relate in a reassuring The procedure is almost always carried out with local anes-
fashion that only certain complications have occurred in one’s thesia. Although 1% lidocaine with epinephrine 1:100,000 was
own practice. In the hands of a competent physician, extremely initially used for local anesthesia, now 2% lidocaine with epi-
few complications are encountered. Possible complications are nephrine 1:100,000 is almost always used. This provides a more
discussed more fully near the end of this chapter. intense anesthesia to the area involved, and because the volume
required is usually 20 mL or less, the safety margin for any
Preoperative Preparation toxic reaction is still extremely good.
Field block anesthesia is produced by injecting in a circle
I have always performed this surgery as an outpatient procedure. around the circumference of the head, inferior to the expected
The patient arrives 1 hour before the scheduled time, removes extent of undermining. A 25-gauge, 3-in. spinal needle is used
all his clothing, except underwear, and is given a hospital gown. for this ring block. Following this, local anesthetic is instilled
While resting in bed, he is given either 15 mg of diazepam for hemostasis along the proposed lines of the area to be excised
orally, 30 min before surgery, or 10 mg of diazepam intrave- using a 30-gauge needle.
nously immediately before it. Meperidine (Demerol), 50 mg
intramuscularly, 30 min before the operation, is optional with Surgical Technique
each patient. Photographs are taken and the pattern is marked
on the area of alopecia. With the midline reduction, a series of The operation is carried out under sterile surgical conditions.
dots are initially marked directly in the midline with a marker, The patient is usually placed in a prone position with a bulky
such as the Micropoint Super Marker (Micropoint Super pillow under the chin for comfort. This positioning gives the
Marker, Micropoint, Inc., Sunnyvale, CA), and then the pro- greatest exposure to all areas of the scalp; however, care must
posed ellipse is added symmetrically on each side of the marks. be taken to avoid any blood running down onto the facial region.
With most patients, the accuracy of these markings increases On the rare occasion when a general anesthetic is employed,
proportionately with the surgeon’s experience in judging scalp the patient is usually positioned on his side.
laxity. For the beginning, the paper by Bosley and colleagues After the surgeon has donned gown and gloves, the surgical
is helpful (28). It is wise to terminate the posterior end of the area is cleansed with a chlorhexadine solution (Hibitane), and
ellipse within the area of alopecia to avoid a change in hair sterile drapes are applied. With the exception of the Y and T
direction posteriorly. Alternatively, as described earlier, the patterns, one initiates the operation by incising along the entire
posterior end of the ellipse can be curved slightly to one side length in short segments on one side. Each incision is carried
(see Fig. 19A-11). out down to and through the galea aponeurotica, and the scalpel
With the Y-shaped pattern, an initial series of dots are blade should be angled to avoid severing any adjacent hair folli-
marked directly in the midline for the desired length. A mark cles. If previous hair transplantation grafts are in the area, a 2-
is then made at the most posterior point along the lateral fringe mm margin of safety is normally employed. Surgical skin hooks
on each side in a symmetric fashion. Another series of dots are are used to separate the wound edges in a nontraumatic fashion,
then marked from the lateral side to the midline on one side so after which curved Mayo scissors are employed to undermine
that the lateral line and midline markings meet at the desired the loose connective tissue between the periosteum and the
angle. Markings are then made on the opposite side, usually galea aponeurotica for 10 cm or more on either side (Fig. 19A-
symmetrically. The proposed area for excision is then marked 21). This dissection is relatively bloodless except in the vertex
symmetrically on each side of the midline and the two lateral region where one or more perforators are often transected. The
lines previously marked. perforators, as well as any other bleeding vessels, are cauterized
Similarly, with the S, T, and I patterns, the center of the to obtain hemostasis.
proposed area to be excised is marked, and then the proposed There are three useful methods of determining the amount
area is outlined on each side. of redundant scalp tissue present. For the novice, the best way
With all lateral patterns (except the S), and the U pattern, is to overlap the tissues by placing the portion of the flap to be
the marking technique is slightly different. Initially a marking removed on top of the other flap. Following this, a series of
is made either along the periphery of the bald area for the desired perpendicular incisions are made through the top flap, stopping
length, or immediately behind the U-shaped region of transplan- at the point where the tissues will meet (Fig. 19A-22). Then,
Figure 19A-21 Skin hooks in galea aponeurotica elevating flap Figure 19A-23 The ends of the horizontal incisions have been
on the left during undermining. Note periosteum is intact. joined in an anterioposterior fashion to complete the ellipse to be
removed.
by joining the perpendicular cuts, the redundant tissue is effec-

tively removed (Fig. 23). Alternatively, a D’Assumpcao rhyti-
doplasty marker can be used in a similar fashion to determine
the amount of redundant tissue to be excised (Figs. 19A-24 and
19A-25). For more experienced surgeons, a skin hook attached
to the galea can be used to pull one flap on top of the other.
The blood stain on the underlying flap can be used as a marker
for the amount of tissue to be removed (Fig. 19A-26). Once
the redundant tissue has been discarded, hemostasis is again
accomplished with cauterization to maintain as dry a field as
possible (Fig. 19A-27).
For the Y and T patterns, the technique is similar, but slightly
different. Initially, one incises along one side of the midline
component of the area to be excised (Fig. 19A-28). Following
this, skin hooks are used, and extensive undermining is carried
out (Fig. 19A-29). The second incision is then made at the
anterior margin of the lateral component on the same side (Fig.
19A-30). After hemostasis has been obtained, additional under-
mining is usually carried out. The amount of redundant skin
tissue present is then determined along the midline and lateral
component on the same side (Figs. 19A-31–19A-34). After
using the blood on the underlying flap as a marker, the redun-
dant tissue is removed (Fig. 19A-35). Hemostasis is again
achieved with cautery. With the remaining lateral component,
an incision is made along one side. Further undermining is
Figure 19A-22 Undermining has been completed, and three performed, and the redundant tissue is then similarly measured
horizontal cuts have been made across the redundant scalp tissue. and removed (Figs. 19A-36 and 19A-37).
Skin hooks in the galea apply traction in opposite directions to Closure of the reduction is always carried out in two layers.
determine length of each horizontal incision. The galea aponeurotica is sutured using interrupted 2–0 Dexon
724 Chapter 19
Figure 19A-24 Lower part of the D’Assumpcao rhytidoplasty, marker has been placed at the edge of the left flap and a skin hook
placed on the right flap before measuring the amount of redundant scalp tissue present.
Figure 19A-25 The right flap has been pulled over the left flap and the lower part of D’Assumpcao marker by the skin hook. The
upper part of D’Assumpcao marker indicates the amount of redundant scalp tissue to be removed.
Figure 19A-28 Initial incision of Y pattern along one side of

Figure 19A-26 Alternative method for determining width of the anterior component.
redundant scalp tissue. The flap on the right has been pulled with
a skin hook in the galea at several points to overlap the other flap.
The staining of blood from the underside has marked the ellipse
to be removed on the surface of the flap on the left.
Figure 19A-29 Skin hooks separate the wound edges for non-
traumatic undermining.
Figure 19A-27 Resultant defect after an ellipse 4.2 cm wide

has been removed.
726 Chapter 19
Figure 19A-32 Overlapping of flaps at junction of the Y. Ele-

Figure 19A-30 Second incision along the anterior margin of vated flap is first overlapped laterally and then posteriorly.
the lateral component.
Figure 19A-33 Overlapping of lateral component flaps.
Figure 19A-31 Overlapping of anterior component flaps.

Figure 19A-36 The flaps of the opposite lateral component

are overlapped to mark redundant tissue.
Figure 19A-34 The staining of blood on the underlying flaps
marks the redundant tissue to be removed. This corresponds well
to the preoperative markings.
Figure 19A-37 Resulting defect after all redundant tissue has

been removed.
Figure 19A-35 The extra tissue has been removed from the
anterior and lateral component of the patient’s left side.
728 Chapter 19
or Vicryl sutures placed approximately 1.5 cm apart (Fig. 19A-

38). With the Y and T patterns, the lateral components are
usually closed first and then the midline element (Figs. 19A-
39 and 19A-40). The most medial suture with each lateral com-
ponent is placed very close to the junction where the three flaps
meet, whereas, with the vertical component, the most posterior
suture is 0.5 cm from this junction.
During closure of the galea aponeurotica, it is imperative
to have the patient refrain from talking, because this causes
separation of the galeal edges from the contraction of the tem-
poralis muscle on each side. Another important consideration
is the strength of the galeal tissue itself. As previously reported
(12,22,29,30), seven cases have now been confirmed by four
different physicians in whom the galea aponeurotica has a soft,
almost cheeselike consistency, rather than its normal strong fi-
brous nature. In view of this, it should be emphasized that the
strength of the galea should be tested with a skin hook before
any scalp tissue is removed. If the skin hook pulls through the
galea as if it were butter, then no tissue should be removed,
and closure is carried out immediately, If one has made the
mistake of not testing for this and has already removed scalp
tissue, the only solutions are closure with very large bites of
galea, or interrupted retention sutures through the entire thick-
ness of scalp tissue. Figure 19A-39 Galeal sutures have closed the lateral compo-
Once the galea has been closed, the skin edges are approxi- nent on the patient’s right side.
mated with a running 4–0 chromic catgut suture (Fig. 19A-
41). In patterns where three flaps meet at a junction, a single
interrupted corner stitch is used, and then each component is
closed with a running suture (Fig. 19A-42).
It is not necessary to apply a pressure dressing at the comple-
tion of surgery. Instead, three or four layers of gauze are placed
Figure 19A-40 Closure of all components of the galea aponeu-

rotica has been completed with interrupted 2–0 Dexon sutures.
Figure 19A-38 The galea aponeurotica has been closed with

interrupted 2–0 Dexon sutures.
Figure 19A-43 Postoperative dressing of gauze and stockinette

modified to form a cap.
Figure 19A-41 Closure of the skin has been completed using
a running 4–0 chromic catgut suture.
over the area and then a piece of 6-in. stockinette modified to

form a cap, is applied to hold the gauze in place (Fig. 19A-43).
In view of the simplicity of this dressing, the patient is instructed
to remove it himself the next morning and then comb any hair
present over the incision to hide it as effectively as possible.
AREAS OF POSSIBLE CONTROVERSY

Tension of Galeal Closure
In my view, the proper tension for closure of the galea occurs
if the galeal edges just meet when the fingers are used to approx-
imate the flaps toward each other. If one is questioning whether
or not to remove additional tissue, I feel that it is best to be
conservative. Although one always wants to give patients the
most benefit, elective cosmetic surgery is being performed, and
it is in the best interest of both physician and patient to err on
the side of safety. Alt, among others, has advocated substan-
tially more tension on galeal closure to maximize cosmetic gains
(5,15). Obviously, each surgeon will have to make his or her
own decision about what the proper tension is for closure of
this layer. I personally feel that closure with minimal tension
is responsible for excellent wound healing, minimal decreased
hair density in the lateral fringes, and the minimal
‘‘stretchback’’ that is achieved with my patients.
Interrupted Sutures Versus Continuous Suture

Closure
Figure 19A-42 The skin edges have been closed with 4–0
chromic catgut sutures. The anterior two-thirds of the original area There is some controversy about whether the galea should be
of alopecia has been reduced in size. Compare this end result with closed with interrupted sutures or a continuous suture. I have
Fig. 19A-40 in which the hair is also moistened. always advocated interrupted sutures because it is an accepted
730 Chapter 19
surgical principle that closure with interrupted sutures is

stronger than a continuous suture of the same material. This
becomes even more important if tension on closure of the galea
is increased.
Galeotomies
The routine use of galeotomies for scalp reductions is no longer
controversial. Although this technique allows an increased
amount of scalp tissue to be removed, the practice similarly
results in more bleeding during the operation and a greater risk
of postoperative hematoma. In addition, the possibility of dam-
aging the circulation to the overlying scalp tissue is markedly
increased. Although there is unanimous agreement that galeoto-
mies, if used, should be performed in the areas that are perma-
nently hair-bearing, rather than in areas of alopecia, it is also
acknowledged that if that area is used as a donor area in the
future, the number of hairs per comparable-sized graft will
likely be diminished.
In the opinion of most physicians in this field, it is no longer
necessary or advisable to carry out parallel galeal incisions or
both parallel and vertical incisions (scoring) of the galea except
in rare cases. The two possible exceptions to this general rule
are as follows: (a) when one has been slightly too aggressive
and feels the tension on closure will be greater than ideal, and
Figure 19A-44 Postoperative patient demonstrating the three
(b) when one wants to raise the hairline more on the part side.
sets of tattoo marks in the stretch-back study. Each pair of tattoo
In the last few years, even strong proponents of routine galeal
marks are exactly 3 cm apart.
scoring have begun to advocate a less aggressive approach. Alt,
for example, no longer routinely scores the galea (31).
Stretch-Back
operatively. Because of this, I was forced to switch to making
In 1984, Nordström coined the term stretch-back to refer to a the horizontal pairs of tattoo marks at the completion of the
stretching of the scalp and an increase in the area of alopecia scalp reduction. In 56 patients the galea was closed with Dexon
after a scalp reduction (32,33). He measured this phenomenon (polyglycolic acid) and pairs of tattoo marks made exactly 3
in 13 patients reported in his first paper (32) and stated that up cm apart anteriorly as well as in the midscalp and crown regions
to one-half of the benefit of scalp reduction could be lost owing (Fig. 19A-44). The tattoo marks were measured monthly for 3
to stretch-back. He felt that ‘‘most of this stretch-back occurs months, and the widening of any pair of marks was considered
during the first eight postoperative weeks and is completed at stretch-back in that patient. The results are shown in Table 19A1
twelve weeks’’ (32). In a subsequent publication (34), Nords- and indicate that 91.1% of all patients had less than 7% stretch-
tröm related that this phenomenon seemed to occur to a greater back. These findings were first presented in April 1990 in Dallas
extent if absorbable suture material was used for closure, instead (35) and have been presented at several medical meetings since
of nonabsorbable suture material. that time (36,37).
I could not agree with these findings based on my own exten- Hitzig and Sadick found that 75% of their 40 patients had
sive clinical experience and, in 1989, carried out my own scien- less than 10% stretch-back, and 50% of them had no change
tific study to investigate this area. Initially, the patients were at all (38) These findings were similar to those of my own study
tattooed before surgery, but with the shifting in position of the and support my clinical experience.
flaps with the scalp reduction procedure, the tattoo marks also Stretch-back was discussed by a panel of experts (which
shifted and one could not compare ‘‘apples-to-apples’’ post- included the author) in 1992 at an international symposium (39).
Table 19A–1 Stretch-Back Results in 56 Patients
Widening
0 mm 1 mm 2 mm 3 mm 4 mm 5 mm Total
Number of patients 31 13 7 4 0 1 56
Percentage of patients 55.4 23.2 12.5 7.1 0 1.8 100
91.1%
98.2%
The entire panel agreed that this phenomenon really refers to CO2 laser and produces far less lateral heat conduction than
four different situations that have become confused with each other types of CO2 lasers. Because of this, it does not signifi-
other. First, in many patients there is progressive MPB between cantly harm hair follicles adjacent to the incision. It was hoped
reductions, and this obviously is not a stretching of the scalp that this laser would cause minimal intraoperative bleeding from
tissue. Second, in some patients, there is hair loss between scalp the incision, less postoperative edema and discomfort, and
reductions because of vascular changes with the reductions; this equally good, or better, healing than with a scalpel.
is usually of a temporary nature (telogen effiuvium), but in There are four parameters to consider when using a laser,
some patients, might be an acceleration of the MPB and more and these are best understood by comparing a laser’s incision
permanent. Third, when closure of the galea has been carried to digging a trench. The first consideration is spot size and this
out with more than moderate tension, a widening of the scar can compares to the width of the shovel used for a trench. The wider
occur in some patients that increases the total area of alopecia. the spot size or shovel width, the wider the incision or width
Finally, in a few individuals, there actually is postoperative of the trench. Second, one must consider the number of milli-
stretching of the scalp tissue and an increase in area as a result joules per pulse. This is comparable to how deep the shovel
of true stretch-back. penetrates each time it goes into the ground. Third, one must
The author advocates removal of the redundant tissue present consider the number of watts. This compares to how many times
and then closure with minimal, rather than substantial tension. the shovel strikes the ground per minute (or with a laser, how
Under ideal conditions, the edges of the galea should just meet many times per hundredths of a second). Lastly, the total time
when bimanual pressure is applied. If this practice is adhered is the fourth variable factor (i.e., does one shovel for 5 min or
to, the degree of stretch-back post-operatively in almost all pa- 1 h). Thus, in digging a trench, we use a shovel of defined
tients is minimal and not clinically significant (40). width, penetrate the ground a certain depth each time we strike,
strike so many times per minute, and work for a set time period.
Intervals Between Scalp Reduction With the Ultrapulse laser, each of these four parameters were
decided and varied only slightly, if at all, with each patient. A
Although some physicians advocate an interval of only 4 weeks 0.2-mm spot size was used on all patients; the millijoules per
between scalp reductions (28), my recommendation is a mini- pulse varied from 200 to 250; and the watts varied from 10 to
mum of 8 weeks between operations, and I usually extend this 15. The laser beam was kept in the same location a sufficient
to a 12-week period, as previously related. time to penetrate all layers of the scalp tissue.
There is general agreement that active massage of the scalp I reported my findings at the first World Congress of the
before scalp reduction is beneficial in improving scalp laxity. International Society for Hair Restoration Surgery in Dallas, in
I encourage my patients to do so for 3 weeks or more during May 1993 (41). Basically, the amount of incisional bleeding
the interval between scalp reductions. with the laser was much less than with a scalpel, and the time
for initial wound healing was slightly prolonged with the laser.
‘‘Shaw Knife’’ and Carbon Dioxide Lasers I did not feel that the postoperative edema and discomfort, or
the ultimate healing, was affected by the laser in either a positive
Some physicians have employed either a Shaw knife (a hot or a negative fashion. My conclusion was that the Coherent
knife) or a CO2 laser in scalp reductions. With the Shaw knife, Ultrapulse CO2 laser was a useful tool for scalp reduction inci-
the epidermis and dermis are initially incised with a standard sion, if one was also going to use the laser for other purposes
scalpel. Both of these instruments cauterize blood vessels as (e.g., epidermal resurfacing). If one planned to use the laser
they cut through the tissue. With the Shaw knife, the blade is only for scalp reduction, the cost of the equipment might not
heated by electrocautery, whereas the CO2 laser is used in the be justified.
focused cutting mode to photocoagulate blood vessels. As ex-
pected, use of either of these devices results in minimal opera- Concomitant Scalp Reduction and Graft
tive bleeding and blood loss and a shorter operating time. A Transplantation
secondary benefit is the decreased likelihood of postoperative
bleeding and hematoma formation. With certain patients who either have to travel a great distance
The disadvantages of the Shaw scalpel are the cost of pur- for each procedure, or who are limited in the amount of time
chase and thermal tissue damage that may impede healing and they can be away from work yet wish to progress as quickly
adversely affect the quality of the scar. With the CO2 laser, as possible, a procedure combining both scalp reduction and
there is less thermal tissue damage, and wound healing is less graft hair transplantation can be performed. Usually, the scalp
likely to be as impaired. On the other hand, the purchase cost reduction operation is completed first, followed by the hair
of the laser is far greater, and special training is required for transplantation.
its proper use. Fire and eye damage are potential dangers that The ring block anesthesia is designed to encompass the area
must be avoided with this type of laser. of reduction as well as the transplant recipient area. Most often,
Almost all physicians now use the standard scalpel for reduc- a modified S or Y pattern is surgically carried out and then a
tions and epinephrine to decrease bleeding. Although there is U-shaped area is transplanted anteriorly. Sometimes, a crescent
less bleeding with the Shaw knife and CO2 laser, either insuffi- of the crown or sagittal midline pattern has been used in combi-
cient knowledge of their application in this field or their disad- nation with transplantation to the anterior region. On one occa-
vantages have so far prevented their widespread use. sion, a lateral pattern was carried out on the right side while
During the first half of 1993, I used a Coherent Ultrapulse transplantation was carried out to a ledge along the left side of
CO2 laser instead of a scalpel for the scalp reduction incision the midscalp and crown regions. The primary consideration for
on several patients. The Ultrapulse laser is the newest type of the combined procedure is blood supply. If there is any question
732 Chapter 19
about whether the blood supply to either region will be compro- Continued tissue expansion does have some inherent diffi-
mised, it is wiser to carry out each procedure separately. culties. The expander(s) can be uncomfortable, especially each
Concomitant scalp reductions are also used during repair time saline is added, and an enlargement of the scalp region
sessions on patients who have had poor results with previous that has been compared to a hydrocephalus deformity is created
transplants. Worthwhile grafts are removed from the area to be during the last 6 weeks of treatment. Tissue necrosis, hematoma,
excised and retransplanted to thicken the remaining areas (see infection, nerve dysfunction, seroma formation, bone resorp-
Fig. 19A-8). Frequently, today the grafts are divided into micro- tion, chronic pain, expander extrusion, and expander malfunc-
and minigrafts before retransplantation. tion, all have been reported. Overall, however, continued tissue
expansion of the scalp can be extremely useful for patients
with minimal scalp laxity (Figs. 19A-45 to Figs. 19A-48) or
Minireductions for correction of extensive areas of alopecia. Because of the
Another type of combined procedures involves hair transplanta- appearance deformity that is created before improvement is
tion and minireductions (18,22). Although it is acknowledged gained, this method of scalp reduction is often not accepted by
that repeated minireductions may eventually save one standard the patient for the treatment of MPB. Please refer to the works
type of reduction, I do not routinely employ them. If the galea of Vogel, Nordström, and Anderson in this text for additional
is not closed in a minireduction, there is a significantly increased information on this subject.
risk of bleeding and postoperative spreading of the scar. On the
other hand, if one does close such a minireduction in two layers, Intraoperative or Rapid Tissue Expansion
considering the amount of time required, I prefer to do a stan-
A newer technique based on the principle of ‘‘tissue creep’’ is
dard-type reduction, as the latter procedure would have substan-
intraoperative tissue expansion, initially described in 1977 by
tially more beneficial results.
Gibson (46). Much of the pioneering work in this area has been
I do use minireductions in some persons with poor punch
done by Sasaki (47). In this technique, a tissue expander is
graft transplant results. Sites that can be punched out and su-
inserted in a pocket at the time of surgery and then inflated
tured closed are treated in this fashion to remove bald areas,
and deflated for several stress-load cycles during the operation,
without consuming any of the limited remaining supply of
rather than being left in place for several weeks. Each cycle
donor grafts (22).
the expander is inflated with saline for 2 to 3 min, followed by
a deflated rest period of similar duration. Usually three or more
cycles are carried out during the operation and each time the
SCALP REDUCTION WITH TISSUE expander can be inflated a little more. The reported average
EXPANSION ‘‘gain’’ in tissue varies with the anatomical location.
Classic or Continued Tissue Expansion
The concept of tissue expansion before excision was popular-
ized by Radovan. Initially, the procedure was used for the ex-
pansion of chest tissue as part of postmastectomy reconstruction
(42). Following this, the technique was applied to the treatment
of lesions of the limbs, including giant nevi and tattoos (43).
In more recent years, several physicians have applied the princi-
ples of tissue expansion to scalp surgery (44,45).
To date, tissue expansion of the scalp is most frequently
being carried out to successfully remove large areas of cicatri-
cial alopecia or posttraumatic defects. Recently, the use of one
or more tissue expanders has been applied to the treatment of
male pattern baldness. This usually occurs in patients who have
very limited laxity and in whom other types of reductions pro-
vide very little benefit.
During the first operative procedure, the tissue expanders
are placed under the hair-bearing scalp that is to be expanded.
Wound healing is then allowed to occur for 2 weeks, following
which saline is added progressively (approximately 10% of the
volume of the expander) to each expander on a weekly basis.
After the first few weeks, saline can be added twice a week or
even more frequently if suitable care is taken. Once the hair-
bearing region has been fully expanded, the second operative
procedure is carried out, during which the tissue expanders are
removed and the scalp tissue is suitably advanced and rotated
to replace as much of the area of alopecia as possible. This Figure 19A-45 Dorsal view of male patient with tissue expan-
second operation is basically carried out in the same fashion ders inserted through a lateral crown incision on each side. The
that would be used with tissue expansion in other parts of the scalp tissue to be expanded was used as the donor area for the
body. anterior grafts.
Figure 19A-46 Dorsal view of Fig. 19A-45 10 weeks later

with the scalp tissue fully expanded. Figure 19A-48 Postoperative posterior view of same patient
as Fig. 19A-47.
Several authors have published their findings when this tech-

nique is carried out in the scalp area (48–50). Mandy has re-
ported that he can remove up to 30% more scalp tissue when Arnold described an alternative method for rapid, intraoperative
intraoperative tissue expansion is used (50). tissue expansion using modified towel clips, called tension
In May of 1993, at the First World Congress of the Interna- clamps (51). He purposely excises approximately 20% more
tional Society for Hair Restoration Surgery, in Dallas, Texas, scalp tissue with his rocketship-type scalp reduction, and then
approximates the wound edges by ‘‘tension clamping.’’ Three
or four tension clamps are used to place continuous tension
along the lateral flaps, which results in tissue creep and the
approximation of the wound edges after 10 min or so. Arnold
has utilized this technique for the past 5 years on approximately
300 patients, but had never previously reported its use. He did
not feel that stretch-back or widening of the scar was a problem
postoperatively and has recommended that initially only 10%
extra tissue be removed, then 15%, and then 20% when one is
comfortable with the technique. This technique could also be
extremely useful to bring about minimal tension closure of the
galea if inadvertently more than an ideal amount of tissue is
removed during scalp reduction.
Presuturing
Presuturing is also a relatively new technique that primarily
involves Gibson’s principle of tissue creep (46). The inherent
distensibility of scalp tissue limits the amount of tissue that
can be excised and still allow a cosmetically pleasing result.
Recently, however, it has been shown that tissue distension
can be increased by tissue creep. This mechanical creep is the
property that allows the gradual stretch of the skin beyond the
limits of its inherent extensibility when a constant, extending
load is applied (46). Stress reduction—the phenomenon that
describes the decrease that occurs, with time, in the force re-
Figure 19A-47 Posterior view of Fig. 19A-46 with preopera- quired to hold skin at a certain length (46)—is likely an impor-
tive markings for lateral incisions and anesthesia. tant factor with presuturing as well.
734 Chapter 19
In 1988, Liang et al. described the technique of presuturing With regard to scalp extension, my own findings to date
to increase the distensibility of tissue before the excision of confirm those of Dr. Frechet (58). Between September 1993
malignant neoplasms (52). Their study demonstrated that, if the and the end of that year, I carried out scalp extension on 11 of
area was presutured 12 to 24 h before surgery, areas that often my own patients and, in December 1993, had the privilege of
required flaps or grafts for closure could be primarily closed working with Dr. Frechet in Paris. With each patient, I was
even without undermining. Recently, presuturing has been used able to carry out the second scalp reduction after only 30 days,
by several physicians 12 to 24 h before scalp reduction surgery whereas formerly, I routinely waited 3 months. In addition, all
(53), and Meirson et al. reported that 25% to 35% more scalp of my patients had a ‘‘bonus’’ amount of scalp alopecia re-
tissue could be removed using this technique (54). In this latter moved because of the compression of tissue that was removed
study, the tissue for excision was plicated by using several during the second operation. In essence then, tissue extension
cross-horizontal or horizontal mattress sutures of 2–0 nylon, allows us to remove a greater amount of tissue in two operations
12 to 24 h before the scalp reduction. than we normally would, and also allows us to perform the two
Presuturing does involve two procedures instead of one, and operations only 30 days apart. I am now carrying out a study
many patients prefer not to have local anesthetic and a dressing with the University of Toronto and Dr. James Vogel of Johns
twice, despite the benefit. Provided the patient is agreeable, Hopkins, to determine if the changes that occur in the scalp
this technique is a useful adjunctive procedure before scalp tissue from scalp extension are the same as those produced from
reduction and should be encouraged. This is particularly true tissue expansion. The scalp biopsies are being studied for the
for patients with limited scalp laxity, that is, Bosley classes I number of mitotic figures present both before and after each
and II (28). type of operation.
A side effect with this procedure, which I first reported pub-
THE FRECHET SCALP EXTENDER licly in Palm Springs (58), is that two-thirds of my own patients
built up some fluid in the immediate area of the extender. This
At the First World Congress of the International Society for first occurred after 1–2 weeks and varied in volume from 4 to
Hair Restoration Surgery, Frechet presented for the first time 10 ml. With each patient in whom this occurred, the fluid was
his surgical technique which he calls scalp extension (55). In removed with sterile technique and culture of the fluid con-
this technique, a thin sheet of silicone elastimer is used, and at firmed that no infection was present. This side effect was signif-
each end is attached a piece of titanium metal, approximately icantly visible in only one patient and readily correctable by
5 cm long, from which protrudes a row of hooks. The device sterile aspiration. In all likelihood, this fluid is the result of the
itself is called an extender and the silicone sheet has elastic body reacting to a foreign material in the subgaleal space. It is
properties that enable it to stretch up to 200%, yet like an elastic not uncommon for a serous fluid also to develop in the subgaleal
band maintains a strong natural tendency to return to its original space when tissue expansion is being carried out.
size. Some patients do temporarily experience more postoperative
The term scalp extension really refers to a combination of discomfort or a greater feeling of tightness after scalp extension
tissue expansion and scalp reduction (56). In this procedure, an than with scalp reduction. This has occurred in approximately
Unger modified major type of scalp reduction is carried out, but half of my patients, but has not posed a significant problem.
before closure of the galea, the row of metal hooks is attached to The only real disadvantage of extension is that the patient must
the underside of the galea, 1 or 2 cm lateral to the hair margin pay for two separate procedures as well as the extender only
on that side. Following this, the silicone sheet is stretched signif- 30 days apart rather than at the usual 3-month interval. For
icantly to double its length or slightly more and then is similarly patients who prefer to proceed as quickly as possible, and are
attached to the underside of the galea, 1 or 2 cm lateral to the financially able to do so, scalp extension is an excellent addi-
hair margin, on the opposite side. With experience, apparently tional option. Both my patients and I are extremely pleased
the insertion of the extender can be done in 1 or 2 min. Follow- with the results we have been able to achieve with this proce-
ing this, the scalp reduction is closed in the usual fashion, using dure. There is no doubt in my mind that increasingly, in the
only moderate tension for the galea. future, more and more colleagues will offer scalp extension to
The extender is left in place for 30 to 40 days, during which their patients.
time the lateral fringes from each side move closer to each other
because of the elastic nature of the silicone sheet. After this
time interval, a second similar scalp reduction is carried out, THE MAJOR REDUCTION OR EXTENSIVE
during which the extender is removed as well as significantly SCALP LIFTING
more redundant tissue than usual. It is believed that the elasticity
causes almost a type of internal tissue expansion of the hair- As related previously, in 1983, an extensive type of lateral scalp
bearing region on each side. Dr. Frechet related that often he reduction was first described by Marzola, who virtually under-
is able to remove a width of up to 10 cm in total with the two mined the entire hair-bearing portion of the scalp on one side
scalp reductions when the extender is used. This represents a (59). The incision was made vertically in the anterior temple
very significant surgical advancement, because we seem to be region and then followed the superior margin of the lateral
having all of the benefits of tissue expansion without the defor- fringe on the dorsum of the scalp to the opposite occipital re-
mity caused by it. Dr. Frechet’s paper on the subject was pub- gion. This procedure was first performed bilaterally in 1985 by
lished in the Journal of Dermatological Surgery and Oncology Bradshaw of Australia (60), and the operation became known
in July of 1993 (57). The author is privileged to be a reviewer as a bilateral lateral scalp reduction or, alternatively, a major
for that journal and strongly recommended expediting publica- scalp reduction. The operation was subsequently introduced to
tion of this new concept. North America by Brandy, who published several papers dem-
onstrating excellent results with this type of surgery. These ini- Equally important is that I am able to achieve similar results
tial articles reported that the complication rate was ‘‘similar with other types of scalp reduction procedures.
to those of conventional scalp reductions (61)’’, and that the
incidence of postoperative necrosis was less than 1% (61,62)
In May 1987, at the International Congress for Hair Replace-
THE UNGER-MODIFIED MAJOR REDUCTION
ment Surgery in Los Angeles, the bilateral lateral scalp reduc- I developed this operative procedure as a compromise between
tion procedure was the focus of several papers as well as of a the standard reduction and the major reduction (69,70). In this
panel discussion. Several physicians, including myself, related procedure, usually a modified S-shaped pattern, or a Y pattern
their experiences with serious post-operative complications, in- is now most commonly used, and undermining is carried out
cluding necrosis of the scalp itself. As previously reported (63), far more extensively than with the standard reduction. Occa-
Bradshaw experienced ten cases of postoperative necrosis fol- sionally, a modified sagittal midline ellipse pattern (Figs. 19A-
lowing 35 operations. Marzola carried out five operations and 49 and Figs. 19A-50), or an anteriorly based U-shaped excision
had necrosis in 100% of these cases. The author had two cases pattern is used. With each pattern, undermining is carried out
of postoperative necrosis following the procedure in a total of laterally down to the attachment of the ear on each side and
ten cases and, in addition, witnessed several other patients with laterally and posteriorly to the superior nuchal ridge. The occipi-
severe postoperative necrosis following this surgery done else- tal nerve and artery are not divided, and the occipitalis muscle
where. In Australia, there have been several cases where the itself is left intact. The posterior auricular vessels are divided
entire hair-bearing portion of the scalp has been lost on one only when necessary (approximately 50% of the time), and in-
side, and in one Australian man, the scalp was totally destroyed jury to the superficial temple vessels is avoided. The U-shaped
on both sides (63). As a result of this complication, both Mar- pattern provides better exposure for undermining than the other
zola and myself abandoned the bilateral lateral reduction (64). patterns, but does require substantially more time for operative
In all of these cases the occipital arteries were not ligated before closure as well as postoperative suture removal. During the
the major reduction, nor preserved during the surgery. dissection, exposure of the deeper portions of the wound can
The incidence of postoperative necrosis following the bilat- be facilitated using Unger retractors, which were developed for
eral lateral reduction has been significantly higher than initially this purpose (70). As a result of this more extensive undermin-
reported and, in December 1991, Brandy reported this compli- ing, a significantly larger area of alopecia on the dorsum of
cation in 6.5% of 168 cases when the occipital arteries were the scalp can be removed than with standard reductions. These
not ligated before the major reduction (65). In 160 other cases reductions can be repeated in 3 months, as with the regular or
where these arteries were ligated 4 to 8 weeks before surgery, standard reduction, or in 30 to 40 days if a Frechet extender is
the incidence of necrosis was 7.5% if a horizontal incision was used.
made (80 patients) but 0% if a vertical incision was carried out The preoperative preparation and anesthetic techniques are
instead (also 80 patients)(65). I cannot account for this latter the same as those previously described for the standard reduc-
difference in findings. At the present time Dr. Brandy continues tion.
to ligate both occipital arteries 4 to 8 weeks before surgery and
uses a vertical incision for this. Readers will have to judge the
procedure for themselves.
Other authors have preferred to reduce the possible risk of
postoperative necrosis following extensive scalp lifting by intra-
operative unilateral occipital artery ligation (i.e., one occipital
artery is divided and one is left intact). Swinehart and Griffin
have reported this technique in more than 50 cases without any
incidence of necrosis (66). Similarly, Konior has used this same
technique for at least 2 years, with similar results (67). In es-
sence, with these physicians the operation carried out is a com-
promise midway between the Marzola lateral reduction and the
bilateral lateral reduction, as originally carried out by Bradshaw.
Their experience to date has been very favorable and, one hopes,
this success will continue in the future.
At the present time, Dr. Marzola continues to carry out Mar-
zola lateral reductions on one side at a time, but is now able
to preserve the occipital artery during each operation most of
the time (68). This represents an important advancement in the
safety of his procedure and represents yet another possible
variation of extensive scalp lifting. Certainly the technical skill
to preserve the occipital artery intraoperatively during an exten-
sive scalp lift is far greater than when it is not preserved. When-
ever possible, I would strongly advocate preserving the occipital
artery during extensive scalp lifting of any type.
In view of my unfavorable past experience with postopera-
tive necrosis and scalp numbness with extensive scalp lifting, I
am still reluctant to carry out this procedure on my own patients. Figure 19A-49 Preoperative view of Fig. 19A-50.
736 Chapter 19
view of this, I still prefer not to carry out major reductions on

my patients. In addition, in the next few months I plan to use
a T-shaped extender, in which operation the third set of hooks
will be used to elevate the occipital region. This, I hope, will
be even more beneficial and give all the advantages of extensive
scalp lifting in the occipital area as well, without any of its
disadvantages.
COMPLICATIONS
In my experience (over 8000 operations), remarkably few com-
plications have occurred (70). By far, the most common compli-
cation has been a superficial catgut reaction. During the first
year of carrying out scalp reductions, the skin sutures were left
to dissolve, and 20% of the patients had these reactions. This
consisted of either erythema or small pustules where the sutures
penetrated the skin along the suture line. Treatment consisted
of removing the sutures, after which the problem resolved in a
few days without any long-term consequences. A 4–0 chromic
catgut suture has continued to be used because of its closeness
to normal skin color, but it has since been removed after 5 to
7 days. This has virtually eliminated the problem.
The next most common complication has been a deep or
galeal suture reaction. Intially, healing occurred beautifully but
then, after 3–4 weeks, a small opening would develop at one
Figure 19A-50 Postoperative result of an Unger-modified or more sites where 2–0 chromic catgut sutures had been used
major reduction using a sagittal midline elliptical pattern. for galeal closure. If left untreated, often two or more openings
coalesced (Fig. 19A-51). This reaction occurred in 10% of the
patients (12 patients) during the short time that I used catgut
for the galea. Since that time, 2–0 Dexon has produced only
The surgical technique is also similar to that previously de- 12 cases, and none has yet occurred with 2–0 Vicryl sutures,
scribed for the standard reduction, with the exception that the although this material has been used much less frequently than
dissection is carried out far more extensively. Initially, the Dexon. Treatment consists of suture removal and suitable daily
curved 7-in. Metzenbaum scissors is used to complete the dis- cleansing until the openings are closed.
section just beyond the lateral fringe. Following this, either Temporary postoperative facial edema has occurred in ap-
an 11-in. curved Metzenbaum scissors is used to continue the proximately 20% of my patients. The incidence of postoperative
dissection or, alternatively, blunt finger dissection is used to the edema is far higher in those patients who refuse or who medi-
extent previously described. The measurement of the amount of cally cannot receive systemic steroids. Fewer than 20 patients
tissue to be removed and the closure are exactly the same as have had wider scars than the usual fine line, and perhaps 20
with the standard reduction. to 30 patients have had a grooving or indentation of the scar
The Unger-modified major reduction has several very signif- itself. In all these latter cases, the patients had a much thicker
icant advantages over the major reduction. Sensation to the oc- scalp depth than usual, yet this complication did not occur in
cipital region is always preserved, postoperative hair loss is hundreds of other patients with similarly thick scalp tissues.
prevented, and the scars anterior to or in the temporal region Most likely, poor healing ability of the patient was the cause
are avoided. The operating time and blood loss are considerably of the indentation as well as the wider scars, as each patient
less, and no postoperative drain is required. The amount of had the galea closed with minimal tension.
bruising, edema, and discomfort after the procedure is similar A small number of patients have had superficial necrosis of
to that of a standard reduction, and there is no significant prob- the skin edge, and one patient had superficial necrosis of a small
lem with postoperative nausea. The risk of tissue necrosis is adjacent transplanted area. The area had been transplanted on
minimized because there is less interruption of the blood supply four separate occasions and, after undermining, obviously had
of the scalp, and this has not yet occurred, even when the donor inadequate circulation. To prevent this complication from oc-
area has been extensively harvested on previous occasions. curring again, I no longer undermine transplanted scalp tissue
With extensive scalp lifting, usually the first operation in- if more than two hair transplants have been carried out to the
volves ligation of the occipital arteries, and then the actual re- area. A postoperative infection (Staphylococcus aureus) oc-
duction is carried out in 4 to 8 weeks. I prefer to carry out curred in two patients, despite prophylactic antibiotics. No other
two intermediate operations (modified majors), rather than one complications have been seen in my practice with the regular
minor procedure (artery ligation) and then one major operation. and Unger-modified major reductions.
The area of alopecia removed after two operations either way Postoperative bleeding, hematoma (especially after galeoto-
is often quite comparable. However, if a Frechet extender is mies), would dehiscence, flap necrosis, and permanent hair loss,
used with the Unger-modified major reductions, the area of all are potential complications of scalp reductions (71). One
alopecia removed is certainly equal or greater in amount. In case of osteomyelitis of the skull has been reported (72).
wound dehiscence and permanent hair loss. In my opinion, it

is always much wiser to take a little bit less than to take a little
bit more. When the procedure is carried out as advocated, the
likelihood of any complication is far less than with most cos-
metic surgical procedures (70). The improvement in appearance
and patient gratification from alopecia reductions is extremely
rewarding.
19B. My Approach to Alopecia

Reductions
Mario Marzola
INTRODUCTION
In the 6 years that have elapsed since the last edition of this
textbook, alopecia reductions (ARs) have undergone enormous
change. Not only has the name changed from scalp reduction
to alopecia reduction but also the whole emphasis has changed
from large heroic procedures to a minimalist approach. The hair
loss sufferer is no longer interested in major surgery regardless
of the benefits, but will contemplate an AR as long as the proce-
dure is not too difficult to cope with. Pain, time off work, com-
plications, and visible scarring can now be deciding factors,
Figure 19A-51 Severe ‘‘deep suture reaction.’’ Openings of whereas, in the past, they were accepted as part of the improve-
suture sites have coalesced anteriorly. ment process. This evolution is welcomed by enlightened sur-
geons who now see a resurgence of smaller, quicker, and easier
ARs that allow the excision of 20, 30, or 40 square centimeters
of scalp, with almost no complications. This can be done once
Norwood and co-workers have concluded that the incidence or twice, for example, reducing the need for 1000 to 1500 follic-
of complications decreases very significantly with increasing ular unit grafts (FUGs) each time.
experience (73). My findings indicate that scalp reductions, in
general, are safe and relatively complication-free when per-
formed as recommended in this chapter. TODAY’S RULES
1. No scarring in visible areas. The design of the AR must
CONCLUSIONS restrict incisions and thereby scars, to areas that will
subsequently be transplanted with micrografts. In this
Scalp reductions have now been carried out for over 18 years. way, all evidence of surgery will be buried under perma-
Modifications and improvements over the years have contrib- nent hair growth (Fig. 19B-1).
uted significantly to the results, and the concept of scalp reduc- 2. No cutting of large arteries or nerves. It is possible to
tion itself has now gained widespread recognition and accep- perform successful ARs and multiple micrograft proce-
tance. dures without destroying any significant arteries or
Although scalp reduction has been used by itself to decrease nerves. Therefore, complications such as severe anagen
the area of alopecia present, it is most commonly used in combi- effluvium, necrosis, hypoesthesia and hyperesthesia can
nation with hair transplantation to remove a large percentage be a thing of the past.
of the alopecia of the midscalp and crown areas or, alternatively, 3. No discarding of reasonable hair. With the advent of
to assist in the repair of previous unsatisfactory hair transplanta- medical hair treatment, ARs may no longer be necessary
tion. The Unger-modified major scalp reduction has proved where the scalp to be discarded still contains reasonable
most beneficial in these areas, but for some patients with limited hair. The miniaturization process of baldness can often
mobility of the scalp tissue, classic and intraoperative tissue be halted or reversed with finasteride therapy—at least
expansion and presuturing have also been very useful. The use for 5 or more years—if it has not gone too far.
of the Frechet extender in combination with the Unger-modified 4. Remember stretch-back. A gain of 4 cm will be reduced
major scalp reduction is proving to be extremely effective for to 3 cm if no measures are taken to prevent it from
patients with extensive hair loss. No single pattern for scalp happening. Deeper undermining and closing with slow-
reduction is ideal for all patients, and the surgeon should have dissolving sutures (PDS, Panacryl) has been my pre-
the talent and desire to modify each operation to achieve the ferred method so far. Periosteal suturing described by
goals of that individual patient. Dr Gerard Seery (1) is simple to do and appears promis-
Attempts to remove the maximum amount of skin in each ing, while the use of any stretching device is best left
patient could conceivably lead to severe complications, such as until more experience is gained.
738 Chapter 19
3. Economy. Less cost, per hair moved, compared with

micrografting.
4. Better use of the available hair. Traditional micrograft
harvesting rarely uses the hair posterior, superior, or
anterior to the ears, whereas an AR can make this good
hair contribute toward the overall hair coverage.
5. A more balanced end result. The decreased density of
the lifted sides and harvested occipital areas approxi-
mates more closely the density achievable with micro-
grafting, i.e., the strong contrast between the heavy
growth on the back and sides and see-through grafted
area on the top will be avoided.
6. Useful in repair work. Previous unaesthetic surgery, low
hairlines, or alopecia from injury, unanticipated pro-
gression of MPB, burns and diseases such as lichen
planopilaris can be treated or improved with AR.
THE CONSULTATION
Tell the patient that this is a new procedure for you, but that
you have had training and that the excision will be very conserv-
ative. Also, that the cost to him will be minimal compared to
covering the equivalent area with micrografts. Show him the
pictures and drawings supplied with your training and as many
as possible from textbooks and articles so he can see that this
is not a new idea.
If he has little or no hair on the scalp to be excised, has
dense side hair, a mobile scalp and is interested in the economic
Figure 19B-1 Scars after one alopecia reduction sited in areas benefits of AR, he is a suitable candidate for the procedure. If
that will later be transplanted. his scalp is too tight or too loose, if the hair is sparse on the
sides or if there is still lots of hair in the balding scalp, then
ARs are contraindicated, even if the patient is keen.
5. Remember ongoing hair loss. The young patient with Tell Him What to Expect
a family history of extensive hair loss must be treated 1. Headache for 12 to 24 hours, controllable with analge-
very conservatively with AR or not at all. He may be a sics and sedation.
Norwood Class VII—in the making—with only enough 2. A tight feeling, as if wearing a tight hat, for two to three
donor supply for an isolated forelock which cannot days.
cover a lot of scarring. 3. A suture line on the top scalp ,which will be neat and
clean, but may be visible if little hair exists for camou-
flage.
ALOPECIA REDUCTIONS FOR BEGINNERS 4. Very few complications, such as black eyes or infection,
With the renewed interest in ARs, there will be many beginners. will occur if instructions are adhered to.
Medico-legally, it is not wise today to read an article or a text
and then go ahead with the first procedure as some of us did
many years ago. It is important to read widely on the subject, PREOPERATIVE INSTRUCTIONS
befriend an experienced practitioner and visit to observe, and, 1. Massage the scalp to increase mobility, e.g., 10 min-
if possible, get hands-on experience while you are there. Once utes twice a day for 3weeks to 5 months before sur-
the basic safety aspects have been mastered, all that is needed gery.
is a degree of surgical and artistic ability, which most cosmetic 2. Leave hair long to aid coverage of sutures after sur-
surgeons possess, whether it is used or not. gery.
3. Wash and dry hair with usual shampoo the night before
or morning of the operation, but apply no treatment
SETTING THE SCENE lotions or sprays.
Advertise the benefits of ARs among your existing patients, and 4. Wear comfortable clothes – no tight collars.
in the media, to get your alopecia reduction practice underway: 5. Eat normal but light meals and then fast for four hours
before surgery. No alcohol for 2 days or acetylsalicylic
1. Instant result. acid compounds for 2 weeks preoperatively.
2. ‘‘Will it grow’’ is not a concern. 6. Arrange for someone to pick-up the patient after the
procedure and get their telephone number so that they 3. Operating table that can be flat or tilted with the head
can be called when the patient is ready. Taxis may be up or down
used, but patients MUST NOT DRIVE on the day of 4. Set-up for intravenous delivery of drugs and fluid
the surgery. 5. Oxygen delivery system
7. Out-of-town patients should arrange to stay in the city 6. Pulse oximeter with BP monitoring facility
overnight, because long distance travel, immediately 7. ECG monitor and defibrillator
after surgery, is not advisable. 8. Sterile drapes and gowns (disposable)
8. Ask patients to give as much notice as possible if it 9. Suction machine, tubes, and sucker instrument
is necessary to change the surgery date. 10. Diathermy machine
9. Half of the surgery fee should be paid, at the time of 11. Two helpful staff, one scrubbed and one for various
booking, to secure a surgery date. needs as they occur
10. The remainder of the fee is paid, on arrival, on the 12. Drugs: midazolam (Versed) and sublimase (Fentanyl),
date of surgery. 2% lidocaine with epinephrine (Adrenaline) 1:40,000
for the ring block. Also 10 mL of normal saline with
1:20,000 epinephrine for intradermal injections into
PREPARE YOUR OPERATING ROOM proposed incision lines
ARs require more invasive surgery than grafting hair, thus more 13. Instruments
instruments and monitoring equipment will be needed in the Place a sterile drape on stainless steel trolley; 2 ⳯ sterilizing
operating room (OR) to facilitate a safe, comfortable, and strips; large bowl; kidney dish; 2 ⳯ Gallipots; light handle;
smooth surgery (Fig. 19B-2). diathermy lead; diathermy forceps; Yankeur sucker; comb;
This is the list of equipment, instruments, and staffing used ruler; 2 ⳯ small towel clips; 2 ⳯ large towel clips; 2 ⳯ Cat’s
in my surgical room: paws; 2 ⳯ Darling retractors; 2 ⳯ Artery clips; large needle
1. Photography corner with professional lighting and holder; small needle holder; blade handle; 1 ⳯ Metzenbaum
light-blue background scissors (extra long); 1 ⳯ Metzenbaum scissors (thin variety);
2. Clean air-conditioned room with operating light or scissors small; large forceps; small forceps; sponge holder; skin
equivalent hook; No.10 blade; Nylon 4/0 clear; Panacryl or PDS; 2 packs
Figure 19B-2 An operating room equipped for safe local anes- Figure 19B-3 This design stays out of the crown area but other-
thesia procedures with conscious sedation. wise perfectly matches the bald area.
740 Chapter 19
abdominal sponges; 2 sterile drape sheets; Betadine; chlorhexi-

dine; normal saline.
WHICH DESIGN?
The scalp is so malleable and forgiving that just about any
design is acceptable from a safety point of view. The incisions
must not go deep into the crown or anterior to the hairline, but
otherwise we choose the design which best suits the presenting
pattern of alopecia. We also remove the most alopecic areas of
the scalp and leave that part of the scalp which still contains
good hair.
If we are lucky enough to be presented with a long, narrow
pattern of baldness as in Figures. 19B-3, 19B-4, and 19B-5, an
ellipse, modified at each end, if necessary, chooses itself. It can
have an S curve at the end or a rocket-ship design, if we wish
to raise the occipital hair-bearing rim as well. In Figures 19B-
3 and 19B-5, the curve at the crown can be reversed, if a second
procedure is desired 2 months later, allowing a more even exci-
sion of the crown alopecia. When a central forelock remains
and the temples and midscalp and crown are alopecic, as in
Figs. 19B-6 & 19B-7, the incisions are made in two locations,
as lateral ellipses, so that the posterior hair-bearing rim is not
raised (see Fig. 19B-7). Alternatively, they may be joined to
form an M-shaped AR, previously described.(see Fig. 19B-7).
Figure 19B-5 Similar to Figure 19B-3. If a second alopecia

reduction is desired 2 months later, it can curve to the right side
for an even excision of the crown baldness.
The M-shaped design allows deep undermining in all areas,

thus making it a very efficient lifting procedure. However, it
is a more complicated procedure than other AR designs and it
would be prudent to utilize this method after the surgeon has
become more experienced with ARs.
When the alopecia is more advanced, as in Figs. 19B-8 &
19B-9, negotiating the design around remaining hair is not an
issue. As noted earlier, as long as the incisions are not made
in the most posterior aspects of the crown and remain behind
the hairline, we can choose any design. Burrow’s Triangle, de-
scribed by Bernard Cohen (3) or the Modified S-pattern, de-
scribed by Schauder et al (4) are eminently suitable. It is best
not to modify the established designs during the early stages
of one’s AR career. However, after a good deal of experience,
the surgeon is encouraged to modify, change, and adapt any of
the above designs in a manner which better suits the individual’s
needs.
If the patient presents with early stages of male pattern bald-
ness (MPB) (Fig. 19B-10), it is advisable to prescribe finaster-
ide (Propecia) in order to maintain existing hair for as long as
possible. However, some transplanting can also be carried out
to improve aesthetics. In patients who have reached, or may
Figure 19B-4 Rocket-ship design helps to lift the occipital reach, Norwood Class VII, (Fig. 19B-11) ARs are contraindi-
hair-bearing rim but must not stray into the vertical part of the cated. Not enough hair is available in the permanent donor rim
crown. to allow for camouflage of the resulting scars.
Figure 19B-6 Two ellipses remove the most alopecic scalp without lifting the back.
Figure 19B-7 The M-shaped alopecia reduction gives access

to all areas for deep undermining and therefore generous lifting of Figure 19B-8 A Burrow’s triangle, alopecia reduction also al-
the hair-bearing scalp. lows good undermining access and usually produces minimal scars.
742 Chapter 19
Figure 19B-9 The Modified S-pattern. Remember the result-

Figure 19B-11 This candidate with Norwood Class VII alope-
ing scar must eventually be covered by hair grafts.
cia is best treated with limited micrografting, not alopecia reduc-
tions.
Figure 19B-10 a and b) These candidates should use finasteride to retain existing hair and grafting can be added to the sparse areas.
Alopecia reduction is not indicated because too much hair would be discarded.
THE SURGERY If a patient has a naturally lax scalp, or has massaged it

preoperatively to make it more lax, it is possible to excise 3
The patient needs to be comfortable and relaxed before cm to 4 cm of bald scalp in the coronal direction. With the
undergoing surgery. This is achieved and maintained by seda- assistance of the nurse, the lateral sides of the scalp are pushed
tion with Fentanyl. Two percent lidocaine, with epinephrine 1: upward to waist coat over the alopecic scalp. When it is laid
40,000, (Fig. 19B-12) is utilized to create a ring block around out over the alopecic area, an imprint is left (see Fig. 19B-13b).
the entire scalp. The greatest challenge is to control bleeding. This indicates the amount that should be excised and then the
It is important to proceed slowly and inject the epinephrine 15 to edges can be approximated. It is often possible to remove .05
20 minutes before beginning the procedure, in order to produce cm to1 cm more of the alopecic area than indicated by the
vasoconstriction. Clean the scalp and hair with a nonalcoholic overlap, while still allowing for closure with minimal tension.
antiseptic (chlorhexidine or Betadine) including forehead, ears, The entire undermined area should be irrigated with a few mL
and upper neck. Make the incisions and immediately cauterize of Betadine and checked for any remaining bleeders. The wound
any pulsating bleeders. A clean field allows clear vision during is then closed with subcutaneous sutures that dissolve slowly
undermining, thereby helping the surgeon to remain in the sub- (PDS, Panacryl), in an effort to minimize stretch-back. Incon-
galeal plane and to keep away from significant structures. The spicuous sutures such as clear 4/0 Nylon are used for the superfi-
incision must be deep enough to sever the galea and open the cial skin closure. Once the edges of the skin have been brought
subgaleal, undermining plane. Once the bleeding is under con- together evenly and neatly, there will be no need for a bandage
trol, lift the galeal edge with a cat’s paw or hook, and look for (see Fig. 19B-13C). Remember, there were no significant ves-
the white connective tissue. Metzenbaum scissors are ideal to sels severed, and the sutures control any bleeding from the su-
separate the connective tissue fibers and cut through the tough- perficial vessels. Thus, it is rare for there to be any further
est ones (Fig. 19B-13a). significant blood loss.
This undermining dissection can proceed as far as one
wishes, while under direct vision. If the incision has been made
along the lateral hair fringe, direct view is possible up to the RECOVERY
reflection of the external ear and scalp, which is more than
sufficient for our purposes. If the incision is in the midline, the Allow the patient a few hours to recover in a quiet room. He
last half of this undermining may need to be done blindly, but should now have a feeling of tightness but not of pain. If there
still safely, if the instrument is blunt such as one’s finger or is a particularly painful area, inject a few milliliters of 2% lido-
large, broad closed scissors. If one is aiming for minimal exci- caine with epinephrine 1:80,000 until the pain has subsided.
sion, undermining the entire lateral scalp will be sufficient. Some patients sail through the experience, while others make
There is no need to undermine the frontal scalp, nor the occipital ‘‘heavy weather’’ of it. At all times, however, they should stay
scalp, which represents most of the donor area and must be in the office until the sedation has worn off and all pain is under
protected. good control with local anesthesia. Supply the patient with anal-
Figure 19B-12 Ring block with lidocaine and epinephrine along the indicated lines anesthetizes all the scalp.
744 Chapter 19
Figure 19B-13 a) Undermining in the subgaleal plane exposes loose white connective tissue. b) Imprint left on the bald scalp to help
approximate the amount of tissue to be excised. c) Neat and clean after the surgery.
gesic tablets (codeine strength) and hypnotics, such as temaze- 2. Normal diet but no alcohol or acetylsalicylic acid for
pam, which may be needed for a few days. The whole proce- 2 days
dure, although not sterile, has been a clean one, and given the 3. For three days, sleep on a recliner chair or raise the
scalp’s ability to fight infection, antibiotics are not routinely head of the bed by 30⬚ to avoid ecchymosis around
required. the eyes
It is important that the patient not sleep in the prone position 4. Take the pain relieving medication and the sleeping
for three nights, postoperatively, in order to avoid ecchymosis tablets provided.
around the eyes. Sleeping in a recliner chair, or raising the head 5. With precautionary advice from the staff, a hat, cap
of the mattress to 30⬚ ensures this instruction is followed. or hairpiece may be worn immediately after surgery.
6. Minimize bending, stooping, or straining for 2 days
postoperatively.
POSTOPERATIVE INSTRUCTIONS 7. No strenuous physical activity, including swimming
1. Rest, sleep, read or watch TV for the rest of the day for one week and no contact sports for 3 weeks postop-
of surgery and also reduce activity the next day. eratively. Take care getting in and out of the car and
in other situations that may cause you to bump your 2. Stretch-back: It is inevitable that some of the initial gain
head. Protect the head from sunburn as much as pos- will be lost in most patients but this can be minimized.
sible. 3. Edema: Forehead swelling will occur in 25% of cases,
8. Report to the office any bleeding, infection, swelling, and resolves with rest, ice packs, and corticosteroids.
or excessive discomfort. Any operation-induced tem- 4. Black eyes: This occurs very rarely—perhaps 1% of
porary hair loss (anagen effluvium), should also be patients—and usually is due to the patient having slept
reported. in the prone position.
9. Wash hair and scalp daily with the antiseptic shampoo 5. Infection: Postoperative infection is seen in patients
supplied until it is finished, then use your usual with poor hygiene or in those with compromised resis-
shampoo. tance to infection..The rate is approximately 0.5%.
10. Medical certificates are issued where required, but 6. Anagen effluvium: Marginal hair loss near the sutures
usually 2 days from work is ample. may occur, but there is no severe loss.
11. If there are any problems at all, postoperatively, please
don’t suffer in silence because simple solutions are
DEGREE OF DIFFICULTY
often available. Please call the professional staff at our
office. Most practitioners express concern with—and fear of—under-
mining. This need not be so. A clean field, with little or no
bleeding, will expose the loose subgaleal space which can often
COMPLICATIONS be opened up with finger pressure only. To avoid major blood
As is the case with any surgical procedure, care, attention to vessels and nerves, the surgeon only has to be sure to proceed
detail, and good postoperative care minimize the rate of un- slowly and maintain a clear visual field. Furthermore, closure
pleasant side effects and complications. of an AR is very similar to that performed in the donor area.
After large transplant procedures of 2000 FUs or more the big
1. Pain: Every person experiences a headache and a tight difference is the depth of undermining, but otherwise the princi-
feeling in their scalp. These are easily controlled with ples of wound closure are the same. Clearly, in the alopecic
medication. scalp, we always have a strong fibrotic galea at the base of the
Figure 19B-14 a) Coronal distance (between lateral hair fringes) is 8.5cm and sagittally (between glabella and crown hair fringe) is
27cm before ARs. b) After two alopecia reductions coronal distance is reduced to 3 cm and the sagittal length is 22 cm after stretch-back.
Here the crown scalp was undermined and raised with good benefit.
746 Chapter 19
Figure 19B-15 a and b) Superior and posterior views of the alopecic area preoperatively. c) After two ARs, the alopecic area is almost
completely excised. Micrografts complete the treatment and finasteride maintains it.
Figure 19B-16 a) Hairline is too low at 6 cm above the glabella. b) After one M-shaped reduction the hairline was lifted with the
forehead. A temporary black eye was the only complication.
wound, and any tension on closure must be borne by this layer.

Strong, interrupted, long-lasting sutures help to keep the galeal
edges together. The physician needs to utilize the same preci-
sion that is used to close the skin edges of the donor area in
hair transplant procedures.
RESULTS
Figures. 19B-14a & b and 19B-15a, b, & c show the type of
results which can be achieved with simple AR. Too many practi-
tioners have now established practices that do not include the
option of AR. I feel that their patients are not always being
offered the best combination of procedures. There are very clear
situations where ARs, in conjunction with hair transplanting,
would be advantageous to the patient. I would encourage every
serious hair restoration practitioner to consider incorporating
this simple and effective procedure into his/her practice.
ADVANCED ALOPECIA REDUCTIONS

Many situations will present themselves during a hair restora-
tion surgeon’s career, where an ingenious use of ARs will be
very helpful to the patient. Unfortunately, we are still seeing
many hairlines that have been placed too low, despite the con-
tinued caution issued about this subject at multiple yearly con-
ferences and in many articles. The M-shaped AR can be used
to raise and correct the hairline, as in Figs. 19B-16a & b, and
as described by Dr Vogel (5) Undermining to the orbital rims Figure 19B-17 Lateral hair fringe has dropped away from the
allows generous lift of the forehead scalp and any grafts found in punch grafts on top. One reduction each side reapproximates the
the excised portion of the scalp can be reharvested and planted two.
748 Chapter 19
Figure 19B-18 a) Traumatic alopecia, first reduction. b) Plan for second reduction 2 months later. c) Final scar can be further improved
with a few micrografts.
elsewhere. There are many old punch-graft patients, who are This then makes AR the most frequently performed operation
now presenting with a halo of bald scalp around the transplants, in hair restoration surgery. Admittedly, the majority of surgeons
as in Fig. 19B-17. The design of the AR can be customized to will perform ARs (outside of the donor area) infrequently or
bring the two hair-bearing areas into close proximity. After this, not at all. Pomerantz reported, in his 1996 survey, that approxi-
the repair work can be completed with micrografting. mately 32% of all physicians never employ AR, 49% will use
In cases of scarring alopecias that are burnt out, or in trau- it occasionally, and 9% will use it in almost all patients. Of
matic alopecias, as in Figs. 19B-18a, b, & c, simple excision those who employ the procedure occasionally, 42% percent will
makes a lot more sense than trying to grow grafted hair in this perform no more than two per patient, and 4% will do as many
scarred area, especially when there is sufficient hair around the as three ARs or more(1). I have used AR as part of my hair
alopecic area. Certainly, it will be more efficient and therefore restoration practice for the past 22 years. The need for this
more economical for the patient. Because patient benefit is our modality has decreased over the years and most patients have
primary consideration, those of us who do not have expertise no more than two ARs. Nevertheless, it is a useful surgical
in AR should refer the patient to those who do. There is litera- alternative that is utilized in approximately 5% of my patients.
ture against (6,7) and for (8,9) the use of ARs, and this text I have found that it is an especially valuable tool for the repair
discusses AR at length. Thus, the reader has the opportunity to of poorly performed grafting operations, where the patient is
develop an informed opinion without much difficulty. left with widened temporal gulfs, misplaced hairlines, and donor
The reader will also find that many maneuvers and devices depletion. (See also Chapter 17A.)
have been recommended to increase the amount of alopecia Some hair restoration surgeons believe that those who em-
excised during each operation. Scalp expansion prior to surgery ploy AR in nearly every patient have a misguided approach.
(10), scalp extension between operations (11), Pate (12) Sure Yet, if one reads other sections of this chapter, with an open
Closure (13), Miami Star (14), and any number of other devices mind, there is much to suggest that those surgeons who never
can be used to further stretch the scalp before closure. At this employ, or for that matter never consider AR, have an approach
time, Frechet’s extension system is the most widely used, be- that is misguided. If the hair restoration surgeon wants to offer
cause it is both effective and unobtrusive. It should be offered patients as many options as possible, he or she has to be totally
to willing patients as soon as the surgeon has enough experience familiar with the concepts and goals of AR, be prepared to use
to utilize it. Galeotomies made in the same direction as the the technique where indicated, have a thorough knowledge of
scalp incision will help to approximate the wound edges with its consequences and potential complications, and a command
less tension, especially in cases where the galea is strong and of their management. The latter is the purpose of this chapter.
inelastic. However, these incisions must be made with great care
because the vessels, which traverse the plane just superficial to Photo Documentation
the galea, can be easily injured. In the past, I have used endo-
scopic undermining (2) but its value has been found to be mini- It is impossible to always avoid complications in AR—or any
mal compared with the difficulties involved. other type of surgery. Yet, problems and misunderstandings
between patient and physician can be minimized from the start
Editor’s Comment by maintaining precise photo documentation. It is imperative
Dr. Marzola was an early and strong proponent of AR. Later, that accurate, high-quality photographs be taken before and
he changed his mind. At one point, he felt that because of the after the hair restoration process. Although this topic is covered
potential long-term consequences of AR that it should virtually in more detail in other parts of this text, I would like to offer
never be used. I attended several lectures he gave, in which a few suggestions here for the surgeon who is performing AR
he strongly elaborated on that position. His conversion to that surgery, in the hope that they may help avoid future problems
opinion was hailed by opponents of AR as positive proof that and enhance communication between the patient and the physi-
the procedure was obsolete. This submission to the text clarifies cian.
his now more moderate views. (WU) I have, for many years, employed both standard photogra-
phy, as well as instant-production photography but recently has
changed to a digital system. The digital reproductions are accu-
19C. The Complications of Alopecia rate and precise, but more importantly, they are easier to stan-
dardize and the photos can be produced almost instantaneously.
Reduction These benefits easily justify the initial expense of the system.
Robert V. Cattani Your photographs, whatever system you may employ, must be
as representative as possible and must be shown to the patient
INTRODUCTION before any procedure is started. With photos for illustration, I
would advise the surgeon to demonstrate to the patient the ra-
I consider Alopecia Reduction (AR) an important surgical op- tionale behind performing the AR, the expected results of the
tion in the field of hair restoration surgery. It would be nearly surgery, and the problems that may be encountered preopera-
impossible to practice hair replacement surgery without en- tively. In my opinion, one should never perform any kind of
countering patients who need, desire, or who have had previous hair restoration surgery without taking accurate and detailed
AR. Therefore, knowledge of this procedure should be part of preoperative photographs. I use a triple-check system in my
the repertoire of every hair restoration surgeon. Further- office to assure that all patients are preoperatively photo-
more—and considered from an alternative viewpoint—each graphed—at least twice. It includes a checklist on the front of
and every time the surgeon harvests donor tissue in a grafting the chart, a checklist on the preoperative sheet, as well as a check-
procedure he is in point of fact, performing a scalp reduction. list in the operating room. Despite all precautions, and my
750 Chapter 19
triple-check system, one patient slipped through it; we assumed exploration, evacuation, saline lavage and drainage, and then
photos taken would be developed promptly and discovered that, closure of the wound. During exploration, significant bleeders
although the photographs had been taken, they had been lost. are often not found out and careful inspection for them is neces-
This is really an inexcusable event in modern day medicine. I sary. There are also rare instances where the surgeon detects
recommend a photographic consent form, which I have used troublesome bleeding arising from bone perforators. Since these
for the last 15 years. The photographic consent form has become are not amenable to the usual treatment utilized to control hem-
an invaluable legal asset in my practice. (Appendix 19C-1) orrhages, the prudent surgeon should have bone wax in the
surgical suite ready to be applied in such cases. I recommend
The Dissatisfied Patient that Penrose drains be inserted and removed after 24 to 48
hours. Antibiotics are optional.
Without question, the most frequent complication of AR sur- There are some hair restoration surgeons who feel that galeo-
gery is the dissatisfied patient. This complication far outnum- tomies produce troublesome bleeding and may be associated
bers the other cited problems, including bleeding, hemorrhage, with an increased incident of hematoma in AR surgery. These
infection, suture reaction, and obvious scarring. If the surgeon physicians have generally decided to abandon the use of galeo-
is planning to perform AR, he or she must completely and tomies.
thoroughly explain the procedure to the patient, not simply as
an isolated operation but as an integral part of a complete pro- Infection
gram of surgical hair replacement that includes transplantation
as well as scalp surgery. The surgeon must be certain that the Infection is a very rare complication of AR, provided that the
patient is informed and willing to follow through the entire surgeon employs proper surgical techniques, perioperative pro-
treatment process. Whether one begins or ends with scalp reduc- phylactic antibiotics similar to those used for hair transplanting
tion, or utilizes it in the middle of the surgical sequence, the and tension-free closure. I have encountered only one small,
patient must understand the complete surgical program that has localized infection in over 20 years of practice. This was cul-
been recommended. Always remember knowledge given before tured and found to be Staphylococcus aureus that responded
an operation will be considered information, but that same in- to drainage and antibiotics and healed with normal incisional
formation given to the patient after a procedure is interpreted scarring. A review of the literature to date revealed only one
as an excuse! If this initial discussion is thorough and clear, reported case of osteomyelitis of the skull(2). If the patient
the surgeon can be certain to encounter very few dissatisfied demonstrates any of the classic symptoms or signs of infection
patients. postoperatively, (erythema, tenderness and/or purulent dis-
Hair restoration surgery is a cosmetic procedure and the goal charge), I advise taking aerobic and anaerobic cultures from the
of all cosmetic surgery is to please the patient. It must, therefore, wound, performing a saline lavage, and administering empirical
be established from the beginning whether the patient is capable antibiotics until culture results are available. It is important to
of being pleased, what it will take to please him, and if that adhere to the rules of basic medical follow-up: daily examina-
goal can be achieved. The surgeon may feel very proud after tions, documentation of vital signs, wound care and treatment
performing what is considered a perfect AR, yet if it has not based on culture and close contact.
met the patient’s expectations or if the patient is dissatisfied
because he did not understand the purpose of your sur- Superficial Catgut Reaction
gery—then the procedure has been a failure. This is a complication that is commonly encountered in AR.
In the 21st century, in America, I would strongly advise an Although morbidity is limited, it is uncomfortable for the pa-
itemized consent form, initialed and signed by the patient in tient. The reaction results in tenderness, erythema, and (occa-
each and every case of AR (Appendix 19C-2). In years past, sionally) pustule formation over and about the suture area. It
the incidence of litigation in hair restoration surgery was mini- may involve the full length of the surgical closure. This problem
mal. But now, its occurrence is increasing and doctors must can be avoided by meticulous attention to cleansing, avoidance
protect themselves. of tension in closure, and timely removal of the suture material.
For many years, I have used 4.0-chromic catgut to close donor
Hematoma wounds and reactions are eliminated or minimized if the sutures
are removed on postoperative day 5 to 7. Antibiotics are rarely,
Hematomas will occasionally occur with ARs, even if all pre- if ever, necessary.
cautions are followed. These precautions include rigorous pre-
operative evaluations (both a thorough history and lab studies), Wide or Unacceptable Scars
medical clearance, meticulous interoperative hemostasis, and
adequate training in all aspects of the surgery. As described This is a too common and distressing complication of AR. It
elsewhere in this text, the scalp is supplied with a vast anasto- is usually avoidable. Before surgery, the doctor should take a
motic system of branches of the external and internal carotid thorough history and perform a focused preoperative examina-
arteries. This anastomotic arcade lies in the subcutaneous layer tion to look for existing scar tissue. If the findings are accept-
of the scalp and connects with a system of veins and lymphatics. able, surgery can proceed, paying particular attention to rudi-
Vascular contributions are also supplied by meningeal vessels mentary surgical principles, which include (in the case of AR):
that perforate the skull. Although hematomas are infrequent, 1) judicious undermining; 2) a layered closure—first of the
the surgeons should be mindful of their potential occurrence galea and then the dermis and epidermis; and most importantly,
and, for this reason, the patient should be examined 24 hours 3) final resection and approximation of tissue in a manner which
postoperatively. The management of hematomas involves open allows for tension-free closure.
Please note, that the term judicious undermining has been Sensory Nerve Damage
used. This is because it is believed that undermining is usually
essential and indispensable to optimal wound closure. However, The sensory nerve supply of the scalp follows alongside the
Seery, in his study of the surgical anatomy of the scalp, has vascular network. It arises peripherally and courses subcutane-
stated… ‘‘in very lax scalps, it is possible to remove 5 cm ously in a centripetal direction. It is, therefore, well removed
widths at the mid-sagittal ellipse and yet easily close the wound from the usual area of resection in scalp reduction surgery.
without any undermining. Conversely, in tight scalps, removing Nevertheless, nerves can be injured or severed when the scalp
5 cm and achieving closure is impossible, regardless of the surgery involves extensive undermining and blind dissection.
extent of undermining. This leads to the conclusion that the The result of such injury is loss of sensation in the region.
more important factor, by far, and in determining the extent of Permanent loss of sensitivity is not very common. Most numb-
tissue amenable to excision, is not the extent of undermining, ness is temporary, lasting 2 to 3 months, and the patient should
but the degree of laxity. It is also concluded, that the extent of be warned preoperatively about its occurrence. However, to put
undermining and (the)tissue amenable to removal, are not line- things in perspective, it is far less common than when the occipi-
arly related(3).’’ Seery goes on to explain that both too little tal area is harvested for several sessions of hair transplantation
and too extensive undermining not only may be ineffectual, but surgery.
is associated with problems that include opening tissue planes
to infection, traumatizing blood vessels and nerves, and causing Postoperative Edema
fibrosis throughout the undermined area. I believe that he is
Swelling of the forehead, periorbital area, and upper face occurs
not wrong in his conclusions. Therefore, I recommend the re-
frequently (in up to 30% of patients) after AR. Swelling usually
moval of excess skin with only judicious undermining. The
commences on the second or third postoperative day. It results
surgeon should never presume that a certain fixed amount of
in unsightly edema and occasionally can cause a temporary
skin can be removed in each and every patient. To do so would
visual disturbance, but these effects are self-limiting. In reality,
guarantee that he or she will eventually encounter a problem
postoperative edema should be considered a sequela or conse-
or a disaster. It is recommended that the surgeon undermine
quence of surgery rather than a complication.
and then test for tension at all points of closure, before any
I have found that the use of systemic corticosteroids, as sup-
resection is undertaken. An estimation is then made as to the
plied in a Dose-pak, for example, helps to minimize or prevent
maximum amount of tissue that can be removed, and the sur-
edema if started 1 day preoperatively. Patients should always
geon is advised to remove even less than the amount suggested.
be warned of the probability of this sequela.
If the surgeon follows this method, closure without tension is
virtually guaranteed. Closure under tension will not only pro-
duce widened, unsightly scars, but will also result in thinning CONCLUSION
of the dermis and, possibly, permanent hair loss in certain
areas—perfectly avoidable problems. AR remains a viable option in the armamentarium of hair resto-
There are some patients who will not heal well, despite con- ration surgery. Surgeons should, therefore, be familiar with all
servative resection and careful attention to all of the basic prin- the techniques of AR, its use, limitations, complications, and
ciples of surgery. Examination of previous operative sites may management. Patients should be thoroughly counseled preoper-
often reveal widened scars and one should not automatically atively to ensure that the goals of the procedure and its possible
presume that these are secondary to bad surgical tech- complications are clearly understood. This, along with photo
nique—they may demonstrate the innate healing qualities par- documentation and itemized consent forms, helps enhance com-
ticular to the patient. This subject, including hypertrophic and munication with patients and thereby minimizes the possibility
keloid healing, is discussed in detail in Chapter 14C. of dissatisfaction—the most frequent complication seen after
AR.
Wound Dehiscence
The incidence of wound dehiscence in AR is quite low—less 19D. Galea Fixation: Alopecia
than 1%—and patients usually present with a segmental area
of wound separation, which does not involve the entire suture
Reduction Surgery
line. Causative factors will include an overly aggressive surgical Gerard E. Seery
resection, closure under tension, or failure to suture the galea.
This complication can also be caused by trauma postoperatively HISTORICAL BACKGROUND
and premature, strenuous physical exercise. Unfortunately, this
latter etiology is not an uncommon one. Alopecia Reduction (AR) surgery for male pattern baldness
A small regional wound dehiscence should be treated in the (MPB) was introduced in 1977(1,2). As originally described,
most conservative fashion, with basic wound care and daily the operation employed a sagittally orientated excision pattern
examination. This regimen will usually result in wound closure that paralleled the orientation of collagen fibers in the dermis,
and epithelialization. Larger dehiscences necessitate a return to thereby allowing removal of the maximum amount of tissue
the operating room, anesthesia, elevation of the flaps, further and the best possible scar. The operation was quickly accepted
judicious undermining (if necessary), and a layered closure be- as a worthwhile adjuvant treatment in hair restoration surgery,
ginning with galeal sutures. It is my opinion that patients who but there was trouble ahead.
must return to the operating room for surgical correction should Not satisfied with removing only modest amounts of bald
receive perioperative antibiotic therapy as well. scalp, the surgical mindset became how much can I get out.
752 Chapter 19
This thought process led to the devising of a series of alternative

excision patterns (paramedian, Mercedes pattern, curvilinear,
zig-zag, Y-pattern, T-pattern, etc.) and other operative modifi-
cations including the radical scalp-lifting procedures(3). In the
main, these innovations were counter-productive and inappro-
priately placed incisions in the peripheral scalp that not only
transected collagen but also severed centripetally directed cuta-
neous arteries and nerves at proximal levels with resultant wide-
spread devascularization and desensitization of tissues.
Furthermore, more aggressive undermining was done in the
belief that this was necessary to allow maximal removal of
tissue. Undermining and retraction of frontal tissues distorted
the frontal hair and hairline. Undermining and advancing the
occipital donor distorted hair patterns and decreased density.
This, when coupled with traction closure, further exacerbated
the problem and resulted in a cascade of complications that
bedeviled progress in alopecia removal surgery.
In summary, the modifications of the original scalp reduction
operation, while successful in terms of removing increased
amounts of bald scalp, exacted the very high price of largely
intractable complications of unsightly scars, diminished sensa-
tion, decreased hair density, distorted hair patterns, stretch-
back, and poorly vascularized, stretch-atrophied tissues. Scalp Figure 19D-1 Midline elliptical exposure with subgaleal dis-
reduction, initially a well conceived simple and effective proce- section to about 5 cm from each wound edge. Undermining is
dure had, in the course of a few years, produced a quagmire confined to areas indicated.
of complications and caused many surgeons to abandon the
operation. (It is perhaps easy to be critical of surgeons who
devised and performed these operations but this would be pat-
ently unfair. Surgery is evolutionary in nature and most surgical
procedures, now mainstream, had origin in precursors replete of 20 mg is used for sedation. More than 35 mL of 1/100,000
with missteps and well-intentioned errors.) epinephrine is rarely required.
In 1993, a brief but shining moment occurred with the advent
of Patrick Frechet’s brilliant extender innovation with its prom- Step 1 Incision and Exposure (Fig. 19D-1). A sagittal or
ise for controlling tension vector forces in the tissues(4). This midline vertical ellipse is recommended as the excision pattern
initially looked like it might save the day, but the inexorable of choice. This allows ample exposure for the limited undermin-
flight from scalp reduction was now in full spate and the opera- ing necessary and, by largely lying in the axis of the lines of
tion too far advanced on the slippery slope to be reprieved. minimum tension, permits maximal excision with minimal
Minds had closed and by late 1994, scalp reduction reached its scar(6). In practice, the ellipse extends from the posterior
nadir and was performed by a limited number of surgeons. reaches of the frontal scalp to the lower limits of the balding
Overlooked, however, in the avalanche of bad news was the fact crown (as relevant to the particular case) but in no circumstance
that, during the so-called dark ages of scalp reduction, enormous should it even remotely enter the prospective donor area. In a
amounts of information were derived pertaining to what is pos- scalp of average laxity, the ellipse should measure about 3.5
sible and what is not, in terms of determining how complication- cm to 4 cm at the mid-ellipse and have a vertical length of
free AR reduction could be done(5). about 10 cm to 13 cm.
The procedure described herein and entitled, Galea Fixation, Step 2 Undermining. One margin of the ellipse is incised
is believed to be based on sound scientific principles and is an down to the pericranium. Two towel clips placed on the wound
attempt to describe how a simple, safe, effective, and complica- edge make excellent retractors to facilitate undermining in the
tion-free alopecia removal may be performed. subgaleal plane for a distance of about 5 cm from each marked
wound margin bilaterally. As much as possible of the loose
connective tissue, attached to the pericranium, should be left
GALEA FIXATION in place. Only minimal bleeding from the wound edge (which
normally stops spontaneously) is encountered and the well-de-
Operative Technique fined subgaleal plane is easily dissected. It is very important
not to undermine the frontal scalp and occipital donor areas.
Case selection—Tight or poorly flexible scalps are excluded
on the basis of unsuitability. Step 3 Testing. Firm upward and medial pressure is man-
Anesthesia—The operation is carried out under local ring- ually applied to the sides of the scalp to approximate the wound
block tissue infiltration anesthesia with the patient in a sitting margins and establish the feasibility of elliptical excision and
position and the backrest slightly reclined. Supraorbital nerve closure. Wound flaps are overlapped, excess tissue measured
block is routinely used. Intravenous Diazepam to a maximum and marked and the ellipse excised.
of these is individually sutured to the central pericranium under

moderate tension. This has the effect of drawing the wound
margins into close approximation. The scalp is then closed with-
out tension in two layers.
If measurement of stretch-back is deemed relevant, two tat-
too marks are made with indelible ink at the outer limits of the
bald area bilaterally and in a transverse axis at the midpoint of
the wound.
Results
The practical effect of the above is that about 450 sq mm of
bald scalp is removed in a single procedure. Two, or possibly
three, operations are usually possible without the development
of a central slot-scar. Good quality scars were consistently
achieved.
Figure 19D-2 Deep plane fixation. Deep aspect of galea is

sutured to central pericranium at approximately 5 cm from the Complications
wound margin. Complications of bleeding, seromas, hematomas, infection,
wound dehiscence, and ulceration were essentially nonexistent
in a personal series of over 1000 procedures(8). Complications
detailed, earlier, of stretched unsightly scars, stretch-atrophied,
Step 4 Deep Plane Fixation: Deep plane fixation is a term devascularized insensitive tissues, and slot formation were rare
used to describe surgical techniques that divert tension vector almost to the point of nonexistence, in over 700 cases with
forces, created on wound closure, away from superficial tissues deep plane galeal fixation. Postoperative pain was considerably
into deep plane pathways, where their deleterious effects are reduced relative to conventional scalp reduction procedures.
harmlessly dissipated. Such techniques have the potential for
allowing as much as 50% greater tissue excision while signifi-
cantly reducing tension closure(7). A series (usually three) of Comparative Statistics
2/0 nylon sutures are bilaterally placed in a vertical axis in the Scalp reduction results are reviewed by Richard Shiell, M. D.
deep aspect of galea at the limit of undermining, i.e., about 5 (Alopecia Reduction Revisited. Hair Transplantation Forum
cm from each wound margin (Figs. 19D-2 and 19D-3). Each
International Vol. 6. No. 2, 1996.) A 35 mm reduction is quoted
‘‘as an average for first reductions by surgeons using central
or paramedian approaches and closing under moderate tension.
Allowing for Nordström’s 40% stretch-back, this reduces the
worthwhile benefit to 21 mm.’’ Martin Unger, M. D. reports
stretch-back to be around 10% with an average excision of 24
mm in his modified major procedure. Dr. Nordström’s own
figures for first central reductions are quoted as 36 mm with
an average stretch-back of 40% or a net gain of 22 mm.
The galea fixation operation has a 39 mm reduction with
13% stretch-back or 34 mm gain as detailed earlier. This repre-
sents a net gain of over 50% compared with the scalp reduction
procedures in Dr. Shiell’s analysis.
Discussion
Pericranial Fixation
Expertise in suturing galea to pericranium is immediately ac-
quired(9). In the rare case in which the pericranium is abnor-
mally thin, the inexperienced may find it useful to raise a small
pericranial flap for purposes of medial fixation. The safety and
efficiency of the procedure becomes apparent when the simple
parameters detailed above are respected. Any reservation the
inexperienced surgeon may have about suturing pericranium
Figure 19D-3 Three 2/0 nylon or polydioxanone (PDS) sutures will be quickly dispelled once it is attempted and the realization
are used to suture deep galea to central pericranium. prevails that the pericranium is a stout membrane of approxi-
754 Chapter 19
mately the same thickness as galea aponeurotica and eminently only in that one group had 5 cm undermining bilaterally and
capable of retaining sutures. There are no associated dangers. the other 15 cm of undermining bilaterally. Excision amounts
and stretch-back were essentially the same in both groups(7).
Immediate Transplantation
Hair transplantation immediately following galea fixation is ef- Central Scar Slot
fective and safe. Blood supply to the scalp is centripetal and Of all of the problems associated with serial alopecia removal,
cutaneous(10), i.e., it is not supplied by perforators and conse- that receiving most disparagement is the unsightly central mid-
quently, following sagittal alopecia removal, the blood circula- line slot. This scar, strictly speaking, is not a complication at
tion in the residual central scalp is in no way impaired. This all but a natural consequence of serial alopecia removal when
conclusion is supported by the personal finding that, in the more than 8 cm to 10 cm of tissue, as measured at mid-ellipse
presence of the fixation procedure described above, hair trans- level is excised.
plantation grafts placed between the opposed edges of the sagit- The previous paragraph is perhaps best understood by con-
tally sutured wound grew vigorously, despite being in a location sidering the effects of alopecia removal on the directional orien-
most distant from their primary arterial source and in tissues tation or drape of hair. It appears that this directionality, once
traumatized by surgery (Fig. 19D-4). established in infancy, is permanently retained, even when hair
The above observations led to the personal routine practice is surgically moved to a different location This is precisely what
of transplanting tissues immediately on completion of deep happens in serial alopecia removal, when hair, originally located
plane galeal fixation procedures. Grafts grew consistently and in the lateral parietal area and exhibiting a predominantly lateral
normally and there were no untoward sequelae in over 100 drape, is surgically advanced into the midline, where by retain-
cases. Immediate transplantation is confidently recommended ing its lateral orientation, now creates a most unnatural appear-
as eminently safe and highly effective. If more than one alopecia ance. This is sometimes referred to as ‘‘the parting of the Red
removal procedure is contemplated, the residual bald area re- Sea’’ (Fig. 19D-5).
maining and earmarked for later excision, is left ungrafted. In
this circumstance, immediate grafting is done only in tissues Stretch-Back
peripheral to this area. On completion of the final operation,
hair transplantation grafts are placed between the opposed mar- Stretch-back is a term coined by Rolf Nordström, M.D. (12) to
gins of the sutured wound. describe the stretching of skin in the residual bald area following
scalp reduction surgery. The term stretch-back may not be ap-
Dangers of Extensive Undermining propriate as it has the misleading connotation of elastic recoil.
A more appropriate term might be stretched out. The phenome-
Extensive undermining is ineffectual, meddlesome, and poten- non is not peculiar to scalp tissue and is described by Gibson
tially dangerous for reasons given earlier. as stress relaxation. As such, stretch-back should not be re-
Raposio (11), in an article published in 1999 on tensiometer garded as a complication but as an inevitable consequence of
measurements of flaps in serial scalp reduction, concluded that excision and suture surgery in elasticized tissue.
extensive undermining (15 cm) offered little benefit in terms In most tissues, stretch-back is not a problem because it
of tissue removal compared with 5 cm of undermining. This occurs gradually and often passes unnoticed by patient and sur-
conclusion is in accord with the surgical research findings per- geon alike. Unfortunately, however, in alopecia removal sur-
sonally derived in two groupings of AR procedures differing gery, stretch-back has the effect of stretching out any residual
centrally located bald skin, thereby decreasing the success of
bald scalp removal as seen immediately postoperatively, by a
figure variously reported as between 10% and 50% (7).
Dr. Nordström’s methodologies for measuring stretch-back
have become the bench-mark for subsequent investigators and
an essentially similar method is used in the studies detailed in
this paper, i.e., two indelible tattoo marks made 10 mm on each
side of the midpoint of the sutured wound.
In order to appreciate the significance of what, for example,
10% or 50% stretch-back actually means, it is necessary to be
aware of what is being measured and the limitations of measur-
ing methods.
With the Nordström method, only the distance between the
tattoo marks, i.e., 20 mm is monitored for stretch-back. This
20 mm is the locus where maximum tension is manifested and
straddles the sutures line at the midpoint of the ellipse. If, for
example, the diameter of the bald area is 100 mm, only its
central 20 mm is being monitored and this latter distance is not
accurately reflective of stretch-back as it applies to the entire
bald area diameter. Raposio’s studies (11) show that tension is
Figure 19D-4 Hair transplant grafts placed between opposed maximal at the sutured wound itself but rapidly trails off and
edges of sutured wound immediately postoperatively are seen to at 50 mm from the wound, 83.3% of the tension has dissipated.
be growing vigorously at 3 months. If, for example, the width of sutured wound measured 1 mm
Figure 19D-5 a) Unsightly divergent scar in significantly bald scalp. b) Central slot scar following serial scalp reduction of more than
8 cm.
and it subsequently stretched to 2 mm, this would represent sumed rationale that extensive undermining, by distributing the
a stretch-back of 100%, which, if extrapolated, would falsely tension vector forces to more remote widespread areas, would
suggest no operative gain whatsoever. lessen stretch-back effects on the wound and immediately adja-
A further drawback of the methodology is that stretch-back cent areas and thereby preserve the initially satisfactory, but
is being measured over a distance of a few millimeters and, as alas transitory, operative result.
such, is notably prone to error. Tension vector forces and stretch-back are maximal at the
If stretch-back is to be accurately measured, the diameter of wound and gradually diminish as they spread into peripheral
the entire bald area should be measured rather, and not just, in tissues where their intensity manifests less and less the farther
the small central segment that exhibits maximum tension. The they travel, before ultimately completely dissipating
extent of stretch-back is likely to be directly related to the degree Consequently, the undermining of peripheral tissues, where
of postoperative tension at the wound and its adjacent tissues. tension is relatively minimal, will do little to minimize tension
This belief led to the assumption that stretch-back could be at the wound site, and the more widespread the undermining,
reduced or eliminated by widespread undermining with the pre- the less effective it becomes. Galeal fixation surgery, on the
Figure 19D-6 Result of one galea fixation procedure.

756 Chapter 19
Figure 19D-7 Pretreatment and post-treatment result following two scalp reductions and less than 500 hair transplant grafts, mainly
to frontal scalp.
other hand, via the fixation mechanism, controls stretch-back Summary and Conclusion
maximally at the wound site and immediately adjacent tissues
by channeling tension-vector forces away from these areas and The Galeal fixation procedure is effective, simple, safe, and
into non-undermined peripheral tissues admirably adapted to virtually complicationfree. Hair transplantation can be safely
harmlessly absorb the deleterious tension forces (and may actu- performed in the immediate postoperative phase. The opera-
ally have the beneficial effect of promoting biological creep in tion does not require any particular surgical expertise or
hair-bearing peripheral tissues). special training and is well within the competence of hair
It must be pointed out that the fixation procedures do not restoration practitioners. To those who embark on it, the
totally eliminate stretch-back (14) but reduce it to about 10%. feasibility and effectiveness of the operation will become
There is, however, at least a possibility that this 10 % is compen- immediately apparent, as will its potential for providing
sated for by the biological creep referred to earlier. Although the key to allowing comprehensive treatment for male pat-
no scientific evidence to support this latter theory is offered, it tern baldness (Figs. 19D-6a, b; Figs. 19D-7a, b & Figs.
remains a confident speculation. 19D-8a, b).
Figure 19D-8 Pretreatment and post-treatment result following two galea fixation reductions and less than 1000 hair transplant grafts,
mainly to frontal scalp.
758 Chapter 19
760 Chapter 19
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22. Unger MG, Unger WP. Midline alopecia reduction combined 49. Auletta MJ. Comparison of skin hooks and Foley catheters for
with hair transplantation. Head Neck Surg 1985; 7:303–311. immediate tissue expansion. J. Dermatol. Surg. Oncol 1993; 19:
23. Frechet P. A new method for correction of the vertical scar 1084–1088.
observed following scalp reduction for extensive alopecia. J. 50. Mandy SH. Intraoperative expander-assisted scalp reduction. J.
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51. Arnold J. Tension clamping, an alternative method of rapid, 3. Cohen BH. The Burrow’s triangle scalp reduction. J. Dermatol.
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52. Liang MD, Briggs P, Heckler FR. Presuturing—a new technique 5. Vogel JE. Correcting frequently seen hair transplant problems.
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53. Lewis L, Stough DB, Unger MG. Personal communications. plant Forum 1996; 6(3):12–13.
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April 13, 1990. plantation. Dermatologic Clinics 1999; 17(2):277–296.
54. Meirson D, Reyes BA, Geronemus R. Presuturing in alopecia 8. Seery GE. Scalp reduction: mirror, mirror on the wall. Hair
reductions. J. Dermatol. Surg. Oncol 1990; 16:818–820. Transplant Forum 1999; 9(3):90–91.
55. Frechet P. Scalp extension with a new tool, the extender. Pre- 9. Unger MG. Shame,shame,shame and shame again. Hair Trans-
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56. Frechet P. Personal communications, May 1, 1993. tion of male pattern baldness. Br. J. Plast. Surg 1988; 41:
57. Frechet P. Scalp extension. J. Dermatol. Surg. Oncol 1993; 19: 154–159.
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20
Scalp Extension
20A. Scalp Extension areas of the scalp are reduced uniformly, and the effi-
cacy of AR decreases as one moves from the occipital
Patrick Frechet to the temporal areas.
2. AR has limited efficacy when performed on tight scalps,
INTRODUCTION which are encountered in 10% to 30% of the patients I
see. In such individuals, a large number of ARs are often
The surgical treatment of extensive alopecia, which affects necessary to reduce extensive androgenetic alopecia to
nearly one-half of all patients suffering from androgenetic alo- any noticeable degree.
pecia (AA), is still less than ideal. One of the main objectives 3. AR creates an esthetically displeasing ‘‘slot’’. A solu-
has been to find a technique that would offer relatively comfort- tion to this problem was elusive until the development
able and rapid elimination of alopecic areas, extending from of the triple-flap correction procedure, which will be
the temporal to the occipital region of the head. My solution discussed in the second part of this chapter.
was to develop a technique, which I have called scalp extension,
as well as a ‘‘tool’’ adapted for this purpose: the extender (1,2). Extensive areas of alopecia (seen in patients with Norwood
Success with this system owes much to experience. I acquired Types V to VII) may encompass as much as 300 cm2 of alopecic
this experience while carrying out alopecia reduction (AR) and scalp. With grafts alone, we are unable to completely cover this
using expanders. In order to clearly understand this new tech- whole area, as will be illustrated by the following explanation.
nique, it is useful to review some of the issues that led to its The donor area in most patients with extensive alopecia is able
development. to yield only a maximum of 6000 follicular units (FUs). This
number of FUs would create a density of only 20 FUs per cm2
if the entire amount were placed in a recipient area that is 300
cm2. This density is one-fifth that of normal nonbalding scalps
ALOPECIA REDUCTION: ADVANTAGES AND
and is cosmetically unsatisfactory. Ideally, at least 50 FUs per
DISADVANTAGES cm2 are necessary to create an adequate illusion of density.
Alopecia reduction (AR) arose from the desire to treat hair loss Only 120 cm2 of alopecic scalp can be corrected to achieve this
in the vertex and other extensive alopecias (stages V, VI, VII) density with the 6000 FUs that are available. For this reason,
(3–6). The main advantage of AR was felt to be its ability to many doctors will limit the use of grafts to the frontal area. For
increase the hair-bearing area, while reducing the alopecic area, the remaining 180 cm2 of alopecia, serial AR may reduce its
taking advantage of the scalp’s natural elasticity. This technique size, but will not lead to its total elimination. Therefore, even
had certain shortcomings, that limited its efficacy. the combination of simple AR, plus grafts, cannot offer these
patients a full head of hair at an acceptable density.
1. The most important of these shortcomings is stretch-
back; a term used to describe enlargement of an area
of alopecia from its immediate post-reduction size. It SCALP ‘‘EXPANSION’’
is made worse when tension is greater. Stretch-back
makes it necessary to excise 13 cm of scalp, or more, The advent of expanders was a giant step forward, demonstrat-
in order to eliminate an alopecic area only 10 cm wide: ing that skin is an elastic membrane that has the ability to stretch
successive stretch-backs occur after each AR. Mayer or enlarge in response to an appropriate physical stimulus (7,8).
and Fleming have estimated that, on average, with tradi- The implanting of expanders, under hair-bearing areas, made
tional AR, six procedures, spread over a 1-year period, it possible to enlarge the hair-bearing scalp, and subsequently
are necessary to remove 10 cm of alopecia (9). Not all perform AR with no wound tension, thereby avoiding any
765
766 Chapter 20
stretch-back. The incremental nature of tissue expansion also

made it possible to overcome the resistance of tight scalps by
stretching them out gradually over time. Thus, the essential
shortcomings observed with AR, do not exist when expanders
are used.
Unfortunately, the advantages of this tool are essentially
theoretical ones. In practice, its use has proved extremely lim-
ited in the treatment of androgenetic alopecia, because most
patients are not prepared to accept the unsightly increase in
scalp volume, the length of time, and the pain that this process
entails.
SCALP ‘‘EXTENSION’’
I wanted to find an approach that had the advantages of AR
and scalp expanders, without their disadvantages. I sought a
technique that would remove alopecic scalp, take advantage of
the elastic properties of the hair-bearing scalp, eliminate stretch-
back, and do all of this without the scalp deformity created by
volumetric expansion. This goal is what led to the development
of a scalp extender and scalp extension. I use this terminology
to denote the difference between expansion, which implies a
volumetric increase, and extension, which implies a flat in-
crease.
Figure 20A-1 The extender’s efficiency depends upon the
strength applied on the ‘‘recall’’ properties of the bioelastic. With
DESCRIPTION OF THE SCALP EXTENDER the new extender, we have increased the recall properties of the
The extender is a thin sheet of silicone elastomer, which is the bioelastic significantly. This extender is composed of titanium and
same material used for expanders. In its simplest form, it is a consists of two rows of titanium hooks, two strips of bioelastic,
rectangle with a row of hooks on the two lateral ends (Fig. 20A- and one sliding sheet underneath to avoid adherence. The extender
1). Its ‘‘width’’, or anterior-to-posterior dimension, is always 5 is affixed to the galea and stretched—usually by 100%.
cm, whereas its length (the distance from left to right) can vary,
depending on the alopecic area to be excised, from 4 to 7 cm.
It is usually less than 1 mm thick (0.15 to 1 mm). This sheet has 1. The width of the extender plays a role. The wider the
elastic properties that enable it to stretch by 100% (it doubles in elastic, the greater the force generated. In my studies I
length), with a natural tendency to return to its original size. found a 5 cm-wide extender optimally effective.
2. The number of extenders used may occasionally play
a role. Two extenders, one posterior to the other, have
HOW THE EXTENDER WORKS been used in very tight scalps. A slightly more effective
The extender is stretched and attached to the underside of the outcome was occasionally observed, but in general, one
galea; each row of hooks penetrate the galea and deep adipose extender is enough for most situations.
tissue (Fig. 20A-2). The extender has a natural tendency to 3. The length of time the extender is left in place has an
return progressively to its original size; consequently, stretching effect. With very tight scalps, one should leave the ex-
the tissue located outside the contraction zone (lateral to the tender in place for a slightly longer period of time in
hooks), and contracting the tissue surface located between the order to obtain better results.
rows of hooks (Fig. 20A-3). 4. The newer extenders have better elastic recoil properties
In other words, the activity of the extender is secondary to and this has improved the effectiveness of scalp exten-
its properties of contractility. If the bioelastic material has little sion.
or no contractility, no extension will result, and the extender 5. An inflammatory reaction that may sometimes be ob-
will act only as a retaining suture. Contraction can occur only served at the edges of the bioelastic material, can de-
if there is a sufficient amount of force generated within the crease the effectiveness of the extender. The less inflam-
bioelastic material to stimulate appropriate tissue reactions and mation the better. For this reason, there was interest
provoke biological ‘‘creep’’. Interestingly, however, effective- in a sliding sheet, which is now a component of the
ness of the extender is not totally related to the amount of extender.
contractile force created. Thus far, clinical observation has re-
vealed that beyond a certain point, not yet defined, increasing DESCRIPTION OF A TYPICAL OPERATION
the tension does not produce better results, and the more tension Initial Phase: Insertion of the Extender
in the extender, the more pain the patient feels.
A number of factors may influence the effectiveness of ex- Initially, the procedure is the same as for a conventional AR.
tenders: For example, in an elliptical midline AR, the same local anes-
Scalp Extension 767
Figure 20A-3 Extender drawn in place, with its stretch-back

effect on the hair-bearing areas and shrink-back effect on bald
areas.
hooks will be attached 0.05 to 1 cm lateral to the medial margin

of the good hair-bearing scalp. This means the extender, which
originally was 4 cm in length, will be stretched to a total of 9
Figure 20A-2 Extender affixed to the galea by a row of hooks.
cm to 10 cm. The degree of extension is thus approximately
100%. At this degree of extension, the elastic recoil forces cre-
ated should be enough to overcome the normal wound tension,
thesia is administered, the same stretching of the scalp is per- and will lead to the gradual retraction of the extender. With
formed, and the same width of alopecic scalp is excised (on experience in this type of operation, the insertion of the extender
average, 4 cm). Before closure of the flap, however, the row requires only 1 minute. Once both ends of the extender are
of hooks on one end of the extender is attached to the underside attached, the flaps are sutured—as in a conventional AR—on
of the galea, about 1 cm lateral and parallel to the good hair two planes, deep and superficial. The effects of the operation
margin. Before the operation, a pen is used to draw a line at are similar to those for a conventional AR. If the patient touches
the exact location where the rows of hooks are to be attached. the scalp, he can generally feel the two rows of hooks. This
To facilitate this attachment, forceps designed especially for makes it possible to detect that they are moving progressively
this purpose, are employed. Then, using a spatula applied to closer together as the weeks pass. For the moment, this is the
the row of hooks on the opposite side, the surgeon progressively simplest way of determining whether the extender has returned
stretches the bioelastic device, increasing its length until it to its original size.
reaches a point approximately 1 cm past the other side of the
lateral hair-bearing scalp at its galeal level. If we attach the Extender Removal Phase: Preliminary Observations
first row of hooks to the left temporoparietal hair margin, for
The patient returns in approximately 4 weeks to remove the
instance, we then attach the second row of hooks to the under-
extender. At this time, various phenomena can be noted that
side of the galea, parallel to the hair margin and 1 cm lateral
differentiate scalp extension from AR or scalp expansion:
to the right temporoparietal hair-bearing scalp (Fig. 20A-4).
The extender used must be able to double in length. If the 1. There is no unsightly volumetric modification of the
distance between good parietal hair-bearing scalp is initially 12 head, such as that seen with expanders (Figs. 20A-5 and
cm wide, and we then excise a 4 cm-wide piece of alopecic 20A-6).
tissue, we are left with a remaining width of 8 cm, across which 2. Instead of observing any stretch-back of the alopecic
the extender needs to be placed. As already noted, each row of area, we have achieved a further decrease in its width.
768 Chapter 20
Figure 20A-4 Extender in place before closure. Figure 20A-5 Patient A before treatment.
This means there has been a contraction or compression

of the tissue in the alopecic scalp during the 4-week 6. There is sometimes a slight laxity, or even a small fold
interval between the first and second surgical opera- in the alopecic area.
tions. In our example, if the width of the alopecic area 7. It is occasionally possible to detect the presence of the
has gone from 8 cm to 6 cm, a reduction of 25% has extender by its rows of hooks, and sometimes by a slight
occurred. This ‘‘shrink-back’’ is a unique phenomenon skin elevation that marks the lateral ends of the elastic
that is clearly superior to the ‘‘stretch-back’’ observed sheet. Although this is not a desirable characteristic, it
with AR (Fig. 20A-7 to Fig. 20A-10). is understandably more esthetically acceptable than the
3. The density of the temporoparietal hair-bearing areas head deformity which is seen with scalp expanders.
decreases more than with conventional AR, a phenome-
non that indicates a significant stretching of the hair- Removal of the Extender
bearing scalp in scalp extension, and that, even more
importantly, is limited to the hair-bearing scalp. The second operation is performed, for the most part, in a simi-
4. It is striking to note that when we use an extender, which lar fashion as a conventional elliptical midline AR. There is
is attached to both the temporal and parietal areas, both one difference—after the initial incision, there may be some
areas stretch very well. This phenomenon also differen- adhesion to the periphery of the extender, or even less fre-
tiates scalp extension from AR, during which any tem- quently, a collection of fluid superior to the extender. To remove
poral stretching is minimal. the extender, the rows of hooks must be detached first. To sim-
5. The scar is finer than with the conventional method of plify matters, the extender can be sectioned in the middle, and
AR. The absence of any tension on the line of closure, then the scissors are passed under the rows in the area of greatest
throughout the cicatrization process, is largely responsi- adherence. Following that, we can remove the row of hooks
ble for this. with the use of special forceps.
Scalp Extension 769
Figure 20A-7 Patient B: before treatment; 12-cm wide bald

Figure 20A-6 Patient A with the extender in place. No volume area.
deformity can be noticed.
DATA FROM CASES UTILIZING SCALP

After appropriate undermining, a conventional elliptical AR
EXTENSION
is performed. As a general rule, the ellipse will be almost the
same width as that in a normal AR—an average of 3 cm for a Table 20A-1 summarizes my results in the first 10 patients I
second AR. Consequently, in the example we have chosen, one treated. The subsequent commentary describes my experience
is left with a 3-cm area of alopecic scalp from an initial width with an additional 2000 patients treated over the past 10 years,
of 12 cm before treatment. This is a decrease of 9 cm in two except where indicated.
ARs: (12 cm of original alopecia) – (4 cm-decrease after first
AR Ⳮ 2 cm-decrease due to contraction from extender Ⳮ 3 cm Compression of the Alopecic Scalp
more removed in the second AR) resulting in 3 cm of residual
alopecia. Another important benefit to note is that the two ARs A marking with temporary tattoo points, reveals shrink-back in
can be performed within a shorter time period than usual—with the area located between the rows of hooks, which is more
an interval of 4 to 6 weeks. pronounced the closer the hooks are to one another. Conse-
Subsequently, dependent upon the width of the alopecic quently, it seems logical that to obtain the best shrink-back of
scalp that remains, another extension of smaller dimensions the alopecic area, these hooks should be placed in the hair-
can be performed immediately after the second one. It may be bearing area, but as close as possible to the hair margin. In this
possible to limit the number of operations to three, regardless way, the prolonged traction of the extender has an effect on the
of the initial width of the alopecic scalp, provided it does not entire height of the lateral hair-bearing scalp, which increases
exceed 15 cm. This decrease in the time interval and number in size, whereas the alopecic area decreases in size. That is why
of operations represents a considerable improvement over the the hooks should be placed approximately 0.05 cm to 1 cm
course of treatment required when utilizing conventional ARs. lateral to the permanent hair margin.
770 Chapter 20
Figure 20A-8 Patient B: same day after the first scalp reduction Figure 20A-9 Patient B: 30 days after first scalp reduction and
and with an extender in place: 9-cm wide bald area. just before the second scalp reduction. Shrink-back of the bald area
has reduced it to a 6-cm width.
Stretching Scalp in Parietal and Occipital Areas Recommended Time with the Extender In Situ
Stretching is undeniably more marked in these areas, as com- For many years the extender was left in place for an average
pared to conventional AR. Thus, there is a decrease in the den- of 29 to 30 days. Experience has revealed that 4 weeks is suffi-
sity of hair in the parietal area. It is advisable for the surgeon cient for loose scalps, whereas patients with tight scalps should
to warn the patient of this phenomenon, especially if the exten- have the extender in place for 6 weeks to achieve maximum
der is placed in the temporal position, and hair density is limited. results.
Consideration should be given before reducing that density by
as much as 100%. This having been said, I was not overly Complete Scalp Extension Treatment for Extensive
impressed with the consequences of this phenomenon as seen Alopecia
in most of the first 80 patients treated. It was a more significant
concern from a psychological standpoint, according to the im- Usually, two scalp extensions are necessary, one after the other,
portance each patient awarded to the phenomenon. Neverthe- to eliminate extensive androgenetic alopecia up to 15 cm in
less, it never had significant visual consequences and most pa- width.
tients should be reassured of this fact. After excising a 3 cm to 4 cm-wide alopecic midline area,
The extender effectively stretches all areas of the scalp lat- one will place an extender, which measures 5 cm to 6 cm in
eral or inferior to it, with greater effects in the more posterior length, at rest, but that stretches to 11 cm to 13 cm when placed
zones. Therefore, it is appropriate to place the extender as far in position. The technique of placing an extender, or removing
anteriorly as possible to obtain an equal and superior stretch of it, is extremely simple and well-explained when purchasing the
the entire lateral zone. device. Four to six weeks later, the alopecic area has shrunk
Scalp Extension 771
usually to about 8 cm to 10 cm wide. After removing the exten-

der, one can usually excise enough additional alopecic scalp to
reduce the area of alopecia to 5 cm to 7.5 cm in width. At this
stage, a 3 cm to 4 cm extender will be placed and streched to
7 cm to 9 cm. When the patient returns, 4 to 6 weeks later, the
area is usually 3.5 cm to 6 cm-wide. The second extender is
then removed, and the three, hair-bearing transplantation flap,
or the Frechet flap, is performed, during the same procedure,
to eliminate the slot. (See later.)
SIDE EFFECTS OF THE SCALP EXTENDER

Morphological Changes
No volumetric modification in the crown area was observed by
the patient or by others, contrary to that which is experienced
with expanders. Morphological modifications are the same as
those described for conventional AR—facial features are pulled
somewhat tighter just after the operation. Features have returned
to normal after the extenders are removed. Some swelling of
the forehead has been observed. This occurs in 20% of the
cases, starting 3 days after the first procedure, and lasting 3 to
4 days. The edema is less likely to occur after the second proce-
dure. In 5% of cases, periorbital ecchymosis may also appear.
Infection
Infection occurred in 18 of the 2000 cases performed. Seventeen
of the eighteen occurred during the first insertion. One case
occurred at the second insertion, in a patient with infected artifi-
cial hair that was concomitantly removed. When performing
scalp extension, prophylactic antibiotics are always adminis-
tered, just prior to surgery. I usually use cloxacilline 1 g intra-
muscularly, or trimethoprim 160 mg with sulfamethoxazole 800
Figure 20A-10 Patient B: after the second reduction: 3-cm- mg (Septra-DS) orally.
wide bald area. When an infection occurs, it is almost always preceded by
a recurrence of strong pain 10 to 20 days after the surgery.
Patients should be informed about this possibility, so if it occurs,
antibiotics can be promptly started. In 2 out of the 18 cases,
Table 20A-1 Data Concerning the First Ten Patients Treated for Androgenetic Alopecia Using an Extender (and Not Previously
Treated)
Maximum width Maximum Maximum Maximum No. of weeks

Initial of alopecic width width width of Total between
Patient scalp scalp before excised at excised at alopecic scalp gain the two
No. laxity extensiona (cm) insertion (cm) removal (cm) remaining (cm) (cm) operations
1 Average 13.0 3.5 3.5 4.0 9.0 6.0

2 Very good 15.5 4.25 4.0 5.0 10.5 5.0
3 Average 12.0 3.5 4.0 2.0 10.0 6.0
4 Average 13.0 3.5 2.8 5.0 8.0 5.0
5 Good 11.0 4.5 4.0 0 11.0 5.0
6 Very good 10.5 5.0 3.0 0 10.5 4.5
7 Poor 10.0 3.0 3.0 3.0 7.0 4.5
8 Very good 19.5 5.0 3.0 10.0 9.5 4.5
9 Good 12.0 3.5 4.0 1.0 11.0 4.0
10 Good 13.5 3.5 4.0 3.0 10.5 4.0
a
Measured at the vertex.
772 Chapter 20
the infection could not be controlled by antibiotics, and the the frontal region—approximately 80 cm2 vs. 175 cm2-after
extender had to be removed before the usual time. Once re- AR alone—hair transplanation procedures can aim for a more
moved, the symptoms of infection disappeared within 24 hours. homogenous and denser result. The improvement in the hair
margin (the superior border area of the persisting rim of hair)
Postoperative Pain and Nausea which is made denser rather than more sparse, constitutes an
additional esthetic breakthrough. [Conventional AR results in
Pain may be severe, and once again, all patients should be thinning of the hair in such areas.] The possibility of treating
warned about it. It usually begins 6 to 8 hours after surgery, patients with tight scalps represents another highly important
with a peak during the first night. Ninety percent of patients will advantage of scalp extension over AR.
experience pain, which decreases progressively and disappears Side effects are slightly greater with scalp extension with
after 7 to 10 days. Strong analgesics, excluding morphine, are respect to pain and infection. Apart from that, placing and re-
started 4 to 8 hours postoperatively and may be required for a moving the extender is easy and can be performed by any sur-
few days. geon already practicing AR. Interestingly, I was very pleasantly
surprised to note that the insertion of this ‘‘rubber band’’ (the
term I use with patients), did not pose the slightest psychological
COMPARISON BETWEEN SCALP EXTENSION
problem for patients who had already accepted the concept of
AND ALOPECIA REDUCTION AR. As an example, 49 of 50 patients requiring AR chose scalp
Table 20A-2 shows the average amount of time required to extension, once the differences between the two approaches
complete treatment, the amount of alopecic scalp removed at were explained. Stretching is immediate, continuous, and maxi-
each procedure, and the total number of ARs needed when at- mum with scalp extension. Conversely, expanders begin
tempting to remove 10 cm of baldness—before the use of exten- stretching only 1 to 2 weeks after their insertion and the process
ders. The elimination of a 10 cm wide area of alopecic scalp is discontinuous because it is linked to successive injections.
has been reported to require an average of six ARs, spaced In theory, an expander can be inflated as much as the surgeon
approximately 10 weeks apart, and requiring a total of 50 weeks desires, and, consequently, the surface to be stretched is rela-
(i.e., nearly 1 year) (9). The amount of alopecic tissue removed tively unlimited. An extender, however, has an initial width
decreased with each AR. Because of stretch-back, a total of that limits tissue extension. The morphological deformation of
13.5 cm of tissue had to be removed in order to obtain a 10- the scalp observed with expanders, which is absent with exten-
cm reduction in size. In contrast, I required only 6 weeks and ders, represents the most fundamental difference between the
two ARs in order to eliminate a 10 cm-wide area of alopecic two tools. It is clear that this morphological factor alone ac-
scalp in the first 10 cases of scalp extension I performed. This counts for the limited use of expanders in the treatment of andro-
rapid effect is primarily due to ‘‘shrink-back’’, the continuous genetic alopecia, in spite of the basic theoretical advantages
nature of the contraction of the extender while in situ, and the they offer.
immediate consequences of the maximum stretch. Experience The mechanism of action of both expanders and extenders
indicates that there is a progressive trend toward results are the same—they act by prolonged traction, followed by bio-
achieved within 4 to 6 weeks. logical creep. There is discontinuous volumetric traction when
With extenders, we note an obvious improvement in the expanders are utilized, whereas there is permanent flat traction,
stretching of the temporal areas, a phenomenon that we have when extenders are in place. The results differ greatly, depend-
already pointed out is nearly impossible to achieve with AR. ing on the choice of surgical technique utilized. One should
Furthermore, as the remaining alopecic area may be limited to keep in mind that expanders create an excess of tissue in the
Table 20A-2 Alopecia Reduction (AR) and Stretch-Back: Average Alopecia Reduction
and Time Needed to Reduce 10 cm-Width of Alopeciaa
Weeks required
50 6ar
1
40 5ar
1.5
30 4ar
2
20 3ar
2.5
10 2ar
3
1ar Stretch-back
>
3.5 10 13.5 cm
a
Six alopecia reductions and one year of treatment.
Scalp Extension 773
area inflated. Thus, they are particularly useful when one is

contemplating rotation flap surgery. Extenders increase the two
lateral areas of tissue under traction, while decreasing the area
in between. Therefore, extenders are particularly suitable when
one wishes to reduce or eliminate an area, and replace it with
the surrounding tissues. This is exactly our goal in male pattern
baldness (MPB): the removal of midscalp and vertex alopecia
and its replacement with lateral hair-bearing regions. Excisions
of burns, tumors, etc., are also excellent indications, wherever
they are on the body, if they can be esthetically improved by
replacement with the surrounding tissues.
QUESTIONS REGARDING USE OF AN

EXTENDER IN ANDROGENETIC ALOPECIA
1. What is the approach to vertex alopecia that is very mild
and does not extend posteriorly, but remains on the flat
part of the scalp? These cases are relatively rare and
they will not require slot correction.
2. What is the approach to vertex alopecia, which will not
exceed a width of 9 cm to 10 cm (Figs. 20A-11 and
20A-12)? In such cases, two procedures, including one
scalp extension and one Frechet triple-flap, are enough
to eliminate most of the alopecic area. Then, one or
two sessions of hair transplantation are used to treat the
remaining alopecia.
3. What is the approach to more severe alopecia, expected
Figure 20A-12 Patient C, after one scalp extension, plus slot

correction after 30 days.
to be 15 cm to 18 cm wide? Usually, three scalp exten-

sions and one Frechet Triple-Flap for slot correction (a
total of four procedures) will be required. These are
‘‘borderline’’ cases; only highly motivated patients
should be candidates.
4. What is a good approach to severe alopecia, with a width
that is 18 cm or more? Although I have, on occasion,
treated these patients with extenders (Figs. 20A-13 and
20A-14), I no longer consider them candidates for a full
head of hair. The only wise treatment to propose to
such individuals is a hair transplantation with a frontal
forelock design (as described elsewhere in this text).
5. What about tight scalps? Can they benefit from the scalp
extension procedure? Yes, they are good candidates as
well. However, the extenders need to remain in place
for seven to eight weeks, and one additional extension
procedure may be necessary.
6. Is the hair-bearing lateral scalp density affected by these
procedures? Yes, the density is usually decreased by
50%. Nevertheless, there is no significant esthetic im-
Figure 20A-11 Patient C, 10 cm wide alopecia: before treat- pact of such a decrease. This is why this procedure can
ment. be proposed even for men with relatively low density
774 Chapter 20
Figure 20A-13 Patient D with a 19.5 cm–wide alopecia before Figure 20A-14 Patient D after four scalp extensions, plus 400
treatment. minigrafts for the frontal zone.
(Figs. 20A-15 and 20A-16). On the contrary, women time. Because it is impossible to predict the degree of
are generally not candidates for AR or scalp extension. future hair loss in young patients, I believe that these
This is because they generally begin with significant procedures should be proposed only to patients older
hair loss in the temporal regions, and any further de- than 30 years of age. Currently, I would recom-
crease in density would become noticeable. mend—that ‘‘young’’ patients, under 40 years of age,
7. Is the hair-bearing occipital scalp density affected by take finasteride 1 mg daily, to delay their hair loss, espe-
this procedure? In other words, will the donor zone for cially in the vertex. Data suggests they may gain 5 to
the future grafts be affected by these procedures? The 10 years, or more, with this medication before a need
answer is no. The hair density of the occipital scalp is for surgical procedures.
unchanged after scalp extension. The graft density will 9. Are there other uses for extenders? Yes. An extender
not be affected at all. The scalp extension process can also be used, not for stretching, but simply for pre-
stretches only the lateral sides of the scalp and not the venting stretch-back of the alopecic scalp. From this
occipital area where grafts will be later harvested. perspective, stretching is not the goal pursued, but rather
8. Is there progressive hair loss in the parietal area over a one is aiming to support the tissue laterally, in order to
long period of time? Yes, but provided that the surgeon avoid stretch-back.
accurately predicts the future area of MPB, and removes
it entirely, this problem is avoided. Patients treated in NEWER TYPES OF EXTENDERS
this manner, who started with ARs in my practice 22
years ago, or had scalp extensions and slot corrections A very simple type of silicone elastomer extender has been
10 years ago, still have excellent results today (Figs. used quite extensively. As noted earlier, this type of extender,
20A-17 and 20A-18). Therefore, good planning of these the thickness, width, and length of which can vary, offers the
procedures is essential, always taking into account that immense advantage of moulding perfectly to the cutaneous and
androgenetic alopecia progresses—with the passage of bony structures of the head. Its thickness is under 1 mm, similar
Scalp Extension 775
Figure 20A-15 Patient D, profile view: before treatment.

Figure 20A-16 Patient D, profile view: after treatment. Al-
though the density in the lateral scalp has been decreased by nearly
two-thirds, visually speaking, the difference is not obvious.
to that of cigarette paper, making it imperceptible. Only the

two rows of biocompatible metal hooks are slightly noticeable
on close scrutiny.
A newer variety of extender is identical in shape to the origi- extensive androgenetic alopecia. Today, by replacing AR with
nal one, but differs only in that it has superior elastic properties. scalp extension, I feel it is possible to improve the quality of
It can be stretched to 200% to 300% instead of 100%, offering the results obtained, and make the entire treatment more accept-
greater recoil and efficiency while still applying the same ten- able to the patient. Using this approach, one can reduce the
sion. number of operations (two or three, instead of six or more),
Other newer extenders use a ring of silicone elastomer. The and at the same time obtain better results. One can also reduce
major benefit of this variety is its recoil capabilities. The two considerably the treatment time with scalp extension vs. AR (4
bars of hooks touch one another when ‘‘at rest’’ (Fig. 20A-19). to 10 weeks, instead of 50 or more weeks), yet offer comparable
These extenders can be stretched, for example, from 0 cm to comfort and safety. I was initially surprised to see how many
12 cm, and come back to 1 cm (Fig. 20A-20). This total recoil patients, in general, preferred this new approach to the previous
offers more efficiency without increased tension. However, they one. I hope that many colleagues and their patients will come
are still in an experimental stage, and are somewhat more diffi- to the same conclusion. As with any new approach, further
cult to use in practice. improvements will be made. This is only the beginning in a
field that, I believe, is destined to greatly expand.
CONCLUSION
THE FRECHET THREE HAIR-BEARING FLAP
Like many surgeons, I feel that the treatment of androgenetic TRANSPOSITION PROCEDURE FOR SLOT
alopecia should be as simple as possible, present no risk for CORRECTION
the patient, and be compatible with daily life, while providing
the best esthetic results possible. That is why I originally sug- In the treatment of extensive forms of androgenetic alopecia,
gested combining AR, with grafts, to patients suffering from that includes significant inferior extension of vertex alopecia,
776 Chapter 20
Figure 20A-17 Patient E after removing a 15 cm wide alopecic Figure 20A-18 Patient E seen 19 years later. Note, that there
area followed by the later insertion of grafts. has not been any progression of the MPB, or stretch-back of the
alopecic area, because none was left in the occipital zone.
the complete elimination of alopecia in the posterior aspect of

the scalp by AR, results in the formation of a ‘‘slot’’ (10,11).
Correction of this slot has always been difficult. None of the different flaps (16–17). In this way, excessive tension in the
conventional surgical techniques used, such as hair grafts and Z- flaps is minimized. The parameters of the length and width of
plasties, (12–14) provide completely acceptable esthetic results. the slot are of utmost importance. It must be kept in mind that
Since 1988, treatment of the slot by means of one or two- the right and left scalp borders of the slot must be opposing
hair-bearing scalp flaps, plus one non-hair-bearing scalp flap one another, and the inner border of the different flaps must
has resolved this esthetic problem (15). The transposition flaps contain healthy hair that is predicted to last for many years.
turn the hair through the required 90 degrees. My own experi- The morphology and dimensions of the skin flaps are basic
ence with this procedure, as evidenced by results obtained in considerations. For example, in the model patient whose scalp
nearly 200 patients, has demonstrated ‘‘good’’ viability of these measurements can be considered as ideal, the following dimen-
random flaps. However, with this original procedure, there were sions are used: (refer to Figs. 20A-21 and 20A-22):
two problems that remained to be solved. The first was the need 1. Superior flap (flap 1) 2.0 cm in width at its base and
for one or two follow-up procedures to eliminate the area of midwidth
non-hair-bearing scalp. The second involved the position of the ⬃4.5 cm in length from point B to C
superior flap, which was too inferior, relative to the vertex, if Ratio of length to width ⳱ 2.2: 1
the slot being corrected was a particularly long one. For these 2. Intermediate flap (flap 2) 3.0 cm in width at its base
two reasons, we sought to improve the technique. The following and at midwidth
is a description of an approach that involves three-hair-bearing ⬃ 7.0 cm in length from point G to I
scalp flaps (Figs. 20A-21 and 20A-22). Ratio of length to width ⳱ 2.2: 1
Dimensions the Frechet Triple-Flap Procedure 3. Inferior flap (flap 3) 3.0 cm in width at its base and at
midwidth
For the success of this procedure, it is essential to maintain, as ⬃ 10 cm in length from point D to H
much as possible, certain dimensions and relations between the Ratio of length to width ⳱ 3.3: 1
Scalp Extension 777
Figure 20A-19 New ring Silastic extender at rest. Both bars of hooks are in contact. Stretched, the bars may be 10 cm to 12 cm apart.
Figure 20A-20 New ring Silastic extender seen from the galeal side once the full recall has been obtained. The bars of hooks are back
to their initial position and close one another.
778 Chapter 20
Figure 20A-22 The three hair-bearing scalp flaps in place after

transposition showing the hair direction. Superior flap rotated left
to join points J and B. Middle flap rotated right to join points C
and G. Inferior flap rotated left to join H and I.
eters to avoid putting tension on the flaps. The width of the

Figure 20A-21 Lines of incision of the three hair-bearing scalp slot should also be as narrow as possible, thus patients with
flaps procedure before transposition. Points B and H are the lower borderline results should usually have an additional AR. The
extremities of the superior and inferior flaps, respectively, to be length of the slot, LE, should be close to the ideal length of
rotated to the left. Point G is the lower extremity of the intermediate about 6.5 cm 7.5 cm, as we will see later.
flap to be rotated to the right. The relations between BC-CJ, Gi-iC, and DH-Di are of
major importance. Based on 10 patients, in whom systematic
measurements were made, I established the range of dimensions
Other parameters are defined as follows: for procedures that were carried out under excellent operative
conditions:
A ⳱ the most anterior extremity of the alopecia reduction BC⳱3.5 cm to 4.5 cm
L ⳱ epicenter of the vertex CJ⳱5.0 cm to 6.0 cm
E ⳱ lower extremity of the slot scar The difference between BC and CJ varied from 1.5 cm to
LE ⳱ 7 cm 2.0 cm.
BC ⳱ 3.5 cm CJ ⳱ 5.5 cm difference ⳱ 2.0 cm Gi⳱6.5 cm to 7.5 cm CI⳱8.0 cm to 9.5 cm
Gi ⳱ 6.5 cm Ci ⳱ 8.0 cm difference ⳱ 1.5 cm The difference between Gi and Ci varied from 1.0 cm to 2.0
DH ⳱ 10 cm Di ⳱ 10.3 cm difference ⳱ 0.8 cm cm.
EE ⳱ 2.5 cm DH⳱9.5 cm to 11 cm Di⳱10.3 cm to 11.8 cm
BB′ ⳱ 2.0 cm The difference between DH and Di varied from 0.0 to 1.3
J, K, C are in the same horizontal plane. cm. These flap parameters are summarized in Table 20A-3.
i is 1.50 cm inferior to CKJ; D is 3.0 cm inferior to CKJ.
The three distal extremities of the skin flaps (B, G, and H)
undergo rotation from inferior to superior; from right to left for
the superior and inferior flaps; and from left to right for the Table 20A-3 Summary of Flap Parameters
intermediate flap. The surgeon may choose to reverse the flaps,
by placing the superior and inferior flaps on the left and the Width (cm) Length (cm)
intermediate flap on the right.
Flap 1 2.0 3.5 to 4.5
The dimensions noted above are not fixed, but it is necessary Flap 2 2.5 6.5 to 7.5
to keep them as close as possible to those numbers and param- Flap 3 3.0 9.5 to 11.0
Scalp Extension 779
Technique Used in a Typical Frechet Triple-Flap to C. The inferior flap is then rotated by bringing point H close
Slot Correction to point I (see Fig. 20A-22).
Suturing of the entire deep layer of the three flaps is then
A 2-month interval separates the slot correction procedure from completed using interrupted sutures, starting, preferably, at
the preceding AR or hair graft session. This period is reduced point D, gradually ascending to point i, then proceeding to
to one month if a scalp extension procedure is utilized. As with points C, J, and K. The surgery is finished by suturing the
ARs, only one assistant is necessary for this surgery. superficial layer with interrupted sutures or staples, preferably
Immediately before the procedure, the scalp is disinfected progressing from inferior to superior—from D toward A—be-
using an antiseptic solution. The design for the scalp incisions cause it seems easier to close following this direction. Figs.
is made using an indelible marker pen, with the patient seated. 20A-24 to 20A-27 show the appearance of the three flaps imme-
Hairs in each skin flap are held using adhesive tape or elastic. diately after surgery for slot correction.
The patient is then placed in a semireclining position.
Preoperative medication and local anesthesia with a vaso- Chronology of the Frechet Triple-Flap Procedure
constrictor agent (the author uses 1:100,000 epinephrine ) are
To prevent injury, to the skin flaps, to the galea and its blood
administered in the same concentrations as in conventional AR
vessels, or to the occipital arteries, I recommend following a
procedures. Ring-block anesthesia extends from the forehead specific chronology during the procedure (Figs. 20-8, 20-11,
to the border of the scalp and continues posteriorly 2 cm supe- 20-13, 20-17, 20-24, 20-28, and 20-30):
rior to the inferior border of the hair-bearing occipital scalp.
Incisions are made, beginning in the most anterior area of 1. Incision is made from point A to point B.
the AR scar, and should take into consideration the direction 2. Right and left lateral scalp undermining.
of hair in the flaps, ensuring that the surgeon makes incisions 3. At this stage, evaluate the possible width of the AR.
at an angle parallel to the hair follicles. In certain areas, the 4. An incision is made from point A to point G, passing
extreme angulation of these follicles requires special attention through curve K.
to ensure appropriate angulation of the scalpel through the 5. End of the lateral scalp undermining and suturing of
borders AK—AH.
galea. In all cases, blood vessels are electrocauterized through-
6. Incision of BC and Gi.
out the procedure, to stop significant bleeding.
7. Rotation of the upper flap, fastening point B to point
For this procedure, as for AR, all the undermining is done
J, and rotation of the intermediate flap, fastening point
in the avascular plane, deep to the galea aponeurotica. The ex- G to point C.
tent of the undermining will be similar to that of conventional 8. The patient is then placed in a lateral supine position
AR in the lateral regions of both the left and right temporal and with the head turned on the left side. Keep in mind
parietal areas. Great care should be taken not to injure the galea that some surgeons prefer to have the patient supine
and the superficial temporal arteries; accidental severing of during the entire procedure.
these blood vessels could impair the viability of the three flaps. 9. Undermining of the occipital scalp, approximately 4
Inferiorly, the undermining will reach the upper auricular cm.
sulcus, just superior to the ears. Posteriorly, the limit of the 10. An incision is made at the lateral border of the inferior
undermining will be the nuchal ridge, where the occipital mus- flap along curve DH. Point H is sutured to point i.
cles can be seen. It is unnecessary to undermine any deeper. 11. A deeper undermining of occipital scalp is made main-
This will prevent injury to the occipital arteries, which emerge taining excellent visibility of the galea aponeurotica.
at a lower level. Because undermining of the galea in the occipital area
The surgeon then proceeds to the AR itself, ensuring that is more difficult, and because there may be perforating
the right and left borders join without excessive tension. In arteries in this area, good visibility is essential to safely
practice, I make an excision, the width of which is approxi- continue the procedure.
mately two-thirds of the previous AR. The alopecic area is then 12. A permanent suture is affixed superiorly, from the
eliminated and the tissues are brought closer together. This is galea of the occipital scalp situated under flap three
done first by suturing together the galea at points K and M, to the pericranium, thereby avoiding tension and
and then placing deep interrupted sutures along the anterior area stretch on flap three, as well as minimizing later scar
of the AR. widening.
To avoid stretch-back of the remaining alopecic scalp, it is 13. If there is an excess of scalp found in triangle GBK,
essential to affix galea-to-galea using two or three-interlocked it can be removed at this stage of the surgery—not
permanent mattress sutures situated at the level of the perma- before.
nent hair-bearing areas of the left and right scalp (Fig. 20A- 14. Suture the flaps as described in item 12.
23). All the tension will be transmitted to the area where the
mattress sutures are affixed. The remaining alopecic area, as Complications Following the Frechet Triple-Flap
well as the scar at this level, will be tension free and no stretch- Procedure
back will be produced in the future months or years. The next In the 1500 triple-flaps done, over the past 14 years, I have had
step is closure of the deep plane of the wound, from point A very few complications other than a 13% incidence of moderate
to KM, using a running absorbable suture. Rotation of the supe- or severe temporary anagen/telogen effluvium of a flap. Com-
rior flap is then carried out. This is started by suturing the galea plications are summarized in Table 20A-4. Seven patients
at point B to point J. Subsequently, and in a similar fashion, (0.5%) developed severe tip necrosis of a flap – defined as a
the intermediate flap is rotated with deep suturing of points G 10% to 30% loss of the flap. Revision of these seven cases of
780 Chapter 20
Figure 20A-23 The dotted line represents the midline wound-closure with superficial sutures. The rectangles denote the location of
galeal mattress sutures and the crosses denote the knots of those sutures.
necrosis has been possible in one or two surgical steps. The 20A-29). Figs. 20A-30 and 20A-31 show the before and after
end result, in all seven of them, was good to excellent, and all photo of a patient who had complete coverage of his crown,
patients were satisfied after the revisions. However, prior to using a scalp extension procedure, followed by a triple flap 6
any surgery, patients should always be aware of the possible weeks later, and ultimately completed with grafting.
risks of complications, and only those ready to accept them It is worthwhile to emphasize certain key points with regard
should be considered as candidates. to case selection and operative technique, keeping in mind that
all of the blood supply to the three flaps comes from the frontal
Further Esthetic Considerations and Discussion arteries, which include the supratrochlear arteries.
Slot correction, using the earlier technique of two hair-bearing 1. The risk of problems is significantly reduced by main-
scalp flaps, offered a very satisfactory esthetic result. However, taining certain dimensions between the flaps (as de-
with three hair-bearing scalp flaps, the esthetic result is further scribed in the foregoing) and having the slot as narrow
improved, and there is seldom a need for additional scar revi- as possible. It is important to have no tension in the
sions. The difference between the two approaches is the superior flaps, so there must be some laxity in the vertex region
flap, which now can be located at the ideal height for each before attempting the flap procedure. If the surgeon
patient. Point L, in Fig. 20A-21, lies at the center of the vertex. decides to perform this procedure after serial AR,
In practice, esthetic sensitivity will enable the surgeon to situate rather than scalp extension; more tension at the top of
at the flap at the most natural position. the scalp is to be expected. In such cases, sometimes
It should be remembered that the vertex curvature of each a 1.5 cm-wide AR may be difficult.
skull, as viewed in profile, varies substantially. There are two 2. I have used midline elliptical ARs in almost every
extremes: the vertex with a gentle slope, and the vertex that case (100% of two-hair-bearing flap cases, and 95%
slopes almost at a right angle to the top of the head. This must of three-hair-bearing flap cases). This pattern of AR,
be taken into consideration, so that the inferior border of the in contrast with the other patterns, tends to bring down
superior flap will always remain invisible, even in a patient part of the occipital scalp at the posterior end of the
with short hair. When this procedure is done to repair a slot reduction. This way, more occipital scalp may be lifted
deformity, the esthetic result obtained at the vertex with the during the transposition procedure and less tension
superior flap can mimic part of the whorl (Figs. 20A-28 and will occur.
Scalp Extension 781
Figure 20A-24 Patient A: before to slot correction.

Figure 20A-25 Patient A: The intermediate and inferior flaps
are shown.
3. When performing the series of AR, prior to the flap

procedure, it is important not to extend the incisions
into the fringe of remaining ‘‘good hair,’’ as the fringe closure problems in the harvesting zone. Flap surgery
will later become the flaps and must not contain scar can be performed, if necessary, at the same time as a
tissue. scalp extension.
4. Scars in the occipital scalp, as a result of graft harvest- 8. Patients who smoke should be asked to reduce or stop
ing, present no danger to flap surgery, provided that smoking 4 days before and after the procedure. The
they are not situated inside the future flaps. If they are same holds true for alcohol consumption.
located in the flap(s), they constitute an important risk 9. Ingestion of acetylsalicylic acid and the use of minoxi-
factor. dil (Rogaine) also must be discontinued, 8 days before
5. Patients with prior face-lifts are still good candidates and after the procedure, to reduce the risk of bleeding.
for this surgery, as long as the superficial temporal 10. Systemic perioperative antibiotic therapy, similar to
artery has not been damaged. that used for hair transplanting, should be prescribed.
6. Hemostasis is important because a subgaleal hema- 11. As mentioned in Table 20A-4, surgeons should avoid
toma may cause increased postoperative tension in the treating patients who have more than one of the five
flaps and compromise their circulation. Use an over- risk factors noted in that table—at least until they are
night drain if necessary. very experienced with this type of surgery.
7. It is preferable to perform all the ARs and flaps before 12. In patients with risk factors, minoxidil 2% to 5%
attempting hair transplant procedures. However, trans- should be applied twice daily, for 3 months, prior to
plants can be done prior to the alopecia removal phase this procedure. In doing so, it may be possible to re-
if necessary. Transplants and triple-flap procedures duce or avoid necrosis or to significantly reduce the
should not be done on the same day. This will avoid incidence or severity of telogen effluvium.
782 Chapter 20
Figure 20A-26 Patient A: immediately after the three hair- Figure 20A-27 Patient A: The superior and intermediate flaps
bearing scalp flaps procedure. are shown.
TIPS FOR BEGINNERS

it is hairless and contains the old AR scar tissue. The
Practice caution when undertaking your initial cases. Ideally, dimensions of the superior and intermediate flap are the
one should watch another surgeon perform this operation before same as those utilized in the three-hair-bearing scalp
attempting it. For your first 10 to 20 cases, it may be wise to procedures.
limit the use of this procedure to virgin scalps (where punch
grafts have not been taken, and there are no existing scars) and Have your patient regularly massage his occipital and postauric-
only after midline ARs. ular scalp for one month before surgery, to facilitate the opera-
By choosing patients with good scalp laxity and short slots tion. During the procedure, if there is too much tension, keep
(less than 7.0 cm long) you will make your first procedures in mind that a large graft or an ‘‘island flap’’ taken from the
much easier. Remember that the two-hair-bearing transposition AR may solve your problem.
flap procedure, plus one non-hair-bearing flap is an easier oper- It must be emphasized that all of my patients have been
ation and is a good way to start. happy with the results of this triple-flap procedure. The im-
Two main differences between the two-hair-bearing flap provement in hair direction makes hairstyling so much easier.
procedure, and the three-hair-bearing flap procedure are as fol- Thus, even when there has been a temporary setback, due to
lows: anagen/telogen effluvium or necrosis, the patients are able to
appreciate the great advantages that this procedure has to offer.
1. In the two-hair-bearing flap procedure (Fig.20A–32)
the inferior hair-bearing BHD flap does not exist and Editor’s Comments
is replaced by the non-hair-bearing GIB flap. Frechet’s scalp extension, and the triple-flap correction proce-
2. The rotation of this inferior flap goes inferiorly, instead dure that he uses to correct the slot defect he produces, are
of superiorly. This flap will be excised later because described together here. This is because his objective in scalp
Scalp Extension 783
Table 20A–4 Complications Following the Frechet Triple-Flap Procedure
Infection Incidence (%)

1 case 0.07
Telogen effluvium of a flap
Moderate: (10% of a flap) 10
Severe (10% to 30% of a flap) 3
Tip necrosis
Moderate (10% of a flap) 2
Severe (10% to 30% of a flap) 0.5
Risk factors encountered in the 7 cases of severe tip necrosis:
1/7 cases: obese ⫹ high blood pressure ⫹ diabetes
1/7 cases: scars in the flap
2/7 cases: previous face-lift with temporosuperficial artery injury
4/7 cases: smokers
7/7 cases: more than 50 years of age
Figure 20A-29 Patient B: after slot correction. The superior

flap mimics part of the whorl.
Figure 20A-28 Patient B: before slot correction.
784 Chapter 20
Figure 20A-30 Patient D, extensive MPB with a 15 cm-wide Figure 20A-31 Patient D, after scalp extension followed by
alopecic area before treatment. triple flap and ultimately followed by grafting the frontal area.
decrease in hair density in those areas; thus, its use for subsequent
donor strip harvesting will result in considerably fewer grafts per
extension is to remove all the midscalp and vertex alopecia that strip. Occipital ‘‘permanent’’ rim hair is not affected by scalp ex-
is present. Therefore, his ultimate goal with scalp extension is, tension but, in my experience, this donor area is too small to sat-
in fact, a slot that must be corrected. isfy most of my patients’ density objectives. Thus, I must also
As Frechet notes, scalp extension is a fairly simple procedure use parietal and temporal donor areas in those individuals. The
that should be easy to learn, for anyone capable of carrying out degree of thinning of these areas, after scalp extension, (with total
an AR. The triple -flap correction, on the other hand, is far more excision of alopecic areas) has to be seen to be fully appreciated.
complex. It is, in many cases, this latter procedure that has de-
terred other surgeons from incorporating scalp extension into
their practice. A relatively simple solution to this impasse is to
use scalp extension to maximize and accelerate what can be ex-
cised during a second AR but to specifically aim to not remove
all of the midscalp and vertex alopecia. (The second AR could be
closed using deep plane fixation as described by Seery in Chapter
19D—thus minimizing any potential ‘‘stretch-back’’.) The goal
should be to leave enough midline alopecia to allow for trans-
planting of hair into that area with a gradual and natural change
in hair direction within that zone. This would also prevent signifi-
cant thinning of the lateral aspects of the hair-bearing scalp—an
added advantage. It is true that excising all of the alopecia does
not usually lead to a noticeable decrease of hair density in the
lateral hair-bearing scalp. It does, of course, result in a substantial Figure 20A-32 Two hair-bearing flaps.
Scalp Extension 785
As noted above, it is substantial. I offer this treatment option only 1. A CORRECT INDICATION FOR THE
to that minority of patients who want total coverage and who also SURGERY
have very dense temporal and parietal hair (and whom I believe
will maintain good density throughout their lives). Frechet is less The correct indication for SE is alopecia involving the vertex
restrictive in this regard than I am. In summary, not removing and/or the middle third of an area of Male Pattern Baldness
all of the alopecia—leaving perhaps a 5 cm to 6 cm zone to be (MPB). (1) It can be complementary to autografting in the fron-
transplanted later—has two advantages: a slot is not created and tal region (2,3) but it is not intended to replace frontal grafting.
thus a triple-flap procedure is unnecessary and denser parietal The aim of the surgery is to exploit the natural elasticity of the
and temporal donor areas will remain for harvesting. The first of scalp (4). It is therefore necessary to pay particular attention to
these two advantages would also avoid the scars of the triple conditions that may interfere with a correct extension of the
flaps, and would thus minimize vascular compromise for possi- scalp, in particular: a) old scars b) a scalp with poor mobility,
ble later grafting into the vertex and midscalp areas that some- and c) a history of smoking cigarettes. The presence of existing
times require such ‘‘touch -ups.’’ scars is particularly important when they are found in the tem-
The pain involved in scalp extension can be severe. I always poral areas and/or where the 3-Flaps will be obtained. Scars in
warn my patients that if they decide to proceed with this surgery, the occipital area, such as those created by previous autograft
they can expect the pain to be ‘‘excruciating’’ for the first 24 harvesting, are less negative, and do not exclude the possibility
to 48 hours, bad for another 24 to 48 hours, and then it will of performing SE and 3-FTSC. However, bear in mind that scalp
taper-off over the balance of the first postoperative week. This, mobility can be reduced by such scarring and may therefore
in fact, is an exaggeration of the potential for pain in most complicate suturing of the incision that remains caudal to the
patients. However, by presenting scalp extension this way, only third Flap. Minimal elasticity and cigarette smoking constitutes
the most strongly motivated will proceed. Most patients who alarm bells, but they should not be considered absolute contrain-
have been told this have told me afterwards that I greatly exag- dications.
gerated the degree of postoperative pain. These procedures on
my patients are carried out either by Dr. Martin Unger or Dr.
Patrick Frechet. All of the patients (approximately 18) have 2. A MOTIVATED PATIENT
said they were happy they had gone ahead because the results
were worth it. Just as the decrease in temporal and parietal hair A patient who wants to undergo an SE must be well aware of
density has to be seen to be fully appreciated, the positive results the limits and advantages of this procedure. Above all, he/she
of scalp extension have to be seen to be fully appreciated. must be aware that there will be post-operative pain for the first
(WU) 24 hours or longer and that a sense of scalp tension will be
temporarily felt. With appropriate analgesia therapy, pain is,
however, bearable. Scalp tension also slowly diminishes usually
20B. Tips for the Novice in Scalp over a period of 3 to 10 days, until it is no longer felt. If the
patient is not properly informed about these aspects or is not
Extension fully motivated, the surgeon may run the risk of facing serious
Ciro De Sio problems. In my view, poor patient preparation and motivation
are the most serious contraindications for this type of surgery.
INTRODUCTION Fortunately, in my personal experience this has never happened
with my patients.
This discussion is intended to assist surgeons who are interested
in learning how to perform scalp extension (SE), as well as the
3-Flap Transposition Slot Correction (3-FTSC). It will hope-
fully provide them with the advantage of learning the skills I,
3. AN ACCURATE SURGERY PLAN
as an experienced plastic and reconstructive surgeon, had to This is the key component of a successful execution and out-
develop during the course of treatment of my first 15 patients. come for Dr. Frechet’s procedure.
I shall specifically focus on the critical problems I met and THE DRAWING HAS TO BE VERY ACCURATE. Ignor-
suggest little ‘‘secrets’’ that will help reduce the risk of compli- ing this requirement will often result in problems in the transpo-
cations and improve results. sition of the Flaps that, as we know, has to be done without
producing any closing tension. Unfortunately, I have not been
able to find an ideal skin marker that would leave a durable
GENERAL COMMENTS
mark throughout all the surgical manoeuvres. Consequently,
Dr. Frechet’s Procedure, just like any surgical technique, re- the surgeon runs the risk of finding the pre-operative drawing
quires: gradually disappearing. This can be very problematic even for
a very skilled surgeon. In order to minimize this possibility,
1. A correct indication;
before starting any procedure you should wash the hair thor-
2. A motivated patient;
oughly; repeatedly degrease the skin with an alcoholic detergent
3. An accurate surgical plan;
so that the drawing lasts longer; then create the drawing and
4. Adequate knowledge and experience.
finally—perhaps most importantly—use various suture threads
If these requirements are satisfied, the surgery will be smoothly at strategic points as ‘‘landmarks’’, and then, as if it were a
performed in various stages and will produce an excellent result ‘‘basting’’, mark the perimeter of the flaps with continuous
that is rewarding for both the patient and the surgeon. sutures.
786 Chapter 20
Figure 20B-1 Correct positioning of the Frechet Extender Landmarks before the Scalp Reduction Surgery: Vertex; the spindle-shaped
bald area to be removed; the correct projection of FSE on the scalp.
Scalp Extension 787
Planning the Scalp Reduction and the Sub-Galeal ABBREVIATIONS

Positioning of Frechet’s Skin Extender
F Frontal border of the Frontal scar
The first important decision to be made is the choice of the V Vertex on the median scar
vertex (‘‘V’’ in the subsequent schematic drawings). It is a V′-V⬙ Vertex after the removal of the spindle-shaped bald
fundamental decision because this point will guide the operation area
and the subsequent 3-FTSC. It will indicate: O Occipital border of the 3rd flap
O′ On the right lateral margin of the 3rd flap so that
● The cephalic border of the median scar in the occipital B′ ⳮ O ⳱ B′ ⳮ O′
region that must not be longer than 7cm; a longer scar A B C Lateral margin of the bases of the 3 flaps:
could be a problem for the proportions of the 3 Flaps A ⳱ 1st flap
(Fig. 20B-1). The length of the scar from the VERTEX B ⳱ 2nd flap
‘‘V’’ to the frontal region may vary. However, it is better C ⳱ 3rd flap
to avoid a scar that goes beyond the real or ideal trans- A′B′C′ Apex of the 3 flaps:
planted frontal hairline for obvious aesthetic reasons. A′ ⳱ 1st flap
● The caudal, occipital border of the area where the exten- B′ ⳱ 2nd flap
der will be positioned (Fig. 20B-1). Positioning the ex- C′ ⳱ 3rd flap
tender more towards the caudal area, over the vertex A⬙ Left lateral margin of the spindle-shaped bald area
means distributing the force of the extender in a dis- to be excised. This will receive the apex A′ of the 1st flap.
advantageous direction and running the risk of creating B⬙ Medial margin of the base of the 2nd flap B ⴑ B⬙
an unnatural stretching of the tip of the eyebrows. On C⬙ Medial margin of the base of the 3rd flap C ⴑ C⬙
the other hand, positioning the extender more anteriorly
● Design of the median spindle-shaped bald area to be
towards the frontal region, means exploiting the exten-
excised
sion of the scalp in an area that is not as useful for Scalp
Reduction in the occipital area (Fig. 20B-2). F Frontal border of the median scar
B′ Occipital border of the median scar
V VERTEX on the median scar no longer than 7cm from
Drawing for the Scalp Reduction and the Position B′.
of the Extender
Trace the ideal line that intersects the median scar passing
Before the surgery, use a skin marker to draw: through the VERTEX V. It corresponds with the caudal border
of the FSE position during the preceding scalp extension and
● The VERTEX V
reduction.
● The spindle-shaped alopecic area to be excised with a
caudal-occipital pole at a distance of 7cm from the vertex ● Draw the frontal portion of the spindle-shaped bald
(V) area
● The two lateral borders in the hair-bearing areas where
the extender is to be attached Start from F until you meet the imaginary line in V′ and V⬙
that passes through the VERTEX V. It will have:
Dr. Frechet explains elsewhere in this text how to choose these
‘‘landmarks’’, which I mark with a ‘‘basting’’ suture, but I A variable length (see the paragraph on SR Planning)
A maximum width of 2.5cm that reduces to 1cm at the level
would like to add another for novices with the procedure: a
of V′ ⳮ V⬙ (Fig. 20B-3a)
transverse line through the vertex. The correct projection on
the scalp of the FSE outline onto the caudal and occipital margin ● Draw the occipital portion of the spindle-shaped bald
has to coincide with this transverse line (Fig. 20B-1). area
Mark A⬙ on the imaginary line passing through the VERTEX
Planning the Slot Correction with 3-Transposition V at 2cm from V′.
Flaps Trace a very arched line that joins A⬙ to V′.
Complete the drawing of the bald area to be excised joining
It is essential to do a very accurate drawing for this stage of B′ with A⬙ and with V⬙.
the procedure. It may easily be accidentally washed or wiped It is important that:
away during the course of the operation so, as indicated earlier,
sutures are very useful to permanently fix some landmarks. I The maximum width of the spindle is 3cm
shall use some arbitrary abbreviations that are different from The line V ⳮ B′ is exactly 7cm long (Fig. 20B-3b)
those adopted by Dr. Frechet (5). Before starting, we stand
● Drawing of the 1st Flap
behind the patient who is in a sitting position. We copy Frech-
et’s classical drawing that includes the 1st and 3rd flap on the Base: V⬙ ⳮ A on the right lateral margin of the spindle-
right of the median line. (Previously, a median scalp reduction shaped bald area, on the imaginary line that intersects the
was always performed.) The different measurements, always VERTEX V. It should be 2cm wide.
within the range fixed by Dr. Frechet, are shown in Figs. 20B- Apex: A′ on the right lateral margin of the spindle-shaped
3a to 20B-3e. bald area to be excised.
788 Chapter 20
Figure 20B-2 The wrong position of FSE.

Scalp Extension 789
Figure 20B-3 (a)Drawing of the frontal portion of the spindle-shaped bald area you intend to remove: Height: variable; width: maximum
2.5 cm that reduces to 1 cm at the vertex. (b)Drawing of the occipital portion of the fusiform bald area you intend to remove: Height:
from the vertex V to the occipital hairline, maximum 7 cm; width: maximum 3 cm. (c)Drawing of the 1st Flap: Base on the imaginary
line that passes through the vertex; width 2 cm. (d)Drawing of the 2nd Flap: Base: parallel to the imaginary line passing through the vertex
not at the same level (2 cm more caudally; apex: of the same dimensions of the base, 2.8 cm. (e)Drawing of the 3rd Flap: Base: not parallel
to the line of the vertex and not on the line of the vertex; apex: corresponds to the apex of the 2nd Flap. Note: In B′-O′ and B′-O the
width of the flaps reduces itself and there is the risk for vascularizations.
790 Chapter 20
Base C⬙ ⴑ C on the right lateral margin of the spindle-

shaped bald area
C goes 4cm caudally to the imaginary line of the VERTEX
V
C⬙ goes 3cm caudally to the imaginary line of the VERTEX
V
The C⬙ ⴑ C line not parallel to the ideal plane of the VERTEX
V measures 3cm and forms the base of the 3rd Flap.
Apex: C′ ⴑ B′ corresponds to the apex of the 2nd Flap with
same dimension of 2.8cm.
In order to draw the right lateral margin of the 3rd Flap it
is useful to note
● the O point at 2cm from B′, but on the continuation of
the line that passes through the median scar;
● the O′ point also at 2cm from B′, but on the continuation
of B′ ⳮ C′.
After drawing these landmarks, you join C to C′ passing through
O′ and O.
The line C ⳮ O is slightly arched.
However, the line C′ ⳮ O is very arched to increase
the vascularization of the apex of the flap.
The apex C′ will move to B (Figs. 20B-3e, 4, 5)
PERSONAL MODIFICATION OF THE

ORIGINAL TECHNIQUE
After positioning the 3rd Flap into its ultimate location, there
remains a gap that must be closed between the caudal margin
The right lateral margin of the 1st Flap will consist of the line
that joins A to A′ passing through C⬙.
It will be curved, with its specular concavity to the V′ ⳮ
A⬙ line.
C⬙ at 3cm from A indicates where the width of the Flaps
reduces to 1.8cm.
The dimension of the Flap measured on the chord A ⳮ A′
will be 4cm.
A′ will be moved to A⬙ (Fig. 20B-3c)
● Drawing of the 2nd Flap
Base: B ⳮ B⬙ on the left lateral margin of the spindle-
shaped bald area
2cm caudal to the imaginary line of the VERTEX V
and 2.8cm wide
Apex: C′ ⳮ B′ on the imaginary line passing through B′
parallel to the base B ⳮ B⬙
with a dimension of 2.8cm the same as B ⳮ B⬙
The line that joins B to C′ (the left lateral margin of the 2nd
Flap) will be curved, specular to the left lateral margin of the
spindle-shaped bald area.
B′ will be moved to A. (Fig. 20B-3d)
● Drawing of the 3rd Flap Figure 20B-4 Drawing of the three Flaps on a dummy.
Scalp Extension 791
Figure 20B-5 Drawing of the three drawings on the patient

Figure 20B-6 To make the two sides the same, after position-
and preparation for surgery.
ing the 3rd Flap, you create a dog-ear.
of the 3rd flap, that is shorter, and the cephalic margin of the real ‘‘gymnasium’’ where my experience matured. I became a
occipital scalp, that is longer. In order to reduce tension and specialist in Plastic Surgery in 1983 and my surgical experience
to facilitate the closure, in addition to deep undermining and has given me a maximum respect for the skin and care for
anchoring of the occipital scalp, I thought it would be advanta- details. Both have, no doubt, helped me to appreciate the impor-
geous to add a modification to the original technique. This little tant ‘‘basics’’ of Dr. Frechet’s method. Therefore, when I
modification consists in using a suture to shorten the occipital started performing these operations on my own, my surgical
scalp, thus creating a ‘‘dog ear’’. Initially, I regulated scalp background was enough to make me feel safe in front of the
excess with a residual vertical scar, but in later cases I decided operating table. I operated on my first patient in January 1998.
to leave the ‘‘dog ear’’ because it is not visible, it did not trouble In each patient I carried out one or more Scalp Reductions
the patient and could be a reserve for hair for possible future always using the FSE. In all but one of the patients, I also did
autografting (Fig. 20B-6). a 3-FTSC (Figs. 20B-7a to 7c).
4. ADEQUATE SURGICAL KNOWLEDGE AND PROBLEMS ENCOUNTERED

EXPERIENCE ● Telogen on the apex of the 2nd and/or 3rd Flap
● Diastasis of the scars
Dr. Frechet’s Method, SE but especially the 3-FTSC requires
● Difficulties suturing the final gap caudally to the 3rd
not only precise planning but also an adequate surgical back-
Flap
ground and ability. The first time I assisted at the positioning
of the FSE by Dr. Frechet was in 1996 on the occasion of the I encountered this problem in two patients. In both
2nd International Meeting on Hair Transplantation and Scalp cases, the inconvenience was due to a mistake I had
Reduction organised by the Instituto Dermopatico dell’Imma- made planning the drawing. In the first case, I had
colata (IDI) in Rome where I work. Subsequently, I started difficulties finding the drawing that had disappeared
studying this Method, to create a solid theoretical basis for the during the surgical manoeuvres. As a result of this, I
surgery. I not only had the opportunity to go to Dr. Frechet’s had to create a 4th flap as an extemporary solution. In
office in Paris, but I developed and enriched my knowledge on the second case, I was more audacious than wise and
this method during the courses held by Dr. Frechet at the IDI in had arbitrarily changed the usual measures of the
Rome between 1996 and 1997. On these occasions, Dr. Frechet drawing. This resulted in a gap in the closure that I
operated on approximately 10 patients and this has been my was fortunately able to resolve only because I was able
792 Chapter 20
a b
Figure 20B-7 (a)A 10 cm-wide bald area. (b)Before the slot correction. (c)Final result after the 3-hair-bearing scalp flap transposition.
Scalp Extension 793
to use part of the spindle-shaped bald area that I had 2. Frechet P. Scalp extension. J. Dermatol. Surg. Oncol 1993; 19:
prudently still not eliminated. Surprisingly, the Flap 616–622.
3. Blanchard G, Blanchard D. Obliteration of alopecia by hair lift-
survived.
ing: A new concept and technique. J. Natl. Med. Assoc 1977;
Notwithstanding this good fortune, it had a very 69:639–641.
unbalanced base/height ratio and the distal part was 4. Sparkuhl K, Sparkuhl AR:. Serial-excision of the scalp with flap
advancement, presented at the International Hair Transplant Sym-
marked by the scar of the previous Scalp Reduction. In posium. Lucerne. Switzerland, 1978.
any case, I paid for my inappropriate planning with a 5. Unger MG, Unger WP. Management of alopecia of the scalp by
considerable discharge of adrenalin. After three a combination of excisions and transplantations. J. Dermatol Surg
months, I removed the alopecic area and the patient Oncol 1978; 4:670–672.
was well satisfied. 6. Bosley L, Hope C, Montroy RE. MPR for surgical reduction of
male-pattern alopecia. Curr. Ther. Res 1978; 25:281–287.
● Wrong levelling of the 2nd and 3rd Flap formed a little 7. Radovan C. Breast reconstruction after mastectomy using the
bulk, that was bothersome when touched by the patient. temporary expander. Plast. Reconstr. Surg 1982; 69:195–205.
● Seroma. 8. Kabaker S, Kridel R, Krugman N, Swenson R. Tissue expansion
● Massive oedema on the face with long-lasting eyelid in the treatment of alopecia. Arch. Otolaryngol 1986; 112:720.
9. Shiell R. Scalp flexibility. Presented at The International Sympo-
echymoses. sium on Hair Replacement Surgery. Los Angeles, Feb. 8–11,
● To date there have been no hematomas, no necrosis, no 1992.
infections and no exposure of the FSE. 10. Norwood OT, Shiell R, Morison I. Complications of ARs. J. Der-
matol. Surg. Oncol 1983; 9:831–834.
My experience, to date, has brought the following conclusions: 11. Nordstrom RE. A Change in direction of hair growth. J. Dermatol.
1. Positioning the FSE surely requires little time but it is Surg. Oncol 1983; 9:156–158.
12. Frechet P. How to avoid the principal complication of AR in the
not easy.
management of extensive alopecicness. J. Dermatol. Surg. Oncol
2. The first surgery, even if smooth, conditions the dura- 1985; 11:637–640.
tion of the subsequent surgery and the final result. 13. Mayer TG, Fleming RW. Management of alopecia. Presented at
3. The most scrupulous attention has to be given to the The International Symposium on Hair Replacement Surgery. Los
planning stage of the 3-Transposition Flaps and the time Angeles, 17–20 March, 1988, p. 89.
you spend doing this is never too much. 14. Bell M. Complications of alopecia reduction and their manage-
4. If you do not perfectly follow Frechet’s original mea- ment. In Hair Transplantation Unger WP, Nordstrom REA, eds.
2nd ed. New York: Marcel Dekker, 1988:497–503.
surements in your drawing, you may run the risk of 15. Frechet P. A new method for correction of the vertical scar ob-
facing problems for the transposition of the Flaps. served following AR for extensive alopecia. J. Dermatol. Surg.
5. It is prudent to complete the removal of the spindle- Oncol 1990; 16:640–644.
shaped bald area only when you are sure that it is possi- 16. Shiell R. Frechet’s flap procedure. New treatment to correct cen-
ble to perform the final suturing without any tension. tral slot defect. Hair Transplant Forum 1992; 2(5):2–5.
6. Four patients had already undergone autografting ses- 17. Frechet P. Slot correction by a three-hair-bearing transposition
flap in combination with AR. Int. J. Aesth. Rest. Surg 1994; 2:
sions. The scars in the occipital region did not compro- 27–32.
mise a good undermining of the scalp and I was able
to suture the 3rd Flap without any tension. However, it
is far better to perform the SE and 3-FTSC prior to any
autotransplant surgeries. Tips for the Novice in Scalp Extension
1. Frechet P. Traitement des alopecies androgenetiques. Approches
ACKNOWLEDGMENTS therapeutiques actuelles. J Med. Esthet Chir Derm. Juin 97; Vol.-
XXXIV 94:97–103.
The author wants to thank Mr. Giuseppe Aleo and Mr. Augusto 2. De Sio C. Cirurgia da calvicie: nao apenas transplante 36⬚ Con-
Mari for their help with translation and illustrations for this gresso Brasileiro de Cirurgia Plastica. Rio de Janeiro nov 1999:
presentation. 12–16.
3. De Sio C, Scalp Reduction with Skin Extender. 30th Annual
Meeting of the Egyptian Society of Plastic & Reconstructive Sur-
REFERENCES geons, February 2000, Cairo, Egypt.
4. Magalon G, Aubert JP. Tissue expansion, eds.: Lamy Marseille,
Scalp Extension 1992:pp. 31–62; 218–233.
5. Frechet P. Management of extensive alopecia by scalp extension
1. Frechet P. Du nouveau as la chirurgie de la calvitie. Panorama in combination with occipital slot correction. Int J Rest Surg 1995;
Med 1992; 7:3685. 3:103–114.
21
Flap Procedures
Introduction to Flap Procedures vascularized pedicles. Combining flaps with tissue expansion
adds another dimension to their usefulness.
Gerard E. Seery So what is the problem?
There appears to be little doubt that flaps are an effective
HISTORICAL PERSPECTIVE modality of treatment for traumatic and other scalp defects.
Considerable skepticism exists about the use of flaps in the
Modern scalp surgery had its beginnings early in the 20th cen-
treatment of MPB.
tury at a time when scalp reconstruction was done to save lives
or treat deformity, or both. At that time, niceties of cosmesis
and preservation of sensation were considered of little or no TECHNICAL CONSIDERATIONS
importance. In the early days, progress in scalp surgery was
measured in terms of the construction of scalp flaps designed Flaps, in general, share strikingly similar characteristics. They
to address some specific reconstructive problem or need. are variously described after the site of anatomical derivation
In 1908, Cushing described advancement flaps for closure or the surgeon who originated them. Their object is to move
of scalp defects. (1) In 1919, Dourfermentel reported success hair-bearing tissue to alopecic areas without losing hair during
with bipedicled flaps. (2) Mitchell, in 1933, was the first to transit. Baldness eliminated immediately is often claimed. Flaps
use flaps in the treatment of alopecia, without the procedure differ only in sites of origin, anatomical dimensions, and content
achieving any notable popularity. (3) In the 1940s and 1950s, (e.g.,vasculature) and in the nuances of the surgical techniques
Kazanjian (4) and Gillies (5) successfully reconstructed large used to effect transfer. Small flaps (w-plasty, z-plasty) move
scalp defects with flaps, and in the 1960s Orticochea showed small amounts of hair; intermediate-sized flaps (e.g., Elliott
that scalp flaps could be raised on their own vascular pedicles. flaps) move modest amounts of hair, and large flaps (e.g., Juri
(6) In 1969, Juri described large temporo-parieto-occipital flaps flaps) move large amounts of hair. The directional orientation
for the surgical treatment of alopecia (7) and, although this of the hair moved is virtually always at variance with hair pat-
represented a milestone in surgical technique, flaps continued terns at the recipient site. In the case of frontal baldness, the
to play a limited role in the treatment of male pattern baldness frontally transposed hair is orientated in a ‘‘front to back’’ un-
(MPB). The advent of alopecia reduction (AR) in 1977, because natural direction opposite to that desired. Dense flap hair, when
of its relative simplicity and apparent success, made flaps even transposed to an alopecic or balding area, often represents a
less relevant in the treatment of MPB, and they were largely striking contrast with existing hair. A localized wall or shock
reserved for solving reconstructive problems. Still, an additional of hair, particularly in totally alopecic areas of MPB, looks
decline in flap utilization came in the 1980s, when tissue expan- unnatural and attracts the eye. A scar represents the leading
sion further pre-empted their use. This, coupled with the ever- edge of the hairline.
increasing sophistication of hair transplantation techniques, rel- The temporo-parieto-occipital (TPO) Juri flap is perhaps the
egated flap treatment of androgenic alopecia to the limited niche best-known and the most utilized flap in the treatment of MPB.
it occupies today. Because it is representative of scalp flaps in general, the techni-
Scalp defects, at least theoretically, are uniquely suited to cal aspects of its construction and the sequelae of same are
flap reconstruction. Blood supply is profuse and, unlike tissues discussed here:
supplied by perforators, cutaneous arteries that allow flaps to
be raised without delay procedures largely supply the scalp. A The Juri Flap
further advantage is the subgaleal fibroareolar layer that permits
the sliding or gliding phenomenon unique to the scalp. Doppler The Juri flap aspires to transfer a large amount of hair (more
scan technology allows arterial mapping that ensures optimally than twice that of the temporoparietal or lateral flaps). It has a
795
796 Chapter 21
high length-to-width ratio that not only increases the possibility 21A. Pedicle Flaps in the Surgical
of pedicle ‘‘kinking’’ and ‘‘dog-ear formation,’’ but also re-
quires two delay procedures at an approximately 1-week inter-
Treatment of Alopecia
val to help ensure survival. A week after the second delay, the José Juri
flap is transferred under general anesthesia to its recipient site.
The extremity or tip of the flap is supplied by perforating arter- Since 1969, we have been using temporo-parieto-occipital pedi-
ies and, as such, is vulnerable to vascular embarrassment. cle flaps to treat alopecia. The pedicles, designs, and number
A second, again, two-delay flap, if necessary, is done a of flaps vary according to the degree of baldness (Fig. 21A-1).
month later and a third additional two-delay flap may be done, In first-degree alopecia, we utilize a flap with a temporo-pa-
in due course, where extensive baldness exists or develops. It rieto-occipital pedicle. In second-degree alopecia, we use two
is recommended that alopecic spaces or ‘‘bridges’’, no less than flaps with the same type of pedicle, taking one from each side
2 cm wide, be left between the flaps. It is further recommended of the head. In third degree alopecia, we use three flaps (two
that these bridges be removed via AR procedures during the with temporo-parieto-occipital pedicles and one with a retroau-
course of treatment. Hair transplantation, to camouflage the ricular pedicle or occipital pedicle) Fig. 21A-2.
abrupt hairline, is also suggested as an adjuvant treatment. Revi-
sion of ‘‘dog-ears’’ and scars may take several more operations.
In its entirety, the operative regimen represents a truly multi- TECHNIQUE
staged tour de force surgical assault, with attendant absence The superficial temporal artery on one side is palpated and
from work, use of several general anesthetics, and considerable marked. This will be the center of the base of the pedicle that
fortitude on the part of surgeon and patient alike. Smaller flaps we are going to incise and shape. Our intention is to place the
involve less surgery but the treatment modalities differ only in terminal parietal branch midway inside a flap approximately 4
degree. cm wide, and long enough to reach the fringe of hair on the
opposite side of the area of alopecia. A Doppler flowmeter may
be used to help trace the course of this artery for usually at
BIOMECHANICAL CONSIDERATIONS least one-half the length of the proposed flap (Kabaker, 1978;
Toomey et al., 1977). The flap, starting from the temporal area,
The methodologies used to effect flap transfer, in general, vio- runs through the entire parietal zone and descends to the occipi-
late the principles of optimal scalp surgery. Hair orientation tal region without crossing the midline (Fig. 21A-3). It must
patterns and tension lines are not respected; peripheral incisions
transect vital neurovascular structures; extensive undermining
and stretching of tissue is the rule. Taken collectively, the flap
transfer produces distorted hair patterns, transection scarring,
poorly sensate and vascularly deprived tissues, and extensive
scarring and stretch-atrophied tissues. When TPO flaps are
used, the donor area may also be irremediably adversely af-
fected.
COMPLICATIONS
The most notable complication is necrosis from kinking, or
pressure to the pedicle. The effect of this can range from a flap-
hair effluvium to partial or total necrosis of the flap. Detailed
data, with regard to the incidence of necrosis, in the various
flaps, is scant. Reports of over 1000 flaps done, without serious
complications, are viewed with skepticism by most experienced
scalp surgeons.
CONCLUSIONS
In fairness, it must be said that in the hands of highly skilled
experienced surgeons, a satisfactory result may be obtained fol-
lowing large flap transfer. This, however, may be achieved at
the price of considerable and irremediable adverse effects to
the scalp—a price that may require payment downstream by a
scalp tapped out of remedial resources. The conclusion that
flaps should play a very small role in the surgical treatment of Figure 21A-1 A, First degree baldness. B, Second degree bald-
alopecia seems reasonable. ness. C and D, Third degree baldness.
Flap Procedures 797
Figure 21A-2 A, One flap with temporo-parieto-occipital pedi-

cle. B, Two flaps with temporo-parieto-occipital pedicles (one from Figure 21A-3 A, The flap, starting from the temporal area; B,
each side of the head). C, Three flaps, two with temporo-parieto- runs through all the parietal zone; and C, descends to the occipital
occipital pedicles and one with retroauricular pedicle. D, Three region without crossing the midline.
flaps, two with temporo-parieto-occipital pedicles and one with
occipital pedicle.
shafts. The bed is not raised. The incision lines are closed with
running sutures, 3–0 nylon or Prolene. A 24-hour head dressing
is applied.
be carefully designed so as to produce a sufficient length, e.g., One week later, the posterior 6 cm of the flap is cut and
by employing a greater or lesser curvature in the flap, and to elevated. Any occipital perforators encountered are cauterized
minimize problems with dog ears, e.g., by placing it as high as or ligated with 3–0 Dexon. Incision lines are sutured as de-
is practical in the parietal scalp. The superior border should be scribed above. These two delays allow for the autonomy of the
inferior to the hair-bearing margin in order to facilitate covering flap with regard to arterial supply as well as venous return.
of the final scar, but, in addition, in younger individuals, one A week after the second delay, the entire flap is raised and
should try to anticipate future hair loss and lower the superior transposed to the anterior line that we have already drawn with
margin to areas judged to be permanently hair-bearing. Because the cooperation of the patient (Fig. 21A-4). Initially, an incision
of the design requirements noted above, some patients are not is made along this line, and the anterior scalp is undermined.
good candidates for this procedure, in that they do not have The incision should be beveled anteriorly as one cuts toward
prospects of maintaining a wide enough fringe of permanent the galea. This maneuver will result in a better ‘‘fit’’ for the
hair. beveled edge of the flap and in addition will result in hair grow-
For security reasons, we employ two delays. The first opera- ing through the scar at the anterior border of the flap, minimiz-
tion can be carried out in a properly equipped office. Patients ing the obviousness of this line. Closing the donor site at this
are asked to let their hair grow a little longer than usual to point in the procedure reduces the amount of glabrous skin,
facilitate postoperative coverage. The flap is designed and the which must be removed to accommodate the flap. Extensive
hair is clipped short in narrow bands superior and inferior to undermining of the skin of the anterior scalp helps to avoid a
the proposed borders. Hair within the flap can be braided and dog-ear.
taped out of the way (Kabaker, 1978). Xylocaine 1%, with 1: To close the donor wound, without tension, it is necessary
100,000 epinephrine, is infiltrated along the incision lines pro- to perform a deep undermining of the retroauricular area, some-
viding anesthesia as well as minimizing bleeding. If a general times as low as the nape of the neck (Fig. 21A-5), and to suture
anesthetic is not used, preoperative sedation may be employed, on two levels; aponeurosis and skin. Dissection of the flap
e.g., intravenous diazepam (Valium) 10 mg to 20 mg. The supe- should be made deep to the galea in the scalp region and in
rior and inferior borders are incised down to and including the the cervical-fascial plane posteriorly and inferiorly. Suturing is
galea aponeurotica. Care is taken to cut parallel to the hair started from the proximal end. The aponeurosis is sutured with
798 Chapter 21
fibrous tissue on the distal undersurface of the flap should be

removed prior to transposition. The edges of the flap are sutured
with 5–0 nylon.
Transfusions have not been required. The operation, on the
average, lasts approximately 1 hour, but may take considerably
longer in less experienced hands.
One month later (if necessary), a second flap (from the other
side of the scalp) is carried out with a similar design and tech-
nique. This flap is placed posterior to the first one.
If the bald area is large, a bridge of intact skin no less than
2 cm-wide should be left between both flaps. This hairless gap
can be excised 2 months later, and the flaps brought toward
each other. The aponeurosis is removed and parallel incisions
are made in the remaining aponeurosis to aid this advancement.
Fig. 21B-6 demonstrates typical results.
In third degree alopecia, we design a third flap using the
scar from the first flap (Fig. 21A-7A), as the superior edge, and
a parallel incision 4 cm to 6 cm inferior to it as the inferior
edge. It should be made long enough to reach the hairy scalp
on the opposite side of the head. While the pedicle may be
placed at either the retroauricular or occipital end (Fig. 21A-
7B, C), in our experience, a flap with a retroauricular pedicle
most effectively covers 95% of the presenting patterns of alope-
cia (Fig. 21A-8A, B). When dealing with isolated occipital alo-
pecia, one also has the option of a flap with a retroauricular or
an occipital pedicle (Fig. 21A-9A to 9F), In our experience, a
flap with a retroauricular pedicle has also been best in 95% of
these patients. The exceptions are those who have small and/
or ovoid spots of occipital alopecia with the long axis running
anteroposteriorly (Fig. 21A-7C to 21A-8B).
Figure 21A-4 A, closure of the donor wound following under- Once again, two delays are used. The edges of the flap are cut
mining. B, Resection of the glabrous frontal zone. C, Placing and and sutured as described earlier. The tip is cut and undermined 1
suturing of the flap. week later. The transposition takes place one week after the
second delay.
3–0 interrupted buried Dexon sutures and the skin with 5–0
interrupted nylon. Attempts to use sutures that go through the
full thickness of the scalp tend to produce small areas of alo-
pecia.
The flap is transposed with the hair unshaved and the opera-
tion must be performed under general anesthesia. Xylocaine
1%, with 1:100,000 adrenaline, are used along incision lines to
minimize bleeding and cautery is used where necessary. Any
a b
Figure 21A-6 a, Preoperative view of a patient undergoing

surgery for second-degree baldness. b, Same patient, postoperative
Figure 21A-5 Retroauricular undermining area. view.
Flap Procedures 799
Figure 21A-7 A, Two flaps have been rotated for temporopa-

rietal baldness, and the residual donor scar on one side is seen
(arrow). B, The design of a third flap with a retroauricular pedicle. Figure 21A-9 A, Design of a rotation scalp flap with a retroau-
C, The design of a third flap with an occipital pedicle. (Reprinted ricular pedicle. B, The flap is lifted up and both donor edges under-
with permission from Juri, J. 1978. Use of rotation scalp grafts for mined widely (lines). C, The donor wound is sutured in two layers.
treatment of occipital baldness. Plast. Reconstr. Surg. 61:23–26.). The aponeurosis is closed with Dexon, and the skin is closed with
5–0 nylon sutures. D, The occipital bald area is resected to prepare
a recipient bed. E, The flap is sutured in the bed with simple 5–0
sutures. F, Two months later, the residual bald area is resected;
then the flap is extended, and the occipital area is undermined
When the pedicle is retroauricular, the upper edge of the widely (lines), so closure can be done by suturing. (Reprinted with
flap is along the margin between the hairy area and the occipital permission from Juri J.1978. Use of rotation scalp grafts for treat-
bald spot (see Fig. 21A-9A). This is an important detail because ment of occipital baldness. Plast. Reconstr. Surg. 61:23–26.)
the parietal zone (where the proximal flap edge will be sutured
after being transposed) usually does not have dense hair
growth—in this way there will be no notable contrast between
the density of hair in the parietal zone and the proximal portion The incision in the parietal zone should not be straight, but
of the flap. curved with the convexity located anteriorly (Fig. 21A-9A).
This will give a more natural aspect to this hair, and help make
the scar less visible. Before placing the flap, it is necessary to
suture the donor wound (Fig. 21A-9C). We undermine widely,
going beyond the retroauricular angle (Fig. 21A-9B). The occip-
ital zone is also undermined widely, and lifted anteriorly and
laterally, so one can resect (after suturing) most of the occipital
bald area (Fig. 21A-9D). This leaves a smaller bald spot to be
covered by the flap.
As before, the donor wound is sutured in two layers, the
aponeurosis and the skin—with interrupted sutures. When su-
turing, it is most important to avoid tension because this may
cause further complications.
This residual bald zone is resected two months later. The
flap is stretched fully by resecting some of the aponeurosis
posterior to it and advancing the occipital zone (Fig. 21A-9F).
Results of flaps in the occipital area can be seen in Fig. 21A-
Figure 21A-8 A, The rotation of a flap with a retroauricular 10A and B and Fig. 21A-11A and B. The only complications
pedicle. B, The rotation of two flaps with occipital pedicles. (Re- that might occur (necrosis or dehiscence of the suture borders)
printed with permission from Juri, J. 1978. Use of rotation scalp are due to sutures under tension. A deep and adequate
grafts for treatment of occipital baldness. Plast. Reconstr. Surg. 61: undermining, as well as suturing on two levels, avoids such
23–26.). problems.
800 Chapter 21
a b
Figure 21A-10 a, Preoperative parieto-occipital baldness. b, Parieto-occipital baldness 2 months postoperatively.
a b
Figure 21A-11 a, Preoperative occipital baldness. b, Occipital baldness 1 month postoperatively.

Flap Procedures 801
Editor’s Comment 21B. Microsurgical-Free Flaps

Excellent technique and experience always result in fewer com- Kitaro Ohmari
plications. Perhaps this is why Dr. Juri’s comments are so brief
in this area. The procedure, however, requires great skill and Scalp hair grows at varying angles and densities at different
should not be undertaken lightly. Complications such as exces- sites on the head. When Hair Replacement Surgery (HRS) is
sive blood loss, dog-ears, inability to close the anterior portion employed for the treatment of androgenetic alopecia (AA), in
of the donor wound, and necrosis of the distal end of flaps have which hair is sparse or absent in the fronto-parietal area, such
been noted by others. factors as hair direction and density must be considered in plan-
The main advantage of flaps is that when they are properly ning a method of treatment.
carried out, they produce dense bands of hair growth. Futher- This discussion deals with a microsurgical-free scalp flap
more, this growth is nearly always immediate and continuous. transfer. It is not yet well known in HRS, but results in a grafted
The main disadvantages are that the direction of hair growth is flap with a natural hair direction and density after a single opera-
opposite to the usual in the anterior hairline, and incomplete tion (1,2). This type of microsurgical-free composite tissue
survival is more noticeable and potentially more serious (in transfer has been employed and is a fundamental and accepted
respect of depletion of donor reserves.) An additional disadvan- technique of plastic surgery (3).
tage lies in the fact that hair growth occurs in narrow bands.
Because of this less diffuse spacing of transplanted hair, careful
hair styling is more necessary and more difficult (even with MICROSURGICAL-FREE SCALP FLAP
good flaps) than with good graft transplanting. Alopecia reduc- TRANSFER
tions (ARs) should be used to improve or eliminate these gaps. The outline of a type of free scalp transfer utilizing microsurgi-
Thus, flaps and grafts are roughly equal in their requirement cal vascular anastomosis is illustrated in Fig. 21B-1. The main
of ARs for optimal results. components of this method are the skin flap appropriate for
In my opinion, flaps should rarely, if ever, be used for the transplantation, microsurgical technique necessary for revascu-
hairline. This is contrary to the opinions of other respected larization of the grafted flap at the recipient site, and recipient
physicians, some of whom believe the exact opposite and have vasculature suitable for microsurgical anastomosis. The three
presented their views in other editions of this text. The potential components will be discussed subsequently.
for very natural-looking hairlines (in terms of density, density
gradients, and natural direction of hair growth) exists when
Flap Suited for Transplantation
one uses grafts carefully. This is documented by the numerous
photographs of graft-transplanted hairlines in this book. Al- An appropriate free scalp flap is a flap whose entire blood sup-
though hair density will nearly always be better with well-exe- ply is preferably provided by an artery and paired vein whose
cuted flaps, the absence of any potential for obtaining a natural diameters are suitably large for micro-anastomosis. This holds
density gradient and direction of hair growth as well as the true for any other microsurgical-free skin flap. The donor site
obvious exposure of an abruptly dense hairline are strong argu- after flap preparation should be closed, preferably by direct
ments against the use of pedicle flaps at this site. (WU) approximation, and the line of suture should be perpendicular
Figure 21B-1 A free flap is raised and transferred by means of microvascular anastomosis.
802 Chapter 21
to the direction of hair growth. Four kinds of skin flaps are

clinically applicable: temporo-parietal, temporo-occipito-pari-
etal, occipito-temporal, and occipito-occipital flaps. Their out-
lines are shown in Fig. 21B-2 (4). The specific features of these
are listed subsequently.
Free Temporo-Occipital Flap

This flap is based on the superficial temporal artery and vein
and measures from 18 cm by 4 cm to 20 cm by 4 cm in adults.
For hair replacement of the frontal hairline of AA, this flap
would be the most suitable.
Free Occipito-Temporal Flap

This flap is based on the occipital artery and vein and is slightly
smaller than the temporo-occipital flap. It measures from 16
cm by 4 cm to 18 cm by 4 cm. In some cases, dissection of
the occipital vein is technically difficult. It is indicated for the
repair of cicatricial alopecia in the temporo-parietal region in
which the anterior region is repaired with a free temporo-occipi-
tal flap and further hair transplantation is needed in the site
posterior to the already grafted flap.
Free Temporo-Occipito-Parietal Flap

In the case of a free temporo-occipito-parietal flap, a large flap Figure 21B-3 A pair of artery and venous anastomoses.
of over 24 cm in length can be raised, with a vascular pedicle
of the superficial temporal artery and vein. The temporal and
anterior hairlines of both sides can be reconstructed with one

flap if this type is used.
Free Occipito-Occipital Flap

This flap is based on an occipital artery and vein, and a flap
of about 16 cm can be taken. It seems to be the best location
for raising a flap in the treatment of vertex baldness, but in
actual use, closure of the donor defect is extremely difficult.
Microsurgical Vascular Anastomosis

Blood vessels with diameters of 3 mm or less are usually anasto-
mosed under a microscope (Fig. 21B-3). Similar to the tie-over
dressing technique used in the traditional free skin graft, this
is considered one of the fundamental techniques in the field of
plastic surgery. It is widely employed in the replantation of
amputated fingers and transplantation of free tissues and organs
with a vascular pedicle. The fundamental techniques and instru-
ments are basically the same internationally. The details are
discussed subsequently (5).
Operating Microscope
Most of the currently available operating microscopes may be
used. The author performs microsurgical anastomosis alone,
and for this purpose, the type 6 microscope made by Zeiss
Corporation is sufficient.
Suture Materials
Figure 21B-2 Four types of free scalp flaps: (a) Free temporo- Several companies now manufacture 10–0 nylon suture mate-
parietal; (b) occipito-temporal; (c) temporo-occipito-parietal; and rial with a needle for vascular anastomosis. The author prefers
(d) occipito-ocipital. 35 cm 10–0 nylon with a 75-mm needle.
Flap Procedures 803
Microsurgical Instruments Micro-forceps Formerly we used ordinary jeweler’s for-

Micro-scissors Ordinarily, micro-scissors with a spring ceps. Currently, we use no. 2 type jeweler’s forceps, which
handle are employed. There are straight and curved varieties. are modifications of the original type designed to allow less
The straight ones are used to cut and prepare the blood vessels traumatic operative procedures. No. 5 type forceps are used to
for anastomosis, whereas the curved ones are used for adventi- pick-up the vascular adventitia during anastomosis and to insert
tectomy, microdissection, and cutting suture materials. The fol- the tip into the vascular lumen in assisting anastomosis. In con-
lowing points should be taken into account in selecting scissors. trast, no. 2 forceps are used for rougher procedures, such as
The spring should possess just enough strength to open the adventitial dissection and other microdissection procedures.
blades; the blades should be long enough to cut blood vessels Vascular Clip We have been using Heifetz clips, although
of 3 mm; and the entire scissors should have a length such that there are clips available that have been developed for the pur-
the midpoint of the spring falls between the interphalangeal pose of micro-neurosurgery. Although it is true that Heifetz
joint of the thumb and the proximal phalanx of the index finger clips appear to compress and contuse blood vessels, we have
when held with an internal grip. never experienced, in over 800 clinical procedures, operative
Needle-Holder Unlike animal experimentation, the blood complications that seemed to arise from the use of this type of
vessels we deal with, clinically, are somewhat thick and large. vascular clip. Even relatively large blood vessels can be effec-
The suture material is very thin, 10–0 nylon. We prefer the tively clamped with these clips. Therefore, blocking of blood
Castroviejo-type needle holder with a ratchet. This holder al- flow, necessary during vascular anastomosis, can be managed
lows one to hold the needle at its tip with enough strength to with this type of clip.
pierce the vascular wall with the ratchet not on. In other words,
the holder should be such that at the first catch, the surgeon
can hold the 10–0 nylon needle with the holder without having Vascular Anastomosis
recourse to the ratchet. With further gripping, the ratchet comes Vascular anastomosis is started when the vascular pedicles of
‘‘on’’ for the first time. In actual use, we use it as if it had no the donor and recipient sites are brought together to the same
ratchet while looking at the operative field under a microscope. operative field and the operative microscope is aimed at this
The ratchet is used to hold the 10–0 nylon suture that has come field. First, it is confirmed that there is no twisting or tension
out of the microscopic field. This is the way we handle the very of the arteries and the veins on both donor and recipient sides.
fine microsurgical suture material, which is very difficult to Vascular clips are clamped at least 5 mm away from the vascular
manipulate without a microscope. The advantage of this method ends so that the vascular lumina are free of blood. Then the
is that the needle can, at each suture pass, be brought and kept vascular ends are washed with a sufficient amount of heparin-
outside of and away from the operative field. This minimizes ized saline. With this washing, the conditions of the intima,
the danger of losing, within the operative field, such a fine adventitia, and accompanying areolar tissue, and the presence
needle that it is difficult to see microscopically (Fig. 21B-4). of venous valves become clearly visible. Based on this observa-
tion, adventitectomy and resection of venous values can be car-
ried out. During this preanastomosis preparation, the working
condition of the operating microscope can be checked and the
most suitable position of the surgeon’s hands and elbows, for
microvascular anastomosis, can be determined.
Adventitectomy should be limited to the minimum required
for both artery and vein. Adventitectomy over a long distance
is unnecessary, and preservation of the vascular supply to the
cut ends of the vasculature is important. When the adventitia is
seen to stand out from the vascular wall, as a result of washing, it
should be pulled from the vascular end using micro-forceps and
trimmed with micro-scissors.
Having trained a number of surgeons, and having performed
numerous microvascular anastomoses myself, I have come to
believe that although microvascular anastomosis is a possible
discipline, it is by no means easy, no matter how experienced
one has become. The best result seems to be obtained by assum-
ing the easiest possible posture in relation to the operative field
during micro-anastomosis. In other words, one should avoid
difficult postures and extreme inclination when performing
anastomosis. If a difficult posture is necessary for a certain
anastomosis, one should abandon such an anastomosis and con-
sider adding venous transplantation, which can be performed
with a good posture.
A good posture is that which one assumes when writing. The
vasculature corresponds to what is written, and the microscope
happens to come between the writing and the writer. When one
Figure 21B-4 The needle holder with needle is placed outside writes, the paper is usually positioned more or less diagonally
the field of the operating microscope. in relation to the writer’s body. By the same token, the vascula-
804 Chapter 21
ture to be anastomosed should be somewhat diagonal in relation

to the operating surgeon’s body. The operative field should be
positioned so that in relation to gravity, during anastomosis,
the heparinized saline that is to be sprayed to prevent drying,
does not stay for an unnecessarily long time under the micro-
scopic field and is drained spontaneously.
Vascular anastomosis should be the same whether the vascu-
lature is less than 3 mm in diameter or larger. Even when using
an operative microscope; microsurgical suture material and in-
struments; certain limitations exist as far as actual usable suture
material and manual technique are concerned. For this reason,
damage to the vessel becomes larger as its diameter becomes
smaller. Micro-anastomosis is performed on this basis.
The smallest blood vessels ever anastomosed, microsurgi-
cally, were less than 1 mm. They were sutured in an operation
on the amputated fingers of a 9-month-old infant at the distal
interphalangeal joint. In dealing with free scalp flaps, such small
blood vessels are rarely sutured. For example, in the operation
of a 3-year-old child we treated for cicatricial alopecia, the
outer diameters of the vasculature were well over 1 mm. In
the treatment of adult baldness, most arteries and veins to be
anastomosed are in the neighborhood of 2 mm. However, one
should be trained so that one can perform microsurgery of the
vasculature of a smaller size than is actually required.
The goals of vascular anastomosis are approximation of the
intima of one vessel to that of the other and leakage-free anasto-
mosis. In the following discussion, our method of manual
micro-anastomosis is delineated. Although end-to-side anasto-
mosis of the vasculature can be performed, we exclusively use
end-to-end anastomosis.
Technique
Anastomotic stitches are classified into key stitches and inter- Figure 21B-5 An example of microvascular anastomosis.
mediate stitches placed between the key stitches. By so classify-
ing them, the steps of anastomosis and important points of anas-
tomosis are better explained. The concept of key stitches is
typically found in the idea of the eccentric biangulation method
proposed by Cobbet (6). In this method, three key stitches are
placed along the circumference of the vascular wall 120degrees
apart from each other. Intermediate stitches are placed while
the interval between any two of the three stitches is stretched.
The part of the vascular wall thus stretched becomes separated
from the rest of the wall, and accidental suturing up of the
opposite wall can be avoided, according to Cobbett.
These basic steps of anastomosis and the role of key stitches
are still considered important in microvascular anastomosis. In
practice, anastomosis is made while the vasculature is clamped
with a vascular clip. Suturing of half the vascular circumference
is first made. The clip is then turned over to rotate the blood
vessels to suture the untreated half. Any two stitches can func-
tion as the key stitches, and precise 120-degree intervals do not
have to be made. At present, key stitches are made about 150
degrees apart from each other, and three or four intermediate
stitches are then placed before the blood vessels are rotated for
further suturing, which begins adjacent to the key stitches al-
ready in place. Suturing of the midpoint is then made to com-
plete the anastomosis (Fig. 21B-5).
The bite or site of needle entry into the vascular wall from
the end of the blood vessel should be about twice the thickness Figure 21B-6 Site of needle entry into the vascular wall from
of the vascular wall (Fig. 21B-6). This is determined while the end of the blood vessel should be about twice the thickness of
looking at the structure of the vasculature at sufficient magnifi- the vascular wall.
Flap Procedures 805
cation, which is usually 16⳯ or more. The needle enters the After assuming this posture, the tips of the no. 5 micro-
wall perpendicularly and the suture material is tied tautly but forceps are slightly opened and inserted into the lumen of the
not too tightly. There has been a tendency to make the width blood vessel on the right side. The forceps give counterpressure
of bite larger, that is, farther away from the end of the blood when the microvascular needle on the holder, kept in the right
vessel. This is particularly true with veins. This is because the hand of the surgeon, pierces the vascular wall vertically. The
vascular wall is too thin to be considered to have thickness. needle then comes down between the tips of the forceps (Fig.
The vascular elasticity and firmness are also taken into account 21B-7). The spring of the holder is then released to free the
in deciding how large the bite width should be. In other words, needle, and the needle is then held with the forceps to move
there are certain empirical aspects in microsurgery as in skin the needle out of the vascular lumen. Then the needle is trans-
surgery. ferred from the no. 5 forceps to the needle holder. The adventitia
Anastomosis begins when the pretreated blood vessels are of the blood vessels on the left side is then held with the forceps
placed under a microscope. The following explanation assumes in the left hand. The vascular wall is then carefully pierced
the surgeon is right-handed and the vasculature to be anasto- vertically from within. The needle is then freed to be transferred
mosed is placed approximately parallel to the operating sur- to the forceps and is pulled slowly outside the vascular wall.
geon. The needle pulled out is again held with the needle holder. The
The surgeon holds the no. 5 micro-forceps in the left hand forceps are then placed on the external wall of the blood vessel
and the needle holder in the right hand. To minimize hand at the proximity of the site of the needle insertion. The needle
tremor, the midpoints of the surgeon’s forearms are placed on holder, catching the needle, is then slowly withdrawn until the
firm supports. To stabilize the left wrist, a small pillow can be end of the suture material comes into the microscopic field.
used. Hand tremor can be prevented by reducing the weight of The ratchet of the holder is then hooked on for the first time
the forearm, having it rest on a support, and by stabilizing the to hold the needle more securely, and the holder is brought to
wrist. the resting position. The no. 5 forceps are then held by the right
a b
Figure 21B-7 The usage of needle: (a) the way to bite the right end of the vessel. (b) After biting the left end of the vessel.
806 Chapter 21
Figure 21B-8 Clinical cases with preoperative and postoperative views. (a) Type I baldness. (b) Type II baldness (c) Type III baldness.
(d) Preoperative and postoperative frontal views of a case.
Flap Procedures 807

808 Chapter 21
operative position for free scalp surgery is the supine position,

and the blood vessels, other than the superficial temporal ves-
sels, are unsuitably situated. Therefore, either right or left super-
ficial temporal vessels, which will give a natural flow of hair
at the recipient site, are chosen as recipient vessels.
CLINICAL RESULTS
The results, after application of microsurgical free temporo-
occipital flap for restoration of anterior hairline, are illustrated
in Fig. 21B-8.
COMMENTS
The schematic diagram of the suture lines is shown in Fig. 21B-
9. The actual example of the new anterior hairline, and the
results after the donor site was closed by direct approximation,
is shown in Fig. 21B-10.
After having performed more than 200 cases of this type of
flap, my opinion is that this procedure is less complicated than
a face-lift operation. However, only a good operative plan, as
well as good anastomosis technique, will produce good results.
21C. Microsurgical Free Temporo-

Figure 21B-9 The suture lines of the operation, with a dotted Parieto-Occipital Flap
line that shows the area of baldness.
José Juri
After the advent of microsurgical techniques, I considered the

hand before starting ligation. The ligature is made using two transposition of the temporo-parieto-occipital flap, as a free flap
pairs of no. 5 forceps held in both hands. to obtain normal hair direction. The latter has the additional
advantages of providing more hair density and hiding any hair-
line scar (Fig. 21C-1).
Vasculature of the Recipient Site
On the circumference of the scalp, there are blood vessels with DESIGN
diameters suitable for microsurgical vascular anastomosis: the
superficial temporal artery and vein, occipital artery and vein, The flap design and dimensions are similar to those of the con-
and the posterior auricular artery and vein. The most suitable ventional flap, although the free flap has a modification in its
a b
Figure 21B-10 (a) Showing the new anterior hairline. (b) The donor site scar.
Flap Procedures 809
base because it is necessary to add an extension in the form of

a wedge that descends up to the area where the flap vascular
pedicle is explored. The wedge has a length of approximately
6 cm, from which the base of the conventional flap would begin.
The flap length is about 23 cm to 30 cm (depending on the
extent of the alopecia to be covered); its width is between 4
cm and 5 cm, according to the possibilities offered by the donor
site.
SURGICAL TECHNIQUE
Individualization of the Recipient Vessel
The operation begins with microdissection of the recipient su-
perficial temporal artery and vein (Fig. 21C-2). The artery has
an average caliber of 1.2 mm and the vein of 1.5 mm (although
sometimes we find arteries of wider caliber than veins). The
selected anastomosis site is at the level of the tragus; if it is
done more superiorly the flap will be shorter.
Individualization of the Flap Vessels
The flap vessels are then prepared, isolating them from the
bed and the neighboring tissue and ligating the corresponding
collateral vessels (frontal, zygomatic, cutaneous, and retroauric-
ular). The flap is completely raised from its bed, thus verifying
good vascularization, with bleeding from the edges to the tip.
This clearly indicates that delays are unnecessary, which be-
comes more evident if it is considered that this pedicle does
Figure 21C-1 Free flaps can be performed with only local
not undergo torsion during its transfer.
anesthesia. Here we show the patient totally awake, immediately
after the surgery. Flap Transfer
Once the pedicle vessels are clamped, the flap is transferred to
the recipient site, performing the arterial and venous anastomo-
Figure 21C-2 (1) Design of the temporo-parieto-occipital flap following the course of the superficial temporal artery. (2) Scanning of
the vascular pedicles of the superficial temporal artery of the recipient zone. (3) Scanning of the vascular pedicles of the superficial temporal
artery of the flap. (4) Free flap with artery and vein clamped and identified. (5) Placing of the free flap and terminal vascular anastomosis.
(6) Completed and sutured flap; three-quarters side view. (7) Superior view of flap. The arrows indicate the direction of hair growth. (8)
Donor zone closed by undermining and simple advancement.
810 Chapter 21
Figure 21C-3 (a) Before free flap procedure. (b) After free flap procedure. (c) After free flap procedure. (d) After free flap procedure.
Flap Procedures 811
Figure 21C-4 (a) Before free flap procedure. (b) After flap procedure. (c) Design of the flap. (d) Design of the flap. (e) Free flap with
the artery and vein indentified and clamped.
812 Chapter 21
a b
c d
Figure 21C-5 (a) Before free flap procedure. (b) After free flap procedure. (c) Free flap with surrounding aponeurotic fascia, and
arteries and veins clamped; (d) Length of free flap shown above.
sis. When the clamps are released, circulation within the flap dressing completes the operation. The average total operative
is confirmed. time is 4 hours. Sutures are removed between the seventh and
tenth postoperative day.
Suture of the Anterior Implant Line
DISCUSSION
A previously designed hairline incision is carried out, under-
mining the scalp in this region to facilitate placement of the The free flap, owing to its dimensions, its extraordinary blood
flap, the anterior border of which is sutured to the frontal skin supply, and the good caliber and similarity of its donor and
with 5-0 nontraumatic monofilament nylon as a continuous su- recipient vessels, is now my first choice for the surgical treat-
ture. ment of most patients with alopecia (Figs. 21C-3 to 21C-5).
At the moment, my patients are treated as follows: 60% free
flaps; 30% conventional flaps; and 10% micro-punch technique.
Closure of the Donor Site
This applies both for the treatment of male patttern baldness
Closure is performed before the resection of the corresponding (MPB), and for alopecias of various etiologies, especially those
alopecic area and suturing of the posterior edge of the flap. To that affect the scalp from the frontal to the occipital region,
achieve this objective, a wide undermining of the retroauricular where hair grows in a more or less anterior direction. This flap
and neck region is required, as described in Chapter 21A. The has also been useful for patients with alopecia of the frontotem-
only difference is, here a forward rotation of the flap should poral region, secondary to thermal injury.
be added.
21D. The New Expanded Scalp Flap
Resection of the Alopecic Area and Final Suture Technique
Now, the alopecic region corresponding to the flap is resected Richard D. Anderson
and the posterior edge of the flap is sutured in place. Two drains
are placed: one is in the retroauricular region, and the other is Scalp expansion ranks as one of the most significant advances
through the incision posterior to the flap. An elastic, padded in Hair Replacement Surgery (HRS). Since the 1988 second
Flap Procedures 813
edition of Hair Transplantation 1, we have developed new com- gion in the future, it is unlikely that there will be any significant
binations of expanded scalp flap techniques that provide even progression of loss at the new frontal hairline.
more predictable and superior results than those previously re- Many varieties of vertical, temporal, superior-based, poste-
ported. The purpose of this discussion is to describe the Ander- rior-based, preauricular, and postauricular transposition flaps
son expanded bilateral advancement transposition (BAT) and have been previously described and redescribed by other au-
expanded triple advancement transposition (TAT) flap tech- thors (11,13) The previously described ‘‘vertical flaps,’’ how-
niques for the elimination of moderate and extensive degrees ever, did not provide a flap or flap combination that would
of male pattern baldness (MPB). The advantages and results of completely cover the frontal area (unless done in numerous
these techniques will also be presented. stages); nor did the previously described procedures provide
coverage for the crown and vertex balding areas.
The second component of our new BAT flap combination,
THE EVOLUTION OF EXPANDED FLAPS the temporo-parieto-occipital advancement procedures, has
been previously described as extensive scalp reductions by Mar-
The abundant hair-bearing scalp, created by scalp expansion,
zola (14), and Brandy (15). Those reports, however, did not
makes possible many varieties of flap combinations for the
involve expansion and were not combined with simultaneous
treatment of MPB. The first contributions to scalp reconstruc-
transposition flaps. Our combination of simultaneous advance-
tion with expanders were reported in the early 1980s by Argenta
ment and transposition flaps, after scalp expansion, makes the
et al. (1,2), Radovan (3), Manders et al. (4), and Kabaker and
BAT flap an improved treatment for hair loss involving the
others (5). Encouraged by Argenta and Austed, I began using
frontal, crown, and vertex regions.
expanders for the treatment of MPB in 1983. We first presented
the use of expanders for the treatment of MPB at the Second
International Congress on Hair Replacement Surgery, in New EXPANDED TRIPLE ADVANCEMENT
York in 1984.
TRANSPOSITION FLAPS
Our first expanded flaps, done in 1983, were expanded tem-
poro-parietal advancements or simply, expanded scalp reduc- Our expanded TAT (Fig. 21D-2) procedure is essentially the
tions. Examples of that technique were presented in our chapter BAT flap technique combined with a third simultaneously
in Hair Transplantation, 2nd edition., in 1988 (1). We recog- transposed expanded occipital flap to replace the alopecic vertex
nized, however, that frontal hairline coverage was not improved scalp.
with that procedure alone and we added a unilateral expanded The primary advantage of the TAT technique is the improved
temporo-parieto-occipital (TPO) Juri flap for frontal coverage vertex coverage that is afforded. The transposed occipital flap
in 1984. This evolved to bilateral simultaneous TPO flaps. Al- avoids the midline vertex scar. This is a great advantage for
though the results with these bilateral simultaneous TPO flaps postoperative styling of hair in this region, by the patient. The
were very dramatic, we were rarely able to achieve total cover- midline vertex scar that is present, after standard midline scalp
age of the alopecic area with this procedure. In an attempt to reduction, makes coverage of the area difficult because the hair
achieve complete and total coverage of extensive alopecia, a diverts to either side. The diversion creates a flat and ‘‘parted’’
variety of expanded transposition and advancement flap combi- area at the center of the crown-vertex region. The problem is
nations were begun in 1987. We have previously described avoided with the TAT procedure because a more desirable hair
some of these earlier combinations (1,6–9). The expanded BAT direction is achieved. That results in a more desirable fullness
(10) and expanded TAT flaps are our latest and most effective and easier styling and coverage at the vertex-crown region.
refinements to date.
PLANNING FOR EXPANDED FLAPS

EXPANDED BILATERAL ADVANCEMENT
TRANSPOSITION A successful result in scalp surgery depends on careful preoper-
ative preparation and planning. With flap surgery of the scalp,
Expanded BAT flaps (Fig. 21D-1) are bilateral, vertical, tem- a specific preoperative plan is essential, and you must not im-
poral, posterior-based transposition flaps in simultaneous com- provise as you go along. This is particularly true at the frontal
bination with expanded temporo-parieto-occipital advancement hairline region.
flaps. The BAT flap combination has provided many desirable It is important to remember that balding is progressive, and
benefits and advantages with which we are very pleased. These the present alopecic scalp will progress in the future. Do not
advantages include much superior frontal coverage, with a very transpose hair-bearing tissue from an area that will soon be
wide frontal flap that often measures 9 cm to 10 cm in antero- alopecic, or harvest grafts from an area that will soon be needed
posterior width. The new frontal flap coverage also provides a for a flap or from one that will lose the present follicles with
natural horizontal frontal hairline, desirable temporal recessions future hair loss.
bilaterally, and ease of design. In addition, the hair direction is One of the most common errors I see in HRS is a poorly
superior to that of Juri (TPO) flaps and there is no significant designed and poorly constructed frontal hairline. The new fron-
dog-ear deformity. Improved vertex and crown coverage is af- tal hairline should be placed horizontally and the distance be-
forded because of ease of re-expansion. The entire process from tween the temporal recessions should be approximately parallel
start to finish is accomplished in less time when compared with to the lateral brow. The new frontal hairline should preserve
multiple graft techniques available. the temporal recession bilaterally and avoid blunting in these
The BAT flap result provides reliable transposed hair from areas.
the temporal area to the frontal balding region. Unless the pa- A hairline that is placed too low on the forehead will create
tient progresses to total loss of hair in the temporo-parietal re- an unnatural appearance, especially in a mature man. Most pa-
814 Chapter 21
Figure 21D-1 a) The anticipated BAT flap final result. Note desirable anterosuperior hair direction and fullness at the frontal, crown,
and vertex regions. b) The outline of the BAT flaps plus the anticipated advancement from the posterior parietal and occipital regions. c)
The result after BAT procedures, showing a residual alopecic area at the crown region. d) Final closure with complete coverage following
the second expansion at the occipital region with a transposition flap from that expanded region.
tients will request filling of the temporal recession and a very more prudent to leave residual alopecic scalp and complete
low hairline. They must be counseled that this is not desirable another series of expansion than to risk excessive tension on
in the long run. The new hairline should be drawn with the closure that may result in tissue necrosis, hair loss, and wide
patient, preoperatively, and agreed on, before one commences undesirable scars. We discuss this possibility with the patient
the surgical procedure. before the first expansion series.
It is also essential to discuss, with patients, the possible need
for another expansion series. Depending on the size of the alope-
cic area, and the amount of expansion accomplished, it may not TECHNIQUE
be possible to remove the entire alopecic area in one expansion
series. It is imperative that the patient be counseled that another All expansion procedures require at least two stages and two
expansion series may be necessary to achieve the result that he operative procedures. The first procedure is placement of the
desires. expander, and the second involves removal of the expander and
One of the principal advantages of scalp expansion is avoid- the advancement and transposition of the expanded scalp to its
ance of tension on closures. I believe that it is much safer and new coverage area.
Flap Procedures 815
Figure 21D-2 a) The anticipated incisions along the alopecic hair-bearing fringe for placement of the expander. b) The expanded hair-
bearing area with the triple TAT flaps marked before transposition. c) Anticipated incomplete coverage following the TAT procedure. d)
Anticipated complete coverage following the TAT procedure. This will vary with factors discussed in the text. e) Lateral view showing
the outline of the flaps before transposition.
Expander Placement in the prone position on the Pron-Pillo [Chattanooga Pharma-

ceutical Company, Chattanooga, TN]. We recommend monitor-
I prefer one large U-shaped expander placed under the hair- ing with cardiac, blood pressure, and oximeter monitors and
bearing temporo-parieto-occipital (fringe) scalp, away from the use of intravenous sedation and nasal O2 during the placement
alopecic area. I currently use a custom, smooth expander with procedure. No trimming or shaving of hair is necessary, but
a remote port, but have used expanders with a self-contained rubber bands are used in the fringe hair. After intravenous seda-
port, as well. I have also used expanders with textured surfaces tion, a ring block of 1% lidocaine (Xylocaine) with 1:400,000
but I did not like them for scalp expansion, finding it difficult epinephrine is accomplished for the supraorbital, postauricular,
to avoid wrinkles during placement and expansion. and occipital nerves.
After marking the incision in a U-shape, along the hair- Povidone-iodine (Betadine) or hexachlorophene-entsufon
bearing alopecic junction (see Fig. 21D-2), the patient is placed sodium (pHisoHex) are prescribed preoperatively and used, by
816 Chapter 21
area of the expander port placement. Also avoid unnecessary

undermining of the residual alopecic crown area of the scalp
during placement of the expander.
The scalp is closed in two layers with 2–0 polyglycolic acid
suture at the galea, and skin staples or 2–0 Prolene in the skin.
Care is taken to avoid puncture of the expander during closure.
Dressing consists of K-Y, Telfa, Fluffs, and a Kling or Kerlix
wrap. Antibiotics are used perioperatively and continued for 24
to 48 hours. Dexamethasone (Decadron; 8 mg or methylprednis-
olone (Medrol Dosepak) may be used to minimize postoperative
edema.) The suction drain is usually removed in 24 hours. Nerve
blocks at the occipital, postauricular, temporal, and supraorbital
regions with 0.25% bupivacaine (Marcaine), with epinephrine,
are helpful for immediate postoperative pain control.
Inflation
Injectable saline is used for inflation of the prosthesis. Injection
of the expander usually begins at the time of initial placement.
Only enough saline is injected to obliterate the operative dead
space. No significant tension is placed on the suture line for
the first 2 weeks.
Figure 21D-2 Continued. A 23-gauge butterfly needle, connected to a 60-mL syringe,
is ideal for injection. The injection site is prepared with povi-
done-iodine and the needle is inserted under sterile conditions.
Because most inflation reservoirs have reinforced backing,
the patient, as a shampoo, the evening before surgery and the there is little chance of through-and-through puncture. If there
morning of surgery. The entire scalp is prepared and draped in is any question about whether the inflation reservoir has been
a sterile fashion. accurately entered, a small amount of pressure is exerted on
After the incision is made, undermining is completed at the the main body of the expander and return of saline in the butter-
hair-bearing TPO fringe area, in the subgaleal plane, using a fly tubing is witnessed. I have not used antibiotic solutions in
combination of blunt and sharp dissection. Cauterization of sig- my expanders.
nificant vessels is carefully done to avoid hair follicle damage. Each inflation is carried out until the scalp becomes tense
One may encounter prominent occipital vessels approximately (40–60 mL) and the patient complains of discomfort. Most
8 cm posterior to the external auditory canal. Insulated DeBakey patients notice some mild discomfort and pressure for several
forceps, suction, electrocautery, and Deaver retractors are nec- hours after each inflation. This discomfort is controlled with
essary if these vessels are cut. With careful dissection, the occip- a mild oral analgesic taken approximately 30 minutes before
ital arteries and nerves can often be preserved. This does not inflation. Initial inflations are more likely to result in discomfort
seem to limit the scalp expansion or later advancement. Brandy than later inflations.
advises ligation of the occipital vessels 4 to 8 weeks before his Subsequent inflations are carried out every 3 to 7 days. The
extensive bilateral occipito-parietal advancement procedures, scalp will usually soften within 2 or 3 days following each
feeling that a form of delay is effected (15). I do not usually inflation and more volume will then be tolerated.
ligate these vessels preoperatively and prefer to preserve them, Most scalp expansions can be accomplished in 10 to 12
when possible. weeks, but occasionally more time is required. Patients who
After the temporo-parieto-occipital elevation is completed, come great distances, or who have difficult schedules, often
and hemostasis is ascertained, a split suction drain is placed have their expansions done by a trained family member or
along the inferior margin of the pocket on each side and brought friend, or by a medically trained individual in their local area.
out through a low occipital stab incision. After the drain is The inflation technique is relatively easy to teach and to learn.
placed, the expander is checked for possible leaks. The expan- When complete expansion has taken place, the second stage
der is inserted with special care to avoid puncture and to afford of the procedure can be performed at a mutually convenient
flat placement low in the pocket. If a remote port is used, I time for the patient and the physician. I do not give patients a
place it at the posterior vertex where it can be easily palpated precise timetable for completion of expansion. There is defi-
for facilitation of injection and easily removed at the time of nitely considerable variation in the tolerance of patients to ex-
the second operation. A suture is placed at the port pocket, to pansion and in the time required to achieve expansion.
prevent accidental movement of the port back into the large
TPO expander pocket. The Second Operation Using the Bilateral
Before closure, a limited excision of redundant alopecic Advancement Transposition Technique
scalp may be possible. Do not, however, excise so much that
closure tension becomes excessive. Over-resection, which re- One of the advantages of the BAT flap procedure is the ease
sults in excessive tension, at the time of expander placement, of planning the second procedure. Measuring and marking of
has resulted in compromise of the blood supply at the vertex the frontal hairline and flaps are accomplished. The posterior-
Flap Procedures 817
based temporal transposition flaps are marked (see Fig. 21D- Again, remember to avoid undue tension on closure in this area
1) to allow a base (B–C) of approximately 6 cm to 8 cm and and to be prepared for the need of additional expansion, should
a length (B–A) of 10 cm. This entire transposition flap is out- there be a significant residual alopecic area. It is very important
lined on expanded scalp and the anterior (B–A) incision is 1–2 to remember not to undermine bald scalp that will not be re-
posterior to the temporal hairline, extending in a curved arch moved. Avoidance of undermining and undue tension is essen-
down to the anterior sideburn region anterior to the crus of the tial for preservation of any residual alopecic scalp.
helix. During marking, the hair is placed in rubber bands to
facilitate the surgery. These markings will vary somewhat with Additional Series of Expansion
the placement of the new hairline, the amount of coverage It is not uncommon to have a small residual amount of alopecic
needed, expansion achieved, and advancement achieved. Cut scalp at the crown and vertex area, even after expanded BAT
or shave the hair only in the area to be removed. or TAT procedures. We and our patients would prefer to accom-
I prefer general anesthesia for this stage, and avoid infiltra- plish complete coverage in one expander series, but this is not
tion of the proximal and distal transposition flap with epineph- always possible. As noted earlier, patients are advised preopera-
rine solution. tively that a second expansion series may be necessary to
After preparing and draping the scalp, the U-shaped incision achieve complete coverage, especially with large Juri class III
is accomplished and the expander is carefully removed. The (frontal, crown, and vertex) losses. It is better to plan for a
amount of advancement is ascertained, and the transposition second expansion series and to avoid excess tension on the
flaps are then fashioned as previously marked. Care is taken to initial series closure than to risk flap circulation compromise
bevel these cuts at the same angle as the hair follicles. Hemosta- and tissue necrosis.
sis is accomplished with care to avoid cauterizing hair follicles. Occasionally, we may leave an expander in at the second
The amount of non–hair-bearing recipient scalp that can be stage of the first expansion series. Most frequently, however,
resected is determined after advancement and transposition of a second expander is placed after the initial transposition flaps
the respective flaps. Depending on the area to be covered, and are stabilized. I prefer to wait 2 or 3 months before commence-
the amount of scalp generated with the expansion, there may ment of the second expansion series. When an additional series
be residual non–hair-bearing alopecic scalp that one will not of expansion is commenced, a smaller expander is placed under
be able to be removed at this operation. Any residual non–hair- the parieto-occipital hair-bearing scalp. This second expansion
bearing alopecic scalp must not be undermined and is now com- phase is well tolerated by the patient and can usually be accom-
pletely circumscribed. Although others have said that only one plished in 5 to 6 weeks. The scalp expands much more rapidly
vertical flap can be combined with this extensive scalp lifting, and the patient experiences less discomfort with the second
because of isolation of the residual cutaneous area, this is not expansion. The amount of expansion required during the second
true. This residual alopecic area, however, is dependent on per- series is variable, depending on the size of the residual defect.
forating vessels from below. As long as the residual alopecic The choice of flaps after the second expansion (transposition
area is left attached deeply, and is not undermined or placed vs. advancement) will depend on the size and shape of the
on severe tension, I have had no circulation problems (necrosis) residual alopecic area as well as the initial procedure. I try to
in this area. avoid a midline scar at the vertex area and, generally, advance-
De-epithelialization of the anterior 1mm to 2 mm of the flap ment of the initial occipital transposition combined with lateral
edge at the frontal hairline, in combination with an anterior parietal advancements is effective in obliteration of the residual
bevel of the recipient skin edge, results in an improved frontal alopecic areas.
hairline. A two-layered closure is advised, with running subcuti-
cular 3–0 Prolene at the frontal hairline skin. DISCUSSION
I recommend the use of a split-suction drain that is brought The advantages of the BAT and TAT flap techniques are numer-
out through the posteroinferior occipital area and sutured in ous (Table 21D-1) and include superior frontal coverage, mea-
position before closure. suring 9 cm to 10 cm in anteroposterior width, a natural horizon-
Dressings consist of K-Y jelly, Telfa, Fluffs, and Kerlix tal frontal hairline, desirable temporal recessions bilaterally,
wrap-around dressing. Special attention is taken to avoid an ease of design, ideal hair direction, avoidance of significant
undue pressure at the base of the transposed flaps. dog-ear deformity, improved vertex coverage with avoidance
of a midline vertex scar, and a more rapid course to completion.
The Second Operation Using the Triple
Advancement Transposition Technique
Table 21D-1 Advantages of Expanded BAT and TAT Flap
Measuring and marking of the frontal hairline and temporal Techniques
flaps are accomplished in the same fashion as the BAT tech-
nique. The TAT technique (see Fig. 21D-2) is essentially the Superior frontal coverage measuring 9–10 cm in anteroposterior
BAT flap procedure, with the addition of a third simultaneously width
transposed expanded occipital flap to the alopecic vertex region. Natural horizontal frontal hairline
The dimensions of this third transposition flap will vary with Desirable temporal recessions bilaterally
Ease of design
the amount of alopecic area to be covered and the amount of
Ideal hair direction
expansion achieved. Remember to create a wide base and to
Avoidance of significant dog-ear deformity
avoid compromising the bases of the temporal flaps that have
Improved vertex coverage with avoidance of midline vertex scar
previously been marked. The occipital transposition flap does More rapid course for completion
result in a standing cone, dog-ear deformity on the rotation side.
818 Chapter 21
a b
c d
Figure 21D-3 a) Preoperative view showing Juri class III alopecia of the frontal, crown, and vertex regions b) Postoperative view after
expanded BAT procedure. Note the natural-appearing frontal hairline c) preoperative lateral view showing hair loss at the frontal, crown,
and vertex areas. d) Three weeks after BAT, with excellent coverage of the frontal, crown, and vertex regions. Note the height and fullness
of the transposed hair.
Flap Procedures 819
c b
Figure 21D-4 a) Preoperative lateral view with extensive loss at the frontal, crown, and vertex areas. Note the thin anterior hairline
at the frontal area b) Top view showing the extensive degree of alopecia at the crown, frontal, and vertex regions. c) Postoperative view
showing excellent coverage at the frontal area and excellent improvement at the crown and vertex areas after a BAT flap procedure followed
by a second occipital flap transposition to the vertex area.
With the use of expansion, tension on the closure is avoided. of this preoperatively. They are highly motivated and obviously
The expander can be left in, later reinflated, and an individual feel that the excellent result justifies the procedure. Scalp expan-
reduction can accomplish complete coverage of extensive class sion, combined with simultaneous BAT flaps, obviously pro-
III alopecia. An additional advantage to these procedures, over vides advantages for the treatment of MPB and is a major ad-
multiple grafting techniques, is the relatively rapid course to vancement in the field of HRS.
completion when compared to the 1-year or 2-year completion
date for repeated grafts and multiple reductions.
The disadvantages of the BAT and TAT flap procedures CASE REPORTS
include the need for bilateral expansion, scars at the temple Case 1
regions, and that the transposition flaps are random flaps. Al-
though we have not seen tissue necrosis with these flaps, a This 36-year-old man presented to our office with Juri class III
distal flap loss would necessitate additional reconstruction. alopecia affecting the frontal, crown, and vertex areas (Fig.
Although I frequently read about the disadvantages of the 21D-3). We discussed the various options and he elected to
‘‘strange and unattractive’’ or even ‘‘bizarre’’ appearance of undergo the expanded scalp flap technique.
expanded patients (generally by those not doing scalp expan- A U-shaped scalp expander was placed and sequentially ex-
sion), I have not found that my patients need to restrict their panded over the course of several weeks to a total of 750 mL.
activities significantly. Although there is cosmetic deformity in The BAT flap procedure was accomplished 10 weeks after
the later stages of expansion, our patients are carefully apprised placement of the expander. Two small residual areas of alopecic
820 Chapter 21
a b
Figure 21D-5 (a) Preoperative frontal view with the anticipated new hairline marked. (b) Postoperative BAT flap frontal view with
improved frontal coverage and a natural-appearing hairline.
scalp were left after completion of the first series. About 4 Case 3
weeks later, he underwent placement of a second scalp expander
to remove the residual alopecic areas. This second expander After being presented with all the options, this 30-year-old man
was inflated to 390 mL and 4 weeks after placement, the patient underwent scalp expansion (Fig. 21D-5). Because of business
underwent a second scalp reduction and flap procedure. An and social conflicts, this expansion was delayed on several occa-
occipital transposition was accomplished to the vertex area, as sions. We eventually did inflate the expander to 870 mL and
well as an advancement procedure to the residual alopecic fron- accomplished this BAT flap procedure. This provided excellent
tal area. He has done very well and is extremely pleased with frontal coverage measuring 10 cm in anteroposterior diameter.
the final result. Several weeks following the initial procedure, a second occipi-
tal expansion procedure was accomplished, and a third transpo-
sition from the occipital area was done to cover the crown-
Case 2 vertex area. This man previously wore a hairpiece, but now
finds the present natural-appearing result much more conven-
This 43-year-old woman presented to our office with extensive ient and acceptable to him.
alopecia affecting the frontal, crown, and vertex area (Fig. 21D-
4). Her alopecia was related to a diagnosis of trichotillomania Editor’s Comments
(self-induced hair extraction). She stated that she had been pull-
ing out her hair since she was 11 or 12 years old. She had been The BAT and TAT flaps as described by Richard Anderson
under self-control for 14 months and wished to have reconstruc- have been known to surgeons for many years. Unfortunately,
tion. After several discussions, she elected to undergo scalp very few practitioners seem to employ them. The reasons for
reconstruction using expanded flaps. this aren’t clear but are most probably related to the cosmetic
A scalp expander was placed and was sequentially expanded. problems caused by the expanders during the period of expan-
sion. Nevertheless, as the photos of patients demonstrate, this
Approximately, 31⁄2 months later, we removed her expander
method of treating MPB has definite value in selected cases
and the second-stage scalp reconstruction, with BAT flaps was
and should be known to all hair restoration surgeons. (WU)
accomplished. Several weeks later, she underwent a forehead
lift procedure and placement of a second scalp expander. Five
weeks later, a second scalp flap procedure, removal of her ex-
pander and upper and lower lid blepharoplasty procedures were 21E. Scalp Expansion for Traumatic
accomplished. The second flap procedure was rotated into the and Iatrogenic Alopecia
non–hair bearing area at the crown-vertex region. The transpo-
sition flap, done at that time, was an occipital flap, based on Mark D. Epstein
the left over the expanded scalp area. The flap measured 12 cm
in length and 6 cm across the base. Medium and large defects of the scalp, including those follow-
The patient was extremely pleased with the results of her ing traumatic loss, are often amenable to reconstruction with
scalp reconstruction. She stated that the procedure changed her soft tissue expansion. The principles of reconstruction are as
life, and she is now able to do many things that she was unable follows: The wound must be healed prior to placement of the
to do in the past because of the cosmetic deformity. expanders. Place one or more expanders under the hair bearing
Flap Procedures 821
scalp so as to surround the defect as much as possible. Crescent- she had a 9 cm by 9 cm full thickness defect of her scalp,
shaped expanders are ideal for this. Make sure that the pocket down to bare cranium. The initial procedures were dedicated
easily accommodates the expander; a tight fit might lead to to closing the wound. Because a skin graft would not be ex-
extrusion later. Wait approximately three weeks to begin infla- pected to heal on a bed of bare bone, the initial procedure was
tion. The end point for inflation is when the scalp is expanded designed to make the wound bed amenable to healing with a
approximately 30% more than is needed for advancement. skin graft. First, the outer table of the skull was removed with
Over-expansion is necessary because the wound should never a burr. The exposed underlying cancellous bone was allowed
be closed with the flap under the same degree of tension as is to granulate (the inner table of the skull remained.) One month
seen when the expander is at maximal inflation, or the risk of later, a split thickness skin graft was harvested from her buttock,
wound dehisence and/or skin flap necrosis will be high. staying within borders outlined by her bathing suit. Six months
The three following cases illustrate these principles. Two of later, a single crescent-shaped soft tissue expander was placed
the patients suffered post-traumatic scalp loss, one developed a adjacent to the defect. The patient underwent weekly inflations
scalp defect following Moh’s surgical extirpation of a malignant with saline. Eight months later, the expander was removed and
lesion. In all three cases, the patient underwent one or more the scalp flap was advanced (Figs. 21E-1 to 21E-9). She under-
procedures to close the wound, followed by insertion of the went a minor scar revision 11 months later.
soft tissue expander, followed by its removal. Minor touch-up
procedures such as scar revision, or micrograft transplantation
are useful adjuncts to complete the reconstruction. In the case of CASE 2
traumatic avulsion, always give consideration to microsurgical
An 8-year-old female caught her hair in a go-cart, resulting in
replantation first, because when successful, subsequent scalp
an avulsion of the posterior scalp. Microvascular replantation
reconstruction may not be required. Microsurgical replantation
was not possible due to avulsion of the vessels from the scalp
may require 8 or more hours to complete, thus the patient needs
fragment. The initial defect measured 10 cm. Wound closure
to be hemodynamically stable, and have the cardiopulmonary
was performed by circlage suture of wound periphery, leaving
reserve to withstand such a procedure.
a 7 cm-high by 4 cm-wide defect. The scalp fragment was
defatted and placed on the wound as a full thickness skin graft.
CASE 1 The intent was only to close the wound, hair growth was not
anticipated, because the hair follicles were removed by the de-
This 30-year-old female presented with a recurrent lesion of fatting process. Six months later, she underwent placement of
her scalp with satellite lesions. Following her initial procedure two crescent-shaped soft tissue expanders on either side of the
several years ago, she was told that the lesion was benign. Bi- wound. Five months later, the expanders were removed and
opsy revealed dermatofibrosarcoma protuberans. She was sub- scalp flaps were advanced to the midline (Figs. 21E-10 to 21E-
sequently referred for Moh’s surgery. Following Moh’s surgery, 17).
Figure 21E-1 Case 1: 9 cm by 9 cm defect following Moh’s surgery, bare cranium is visible. Exposed half of the outer table is removed
to demonstrate the cancellous bone underneath.
822 Chapter 21
Figure 21E-2 Case 1: Half of the outer table is completely removed to demonstrate the cancellous bone underneath.
Figure 21E-3 Case 1: Outer table is completely removed.

Flap Procedures 823
Figure 21E-4 Case 1: Granulating cancellous bone is ready for skin graft.
Figure 21E-5 Case 1: Skin graft is healed and now ready for placement of soft tissue expander.
824 Chapter 21
Figure 21E-6 Case 1: Tissue expander at end of inflation.
Figure 21E-8 Case 1: Postoperative result, lateral view is

shown.
Figure 21E-7 Case 1: Postoperative result, vertex view is Figure 21E-9 Case 1: Postoperative result, posterior view is
shown. shown.
Flap Procedures 825
Figure 21E-10 Case 2: 10 cm by 10 cm wound is shown,

following avulsion. Figure 21E-12 Case 2: After partial closure of wound with
circlage suture, the defect now measures 7 cm by 4 cm.
Figure 21E-13 Case 2: Scalp fragment is defatted and placed

on the wound as a full thickness skin graft.
Figure 21E-11 Case 2: Scalp fragment, small vessels have
been avulsed making replantation impossible.
826 Chapter 21
Figure 21E-14 Case 2: Two crescent-shaped expanders are Figure 21E-16 Case 2: Current appearance of the posterior
placed on either side of the wound.They are now maximally in- view and resultant scar are shown (patient did not wish revision).
flated.
CASE 3 expander was placed just posterior to the defect. Four months
later, the expander was removed and the scalp flap advanced.
The hairline was nearly completely reconstructed (Figs. 21E-
A 30-year-old male presented with a healed deformity following 18 to 21E-21). The patient did not wish further surgery to join
an avulsion injury to the left side of his face and lateral scalp. the temporal hairline to the sideburn.
The wound was resurfaced by a skin graft performed several
years earlier. At the initial procedure, a rectangular soft tissue
Figure 21E-15 Case 2: After removal of tissue expanders, Figure 21E-17 Case 2: Current appearance, posterior view is
scalp flaps are advanced medially (drain in place). shown with hair combed normally.
Flap Procedures 827
Figure 21E-18 Case 3: Initial presentation. Healed skin graft on left temple is shown.
Figure 21E-19 Case 3: Rectangular soft tissue expander is maximally inflated.

828 Chapter 21
Figure 21E-20 Case 3: Skin graft is excised and resultant defect is exposed.
21F. Complications of Flaps–

Avoidance and Treatment
Patrick Rabineau
The main complication observed in the treatment of alopecia

with pedicle flaps, is partial or total necrosis of the flap. In
addition to this major complication, which, unfortunately, is
not always easy to avoid, there is a possible series of events,
some of which may be expected to occur in any operation and
are often reversible; others are more serious, such as the perma-
nent loss of hair in the area from which the flap is taken.
All these complications have led many surgeons, even expe-
rienced ones, to abandon flaps, or at least to make a rigorous
selection of prospective patients for this type of operation.
MINOR COMPLICATIONS
Frontal Edema
This occurs the day after the operation and may last for approxi-
mately one week. The edema, which may go down as far as
the cheeks, can be reduced and its duration shortened by a
perioperative injection of corticosteroids.
Ecchymosis
Ecchymosis on the forehead and especially on the neck is more
or less extensive, depending on the degree of undermining of
the cervical area required for closure of the donor area without
tension. It disappears in approximately 10 days.
Discomfort of the Ear in the Undermined Area

Indeed, it is necessary to undermine all the skin of the ear if
Figure 21E-21 Case 3: Scalp flap is advanced and hairline is one desires to get the cervical area to move up easily. The
reconstructed. slightly traumatized auricular cartilage will be painful for a few
days.
Flap Procedures 829
‘‘Dog-Ear’’ part of the flap, of sometimes as much as one-half of its distal

part.
Dog-ear is not, strictly speaking, a complication but an unavoid- Necrosis is more frequent in flaps (that are 23 cm to–24 cm
able unaesthetic aspect that appears at the proximal end of the long and 3.5 cm to 4 cm wide) that cross the total forehead. It
flap as a result of its rotation. It may disappear or subside after is less frequent in smaller flaps, for example, lateral flaps.
2 or 3 weeks, and if not, it will have to be excised at a later It is essential not to confuse hair loss over a more or less
date using only local anesthesia. A mistake that must be avoided extensive area of the flap, which is temporary (this loss reverses
is to try to correct this dog-ear during the transposition opera- itself spontaneously and hair will grow back in 2 or 3 months),
tion, because this would jeopardize the survival of the flap. with real necrosis, which, the day after the operation, shows
signs of disturbed circulation in the flap; the skin is reddish
Scar violet and a thick, blackish crust forms quickly.
There are two options:
The frontal scar, caused when the flap is set in place, is some-
times very visible, erythematous, and wide. It will fade with 1. Wait 2 or 3 months until this crust disappears and leaves
time. De-epithelialization of the anterior edge of the flap over an atrophic scar.
a distance of 1 mm makes it possible for hair to grow through 2. Remove the entire area affected by necrosis as soon as
this scar and makes it less conspicuous. Often it will be neces- possible. In the best circumstances, it is possible to ex-
sary to use an appropriate hairstyle (such as curly hair) or mi- cise it and close it by direct approximation or to cover
crografts to conceal it. A wide and visible scar in the donor it with a thick skin graft. Sometime later, it will be
area of the flap may be excised (if possible) as soon as the scalp possible to cover this area with a flap taken from the
is elastic enough, or covered with grafts. contralateral scalp.
This complication can be avoided by selecting prospective pa-
LESS FREQUENT BUT MORE SEVERE tients very carefully and by performing the operation only on
patients with normal vascularity of the scalp (determined by
COMPLICATIONS
using a Doppler scan, if appropriate); by refusing patients who
Infection have already had grafts, if the outline of the flap overlaps graft
scars; by refusing patients upon whom a ligature of the temporal
This is reported by certain authors but has never occurred in arteries has been performed (Marechal technique); by including,
the nearly 200 flaps of which I have a record. Very rigorous in the flap, the superficial temporal artery (its pulse may be
asepsis, with the operation taking place in an operating room, palpated); and by never infiltrating the flap with lidocaine with
not in the doctor’s office, should minimize the complication. epinephrine—always avoid the epinephrine.
When the flap is transposed into place (third phase), there
Hematoma are two possible options if the flap shows signs of disturbed
circulation:
This may happen especially in the undermined area. There is,
strictly speaking, no undermining plane, and the surgeon may 1. if the most distal 3 cm to –4 cm does not bleed, do not
injure some muscular fibers, which have a well-known bleeding perform the operation.
potential. Very rigorous hemostasis and drainage are required. 2. cut off those 3 cm to–4 cm and thus have a shorter, but
If a hematoma appears, it is necessary to open the sutures, to surviving, flap.
‘‘empty’’ the hematoma, and then to find the vessels responsi-
During the operation, the flap must be handled very gently. It
ble; these will have to be either coagulated or ligated.
must never be folded or twisted. It must be kept wrapped in
moist compresses. Do not try to avoid a dog-ear by flattening
Hair Loss the flap. This dog-ear will disappear after a few weeks and, if
More serious is a permanent extensive loss of hair in the area not, will be easy to correct later. The postoperative bandage
from which the flap was taken. This may result in a palm-like must not be too tight. Finally, even the smaller sized flaps ide-
zone of alopecia. It is caused by either excessive tension on the ally should be delayed. It is not worthwhile to risk necrosis
sutures, resulting in necrosis that is superficial but sufficient to with all its consequences, merely to gain 2 weeks. A delayed
‘‘kill’’ the hair roots, or by improper undermining, which may flap will, in most cases, remain quite healthy.
traumatize or cut them. This complication can be avoided by
1. Gain an exact determination of the flexibility of the REFERENCES
scalp: An overly stretched, rigid scalp will not allow a
very wide flap (4 cm); Introduction to Flap Procedures
2. Significant undermining should be carried out to allow
suturing without tension. This undermining must be 1. Cushing H. A study of a series of wounds involving the brain
and its enveloping structures. Br. J. Plast. Surg 1918; 5:558.
carefully done, and the hair roots must not be damaged. 2. Doufermentel L. Plastic operations on the scalp. Paris Med 1918;
8:503.
3. Mitchell GF. Total avulsion of the scalp: A new method of resto-
MAJOR COMPLICATIONS ration. Br. Med. J 1933; 1:13–14.
4. Kazanjian VH. Repair of partial losses of the scalp. Plast. Re-
Finally, the major complication that makes this technique dan- constr. Surg 1953; 12:325.
gerous in inexperienced hands is the necrosis of a significant 5. Gillies H. Notes on scalp closure. Lancet 1944; 1:310.
830 Chapter 21
6. Orticochea M. Four flap reconstruction technique. Br. J. Plast. 3. Radovan C. Adjacent flap development using expandable Silastic
Surg 1918; 5:558. implants. Presented at the American Society of Plastic and Recon-
7. Juri J. Use of parieto-occipital flaps in surgical treatment of bald- structive Surgery Forum. Boston, MA, Sept. 30.
ness. Plast. Reconstr. Surg 1975; 55:456. 4. Manders EK, Graham WP, Schenden MJ. Skin expansion to
eliminate large scalp defects. Ann. Plast. Surg 1984; 12:305–316.
5. Kabaker S, Kridel R, Krugman M. Tissue expansion in the treat-
Microsurgical Free Flaps ment of alopecia. Arch. Ortolaryngol 1986; 112:720–728.
6. Adson MD, Anderson RD, Argenta LC. Scalp expansion in the
1. Ohmori K. Free scalp flap. Plast. Reconstr. Surg 1980; 65:42. treatment of male pattern baldness. Plast. Reconstr. Surg 1987;
2. Ohmori K. Application of microvascular free flaps to scalp de- 79:906–914.
fects. Clin. Plast. Surg 1982; 9:263. 7. Anderson RD. Expansion-assisted treatment of male pattern bald-
3. Ohmori K. Recent advances in the use of free flap. Ann. Chir. ness. Clin. Plast. Surg 1987; 7:477–490.
Gynaecol 1982; 71:34. 8. Anderson RD. Hair replacement surgery. In Instructional Courses
4. Ohmori K. Hair transplantation with microsurgical free scalp flap. W. B. Riley, ed. Vol. 2. St. Louis: C. V. Moby, 1989:77–103.
Transactions VIII International Congress of Plastic Surgery, 9. Argenta LC, Marks MW, Anderson RD. Treatment of male pat-
1983:682. tern baldness by tissue expanders. In Male Aesthetic Surgery.
5. Ohmori K, Harii K. Restoration of skin cover by free flap transfer 2nd ed. E. H. Courtiss, ed. St. Louis: C. V. Mosby, 1991:212–225.
(microvascular technique). In. Operative Surgery. (3rd ed), Rob 10. Anderson RD. The expanded ‘‘BAT’’ flap for treatment of male
C, Smith R, eds. London: Butterworth, 1979:75. pattern baldness. Ann. Plast. Surg 1993; 31:385–391.
6. Cobbett JR. Microvascular surgery. Surg. Clin. North. Am 1967; 11. Mayer TG, Fleming RW, Patterson AS. Aesthetic and Recon-
47:521. structive Surgery of the Scalp. St. Louis: C. V. Mosby, 1992:
39–45.
12. Nataf J. Surgical treatment for frontal baldness: The long tem-
The New Expanded Scalp Flap Technique poral vertical flap. Plast Reconstr. Surg 1984; 74:628.
13. Dardour JC. Treatment of male pattern baldness and postopera-
1. Argenta LC, Anderson RD. Tissue expansion for the treatment tive temporal baldness in men. Clin. Plast. Surg 1991; 18:775.
of alopecia. In Hair Transplantation. 2nd ed. WP Unger, REA 14. Marzola M. An alternative hair replacement method. In Hair
Nordström, eds. New York: Marcel Dekker, 1988:519–551. Transplant Surgery. 2nd ed. O. T. Norwood, ed. Springfield, IL:
2. Argenta LC, Watanabe MJ, Grabb WC. The use of tissue expan- Charles C. Thomas, 1984:315–324.
sion in head and neck reconstruction. Ann. Plast. Surg 1983; 1: 15. Brandy DA. The bilateral occipitoparietal flap. J. Dermatol, Surg.
31. Oncol 1986; 12:1062–1068.
22
Setting Up an Office
22A. Building a Hair Restoration hair transplantation? Consider expanding your practice to in-
clude, not just the treatment of male pattern baldness (MPB),
Surgery Practice but other forms of surgically correctable hair loss, including:
Paul C. Cotterill female pattern hair loss (FPHL), scarring, hair loss after cos-
metic surgery, and hair loss affecting the eyebrows and eye-
lashes.
INTRODUCTION
Marketing and advertising are not interchangeable terms.
The degree of difficulty of starting a hair restoration surgery Marketing is a broader term that defines the process of finding
practice can obviously differ depending on your prior experi- out who your clients are, what they need from you, how best
ence. The reader of this chapter may be a novice surgeon look- to attract them and, how to give them what they want. The
ing for advice on how to set up an entirely new practice. Alterna- concept of marketing consists of the four Ps (1):
tively, the reader may be an experienced hair restoration
1. Product or service to be sold
surgeon who is looking for some tips to facilitate the start-up
2. Positioning of the product in the market place
of an established practice at a new location.
3. Price/cost of the product or service
It is beyond the scope of this article to put forth all that one
4. Promotion of the product
needs to know when starting a practice. Entire courses or sec-
tions at international meetings are often devoted solely to this Decide early on how much you can afford to spend on promo-
topic. The reader is referred to The International Society of tion. Paid media advertising—one method of marketing—can
Hair Restoration Surgery, (13 South 2nd Street, Geneva, IL allow you to control the place, time, and context of your mes-
60134, Phone-630-262-5399) and The World Hair Society, (120 sage in an effort to create widespread awareness. However,
International Parkway, Suite 204, Heathrow, FL 32746), for media advertising alone may not be that successful when all
dates on major international meetings that offer relevant courses your competitors are doing the same thing (2).
and lectures. The goal of this chapter is to offer suggestions on In addition, creative, effective advertising programs, from
business and marketing pearls to consider when starting and paid external sources, are expensive. Obviously, if one is just
building a new practice. Elsewhere in this textbook, other topics starting out, it is easier and quicker to attract prospective pa-
pertinent to the setting up of a practice, such as instrumentation, tients by advertising. In the long run, however, it may be more
the surgical suite, photography, and patient records have been effective, and less expensive to retain prior patients, gain new
presented. patients through word-of-mouth from your own satisfied pa-
The core of any strategy to build and maintain your practice tients, physician referrals, and in-house marketing techniques.
should be to offer consistent, high-caliber results, and to main-
tain patient loyalty through excellent follow-up care and con-
tact. This ensures that patients will return for repeat visits when EXTERNAL MARKETING
needed, as well as use word-of-mouth to refer friends and rela-
tives to your practice. The following points touch on other basic The Phone Book
methods used to obtain new patients and expand your practice.
The local phone book, both white and yellow pages, is an ob-
vious starting point. Before you start to advertise, it is highly
KNOW YOUR MARKET recommended that you consult your local medical board to en-
sure that advertising is allowed. You will find that the medical
Whom do you want to use your services? Recognize the target licensing boards usually have advertising guidelines, and will
group. What are the appropriate groups that can benefit from be happy to approve of, or suggest recommendations for, your
831
832 Chapter 22
intended advertisements. This can avoid consumer complaints have their own web site. You may be found by prospective
in the future. Your advertisement should be informative, accu- patients by a general search on the web, through your own web
rate and, above all, not misleading. site, through yellow page ads on the web, or by articles that have
been published by or about you. It is important to remember to
Media Advertisements list your web site and e-mail address on your marketing materi-
als (business cards, brochures, media advertising, etc.) Hair so-
This can take the form of the printed word (newspaper, maga- cieties, such as the International Society of Hair Restoration
zine, airport signs, etc.), radio, or television media. To be effec- Surgery will list your e-mail address and host a web page about
tive, sustained advertising can be more beneficial. A one-shot you. There are also various hair loss information web sites,
radio spot or newspaper advertisement has a short shelf-life and such as Hairtransplants.com and Regrowth.com that, for a fee,
will not reach as many people as an advertisement placed in a will advertise your name and web site.
magazine that may sit in an office for several months. However, Web sites have become very commonplace for hair restora-
the cost of daily or weekly advertisements can be prohibitive. tion surgeons and are, for a lot of prospective patients, the pri-
mary source for finding a physician. A good web site can attract,
Brochures and Videos not only local patients, but because the Internet is international,
A well-written brochure describing your procedure and creden- you may find yourself having a consultation, via the Internet,
tials, that can be mailed to a prospective patient or a brochure with someone thousands of miles away. Digital photos can be
that the patient can keep after a consultation can be very effec- downloaded over the net and can facilitate long-distance consul-
tive. A video of your procedure can also be produced to dissemi- tations.
nate to prospective patients. A web site can be posted quite inexpensively when compared
to other forms of media advertising. Web site companies can
Lectures and Seminars do the work for you and are often found at booths at the major
hair transplantation meetings. A high school student, however,
Lecturing at international meetings, while increasing awareness may do just as good a job and less expensively.
of your work to other physicians, may not initially get more Your web site should be, as with any other printed message,
patients through your door. Try to give seminars at the local concise and truthful. Before and after photos of your work
hospital or to nursing groups. One technique for obtaining new should be included. It is much less expensive to update and
patients is to give a seminar at a local hotel or at your office. keep current information on a web site than to create a new
The event can be advertised through the newspaper. At the brochure.
seminar, you can give a description of your work and present The use of testimonials of your work should be approved
some of your patients. Another technique is to contact your first by your local medical-governing body, as they may be
local pharmaceutical medical representative. You will probably considered inappropriate by some boards.
find that pharmaceutical representatives will be happy to spon-
sor a dinner for other physicians so you can present a talk on
the medical and surgical aspects of hair restoration. INTERNAL MARKETING
Staff
Niche Marketing
A well-trained staff is one of the most important aspects of
Niche marketing can include beauty salons, hair-salons, spas,
success with internal marketing. The person who answers the
health clubs, and body-building associations. Go to these orga-
phone makes the first impression. The staff should be able to
nizations, introduce yourself, and let them know what you have
answer questions knowledgeably and be able to put the patient,
to offer. Inviting them to your clinic or one of your seminars
who is often nervous, at ease. At the initial office visit, it is
is useful. In addition, performing a hair or eyebrow transplant
advantageous to create a positive impression. Ensure that your
on an employee of one of these groups, who is willing to be
waiting room is tasteful and portrays a calming, professional
vocal, may be helpful.
aura. If a patient coordinator is used, they should be well
groomed, polite, and knowledgeable about your procedure.
Change of Address and Newsletters Phone messages and e-mails from patients should be re-
If you’re starting a new practice, or moving to a new office, turned promptly. Follow-up phone calls can be made after an
this is a prime time to send out an announcement to all of the initial consultation to inquire about further questions the patient
general practitioners, dermatologists, and plastic surgeons in my have. This can also help to build a relationship and enhance
your target group. A newsletter to all your patients, advising bookings.
them of your move, is a great opportunity to inform them of It is the author’s practice to phone patients the night of sur-
any new services or techniques you have to offer and to discuss gery, one month later; and 6 to 10 months later for follow-up
what’s new in the medical and surgical treatment of hair restora- appointments. Any time you call and take the time to inquire
tion. A periodic newsletter is an excellent way to spur a return about your patient is time well spent in fostering your relation-
visit. ship with the patient.
Internet Consultation
Internet marketing has expanded enormously over the last few A successful consultation is one in which an appropriately edu-
years. Most physicians today have an e-mail address and many cated and qualified patient either books surgery at that time or
Setting Up an Office 833
subsequently. In-house marketing comes into play during the Knudson wrote, ‘‘Minoxidil legitimizes the medical treatment
decision-making process for the prospective patient. The con- of male pattern baldness (MPB), for the medical community’’
sultation room should be quiet, neat, and well lit. The photo- (4). Before minoxidil, general practitioners and dermatologists
graph album you use should be tidy, with before and after photo- rarely treated MPB because there was no effective medical treat-
graphs of your work that are clear and with consistent distances ment. Minoxidil (Rogaine), and now finasteride, complements
and head angles from the camera. You may want to give out the use of hair restoration surgery for many patients. Knudsen
a brochure describing your work and techniques at the end of emphasizes a ‘‘holistic’’ approach to MPB. Hair restoration
the consultation. It is at this time that some physicians use surgeons can expand their practice by prescribing medications
videos to explain their procedures. Whether or not you use a to treat MPB. Patients that are not candidates for surgery at a
nonmedical consultant is your choice. Greater detail of the con- particular time, due to their age or degree of thinning, may be
sultation process, as well as the pros and cons of nonmedical appropriate candidates for medication. The physician can fol-
consultants, are discussed in Chapters 6A, 6B, and 6C.
low the patient, and nurture the relationship until such time as
Computerized Photography and Imaging he or she is a candidate for surgery. Patients may initially come
to see you for medical treatment, but may eventually have surgi-
Computer-imaging techniques are employed more and more cal treatment. Your consultation is a good opportunity to discuss
by cosmetic surgeons. Computers can be used to present your medical and surgical options.
techniques and portray photographs in a clear and concise man-
ner, with cutting-edge technology. Computers can be used to
record a current image of the patient’s scalp, project what he
will look like with further hair loss, as well as his appearance CONCLUSION
when hair is added. Suggested hairlines and densities can be
portrayed. However, similar to still photographs, one must take Ultimately, whatever method you use for external marketing
care not to misrepresent a final outcome. There is a greater to draw new patients, or internal methods used at the time of
tendency with computer imaging for the technique to be seen consultation to create a successful outcome, you should strive
as a scare tactic to entice patients to book surgeries. Used prop- to be truthful with your patients. Don’t promise something that
erly, the technique can add to the usefulness and ultimate suc- you cannot achieve. If you are honest and open with your pa-
cess of your consultation. One useful tool of computerized pho- tients, you will not, hopefully, encounter any problems down
tography is the ability to immediately take a picture of a patient the road.
at a follow-up visit and compare it to the preoperative visit.
Patients often have a difficult time appreciating the early
changes produced by a hair restoration procedure because the Acknowledgement
changes are so gradual. They sometimes forget how much hair
The author would like to gratefully acknowledge Dr. Matt
loss they had before surgery. Placing the patients before and
Leavitt, Orlando, Florida, for his contribution for much of
after photo, side-by-side on the computer screen, at the time of
the follow-up, makes it much easier to demonstrate objective the background material in the development of this chapter.
changes and the patient appreciates this. Dr. Leavitt has extensive experience in both the setting up
The following are a few guidelines in using computer images of successful hair restoration surgery practices and lecturing
(3): on that topic.
1. Do not destroy or delete computer images. Many courts
of law consider preoperative computer images as part
of the medical record.
2. Allow patients access to their images. Refusing to allow 22B. The Surgical Suite
access can arouse suspicion and mistrust on the part of
Walter P. Unger
the patient. A waiver of liability to achieve specific re-
sults with each computer image can be employed.
3. Adopt a procedure to authenticate computer images. OFFICE DESIGN
This alleviates allegations of tampering or altering im-
ages. Electronic time stamping or signing each image Physicians entering the field of hair restoration surgery are often
can be considered. uncertain as to how the operating-room area of their office
4. Use medical images conservatively, to minimize the should be designed for maximum efficiency. This section of
risk of legal claims. Use images to depict less favorable the text describes the design features of one of two offices I
or average outcomes, as well as positive outcomes. have; it is the larger and more pleasant of the two and is ex-
5. A statement in the consent form, which states that the tremely efficient. There are two separate operating rooms be-
patient understands that computer images only consti- cause I normally operate on two patients each day and the sur-
tute a simulation, and in no way guarantees actual surgi- geries typically last five to seven hours. If you intend on
cal results, should be employed. Surgeons may consider carrying out one surgery, or more than two per day, the design
videotaping the consent conversation. can be easily altered. If, for example, you are doing only one
surgery, graft preparation could be carried out in the same room
Medical Treatments
in which the operation is being performed, thus reducing space
New medical treatments for MPB have done a lot to improve demands considerably. At two surgeries per day, however, the
the marketability of the practice of hair restoration surgeons. layout in Figure 22B-1 leaves no one feeling crowded or uncom-
834 Chapter 22
Figure 22B-1 Layout of Toronto office of the author.
fortable over very long days of intense concentration. Features ● The operating table (Ritter 75 Evolution), which is auto-
of the design include: mated and goes into a Trendelenburg position, if neces-
● a sink in each operating room sary, is more or less centered in the space between the
● a long graft preparation counter along one wall of that edge of the graft preparation counter and the opposite
room, with electric outlets every 3 feet and technicians wall. The distance from the wall opposite the window
each having approximately 3 feet of the counter to work to the head of the operating table, is adequate for a com-
on. There is a 12-inch deep shelf, 12 inches above the fortable, height-adjustable seat, similar to the ones used
back of the graft-preparation counter, on which various by the technicians in the room. This wall also has a hook
items such as boxes of gloves, alcohol, Betadine bottles, on which the prone pillow is hung when it is not in use,
and Kleenex boxes may be placed. Eighteen inches a hanging hyfrecator, a phone, and a board on which the
above this small shelf is a wall of storage cupboards. various graft counts are written.
Comfortable, height-adjustable seats are used by the ● The ceiling is covered with sound-absorbing tiles
technicians. and has enough fluorescent light fixtures to light the
● One wall of the room has a wall-length large window room brightly. I also have two adjustable operating room
which adds to a feeling of spaciousness. (It looks out lights directly over the operating table (Burton Outpa-
onto a small courtyard with two small trees). tient II).
● The floor is covered with easily cleaned seemless their suppliers. Rather than repeatedly mentioning suppliers of
vinyl. various instruments throughout the text they are listed in Appen-
● The room marked ‘‘clean grafts’’ in Figure 22B-1 has dix 22B.
graft-preparation counters on either side of its length, as
well as electrical outlets and adjustable-height seating
as in the operating rooms. Grafts from only one patient ITEMS USED TO ANALYZE THE RECIPIENT
are in this room at any given time. A small shelf and AND DONOR AREAS
storage cupboards, similar to those in the operating
A variety of equipment may be used to gather information about
rooms, are located above the graft-preparation counters.
the recipient and donor area before surgery. The type of infor-
A board, on which graft counts can be written, is on the
mation gathered may include:
far wall opposite the entrance to the room.
● The hallways are wider than usual (4 feet) because there ● The current extent of hair loss documented with stan-
are so many people in a relatively small space. For the dardized photographs
same reason, there are two easily accessible bathrooms. ● The actual size of the recipient area in cm2
● There are two ‘‘clean-up’’ rooms with hairdressing sinks ● The potential available donor area in cm2
on a long counter. These are used for bandage removal ● The donor density in FU/cm2 or hair/cm2
(if a bandage has been used) and hair washing and styl- ● The caliber of hairs in the donor area.
ing, the morning after surgery. ● The degree of miniaturization of hair in the donor or
● There is also an exam table on one wall of each of these recipient area
rooms in case the patient feels light-headed or faint. The The amount of information gathered varies from practice to
rooms can also be used for photographing patients. practice. The method of gathering this information can vary
from estimations based on clinical experience to exact measure-
The rest of the office does not need any specific design for
ments using sophisticated equipment. The following are some
hair restoration surgery and will not be dealt with here. I will,
of the instruments used to gather this information.
however, pass on to you the wise advice of my father-in-law
who was, at different times in his life, a dentist, clinic manager,
and hospital administrator: ‘‘Office space is the least expensive 35-mm Cameras, Digital Cameras, and Imaging
aspect of a medical/dental practice. Very foolishly, it is the Software
place where most practitioners seem to seek economy. Almost
The primary function of the camera is to take standardized be-
as soon as most doctors and dentists move into their new office, fore and after pictures that document progress and results. How-
they realize they ideally should have had a larger space but ever, with macrophotography, one can also take phototricho-
moving is so aggravating and expensive that they stay grams which allow for the measurements of hair density, hair
there—uncomfortable, for many years, before they make the growth, and hair caliber. The improvement in digital imaging
same mistake again. Most of us also live more of our waking has made these measurements much more accurate. These sub-
hours in our office than in our home. Take more office space jects are discussed in detail in Chapter 22E, Chapter 22F, and
than you think you need and decorate it nicely.’’ Chapter 22G. Also, an excellent example of using the technique
of digital imaging to measure these parameters is illustrated by
Dr. Yoo in Chapter 23B.
Simple Rulers, Measuring Tapes, Templates, and

22C. Instrumentation and Supplies Grids
Used in Hair Restoration
Actual measurements in cm2 of the recipient and donor areas
Surgery is useful for more accurately planning a hair restoration proce-
Sharon Keene and Ron Shapiro dure (1). A simple ruler or measuring tape can be used to mea-
sure the length and width of these areas. These measurements
can then be used to calculate in square centimeters the bald
INTRODUCTION area being covered or the donor area needed for extraction.
Miltex surgical stainless steel rulers for use during surgery are
In the past decade a virtual revolution in hair restoration science available from various medical supply companies. Sterile dis-
has occurred. posable donor templates such as the Kabaker Template also
This chapter will discuss many of the instrumentation and exist for rapidly measuring and marking the donor area. A Re-
supplies used during the hair restoration process. Some of the cipient Site Grid made of one centimeter squares drawn on a
instruments discussed have been used for decades and some clear plastic sheet and placed over the area of balding can also
are new. As the science of hair restoration is evolving, it should be used to quickly estimate the size of the recipient area (Fig.
be expected that the instrumentation will evolve with it. 22C-1). Sandoval uses a one cm2 stamp to accomplish the same
Some instruments have already been discussed in detail in task (see Fig. 16F-9b in Chapter 16F). DiBernardo discusses
other chapters and, when appropriate, the reader will be referred and illustrates a more high-tech way of measuring the recipient
to the text and figures in those chapters. Appendix 22A contains area, using Canfields ‘‘Mirror Suite’’ Imaging Software (see
a list of the instruments mentioned in this chapter along with Figs. 22F-13a and 22F-13b in Chapter 22F).
836 Chapter 22
Figure 22C-2 The Starrett威 Digital Micrometer can be used

to measure hair shaft diameter.
Figure 22C-1 Clear plastic template with grid marked in 1 cm2 Marking Pens
black squares and an outline of the frontal-third (70 cm2) and mid-
scalp (50 cm2) marked on it. This tool can help give a quick estimate Various types of marking pens can be used to mark the hairline
of the size of the recipient area. The anterior half is approximately and donor area. We prefer China markers because the marks
100 cm2 and the anterior two-thirds is approximately 120 cm2. are wax based and water resistant but still easy to wipe off for
making changes if necessary. Others prefer to use Sharpie fine-
point pens or gentian violet-based surgical pens such as the
Densitometers Accu-Line surgical marking pen.
There are several commercially available instruments to mea-

sure hair density. These include the Rassman Densitometer, the Hair Cutting and Styling Equipment
Welch Allyn Trichoscope, and the Kahn Densitometer. The
For cutting the donor hair we use either barber quality hair-
viewing surface area seen through the Rassman Densitometer
is a circle of approximately 10 mm2. Therefore, multiplying the cutting scissors or a Panasonic beard trimmer with a 3 mm
number of FUs seen in the viewing area by 10 gives an estima- guard. A wide toothed comb, with a rat’s tail, is used to help
tion of FU density (FU/cm2). The viewing areas in the Welch move the hair out of the donor area. This comb is also used
Allyn and Kahn devices are circles of 12.56 mm2. Therefore, later in the procedure to move hair out of the way while making
if either of these instruments were used, the number of FUs recipient incisions, and placing grafts. Some physicians use a
seen in the viewing area would have to be multiplied by 7.96 metal comb that can be autoclaved, whereas others prefer a
to estimate the FU density (FU/cm2). Ellis Instruments has in- plastic comb that can be cold sterilized. A plastic spray bottle
troduced a new densitometer that has a square viewing area of filled with normal saline is useful for wetting the hair and identi-
1 cm2 that is further divided by a grid into quarters. Knowing fying that the safe donor area. Spray bottles filled with saline
the FU density (FU/cm2) is useful for estimating the amount or dilute solutions of hydrogen peroxide (H2O2) are also used
of donor tissue needed (length and width) to produce a specific to keep the recipient area clean while making incisions and
number of FU grafts (2,3). placing. Hair clips, hair bands, and 1 inch surgical paper tape
are used to secure the hair up and away from the surgical field
Digital Micrometer before donor harvesting. Figure 22C-3 shows the patient prepa-
ration set-up tray we use in our offices with a number of the
A digital micrometer is a device that can measure hair shaft above supplies.
diameter, and is useful in preoperative evaluation of this hair
characteristic. The Starret威Electronic Digital Micrometer can
be purchased through Mediquip (Fig. 22C-2). Hair shaft diame- Monitoring Equipment for Vital Signs
ter is an important determinant of cosmetic outcome, and this
tool yields information that can help predict the eventual cos- Many physicians use a simple blood pressure cuff and stetho-
metic effect of transplantation (4,5). scope to monitor a patient’s blood pressure and pulse. Although
more expensive, we use the Welch Allen 5200 Series Blood
ITEMS USED TO PREPARE THE PATIENT Pressure/Pulse Oximeter unit that monitors blood pressure,
pulse, and oxygen saturation (Fig. 22C-4). It will continually
BEFORE SURGERY
monitor the pulse and oxygen saturation through a small nonin-
A number of preparatory steps usually take place before surgery trusive sensor placed on the finger. The blood pressure can be
actually begins. These include drawing the hairline, taking vital set to be taken at regular intervals or manually, when desired,
signs, and preparing the donor area. at the simple touch of a button.
Figure 22C-3 Patient preparation tray. From lower left and

moving counter clockwise: Plastic spray bottle with saline, rat-tail Figure 22C-5 Alternative instruments that can be used for an-
comb, barber quality scissors, Personna beard trimmer, low stick esthesia: a) Small hand vibrator used for diminishing pain during
tape, dressing material for the donor area (towel clamp, ace band- anesthesia; b) dental syringe with dental needles and anesthetic
age, and Martuff pads), china marking pencil, and drapes and capsules; c) the ‘‘unimatic’’ syringe for the delivery of tumescence;
gowns. and d) the Dermot-Jet威 needleless injector.
ITEMS USED FOR ANESTHESIA AND

TUMESCENCE
anesthetic solutions (see Fig. 22C-5b). A specialized 27-gauge
Anesthetic techniques were discussed in detail in Chapter 8A. dental needle attaches to this syringe. The small volume of
Most commonly anesthetic and tumescent solutions are drawn anesthetic in each carpule combined with the tiny needle ena-
up and dispensed with the use of various-sized syringes and bles a great deal of control over the volume of anesthesia admin-
needles. In general, 18-gauge needles are used to draw up the istered when depressing the plunger. Anesthetic can be deliv-
solutions while finer, 25 to 30-gauge needles are used for inject- ered very slowly and, thus, less painfully. In addition, color
ing to decrease pain. A small hand-held vibrator (Fig. 22C-5a), coding of the various anesthetic Carpules limits the danger of
placed on the skin next to the site of injection, has also been accidentally injecting the wrong solution. A disadvantage is
used during anesthesia to limit the pain of injection. that it is more expensive and you are tied to a limited number
of anesthetic solutions that can only be delivered individually
Dental Syringes and sequentially. This is a limitation for physicians who like
Another system of dispensing anesthesia is with the use of a to mix their own combination of anesthetic solution to be deliv-
dental syringe that can house 1.8 mL dental carpules of various ered at one time.
The CompuMed姟 (Wand) anesthetic delivery system from
Milestone Scientific is another instrument that is supposed to
limit pain by ensuring slow, steady delivery of anesthetic solu-
tion (Fig. 22C-6). It has been used in the dental industry for a
number of years. This instrument is a computerized mechanical
pump that pushes the anesthetic solution at a steady, slow rate
through a very fine 30-gauge needle. The person performing
anesthesia does not depress a plunger, as with a syringe, but
instead, simply slowly advances the needle under the skin while
the pump pushes out the anesthetic fluid.
The ‘‘Uni-Matic’’ Tumescent Syringe

The ‘‘Uni-Matic’’ Tumescent Syringe from Byron Medical (see
Fig. 22C-5c) is very useful for the administration of tumescent
solutions. It is basically a pump gun that connects to a needle
at its distal end but also has a side port that can connect to any
size syringe. The gun houses a small 3 mL capillary tube. Due
Figure 22C-4 Welch Allen Series 5200 blood pressure and to a one-way valve mechanism, when the gun of the handle is
pulse oximetry unit. squeezed and released, fluid is drawn in from the attached sy-
838 Chapter 22
Plus威 brand of scalpel blades because we feel they are sharper

than other brands.
Multi-Bladed Knife Handles

In the early 1990s the multi-bladed scalpel became popular for
the production of large numbers of micrografts and minigrafts.
These scalpels are designed to harvest donor hair in multiple,
narrow, linear strips of varying widths determined by spacers
placed between the blades (6,7). A variety of models exist today.
The earlier models had a fixed angle and a fixed distance be-
tween the blades, i.e., Brandy Knife, Rassman Knife, (Fig. 22C-
7a). Newer models use spacers of different widths to offer vari-
able spacing between the surgical blades, i.e., Arnold Mul-
tiblade Knife姟 Universal Multi-Blade handle (see Fig. 22C-
7b, c). Most of these models have a preset angle that is either
straight or angled. Another model called the Vari-Knife姟 from
Mediquip, allows you to adjust the angle of the blade, as needed,
Figure 22C-6 The CompuMed姟 (Wand) anesthetic delivery to accommodate the angle of the donor hairs as they exit the
system pushes anesthetic solution slowly through a fine needle. scalp (Fig. 22C-8). A multi-bladed scalpel can also be used
instead of a single-bladed scalpel to take a single strip. This is
done by using only two blades placed at either end of the multi-
bladed scalpel.
ringe and then pushed out through the small needle. This gun
makes it very easy to inject fluid from a large syringe through Surgical Scissors
a very small needle without having to continually refill a small
syringe. It also limits the potential for an accidental needle stick. After the initial scalpel incisions have been made at the lateral
borders of the donor strip, a surgical scissor is often used to
Nitrous Oxide Delivery Machines dissect the strip away from the scalp, cutting beneath the hair
follicles, along the adipose tissue plane. Metzenbaum, Mayo,
Nitrous oxide (N2O) is sometimes used as an adjunct during or Iris scissors can all be used for this purpose, depending on
anesthesia. Unger uses a hospital model Nitrox delivery unit the surgeon’s preference. For patients who have had previous
that will allow delivery of 100% oxygen or a mixture of nitrous surgery, with scar tissue formation, a serrated scissors offers
oxide with oxygen up to, but not exceeding, 50% nitrous oxide. enhanced cutting ability. Some physicians use a single-bladed
An evacuation system must be used with N2O as per OSHA scalpel instead of scissors to perform this task.
guidelines.
Dermo-Jet威
The Dermo-Jet威 is a needleless injector that uses air pressure to
inject anesthetic solution under the skin to create small circular
wheals (see Fig. 22C-5d). As a marketing tool it enables one
to say they do not use a needle for anesthesia. This may be
attractive to patients who are needle phobic. However, we have
used this instrument in the past and it is not painless. It is often
described by patients as similar to having a rubber band snapped
against your skin. Although it was useful in the extremely
needle phobic patient, most of our patients did not show a pref-
erence for this injector over anesthesia gently delivered by a
needle.
ITEMS USED FOR DONOR HARVESTING

Single-Bladed Scalpel
A single-bladed scalpel is often used to harvest donor tissue as Figure 22C-7 Various multi-bladed scalpels used in donor har-
a single strip (or ellipse) during FU Transplantation (FUT). We vesting: a) Brandy Knife with fixed number of blades and fixed
use a No. 10 scalpel blade placed on a single-bladed scalpel distance between the blade; b) the Universal Knife with spacers to
handle. Others prefer to use a single scalpel with a No. 15 or adjust the number and distance between blades (straight or angled);
No. 11 blade for donor ellipse removal. We prefer the Personna c) The Arnold Knife姟 (straight or angled).
Figure 22C-8 The Vari-Knife姟 from Mediquip allows one to Figure 22C-9 Photos of various types of clamps: x) Tissue
alter the angle of the blade up and down by 45⬚ to match the tension clamps; y) Towel clamps;z) Versi-Clamp姟 with four points
direction of the donor hair. of pressure.
Tissue Forceps Used in Donor Harvesting Suture Material

Different tissue forceps are used at multiple phases of the trans- Various types of both nonabsorbable and absorbable sutures
plant procedure for different purposes (suturing, graft dissec- are used in hair restoration surgery. For a list of these sutures
tion, and placing). Many brands and styles exist. Choices need and their properties see Appendix 10A at the end of Chapter
to be made with respect to tip size (standard, fine, or extra 10. Absorbable sutures can be used for small blood vessel liga-
fine), tip shape (straight, angled, or curved) and the presence tion or for closure of the subcutaneous space to relieve tension
or absence of teeth. During donor harvesting, I feel a sturdy on the skin in a double-layer closure. Vicryl or Dexon are
pair of forceps are needed to grasp the donor tissue when dis- braided absorbable sutures of polyglycolic acid; Maxon and
secting it away from the scalp, as well as to place gentle traction Monocryl are absorbable monofilament sutures. Absorbable su-
on the skin edges during either staple or suture closure. For tures have been used for primary closure of the skin as well
this part of the procedure we use either the Hudson-Ewald or (8). When an absorbable suture is used for the skin closure, in
Standard Adson-Brown tissue forceps with 1 by 2 teeth. Finer a subcuticular stitch, it obviates the need for later suture re-
types of forceps (Jewelers or Forrester, etc.) used for graft dis- moval. The risk of an absorbable suture is that it can elicit a
section and placing are described later. foreign body reaction and can become contaminated during the
period of time between suture placement and absorption. The
Towel and Tissue Clamps risk of infection is less with a monofilament suture, which has
no interstices to harbor bacteria.
A regular Backhaus towel clamp can be used to approximate Non-absorbable suture material is only used for skin closure.
the scalp wound edges during closure. It assists with fast home- Nylon suture (Ethilon, Novafil) is a monofilament suture that
ostasis during donor excision by allowing immediate wound provides excellent cosmetic closure for us. Both the skin and
approximation prior to definitive closure. It also assists in re- subcutaneous sutures can range from 2–0 or 4–0 caliber de-
lieving wound tension during closure and can accomplish some pending on the tensile strength needed.
degree of acute intraoperative mechanical creep. (See Chapter
18C.) Dr. James Arnold introduced a modification to this towel
Staple Device
clamp whereby the clamp teeth do not touch, creating a signifi-
cant distance between the clamp points when it is closed on Skin staples are an alternative and efficient method of donor
the tissue (7). These modified clamps are called tissue or tension area closure. 3M Company offers a disposable skin stapler, with
clamps and offer less traumatic force to the skin being approxi- 25 staples. Although this method of wound closure is rapid, it
mated. Another clamp called the Versi-Closure姟 device offers is not as comfortable for the patients. Nevertheless, incisional
a four-pronged clamp, which distributes tension more evenly healing is comparable between staples and suture (9).
over four points instead of two points (Fig. 22C-9).
Punches Used for Donor Harvesting
Needle Holders
Linear strip excision has been the standard harvesting technique
Needle drivers are needed to guide the suture for subcutaneous of most hair restoration surgeons for the past decade. Prior to
and/or skin closure. A variety of types exist (Mayo-Hegar, that, 4 mm punch excisions were the norm, using a hand engine
Ryder, Halsey, etc.) and the one chosen is a matter of personal (Bell engine or other brand) to power the punch in a circular
preference. We use a needle driver with a serrated tungsten fashion. This machine carved out round sections of donor hair.
carbide tip to prevent slippage of the needle. These punch grafts were then placed in holes in the recipient
840 Chapter 22
area, or later when grafts became smaller, they were bisected Optivisor, for example, has a working distance of 4
or quadrisected to make a minigraft. inches.
Today, punch excision is making a resurgence, only this ● True Surgical Loupes (see Fig. 22C-11) – Vision Engi-
time the punch that is used is much smaller. A 1.0 mm punch neering, Surgitell, and Designs for Vision, among other
is used to perform Follicular Unit Extraction (FUE) (10). This companies, offer tailor-made surgical loupes that mag-
is a method touted to remove individual FUs, without producing nify objects in the surgeon’s field of vision, from 3X to
the linear scar of strip excision, but involves applying the small 6X magnification, and can be used to facilitate all parts
punch over an individual FU and punching it out. It remains of the surgical procedure, including graft harvesting, dis-
to be determined if this method will enjoy a wide resurgence, section, and graft placement. Loupes use a different
given the risk for significant transection of hairs during blind method of magnification than simple magnifiers. A 2.5
harvesting. Furthermore, while the individual scars appear small X magnification from true surgical loupes is much
and difficult to see, this wound does produce scar tissue. It greater than the magnification obtained from 2.5X mag-
can be expected that if large numbers of grafts are eventually nifying glasses. With loupes, the 2.5X is referring to true
removed with this method, there will be significant donor scar- magnification while with magnifying glasses the 2.5X
ring, both visible and nonvisible. FUE is discussed in more is referring to diopters, which is a much smaller degree
detail in Chapter 10A. of magnification. The advantage of loupes over other
magnifiers is twofold. First, the degree of magnification
is much greater. Second, they offer a more generous
Cautery and Vacuum Devices working distance at this higher power of magnification.
Significant bleeding in the donor area is usually not a problem, Designs for Vision offers a loupe with an extended field
especially with the increased used of donor tissue tumescence. option that we find easier to use because of the larger
However, on occasion, bleeding needs to be controlled and there field of vision.
are a number of options for accomplishing this. Small vascular ● Microscopes (Fig. 22C-12a, b, c – The use of micro-
hemostats such as Halstead mosquito forceps should be avail- scopes has been the subject of a great deal of contro-
able on the surgical tray to clamp any large bleeders that can versy. Currently, they are used most often for the prepa-
later be tied off or cauterized. Cautery can be performed with ration of large numbers of FU grafts during FUT (14,15).
a unipolar hyphercator such as the Hyphercator 2000威 (Fig. Recently some physicians have been using the micro-
22C-10a). More expensive and versatile bipolar cautery ma- scope to create small slit grafts that contain two or three
chines, such as a Bovi can also be used.When significant cautery FUs, whereas in the past, these types of grafts were tradi-
is being performed, a smoke plume may be formed. Plume tionally cut to size. The Meiji, the Zeiss, and the Mantis
smoke may be carcinogenic or contain live viral particles (11). microscopes are the most commonly used for hair resto-
To evacuate the plume, secondary to cautery, one can use a ration surgery. The Meiji was the first microscope used
smoke-evacuator system such as the Plumemaster ESU system in hair transplantation and it offered 10X to 20X magni-
(12). These evacuators are more commonly used and necessary fication. However, assistants found it difficult to use and
for the larger plumes produced with CO2 laser ablation and resisted its implementation. The Mantis microscope was
may not be necessary for the minor amount of cauterization more accepted by assistants due to its single upright
performed during hair transplantation. The Infrared Coagulator viewing screen and a greater working distance between
from Redfield is another instrument used in hair restoration to the lens and hands (see Fig. 11A-1 in Chapter 11A). The
control bleeding in the donor area (see Fig. 22C-10b). It pro- mantis microscope only offers magnification up to 6X,
duces coagulation by generating heat from infrared light. At but many feel this is adequate. The Zoom microscope
the intensity used to cause coagulation, it is deemed to be safe is currently becoming popular and, although it is similar
for the surrounding tissue. It also has the advantage of not pro- in shape to the Meiji, it has ocular viewing lenses that are
ducing a plume. It is not as effective as cauterization and some- larger and easier to use. It also has very clear, continuous
time takes multiple pulses to produce a result (13). zoom magnification that reaches 45X and a built in back-
light.
● Microscopic Video Systems (see Fig. 22C-12d)—At-
tempts have been made at focusing either a digital or
ITEMS USED FOR DONOR GRAFT fiberoptic camera on the donor tissue and projecting the
DISSECTION image onto a monitor for visualization during graft
Instruments of Magnification preparation. This technique is not widely used and the
major drawback has been said to be a loss of three-
● Magnifying glasses (Fig. 22C-11)—Several types of dimensional visualization. However, many types of very
magnifying glasses exist. There are those that are worn complicated surgery are currently being done with fi-
like reading glasses or those that are attached to a band beroptic cameras and appear to have overcome this ob-
or apparatus that flips up and down and are fashioned as stacle. It is not unforeseeable that this method may be-
a visor (Optivisor, Magni-focusor, Mag-eyes). A goose come more popular in the future.
neck-shaped magnifier that is attached to a stand and
placed over the cutting area can also be used. The power Backlighting Systems
of these glasses varies from 1.5X to 3.5X, and in most
cases the working distance of the tool diminishes, as the Backlights were originally designed to illuminate photographic
magnification increases. A 3.5X magnification with the slides, and later described for use in hair restoration surgery by
Figure 22C-10 Cautery devices: a) Infrared Coagulator; b) Hyfercator Plus威 2000.
Dr. Paul Rose. The backlight transilluminates the graft speci- Cutting Surfaces
men and improves the visibility of the hair follicles by outlining
the opaque structures within the adipose connective tissue. This Tongue blades have been, and continue to be used, as a surface
tool is often used in combination with some type of magnifier, for graft dissection. They are inexpensive, but inhibit transillu-
and works particularly well when the room lights are dim. Two mination of the specimen by a backlight. They also tend to
commonly used backlighting systems are the Visual Plus姟 absorb water and can dry out grafts unless kept wet. A variety
backlight and the Tundra威 backlight (see Figs. 11C-13a and of nonslip, clear, plastic dissecting surfaces have been devel-
11C-13b in Chapter 11C). oped that are particularly useful to place on top of a backlight-
dissection system. Among these are the Greco cutting pads and
several tongueblade-shaped, clear plastic surfaces (i.e., The
Clear-Vue姟 cutting surface, etc).
Slivering Boards
The Blugerman Board, designed by Dr. Guillermo Blugerman,
is a plastic, autoclaveable cutting board with a rubber flange
that allows fixation of the donor strip during graft slivering (see
Fig. 11A-3 in Chapter 11A). This permits traction to be placed
on the donor strip and has made the process of microscopic
‘‘slivering’’ during FUT much easier (16).
Forceps Used for Graft Preparation

The forceps used to stabilize tissue during graft preparation are
usually finer than those used for suturing, but not as fine as
those needed for the placement of micrografts. Common forceps
used are either a Jeweler’s forceps or Forrester forceps with
standard tips. When applying traction during slivering, we use
Figure 22C-11 Magnifying Instruments: x) Magni-specs a jeweler’s forceps that has been modified by bending the tip
(2.5x) y); Surgical loops (3.5x) with extended field from Design inward to create a small hook. This prevents slippage when
for Vision; z) Surgical loops (2.5x) on light titanium frames; xx) applying traction. An alternative is to use a Micro-Adson For-
Goose neck magnifier; yy) Optivisor magnifier (3.0x). ceps with 1 by 2 teeth.
842 Chapter 22
Figure 22C-12 Microscopes used in hair restoration: a) Meiji Microscope; b) Zeiss microscope with large eyepiece and backlight; c)
Mantis microscope with ergonomic upright viewing area; d) Microscopic digital video system.
Blades Used for Graft Preparation ever, many surgeons do place their grafts in iced saline as a
precaution. Petri dishes or plastic cups are typically used for
Grafts can be cut from a donor strip using several different graft storage during dissection. Chilled saline keeps them hy-
blades. Very often either single or double-edged razor (shaper) drated. Specialized coolers that are specifically shaped to hold
blades are used. The Personna Plus brand of shaper blades is an individual petri dish have also been developed (i.e., Le-Paw
very popular owing to their sharpness. A specialized razor-blade Cooler). Alternatively, a petri dish can simply be placed on a
holder (i.e., the Blade Aide) exists for holding double-edged frozen gel pack. The latter is an inexpensive way to keep the
razors (Fig. 22C-13). Although most physicians use razor blades grafts cool.
for graft preparation, there are some that prefer to use scalpel
blades, particularly a No. 15 scalpel blade, to dissect grafts from Automatic Graft Cutters
donor tissue.
Two graft cutting machines have been designed for cutting mul-
Graft Storage Containers and Cooling Systems tiple grafts at one time. Dr. Guillermo Blugerman from Brazil,
and Dr. Anthony Mangubat from the United States, both de-
The evidence to support graft cooling, in order to enhance graft signed a multiple razor-blade device to achieve rapid dissection
survival, prior to transplantation, is currently equivocal. How- of donor strips. Dr Mangubat refers to his machine as the Impul-
needles. Special solid core needles have been developed for

hair transplantation in the hope that this would limit any epithe-
lium from being cored out and deposited under the skin. Seager
believes that for dense packing one should use a 19 or 20-gauge
needle (18). NoKor needles are also used for FUs; however,
the smallest NoKor needle is an 18-gauge caliber. In the past,
we would modify the 18-gauge NoKor for smaller FU grafts
by shaving it down.
Microblades
Different types of microblades can be used to make the incision
for FU grafts or small slit minigrafts (see Fig. 22C-14b). Stan-
dard microblades from companies such as Swann-Morton come
in a variety of shapes (i.e., spear tip, chisel tip, lance tip, round
tip, and curved tip). Spear tip and chisel tip blades can range
in size from 1 mm to 4 mm. In general, 1 mm to 2 mm blades
are used for FU grafts and 2 mm to 3 mm blades are used for
Figure 22C-13 Blades commonly used for graft preparation: small to medium slit minigrafts. Some physicians prefer razor
x) Single edge Personna Plus shaper (razor) blades and blade sharp specialty blades such as Sharpoint or Minde blades to
holder; y) Double edge Personna Plus shaper (razor) blades and make their incisions. These blades also come in various sizes.
blade holder; z) No.15 scalpel blade. Appendix 22C lists the incision length produced by commonly
used microblades and needles. Some of the more common-sized
type microblades used in hair restoration surgery include the
following:
sive Force Graft Cutter (see Fig. 11D-5 in Chapter 11D) (17).
These cutting machines are used with the multibladed donor ● A Spear tip SP90 (1.5 mm) from Swann Morton is com-
harvesting scalpel, which produces multiple, thin donor strips. monly used for small FU grafts while the larger end
The donor strips are placed on a bed of upright razor blades, SP91 (2.0 mm) is often used for larger FU grafts or small
a sheet is placed over the top of the graft strip, and a mallet is slit minigrafts.
used to force the strip down over the blades, dissecting them ● Chisel tip blades from the same manufacturer are also
at the specimen blade interface. Large numbers of grafts can commonly used. A no. 61 chisel tip (1.5 mm) is used
be made in a short period of time. Transection through the for FU grafts and a no. 62 chisel tip (2.75 mm) for me-
follicle is a risk, and these instruments cannot be used in patients dium slit grafts. Both spear and chisel tip type blades
with significant curl or wave, because this risk becomes much come in other sizes as well..
greater in these patients. ● Sharpoint scalpel blades are razor sharp specialty blades
that were originally used for ophthalmologic surgery
(see Fig. 22C-14b). They are sharper than standard chisel
ITEMS USED FOR RECIPIENT SITE tip or spear tip blades and slide through skin like butter.
CREATION The 15⬚ Sharpoint can, when only partially inserted, pro-
duce a very fine linear incision of less than 1 mm. This
Incisional Recipient Sites is useful for dense packing finely trimmed one to two
A wide variety of needles and blades are available to create hair grafts. The slightly wider 30⬚ and 45⬚ Sharpoint
incisional recipient sites (Fig. 22C-14a). The particular needle blades are used for larger FU grafts and, occasionally,
or blade chosen will depend on a number of factors including small slit minigrafts. The width of the incision made
the size of the graft, skill of the placer and personal preferences. with these larger Sharpoints varies, depending on the
When comparing techniques it is not unusual to find different depth and angle at which they are inserted and can vary
physicians using different sized blades for the same-sized graft from 1.5mm to 2.5mm.
(i.e., – Physician A uses a 15⬚ Sharpoint for his two-hair grafts ● The Minde blade is another variety of razor sharp mi-
while Physican B uses a slightly larger 22.5⬚ or 30⬚ Sharpoint croblade that was designed by Dr. James Arnold (Fig.
for his two-hair grafts). The reasons for this difference could 22C-15). It was created by cutting razor blades to differ-
be that one physician cuts his grafts slightly larger or that he ent widths and placing them in a handle that provides
is not quite as skilled at placing grafts into a tinnier incision depth control. The blade comes in either a chisel or an-
without popping or traumatizing them. Therefore, one has to gled shape and ranges in size from 1.3mm to 3.0mm to
allow some leeway when describing what size blades are used accommodate either micrografts or minigrafts.
for specific sized grafts.
Round Punches
Needles A standard round graft punch, two decades ago, was 3.5 mm
Needles are commonly used for the placement of FU grafts, to 4.5 mm in diameter, and was able to accommodate a graft
especially when the ‘‘stick and place’’ method is used (see Fig. of 15 to 25 hairs (Fig. 22C-16). In 1980 Dr. Pierre Pouteaux
22C-14a). They can range in size from 16-gauge to 21-gauge reported on the use of small punches to achieve improved cos-
844 Chapter 22
a b
Figure 22C-14 a) Global view for comparison of common needles used to make recipient sites in hair restoration surgery. From left
to right: x) NoKor needle (16-gauge and 18-gauge); y) Standard hypodermic needle (18-gauge and 21-gauge); z) Solid Core Needles (18-
gauge and 19-gauge); b) Global view for comparison of common micro-blades used to make recipient sites in hair restoration surgery: x)
Sharpoint Micro-blades (15⬚, 22.5⬚, and 30⬚); y) SpearPoint (SP90 & SP91); z) Chisel tip (SP no. 61 & SP no. 62); xxx) Round tip (no.
69 Beaver blade) and curved-tip blade.
mesis with punch grafts, and to fill in between the standard

grafts (20). Over several decades the size of punches used in
hair transplantation has become smaller, as graft sizes have
become smaller. Today, those who use punches to create recipi-
ent sites, typically use a punch of 0.75 mm in diameter for small
micrografts, up to 2.0 mm in diameter for minigrafts. Punches
larger than 2 mm are still used in the recipient area to punch out
larger grafts during corrective work. I currently use disposable
punches that come in sizes ranging from 2 mm to 4 mm and
higher for this purpose.
Slot Punch
A slot punch was introduced by Gary Hitzig, in order to create
a linear punch that would incorporate a more linear-shaped graft
(Fig. 22C-17) (21). These punches produce an oval-shaped de-
fect and are currently used to receive slot grafts that are approxi-
mately 2 FUs wide, as opposed to slit grafts that are thinner
and usually 1 FU wide. They are available in sizes that range
from 1.6 mm to 4.1 mm. A recent innovation is the butterfly
slot punch which is dimpled in the center to produce a defect
that is narrower than the slot punch, and allows placement of
a thinner linear graft.
Custom Blade Cutter

Figure 22C-15 Color-coded Minde blades with different tips
(flat, 40⬚ angled, 15⬚ angled): (blue-1.3 mm, black-1.5 mm, green- A very interesting blade-producing instrument has been devel-
1.8 mm, beige-2.0 mm). oped and tested by Dr. Victor Hasson and Dr. Jerry Wong. This
cutting machine allows the surgeon a wide choice of microsur-

gical blade widths that can be produced quickly and accurately
by using a guillotine-type cutting mechanism that sections Per-
sonna Super stainless surgical blades into whatever width seg-
ments are required (Figs. 22C-18a and 22C-18b). The blade
widths range between 0.9 mm to 2.0 mm, in 0.1 mm increments.
They are inexpensive and exquisitely sharp. They are also made
from thinner material than the usual blades used for making
recipient sites and, therefore, have lower friction and produce
less displacement as they enter the scalp. A special instrument
is used to safely and easily remove the backer from the surgical
prep blade and the blade is then put into the instrument where
the width of the blade is chosen (see Fig. 22C-18a).
A microsurgical blade organizer, which consists of a circular
dish with depressed wells, each of which is engraved with the
blade width, permits different widths of blades to be kept sepa-
rated and easily identified by width at the time they are needed
(see Fig. 22C-18b). The organizer, with scalpel blades within
them, is then autoclaved. The sterile blade organizer is brought
to the surgical suite and the width of blade is selected. The
organizer can then be restocked at the end of the day by cutting
new blades as required. The manufacturer is expanding their
product line to include a blade cutter which will produce a
Figure 22C-16 Round punches can come in diameter sizes spear-point blade with 30⬚, 45⬚, 60⬚, and 90⬚ angles. Special
that range from 0.75 mm in diameter to 4.0 mm in diameter and
scalpel handles have also been manufactured to work specifi-
higher; x) Stainless steel punches ranging in size from 1.0 mm to
cally with the surgical prep blade material that is only 0.25 mm
4.0 mm y). One can also use disposable punches (green handle).
Shown here are three disposable punches ranging 2.0 mm to 3.5 thick. The use of this handle provides a more secure grip on
mm in diameter. the blade than the one that is available with handles designed
to be used with thicker blades and minimizes blade slippage.
The handles are available in 1.5 mm and 2.2 mm blade widths
capacity. Use of these handles also allows for a positive stop
control for the depth of the incision. Unger has used an ordinary
Figure 22C-17 Various styles of slots punches: x) Slots punches create an oval defect. Shown are sizes 1.6 mm, 2.4 mm, and 3.3 mm;
y) Redfield slots come in larger sizes and are disposable. Shown are sizes 2.8 mm, and 4.1 mm; z) Butterfly slot punch with dimple in
center creates a narrower slot defect. Shown here are sizes ranging from 1.6 mm to 3.3 mm.
846 Chapter 22
Figure 22C-18 a) The cutting machine works like a guillotine, sectioning Personna stainless surgical blades into segments of varying
widths. The small knob to the right of the handle is adjusted to choose the desired width of a microsurgical blade. b) A pliers-type instrument,
shown at the left, allows easy and safe removal of the Personna blade backer. The dish shown on the right contains depressed wells engraved
with the width of blades that is in each well. After it is covered with its lid, it may be autoclaved.
needle holder to grasp these blades at a length to match the Multi-Recipient-Site Scalpels
depth of the grafts He feels that the blades produced from this
instrument, supplied by Cutting Edge, Inc., are superb to work Today, grafting sessions frequently exceed 1000 grafts, and
with for the reasons noted earlier. sometimes several thousand grafts are placed in a single session.
Creating recipient sites, one at a time, is labor intensive, and
can take a long time. Multi-recipient-blade scalpels were de-
Blade, Punch, and Scissor-Sharpening Equipment signed in an attempt to more efficiently create multiple inci-
When punches, scissors, or placers become dull they can be sions.The first multi-recipient-site scalpels for FU grafts were
sharpened. A number of the medical supply companies offer introduced in the year 2000.
sharpening and repair service. As an alternative, one can buy ● The KMI Multi-Recipient-Site Scalpel (Fig. 22C-20a, b,
his or her own blade sharpening machine and do this work in- c, d) was designed to create more efficiently large num-
house rather than send it out. Such a machine can be supplied bers of closely spaced recipient sites. The blades are
by Rx Honing, Inc. Occasionally, the fine tips of micro-blades staggered and interdigitated, so no rows are formed.
or placing forceps will develop burrs that interfere with either They are also closely approximated and when properly
making incisions or placing. When this occurs a sharpening used can create recipient sites at densities of 20FU to
flint can be used to file off these burrs. 30 FU/cm2. The KMI multiple-recipient-site scalpel is
flexible in that various numbers of blades (3 to 8) and
Needle, Blade, and Punch Handles spacing between the blades can be created. The blade
holder will accommodate various types of blades; how-
Some physicians like to hold the various blades and punches ever, it was initially designed for use with Sharpoint
directly in their fingers. Others use a needle driver to grasp the scalpel blades and with a depth-control gauge to main-
microblade. By grasping the microblade at a specific point along tain uniform, limited-depth incisions. We have found the
its length, a degree of depth control can be obtained. There are, KMI scalpel a quick and efficient way to create larger
however, specialized blade holders that exist for Sharpoints, numbers of multiple sites, especially on a bald scalp with
NoKor needles, punches and microblades (Fig. 22C-19). The no existing hair. Although more difficult, experienced
Lightning Knife姟 developed by Arnold is one brand of blade users state they are able to use this scalpel to go in-
holder that will hold a number of different microblades. The between hairs as well.
Vari-Handle姟 developed by Mediquip does the same thing but ● The Multigraft scalpel is another design of a multirecipi-
will also hold solid core needles and small punches. ent-site scalpel. It holds three Sharpoint blades, which
Figure 22C-19 Various microblade and punch holders. From bottom to top: x) NoKor Needle Holder; y) Sharpoint holder; z) Versi-
holder that holds microblades and small punches; xx) Needle driver being used as a blade holder.
848 Chapter 22
are parallel to each other. These are not interdigitated, other type of super-fine forceps, currently popular for placing
and there is no adjustment for depth control. When using grafts, is straight and has very fine microteeth. Plastic tip covers
this scalpel, it is necessary for the operator to adjust are used to prevent the tips of forceps from being damaged when
incision distance in order to create interdigitation. stored.
Graft Storage/Receptacles During Placing

ITEMS USED FOR GRAFT INSERTION
Most practitioners store grafts waiting to be placed in a chilled
Placing Forceps (Fig. 22C-21) petri dish or some other plastic receptacle placed on a table
Usually either Forrester or a jeweler’s forceps, with very fine tips, near the patient. The assistants will repeatedly retrieve a small
are used for placing. We prefer the angled style at our clinics, number of these grafts from the receptacle and place them on
but many surgical assistants have their own preference and some a hand prior to placing. Blugerman uses a small plastic pin cup
prefer straight or curved forceps. The Microcep姟 forceps was that can be pinned to the scalp to aid him in storing grafts before
designed by Mediquip and has a very fine replaceable tip. This placing (see Fig. 11A-6a and 11A-6b in Chapter 11A).
forceps was designed to answer the need for a very fine-tipped
forceps that has replacement tips because these tips are frequently Banucci Multi-Graft Dispenser姟
damaged. The Millennium Forceps姟 by A-Z is a modification Isabel Banucci has developed a disposable multiple graft dis-
of a Forrester forceps that includes a stop-guard to prevent an penser for holding FUs in saline-filled channels until they are
assistant from squeezing a graft too hard. The Bonn Leveit, an- inserted into the recipient sites. It consists of a ‘‘flat, plastic
Figure 22C-20 a) KMI multi-recipient site scalpel; b) Tip with three blades in multi-recipient site scalpel; c) Tip with seven blades.
Figure 22C-21 Forceps used during graft preparation and placing in hair restoration surgery: x) Millennium (curved, straight). This
is a Forrester-type with a stop guard; y) Simple Forrester (curved, straight); z) Fine point Jeweler’s forceps (45⬚ and straight); xx) Bonn
Forceps with micro-teeth; zz) Microcep forceps with disposable tip. The plastic guards shown protect the tips from damage.
tray with five channels containing slots with premarked spaces be preloaded with one graft for each use. The implanters
to facilitate the graft loading process and a specially engineered come in three types: type L uses an 18-gauge needle and
tip that gently dilates the performed incisions and guides the accommodates two to four-hair grafts, type M uses a 20-
graft in the right position into the incision (Fig. 22C-22). Each gauge needle and is used for fine single hair grafts, and
dispenser holds 75 grafts. Banucci lists the advantages of the type S has a 22-gauge needle to accommodate only very
dispenser as follows: fine single hairs for eyebrow and eyelash reconstruction.
● Significantly reduces implantation time It is designed to make the incision and is spring activated
● Facilitates counting process to help unload the graft into the recipient site, much like
● Dilates performed incisions an injection. It is most efficient when several devices
● Organizes working area are loaded, and can be used by the doctor to place the
● Keeps the graft moist graft, while the assistant(s) reloads the newly emptied
● Places graft in correct position for implantation cartridge. This facilitates continuous and rapid graft
● Hold grafts in position after implantation placement. Variations of the Choi implanter include the
● Keeps surgeon’s sight focused on transplant area HANS implanter and Knu implanter, both of which have
● Ideal for megasessions replaceable tips.
Our experienced nurses and technicians tried this dispenser and
found it slowed them down. Less experienced individuals, how-
ever, may find the Multi-Graft Dispenser姟 very helpful. More CONCLUSION
importantly, it helps keep the grafts moist at all times.
Most recent trends in hair restoration surgery indicate that sur-
geons will be placing greater numbers of grafts as long as excel-
Automatic Graft Placing Devices lent graft survival is maintained. The time and labor involved
● The Choi implanter, introduced by Dr. Yung Chul Choi in these procedures is considerable, and may impact graft sur-
and Dr. Jung Chul Kim from Korea, is currently the most vival, as well as patient comfort. It can be anticipated that tools
successful automatic graft placing device. This device will be developed to achieve greater efficiency. New instru-
is discussed and illustrated in Chapter 13A and Chapter ments will hopefully continue to be developed to improve the
16G. The Choi implanter is shaped like a pen, and must process. In the future it may be possible to perform some of
850 Chapter 22
Figure 22C-22 The Bannuci graft placer.

the repetitive tasks using robotics, as is currently used in other ing, at this stage of the procedure, is that those preparing grafts
surgical specialties, such as ophthalmology and cardiac surgery. obtain a very accurate sense of the size of the average graft and
tissue consistency, which may help in planning recipient site
Editor’s Note size and density. For example, wide grafts require a larger recip-
As indicated elsewhere in this text, I often use a beaver mini- ient site or fewer sites per unit area, in order to accommodate
ES blade for making recipient sites for small slit grafts. More the volume of tissue being transplanted. The staff should be
and more often, however, I am using the custom blade cutter trained to produce slivers without follicle transection. These
described in this chapter to make the exact size blade that is individuals will also divide the slivers into FU grafts.
required for the grafts we produce. In offices where minigrafts of a uniform size are used exten-
We also employ ordinary escargot dishes that fit nicely on sively, fewer staff members may be required for graft prepara-
the Le Paw cooler and are sterilizable. Each well is marked tion. However, in those settings where the minigrafts are vari-
with the type of graft that is placed into that well. The little able in size and shape, such as those utilized by Dr. Walter
handle has the technician’s initials on it and the grafts within Unger, the number of staff required may be equivalent to that
the wells can be completely submerged by saline (WV). needed by an office producing exclusively FU grafts. A special
mention should be made of the ‘‘Manguwhacker’’, used and
described by Dr. Mangubat in Chapter 11D, for graft produc-
tion. Although this device is still being evaluated, in terms of
22D. Surgical Assistants its ability to deliver a transplant of equal quality to existing
James A. Harris and Shanee Courtney methods, it deserves some attention. This device has the ability
to produce a large number of small grafts in a short amount
The current trend in hair transplantation is toward the implanta- of time, with minimal staff requirements. The physician, and
tion of large numbers of smaller-sized grafts. The increase in possibly one assistant, can produce thousands of grafts in min-
work associated with this change makes the role of the surgical utes. The critical portions of this procedure, including the multi-
assistant much more critical, as physicians are less able to per- blade donor harvest and the impulse delivery, are typically per-
form a substantial portion of the work on their own. The assis- formed by the physician.
tants become an extension of the physician, who assumes the The issue of which member of the team creates the recipient
role of manager of the entire surgical team. The attention to sites is somewhat controversial, because the planning and exe-
detail, the care for the patient, and the fund of knowledge re- cution of these sites are critical to the final result. This is impor-
quired of an assistant regarding a few specific aspects of the tant because issues of graft density, irregularity of graft place-
procedure can, in fact, be no less than that of the physician. ment, as well as angle and direction of hair growth, are all
This chapter is devoted to those aspects of a transplant practice determined by the recipient sites, and obviously, these factors
that relate to medical assistants because, their role is not only influence tremendously the final cosmetic result. It has been
vital to completing the work, but also substantially affects the shown that graft density has an impact on follicular survival
outcome of every surgery. (See Chapter 9A). There are some physicians who are comforta-
ble delegating this responsibility to an assistant, and there are
others who feel the surgeon should personally produce the re-
THE DIVISION OF LABOR cipient sites. In most offices, the physician will create the recipi-
ent sites. However, the follicular unit transplantation (FUT)
The hair transplantation procedure may be divided into four method designated as ‘‘stick and plant’’ or ‘‘stick and place’’,
basic components: 1) donor tissue harvest, 2) graft production, in which the technician, who is trained to create the recipient
3) recipient site creation, and 4) graft placement. For the pur- sites, has specific advantages that are described in Chapter 13B.
pose of this chapter, it will be assumed that the typical office Decisions regarding graft size, density, irregularity, angle and
will use a strip harvest technique, whether it is single or multiple direction, are routinely made by this individual. In brief, propo-
blades. The physician typically performs the donor strip harvest, nents of the stick and place method state that properly trained
with the help of a staff member experienced in surgical assist- individuals can not only make these decisions well, but can,
ing. This may be a registered nurse, but it can also be an individ- with enough experience, more readily make adjustments to ac-
ual, without such credentials, who has been trained to assist the commodate variables, such as graft size, tissue consistency,
surgeon with this task. Depending on the qualifications of the popping, and bleeding. Detractors believe that surgeons have
assistant, this person may be asked to help in the administration very little control over the outcome of the transplant if nonphy-
of the local anesthetic or to assist in the closure of the incision. sicians are permitted to make all of the noted decisions. Some
Obviously, the assistant’s level of training and ability will dic- add that technicians are actually performing surgery and, in
tate their level of responsibility and involvement. There is usu- many jurisdictions, there are possible legal ramifications for the
ally one person, per case, who assumes this role. physician, who is, after all, responsible for the ultimate aesthetic
Once the donor strip is removed, there are several ways in outcome. It is doubtful that a consensus will be reached, how-
which grafts can be produced. In an office where only follicular ever, if the results achieved with a stick and place technique
unit (FU) grafts are utilized, several staff members may be are shown to be of equal quality to ones in which the physician
assigned to this task. As discussed elsewhere in this text, ini- makes all the recipient sites; it would be difficult to condemn
tially, one or two individuals may be responsible for producing this method of transplantation.
smaller ‘‘slivers’’ of tissue, which are subsequently divided into Graft placement, for the most part, has been the responsibil-
individual FU grafts by other assistants. The physician may or ity of the assistants in most offices, whether utilizing minigrafts
may not participate in graft production. The advantage in help- or FU grafts. The number of assistants delegated to this task
852 Chapter 22
will vary, depending on the number of grafts being placed. during surgery are both very important characteristics. This as-
Cases involving large numbers of FU grafts (e.g., over 1500 sistant may be chosen from the ranks, and may be the RN or
grafts) require two to three assistants. Those cases that primarily one of the other assistants.
utilize 300 to 400 minigrafts may require only one assistant for We have mentioned several times the need for good hand-
planting. Allotted time, operating room availability, and total eye coordination and there is a screening test for this. It is
number of qualified staff will also dictate the number of assis- the O’Connor Tweezer Dexterity Test sold by the Lafayette
tants utilized for any given case. Instrument Company (Lafayette, Indiana). The test involves
Regarding both recipient site creation and graft placement, placing 100 metal pins, into the same number of holes, using
I would urge the reader to re-read Dr. Ron Shapiro’s excellent tweezers to grasp and place the pins. The time is recorded and
treatise on this subject in Chapter 12D. He examines some con- it is used to categorize potential employees. Although the test
troversies and provides cogent arguments for physician involve- is probably good at screening gross inability, in our experience,
ment in these phases of the transplant. it has not seemed to correlate with the long-term ability of an
It should be noted that there are multiple tasks, which any individual to perfect cutting or planting procedures, nor does
individual, with proper training, may perform. Each office de- it gauge the amount of patience a prospective employee may
cides how to divide these different tasks among the staff. In possess.
some practices, particular assistants are trained specifically for
one part of the surgery or another (either microscopic graft
dissection or graft placement). Others prefer an approach in HIRING
which all the assistants are qualified to perform all functions.
The division of labor will be dependent on the needs of the Routine avenues, such as newspapers, trade journals, or em-
individual case, the capabilities of the assistants, and the staff ployment agencies for advertising open positions, will not be
availability. discussed here. Bulletin boards at schools offering course work
in cosmetology, styling, and aesthetics can be useful in obtain-
ing potential employees. In addition to this, trade schools offer-
STAFF MEMBERS AND QUALIFICATIONS ing certification for medical, surgical, and dental assistants can
be a good resource for recruiting. The interview process should
A typical surgical team is composed of the physician, a regis- not only serve as an opportunity to assess the qualifications of
tered nurse (RN), and several assistants. There does not seem the candidate, but also to impress upon the individual the nature
to be too much discussion regarding the qualifications of the of this field. The specific information to be imparted includes
physician or the nurse, but those of the assistants is frequently the potential for repetitive work, the need for precision, the
debated. The role of an RN is not one that can usually be sup- requirement for attention to detail, and the willingness to work
planted by staff members of lesser training or credentials. Be- as part of a team. To determine team compatibility, it is always
cause of the training an RN has received, a supervisory role is prudent to suggest that the applicant spend at least one day at
reasonable. Obviously, depending on the size of the staff, an the office, prior to being hired. This provides an opportunity
RN may serve in the technical roles of surgical assistant, graft for both the team and the applicant to judge for themselves how
cutter, or graft planter. In addition, however, an RN can provide they might work together. As previously mentioned, a screening
support in many areas, such as the administration of medications test for basic eye-hand coordination may be administered. We
or local anesthetics under the supervision of the physician. This would recommend that any scores obtained be compared with
individual should, ideally, have experience in postanesthesia those of existing staff members and if the score falls within a
recovery, surgical techniques, and quality control. As experi- predetermined range, that the applicant be considered for em-
ence is gained, the RN may also assist with patient consulta- ployment (if other criteria have been satisfied).
tions. Somewhat less tangible than qualifications for eye-hand co-
The complement of staff members required to prepare and ordination, is the potential ability of the candidate to assimilate
place grafts may come from a variety of educational and voca- into the team. The contribution of an assistant is not only a
tional backgrounds. The common characteristics necessary in- technical one, but given the length of many cases, the ability
clude an interest in the procedure, commitment to quality for the to communicate effectively with the patient and other team
sake of the patient, and good eye-hand coordination. Although members is essential. Team members must make the commit-
certified paramedics, medical assistants, and surgical assistants ment to quality a key part of their job description.
have been utilized to assist in transplant surgery, in our opinion,
a medical background is not mandatory. In particular, we and
others have found that individuals that have held positions in TRAINING
cosmetology seem to have an appropriate attention to detail
and eye-hand coordination. These potential employees can be As with all technical training, a new staff member will need
stylists, aestheticians, or nail technicians. Regardless of previ- detailed explanations and immediate feedback. The extent of
ous occupation, it is the extensiveness and thoroughness of the direction will depend on the prior experience of the employee.
training that is the most important factor in qualifying them for All assistants should receive a thorough orientation to hair trans-
this very specialized field. plantation and be required to read the medical literature to en-
The staff member chosen to assist with the donor area har- hance their knowledge of the field. The new assistant should
vesting should ideally have some prior training, whether it is also be instructed on OSHA regulations, and how this affects
provided in-house or by certification. A good rapport with the their particular job function. General guidelines of sterile and
physician and the ability to anticipate the physician’s needs aseptic technique are necessary to orient the new assistant to
the operating room setting and discussions of appropriate offices group their grafts in piles of 10, others count as they
professional behavior are encouraged. are cut and then transfer them to petri dishes or other containers
labeled according to the numbers of hairs per FU graft. Mini-
Training for OR assistant grafts are usually grouped according to size.
As is the case with all aspects of the transplantation process,
Training of a surgical assistant may take many days of one-on- supervision and quality assurance are critical to ensuring consis-
one observation. The first day is typically an observation day, tently well-prepared grafts and, therefore, consistent results.
in which the new assistant observes the veteran assistant. During Many assistants tend to increase speed and improve accuracy
this period, it is helpful to have the supervisor/trainer explain with experience. Care should be taken to be certain that speed
each step of surgical set-up, hands-on assisting, medication ad- does not increase at the expense of precision.
ministration, patient assessment, and clean up. Important points
that should be further emphasized include sterile technique, Training for Graft Placement
handling contaminated instruments, hemostasis during the pro-
cedure, and interventions to help make patients comfortable The most labor-intensive, yet critical part of the transplantation
throughout each stage of the procedure. process is planting. Choosing the right assistant for planting is,
The second day is the actual beginning of ‘‘hands-on’’ train- therefore, very important. This individual needs to be well-
ing. Each step of the procedure must be explained again and organized, have superior eye-hand coordination, have an innate
the new assistant should be carefully monitored to ensure proper ability to anticipate many things at one time, and also have the
technique is maintained. Each office will have general ideas of personality to endure long hours in a labor-intensive procedure.
how to train this individual, however, direct feedback with re- Many cutters are able to move into a planter position; however,
gard to the physician’s particular needs is essential. Anticipation discretion needs to be exercised because, as Dr. Seager dis-
of the doctor’s next move, during the harvest and creation of cusses in Chapter 12B, some good cutters are not good planters.
recipient sites, is the most difficult skill to develop; yet it is The planter is usually present with the doctor when recipient
essential to a smooth and efficient procedure. sites are made. In this way, the doctor is able to communicate
As noted, if the surgical assistant has not been employed by with the assistant so that the goals for density, the areas where
the office for very long, part of the training should include the various types of grafts are to be placed, and any special
reading of the relevant literature. Many patients ask questions issues which may be particular to that patient’s case are under-
during the procedure and because the assistant is working very stood. This is especially important when a mixture of different
closely with the patient, basic information about hair transplan- sizes of grafts is utilized.
tation must be accurate. New assistants should not answer any Before attempting to place grafts, the new technician should
questions until they have been trained to do so, and past experi- spend several hours in observation. Then the assistant can start
ence is not always indicative of one’s fund of knowledge. planting a limited number of grafts at a time. Often these short
The supervisor/trainer needs to be available for immediate practice runs help make the observation periods more useful
feedback initially, and daily feedback is necessary for a signifi- because it guides the new assistant to pay particular attention to
cant period of time (which, in our office, varies from 2 weeks certain techniques. It is often helpful to watch several different
to 6 weeks). Performance evaluations will be discussed later in planters, to find a system for that technician that feels most
this chapter. comfortable. There should be a thorough explanation of meth-
ods used to control bleeding, to determine the angle and direc-
tion of the recipient sites, to handle grafts properly, and to plant
Training for Graft Preparation with precision. Assistants are taught to limit the number of
When training assistants to dissect tissue into FU grafts or sliv- grafts placed on their gloves, so that the grafts are not outside
ers, the first step is to orient them to the equipment. Many the cool saline solution for more than 3 minutes. Because there
offices use backlighting with loupes for cutting minigrafts, are many different types of forceps, training also involves learn-
whereas offices that utilize large numbers of FU grafts use mi- ing to utilize the appropriate type of forceps for a given type
croscopes. With either set-up, most new assistants will require of graft.
between 3 and 5 days to adjust to working with magnification. Because this stage of the procedure involves direct patient
After 3 to 5 days, most of their training concentrates on tech- care, the planters must also be aware of patient comfort and
nique and coordination. A thorough review of the anatomy of make decisions regarding the administration of additional anes-
the FU graft is necessary, in addition to demonstration of the thetics. The planters are also involved in quality assurance.
cutting technique. The assistant must understand that the grafts They must make judgments regarding size, shape, and hair cali-
are delicate and must be handled very gently in order to avoid ber of the grafts, and place them in the appropriate sites, as
unnecessary trauma. Points that need to be emphasized include detailed in the doctor’s treatment plan.
proper organization of grafts within the petri dishes, mainte- Supervision of the planters is critical. Due to the detail in-
nance of graft hydration during the cutting process, the proper volved in good planting, frequent checks of technique and as-
transfer of the prepared grafts, and precision in dissection. The sessment of fatigue in the assistants is important to ensure effi-
supervisor/trainer must observe the new assistant to make sure ciency of the team and superior aesthetic outcomes.
that care is taken in all aspects of the cutting process.
Again, each doctor’s office has different priorities and tech- STAFFING REQUIREMENTS
niques in training, and each has its own method for counting
grafts. Some offices don’t count grafts, but estimate a total yield The number of people needed on the staff is dependent on sev-
based on density assessments prior to the strip harvesting. Some eral factors, the most significant being the type of surgery per-
854 Chapter 22
formed. For example, as noted earlier, in offices performing taken into consideration when attempting to create an ergonom-
primarily FUT, more staff members are generally required as ically sound workplace.
compared to an office performing primarily mini-micrografting,
because longer sessions are more common. Other factors that
influence staffing needs include the speed and experience of PERFORMANCE REVIEWS
the team, the level of cross training, the number of cases that
Perhaps one of the most important quality-control methods in
are performed in a single day, and the average number of grafts
the transplant office is the performance review. This tool incor-
planted per session. An experienced team for an office perform-
porates regular periodic assessments of the assistant’s skills,
ing one FUT case (1200 to 1500 grafts) or two mini-micrograft
and can have a significant impact on improving surgical results
cases may consist of the physician, an RN, and one or two
and patient satisfaction. The review should be conducted in an
assistants. This estimate is based on the assumption that the RN
atmosphere that encourages further education and emphasizes
and the assistants are able to fulfill a variety of roles, including
the common goal—quality work for the good of the patient.
surgical assisting, planting, and cutting. As the number of grafts
All staff members benefit from this process, because behavior
increase, or the number of cases increase, the staff needs to
and technique are continuously monitored. Criteria, which are
increase proportionately.
to be regularly evaluated, should be described clearly and
What has seemed to work well in our practice is a core team
should be understood by the employee at the time of hiring.
of full-time staff which includes the minimum number of staff
Throughout the training or probationary period, feedback
required to perform a case consisting of 1000 to 1200 FU grafts.
should be provided so that the new assistant can make the neces-
This team of three individuals consists of two team members
sary adjustments to the set standards. It is important to remem-
cross-trained in cutting, planting, and surgical assisting. The
ber that the new staff person needs encouragement as well as
third team member primarily prepares grafts, but is also as-
guidance during the training phase.
signed clerical duties, which are attended to when graft produc-
The Performance Review Standards as well as the Quality
tion is completed. In addition to this core staff, there are several
Assurance Profile are tools to help the doctor and the supervisor
part-time members, who are called in to help with larger cases
assess the team, so that areas of weakness are identified and
or when there are multiple cases in one day. In my experience,
corrected. Performance appraisals for new employees may need
the use of part-time employees helps prevent burn out. The
to be done at 3 months, 6 months and 12 months after the
majority of the part-time staff is dedicated to either planting or
date of hire. In our office, each employee is graded, on every
cutting, although several are cross-trained. Thus, some of the
standard, on a scale of 1-5. The points are then averaged to
staff can leave once all the grafts have been prepared and the
give an overall performance number. That number corresponds
dedicated part-time planters can arrive to work later and remain
with a percentage of salary increase. In this way, salary raises
until the completion of the case. It also allows staff members
are not subjective but defined and objective. Employees under-
to concentrate on developing skills in one area, and helps to
stand that this is the standard that must be met.
prevent burn out by reducing the length of the work day of each
The reviews for cutters and planters (which include the sur-
assistant. In addition, the physician can keep over-head costs
gical assistant) are included in Addendum 1. The quality assur-
at a minimum, while still allowing for adjustments on a case-
ance profile should be used to assess the surgical team on a
by-case basis.
quarterly basis, or as needed. It is utilized as an objective tool
to provide guidance to the team as to areas that need to be
EMPLOYEE SATISFACTION improved. It is also a useful precursor to the individual perfor-
mance reviews and helps to identify areas in which further in-
Studies have shown that employee satisfaction is related to rec-
struction may be required. The quality assurance profile is pro-
ognition and positive reinforcement. In a typical hair transplant
vided in Addendum 2.
office, the areas of concern include delegation of responsibility,
the need for positive reinforcement and proper ergonomics to
limit stress and injury on the job. If an individual’s responsibili- SUMMARY
ties are increased, it should be clearly delineated in a detailed,
written job description and possibilities for advancement may This chapter has attempted to describe the surgical assistant
be discussed at the same time. staffing requirements of a typical hair transplant office. Regard-
Positive reinforcement can be provided in a number of ways. less of the type of grafts utilized, the staffing needs are very
Usually the employee is given evaluations that comment on similar—it is the training and performance review that would
many technical and nontechnical criteria. The areas reviewed vary. Adjustments for caseload, experience, and average-sized
can include graft production (skinny versus fat, speed, tissue sessions need to be made on a regular basis as the practice
handling, etc.), graft planting (handling, time on the glove, etc.), evolves. Because training staff requires a great deal of time and
or nontechnical skills, such as demeanor and professionalism effort, which also translates into cost, their satisfaction is very
in the operating room, and patient-employee interactions. Rein- important. A practice should strive to reduce employee turnover
forcement can also be provided by allowing the staff members in order to maintain efficiency, reduce costs, and promote conti-
to visit the postoperative patients to see the actual results that nuity. Satisfied employees rarely quit, and some of the sugges-
they have helped to produce. This will help to ensure satisfac- tions provided above may help to promote a positive work envi-
tion and pride in their work. ronment. Physicians should also be cautioned to remember that
Ergonomics that help protect the employees’ physical condi- assistants spend many hours in close proximity to the patients;
tion have been discussed elsewhere in this text. Seat heights, their mood directly affects the patient’s experience, which di-
hand and arm placement, lighting, and microscopes need to be rectly affects their perception of the entire team.
ADDENDUM 1 PERFORMANCE REVIEW Positions patient for best comfort and exposure
STANDARDS Is aware of patient’s medical and emotional condition
at all times
CUTTERS Restricts personal conversations with other nurses
OPERATING ROOMS
OR SET UP:
GENERAL COMPETENCIES FOR ALL EMPLO-
Can set up station and prepare adequately for cutting
Demonstrates ability to break down and clean station YEES:
Completeness INITIATIVE:
Cleanliness Sees beyond the immediate assignment and acts on op-
Follows procedure guidelines
portunities and problem areas
GRAFT PREPARATION:
Attends staff meetings with a positive, attentive manner
Slivers:
Consistently sets personal goals toward next level of
Cleans strip within guidelines taught
learning
Demonstrates understanding of ‘‘H’’ factors to
Makes sure that objectives and actions steps are com-
keep strip moist
Cuts without transection pleted
Follicular units: INTERPERSONAL RELATIONS:
Cuts within guidelines taught consistently Communicates, listens, presents self and one’s ideas in
Demonstrates understanding of ‘‘H’’ factors an effective manner
Cuts without transection Is respectful of others needs and acknowledges supervi-
Cleanliness sor’s position
Follows OSHA regulations Presents a professional manner and proper dress in office
Utilizes equipment properly at all times
Demonstrates understanding of sorting for density Contributes to team morale and maintains enthusiastic
O.R. ETIQUETTE: attitude
Is aware of patient’s medical and emotional condition PROBLEM-SOLVING:
at all times Clearly identifies problems and their causes, plans for
Restricts personal conversation with other nurses and airs potential solutions
Acts in a professional manner while in the office Contributes to problem-solving discussion actively
Respectful of solutions that may not work as alternatives
SCRUB NURSES and PLANTERS: to try
Follows established guidelines in presenting problems
OPERATING ROOMS
TEAM WORK:
OR SET UP:
Works effectively with others to maximize group goals
Completeness
Demonstrates ability to see all areas of the office as
Cleanliness
equally significant
Follows procedure guidelines
SCRUBBING: Restricts negative input among peers
Anticipates the doctor’s needs JOB KNOWLEDGE:
Able to organize and prioritize duties Demonstrates strong understanding and practical skill
Makes an accurate count of recipient sites base
Controls bleeding Shows interest in learning new concepts and trying new
Assumes responsibility of OR function ideas
Meets level of learning Demonstrates an acceptance of stated overall office phi-
Follows procedure guidelines losophy
Is OSHA compliant Pursues expertise in knowledge base aggressively
PLANTING: ATTENDANCE:
Confirms plan for surgery with doctor Consistently arrives on time
Is aware of density issues and sorts accordingly Has perfect attendance
Uses equipment for detailed work and placement Schedules personal appointments around the surgical
Places grafts within guidelines taught schedule
Uses gauzes for pressure and keeps area clean Requests vacation according to office policy
Demonstrates understanding of H factors Follows guidelines for calling in sick
856 Chapter 22
ADDENDUM 2 Quality Assurance Profile

Area of inspection Explanation Above avg (1) Exp (2) Below avg(3)
SCRUBBING
Hemostasis Maintains a bloodless field
Incision is free for suturing (hair/gauzes)
Sterile field Instruments not caught in suture
Changes gloves when appropriate
Incision maintained by scrub
Preparation O.R. is set up correctly
Monitor set up correctly
Recipient area adequately infiltrated
Doctor’s needs are anticipated
Patient’s needs are taken care of: meds
Transition from harvest to sites timely
Counting is accurate
Turn over Instrumentation handled timely
Stat sheets filled out on a timely basis
Other Maintains a professional atmosphere
Comments:
Planting Preparation Ice, instruments, gauzes, saline ready
Patient appropriately cleaned and ready
Hemostasis Recipient field cleaned; gauzes used
Recipient field Grafts in correct placement: 1,2,3,4
Angle and direction noted
Graft integrity Handling appropriate
Grafts placed within 3-minute time limit
Grafts moist on fingers
Grafts flush with epidermis
Grafts inspected for correct size/shape
Grafts at correct temperature
Other Demonstrates ability to work with others
Comments:
CUTTERS
Graft integrity Units in bubble and moist; ice used
Station left appropriately: grafts/gloves
Size and shape Units are conical with epidermis wedged
Columns total Columns total less than 60
Counts correct Counts on stick are correct
Dishes have correct units: 1,2,3
Transection rate Trash checked
Minimal or no transection
Comments:
SLIVERS
Strip integrity Strip kept moist during cutting
Blade changes Blades changed appropriately
Sliver width Consistently 1 mm wide/1 cm long
Transection rate Zero: slivers checked for transection
Speed Slivers/minute
Comments
PATIENT CARE
Manner Courteous, friendly, professional
Teaching detail All parameters met
Understanding clarified
Patient prepared correctly
Task detail Procedure followed
Patient completed
Discussion restricted to patient interests
Comments
PATIENT TEACHING
Manner Courteous, friendly, professional
Teaching detail Understanding clarified
Examples used for clarification
Written literature given
Comments:
22E. The Phototrichogram: An tered over this micro-tattoo dot (7,8). Two photographs were
taken at an interval of three days. The initial photograph (day
Objective Macro-Photographic 0) was taken on a scalp that had not been washed or brushed
Evaluation Method for three days, with hairs cut at their emergence (Fig. 22E-3).
The second photograph (day 3) was taken after the scalp had
Pierre Bouhanna
been washed and brushed. Both slides are then projected on a
calibrated screen to make the hair count easier (Fig. 22E-4).
In 1970, Saitoh first described a photographic method for the Today, we have further modified our method of taking the
evaluation of different body and scalp hair parameters. He com- phototrichogram by using a Polaroid Macro 5 SLR camera with
pared two photographs of a 2 cm2 area with a 1 week interval a grid film inside it (9) (Fig. 22E-5). When the aperture of
between them (1,2). In 1979, Fiquet and Courtois modified this this camera is placed against the scalp, it produces a macro-
method by restricting the area to 0.25 cm to 0.50 cm2 of the photograph of the scalp with a superimposed calibrated grid
scalp, and narrowing the interval between the two photographs that can be used for counting hairs (Fig. 22E-6).
from 3 to 5 days (3,4).
In 1982, we proposed the use of the phototrichogram to coin
a standardized macro-photographic method for the evaluation USES OF THE PHOTOTRICHOGRAM
of scalp hair based on the works of the preceding authors (5,6). By using the phototrichogram we can determine the number of
In the original technique, an area of 0.5 cm2 was determined hairs present in anagen phase (grown and thick hairs) and in
by the intersection of two plastic bands across the scalp from telogen phase (hairs that have not grown over the three day
four fixed points of the face: the upper incisors and tip of nose interval or have been removed by shampooing and brushing on
vertically and the external auditory meatus transversally. These the third day).
bands contained 2 cm2 clear apertures. The intersection area Therefore, the percentage of telogen hairs can be obtained
was marked with India ink and then divided into four squares by comparing the different hair counts between the two photo-
of 0.5 cm2 (Fig. 22E-1). graphs, as follows:
In 1986, we began demarcating the area to be studied by
using an aluminum frame screwed to the objective lens of a ● T ⳱ total number of hairs on photo no.1
camera, divided by 8 nylon threads into 0.25 cm2 squares and ● A ⳱ number of anagen hairs ⳱ hairs that continued to
placed directly on the scalp (Fig. 22E-2a and Fig. 22E-2b). At grow on photo no.2
that time we used a 24⳯36 Olympus OM2 camera with an ● Tel ⳱ number of telogen hairs ⳱ T–A / t ⳯ 100
OTF aperture, a 50 mm Zuko Olympus macro lens with a teles- ● %Tel ⳱ T–A/T ⳯ 100
copic 65 to 116 mm tube, a lateral Olympus T32 flash, and an The phototrichogram can be useful in evaluating additional hair
Ektachrome 100 ASA film (see Fig. 22E-2b). For reproducibil- parameters including:
ity, the area studied was marked with a micro-tattoo dot and
the central 0.25 cm2 square in the middle of the grid was cen- ● Hair density: We found an average hair density of 200
to 400 hairs/cm2
● Hair growth rate: We found an average growth rate of
1 mm in 3 days
● Average number of hairs per follicular unit (See Chapter
10)
● The number and length of hair growth cycles can be
evaluated by repeating the procedure every 3 months in
the same area
● Changes in hair diameter
Moreover, this hair analysis method constitutes a valuable tool:
● To follow-up the androgenetic alopecia evolution in both
donor and recipient areas, especially in the superior and
inferior borders of the crown
● To assess the efficacy of different medical treatments
for androgenetic alopecia, such as minoxidil (Rogaine),
finasteride, vitamins, etc.
● To study the effect of various parameters in hair restora-
tion surgery, such as graft size selection, angling, sutur-
ing method, etc. We have used the phototrichogram to
assess whether certain surgical techniques produce better
hair density than others. In addition, single sutures or
staples were found to minimize injury to hair bulbs.
● To study the effect of pustules, crusts and seborrheic
dermatitis on viability and growth of hair grafts
● The phototrichogram can confirm contraindications to
Figure 22E-1 Our original method of locating the area of study surgery such as alopecia areata, trichotillomania, and
by using two intersecting plastic strips with a 2 cm2 plastic aperture. evolving cicatricial alopecia (10).
858 Chapter 22
a b
Figure 22E-2 a) Grid (with 8 nylon threads) attached to the lens of the camera and placed against the scalp. b) Reflex camera, macro-
lens, telescopic tube, and grid attached.
POTENTIAL PROBLEMS WITH THE ● It may be difficult to distinguish fine anagen hairs from
PHOTOTRICHOGRAM telogen hairs which did not grow on day three photo-
graph
The use of Macro 5 SLR Polaroid camera with a grid film ● It may be difficult to distinguish two hairs that cling
allows an instant count of hair, as well as the evaluation of together, especially if one is finer than the other.
the various hair parameters (hair density and growth rate) and
efficacy of medical treatments (topical solutions and oral drugs)
and surgical treatments. However, the potential for errors exists COMPARISON OF PHOTOTRICHOGRAM
with this technique and include: WITH OTHER PHOTOGRAPHIC TECHNIQUES
● Anagen hairs can sometimes be very thin and are, there- ● The photographic evaluation method, originally devel-
fore, sometimes hard to distinguish from vellus hairs. oped by Saitoh (1),used a somewhat complicated mate-
Figure 22E-3 First photograph (day 0) of the scalp, unwashed Figure 22E-4 Second photograph of the scalp taken on day
and unbrushed for 3 days. three, after the scalp had been washed and brushed.
prone to error due to the length of anagen hairs that

had grown and masked the finer and shorter hairs. His
technique also used a 2 cm2 area which was less practical
than an area of 0.25 cm2.
● The rigid frame with a superimposed graduated-glass
window, used by Friedel and Will, had the potential to
produce biased readings. This is because of the gradua-
tions on glass that may mask hairs present at the periph-
ery of the study area. Besides, flattening of hair by the
glass slide increases the masking effect of finer hairs
and significantly decreases the three-dimensional aspect
of the skin which enhances hair count. It was for this
reason that we first developed our frame equipped with
nylon threads.
● The traction-phototrichogram, for the evaluation of an-
drogenetic alopecia and hair loss intensity in a single
session, lacks sensitivity. With this method, the second
photograph is taken after a pull test is done to pull out
telogen hairs. Traction force exerted to pull out hairs
differs from one operator to another and is not reproduci-
ble. Besides, this method doesn’t allow growth rate mea-
surement and the number of telogen hairs are underesti-
mated. (4)
● The video-trichogram developed by Hayashi, Miya-
moto, and Takeda (11) needs to be validated because it
Figure 22E-5 Polaroid Macro 5 SLR camera with a grid film is still under study. This method has been tested only
inside it. on Asians, in whom there is better contrast existing be-
tween hair and scalp. The lower hair density revealed
by this procedure might be due to ethnic variation. The
use of high magnification drastically reduces the field
of study and the number of analyzed hairs with an in-
rial. Photo development was done on paper and enlarge- crease in risk error.
ment was limited. The method of locating the area of ● Unit area-trichogram, defined by Rushton (12) is an in-
study was rather difficult to perform and not accurate. vitro analysis method that does not evaluate growth rate.
Moreover, hair counts on the second photograph were It also may cause disagreement with the patient due to
taken after one week. Hair counts after 3 days were more epilation of hair that is avoided by phototrichogram.
CONCLUSION
The use of phototrichograms is a simple, painless technique
that is well accepted by patients who seek either an evaluation
of their alopecia or wish to undergo hair restoration surgery. It
is a noninvasive, sensitive, and reproducible method of evaluat-
ing the evolution of androgenetic alopecia and the efficacy of
medical or surgical treatment. Furthermore, it provides an ob-
jective way of evaluating other disorders of hair loss and various
hair parameters such as growth rate, hair density, quality and
cyclic changes of one or several groups of hairs located on
grafts or flaps.
Acknowledgment
Thanks to Dr. Danny Bakhos for his contribution to this chapter.
Editor’s Comment
Jae-Hak Yoo et al, of the Department of Dermatology at Sung-
kyunkwan University, Seoul, Korea, described their method of
Figure 22E-6 Macro-photograph taken with a Polaroid Macro tabulating numbers of hairs, hair calibers, and hair growth rates
5 SLR of a marked area of the scalp. Grid present on film allows in a poster exhibit at the annual meeting of the American Acad-
a faster and easier count of emerging hairs. emy of Dermatology, 2002. They used digital images at a fixed
860 Chapter 22
distance and focus, produced with a color CCD camera (Sony ● Resolution: Defined in pixels (picture element: the
4200 SCH color camera DSP). This was connected to a Sony smallest element composing an image), it represents the
3CCD digital camcorder. A site on the scalp was tattooed and total number of pixels of an image and is a measure of
this small tattoo was then used as a center point for the study the visual information in an image. Resolution has a
areas, which in their patients were located in occipital, vertex, direct relationship to image quality. It can be represented
and temporal areas. The hair in the study sites was shaved, by the total number (1.92 million pixels), by height and
and a photograph was taken. Forty-eight hours later, a second width (1600 ⳯ 1200 pixels), or by pixels per inch (PPI)
photograph was taken. Measurements of hair characteristics when height and width are known (96 PPI, 16.7⬙ ⳯ 12⬙).
were carried out by comparing these two photos with a Pho- These all represent the same resolution.
toshop and image analyzer program (Sigma-Scan Pro). Low ● Compression: A technique to reduce file size by elimi-
magnification was sufficient to count the number of hairs and nating redundant information in the photograph. Lossy
the total number of anagen and telogen hairs. (The latter did compression results in original information from the
not grow, while the former did). A higher magnification allowed image being discarded at the expense of reduced file
for tabulation of linear growth rates as mm per day and shaft size. Lossless compression reduces file size, but retains
diameters. (See Chapter 23B.) (WU) all original image information.
● Bit: The most basic unit of digital data. 8 Bits ⳱ 1
Byte, and 1024 Bytes ⳱ 1 Kilobyte (KB) 1024 KB ⳱
1 Megabyte (MB). A digital picture is a digital file, rep-
22F. Standardized Photography resented by an amount of data or space it occupies, and
is usually displayed in KB or MB.
Barry E. DiBernardo and Gregory M. Galdino ● File Formats: Digital pictures are generally saved in one
of two formats, JPG and TIF. The file name ends with
INTRODUCTION the extension jpg or tif. Jpg (jpeg): (Joint Photographers
Expert Group) is a standard graphic format, it is a lossy
Since the last edition, the use of digital photography in photo- compression format interchangeable on both the Mac
documentation has become commonplace. Digital photography and PC platforms. It is often represented by the quality
introduces new terminology and variables to consider for stand- setting (super, fine, normal, or low) on the digital cam-
ardization. Standardization of photography and comprehensive era. While compression is used in various ratios, it is
documentation is absolutely critical in hair restorative surgery, undetectable to the eye when compared with the original
permitting objective evaluation of surgical results before, dur- image at most settings. Tif (tiff) (Tagged Image File
ing, and after surgery. Reproducibility is essential. Standardized Format) is a standard graphic format that contains all
positioning of the patient is necessary to objectively demon- original information from the photograph in the file, but
strate results between different techniques or with a single pro- often is very large in file size, making its use inefficient.
cedure over time, especially when used in publications, presen-
tations, or for patient education. Controlling for the variables,
such as camera position, lens focal length, lighting, back- Differences Between 35-mm and Digital
grounds, and patient position permits standardized, reproduci- Photography
ble, high quality, and objective photographs. Variables directly The first basic rule in standardized, quality photography, is to
related to digital photography, such as resolution, compression, adhere to basic photographic principles, such as adequate light-
color temperature, viewfinder error, focal length ratio, and ing, standard patient positioning, and the use of anatomic
image processing also must be controlled to allow standardiza- boundaries for standard views. There are, however, inherent
tion. differences between 35 mm and digital photography that must
be recognized to effectively usee digital photography in one’s
practice.
DIGITAL PHOTOGRAPHY Digital cameras are more akin to scanners or video cameras
than conventional cameras because they all employ a CCD* as
Terminology the light sensitive sensor rather than film. Instead of storing the
Digital photography has introduced a new set of terms and acro- image on film, the CCD transfers the images to a filmcard
nyms to photography. It is essential to understand some of the (removable storage media, of different general types: Compact
basic terms and functions of digital photography to use it effec- Flash, Smart Media, PC Card, Memory Stick). One of the ad-
tively in one’s practice. vantages of digital photography is the ability to immediately
review the picture, via a Liquid Crystal Display (LCD) on the
● CCD: (Charged Coupled Device) the light sensitive mi- back of the camera. Images can be deleted or saved immediately
crochip that captures the image; it replaces film in the after viewing. The images can then be transferred to a laptop
digital camera. It is the sensor used most frequently in or desktop computer via a direct connection (Serial, Universal
digital cameras. Serial Bus, or FireWire), Card Reader (desktop) or PCMCIA
● CMOS: (Complementary Metal Oxide Superconductor) card slot (laptop) and viewed on the monitor.
Also a light sensitive microchip, it is cheaper to produce
and integrates better with electronic architecture.
Marked advances in this technology may contribute to *
CCD is used to represent either CCD or CMOS; however, either could
more frequent use and less expensive cameras. be used interchangeably.
Because digital cameras are filmless, they do not have stan- pus, Fuji) now have a professional ‘‘35-mm like’’ digital SLR
dard ISO ratings for film speed. Instead, they use ISO equiva- with the same features as the standard 35-mm SLRs. Our digital
lenciesthat represent the sensitivity of the CCD to light, which set-up uses the Nikon D1X model, which permits interchangea-
can be adjusted to compensate for lower light conditions. Higher ble lenses using our standard 35-mm lenses.*
ISO settings, however, may frequently introduce noise into the
image, reducing its quality; therefore, the lowest ISO setting is
recommended. LENSES
Resolution and compression settings are adjustable, and Lenses are one of the most important factors contributing to
should be selected based on the amount of storage available photograph quality. For hair photography, medium telephoto
and based on the intended use of the image. We advocate using (90 mm-105 mm) lenses are recommended. There are several
the highest resolution available and a compression setting of advantages to using this focal length. First of all, they represent
normal or standard giving a file size typically less than 1 MB, some of the sharpest lenses available. They produce a flat field
depending on the total resolution of the camera. that depicts the most accurate representation of the subjects
Becaue digital cameras are not balanced for specific color face, avoiding the proportional widening distortion observed
temperatures or light (such as the red-orange cast of incandes- with wide angle lenses (⬍40 mm). Macro lenses have the ability
cent light), they record all color casts from different types of to focus close up without additional accessories such as close-
lighting sources. However, most cameras contain a setting for up filters, and are especially important in close-up views of the
white balance (defining the color white in any light condition) hairline. For 35-mm photography, we use the Nikon 105-mm
and several preset settings, intended to eliminate color casts Micro 2.8 Nikkor lens (Nikon Inc, Melville, NY).
from specific light sources. Most photo room settings contain In digital photography, understanding lenses is imperative to
multiple light sources (i.e., flash, incandescent, or fluorescent). standardized photography. Most prosumer cameras have fixed
The auto white balance setting should be used unless the source lenses without reproduction ratios. Therefore, the telephoto and
of light is pure. Another way to correct for color casts is to use wide-angle adjustments are not easily reproducible. In those
a gray card and software to correct any color casts in the image. cameras, photographing on full telephoto allows some repro-
If the light conditions remain constant (as in a photo room), ducibility if coupled with anatomic framing of the patient using
this calibration has to be performed only once. either the grid system mentioned earlier or the borders of the
Digital cameras process the image inside the camera, which viewfinder. Most of the newer professional model digital SLRs
may differ from camera to camera, and especially manufacturer have interchangeable lenses with standard 35-mm lenses. How-
to manufacturer. Therefore to maintain consistency in digital ever, the focal length in digital cameras is not the same as 35-
photography, presurgical and postsurgical images should be mm film because the dimensions of the CCD are typically much
recorded with the same camera. Switching digital cameras is smaller than 35-mm film (Fig. 22F-1). Therefore, focal lengths
akin to switching film types, producing variable results in color reported in digital cameras are often also given in 35-mm equi-
and contrast. valencies for the prosumer models. For standard attachable
Both 35 mm and digital cameras can be single lens reflex lenses (i.e., Nikkor), the lens often has a conversion factor based
(SLR) units. Digital cameras that are not SLR, typically produce on the size of the CCD to give the 35-mm focal length equiva-
errors, known as parallax error, when using the viewfinder at lence. For the Nikon D1, the conversion factor is 1.5⳯. There-
close distances to the subject, such as at grafting sites or hair- fore, a 60mm lens behaves like a 90mm lens on a 35-mm cam-
lines. In these cases the LCD should be used to frame the picture era. This 60mm lens falls in the range of recommended focal
instead of the viewfinder. This error diminishes at greater dis- lengths for hair photography. Be sure to perform the conversion
tances from the subject. before using existing interchangeable lenses.
Macro-lenses usually have two adjustable rings, one that
controls the camera aperture and one that controls the manual
CAMERA focus. The aperture regulates the amount of light that reaches
the film and is represented by f-stops. The higher f-stop numbers
The 35-mm, SLR camera is still the gold standard for conven- represent smaller apertures, and thus a greater depth of field.
tional photography. A manufacturer with a reputation for excel- Greater depth of field results in more of the subject being in
lent quality, such as Nikon, Canon, Minolta, or Olympus, is focus from front to rear. We recommend shooting at the highest
recommended. Our set-up uses Nikon equipment (Nikon USA, f-stop possible for proper exposure. In digital cameras, the aper-
Inc., Melville, NY). Regardless of the manufacturer, it is highly ture is controlled electronically, and the lenses are physically
recommended that the camera body accepts a grid screen in its adjusted to the smallest aperture. The electronic aperture is often
viewfinder to assist with patient positioning using anatomic adjustable, especially in the digital SLRs, in different modes
framing. A grid screen is a specialized viewfinder with horizon- such as aperture priority or are set automatically by the camera
tal and vertical lines etched into the screen. It allows anatomical for proper exposure.
framing of the patient within the viewfinder and facilitates con- The focusing ring typically has three sets of numbers includ-
sistency and reproducibility. Cameras without a grid screen may ing camera-to-subject distance in feet and meters, and reproduc-
be less accurate. tion ratios. Table 22F-1 lists recommended distances and set-
Digital cameras come in many forms. However, those suita- tings, based on inches, using a 100 mm macro lens and a 35-
ble for medical photography are the Digital SLRs. The afford-
able prosumer SLRs (Sony and Olympus) produce high quality
images, but are less amenable to controlling variables for stand- *
Focal lengths of lenses may change depending on the size of the CCD
ardization. Most 35-mm manufacturers (Nikon, Canon, Olym- when used on a digital camera.
862 Chapter 22
focus (often indicated by a circle on the LED camera display).

Using this method assures consistency of the subject from frame
to frame, but may be more time consuming than using autofo-
cus. If positioning of the subject is done first and focusing sec-
ond, the subject size (patient’s head) may vary from photograph
to photograph. Another method for assuring consistency is ana-
tomic framing of the subject, for example framing the entire
circumference of the head, leaving a small amount of back-
ground above the top of the head to the sternal notch or anterior
clavicular heads. This method may be helpful when using digital
photography because the images can often be adjusted (correct-
ing zoom between two photographs) using software afterward
to assure consistency. We recommend, however, using repro-
duction ratios, whenever possible, for 35-mm photography and
standard camera-to-subject distances in digital photography to
ensure the highest consistency and reproducibility.
Digital camera manufacturers often represent the degree of
zoom capability of the lens in terms of a multiplication number
(e.g. ⳯ 10), especially with prosumer cameras. This number
may represent a combination of optical and digital zoom, and
it is important to identify the distinction between each. Zoom
capability should only be measured in optical zoom (using lens
magnification only) because this produces a true magnification
Figure 22F-1 Illustration of digital clinical photography room without loss of information (it uses the whole CCD for image
set-up. capture). Digital zoom allocates a small portion of the CCD to
capture the picture and then enlarges it to full frame by adding
in information (pixels) using a process known as interpolation,
ultimately resulting in a lower quality image.
mm camera, and correlated with the standard patient views pre-
sented in Figs. 22F-4 to 22F-11). For standard 35mm lenses LIGHTING
used on digital cameras, given the CCD size discrepancy with
35-mm film, the reproduction ratios will not be correct as indi- Lighting principles are the same using conventional or digital
cated on the lens. However, because the CCD is located at the photography. To avoid distracting shadows and to provide the
same plane as film in most digital SLRs, the distance-to-subject best lighting, a studio flash set-up is highly recommended. Sev-
scale is accurate. eral manufacturers produce flash units suited for a studio set-
To use reproduction ratios for standardization, move the up in a photo room that can be ceiling or wall mounted or
focus ring to the desired ratio indicated on the lens, then adjust selfstanding. One recommended brand is the Briteck, Model
the distance from the patient to bring the subject into sharp HS 1000 (Santa Fe Springs, CA) for the main lights and the
Table 22F–1 Camera Adjustments and Orientation for Photographic Sessions
Camera Reproduction
View orientation Lens Distance (in.) ratio Focal point Hair style
1a Vertical 105 mm 51 1 : 10 Nearest eye Patient’s usual style

1b Vertical 105 mm 51 1 : 10 Nearest eye Combed back if
different from 1A
2 Vertical 105 mm 51 1 : 10 Nearest eye Patient’s usual style
6 Vertical 105 mm 51 1 : 10 Scalp vertex Patient’s usual style
7 Vertical 105 mm 51 1 : 10 Scalp vertex Patient’s usual style
8a Vertical 105 mm 51 1 : 10 Frontal hairline or Patient’s usual style
equivalent
8b Vertical 105 mm 51 1 : 10 Frontal hairline or Hair combed forward
equivalent if different from 8a
9 Horizontal 105 macro 24 1:4 Frontolateral hairlinea Hair combed back to
see hairline
Briteck Model AS32 for the background lights. These lights tively (without a control box), one flash is connected to the PC
typically provide significant power at a modest price. Other outlet, and the other flashes are set to slave mode, which trigger
fine units are made by Elinchrome, Sunpak, Novatron, and the flash via electronic photo eye in response to the flash light
Dynelight. Recommended features on the lights include model- from the main flash. Wireless control is also possible using
ing lights, self-contained power units, and slave functionality, radio or infrared control. Many prosumer digital cameras do
which trip automatically to the main flash output, eliminating not have PC outlets, but do contain a hot shoe plate. A PC
the need for multiple cords. In addition, the power output of outlet adapter can be used with the PC cord to trigger the flash.
all flashes should be adjustable. Lights are available from most However, the flash mode setting often needs to be adjusted to
professional camera and photographic equipment stores. external flash mode to allow studio flash operation.
The set-up of the studio flashes is illustrated in Fig. 22F-2. Single flash units on the camera or attached to the hot shoe-
The typical set-up consists of two main lights, positioned at an plate often permit, through the lens (TTL), metering in conven-
angle of 45⬚ from the patient’s face. Lights should be even tional 35-mm cameras. TTL metering automatically adjusts the
with the patient’s head or angled slightly downward in terms flash output and camera settings for proper exposure. However,
of elevation from the floor. Flash-to-subject distance may vary when multiple flashes or studio flashes are used, TTL is not
based on the photo room size and flash output size, however, possible, and exposure must be determined using a handheld
4feet to 5 feet is optimal. This distance allows sufficient lighting light meter, or through trial and error. If lighting conditions
to permit smaller apertures, maximizing depth of field. A back- remain constant (film speed (ISO), flash power, and lens), set-
ground or hair light is highly recommended in hair photogra- tings only need to be determined once, and therefore may be
phybecause shadows cast by the two main lights around the rented or borrowed instead of purchased. The light meter is
hairline can give the false appearance of additional hair on the connected to the studio flash via the PC cord, then tripped using
final photograph. Two low-power flash units can effectively a button on the light meter. The light falling on the patient’s
eliminate evenly all shadows when positioned at 3 feet from the face is recorded and the correct exposure settings are indicated
background and angled 45⬚ toward the center of the backdrop. (f-stop for particular speed and ISO selected). Digital camera
Alternatively a single background flash can be centered behind settings may vary, depending on the make and manufacturer of
the patient and directed up from below or down from above. the camera. Most prosumer models only allow limited exposure
A twin flash or ring flash attached to the lens and hot shoe control (e.g., Maximum f-stop f11, or preset aperture for focal
often provide excellent lighting for macro-photography. length used). In addition, some professional models such as the
When using a studio flash set-up, the control box (which Nikon D1X behave differently using a light meter in studio
connects all the flash units) is connected to the PC outlet on flash conditions than expected. Therefore, in our experience,
most 35-mm and professional digital SLR cameras. Alterna- trial and error is the best method to determine proper exposure.
Because review is immediate and this is usually a one time
task, it can be accomplished quickly.
Diffusers (umbrellas or soft boxes) are often desirable to
reduce the harsh light of the strobe flashes and reduce the glare
on oily skin.
BACKGROUND
The choice of a background color can have a dramatic impact
on the result of photographs, whether shooting black and white
or color, digital or conventional 35-mm photography. Most
medical photographers recommend sky blue for the background
color because it complements skin tones in color photography
and appears as a neutral gray in black and white photography.
Darker colored backgrounds, especially black, can obscure the
hairline. Because most hair is darker in color, use of darker
backgrounds is highly discouraged in hair photography. In addi-
tion, we have observed that light backgrounds (white) and dark
backgrounds (black or dark gray) can have an effect on exposure
when using a digital camera, even using automatic exposure
settings. Sky blue or 18 % gray have the least effect on image
exposure.
The choice of the background material should be nonreflec-
tive in nature and may include fabric stretched over a frame,
standard background paper (available in 4 foot or 8 foot rolls
at better photography stores), or flat paint (if space is limited).
Mounting hardware for rolls is available and recommended.
ACCESSORIES
Figure 22F-2 CCD (From 1.5 megapixel camera) shown with There are accessories available to help ensure good quality pho-
standard 35-mmslide. Note large size discrepancy. tography. Tripods are recommended to ensure reproducibility,
864 Chapter 22
especially when using modeling lights or room lights as the to provide instant photodocumentation for the patient’s chart.
sole source of lightbecause the recommended exposure in those The monitor should be at an easily viewable location if import-
light conditions may fall below 1/60 second, introducing the ing the photos directly to the computer, so that poor quality
element of camera shake. If using reproduction ratios, it is often photos can be identified and retaken. We recommend allocating
necessary to adjust the camera forward or backward. A dolly 8feet ⳯ 12 feet. for an optimally functioning photo room,
with wheels allows this adjustment smoothly and easily. Dollies whether conventional or digital.
are available in most video camera stores.
To assist with patient head positioning and eye positioning,
it is often helpful to place specific markers around the photo FILM
room for patients to focus on at certain standard positions, espe-
The choice of film, for conventional photography, is very de-
cially the profile position, and at the oblique position. In addi-
pendent on the experience and preference of the practice or
tion, it often helps to make a conscious effort to instruct the
individual. There are many options: Black and white slide or
patient to make slight adjustments in their head or eye position
print film, or color slide or print film. The most widely used
to assure standardization. In those views in which the camera
medium, however, is color slide film. There are several different
looks down on the subject, a light blue operating sheet with a
types available from multiple manufacturers, and even several
central hole removed for the patient’s head is helpful to elimi-
types made by the same manufacturer. The most widely used
nate distracting objects (clothing, ties, jewelry, etc.) often pres-
film today is the Kodak Ektachrome line. It has the advantage
ent in this view and produces a cleaner-looking photograph.
of using the E6 developing process, which is available at almost
If using conventional photography, all photographic rooms
all photographic processing stores. We recommend film speeds
should have a log book available that logs each patient by name,
of ISO 100because it is a fine grain based film. Elite Chrome
date, roll of film, exposure number, and descriptive information
(Eastman Kodak, Rochester, NY) 100 uses the E6 process, is
on preoperative or postoperative status. This helps to ensure
widely available, and represents skin tone well. Kodachrome
proper labeling of slides or prints. If using digital photography
(Eastman Kodak, Rochester, NY) is still recognized as the gold
and importing the images into the computer at a location re-
standard in slide film, due to its accurate skin tone rendition,
moved from the photo room, it is helpful to keep track of images
fine grain, and archival nature (the only true archival slide film).
using a list or by photographing the patient information before
However, the special developing process required for Kodach-
each session. This information can then be entered into archiv-
rome is available only at a limited number of photographic
ing software when the images are imported into the computer.
laboratories across the country, and has largely been abandoned
Alternatively, if space is available, a computer serving as the
for the more easily accessible E6 films.
photo server may be placed in the photo room and images are
The choice of print film, black and white or color, is less
entered directly at the time of shooting (using a direct connec-
critical because color can be altered in the printing process.
tion to the computer) or after the session is through via the
There are a wide number of choices available; however, we do
removable film card and a card reader. This practice of entering
recommend using ISO 100 film speeds.
images immediately saves the chore of entering a large number
Digital photography has the advantage of being filmless,
of images at a later time and is recommended.
without the cost of recurrent film rolls and processing. Storage
In addition, all photo rooms should have an ample supply
cards (removable film cards) come in four general categories,
of photographic consent forms to be signed before photograph-
as mentioned above. Certain digital camera manufacturers may
ing the patient. Signing of these forms should be mandatory,
use only one type of film card; some cameras accept two, typi-
and indicate that the physician has permission to use the photo-
cally Compact Flash and Smart Media. The cards are available
graphs only for office charts, scientific publications, or presen-
in different sizes, indicated by the amount of available memory
tations. If the patient objects to such use, they may indicate this
or capacity (in megabytes, MB) that the card can hold, and
on the consent form.
depending on the type of film card it is. The image-capture
Combs are essential to aid in draping the hair, as shown in
settings, resolution and compression, determine how many im-
views 1B, 8B and as required. A height-adjustable swivel chair
ages can fit on a card. Because most images for hair photogra-
is necessary to position the patient easily in all standard views.
phy are about 1MB using the settings mentioned earlier, we
recommend at least a 48MB or 64 MB card. It is also helpful
to have a back-up card. Larger capacity cards (some newer
PHOTOGRAPHY ROOM SET-UP forms of storage such as micro hard drives are available with
a capacity up to one gigabyte (GB) may avoid frequent dow-
A sample photo room set-up is illustrated in Figure 22F-2, using
nloading to the computer. We discourage this and recommend
the aforementioned equipment, with items specific to digital
frequent downloading. Otherwise, when this task is postponed,
photography indicated. The sitting stool should be placed at
it can become unnecessarily time-consuming and can cause
least 3 feet from the backdrop to allow the background lights
confusion with patient images, unless proper documentation has
to eliminate the shadows. The tripod or monopod is located
been recorded (which is more difficult using digital film be-
directly in front of the patient, on a dolly (wheels) for adjustabil-
cause the images can be erased and added in any order).
ity. The main lights are situated at 45⬚ angles from the subject,
with the background lights located 3 feet from the backdrop
oriented at 45⬚ degrees toward the background. STANDARDIZED VIEWS
For digital photography, a mobile computer cart supporting
the monitor, the computer, the keyboard, and the mouse is very The use of standardized views in clinical photography is abso-
helpful in saving space. In addition, a color printer can be added lutely essential to achieve consistency in clinical photography,
especially with the same patient in preoperative- and postopera- The eyes should be looking straight ahead in all views, and
tive photographs. It is even more important in hair photography focused on the numerical markers on the walls as the patient
because multiple sessions are often required, and comparable swivels to all positions. The chair height should be adjusted
photographs can depict the changes after each session. It is accordingly to assure level view. A fenestrated sheet, preferably
important to have the patient sign a photo release form (Fig. the same color as the background, is helpful to eliminate dis-
22F-3). Table 22F-2 indicates a list of standardized views and tracting shirts, ties, and jewelry.
their descriptions. Figures 22F-4 to 22F-11 illustrate examples The final close-up of the hairline has the patient turned in
of the most important standardized views. Note that view 1a the oblique position, such that the hairline is horizontal in the
(frontal) and view 8a (frontal tilt) may need to be taken two frame and facing the camera. The hairline should be centered
different ways, depending on the hair style of the patient. If the appropriately.
patient’s hair style hides his hairline, the frontal view should
be photographed in his natural style (view 1a) and then combed
back and photographed to reveal the hairline (view 1b). If the THE PHOTOGRAPHIC SESSION
patient naturally combs his hair back, view 1b is not necessary
The patient is brought into the photography room, and the name
(see Fig. 22F-4). Views 2 to 7 are taken only with the patient’s
and data are recorded in the photographic log book. The patient
existing hair style (see Fig. 22F-5 to Fig. 22F-8). View 8a photo-
is asked to sign the photographic release form (see Fig. 22F-
graphs the patient in the frontal tilt position with his normal
3). The lighting system and camera are turned on, and the cam-
hair style; View 8b photographs the patient in the frontal tilt
era and lens settings (Mode, Aperture, Shutter Speed, and ISO)
position with his hair combed forward (see Figs. 22F-9 and
are verified before each use. The camera should be oriented
22F-10). This view is necessary for patients who normally style
appropriately as in Table 22F-1. Views 1 through 8 are then
their hair toward the back. View 9 is a close-up view of the
taken. Combing is performed for views 1b or 8b, if necessary.
hairline (see Fig 22F-11). This view is particularly useful for
When shooting views 8 and 9 with the head titled forward, a
planning minigrafting and micrografting to create a natural hair-
blue fenestrated sheet can be used to eliminate the foreground.
line and following the progress with multiple sessions.
At completion of the session, the frame numbers used for this
Table 22F-3 indicates each view used in hair photography
patient are indicated in the photographic log book. System and
and the variable anatomical landmarks associated with each.
camera power are turned off.
Camera orientation is mostly vertical, except the close-up of
If using digital photography, make sure the camera is set to
the hairline, which is horizontal. The lens used throughout is
show the image on the LCD screen (or on the monitor if the
a medium telephoto macro-lens, or digital 35-mm equivalent.
camera is connected to the computer directly) to verify the qual-
The camera-to-subject distance is approximately 51 inches
ity of the photograph, then proceed with the remaining views.
(4.25 ft), and will vary on the particular lens being used. For
If the archiving software and computer are located in the photo
the 100 mm lens indicated, a reproduction ratio of 1:10 was
room, enter the patient information into the archiving software
used for all views except the close-up hairline view, in which
before or immediately after the photography session.
case a 1:4 ratio was used. Table 22F-1 also indicated the focal
point, the area of the face or head used to focus the camera.
Hair style is the patient’s normal hair style, except as noted. USES OF THE DIGITAL PHOTOGRAPH
Views 1b and 8b may be necessary depending on the hair style
to provide the maximal amount of information to the hair resto- Capturing a photograph in digital form avoids conversion from
rative surgeon. traditional formats to digital format through scanning. Digital
Anatomical landmarks listed in Table 22F-3 should be posi- images have the advantage of easy achievability in a database
tioned along the grid screen lines or aligned with the viewfinder and may be searchable from many criteria depending on the
edges in SLRs. The superior landmark denotes the uppermost software used. They are readily converted to other formats such
horizontal grid screen line; the inferior line indicates the lowest as printouts, 35-mm slide or print film (via a film recorder), or
horizontal line of the grid screen; and the left and right lateral transported on any one of a number of removable media (i.e.,
lines indicate the vertically oriented borders of the grid screen zip disks, floppy disks, CD-ROMS). They can be imported di-
lines. These lines act as guides for positioning the head and rectly into presentations using PowerPoint software, and most
scalp within the frame. publishers now accept digital images for manuscript submis-
sion. Because digital images are files, they can be attached to
email messages for communication with peers, patients, and
insurance companies.
One of the best advantages of digital photography is the
Table 22F–2 Standardizing Position of Patients for immediate access to images for use in patient consultation. Hav-
Photography ing access to an immediate picture affords the patient and the
hair restorative surgeon improved communication during the
View 1a: Frontal View 6: Posterior upright
consultation. The planned procedure can be shown visually and
View 1b: Hair combed back View 7: Posterior back-tilt
complications and risks can be outlined. Some software, such
View 2: Left oblique View 8a: Front tilt
as Mirror (Canfield Scientific Fairfield NJ) specializes in com-
View 3: Left lateral View 8b: Front tilt—hair
combed forward
puter simulation and has specific programs designed especially
View 4: Right oblique View 9: Close-up hairline for the hair restorative surgeon. Using the digital image, the
View 5: Right lateral FU/cm2 of the scalp can be determined and the specific grafts
illustrated (Fig. 22F-12). The surface area of the balding scalp
866 Chapter 22
Figure 22F-3 Photo release form.
Figure 22F-5 View 2, Left Oblique. (View 4, Right Oblique,

Figure 22F-4 View 1a, Frontal. not shown)
Figure 22F-6 View 3, Left Lateral. (View 5, Right Lateral, Figure 22F-8 View 7, Posterior Back-Tilt.
not shown)
Figure 22F-9 View 8a, Front Tilt.
Figure 22F-7 View 6, Posterior Upright.

868 Chapter 22
Figure 22F-11 Close-up of hairline.
that is to be transplanted can be measured with this software

(Fig. 22F-13a and 13b). In addition, anticipated hair loss with-
out corrective surgery can be demonstrated on the patient’s
Figure 22F-10 View 8b, Front Tilt, hair combed forward. current photograph to illustrate the natural progression of hair
loss. Likewise, the same image can illustrate the predicted ap-
pearance of the hair restorative procedure (Fig. 22F-14). The
software is also able to demonstrate how a scalp reduction might
Table 22F–3 Anatomical Landmarks Associated with Different Standardized Views
View Superior Inferior Left Right
1a Top of head Clavicles Patient’s right ear Patient’s left ear

1b As above As above As above As above
2 Top of head Clavicles Right frontal and malar N/A
Note: rotate patient such that nasion and
medial canthus align; eyes ahead
3 Top of head Clavicles Back of head Forehead; chin
Note: full lateral; align philtral columns;
eyes straight ahead
4 Top of head Clavicles N/A Left malar and brow
Note: see view 2 above
5 Top of head Clavicles Forehead and chin Back of head
Note: see view 3 above
6 Top of head Shoulders Left side of hair/head Right side of hair/head
7 Top of hair or forehead Shoulders Left side of hair/head Right side of hair/head
8a Vertex N/A Right side of head Left side of head
Note: (optional) fenestrated sheet same
color as background used to block
clothing
8b As above As above As above As above
9 Oblique view with frontolateral hairline
centered. Hairline should be oriented
horizontally across photograph
Figure 22F-12 Video macro of hair follicular density.
a b
Figure 22F-13 (a) Mirror Software analysis of digital photograph showing posterior scalp surface area to be grafted. (b) Mirror Software
analysis of digital photograph showing anterior scalp and hairline surface area to be grafted.
870 Chapter 22
Figure 22F-14 Mirror Software computer simulation showing before grafting and simulated postgrafting. (Canfield, Clonical Systems,
Fairfield, NJ)
appear and provide the necessary information for patients to 22G. Digital Photography and Office
make informed decisions on the correct hair restorative proce-
dure that is best for them.
Automation
E. Antonio Mangubat
SUMMARY
INTRODUCTION
Standardization is essential in clinical photography, for scien-
tific publications, presentation, or patient education. Reproduci- The digital revolution is exploding with wondrous technology
ble, consistent clinical photography requires standardized light- that has numerous applications in medicine. Melding computer
ing (preferably studio flash lighting), background lighting to technology with photography has created digital photography,
eliminate shadows, the grid screen for precise positioning a method of taking pictures without film, storing them without
within the frame, and a conscious effort to have the patient a paper photo album, and recalling any photo by name, date,
maintain proper head and eye position, and the use of reproduc- or procedure. For the surgeon with a limited photography col-
tion ratios to maintain constant size of the patient’s head within lection, the old film method will suffice, however, most of us
the frame of each photograph. In addition, when using digital have tens of thousands of photos and managing them has be-
photography, particular attention should be given to the type come a paper nightmare. The quality of digital photographs,
of viewfinder to avoid parallax errors (SLR is recommended); digital cameras, and high-powered personal computers has
to the resolution setting being kept at a maximum and the paved the way for doctors who require photographic documen-
compression (quality) setting adjusted to normal/standard; to tation to take advantage of digital photography. Best of all,
eliminating color casts from different light sources using the digital photography will only get better with time. By the time
auto-white balance setting, a gray card, and software correction this manuscript is printed, hardware and software will have
when there are multiple light sources, or to using the white advanced and there will be more products with more powerful
balance setting specific for the pure light source used (i.e., features.
flash); to setting the ISO at the default (lowest); and to avoiding In this chapter I will discuss the advantages and disadvan-
switching digital cameras between preoperative and postopera- tages of digital photography, the process of taking a digital
tive sessions. The photographic room set-up consists of four photo, the essential elements of a digital photography system,
studio flashes (two main lights and two backlights), tripod or and the costs of obtaining a digital photography system.
monopod, sky blue background, and swivel chair. A computer
and printer may be needed when using digital photography. A WHY DIGITAL PHOTOGRAPHS?
log book and consent forms should also be present in the photo
room. The standard 9 views of hair photography were illustrated Why should a surgeon who has a satisfactory photography sys-
and discussed. Digital images lend themselves easily to use in tem consider making the transition to digital photography? Let’s
computer simulation software to allow patients to visualize the examine the advantages and disadvantages of this technology
procedure, predict possible surgical results, and provide a com- in more depth. The quality of digital photos taken today is
municative tool during consultation. excellent. Although digital photographs have not matched the
resolution and quality of the best film cameras, they are cer- because, once the transition has been made, it will be the pri-
tainly more than adequate for most photographic documentation mary method of capturing images. Scanners are somewhat im-
today. Examples of the quality are seen every day (Fig. 22G- portant in digitizing existing slides and prints; however, the
1). prudent surgeon will only convert those images needed. Fur-
The dangers of missing the shot, losing the photos, or run- thermore, any photos that require digitizing should be taken to
ning out of film are virtually eliminated. With film, the typical the local photo/computer store where the task can be performed
surgeon must finish the roll, develop the film, sort the photos, in mass quantity for a nominal fee. It is not worth the investment
and file the photos. This is a process that usually takes days, in time and equipment to scan old photos that you may never
if not weeks, to complete and requires purchasing film, running use. It is more prudent to make the transition to a digital system
to the store for development, secretarial manpower to sort and without converting old photos. Over time, the digital system
file the photos in patients’ charts, and all along the way, the will become dominant and referring to old photos will become
danger of losing the photos through misfiling, inadequate film less and less frequent.
exposure, or a bad set of photo chemicals, is ever present.
Digital photography saves considerable money by eliminat- Storage
ing the recurring costs of film, development, and employee
Storage of digital images requires appropriate computer equip-
salaries required for filing. It also saves considerable filing
ment and database software in order to be reliable and effective.
space. Slides and prints add significantly to the thickness of
It is not adequate to simply capture an image. It must be stored
patients’ charts.
in an organized and retrievable system. Computer specifications
The cost of digital equipment has plummeted. The average
capable of running these systems change, however, converting
cosmetic surgeon will spend more money on film and develop-
to a digital photography practice is serious business. Purchasing
ment than on the purchase of a medium-priced digital camera.
a reliable system is critical to daily function and peace-of-mind.
I will discuss this in more detail later in the chapter.
In general, more is better: more memory, more speed, more
Digital photos offer much more flexibility. Reproducing
hard-drive storage, and more tape back-up capacity. Computers
them is as easy a copying a file. Sharing them with other practi-
have plummeted in price and hardware capable of running digi-
tioners is immediate by sending them via email across conti- tal photography systems can be purchased for less than $2000.
nents and around the world. Using them in newsletters, publica- Transferring the images from the digital camera to the com-
tions, and advertisements is simple and does not require the puter is analogous to developing film and filing the photos in
usual paste-up and color separation of prints and slides. Integrat- the patients’ charts. There are several different methods. The
ing the photos into a database makes recalling specific images two most common are: 1) a direct cable link between the camera
immediate, reliable, and cost efficient. and the computer and 2) via transfer media (taken out of the
camera and placed in a reading device) such as floppy disk, PC
Card, Smart Media, Compact Flash, Memory Stick, micro-hard
THE DIGITAL PROCESS drives and other newer technologies that are being developed
Capture regularly. The combinations and permutations are numerous,
but in the author’s opinion, the most practical are direct camera
Obtaining a digital image can be made via a digital camera, connection cable, Smart Media and Compact Flash. These
scanner (slides and prints), or a capture from a video. Most media are physically small, capable of holding several mega-
important to this discussion is the use of the digital camera bytes of data, inexpensive, reusable, and transfer rates between
camera and computer are fast. Floppy disk transfer rates by
contrast are 5 to 10 times slower and are limited in storage
capacity. Direct camera connection is a bit slower than media
transfer; however, it eliminates the need for a card reader and
media type considerations become irrelevant. These factors be-
come important when dealing with high-resolution images and
large file sizes.
Database software must be reliable and must have clinical
support. Most doctors are not computer scientists and getting
a system up and running typically requires a lot of hand-holding
to develop confidence. I am is familiar with three companies
who provide digital photography database systems. (They are
listed subsequently.) The most important factor is feeling com-
fortable and confident that your office can adapt to the system
implemented. Successful implementation will allow rapid cost
recovery for the system by decreasing film expenses and staff
time required to maintain the traditional film-based system.
DIGITAL IMAGING AND DATABASE

SOFTWARE COMPANIES
Figure 22G-1 Example of high quality macrophotograph taken The following companies provide software products and ser-
with a digital camera. vices:
872 Chapter 22
Canfield Clinical Systems have taken a photo indoors under incandescent lighting are
Mirror Digital Photography System (DPS) familiar with the greenish-yellow tint of the prints. The color
253 Passaic Avenue aberrancy has to do with the color balance of the film. Indoor
Fairfield, NJ 07004-2524 film is called tungsten balanced, whereas outdoor or flash
(800) 815-4330 photography uses daylight-balanced film. Digital cameras are
Email: info@CanfieldSci.com subject to the same lighting effects. White balance is a very
Website: www.canfieldscientific.com important feature if light other than flash (e.g., studio lights)
Retail price: $3500 is used. Fortunately, many cameras now include automatic
white balancing, eliminating the need to remember. Choose
Niamtu Imaging Systems a camera with a maximum resolution of at least 5 million
10230 Cherokee Road pixels. Although, most photos will not be taken at this high
Richmond, VA 23235 a resolution (if every picture you took was 2MB in size,
(804) 320-2256 your hard drive would be overloaded in a very short period
Email: niamtu@niamtu.com of time), at some point in time, you will need the capability.
Website: www.niamtu.com Most clinicians use flash photography. It is compact, repro-
Retail price: $1995
ducible, and reliable; however, flash tends to give high contrast
United Imaging, Inc. and shadowy results. For most clinical applications, the built-
AccuStor Photo Archiving in flash on most cameras will suffice.
4401 North Cherry Street, 噛30 There are so many digital cameras available; I feel that it is
Winston-Salem, NC 27105 necessary to sort out a few models that fit the above criteria
(800) 511-5416 (Figs. 22G-2a to 2f). This is certainly not an exhaustive list and
Email: info@uimaging.com I do not have personal experience with all the cameras listed,
Website: www.uimaging.com however, they do fit the above specifications and this is a good
Retail price: $7995 place to start a search. I have personally used the Sony DSC
F717 (see Fig. 22G-2c) for the past 2 years, taking well over
10,000 photos without a single failure. It has been reliable and
Output is very affordable. I recently began testing the Sony DSC-F8XX
with even better performance and photo rendition. It is impor-
Photographic output is most often a matter of choice and need.
tant to keep in mind that digital photography technology is
Most of the time, images are simply stored as files on the com-
puter, however, there are many times when a photo print is exploding and by the time the reader absorbs this information,
necessary. Amazing photo-quality prints can be obtained from there will be even better equipment available for less expense.
a wide array of inexpensive inkjet printers ranging from $100 There are many brands of good digital cameras that exist in
to $400. More expensive color laser printers produce excellent today’s market (see Figs. 22G-2a to 2f).
prints and their cost has fallen below $1000. Thus color laser
printers are now a reasonable alternative. The Database and Computer Files
The computer filing structure is the heart and soul of a success-
ful digital photography system. The computer database is criti-
THE DIGITAL CAMERA
cal to the reliable organization and retrieval of large numbers
The digital camera specifications are not stringent. Many cam- of digital photos. The database software must be easy to use
eras can produce excellent images; however, certain features and user maintainable. In addition, it is a short step to integrating
greatly enhance the ease of obtaining quality images. Only re- the database of patients and prospective patients into a market-
cently has the price of digital cameras, capable of taking high ing database or contact management system. Because all photos
quality images, fallen to levels attainable by most people. Let’s and patient demographics are kept in the same data file, power-
discuss some of the more important camera features. ful information management is possible. For example, many
Accurately viewing the image to be taken is important to surgeons advertise their services in multiple different media
getting the shot right. For this reason, through-the-lens (TTL) including Yellow Pages, newspapers, TV, Internet, and radio.
viewfinders have a big advantage and are highly recom- Knowing what media brings in the most patients makes it possi-
mended. The only exception is the LCD screen viewfinder ble to maximize the advertising budget. Given that all data is
cameras like the Nikon Coolpix 990 that acts much like a kept in one place, the potential for disaster exists; therefore,
video camera viewfinder. Macro focusing is required for reliable back-up must be in place. A computer failure could
close-up photography. Most cameras also have lens attach- lead to the complete loss of all information if a back-up system
ments that enhance the macro photograph. Today, the best fails.
image-capturing sensor is the charge-coupled device (CCD). A word about photo file formats. The type of file format
The exact mechanism of action is beyond the scope of this chosen to store the photo information will make a difference
discussion, but suffice it to say that the image quality with in photo quality and file size. File types can generally be broken
these sensors is excellent. Technology, however, changes (in layman terms) into large and small file formats. The large
daily. White balance is a feature that allows the adjustment formats (Raw data, TIFF, BMP, etc.) tend to keep all photo-
of the color rendition in various types of lighting. Those who graphic information including redundant data. The small file
aA
d
D
b
B
e
E
c
C f
F
Figure 22G-2 a) Sony DSC-F707. b) Nikon Coolpix 990. c) Olympus C-2500L. d) Olympus C2100UZ. e) Fujifilm FinePix 4900Z.
f) Sony Mavica CD 1000. Keep in mind that technology moves rapidly and these models will likely be obsolete at the time of publication.
874 Chapter 22
formats use compression algorithms that get rid of redundant that can be unnatural and it tends to produce shadows. Studio
data and allow the photograph to be reconstructed to almost lighting tends to give the best results by reducing or eliminating
100% of the original depending on how much compression shadows, giving high contrast, and being very consistent. Un-
is allowed. In practical terms, most cannot see the difference fortunately, it is often impractical in the average office. It is far
between moderately compressed and noncompressed photo from being portable (you cannot take it from room to room)
files. The major practical difference is in the size of the file and it requires a lot of space not typically found in a doctor’s
itself, which has a major impact on how fast the hard drive will exam room (Fig. 22G-3). It addition, studio lighting is typically
fill up over time. A 24 bit (true color) raw data file with no tungsten-based light, which would require that your camera
compression of a 1024 ⳯ 768 pixel photograph will take up have a white balance feature, otherwise, your photos will turn
approximately 2500 KB of disk space. The same file in TIFF out with an odd and displeasing tint.
or BMP will be about 1500 KB in size giving moderate Choose a photo background that is pleasing, uniform, not
compression but no loss of data and picture quality. The same flesh tone, and reproducible. Do not take clinical photos that
file saved in a JPG format may be as small as 300 KB yet the include the room’s objects which detract from the patient.
human eye cannot discern any degradation in image quality. Choose a single colored wall, hang a flat sheet, or use a profes-
You can see that using TIFF or BMP will fill the hard drive sional paper background. The quality and professionalism of
five times faster (or cut the storage capacity by almost 80%). the photos are easily and inexpensively enhanced with a quality
background. I have settled on a simple white background.
This is why the average clinical photography system stores the
files using JPG format and has a very large disk for storage.
For the novice, these acronyms of file type can be confusing
so they are worth explaining in slightly more detail. A pixel is
MAKING THE TRANSITION
a single dot on your computer screen defined by location, color Making the transition from film to digital photography can be
and intensity. File compression is the elimination of duplicate very difficult. Losing the physical touch of a print photograph
data so that the file can be stored in a smaller amount of space. can be disturbing to the novice digital photographer; therefore,
BMP (Bit Mapped) files in which each bit or pixel on the screen a gradual transition that uses both systems for a period of time
is mapped for color, intensity, and location and TIFF (Tagged is usually best. Choose a time period (3 months is usually suffi-
Image File Format, .TIF) uses modest compression but all of cient) during which time you will take photos with both film and
the original information can be recalled to reproduce the origi- digital cameras. Redundancy is important during the transition
nal photo. JPEG (Joint Photographic Experts Group, .JPG) is period while the surgeon becomes comfortable with image cap-
probably the most commonly used format because it allows ture and retrieval. Furthermore, the surgeon should develop the
the files to be variably compressed as much as 10:1 with little confidence that the digital system will be at least as reliable as
perceptible loss of photo quality to up to 40:1 when minimizing the film, but enjoy the immediacy of the photographic process.
file size becomes a critical issue (e.g., saving disk space, using Over time, the cost saving of filmless photography, staffless
it on a web page, or sending it via email). photo filing, and patient file space will soon become apparent
It is not critical to understand these concepts to establish a and the decision to ‘‘cut the cord’’ and discontinue the film
reliable digital photography system but some knowledge will camera becomes much easier to accept.
allow the user to create a more efficient system that is optimized
to suit their needs and meet their goals. For the typical doctor
taking clinical photographs, who wants to store a large number
of photos with good quality, JPEG with moderate compression
(10:1) makes sense. . This would not be acceptable to the profes-
sional photographer who relies on the highest quality image for
his livelihood.
Transferring the files from the camera to the computer can
also pose some speed obstacles. Most cameras include a USB
cable that connects to the computer and most computers today
treat the camera as another disk drive, so moving the picture
files to the computer is now a simple file transfer.
Lighting
The choice of lighting in all photography affects the photo qual-
ity. Adequate lighting is essential to high quality and reproduci-
ble photographs. There are three categories of lighting: ambient,
flash, and studio lights. Ambient lighting is the use of existing
light. This is unsuitable because it is too variable (day, night,
cloudy, sunny) and thus not reproducible. Flash is most com-
monly used and it is portable (most cameras have a built in
flash), reliable, reproducible, and is acceptable for most clinical Figure 22G-3 Example of studio lighting with Lowell total
applications. Flash has the shortcomings of high contrast photos umbrella.
OFFICE AUTOMATION Perhaps the most important factor of any successful software
system is how your staff interacts with it. This is highly depen-
A busy physician’s office requires adequate systems to track dent on the user interface, meaning what the user has to do to
important clerical functions. Most of us take for granted (or even accomplish a task in the system. Perhaps the best example of
completely ignore) the tasks of patient tracking, scheduling, the importance of user interface is the Macintosh computer by
inventory control, billing, and marketing. The more a clinical Apple who first introduced the graphical user interface (GUI)
practice expands, the more the surgeon will rely on computer wherein tasks are performed by pointing rather than by typing
systems to automate these critical tasks. Having answers to criti- a command. It was widely accepted because it was so easy to use
cal questions at your fingertips is a powerful capability in the and it spawned the development of other GUIs, most notably,
management of a busy practice. Some very important informa- Microsoft Windows, which is what most computer owners use
tion always to have available is: today.
Features of an effective office automation user interface re-
● Patient database
volve around having easy and intuitive access to all office func-
● Patient scheduling
tions on the same screen. Fig. 22G-4 demonstrates the user
● Inventory on hand
interface of the office automation software produced by Nex-
● What marketing is most successful
tech Inc. Personal information has been blacked out. Notice the
● Insurance billing receivables
use of ‘‘file tabs’’ that allow the user to click on a single button
Having this information available at all times requires a com- to go to the specific task. The interface is intuitive and requires
puter system that is incorporated into the standard daily office little explanation. It can be used in realtime while interacting
routine. The entry of essential data should become second na- with the patient either in person or on the phone. Being able
ture to office staff. The computer software must allow these to easily and instinctively navigate the software is an absolutely
tasks to be easy to accomplish so as to enhance, not encumber, critical feature in a successful system.
the duties of office staff. Once this occurs, office management The essential information is not new and is contained in
becomes easier and almost second nature. the paper forms already in use. The critical task then becomes
Like digital photography, the system will require a computer entering the data into the system so that it can be used. Having
system, appropriate software, reliable back-up, and system tech- the information displayed efficiently and logically is important
nical support. There are many general medical office manage- to data entry, especially if it is to be done in realtime while
ment systems available; however, most of these are highly fo- interacting with the patient. It is a good idea to train clerical
cused on insurance billing. The typical cosmetic surgery staff to ask questions that exactly match the data-entry form on
practice requires more highly developed patient tracking capa- the computer screen.
bilities because they are the primary source of income. In addi- The major universal office tasks of today are the collection
tion, cosmetic surgery practices tend to have in-office operating of patient information, scheduling, billing, correspondence, and
suites and inventory tracking becomes a critical issue. I have marketing. The choice of other system features will greatly de-
used four systems in my career: the first two I wrote myself, pend on the nature of a given practice. For example, I rarely
the third system became outdated because the development have cases that require filing insurance claims; therefore, the
company went out of business and I therefore have settled on added expense of the insurance billing feature would not be
the company listed below for my office automation needs. cost effective.
Nextech Inc.
Practice 2000
2717 Miamisburg-Centerville Road, Suite 217
Dayton, OH 45459
(800) 829-0580
Website: www.nextech.com
Retail price: $8,650.
Developing your own software is an inefficient use of surgical

time (unless you do not have anything better to do). The major
issues of technical support, continuing development, and keep-
ing up with the explosion of technology cannot be done cost
effectively with in-office software development. When possi-
ble, it is always best to buy off-the-shelf systems that meet most
of your needs. The major issues are then borne by the software
vendor and you will get technical support as well. Two other
off-the-shelf contact management programs that are commonly
used for office automation at the time of this writing, are ACT
and Goldmine. However, these two products still need to be
tailored to the needs of an individual’s office and it is probably
best to hire an expert consultant who is experienced in the use Figure 22G-4 Example of one office automation program
of these two programs to accomplish this task, if you decide (Nextech Inc., Practice 2000) with easy-to-understand user inter-
to use either program. face and tab features for specific tasks.
876 Chapter 22
Scheduling for a very busy practice is almost critical to effi- moted and improved. However, in hair restoration surgery, the
cient time management. Knowing the rapid answer to simple most important questions for patients suffering from hair loss
questions such as ‘‘what is the first available three-hour time are: What can be achieved through hair transplant surgery with
slot on a Friday next month’’ is readily at your finger tips. regard to the amount of hair that can actually be moved and
Questions such as this are not uncommon and they would re- what will be the aesthetic results after surgery? To answer these
quire several minutes of scanning the appointment book to de- questions and to give a proper prognosis, the surgeon has to be
termine the feasibility of the request. Automated scheduling able to measure, specify, and value the individual preoperative
will give you an immediate answer and help you schedule the and postoperative hair status. At present, some surgeons still use
patient without any hesitation or doubt. more or less subjective means to measure thickness, structure,
Automated correspondence is a powerful and very easy density, etc., of the hair. The more we can make data empirical,
method of maintaining contact with you patients. Because your instead of subjective, the more precise we can make hair trans-
current patients are the single best source of future business, plant surgery evaluation and prognosis. Put differently, al-
constant reminders of your presence and their great results will though the individual subjective experience of the surgeon is
lead to future income from current and prospective patients. very important, objective and standardized measuring methods
Again, the key to success is the ability to use the system in should be used to make evaluating and prognosis more uniform
realtime, everyday, for virtually every aspect of the clerical and transparent.
office. If this occurs, the database analyses such as marketing
effectiveness (which patients come from what marketing), pro- History of Measuring Methods
cedure statistics, and patient demographics (e.g., from what geo-
graphic location do the majority of patients originate) will fol- As discussed elsewhere in this text, human hair emerges from
low quickly. The power of this type of automation cannot be the scalp in groupings or follicular units (FUs) containing one
overstated. to four and rarely five hairs (2). It has become possible to dissect
In summary, computer automation has been an important and prepare these FUs and to implant them in recipient areas
addition to the business of medicine. Although this is not in- with excellent aesthetic results (3). Using macrophotography
tended to be an exhaustive discussion of the subject, the key and computer-assisted methods, these groupings become count-
components have been outlined and fortunately, the system can able and comparable (4), thus the success and outcome of hair
often be running on the same computer that houses the digital transplant surgery can be measured and presented more pre-
photography system. In most cases, the specific needs of each cisely and mathematically.
doctor must be examined to determine the most effective solu- The HMI was first described by James Arnold in 2001 (1).
tions. Hiring a reputable consultant can be helpful, but most of HMI measures and quantifies easily and without extensive tech-
the time, enlisting the aid of each vendor will go a long way nical requirements or equipment the optical effect of hair. Al-
toward understanding the process, benefits, and drawbacks of though the calibre or diameter of an individual hair can also be
each system. Do your homework, and if you find that computer measured, this does not give much indication of the optical or
automation will benefit your practice, make a commitment and aesthetic effect of the whole. In addition, it involves a more
follow through with it. complicated procedure in order to achieve measurable results.
22H. Measuring Hair Density and TRICHODENSITOMETRY

Mass In trichodensitometry, the number of FU/cm2 is counted. Count-
ing the number of hairs individually is too inaccurate; for this
Frank G. Neidel and Petra Bretschneider
reason only the groups are counted. The ratio of single hairs
to hairs in groups of two or more hairs is approximately 1:9 in
INTRODUCTION healthy areas (3).
Trichodensitometry and the concept of utilizing a hair mass Terminology
index (HMI) (1) provide suitable methods and means for rela-
tively easily measuring of both the mathematical and the optical ● HDD ⳱ Hair Density Donor ⳱ Number of FU/cm2 in
status of hair. If the natural and epidemiological influences and the donor area
interdependencies of the main parameters in hair loss and hair ● HDI ⳱ Hair Density Implant ⳱ Number of FU/cm2 that
transplant surgery patients are well understood and considered, are going to be implanted or have been implanted into
HMI and trichodensitometry are very helpful for indication, the recipient area
prognosis, and evaluation of hair restoration surgery. The proce- ● HDR ⳱ Hair Density Recipient ⳱ Density of the exist-
dures are easy and do not require extensive technical equipment, ing FU in the recipient area (preoperative count)
so they can be used by every hair transplant surgeon. This, as ● TI ⳱ Transplant Index ⳱ ratio of HDD to HDI as a
indicated, would help to make the indications, prognosis, and measure of the success of hair transplant surgery.
evaluation of hair restoration surgery more efficient, standard-
ized, and transparent. Practical Procedure in the Occipital Donor Area
The last few years have witnessed hair transplant surgery
developing into a complex and highly specialized microsurgical Hair in the donor area has to be cut to a 1 mm to 3 mm length.
method. In order to achieve the highest aesthetic results, the A metal stencil, with a punched out area is applied and the
dissection and implantation methods have been eespecially pro- number of FUs counted. (Fig. 22H-1). The punched out area
Table 22H–1 Trichodensitometry: Empirical Values There are different ways of counting the FUs
Transplant Index ● FUs are counted by using a magnifying glass (experience
(TI) HDD/HDI Results – Prognosis necessary)
● A photograph is taken of the area with the stencil applied
20 Insufficient transplant density; poor to it (Fig. 22H-2). The FUs in this photo are subsequently
optical results; further treatment counted.
necessary to improve density; patients
often not satisfied, “beginners surgery”
20 Good transplant density; good optical
results; further treatment to improve
density possible; patients with curly
hair mostly satisfied
10 Very good optical results; further
treatment possible, patients satisfied
5 Mainly micrografts, FUs, excellent optical
results; “professional treatment”,
further treatment possible but mostly
not necessary, patients satisfied
2 BEWARE! Danger of necrosis in spite of
tumescence possible; transplant very
densely packed
should measure 0.5 cm2 (FUs are easily countable with a magni-
fying glass, but the result has to be multiplied by 2) or 1 cm2.
A punched out area of 2 cm2 will actually result in a more
accurate measurement, however, more FUs have to be counted Figure 22H-2 Macrophotography of FUs of the donor area
and the results have to be divided by 2. after hair cut. (Photo by Neidel).
Figure 22H-1 Hair density count. Count of FUs in the outlined area using a magnifying glass and a stencil. (Photo by F. Neidel).
878 Chapter 22
● A photograph is scanned into a computer (special hard Documentation of TI (Transplant Index)

and software necessary, e.g., Program Analysis威, Soft-
ware-Imaging GmbH, Muenster, Germany) and the FUs ● Example: TI ⳱ 70/cm2 (HDD): 10/cm2 ⳱ 7 (TI ⳱ 7)
are counted by computer (Fig. 22H-3). ● TI ⳱ 70/cm2 (HDD): 20/cm2 ⳱ 3.5 (TI ⳱ 3.5)
● Example: HDD ⳱ 70/cm2 means: 70 FUs per square ● TI ⳱ 70/cm2 (HDD): 35/cm2 (HDI) ⳱ (TI ⳱ 2)
centimeter; every hair that emerges by itself, instead of
in a group of two or more hairs is counted as one FU. Special Case
In estimating the operability (indication for hair transplantation)
Practical Procedure in the Recipient Area
in women with androgenetic alopecia (male or female pattern)
If there is still sparse hair remaining in the recipient area, for consider the following:
example, in a female or male patient with relatively early male ● HDD has to be measured very accurately; if necessary,
pattern baldness (MPB), the density of the existing hair (⳱ several times. The mean value must be determined.
HDR ⳱ hair density recipient) should be measured first. ● HDR must be measured very accurately (to determine
● Example: HDR ⳱ 35/cm2 (means: 35 remaining FU/ the remaining hair groups in the recipient area).
cm2 in the recipient area) ● Indication for operating is given only if the difference
in density between donor and recipient area is at least
Practical Procedure in the Transplanted Area 30%. The more distinct the difference and the more alo-
pecic the recipient area is, the better the prognosis is for
After implanting the grafts or FUs, a stencil has to be applied patient satisfaction.
at different points of the treated area in order to determine and
count the number of transplanted grafts or FU/cm2 (by counting
them directly or taking a photograph as described earlier). Once HAIR MASS AND HAIR-MASS INDEX
again a visible single hair always counts as one FU. The mean
value should then be calculated. Hair mass is a qualitative measurement for a group of hairs.
The group of hairs may be all the hairs growing within 1 cm2
● Example: HDI ⳱ 10/cm2 (means 10 FU/cm2 have been of donor scalp; all the hair transplanted into a specific recipient
transplanted into the recipient area) site; the hair within a carefully defined area—such as a 5 cm
circle, etc. Hair mass index (HMI) is measured in a three-step
Transplant Index (TI) process:
The Transplant Index (TI) describes the ratio of FU/cm2 in the 1. The hair to be measured is carefully collected and gently
donor area (HDD) to the number of transplanted FU/cm2 in the twisted into a single-round bundle.
implanted area (HDI). The TI allows conclusions concerning 2. The circumference of the bundle is measured in mm
the expected results (hair density) and prognosis of hair trans- using a simple technique described below.
plant surgery. In medical assessments and expert opinions after 3. From the circumference, the surface area of a cross-
hair restoration surgery, the TI is used to project the number section through the bundle is calculated in mm2. The
of hair-producing implanted follicles. hair mass for the measured hair is then expressed as the
mm2.
The third step in measuring hair mass, converting circumference
to cross-section area, is necessary to reflect the logarithmic
changes in the amount of hair that occurs with small changes
in bundle circumference. That is, as the circumference of a
bundle changes arithmetically, the amount of hair within the
bundle (hair mass) changes logarithmically.
Hair mass measurement is the product of both the number
and the diameter of the hairs that are measured. If either the
number of hairs or the diameter of the hairs increases; hair mass
will increase. Conversely, a loss of hair or a loss of hair diameter
will diminish the hair mass value.
The most useful hair mass measurement for hair transplant
surgeons is the HMI and it represents the hair mass per cm2 of
donor scalp. Many surgeons evaluate donor density, which is
the number of hairs per cm2, to help predict the cosmetic im-
provement that transplantation may provide. While density indi-
cates the number of hairs available, density gives no indication
of hair diameter. Two patients with identical donor density will
have strikingly different outcomes if one has wispy, fine hair
and the other has coarse, full-diameter hair. Hair mass index,
Figure 22H-3 Digital count after scanning the macrophotogra- as stated, reflects both the number of hairs per cm2 plus the
phy. (Photo by Neidel, El-Gammal, Altmeyer). diameter of the hairs. In the two patients with identical density,
the patient with fine hair would have a much lower HMI than ● Divide the diameter by 2 ⳱ radius.
the patient with large diameter hairs. Density alone has a varia- ● Use the formula pi X r2 ⳱ mm2
tion of approximately 50% in patients. By giving value to hair ● Divide the mm2 product by 4 ⳱ HMI (remember we
diameter, HMI varies by approximately 500%, a 10-fold in- started with 4cm2).
crease over density alone. Knowing the HMI of a patient allows ● Values (HMI) between 0.18 – 0.32 correspond to the
a more accurate prediction of what the patient may expect from optical effect of fine hair.
one or several transplant procedures. There is only one basic ● Values (HMI) between 0.32 – 0.5 correspond to an opti-
requirement for obtaining an HMI—the hair must be long cal effect of normal hair.
enough to be bunched together into a single bundle of hair (see ● Values (HMI) between 0.5 – 0.72 correspond to an opti-
later). cal effect of thick hair.
To measure the HMI or hair mass per 1 cm2 of donor scalp:
● Mark a 4 cm2 area of donor scalp (2 cm ⳯ 2 cm) with
a colored pencil or pen (Fig. 22H-4)⬍.It is easier and
more accurate to work with a 4 cm2 than a single cm2.
The end product will be divided by 4 to give hair mass
per 1 cm2.
● Cut the hair surrounding this area leaving the hair within
this 4cm2 area long (Fig. 22H-5).
● Gather the hair together in this area with a comb, and
gently twist into a bundle held between the fingers (Fig.
22H-6).
● Wind a white cotton thread around the bundle of hair
and tie a simple knot (see Fig. 22H-6).
● Mark a point on the knot, where the thread crosses over
itself, with a pen or colored pencil (Fig. 22H-7).
● Untie the knot and measure the distance in mm between
the two marks left on the thread (Fig. 22H-8). This dis-
tance is equivalent to the circumference of the hair
bundle.
● The following mathematical steps are used to calculate
the HMI. Figure 22H-5 Hair mass index. Haircut around the marked
● Divide the circumference by pi ⳱ diameter (pi is 3.14). area. (Photo by Neidel).
Figure 22H-4 Hair mass index. Marking a donor area of 2 cm ⳯ 2 cm. (Photo by Neidel).
880 Chapter 22
Figure 22H-6 Hair mass index. Holding the hair bunched be- Figure 22H-7 Hair mass index. Marking a point on the knot
tween fingers (2 cm ⳯ 2 cm area) winding a white thread around of the thread. (Photo by Neidel).
the bunch, and tying a simple knot. (Photo by Neidel).
Figure 22H-8 Hair mass index. Untying the knot and measuring the distance between the two points. (Photo by Neidel).
Appendix 22A–1 Items Used to Evaluate the Recipient and Donor Areas
Photographic Equipment
• Cameras Canfield Scientific
• Photographic accessories (lighting, grids, etc.) Canfield Scientific
• “Mirror Suite” imaging software Canfield Scientific
Measuring Instruments
• Simple rulers or measuring tapes General office supply or drug stores
• Miltex surgical stainless steel rulers Ellis
• Kabaker donor template Mediquip
Densitometers
• Rassman, Khan, Welch Allen Trichoscope A-Z, Ellis, Mediquip, Robbins Ellis
• Square Area densitometer with 1 cm2 -viewing area
Starret® Electronic Digital Micrometer Mediquip
Items Used to Prepare the Patient for Surgery
General Marking Pens

• China Marker, Sharpie Fine Point General office supply or drug stores
• Accu-line Disposable Gentian – Violet Marking Pen Robbins
Hair Styling and Cutting Equipment
• Hand mirrors, Hair clips and band, barber Any drug store or beauty supply store
hair-cutting scissors
• Wide-tooth rat tail combs (metal or plastic) A-Z
• Panasonic beard trimmer with 3 mm guarde A-Z
Blood Pressure/Pulse Monitor
• Welch Allen 5200 Series Physician sales and service
Items Used for Anesthesia
Dental Syringe and Supplies

• Dental syringe, anesthetic carpules, dental needles Patterson Dental
Small Hand-Held Vibrator Any drug store, Shaper Image,
CompuMed ™ (Wand) Anesthetic Delivery System Milestone Scientific, A-Z
The Uni-Matic Tumescent Gun Byron
Dermojet® Needleless Injector Robbins
Items Used for Donor Harvesting
Single-Bladed Scalpel Handle A-Z, Ellis, Mediquip, Robbins

Multi-Bladed Knife Scalpel Handle and Spacers
• Brandy Knife (fixed number of blades) Ellis,Robbins
• Universal Handle Multi-Bladed Knife (straight and Ellis,Robbins
angled) A-Z
• Arnold Multi-blade Handle ™ (straight and angled) Mediquip
• Vari–Knife ™ (adjustable angle)
Scalpel Blades for Donor Harvesting
• Personna Plus scalpel blades (#10, #11, #15) A-Z, Ellis, Mediquip, Robbins
Surgical Scissors
• Metzenbaum, Iris, etc A-Z, Ellis, Mediquip, Robbins
Needle Holders
• Mayo Hegar, Halsey, Ryder, etc. A-Z, Ellis, Mediquip, Robbins
Tissue Forceps for Donor Harvesting
• Hudson Ewald, Adson Brown with teeth 12 A-Z, Ellis, Mediquip, Robbins
(Standard Tip)
Towel and Tissue Clamps
• Backhaus towel clamp A-Z, Ellis, Mediquip, Robbins
• Tension or tissue clamp A-Z, Ellis, Mediquip, Robbins
• Versi–Closure ™ four-toothed tissue clamp Mediquip
Hemostats
• Halstead 3 inch Mosquito Hemostats A-Z, Ellis, Mediquip, Robbins
Hyphercator ™ 2000 Robbins
Infrared Coagulator Redfield Instruments
Plume Master Smoke Evacuator System Sorenson Laboratories
(Continued)
882 Chapter 22
Appendix 22A–1 Continued
Sutures (absorbable and non-absorbable) A-Z, Ellis, Robbins

3M Precise DS–25 Staples and Staple Remover A-Z, Mediquip
Prone Pillow A-Z, Ellis, Mediquip, Robbins
Magnification Devices Used for Graft Preparation, Recipient Incision, and Placing
Magnifying Glasses
• Store bought magnifying glasses Any drug store
• Mag-Specs (reading-glass style and clip on) Ellis, Mediquip
• Mag-eyes (visor style) A-Z, Mediquip
• Optivisor (visor style) A-Z, Ellis, Mediquip
• Magni-focuser ™ (visor style) A-Z, Ellis, Mediquip
• Goose Neck Lamp Magnifier Ellis
Halogen Head Lights A-Z, Ellis, Mediquip
True Surgical Loupes Design for Vision, Surgitell, Vision
Engineering
Dissecting Microscopes
• Meiji A-Z, Ellis, Mediquip
• Mantis A-Z, Mediquip, Vision Engineering
• Zeiss Mediquip, Zeiss
• Microscope Video System Mediquip
Items Used for Graft Preparation
Backlight Systems
• Visual Plus ™ Backlight A-Z, Ellis, Mediquip
• Tundra Backlight@ A-ZA-Z, Ellis
Cutting Surfaces
• Wooden tongue blades A-Z, Ellis, Mediquip, Robbins
• Tongue blade “shaped” clear plastic surface (i.e., A-Z, Mediquip, Ellis
Clear View ™) Ellis
• Greco Cutting Surface
Slivering Boards
• Blugerman Slivering Board A-Z
Personna Plus Shaper (Razor) Blades
• (Single edge/double edge) A-Z, Ellis, Mediquip, Robbins
Double-Edge Shaper (Razor) Blade Holders A-Z, Byron, Ellis, Mediquip,
Robbins
Forceps Used for Graft Preparation A-Z, Ellis, Mediquip, Robbins
• Jewelers type forceps (curved or straight) A-Z, Ellis, Mediquip, Robbins
(standard tip)
• Forrester type forceps (curved or straight) A-Z, Ellis, Mediquip, Robbins
(standard tip)
• Micro-Adson forceps (delicate tip) A-Z, Ellis, Mediquip, Robbins
“Mangubat” Impulsive Graft Cutting Device A-Z, Ellis
Graft Storage and Cooling Supplies
• Standard petri dish, plastic cups, etc. A-Z, Ellis, Mediquip, Robbins
• Blugerman Pin Cup A-Z, Ellis
• Coolers Shaped for petri dishes (i.e., Le Paw Cooler, A-Z, Mediquip
etc.)
Items Used for Recipient Incisions
Needles Type
• Standard needles A-Z, Ellis, Mediquip, Robbins
• NoKor needles (16 and 18 gauge) A-Z, Ellis, Mediquip, Robbins
• Solid Core™ needles (14 to 20 gauge) Mediquip
• Rosati Star Ellis
Micro-Blades
• Spearpoint (SP91, SP92, etc.) A-Z, Ellis, Mediquip, Robbins
• Chiselpoint ((#61, #62, etc.) A-Z, Ellis, Mediquip, Robbins
• Round, Half (Beaver) A-Z, Ellis, Mediquip, Robbins
Sharpoints (15 °, 22.5°, 30°, 45° A-Z, Ellis, Mediquip, Robbins
(Continued)
Appendix 22A–1 Continued
• Minde (1.3 mm–3.0 mm) A-Z

• Beaver Mini-ES Blade A-Z, Ellis, Mediquip, Robbins
Slots
• Hitzig Slots (2 mm, 3 mm, 3.5 mm and 4.5 mm) Ellis
• Disposable slot punches (2.5 mm to 4.1 mm) A-Z, Ellis, Mediquip
• Butterfly Slot (1.9 mm to 3.3 mm) Ellis, Mediquip
Punches
• Disposable punches (1.5 mm to 8 mm) A-Z, Ellis, Mediquip, Robbins
• Super sharp punch (0.75 mm to 2 mm) A-Z, Ellis, Mediquip, Robbins
• Blade Handles
• Sharpoint handle A-Z, Ellis, Mediquip, Robbins
• Power Punch Adapter Handle A-Z, Ellis, Mediquip, Robbins
• Lightning Knife ™ Type A-Z, Ellis,
• Versi Handle™ Mediquip, Ellis
Wet Stone and Sharpening Flints Rx Honing, Ellis
Multi-Recipient Scalpels
KMI Multi Recipient Scalpel KM Instruments
Blade-Making Machine Cutting Edge Technology
Items Used for Placing
Forceps Used For Placing

Jewelers-type forceps (curved or straight) (fine tip) A-Z, Ellis, Mediquip, Robbins
Forrester-type forceps (curved or straight) (fine) A-Z, Ellis, Mediquip, Robbins A-Z
Millennium ™ Forrester with stop guard A-Z
Bonn Forceps A-Z
Microceps ™ Mediquip
Dilators (Micro, Quad, Mini) A-Z, Ellis, Mediquip, Robbins A A-Z
Choi Implantation Devices
HAN Implanter Ellis
HIP Implanter Ellis
Bannuci Implanter A-Z
Miscellaneous Instruments and Supplies
Burton surgical lights A-Z, Midmark

Hand Engines (Bell, Aroquette, Ram) Ellis,Robbins
Boyd surgical chairs and tables Boyd
Ritter autoclaves A-Z, Midmark
Prone Pillows A-Z, Ellis
Comfort foam body positioners (wedge, roll, half roll) A-Z,Ellis
General Medical Supplies (gloves, gauze, suture, etc.) A-Z, Physician Sales and Service
Ergonomic hair transplant chair A-Z
Post-Op bandanas and hats A-Z
884 Chapter 22
Appendix 22B–1 Appendix 22B–1 Continued
Name & Contact Name & Contact

Information Comments Information Comments
A-Z Specialty Hair Transplant Practicon Dental Dental Anesthetic Carpules and
25 Plant Ave. Instruments 1112 Sugg Pkwy. Supplies
Hauppauge, NY 11788–3804 Mantis Microscopes Greenville, NC 27834
1-800-843-6266 General Medical Supplies 1-800-959-9509
Boyd Industries Surgical Chairs and Tables Redfield Corporation Infrared Coagulator
12900 44th St. N. 336 W. Passaic St.
Clearwater, FL 33762 Rochelle Park, NJ 07662
1-800-225-2963 1-800-678-4472
Burton Medical Product Surgical Lights Robbins Instruments, Inc. Specialty Hair Transplant
Corp. 2 North Passaic Ave. Instruments
21100 Lassen St. Chatham, NJ 07928
Chatsworth, CA 91311 1-800-206-8649
1-818-701-8700 RX Honing Machine Corp. Blade Sharpening Machine
Byron Medical General Surgical Instruments 1301 East Fifth St. Wet Stone Flints
602 Rillito St. Uni-Matic Tumescence Syringe Mishawaka, IN 46544
Tucson AZ 85705 219-2591606
1-800-777 3434 Sorenson Laboratories Plume Master Smoke
Canfield Scientific Cameras and Photographic 2495 S. West Temple Evacuator System
253 Passaic Ave. Equipment Salt Lake City, UT
Fairfield NJ 07004 Mirror Suite Imaging Software 1-800-851-5227
1-973-276-0339 The Industry Source for General Beauty Supplies
Cutting Edge Technology Custom Blade Cutter Beauty Supplies (Combs, Mirrors, Scissors
53 Trickle Ridge Place 23200 Haggerty Rd. Hair Clips, etc.)
Kimberly, BC, Canada Farmington Hills, MI
V1A2H8 48335-2611
1-250-427-5424 1-800-362-6245
Design for Vision Surgical Loupes Van Sickle Surgical General Surgical Instruments
760 Koehler Ave. Instruments Specialty Hair Transplant
Ronkonkoma, NY 11799 Box 210905 Instruments
1-631-585-3300 Bedford, TX 76095
designsforvision.com 817-268-8800
Ellis Instruments Specialty Hair Transplant Vision Engineering Mantis Microscope
21 Cook Ave. Instruments 570 Danbury Road Surgical Loops
Madison, NJ 07940 New Milford, CT 06776
1-800 218-9082 1-860-335-3776
KM Industries KMI Multi-Bladed Scalpel
5941 E. Ft. Krittendon
Tucson, AZ
1888-836-8500 Appendix 22C–1 Length of Incisions of Commonly Used
www.hairtool.com Needles and Microblades
Mediquip Surgical Specialty Hair Transplant
1750 Montgomery St. Instruments Blade Width at Longest Point
San Francisco, CA 94111
1-800-951-9989 Hypodermic or solid core needles
Midmark Corp. Ritter Autoclaves 16-gauge needle 1.6 mm long
60 Vista Dr. 18-gauge needle 1.25 mm long
Versailles, OH 45380 19-gauge needle 1.05 mm long
1-800-643-6575 20-gauge needle 0.90 mm long
Milestone Scientific CompuMed™ (Wand) 21-gauge needle 0.70 mm long
15 S. Pfingsten Rd. Anesthetic Delivery System NoKor needle
Deerfield, IL 60015 16-gauge 2.3 mm long
1-800-862-1125 18-gauge 1.6 mm long
Pearson Dental/Medical Dental Anesthetic Carpules and Sharpoint microbladesa
Supply Supplies Sharpoint 15˚ 1.5 mm long
13161 Telfair Ave. Sharpoint 22.5˚ 1.8 mm long
Sylmar, CA 91342 Sharpoint 30˚ 1.9 mm long
1-800-671-8400 Sharpoint 45˚ 1.9 mm long
Physician Sales and Service Welch Allen Pulse Oximetry (Continued)
141 Cheshire Lane and BP Monitor
Plymouth, MN 55441 General Medical Supplies
1-800-775-2203
(Continued)
Appendix 22C–1 Length of Incisions of Commonly Used 8. Bernstein RM, Rassman WR, Rashid N. A new suture for hair
Needles and Microblades Continued transplantation: Poliglecaprone 25. Dermatol. Surg 2001; 27(1):
5–11.
Blade Width at Longest Point 9. Bernstein R. Staples versus Monocryl. Dermatol. Surg. 2001; 2.
b 10. Rassman W. Follicular Unit Extraction. Dermatol Surg 2002; 28:
Spear-tip microblades
720–728.
Swann Morton SP 91 Spearpoint 1.5 mm long 11. Sawchuk WS, Weber PJ, Lowry DR, Dzubow LM. Infectious
Swann Morton SP 90 Spearpoint 2.0 mm long papillomavirus in the vapors of warts treated with carbon dioxide
Chisel-tip microbladesc laser or electrocoagulation: Detection and protection. J. Am.
Swann Morton #61 1.5 mm long Acad. Dermatol 1989; 21:41–44.
Swann Morton #62 2.75 mm long 12. Smith JP, Topmiller JL, Shulman S. Factors affecting emission
Other microblades collected by surgical smoke evacuators. Lasers Surg. Med.
Swann Morton #64 (round tip & sharp [Suppl.] 1990; 10:224–233.
on only one-sided) 3 mm long 13. Hitzig G. The use of the infared coagulation in hair transplant
Swann Morton #65 (lance tip) 3 mm long and scalp reduction surgery. Am. J. Cosmetic Surg 1995; 12(1).
Swann Morton #67 (curve tip) 3 mm long 14. Limmer BL. Elliptical donor stereoscopically assisted micrograft-
Swann Morton #69 “Beaver Blade” ing as an approach to further refinement in hair transplantation.
(round tip & sharp on two-sided) 3 mm long Dermatol. Surg 1994; 20:789–793.
15. Seager D. Binocular stereoscopic dissecting microscopes: Should
a
The actual length of an incision made by a Sharpoint blade is determined we use them. Hair Transplant Forum International 1996; 6(4):2–5.
by the angle of insertion and depth of penetration (i.e., the length of an 16. Shapiro R. Using a Slivering Specialist to simplify production of
incision made by a 15˚ Sharpoint inserted at a 45˚ angle can range from 0.1 Follicular Units. Lectur Int. Soc. of Hair Rest. Surg. (ISHRS).
mm to 1.5 mm. Annual Meeting, San Francisco, 1999.
b
Additional sized chisel-tip blades exist and can range in length from 0.7 to 17. Mangubat EA. Impulsive force: Anew method to cut grafts. Int.
4 mm. They can be either purchased or produced by a custom blade cutter. J. Cosmetic Surg 1998; 6(1):19–23.
c
Additional sized spear-tip blades exist and can range in length from 0.7 to 18. Seager D. The One Pass Hair Transplant. Hair Transplant Forum.
4 mm. They can be either purchased or produced by a custom blade cutter.
1998; 12(5):1.
19. Brandy DA, Meshkin M. Utilization of NoKor needles for slit-
micrografting. J. Derm. Surg. Oncol 1994; 20:336–339.
20. Pouteaux P. The use of small punches in hair-transplant surgery.
J. Dermatol. Surg. Oncol 1980; 6(12):1020–1021.
21. Hitzig GS, Schwinning JP, Seymour L, Handler MD. Linear graft-
ing using a modified slot method: introducing the linear punch.
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The Phototrichogram
1. Colon GA, Singer R. Introduction of new technology to the office.
Clin. Plast. Surg 1999; 26(3):355–361.
1. Saitoh M, Uzuka M, Samamoto M. Human hair cycle. J. Invest.
2. Farjo N. Business gloom . . . or boom. Hair Transplant Forum
Dermatol 1970; 54:65.
International 1998; 8(6):20–21.
2. Bouhanna P. Le cuir chevelu. Les alopécies définitives et leurs
3. Chavez AE, Dagum P, Koch RJ. Legal issues of computer imag-
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ing in plastic surgery. Plast. Reconstr. Surg 1997; 100(6):
3. Fiquet C, Courtois M. Une technique originale d’appréciation de
1601–1608.
la croissance et de la chute des cheveux. Cutis 1979; 3:975–984.
4. Knudsen R. Finasteride–friend or foe?. Hair Transplant Forum
4. Cabane J. Etude des variations de la formule pilaire à partir d’une
International 1998; 8(3):2–4.
nouvelle technique photographique du trichogramme. Bull. Soc.
Med. Paris 1980; 8(5):150–152.
5. Rook A, Dawber R. In Diseases of the Hair and Scalp. Oxford:
Blackwell Scientific, 1982:544–554.
Instrumentation and Supplies Used in Hair 6. Bouhanna P. The advantage of phototrichogram in hair surgery.
Restoration Surgery The International Advanced Hair Replacement Symposium. Bir-
mingham: Alabama, 1982.
1. Shapiro R. An overview of follicular unit transplantation, Euro- 7. Bouhanna P. Macrophotographic examination. Phototrichogram.
pean Society of Hair Transplantation. London, June. In: Bouhanna P, Dardour JC, eds. Hair Replacement Surgery.
2. Bernstein RM, Rassman WR. Follicular transplantation: patient Berlin and Heidelberg: Springer Verlag, Berlin and Heidelberg,
evaluation and surgical planning. Dermatol Surg 1997; 23: 1996:23–24.
771–784. 8. Bouhanna P. Les différentes méthodes d’appréciation objective
3. Bernstein R, Rassman W. Follicular Unit Transplantation. Inter- d’une chute de cheveux et d’une alopécie. Praxis 1977; 86:
national Journal of Aesthetic and Restorative Surg 1995; 3(2): 1000–1003.
119–132. 9. Bouhanna P. Tractiophototrichogramme. In. Pathologie du
4. Cole J. The affect of hair caliber on the appearance of density. cheveu et du cuir chevelu Bouhanna P, Reygagne P, eds. Paris:
Washington. D.C.: ISSHR, 1998. Masson, 1999:46–50.
5. Bernstein RM. Measurements in hair restoration. Hair Transplant 10. Bouhanna P. Considerations sur le traitement chirurgical des alo-
Forum International. 1998; 8(1):27. pécies masculines. J. Med. Esth. Chir. Dermatol 1981; 29:
6. Bisaccia E, Scarborough D. Hair transplant by incisional strip 182–184.
harvesting. J Dermatol Surg Oncol 1994; 20:443–448. 11. Hayashi S, Miyamoto I, Takeda K. Measurement of human hair
7. Arnold J. Hair replacement, surgical and medical. In: Stough D, growth by optical microscopy. Br. J. Dermatol 1991; 125:
Haber R, eds. Chapter 9. St. Louis: Mosby, 1996:259–266. 123–129.
886 Chapter 22
12. Rushton S, James KC, Mortimer CH. The unit area trichogram in 2. Montagna W. Atlas of Normal Human Skin. New York: Springer,
the assessment of androgen-dependent alopecia. Br. J. Dermatol 1992:314.
1983; 109(4):429–437. 3. Bernstein RM, Rassmann WR. The aesthetics of follicular trans-
plantation. Dermatol. Surg 1997; 23(9):785–799.
Measuring Hair Density and Mass 4. Neidel FG, El-Gammal S. Non-invasive evaluation of growth
rates of mini and micrografts in hair transplantation, 5th Congress
1. Arnold J. Hair mass index, 4th Annual Congress European Soci- of the International Society for Aesthetic Surgery, April 22, Ber-
ety of Hair Restoration Surgery, May 30, Barcelona, 2001. lin, 1994.
23
Some Things New, Some Things Old
PREFACE TO CHAPTERS 23A AND 23B ical behavior of the hair within it. Each zone retains or loses
its hair, to a greater or lesser degree, and does so without influ-
The first two sections of this chapter are devoted to two classifi- ence of an adjacent zone’s behavior. He cited one example as
cation systems that would allow for a more accurate method the isolated round area on the vertex of the scalp, often the first
of evaluating male pattern baldness (MPB) and its treatment. area to undergo follicular miniaturization and subsequent loss.
They are both more complex than the usual Hamilton or Nor- Another example is the horseshoe-shaped area of the lower
wood classifications, so they may or may not be widely adopted. posterior scalp that permanently remains in spite of the most
They provide far more accurate descriptions for the purpose of advanced stages of balding.
scientific investigation. Bouhanna’s review of prior suggested Most recently, Cohen (4) has proposed a classification based
systems of classifications may also prove to be useful to some on those of Hamilton, Norwood, and Arnold. The system is
investigators. quantitative, precise, and capable of depicting the density, dis-
tribution, and hair mass of every possible balding pattern. The
Cohen classification requires two standardized templates: a 10-
zone map of the scalp and a 100-cell bar graph. When the hair
23A. The Hair Loss Profile and density of each zone is entered in the blank graph, the shaded
Index: A Classification System graph becomes a unique profile that characterizes the patient’s
for Pattern Balding clinical status. The total number of shaded cells becomes an
index that quantifies the hair mass. The profile and index may
Bernard H. Cohen then serve as baselines for clinical tracking, comparative stud-
ies, and future evaluations.
BACKGROUND The first standardized template is a 10-zone map of the scalp
(Fig. 23A-1). Three graphic renderings depict the scalp from
In order to classify the stages of androgenetic alopecia, hair multiple perspectives—lateral, top, and posterior. The anatomic
restoration surgeons use a 50-year-old method that compares regions are numbered in a sequential fashion from 1 to 10,
the hair loss pattern to a set of rudimentary black and white reflecting the usual progression of male pattern hair loss. Zone
drawings. The system was originally introduced by Hamilton 1 is the temporal recession area–usually the first region of mini-
(1) in 1951 and improved by Norwood (2) in 1984. The Hamil- aturization and subsequent loss. Zone 10 is the permanent horse-
ton-Norwood classification (H-N) offers 12 categories into shoe-shaped fringe–the area that remains in spite of the most
which the hair loss pattern must be placed. Unfortunately, too advanced balding. Zone 5 is the vertex–the isolated midscalp
often the pattern does not quite correspond to one of the choices. area characterized by its unique propensity for early hair loss.
Another deficiency is the H-N system’s portrayal of hair den- Zone 2 is the frontal area; Zone 3 the forelock region; Zone 4
sity. Its drawings depict the hair as either black or white, either the central bridge; and Zones 6 and 7 the transitional area be-
fully present or absent, using no shades of gray to depict incom- tween the vertex and permanent fringe. Zone 8 is the lateral
plete loss. Most would agree that the H-N system inadequately hump, and Zone 9 is the posterior cervical region. The zones
reflects the science and precision of modern hair restoration were designed to ensure that mosaic combinations of each
surgery. would closely conform to the classic Norwood renderings.
In 2000, Arnold (3) introduced a classification system with Three sets of dots are included within the graphics. They local-
a significantly different perspective. Arnold’s system was based ize and identify critical landmarks pertinent to the evolving hair
on the natural principles of biodiversity. Arnold observed that loss pattern.
a balding man’s scalp has multiple distinct and recognizable The second standardized template is a 100 cell weighted bar
zones, and the configuration of each zone is based on the biolog- graph with 11 fields (Fig. 23A-2). Each field represents 1 of
887
888 Chapter 23
Figure 23A-1 Map of scalp, 10 zone (standardized template). Three sets of dots indicate distances to be measured.
Figure 23A-2 Blank bar graph (standardized template). The bar-graph matrix contains 100 cells and 11 fields. The number of cells
assigned to each field is proportionate to the size of the zone.
the 10 zones, and the number of cells assigned to each field is field. A quick overview of the method is provided ( Table 23A-
proportional to the relative size of that zone. Zone 10 has the 1) and a more detailed description appears subsequently.
largest field containing 25 cells. The vertical axis defines the
percent of terminal hair density. The horizontal axis defines the
fields. Following patient examination or photograph analysis,
METHOD
the user plots the observed density values into the zone of each
Examine the patient or high-quality photographs of the patient
(Fig. 23A-3). A comb, a flexible plastic metric ruler, and a
set of blank standardized templates are required. The examiner
Table 23A-1 Simplified Method for Using the Classification identifies the location of Zones 1 thru 10 on the patient’s scalp,
System at Precision Level 1 as well as the three pairs of dots.
The distance between each pair of dots is then measured
Measure distance between the dots on the forehead, bridge, and (Fig. 23A-4). The hairline is generally 8.5 cm to 9.5 cm superior
vertex. to the base of the nose. If the forehead measurement is greater
Identify the location of Zones 1 thru 10. than 11 cm, one may assume that Zone 2 is hairless. The central
Plot Terminal 100% as value for Zone 10. Use all 5 columns in the
bridge, bridges the space between the lateral humps—Zone 8,
Zone 10 field.
left and right. In patients with minimal hair loss, the lateral
Plot appropriate percentiles as values for Zones 1 to 9. Use all
borders of the bridge may not be visible, and the distance be-
columns in each field.
Shade all cells beneath the plot markings. tween the dots cannot be measured. However, if the borders of
The shaded 100-cell graph is the Hair Loss Profile. the bridge can be identified, they should be measured. The same
The total of shaded cells is the Hair Loss Index. applies to the two concentric circles that define the vertex. The
smaller, central circle is labeled Zone 5v, the larger circle Zone
Some Things New, Some Things Old 889
Figure 23A-3 Photos of patient showing hair loss. Zones 1 and 2 are hairless. Zones 3 through 6 have incomplete hair loss.
5. If the borders of Zone 5 and/or Zone 5v can be clearly identi- fuzzy, hypopigmented, vellus-like hair. The NO HAIR designa-
fied, their horizontal diameter should be measured. tion is applied to zones whose surface is equivalent to the palm
The ears help locate the borders of Zones 6 and 7. The lower of one’s hand.
edge of Zone 7 is located in the area 0.5 cm above or below a When the density of each area has been determined, it is
line which is circumferentially projected around the back of the plotted in the graph using the appropriate horizontal and vertical
head from the top of the ears. Zones 6 and 7 can be more easily axis (see Fig. 23A-4). It is important that the plot on the horizon-
identified when there is decreased density in Zone 5. tal axis spans all columns of the field (there are a few exceptions
Attention is then directed to the blank bar graph (see Fig. below). When all the fields have been plotted, the cells beneath
23A-2). A set of six density values appears on its vertical axis. the line should be shaded or simply counted. The completed
The values TERMINAL 100%, 75%, 50%, and 25% designate bar graph is the patient’s Hair Loss Profile. The total number
the percentage of terminal hairs in the other zones as compared of shaded cells is the Hair Loss Index (see Fig. 23A-4).
to Zone 10. Under almost all circumstances, Zone 10 is arbi- At times, one may observe that Zone 10 has a diffuse density
trarily assigned the value of TERMINAL 100%. The MINIA- that is lower than expected. This may be confirmed by perform-
TURIZED 100% designation is applied to zones with only ing a surface hair count of Zone 10 midline on the nuchal ridge
HAIR LOSS PROFILE
TERMINAL 100%
TERMINAL 75%
TERMINAL 50%
TERMINAL 25%
MINIATURIZED 100%
NO HAIR
Figure 23A-4 Completed Hair Loss Index and Hair Loss Profile. The estimated density for each zone has been plotted, by hand, on
a blank bar graph. The total number of cells beneath the pencil line has been counted. The borders of the forehead and vertex have been
measured and recorded; the borders of the bridge were not well defined.
890 Chapter 23
using a contact video microscope or hand-held surface with a MINAL 25%, 50%, and 75%) are determined by visually com-
4 mm aperture field. Zone 10 should be represented by less paring the amount of hair to the amount of visible skin. Alterna-
than 25 shaded cells if its density is less than 200 terminal hairs tively, the three intermediate categories might be thought of as
per square cm. Mild, Moderate, or Severe. The MINIATURIZED 100% cate-
In some situations, Zone 10 may have isolated areas of lower gory represents an area that contains no full-sized terminal hairs,
density. An example would be a wide donor scar from hair but only fine, hypopigmented hair and/or downy vellus-like
transplant surgery. The actual location of the hair loss or scar- hairs.
ring can be visually represented in the 25 cell field. Large hair- When attempting to interpret the percent of terminal hairs in
less scars may be depicted by leaving a blank horizontal row an area, the observer might cut a few hairs from Zone 10 and tape
of two to five cells in the center of the Zone 10 field. Another them to a sheet of white (or black) paper. When Zones 1 through
example is female pattern alopecia. These patients often have 9 are evaluated, the relative size of a terminal hair will be more
a lowered density in the left and right lateral portions of Zone apparent by comparison. In spite of this maneuver, the criteria
10 with normal density in the central three-fifths. Females with for Level 1 still invite very subjective interpretations within the
low density in the lateral areas may be represented by lowered intermediate density categories. Photographic examples of com-
percentages in the first and fifth columns of the five-column parative densities, similar to the images in finasteride (Propecia)
field. brochures, might further clarify this issue.
The frontal forelock is defined by Zone 3. However, it is
not uncommon for the forelock to exist as an isolated island of
dense hair on the anterior portion of the scalp. Sometimes the Level 2
forelock may be quite anterior—as seen in patients with fore- Level 2 is the intermediate level of precision. At this level,
heads of less than 9cm—suggesting that perhaps it is a part of actual hair counts are performed on closely trimmed hairs with
Zone 2. Other times the forelock may be in the same location hand lens or contact video microscope. Suggested size for the
depicted by the graphics—as in patients with foreheads of 10 hand lens aperture is a 4 mm diameter circle (12.5 square mm
or 11 cm. In either case of the isolated forelock, the surrounding x 8 ⳱ square cm). Suggested size for the video microscope
Zones 1 and 2 have a much lower density than Zone 3 and their field is a 5 mm x 5 mm square area (25 square mm x 4 ⳱
density should be documented in Zone 1 and 2 fields. In the square cm).
case of the isolated frontal forelock, it is critically important Terminal hairs are defined as 50microns to 70 microns in
that the distance between the forehead dots be measured and diameter. An electronic micrometer is used to directly measure
recorded. freshly cut dry hairs. Because most hairs are oval rather than
round, a microscope with calibrated lens tends to give a wider
range of values than a micrometer. The micrometer, with its two
LEVELS OF PRECISION flat surfaces, is more likely to measure the narrowest diameter of
the shaft. In Zone 10, a terminal hair count of greater than 200
Although most clinicians will use the system as a simple visual
hairs per square cm is considered to be TERMINAL 100%.
method for documenting hair density and distribution, others
Accordingly, the MINIATURIZED 100% category describes
may find value in using it for clinical studies. For this reason,
areas in which all the hairs are less than 50 microns. To perform
three levels of precision have been defined—Level 1 being the
lowest, and Level 3 being the highest. the classification at Level 2, all zones need not be measured
Level 1 precision requires direct visualization by an observer with Level 2 precision—only those of clinical significance.
who must estimate the density of each zone. The reproducibility Those zones that are measured should be recorded as such.
of this maneuver has not been studied or published at this time.
Alternatively, precision Level 2 and 3 are based on direct mea- Level 3
surement with scientific instrumentation rather than visual
impression. One might logically assume that these measure- Level 3 is the highest level of precision. Hair counts and hair
ments are more reproducible than those of Level 1. diameter measurements are performed on 4mm scalp biopsy
The observer’s ability to distinguish the defining borders of specimens viewed in cross section under a microscope.
each zone might also be an issue in assessing the system’s
reproducibility. It should be emphasized that the graphics of this
system are directly derived from the graphics of the Hamilton- DISCUSSION
Norwood system. Because the reproducibility of the H-N sys-
tem has been well established and validated, one might logically The Hair Loss Profile is a capsulated, comprehensive character-
assume that the new system has equivalent reproducibility in ization of the distribution and density of an individual’s hair
this respect. loss. It may be applied to both men and women with pattern
balding, as well as patients with scarring alopecia. It is highly
Level 1 individualized, almost like a fingerprint, and it is easily updated
when the patient is re-examined. The Profile (and Index) may
Level 1 is the lowest level of precision. It is used in the method- serve as a standardized method of communication between phy-
ology described above. The palm of the hand represents no hair sicians. It may also be used for patient education, consultation,
(NO HAIR). The density of hair in Zone 10 represents 100% and counseling. The three perspective graphics would serve
terminal hairs (TERMINAL 100%). The other three categories well as standardized anatomic charts for matters pertaining to
fall somewhere in between. The intermediate categories (TER- hair loss or scalp surgery. A 15 mm. tumor described as located
Table 23A-2 Hair Loss Index directly on the top horizontal line. The 10-zone map was specifi-
Calculated for Each H-N Category
cally designed to ensure that mosaic combinations of each zone
H-N category Hair loss index would conform to the classic Norwood renderings.
1 100
2 95 INTERACTIVE COMPUTERIZED SOFTWARE
2A 75
3 85 A working model for an interactive computerized version has
3A 80 been developed and was introduced at the International Society
3V 80 of Hair Restoration Surgery Annual Meeting in October, 2002
4 70 (Fig. 23A-6). The user electronically inputs the values by high-
4A 70 lighting the cells of the bar graph with a mouse. The bar graph
5 60 becomes appropriately shaded and an individualized hair loss
5A 55 profile is generated. At the same time, the three-view perspec-
6 50 tive becomes shaded in four tones of gray, corresponding to
7 25 the values entered for each field. The shaded picture becomes
a hair loss graphic depicting the density of hair in each zone.
Simultaneously, the total number of shaded cells tallies in a
window labeled hair loss index.
in Zone 6-left becomes verbal shorthand for what would other- Because the software generates digital data, the system may
wise require a drawing or photograph to describe. be used to perform statistical analyses related to hair loss. The
The Hair Loss Index is a single value representing the data may be used to track and characterize the growth response
amount of original hair that still remains in spite of the balding to minoxidil (Rogaine) and finasteride. It may be used to track
process. For interest’s sake, the Hair Loss Index has been calcu- patients with untreated hair loss in order to follow its progres-
lated for each H-N category (Table 23A-2). The Hair Loss Index sion. By comparing age, sequence, and speed of pattern evolu-
is a relative measure of the hair mass (number of hairs x diame- tion, insights might be gained into predicting the final stage to
ter of hair); and it provides a simple answer to the question: which baldness might progress. The data might also be analyzed
How much hair does a patient have? The Hair Loss Index states to determine relationships between hair loss patterns and unre-
the following: On a scale of 1 to 100, the patient’s score is 64. lated phenomena. Are there links to environmental factors, ge-
Because the system is new and the H-N classification is well netics, ethnicity, or other medical disorders? Not an unreasona-
accepted, a conversion chart has been created for those who ble proposal. Three years ago, before the software was
would like to compare the distribution patterns of both (Fig. conceived, a Boston medical group reported that men with se-
23A-5). The user simply locates the shaded zones of the profile vere vertex balding (Zone 5 and 5v) had a 36% higher risk of
on the conversion chart. The equivalent H-N category is read coronary artery disease (5).
Figure 23A-5 Zones of map converted to H-N categories.

892 Chapter 23
Figure 23A-6 Printout from working model of HAIR LOSS GRAPHICS interactive software program. Cells are highlighted via
computer mouse to create a profile. Ten zone map of scalp is automatically shaded in tones of gray to create the graphic. Shaded cells are
automatically tallied to create the index.
23B. Analysis of Hair Characteristics years of age (‘‘young’’) or older than 45 years of age (‘‘old’’).
Table 23B-1 shows our distribution of subjects. We used photo-
in Koreans Using trichograms, in a specific way, and also recorded differences
Phototrichograms between the hair of Caucasians and Koreans.
Jae-Hak Yoo
METHODS
INTRODUCTION
Hairs in a precisely defined circle in the vertex, temporal, and
Although the diagnosis of hair disease depends on the compari- occipital areas of the scalp, in balding and non-balding Koreans
son of normal and abnormal findings, data on the hair character- were evaluated. Each circumscribed area of the scalp, centered
istics of normal hair and hair changes in areas of androgenetic with a dot tattoo to ensure reproducibility, was first shaved.
alopecia (AA) had not been reported in Korea. I, therefore, This shaven area was photographed immediately after shaving.
developed some technical improvements in phototrichogram Two days later, the pattern of grouped hair units (GHU, G1 to
methodology to assess hair characteristics. Appropriately mag- G3), as well as total and anagen hair counts were determined
nified, digital images were taken, at fixed focus and distance, from low magnification images (Fig. 23B-2a, b). Telogen hairs
with a color CCD camera which was connected to a 3CCD were determined as those that did not lengthen in 48 hours. At
digital camcorder (Fig. 23B-1a, b, and c). the same time, the linear hair growth rate (mm/day) (Figs. 23B-
3a, b) and hair shaft diameters (Fig. 23B-4) were obtained from
OBJECTIVE high magnification images. Image mapping and pixel enhance-
ment were used. All images were obtained after hairs were laid
This study was performed to quantify the characteristics of scalp against the scalp by using transparent film. Anagen hair counts
hair of male and female Koreans who were younger than 45 and linear hair growth rates were determined based on the num-
Figure 23B-1 Appropriately magnified, digital images were taken at fixed focus and distance with a color CCD camera which was
connected to a 3CCD digital camcorder a) Sony 3 chip digital camcorder; b) color digital CCD camera; c) Camera is placed on patients’
head and image is viewed on monitor and captured when proper view is obtained. A micro-dot tattoo (x) is used to follow the same location
over the 48-hour period.
Table 23B-1 Distribution of Subjects
Normal AGAa
Male Female Male Female
Young (45) Old (45) Young (45) Old (45) Young (45) Old (45) Young (45) Old(45)
Number 7 7 16 10 16 21 – 2
Age range 17–31 45–64 22–38 47–58 29–44 48–73 – 57–58
Mean SD 24.71 3.22 51.89 6.66 29.11 4.39 52.8 3.22 36.6 5.30 56.9 6.60 – 57.5 0.70
Vertexb 6 5 9 10 15 19 – 2
Occiputb 7 5 15 10 10 14 – 2
Templeb 5 5 13 10 4 8 – 2
a
Breakdown of subjects by Norwood’s modified/Ludwig’s classification of AGA: Young male AGA (16): IIv(2), III(1), IIIv(5), IV(3), V(2), VI(2), VII(1) Old
male AGA (21): IIv(3), III(1), IIIv(1), IV(5), V(3), VI(5), VII(3) Old female AGA (2): Ludwig type I(2)
b
Area studied was a shaved area marked in the center with a tattoo for reproducibility. The shaved area was at the border of the balding areas.
Figure 23B-2 a) Initial low power digital picture of non-balding vertex. Micro-dot tattoo is circled and identified; b) Same location
after 48 hours. Telogen hairs that have not grown are circled. Grouped hair units (G1 to G3) can be identified and counted.
894 Chapter 23
Figure 23B-3 a) Initial picture taken at high magnification with digital mapping of grouped hair units. Micro-dot tattoo is circled and
identified; b) Same location, 48 hours later. The image mapping and tattoo makes it possible to locate the same hairs and measure the rate
of growth. Groupings K and D are circled in both photos and in the second photo the additional length outside the circle can be measured.
ber of hairs that had lengthened over the intervening time pe- tables also show the results of other published data found in
riod. Measurements of the hair characteristics were carried out the literature for comparison.
by comparing the two consecutive pictures with a PhotoShop
and Image Analyzer program (SigmaScan-Pro). Statistical anal-
ysis was performed with sample t-test (paired and independent)/ SUMMARY OF OBSERVATIONS
ANOVA, statistically significant P ⬍.05, P ⬍.01. Normal Non-Bald Subjects
● high inter-individual variation
● hair density fell with increasing age in women
RESULTS
● hair density of the temple : lower than other areas
The following Tables show our results: Hair density (Table ● hair densities of the vertex and occipital areas are not
23B-2); Percent anagen/non-anagen hairs (Table 23B-3); Hair significantly different (normal men and women)
diameter (Table 23B-4); Percent of thin hair (diameter ⬍ 40
␮m) (Table 23B-5); Linear growth (Table 23B-6); Percentages Androgenetic Alopecia
of one to three grouped hair units (GHU) (Table 23B-7). These
● significant mean differences for hair variables (vs. nor-
mal) were found only in vertex area
● decreased hair density and linear hair growth rate in ver-
tex (vs. normal)
The above findings show that lower hair density, larger hair
diameter and slower hair growth rate were found more often
in Koreans than in Caucasians. Considering the hair characteris-
tics of Koreans, (thick, darker colored, and lower hair density
than Caucasians), our method of phototrichogram will be a
promising tool in the study of hair diseases, including androge-
netic alopecia, as well as in the quantitative analysis of the
effects of various agents in stimulating hair growth.
Editor’s Comment
This presentation has been included in the text for two reasons:
1. The method of counting hairs and quantifying them, as
described, is relatively simple and easily done, yet very
accurate. It provides a good model for other investiga-
tors.
2. The data collected by Dr. Jae-Hak Yoo is worthwhile
Figure 23B-4 Photo shows digital image with further pixel knowing, as is the summary of the results of other inves-
enhancement for the measurement of hair diameter. tigators that can be found in the tables. (WU)
Table 23B-2 Hair Density (Hairs/cm2 S.D.)
Normal AGA
OUR DATA Young Old Young Old Young Old Young Old
Vertex 13711 13424 13923 12425 11912 10223 – 11531

Occiput 13511 14016 13621 12018 13318 13717 – 12119
Temple 11914 11713 12026 9224 1090 10920 – 11211
PUBLISHED DATA
1) Occiput (Korean) 553 4811

2) In tissue (Korean) 12829
(AA, occiput)
3) Vertex (Japanese) 180.6 156.5
4) Occiput (Caucasian) 31111 27112 2198 18910
5) Vertex (Caucasian) 29361 21155
6) Vertex (Caucasian) 26030 30020
1) Lee SJ, Kor J Dermatol, 1994, Visual count
2) Lee HJ, Kor J Dermatol, 2001, 4 mm punch biopsy
3) Hayashi S, Br J Dermatol, 1991, phototrichogram
4) Rushton, Br J Dermatol, 1983, unit area trichogram
5) Birch MP, Br J Dermatol, 2001, macrophotography
6) D’ Amico D, European J Dermatol, 2001, videomicroscope
AA, androgenetic alopecia; AGA, ;SD, standard deviation
Table 23B-3 Percent Anagen/Non-Anagen Hair
Normal AGA
Vertex 93.7/6.3 91.8/8.2 92.8/7.2 92.1/7.9 82.4/17.6 79.5/20.5 – 84.3/15.7

Occiput 92.6/7.4 91.7/8.3 93.6/6.4 93.1/6.9 88.1/11.9 89.0/11.0 – 89.8/10.2
Temple 91.8/8.2 91.0/9.0 94.2/5.8 91.9/8.1 87.2/12.8 87.4/12.6 – 84.3/15.7
PUBLISHED DATA
1) In tissue, (Korean) 94/6 (AA, Occiput)

2) Vertex (Japanese) 88.8/11.8 27.1/72.9
3) Front (Caucasian) 90/10 90/10 57/63 73/27
3) Occiput (Caucasian) 92/8 91/9 85/15 82/18
4) Vertex (Caucasian) 84/16 89/11
1) Lee HJ, Kor J Dermatol, 2001, 4 mm punch biopsy
4) D’Amico D, European J Dermatol, 2001, video-microscope
AA, androgenetic, alopecia; AGA,
896 Chapter 23
Table 23B-4 Hair Diameter (m)
Normal AGA
Vertex 78 11 64 2 79 7 75 7 60 9 54 6 – 62 7
Occiput 85 11 95 15 83 8 81 8 79 8 73 11 – 88 14
Temple 87 13 81 7 87 5 82 12 74 12 71 7 – 79
PUBLISHED DATA
1) Vertex (Japanese) 81 10 51 7
2) In tissue (Korean) 100
3) Front (Caucasian) 68 2 70 3
3) Occiput (Caucasian) 64 2 67 2
4) Vertex (Caucasian)
1) Ishino A et al, J of Dermatol, 1997, phototrichogram
2) Oh CH, Absts of Ann Meet, 1996, 4 mm punch biopsy
4) Birch MP, Br J Dermatol, 2001, macrophotography
AGA,
Table 23B-5 Percent of Thin Hair (diameter 40 m)
Normal AGA
Vertex 6.1 11.2 2.3 5.5 16.7 23.0 – 11.4

Occiput 5.0 3.8 2.4 3.1 10.5 12.7 – 8.65
Temple 4.5 5.2 4.8 3.1 8.12 9.06 – 7.19
PUBLISHED DATA
1) In Tissue (Korean) 6.3 (AA, Occiput) 7.7

3) Front (Caucasian) 8.3 10.4 30.9 24.1
3) Occiput (Caucasian) 11.3 13 12.3 16.4
4) Vertex (Caucasian) 9.4 9.2
1) Lee HJ, Kor J Dermatol, 2001, 4mm punch biopsy
4) D’Amico D, European J Dermatol, 2001, videomicroscope
Table 23B-6 Linear Hair Growth (mm/day)
Normal AGA
Vertex 0.319 0.316 0.321 0.327 0.287 0.265 – 0.286

Occiput 0.311 0.309 0.302 0.315 0.301 0.294 – 0.313
Temple 0.300 0.325 0.305 0.289 0.311 0.302 – 0.314
PUBLISHED DATA

2) Vertex (Caucasian) 0.35 0.38
2) D’Amico D, European J Dermatol, 2001, videomicroscope
AGA,
Table 23B-7 Patterns of Grouped Hair Units (one to three hair groupings G1, G2, G3)
Normal AGA
OUR DATA (%) Young Old Young Old Young Old Young Old
Vertex
of G1 37.6 42.0 34.3 32.6 58.0 62.6 – 57.9
of G2 38.3 31.0 41.4 42.2 25.0 22.6 – 26.77
of G3 24.8 26.0 23.5 24.7 16.7 14.8 – 15.31
Occiput
of G1 32.7 40.3 31.1 33.1 38.9 46.3 – 41.2
of G2 40.1 35.5 44.8 43.7 37.4 31.7 – 34.9
of G3 26.5 23.6 23.1 22.5 23.0 21.6 – 32.9
Temple
of G1 36.8 37.0 36.8 46.2 39.13 45.8 – 45.1
of G2 40.6 36.0 42.4 38.4 34.5 35.2 – 31.4
of G3 22.5 37.0 20.2 15.1 25.9 18.7 – 23.5
PUBLISHED DATA (%)
1) Front
of G1 46.5 56.9
of G2 41.8 30.6
of G3 6.0 6.2
of Ga 5.5 6.3
1) Occiput
of G1 44.9 38.4
of G2 42.3 43.8
of G3 7.5 13.4
of Ga 5.3 4.3
1) Temple
of G1 54.2 42.1
of G2 41.7 41.5
of G3 6.0 11.3
of Ga 5.4 5.1
1) Lee SJ, Kor J Dermatol, 1994, by visual count of compound hair
AGA,.
898 Chapter 23
23C. The Coronal Incision Recipient

Site
Victor Hasson
In determining the ideal recipient site, the hair restoration sur-

geon should observe the way in which follicles within the follic-
ular unit (FU) and also individual follicular units are arranged
in nature. The follicles within an FU can be arranged in one of
the following patterns:
The follicles may exit the skin through separate openings
in the epidermis, or, through a common exit or follicular
canal.
The follicles may be arranged irregularly as a bunch, or, in
a linear fashion. When the follicles are arranged in a linear
fashion, the orientation of this line is at 90⬚ to the direction Figure 23C-2 Linear arrangement of FUs in donor area.
of hair growth (Fig. 23C-1). The FUs are also frequently
arranged in a linear fashion relative to one another and
again at 90⬚ to the direction of hair growth (Fig. 23C-2).
It is thus apparent that nature has attempted to maximize scalp the same area of skin being repeatedly covered by each
coverage by both orienting the follicles within an FU in a spe- follicle’s hair and gives the impression of stringy grafts.
cific pattern at right angles to the direction of hair growth, and With coronal incisions, the hairs exit the scalp alongside
then by arranging these FUs in lines that run at right angles to one another giving greater scalp coverage (Fig. 23C-3).
the direction of hair growth. 2. The angle of exit of the graft, from the scalp, can be
The follicles exit the scalp at an angle, which varies in the controlled precisely as the graft is sandwiched between
different areas of the scalp, and is most acute on the steep slopes the sides of the slit (Fig. 23C-4). This allows for smooth
of the temporal and occipital scalp. The acute angle maximizes and natural hair flow and is also important where the
the shingling effect of the hair in these follicles. Traditionally, degree of hair angulation is very acute, as in reconstruct-
hair transplant surgeons have oriented recipient site incisions ing sideburns. With sagittal incisions, the effect of one
in the direction of hair growth or the sagittal plane. Presumably, follicle emerging directly posterior to the other is to
this is done to avoid cutting across Langer’s lines and to mini- decrease the degree of angulation of the graft. This
mize transection of the blood vessels arising from the subdermal makes the hair stand away from the scalp, which is
vascular plexus. There are, however, multiple advantages to most noticeable in the frontal hairline when the hair is
orienting the slits at right angles to the direction of hair growth combed forward. The hair at that site will not lie natu-
(coronal plane). These include: rally on the scalp but stands forward and away from the
1. Maximizing the area of scalp coverage and shingling scalp.
effect of the individual FU: In sagittally-directed slits, 3. There is reduced injury to the subdermal vascular
the follicles exit the skin anterior to one another or plexus. This is because the deepest point of the blade
bunch up in the midportion of the slit. This results in
Figure 23C-3 Hairs arising side-by-side with coronally ori-

Figure 23C-1 Linear arrangement of follicles within FUs. ented grafts.
Figure 23C-4 Precision angulation of grafts. Figure 23C-6 Absence of scarring with coronal incisions.
is more shallow for a given graft depth than if the inci- from cutting across Langer’s lines (Fig. 23C-6). There
sion is sagittal. Sparing of this vasculature is especially is, however, a beneficial effect in that the scar does not
important when there are dense packing grafts. contract significantly, so no bunching of the follicles
4. Less Popping occurs within the graft.
In traditional sagittal incisions, the pressure created, The incisions may be arranged in a line created at
when grafts are tightly packed, is in a lateral direction right angles to the direction of hair growth and be stag-
and additive to the pressure created by surrounding gered with respect to the lines of grafts anterior to and
grafts. posterior to them (Figs. 23C-7a & 7b). This minimizes
With coronal incisions, the forces are mainly down- redundancy of scalp coverage by adjacent grafts. The
ward and upward. There is fairly free expansion in these angle of exit of the follicles may also be made more
directions (toward the skull and air above the scalp, acute to exaggerate the shingling effect.
respectively) and these forces tend to not affect sur-
rounding grafts.
Decreased bleeding from sparing the subdermal vas-
cular plexus also reduces popping. Reducing popping
Additional Considerations
allows for more dense packing of grafts (Fig. 23C-5).
5. In practice, with recipient sites that are less than 2.5 1. The best-shaped blade to create the incisions is a chisel
mm long, there is no evidence of increased scarring tip, producing a linear incision, which is rectangular in
shape beneath the skin surface (Fig. 23C-8). (Spearpoint
blades and needles produce crescentic incisions.)
2. The ideal recipient site should be small, allowing for:
a snug fit for the graft
minimal damage to scalp vasculature
rapid healing
closely spaced sites to allow for maximum density
The terminal hair shaft usually has a diameter of 60
microns to 85 microns and extends 3.5 mm to 5.0 mm
deep and into the subcutaneous fat. The depth of the
incision should be measured and fixed to be equal to
the length of the individual patient’s follicles. The ideal
width of the incision for single hair grafts is 0.70 mm
and for multiple hair FUs is 1.00 mm to 1.25 mm.
3. The recipient scalp should be tumesced before and im-
mediately after incisions are created. This has two main
effects: It increases the depth of the subdermal vascular
plexus, giving a greater margin of safety for the inci-
Figure 23C-5 This photo shows a patient who had 3000 FUs. sions. It increases vasoconstriction—which results in
The frontal forelock had approximately 50 FUs/cm2 with density decreasing bleeding—both onto the skin surface and
in the surrounding areas. into the interstitial tissue. Hemorrhage into the intersti-
900 Chapter 23
a b
Figure 23C-7 (a) Staggered pattern of coronal incisions. (b) Staggered incisions with grafts in situ.
tial space increases pressure in the scalp both directly average angling of the recipient sites, and the hair characteristics
as it occupies space and indirectly as blood breakdown of that patient, than to the coronal direction of the incisions.
products affect tissue osmotic forces, which draw more As Hasson points out in the above discussion, one can more
fluid into the interstitial space. The increased scalp tis- easily place FUs very close together laterally, if the incisions
sue pressure may impede the already diminished blood are coronal and the angle is more acute. This is because more
flow into the scalp with resulting tissue hypoxia and of the pressure forces caused by the insertion of the grafts are
possible necrosis. directed superficially and deeply than laterally. More acute an-
gling of grafts also exaggerates the shingling effect. Neverthe-
Editor’s Comment less, I could not think of any reason why a single FU would
At the October 2002 annual meeting of the International Society produce more coverage if directed coronally instead of sagit-
of Hair Restoration Surgery, Victor Hasson presented a patient tally, until I realized that a multiple-haired FU is a miniaturized
in whom the incisions, for the FUs he was using, were made form of a slit graft containing multiple FUs. In Chapter 12F, I
coronally and at a markedly acute angle (1). The results in that pointed out that the FUs within such a slit graft are lined up
patient were excellent. At first, I thought that the excellence one behind the other, and closer together than can ever be repro-
was due far more to fine surgical technique, a more acute than duced by follicular unit transplantation (FUT). This is analogous
Figure 23C-8 Chisel-tip blade.

to hairs in a multi-haired FU being lined up one behind the that everything else relative to planning will then flow from
other (as Hasson points out) and closer together than a single- that, rather than the other way around. In the last few years it
haired FU could ever be placed. If a slit graft is used, it is like appears to us that patients, as well as physicians, are being
planting a hedge of closely spaced bushes (FUs) in a line, closer increasingly sold on process rather than product. What we
together than would be possible if you tried to plant single should be most interested in is the final result, or the product.
bushes (FUs) as close together as possible. If this densely The purpose of the process is to make it as easy as possible to
packed hedge of bushes (FUs) is directed somewhat coronally, achieve that product. Ultimately, the product is what will im-
then combing the hair within it posteriorly, produces more cov- press the patient because he lives with it for a lifetime. The
erage of an alopecic space posterior to it than would a sagittally process seems to sometimes be directed at impressing col-
directed, less densely planted hedge of bushes. The same phe- leagues and uneducated patients, by focusing attention solely
nomenon could be expected to apply to densely packed hairs on the number of grafts per session or the undetectability of
in a multi-haired FU. I would emphasize, however, that while the session (process) without considering whether or not the
FUs planted coronally may cause less or more vascular damage particular number and/or type of grafts per session is consistent
than sagittally planted ones, slit grafts planted coronally almost with the originally envisioned finished product.
certainly do cause more vascular damage. Beehner and others The concept of doing an entire head with micrografting, for
have had relatively poor hair growth with coronal slit grafts. example, sounds very attractive, until we stop to realize that
When I use slit grafts (or slot grafts), they are planted into we cannot insert one-hair to two-hair micrografts as close to-
incisions that are somewhat coronal, so as to follow the direction gether as nature can. If you have any doubts about this state-
of hair in the area in which they are being used. (See Chapters ment, I urge you to take a 4-mm round graft and dissect it into
12F and 12G). I have never observed decreased hair survival one-hair micrografts. Then, take a 16-gauge needle and see if
when doing this. Quite the contrary. I am looking forward to you can get all of the micrografts into a 3.25 mm round circle
seeing the results of other practitioners who have already indi- in the recipient area. I have tried this on several occasions, and
cated that they will be trying coronally directed multi-haired whenever I have, I find that I end up overlapping the grafts and
FUs in the near future. (WU)
producing sometimes three or four hairs coming out of a single
site, rather than the one or two hairs that I was aiming for.
Therefore, it follows that we cannot create the same density as
nature originally produced if we try to do it all with one-hair
23D. Comments on Hair and two-hair micrografts. We can, however, reproduce the orig-
Transplanting inal hair density (or even exceed it) with standard round grafts.
Transplanting a whole head with micrografts, therefore,
Emanuel Marritt
should be directed only at those individuals whose ultimate
objective is light coverage, and who understand very clearly
INTRODUCTION that they could have denser results if they chose a different,
though more noticeable, intermediate route. Dr. Unger and I
Below Dr. Marritt describes his philosophy and technique as are in total agreement about this aspect of transplantation. The
of 1995. As most readers are aware, he subsequently became patient on whom you have just transplanted 500 one-hair to
far more enamored of follicular unit hair transplanting (FUT)
two-hair micrografts may very well call you 3 to 5 weeks later
or total micrografting, yet his reasoning with regard to larger
and tell you that you are an absolute genius because nobody
grafts remains pertinent. Although recipient sites for follicular
has noticed that he is having a transplant carried out. Five
units (FUs) are now made with needles and blades that produce
months later, however, many of these individuals may call you
smaller incisions than those of the 16-gauge needle he was, at
back in a far less generous mood, asking you why they wrote
that time, using for micrografts, FU still cannot be transplanted
as close together as they occur in nature (or closer than nature such a large check for so little hair. Once again they will state:
after tissue contraction). His references to my technique, of ‘Nobody knows that I have had anything done,’ but this time
course, refer to what I was doing in 1995, and my views at that they will add: ‘even me!’ It is at precisely this time that the
time. As is discussed elsewhere in this text, both have evolved. patient downgrades you from AAA genius to junk status car
I have reproduced the photos of one of his patients that were salesman.
used to validate what he was then recommending. While the Although it is true that repeated sessions of micrografts will
hair density toward the midline of the frontal area is the result produce greater density, I will restate that it will never be the
of a combination of persisting original hair and transplanted sort of density that could have been obtained with round grafts
hair, the hair line photos demonstrate density and naturalness of various sizes, instead (for example, from 4.5 mm to smaller
accomplished with a combination of micrografts and minigrafts five to eight-hair round grafts)—and it will involve a good deal
(and essentially no original hair). They speak for themselves. more work, time, and possibly sessions. In addition, it nearly
(WU) always will involve a substantially greater cost.
Let me begin by saying that I believe Dr. Unger and I agree
on the majority of aspects of hair transplanting. We do have
significant differences in several areas that have been previously PLANNING
discussed in published articles, and will be alluded to in this
chapter. The most important area in which we agree, however, Conceptually, in most patients, one should think of the recipient
is that both of us believe in envisioning the final product, and area as consisting of two zones: one in which density is the
902 Chapter 23
goal, and the other in which softness is the goal. The area that ciousness of the healing capacity of any given patient is beyond
is to be transplanted densely should have no micrografts, but the skill and experience of the surgeon, though obviously the
instead, should be treated with all round or pie-shaped five-hair latter will mollify, to some extent, how bad the scar will or will
to eight-hair minigrafts, or if you prefer, all five-hair to eight- not be, (c) density: the more the donor area is stretched (as an
hair square minigrafts. Within the zone of softness, I prefer to inevitable consequence of AR), the lower the density of hair
use all micrografts, whereas Dr. Unger prefers to use a within that donor area becomes. The words ‘‘alopecia reduc-
combination of micrografts and small (three-hair to four-hair) tion’’, when spoken by the surgeon, create such a seductive and
slit grafts. Our approach in this softness zone differs, but the blissfully simplistic image (‘‘let’s make the baldness smaller’’)
difference is not as great as it first seems: a three or four- that the patient, who dreams of perpetually shrinking pink scalp,
hair slit graft can be viewed as two one-hair or two-hair is likely to forget that the term, alopecia reduction, is purely
micrografts in a line. relative. It is a description of surgical procedure described from
I prefer to do the first session with two-hair micrografts only, the point of view of the bald area. But what if the surgeon were
the second session with one-hair micrografts anterior to the to describe the same procedure from the point of view of the
two-hair micrografts, and the third session, which is done after
the first two have grown in, will consist of additional one-
hair micrografts and possibly two-hair micrografts into the
two-hair micrograft zone again (Fig. 23D-1). The latter will
be used just anterior to the round minigrafts that will be
employed in the area that I want to transplant more densely.
I do not use one-hair micrografts at that site—that is, just
anterior to the zone of round grafting.
One of the other aspects of differences of opinion between
Dr. Unger and myself is the issue of what proportion of the
eventual area of male pattern baldness (MPB) I would attempt
to transplant. I am far more cautious than he is with younger
patients, perhaps rightly and perhaps not. For example, the
only 30-year-old patient in whom I would attempt to trans-
plant the whole head would be somebody with a type III
variant of MPB.
My views on Alopecia Reduction (AR) have been spelled
out in great detail in the November/December, 1993 issue of
Hair Transplant Forum (Vol. 3, No.6), and in a chapter that I
have recently written with Raymond Konior for Facial Plastic
Surgery Clinics of North America (Saunders, May 1994), enti-
tled ‘‘Patient selection candidacy, and treatment plan for hair
replacement surgery’’. I will not spend much time on that matter
in this chapter because it is being covered so well elsewhere.
However, briefly, I am concerned about AR in patients with
present or future significant extensive baldness for several rea-
sons: (a) hair direction: the more one repeats AR in patients
with significant or extensive baldness—which is defined as that
degree of present or potential baldness in which the superior
fringe hairs have shifted 90⬚ from nose to ear—the more likely
one will end up with an unnatural hair direction and the effect
referred to as ‘‘the parting of the Red Sea’’ syndrome. Regard-
less of the technique (scalp reductions, scalp lift, extenders,
expanders) used to accomplish this heroic feat in these particu- a
lar patients—the removal of the entire area of MPB—this ab-
normal hair direction will occur, (b) scarring: I am a great be-
liever in the capriciousness of healing in any given individual. Figure 23D-1 (a) Frontal view of patient before transplanting.
I have, on occasion, taken a row of 4 mm grafts from the donor Conceptually, I have divided the frontal area into two zones: the
anterior one for softness that I will treat primarily with micrografts
area and ended up with a scar that was more than 3 mm wide
and, posterior to that, a midzone of density that I will transplant
(this is more likely to occur in temporal areas). On the other
with round minigrafts. (b) Close-up of patient with coarse, dark,
hand, I have had patients in whom 9 mm to 10 mm of donor dense hair before two-haired micrografts are added. (c) Patient with
area has been excised, and a scar of 1 mm is produced. Simi- coarse, dark hair with two-haired grafts added, but still looking
larly, with AR, I am never sure who will develop the fine scar ‘‘micropluggy.’’ (d) Close-up of hairline of the same patient; at
and who will develop the wide scar. Furthermore, I am worried the same time as that shown in Fig. 23D-1c. (e) Same patient as
that even a fine scar will show a detectable shadow under certain shown in previous photos, but now with one-haired grafts added
conditions—not because it is wide—but because collagen con- anterior to the two-haired micrografts. The hairline now appears
traction has caused the scar line to indent. And this capri- considerably less micropluggy.
b c
d e

904 Chapter 23
hairy fringe? What if the surgeon were to say, ‘‘I’m going to The usual number of grafts that I use per session is 200
perform a fringe stretching, inferior hairline raising, density minigrafts to 225 minigrafts, and 50 micrografts to 100 mi-
decreasing, hair disorienting, potentially scarring procedure on crografts. The usual interval between sessions is 4 to 5 months,
your head?’’ Same procedure, different viewpoint (the Rasho- so that I can evaluate growth from the previous session and
mon phenomenon). As a result of these concerns, in the last make adjustments in the size and spacing of subsequent sessions
year, only approximately 5% to 10% of my patients have had according to what I see.
ARs done. I will virtually always use the ‘‘Mercedes’’ or ‘‘in- Quadrisected 4.00 mm and 4.25-mm round grafts are placed
verted-Y’’ pattern. The exceptions are when, because of previ- into recipient sites made with 1.5 mm punches. Quadrisected 4.5
ous grafting elsewhere, other patterns allow me to conserve mm grafts are placed into holes made with 1.75 mm punches.
previously transplanted hair. Quadrisected 5 mm grafts are put into holes made with 2 mm
round punches. Quadrisected 5.5 mm grafts are placed into
holes made with 2.25 mm punches. There is a specific reason
THE RECIPIENT AREA why I use these exact ratios. If one remembers that a 4 mm
graft most often fits best into a hole made by a 3.25 mm punch,
The principles on which Dr. Unger approaches the recipient one can deduce that a ratio of 1.5:1 is the best ratio between
area are almost exactly the same as mine. As noted earlier, the size of the punch used to obtain hair-bearing skin, and the
however, I generally use minigrafts for density and micrografts size of the punch used to drill out the recipient site. All of the
for softness. Conceptually, the objective in the recipient area previously noted numbers reflect the same ratio, that is, 1.5:1.
can be only one of two possibilities: (a) maximum density—re- Why do I limit my sessions to approximately 200 minigrafts?
quiring the removal of all bald skin and its replacement with Patients are always paying for a certain number of hairs in
hair-bearing skin as we used to do with standard 4-mm round a specific and appropriate pattern of distribution. If you are
grafts, or (b) less than maximum density in the form of micro- transferring 100, 4 mm grafts, you would be transferring 1200
grafting. (Note: Less than maximum density transplanting with mm2 of tissue. If, instead, you take 50, 5.5 mm grafts and quad-
minigrafts works only if the patient has the proper camouflaging risect them, you will end up with 1187 mm2 of tissue (alterna-
combinations; e.g., red hair, ruddy complexion). In patients with tively, one could use 60, 4.5 mm grafts and quadrisect them).
dark hair and light skin, it will always look pluggy, unless very Thus, I am at peace with myself when I charge the patient the
small minigrafts are used. In other words, when minigrafts re- same fee for 200 quadrisected grafts, as I would have for 100,
semble micrografts. 4 mm grafts. This personal sleeping remedy, however, may not
Whenever I use minigrafts, I do not use the classic checker- be appropriate for all surgeons, only those with terminal guilt
board filling described in Chapter 8 (3rd edition, 1995) by Dr. and inoperable malignant meshuginomas.
Unger. I prefer a more scattered approach. However, my defini-
tion of scatter incorporates a maximum distance between grafts
of one-graft diameter, so that, in the long run, I can fill the area
solidly. Just as Dr. Unger does, I always use micrografts anterior
23E. The Best Possible Hairline: A
to whatever type of graft I am using posteriorly to the soft
hairline zone. In the past, I would quadrisect a 4.00 mm or Tip
4.25-mm graft, and place these sections into small round holes Martin E. Tessler
to minimize the transitional tuftiness from session to session.
If the patient had particularly dark hair and light skin, however,
I often found that this did not look natural, and I had to go back INTRODUCTION
over the area repeatedly. The question was why go to the extra
work and extra sessions? Why not do large minigrafts from the In this chapter, Hasson recommends a coronal orientation of FU
start and save my time and the patient’s money? grafts. In Chapter 12G, I discuss the advantages of a somewhat
The only reason for using small minigrafts behind mi- coronal direction of slit graft sites and refer the reader to sche-
crografts in patients with dark hair and light skin is to minimize matic drawings in the 1995 edition of this text. In the same
the appearance of tuftiness after the first and second sessions edition (1995), Martin Tessler reinforced this approach and
only, before the spaces between the round minigrafts are filled. showed intraoperative clinical photos demonstrating it. His
Obviously, the smaller the round minigrafts, the less clumpy comments and those figures are reproduced below. (WU)
the transitional appearance will be. As a result, my approach One of the main reasons that most grafts are noticeable when
on the part side, for example, might be a zone of single-hair the first procedure grows in is because of the space that can be
micrografts, followed posteriorly by a zone of double-haired seen between the grafts. This will vary from patient to patient,
micrografts, followed posterior to that by round minigrafts of depending on the hair texture, hair color, and hair style.
various sizes, particularly in the early sessions. Each session I have found that by angling and overlapping the grafts at
would consist of approximately the same number of minigrafts, the frontal hairline (Fig. 23E-1), the sides of the grafts are seen
but the sizes of the minigrafts would change somewhat to take when the observer is facing the patient and looking directly at
into account the absence of hair on the periphery of some of the patient’s hairline. This almost completely eliminates the
the minigrafts, or the growth of hair to the edge of minigrafts clumped appearance, even after one procedure. As one moves
that are inadvertently somewhat closer than one graft apart (just posteriorly from the hairline with the incisions, they are placed
as I do with larger grafts when solid filling is the objective). in a more forward direction. Micrografts are also placed in front
All of the foregoing refers only to patients in whom I am seeking of and between the slit grafts to create more softness. To create
maximum density. more thickness, the process is repeated.
Figure 23E-1 This patient will part his hair from left to right. The slits are directly significantly to the right and are staggered. Therefore,
when hair grows, the sides of the grafts are seen. This significantly reduces graft noticeability that is usually seen (other than with F.U.
grafts) after one session.
23F. Long Term Follow-Up of CASE 1

Patients This patient was initially treated 21 years ago, when he was
Walter P. Unger 45 years old. Figure 23F-1a demonstrates his appearance at
the end of treatment at that time. Although the frontal area
posterior to the hairline zone was somewhat sparse, the pa-
The following section is reproduced from the 1995 edition of
tient, who had originally been nearly totally alopecic in that
this textbook. The types/number of grafts utilized are ob-
area, was very happy with the results. I did not see him
viously outdated but the concepts and lessons that can be
again until he came back with his 29-year-old son, whom
learned from the four patients that are presented are not. The
he had brought for transplanting. Figures 23F-1b to 1d shows
ultimate degree of naturalness and hair densities are also worth-
while noting. (WU) different views of him at that time. Although the frontal area
There has been virtually no discussion in the literature on has thinned slightly, perhaps because of the loss of any of
the long-term follow-up of hair transplant patients and what the original hair he had still retained when I treated him, or
can be learned from them. The most likely cause of this obvious thinning of the donor areas from which the grafts were taken,
gap in our knowledge has been that most patients, once they his appearance was still very good. There are at least three
have completed their treatment, seem to have had no further reasons for this good fortune: 1) his hair has turned white
need of our services. Those of us who have been working in and, therefore, looks thicker than it is; 2) he wears his hair
this field for 15, 20, or more years, however, have been seeing in a short and curly style that also makes it appear thicker
an increasing number of them return to refine earlier work or than it actually is; and 3) he was 45 years old when first
to treat new unexpected areas of male pattern baldness (MPB). treated. His area of MPB was nearly fully developed, and
The latter problem is not the inevitable sequelae of long-term his prognosis was more easily surmised.
follow-up of all patients; however, long-term planning errors Although his MPB has advanced somewhat, and no doubt
are likely to become more commonly seen as time passes. Four will advance further, he had over 20 trouble-free years and still
case histories are presented here. They represent a spectrum of has grafts in reserve because of the total excision techniques
what can be expected, what can be learned from them, and how described in Chapter 7 (3rd edition) and Chapter 10 (present
they can be managed. edition).
906 Chapter 23
a b
c d
Figure 23F-1 (a) A 45-year-old man immediately after completing transplanting 21 years ago. The slightly thin frontal area behind
the left side hairline zone was not noticeable in person. (b) Similar view of the same patient in 1994. (c) Front view in 1994. Both the
color of his hair and the short, curly hairstyle make the results look considerably thicker than they are. (d) Side view in 1994.
CASE 2 by time. Small ellipses were excised bilaterally in the alopecic

areas superior to the temporal hair, to conserve grafts that would
This patient was also treated 21 years ago, but was 21 years have been necessary to transplant these sites. Three weeks later,
old at the time. Figure 23F-2a shows the pattern of transplanting the first of two sessions (6 months apart) of micrografts, round
used in the first session. Figure 23F-2b shows him at the end minigrafts, and slit grafts was carried out. Grafts were obtained
of treatment, and Figure 23F-2c shows how he looked 11⁄2 years from strip excisions through previously harvested parieto-oc-
ago when he came back to see what could be done about his cipital areas, as discussed in Chapter 17. Figure 23F-2d is the
deteriorated appearance. He had lost whatever original hair he result of these two sessions. Another all-micrograft session, to
had retained in the frontal area when I first treated him—includ- further refine the hairline, is being considered.
ing hair in triangular areas adjacent to the superior temporal It is fortunate we never tried to treat his vertex area at any
areas bilaterally. The hairline was also quite pluggy-looking time. He also may well need any grafts he still has left for
and the donor area had been extensively depleted by me and further progression of the MPB. On the other hand, there was
a b
c d
Figure 23F-2 (a) A man who was treated 21 years ago at age 21. This photograph was taken during the first session. (b) His appearance
21 years ago at the ‘‘end’’ of treatment. (c) His appearance when seen again in 1992. (d) After excision of small ellipses superior to both
temporal areas and 6 months after the second of two sessions of micrografts, slit grafts, and round minigrafts.
no necessity for him to have waited so long before returning area to develop, as happened in Case 2. He will return for further
for treatment. He needlessly looked poorly for at least 10 years. treatment if and when thinning is noted. Most likely this will be
done in conjunction with transplanting of thinning areas more
posteriorly, thus avoiding what might be annoying small ses-
CASE 3 sions.
This patient was first treated in 1977, when he was 21 years
old. Figure 23F-3a shows him before treatment and Figure 23F-
3b 5 months after his fourth session 6 years later. At that point, CASE 4
virtually all of the original hair in the frontal area had been
lost and replaced with transplanting. He returned in 1993 for This patient finished his first course of treatment (three and one
treatment of slight-to-moderate thinning superior to the tem- half-sessions) 19 years ago when he was 29. Figure 23F-4a
poral area bilaterally (Figure 23F-3c). Figure 23F-3d is a close- shows a top view just before the last half-session. Figure 23F-
up of one of these areas 6 months after a single session of slit 4b shows the same view 15 years ago when he returned for
grafts that were used to thicken them, as well as to start treat- additional grafting. Figures 23F-4c and 4d are the same view
ment posterior to the previous transplanting. in 1990 and 1994, respectively, when he had returned for yet
Both Case 2 and Case 3 demonstrate the need to anticipate more treatment. Figures 23F-4e to 4L show different views of
future thinning in the frontal corners. This patient, however, the same patient at the same times as those described above.
did not and will not in the future wait for an obviously bald He has slowly kept pace with and thickened any thinning areas
908 Chapter 23
a b
c d
Figure 23F-3 (a) A 21-year-old patient before treatment in 1977. (b) Six years later, 5 months after the fourth session to the anterior
third of the area of MPB. (c) The patient as seen in 1993. Note a thinning area just superior to the black crayon line marking the superior
border of apparently permanent temporal hair. (d) Close-up of the same area (and hairline) after one session of micrografts to the hairline,
slit grafts to the thinning corners, and slit grafts posterior to the area transplanted earlier, all done concomitantly.
over the years, while utilizing four ARs and taking advantage between 500 and 700 more slit grafts. He represents the ideal
of all the advances in transplanting technique that have occurred approach to transplantation.
in the last 19 years. His hair looks thicker now than it did 19 We have been saved from many instances of poor judgment
years ago, and he claims nobody other than his family and hair that we might have had 20 or more years ago, by the graying
stylist are aware of the transplanting. of our patients and the seemingly never-ending advances in the
Furthermore, although I thought we were running out of surgical treatment of MPB. Alopecia reduction allows us to
grafts 4 years ago, because of total excision techniques in the excise some unexpected areas of hair loss. Micro-minigrafting
donor area, I now feel he still has enough donor tissue for of various types permits less dense, but still natural-looking
Figure 23F-4 (a) Top view of transplanted frontal area immediately before a fourth session in 1975; (b) top view in 1979. (c) top view
in 1990; (d) top view in 1994; (e) side view in 1975; (f) side view in 1979. (g) side view in 1990; (h) side view in 1994; (i) vertex view
in 1975; (j) vertex view in 1979; (k) vertex view in 1990; (l) vertex view in 1994.
a b
c d
e f
910 Chapter 23
g h
i j
k l
Figure 23F-4 Continued.

results and involves the need for less donor tissue than standard sorbable 3-0 sutures through the whole thickness of the
grafting would to produce cosmetically acceptable transplant- scalp (Fig. 23G-1). These sutures will obviously destroy
ing. Finally—and perhaps most importantly—strip harvesting some hair follicles. For sites with less closure tension,
of previous donor sites, as described in Chapter 7 (3rd edition) we use nonabsorbable 5-0 sutures through only the epi-
and Chapter 10 (present edition), has led to a bonanza of new dermis and superior (reticular) layer of the dermis. In
graft reserves while improving the hair density in the areas from this way, hair bulbs will not be destroyed, since they
which they were taken. These advances may have saved us in are at a deeper level of the skin.
the past, but we cannot expect to be as lucky in the future. 3. If the donor zone surface has the shape of a parallelo-
We will have already used AR, micro-minigrafting, and total gram, it is sutured letting the edges slide to prevent the
excision techniques in the donor area in our patients. If we formation of a dog-ear at both ends (Fig. 23G-2).
misjudge their long-term prognosis, we will have that much 4. If the donor zone surface has the shape of a rectangle,
less left to fall back on. In brief, although these advances have we begin closing the central zone. At both ends, we do
substantially increased the options we can offer to our patients, not cut a triangle as is usually done, but we suture in
they must be used that much more judiciously. a Y-shaped form, so that no tissue is wasted (Fig. 23G-
3). Both ends will look like a dog-ear, but they will
level off within a few weeks. The triangular zones that
23G. Closure of the Donor Zone could be resected are not suitable for grafting.
5. If the surface has an elongated lozenge or rhomboidal
Felipe Coiffman shape, it is sutured normally. However, the strips with
this shape waste part of the square grafts because many
INTRODUCTION of them are cut incompletely (Fig. 23G-4).
6. When there is not a single zone available from which we
Half of us are blind, few of us feel and we are all can obtain sufficient grafts, many times we use different
deaf. small donor zones during a single surgical procedure.
Sir William Osler 7. We recommend that a mild antiseptic (benzalkonium
chloride) be used on the sutured area. The sutures are
In the 1979 edition of this textbook, Felipe Coiffman sug-
removed 8 to 12 days postoperatively.
gested that a block excision of the donor area would result in
the most efficient way of harvesting grafts for transplanting. It Proper management of the donor zone will not only prevent
was too many years before hair restoration surgeons (including the destruction of hair follicles, but will also preserve the site
myself) saw how important this idea was. Now that a few of for subsequent sessions.
us are beginning to think of different types of donor area strips,
I felt it might be useful to review Coiffman’s thoughts on this
subject. The following is reproduced from the 1995 edition.
(WU)
The surgical treatment of baldness essentially consists of the
transplanting of hair from one area of the head to another in
the same individual. While doing this, one has to be careful to
minimize the destruction of hair follicles since on many occa-
sions we begin with a very low reserve of hair. A great deal
of effort has been focused on developing delicate techniques
that will result in the most atraumatic manipulation of grafts to
prevent the destruction of the hair follicles. However, hardly
any attention has been paid to the donor zone itself. Certainly,
whatever method of harvesting we use, we should try to pre-
serve as many follicles as possible, since most probably we will
have to take more grafts from this same area in a subsequent
session.
We will present some recommendations on how to suture
the zone from which the donor strips have been taken. They
are basic techniques used in plastic surgery, oriented toward
the atraumatic management of tissues.
1. The length of the strip taken from the donor zone varies
between 4 cm and 15 cm, its width between 1 cm and
2 cm. A defect of this width can be sutured very easily, Figure 23G-1 Technique showing how to place the stitches to
even with minimal undermining of the wound edges. If close the donor zone. (a) Nonabsorbable 3-0 sutures are placed
it is necessary to undermine, it is done through the fatty through the whole thickness of the scalp. Obviously, the stitches
layer, being careful not to damage the hair follicles and will destroy some hair bulbs by extreme compression. Therefore,
the galea. we should use as few as possible and place them only at the sites of
2. Sutures are first placed in the center of the wound. For greatest tension. (b) Nonabsorbable 5-0 sutures are placed through
the sites with more tension on closure, we use nonab- the epidermis and superficial dermis without touching the hair bulb.
912 Chapter 23
Figure 23G-2 (A) closure of an elongated parallelogram-

shaped wound surface. (B) The first sutures (nonabsorbable 3-0) Figure 23G-4 Closure of an elongated lozenge- or rhomboidal-
are placed at the sites of greatest tension (a,b,c). They are oriented shaped wound surface. (A) The first sutures are placed in the areas
in an oblique direction to make the closure easier. Note that the of greatest tension (a,b). (B) Closure completed. (C) When we cut
sutures in the areas of greatest tension (a,b,c) are thicker (3-0) a lozenge-shaped strip, some grafts are wasted, as we see in the
than the others (5-0). The latter are confronting stitches that are dotted area. Therefore, we prefer to have a rectangular-shaped
superficial and will not destroy the follicles. donor zone.
Figure 23G-3 (A) Closure of an elongated rectangular-shaped wound surface. (B) The first suture is placed in the middle, where there
is more tension (a). The second and third sutures (b) are placed 0.5 cm from each end. (C) At both ends a dog’s ear will form. We should
not excise these because we waste hair-bearing scalp tissue. We put a superficial suture (c) from the center of the dog’s ear to the superior
string of the loop of each lateral suture. In this way, they will not touch the hair follicles. The small folds that are formed will level
spontaneously within 3–4 weeks. (D) Complete closure.
23H. Medico-Legal Issues in Hair as our desire to best serve the patient and the public in general,
it is therefore incumbent and prudent to give some thought and
Replacement planning to the totality of what a successful hair transplantation
Michael Neff and Paul T. Rose procedure should include.
In terms of medical competency, it should be obvious that
one should not attempt or accept a case without having the
It is appropriate to start any discussion regarding medical proce- proper level of skill, along with any and all necessary and proper
dure and/or treatment with the caveat, do no harm. Total satis- credentials to carry out what is required. The office should be
faction of the patient should be the goal but it must be achieved, properly equipped and in compliance with all rules and regula-
if at all, within the tight framework of medical, legal, and ethical tions for such a procedure. The staff involved must be ade-
parameters. Legally, a physician must perform according to the quately trained and also in compliance with all necessary and
standards imposed by our specialties on a national, not local, proper documentation and licensing. The physician and the staff
level. Some might argue that there may be an international should be prepared for possible emergencies and necessary
standard of care. Obviously physicians must be competent in emergency equipment must be present and readily available.
their medical skills. They must also be attuned to legal and Physicians should be trained in basic life support and may want
ethical considerations as well. to seek training in advanced life support. Similarly, it is recom-
Total satisfaction of a patient is not simple. For example, a mended that the staff be trained in basic life support. Although,
patient may request something that is not legally performed or hair restoration is not usually a life or death situation, problem-
administered in the realm of the physician’s practice. Although atic situations do develop from time to time and provisions
it might be possible to accommodate the request, to do so might must be made to satisfactorily resolve the problems that may
be illegal or, at the very least, against public policy. When a be encountered. Keep in mind that this is not only normal com-
physician administers to a patient with a communicable disease pliance and good defensive medical practice, but if it is also
and cures the patient, both the patient and public are served made known to the patient, it greatly contributes to the peace
well. It may well be that in such a case total satisfaction has been of mind and tranquility of the individual. This is generally reas-
accomplished. A physician acquiescing to a patient’s request for suring and brings some specific sense of confidence that full
a particular appearance, which the practitioner believes is not and proper preparations have been made for individual patient
in the best interest of the patient, should carefully document the safety. In truth this should, and does, also serve much the same
request and the ensuing disclosure to the patient of the doctor’s purpose for the practitioner. Toward this end, physicians should
concerns. It is not enough to make disclosure. The physician consider establishing written protocols for emergencies.
must also ensure that the patient comprehends the situation and Depending on locale, the office may have to comply with
this should be acknowledged by the patient, in writing, along OSHA and CLIA regulations, which are enforced in the United
with his waiver. States. Comparable regulations may exist in other countries. It
We live in a litigious society. The simple rule of do no is important to note that ignorance of the law is not a defense.
harm may not always be enough. One should also ascribe to The current climate in the United States and other countries is
the ethical tenet to always try to do the right thing. to aggressively pursue physicians judged to be practicing at
When a practitioner and patient come to terms, they enter what is deemed to be a substandard level. This includes those
into a legally binding contract. The contract terms are such that physicians who are not abiding strictly by the regulations.
the practitioner provides the service and the patient pays the Every piece of advertising, in all media, must be carefully
fee. This fee is the necessary obligation for the practitioner’s scrutinized to make certain that no claims are made that cannot
services or in legal jargon, his ‘‘consideration’’. Up until there be absolutely substantiated. This is an area where both medical
is a contract, these individuals have no specific duty to each and legal experts might be properly consulted to ensure that all
other. But once a contract is formed, they are both obligated is within the limits of allowable and prudent medical adver-
to perform according to its terms. Implicit, in this agreement, tising.
is that the practitioner will use his best efforts to achieve the With regard to the use of the Internet and web pages to
desired result for the patient. attract not only local patients but also those from all over the
In legal terms, and by tradition, a physician has a special world: Attention must be given to the possibility that individuals
duty to a patient. That is to say that the public recognizes that from other areas and countries may be unfamiliar with certain
physicians and certain other professionals must exercise a de- idioms and expressions. Efforts should be made to cater to those
gree of care not expected in other service interactions. who may not share our cultural background. Some people may
When a plaintiff feels that the medical hair transplantation place a different emphasis on our advertising words. Whether
or, for that matter, any procedure result was not as promised, it is newspapers, TV, lectures, or any device used to promote
there may be a choice available to the plaintiff of seeking a the practice, careful attention must be given to the content and
breach of contract action or some tort action to litigate—usually manner in which the material is to be delivered. The advertising
one of negligence. Most suits against hair transplant practition- must not appear to be overly casual or frightening but must
ers are brought ‘‘in tort’’. Such a strategy allows for the ability adhere to the truth and the demeanor must be within the pre-
to seek certain punitive damages in some cases. In general, scribed parameters for medical advertising. Recently, there have
breach of contract cases do not allow for the amount of damages been several suits based on the libel on the Internet. The courts
a plaintiff may be awarded for a successful ‘‘tort’’ claim. have begun to acknowledge the legitimacy of such suits. Physi-
A negligence claim is one in which certain legal elements cians must be careful when they make claims in advertisements,
are involved. They are duty, breach of that duty, causation (ac- as well as when they participate or respond to discussions on
tual and legal), and damages. Having all this in mind, as well the web chat rooms.
914 Chapter 23
In general, all promotional materials should not overstate The rules and regulations as promulgated must be complied
the hoped-for results of the procedure. The information must with properly. Patients must be made aware as to who is per-
be clearly defined and accurate. Most importantly, this material, forming the procedure. The supervising physician also has the
when necessary, should contain information regarding those responsibility to be knowledgeable of the law and the legal
concerns that a potential patient should be made generally aware requirements involved.
of in regard to the procedure involved. Further discussion and Much time should be devoted to staff training. Staff must
disclosure should take place after the patient has completed the be reminded of the critical importance of confidentiality. This
required patient information forms for the practitioner. The lack is always an area of concern and even more so when celebrity
of full and complete disclosure by the practitioner might be clients are involved. Clients must be reassured that their proce-
construed as withholding the truth. dures are not made public knowledge without their permission.
It is not unusual for a patient who has undergone a previous Patient releases should be signed when appropriate as to the
procedure with one practitioner to seek consultation with yet practitioner use of photos, names, and case histories. Staff must
another practitioner. Some of these patients may be dissatisfied also be impressed with the need of not overstating the benefits
with the previous results and may make derogatory comments of the cosmetic procedure to be performed. Many practitioners
about the previous individuals involved. The patient may seek use regular staff briefings and or staff meetings to reinforce
to elicit a response from the consulting physician that the work these points and to review proper sales technique procedures
was substandard. The consulting physician must be extremely as well. The patient information form should be thoroughly
cautious in expressing negative views about another practi- reviewed and the patient questioned on various critical points,
tioner, his or her work, and business operations. Such negative such as allergic reactions and medical conditions. Many practi-
comments could possibly lead to claims of defamation and or tioners use a checklist of sorts that ensures that all items have
commercial disparagement. Certain patients may well intend to been properly performed and procedures adhered to in the
involve the parties in such situations so as to be able to further preparation of each patient. These items, if carried out by more
their own agendas. Be watchful and proper under the circum- than one individual, should be dated and signed off by the per-
stances. son who performed the task. There is a doctrine in the law
Many physicians utilize lay consultants. Physicians must be known as Respondeat Superior. Basically, it means, ‘‘Let the
careful to delineate the duties of such employees. If the consult- master answer.’’ It is a rule by which an employer is liable for
ant sees a potential client, assesses the client, and recommends the torts (e.g., negligence) of the employee when committed
a course of treatment, without a physician seeing the patient within the scope of employment. Thus, due care should be exer-
at that time, such activity may constitute practicing medicine cised in the selection and supervision of your staff. This is a
without a license. It is conceivable that a person could be seen form of vicarious liability but be assured of its existence. Staff
by only a consultant for hair loss and the person could be training should be ongoing and ideally provable.
deemed a poor candidate by virtue of lack of financial means. Professionals working in a specific discipline may not share
In fact, the consultant may have missed diagnosing a serious the same concerns or assign the same priority to aspects of the
illness. This could present a potential cause for malpractice procedure that a lay person might. It is therefore incumbent
against the physician. Physicians may be inclined to offer free on the professional to make clear what the intended procedure
consultations. In some states the physician must publish a dis- involves. Lay persons may not fully realize how the hairs are
claimer indicating that if a patient signs up for surgery as a to be harvested and what techniques are employed in the donor
result of a free consultation, the patient has a period of days to area. Among other things, the potential patient may be con-
cancel the procedure. Failure to provide such notice may result cerned about the method of anesthesia and the drugs to be uti-
in disciplinary action against the physician. Furthermore, the lized. These items and others should be discussed and made
physician must be aware of regulations that pertain to the use clear to the potential patient so as to provide a full and complete
of ancillary personnel. Some locales may require certification/ disclosure. A patient checklist may provide a record of the pa-
licensure of employees in some aspect of health care. Such tient’s understanding and approval.
regulations may depend on the duties of the employee. It may be Patients should be made aware that the practitioner might
that in some areas of the United States an unlicensed/uncertified not be doing all the work himself or herself but that others may
person may be allowed to give an injection when under a physi- also be involved. It may prove important to relate to the poten-
cian’s supervision, whereas in other states such activity may tial patient the competency and training of the people who will
be illegal. be assisting and performing various aspects of the procedure.
A situation that has arisen is the practice of Physician Assis- When explained that the procedure may be lengthy, and that
tants who open up their own hair transplant clinics. Depending other staff may be required, the patient may be reassured, in
on state law, these PAs may be able to hire a physician who advance, that this protocol is normal and should not cause the
has little or no experience to supervise them. Such actions may patient any anxiety. An unsophisticated patient may otherwise
skirt the intent of the law surrounding usage of PAs but are believe that the practitioner would not leave his side. Ideally,
becoming more common. Patients must be made aware as to permission for assistants to provide services during the proce-
who is performing the procedure and the experience of the su- dure should be obtained from the patient.
pervising physician. To do less may border on misrepresenta- Preprocedure work-ups should include a detailed medical
tion. Again it is the physician’s responsibility to be cognizant history and perhaps blood work. Patients may want something
of law. they cannot have for any number of valid medical reasons—in-
In regard to physician assistants who operate their own hair cluding psychological ones. The physician’s reasons should ex-
transplant clinics; they too must be cognizant of the regulatory plain the rationale for suggesting a different course of action.
laws of the jurisdiction and areas in which they are involved. The patient should be made aware that the effect they are seek-
ing might well involve multiple procedures. Costs must be real- disclaimer that there may be an unsuccessful transplantation
istically addressed and the discussion noted in the patient’s rec- with little or poor hair growth. In truth, this document should
ords. This is an important part of the entire disclosure. Many allow a lay person to understand the procedure to be undertaken,
of the potential problems, if any exist, can be determined at this the risks and dangers involved, the costs and need for further
juncture. Careful analysis should take place and the practitioner procedures, and that no guarantee other than what the practi-
should proceed with care to ensure that all has been covered tioner may provide in writing is being made. The patient must
and meets the criteria necessary to proceed. have had the opportunity to have all this discussed with him
Thought must be given to the possibility of a patient having and acknowledge that fact, must understand the contents, and,
HIV or hepatitis C. In some offices, testing is performed for freely, and voluntarily sign the consent form.
HIV. There are states in America that require the physician to In obtaining the consent, it is important to have the patient
consult with the patient about the disease before acquiring the sign the consent prior to any medication being given, especially
blood tests. If in fact a positive test result occurs the physician pain-relieving or sedating drugs. To do otherwise may open
may be responsible for counseling the patient and /or providing the physician to a potential legal problem. In instances where
further counseling and treatment options for the patient. patients have signed consents after receiving medication, some
A problem may exist if the physician or technician is injured have asserted that the consent was fraudulently acquired or ac-
by a needle or somehow comes in contact with blood. The quired under duress. These patients contend that they were not
procedure itself should be conducted in such fashion that the appropriately informed.
safeguards and safe techniques employed are standard practice We are all aware of some patients who have undergone the
in all cases. In general, the surgeon might do well to consider procedure and feel a sense of exhilaration with their new appear-
every case as possibly being HIV or hepatitis C positive. ance. These patients may want to tell the world. That is their
Jurisdictions may vary as to patient testing and physician prerogative but not ours. Physicians and their staff are under
obligations. It is thus critical that practitioners know what is increasing scrutiny in regard to confidentiality. It is imperative
required and allowed in the areas of their own practice. The that the physician seeks to maintain the patient’s privacy and
physician should be acquainted with such rules and regulations refrain from discussing the health of a patient or procedures
before, not after because that may well be too late. Ask the performed on a patient. There may be a temptation to brag about
specific questions of the authorities involved. Must the physi- performing surgery on a celebrity, but to do so without the
patient’s permission opens the physician to a potentially costly
cian perform the surgery if requested by a patient who is HIV
lawsuit.
or hepatitis C positive? What about the practitioner’s staff? Can
The best position is forthright, complete disclosure with all
they be obligated to perform as part of the surgery team? Does
proper medical, legal, and ethical safeguards in place. An in-
the jurisdiction in question make any provision in this regard?
formed patient is one who does understand all aspects of the
Patients must be told in advance if there are any additional
procedure, the possible benefits and the possible potential areas
requirements out of the ordinary, such as a change of surgery
of danger. The final decision is up to the patient and that is the
setting to an ambulatory surgery, whether different staffing is
way both doctor and patient should approach the matter. After
needed to perform the procedure and whether there will be an
all, they both are seeking the same result.
added charge for which the patient will be responsible. Their Note: Mike Neff is an active member of the State Bar of
understanding and agreement should be noted in writing. In- California; a Florida certified County Court Mediator; a mem-
quire and obtain the information required to properly function ber of the Ethics Committee, Regional Medical Center at Bayo-
in your own area. It is probably a good idea to review one’s net Point, Florida; a professor of law at Southern California
insurance policy to see if anything is said about these issues. University for Professional Studies, Santa Ana, CA, and an
Not all transplantations succeed as planned or hoped for; adjunct faculty and advisory committee member for Legal As-
some do better and some do worse. A patient who has been sisting Study Program, Pasco-Hernando Community College,
prepared for the potentiality of the less than expected scenario New Port Richey, FL. He currently resides on the Florida West
is less likely to be surprised and driven to anger and ultimately Coast where he can be found fishing when not otherwise en-
legal action. gaged.
Not all persons react the same way and it is prudent conduct,
on the part of the provider, to make clear that less than desirable Editor’s Comment
results can potentially occur. These should not be minimized The preceding discussion was a disturbing one for me. Many
but put into proper context for the patient to understand, so that of the recommendations would require discussion of matters
eventual informed consent is truly a fully and voluntarily given which I would not routinely include or frankly, would not be
informed consent. Photographs, both preoperatively and in fol- willing to include in a preoperative consultation. How many of
low-up can be very helpful. us would be willing to discuss our method of anesthesia, which
A great deal of thought and attention should be given to drugs will be used, in what doses, and all the possible side
the actual wording of the Transplant Consent Form (Appendix effects of each of them? Yet, it appears we are obligated to do
23A). Much litigation has involved informed consent. Without that—perhaps even if the patient doesn’t ask—to satisfy the
informed consent, the practitioner may find himself without a obligation of full disclosure.
defense at all. However, just having the informed consent is How many of us ask our patients for permission for assistants
not a perfect shield either. This document should be complete to provide services during the procedure? To be legally satisfac-
with explanations, possible potential pitfalls, perhaps including tory, I assume this should ideally be written permission and full
the possible death of the patient. It is reasonable to include a disclosure of all the details of each service of each type of
916 Chapter 23
assistant. Again, a very brief description of such services might you cannot be certain to satisfy, treating patients as you would
not be deemed satisfactory in a court of law. like to be treated if you were one, and being lucky are the
Where do our legal obligations end? My own feeling is that secrets to avoiding legal confrontations. Please see Dr. Rose’s
an unhappy patient will nearly always be able to find some Transplant Consent Form (Appendix A) of this chapter. Dr.
excuse to sue you if he or she wants to do that. The best way Shiell discusses doctor/patient relationships in Chapter 1C and
to avoid such an outcome is unlikely to be a lengthy document I would urge the reader to review it. My approach to the patient
of disclosure. Choosing patients carefully, not undertaking pro- interview (see Chapter 6A) and my consent form can also be
cedures in which you are not proficient, not making promises found in Chapter 7 Appendix 7e. (WU)
APPENDIX A: TRANSPLANT CONSENT FORM

918 Chapter 23
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system for pattern balding, presented at the annual meeting of
The Hair Loss Profile and Index: A Classification the Internat, Soc. of Hair Restoration Surg., Chicago, 2002.
System for Pattern Balding 5. Ross GL. Male-Pattern Baldness: Another Coronary Risk Factor.
Arch. Int. Med Jan 24.
1. Hamilton JB. Patterned loss of hair in man: types and incidence.
Ann. N.Y. Acad. Sci 1951; 53:708–728.
2. Norwood OT. In Hair Transplant Surgery. 2nd ed. Schiell R, ed(). The Coronal Incision Recipient Site
Springfield. IL: Charles C. Thomas, 1984:5–10.
3. Arnold J. The biodiversity of male pattern hair loss, presented at 1. Hasson V, Wong J. Coronal Recipient Sites, Presented, at the 10th
the annual meeting of the Internat, Soc. of Hair Restoration Surg., annual meeting of the International Society of Hair Restoration
Hawaii, 2000. Surgery in Chicago, October 12, IL, 2002.
Epilogue: Addendums to Chapters and Recent
Developments
A. Mayer’s and Keene’s Study densities of 30 FUs/cm2 or greater. They also wondered whether
the hair density per cm2 would be equal with one pass of 50
Comparing FU Growth with FUs/cm2 to what would be accomplished with two surgeries in
Different Planting Densities the same area, each of which consisted of 25 FUs/cm2. They
At the 2003 annual meeting of the ISHRS, Mel Mayer and intend to try and transplant the same patient, again, at the next
Sharon Keene reported on results of a study they carried out Orlando Live Surgery Workshop. (WU)
on a single patient at the 2003 Orlando Live Surgery Workshop,
whose recipient area was transplanted with different densities
of FUs. In contrast with a previous study that Mayer had done B. Kolasinski Studies
(See Chapter 9A), a 19-gauge needle was used instead of an At the 2003 annual meeting of the International Society of Hair
18-gauge needle, a ‘‘stick-and-place’’ technique was employed Restoration Surgery, Jerry Kolasinski reported on a second
and grafts were prepared using a 10x Meiji stereo-microscope. study, carried out in 2003 at the Orlando Live Surgery meeting,
In addition, incisions were made in a ‘‘coronal’’ orientation that was similar to the one described in Chapter 9A. In the
rather than in a ‘‘sagittal’’ one. Both investigators are experts second study he planted a 1 cm2 box with what he thought
in follicular unit preparation and in FU transplanting. Hair was ‘‘debris’’; at 10x magnification it, in fact, contained four
counts in the test areas were carried out by David Perez-Meza follicles. At seven months, five hairs grew in that box. The
nine months after the procedure. In this study, ‘‘the baldest area result is far less than what could have been expected on the
of the scalp that could be found’’ was used. Four 1 cm2 boxes basis of his first study. It illustrates the necessity of high magni-
were identified by tattooing dots in each corner of the boxes. fication if one is to truly identify and count follicles or partial
Using the Meiji stereo-microscope, two-haired FUs were pre- follicles in debris that, to the naked eye, contains neither. In
pared by technicians. These two-haired FUs were individually another 1 cm2 box, he planted 20 apparently single-haired FUs
inspected by Drs. Keene and Mayer, also using the Meiji stereo- that under 10x magnification actually had 21 hairs. At seven
microscope. Grafts were kept on ice packs and telfa envelopes months 13 hairs grew in that box for a yield of 61.9% (13/21).
saturated with saline. The incision sites for the FUs were made There was no explanation for this remarkably low hair survival
by Drs. Mayer and Keene. Twenty, 30, 40, and 50 two-haired given the careful preparation and insertion of the grafts at a
FUs were placed in the four tattooed boxes. Preexisting hairs density of only 20 FUs/cm2. Yields are frequently lower for all
were counted and were later subtracted from the final hair
counts.
The results at nine months are summarized in Table A-1.
Decreasing hair survival was found as FU density increased Table A-1 FU Survival: Mayer and Keene
from 20 to 30 and 40 FUs/cm2. At 50 FUs/cm2 82% survival
was noted. This latter number, however, was substantially lower Number of 2-haired Number of New Percent
than that achieved when 20 FUs/cm2 were employed (95%). FUs inserted FUs at 9 months survival
The investigators concluded that while placing FUs at a 40 to
20 19 95%
50/cm2 density produced a better appearance at nine months,
30 23 76.7%
the hair survival rate was substantially lower at these densities 40 28 70%
than when FUs were transplanted at 20 FUs/cm2. They were 50 41 82%
both surprised at the relatively low rates of hair survival with
921
922 Chapter
grafts when the surgery is carried out in someone else’s office. temples. He does not realize that as the years pass, his looks
However, it reinforces again, how fragile FUs are to anything will change. Thinning or baldness at the temples is a natural
less than perfect management. (WU) alteration in most men, signaling that a boy is now a man.
Fullness in this area, therefore, usually looks unnatural and arti-
ficial; thus surgeons must carefully estimate what the patient
will look like in the future and ensure that the transplant plan
C. Our Duty as Physicians takes into consideration the likely effects of the passage of time.
As physicians, our first duty is to ‘‘do no harm’’. Bad hair
Catello Balsamo transplants leave the patient with a permanent disfiguration. In
such instances, they would have been better off had they gone
bald. It is the responsibility of hair transplant surgeons to be
Often, the young man or woman who is not already bald, but sure they have the proper training and the patient’s best interest
fears becoming so, seeks a consultation with a hair transplant in mind, before they begin any procedure. Only when all of
surgeon. They wake up in the morning alarmed at the amount these principles have been considered and actively pursued can
of hair found on the pillow; when they run their fingers through it be said that the surgeon has worked specifically and success-
their hair, they count the fallen hairs. They compare themselves fully for the patient.
to other young men/women their age, and at the sight of a
person with thinning hair, they imagine themselves with simi-
larly thinning hair. What may begin as a funny joke between
friends—‘‘you’ll be bald by the time you’re thirty-five’’—can
soon become a neurosis.
D. The Effect of Recipient Site
It is difficult to establish an ideal or categorically reasonable Factors on Transplanted Scalp
age for patients to undergo transplantation. Some physicians Hair
suggest not operating on patients younger than twenty-five
years of age. Typically by this age, the patient’s area of Male Sungjoo Hwang recently elaborated on his prior observations
Pattern Baldness (MPB) is almost or already defined, and time on the effect of recipient area factors in hair transplanting. (See
has dictated a natural division between what can and cannot be Chapter 3C and J Dermatol Surg 2002, 28:9:795–799). At the
done to help the individual. I believe that ultimately the age at 2003 annual meeting of the International Society of Hair Resto-
which the patient undergoes transplantation should not be de- ration Surgery he summarized his findings after scalp hair was
cided by surgeons. We may only suggest an appropriate age, transplanted into the scalp, neck, back, leg, wrist area, as well
because we are not the people living with the problem—a prob- as the dorsum and palm of the hand. His results are summarized
lem whose psychological ramifications vary from individual to in three Examples (D-1–D-3) and two photographs (Figs. D-
individual and which sometimes have dramatic implications. 1a and D-1b).
No matter how hard he/she tries, the operating physician can He and his group of investigators (including Jung Chul Kim,
never fully enter the distinct, particular mindset of a specific M.D., Hyo Sub Ryu, M.D., Young Chang Cha, M.D., Seok
patient and understand his perception of his hair loss. The doctor Jong Lee, M.D., Gun Yoen Na, M.D., and Do Won Kim, M.D.)
should therefore not make the final decision if the patient may at Kyungpook National University School of Medicine, Taegu,
undergo the procedure; instead, the surgeon should grow to Korea, have concluded:
know the patient as thoroughly as possible and offer sound and ● Recipient area skin thickness and/or skin vascularity
helpful guidance. Hair transplantation should not be considered play an important role in the rate of hair survival
simply as a surgical procedure; it is also medical therapy. There- ● The ‘‘thickness’’ or volume of a transplanted hair does
fore, the best time to operate is when the surgeon’s opinion and not change, regardless of the recipient sites
the patient’s motivations coincide. Sometimes a compromise, ● Differences in transplanted hair lengths at 20 months are
such as transplanting only a few well-distributed hairs, eases a due to changes in the hair cycles rather than the rate of
patient’s depression, while a more demanding procedure that hair growth (excepting the scalp).
is aesthetically satisfactory to the surgeon but not to the patient
may increase his/her depression. Provide as much time as is Their belief that the growth rate and cycles of transplanted scalp
needed for the patient to digest the information you present, hair depend on the anatomical site of the recipient area was
before he/she decides on an objective; one should never rush lent important support by a remarkable study conducted at the
him/her. Orentreich Foundation. The latter reported on the transplanting
It is essential to a successful procedure to have a skillful of human hair, from balding areas as well as from areas that
understanding of where and how to place grafts. It is, therefore, showed no sign of miniaturizing, to immune deficient mice (1).
important to understand the patient’s wishes and, if necessary, At 22 weeks post-surgery, the mean length of the trans-
to guide him/her with a more realistic frontal plan. This should planted terminal hair was 54 mm, vs. transplanted balding vellus
take into consideration the likely future hair-loss pattern, and hair 52 mm. The mean diameter of the transplanted terminal
the possibility of a transplant ‘‘halo’’ in men, because only in hair was 93␮, while the transplanted balding hair was 99␮.
the future, when the patient’s MPB has more fully evolved, is Their conclusion was that transplanted miniaturized hair folli-
it clear if the surgeon’s work has been useful. Hoping to re- cles can regenerate once they are removed from the human
achieve the hair of youth, the male patient may want the surgeon scalp, and can grow as well as or better than terminal follicles
to place the hairline as low as possible along the forehead and when transplanted into appropriate recipient tissue. (WU)
Addendums to Chapters and Recent Developments 923
Figure D-1 Mean survival rate according to the recipient site.
Figure D-2 Mean growth rate according to the recipient site.

924 Chapter
Figure D-3 Mean hair diameter according to the site.
Figure D-1A Pubic hair transplantation.

REFERENCE the same risk to younger men with androgenetic alopecia. Fur-
ther research is needed.
1. Krajcik RA, Vogelman JH, Malloy VL, Orentreich N. Transplants
from balding and hairy androgenetic alopecia scalp regrow hair
comparably well on immunodeficient mice. J Am Acad Dermatol
2003; 48:752–9. REFERENCE
1. Whiting DA, Olsen EA, Savin R, Halper L. Efficacy and tolerabil-

ity of finasteride 1 mg in men aged 41 to 60 years with male
E. Efficacy of Finasteride, Minoxidil, pattern hair loss. Eur. J. Dermatol. 2003; 13:150–60.
2. Thompson IM, Goodman PJ, Tangen CM, Scott Lucia M. The
and Ketaconazole Shampoo for influence of finasteride on the development of prostate cancer.
the Treatment of MPB New Eng. J. Med. 2003; 349:215–224.
Khandpur et al. have reported on the efficacy of combining

finasteride 1 mg/day with either a 2% minoxidil solution twice
daily, or 2% ketaconazole shampoo (1). In a randomized, open, G. The Promise of Cell Therapy
parallel-group study, patients were put into 4 groups and fol-
lowed for one year: Jerry E. Cooley, M.D.
Group I (n⳱30): finasteride
Group II (n⳱36): finasteride Ⳮ 2% minoxidil Since the writing of Chapter 2E, research efforts have intensi-
Group III (n⳱24): 2% minoxidil fied and new groups have joined the race to produce a reliable
Group IV (n⳱10): finasteride Ⳮ 2% ketaconazole shampoo cell therapy treatment for alopecia. Over the past several years,
several confusing terms have entered the vernacular to describe
Finasteride alone was superior to minoxidil alone. this form of treatment. These include ‘‘hair follicle cloning,’’
The combination of finasteride and minoxidil was statisti- ‘‘hair multiplication,’’ and ‘‘follicular regeneration.’’ The au-
cally superior to finasteride or minoxidil alone. thor has coined the term ‘‘follicular cell implantation’’ because
Finasteride alone was equivalent to finasteride plus ketaco- it most accurately describes what is actually being performed.
nazole. (WU) The main hurdles to successful implementation continue to be
the same, i.e. maintenance of hair-induction properties through
several passages in culture. The author is currently serving as
REFERENCE chief U.S. consultant for Intercytex, Ltd., a U.K. tissue engi-
neering company based in Manchester, England. Intercytex is
1. Khandpur S, Suman M, Reddy BS. Comparative efficacy of var- beginning human trials with follicular cell implantation, a first
ious treatment regimens for androgenetic alopecia in men. J Der-
matol 2002; 29(8):489–498.
step toward proving safety and efficacy.
F. Androgenetic Alopecia H. The Hair Loss Profile and Index

David Whiting Bernard H. Cohen
A recent study showed that finasteride 1 mg improved scalp The original version of the Hair Loss Profile and Index (Chapter
hair growth in 39% of men with male pattern hair loss, aged 23A) has been dramatically simplified by changing the categor-
41 to 60 years. Improvement was evident by 6 months of treat- ies on the vertical axis of the chart. The six original categories
ment and continued through 24 months (1). The treatment was have been replaced by a six category severity scale that defines
well tolerated. Results of the prostate cancer prevention trial the visual ratio of hair to skin. The severity scale, method, and
were recently reported (2). In a study of 18,882 men aged 55 revised chart may be seen below. Hair length should not be
years or older, treatment with finasteride 5 mg daily was com- considered when assessing the visual ratio.
pared to placebo over a 7-year period. Results showed a 24.8%
reduction in prevalence of prostate cancer in the finasteride
patients. However, in those patients who did develop prostate METHOD
cancer, high-grade, more aggressive prostate cancers occurred
in slightly more of the finasteride patients than the placebo ● Measure and record the forehead, bridge and vertex dis-
patients. The conclusions of this study were that finasteride tances
prevents or delays the onset of prostate cancer. However, before ● Plot each Zone’s severity by using the severity scale
prescribing finasteride, doctors should discuss with the patient ● Extend the plot line across all columns in the zone
the reduction of cancer and urinary symptoms against sexual ● Count the cells beneath the irregular line that has been
side effects and high-grade prostate cancer increase with finast- created.
eride. The chance of finasteride 5 mg daily increasing the inci- ● The number of cells is the Hair Loss Index.
dence of high-grade prostate cancer in older men equals 0.4%. ● The completed 100-cell graph with its 3 measurements
It is not known whether finasteride 1 mg daily (Propecia) offers is the Hair Loss Profile.
926 Chapter
Figure H-1 Revised Hair Loss Profile and Index.
Table H-1 Severity Scale
Clinical appearance Hair to skin ratio
No loss All hair

Minimal Much more hair than skin
Mild More hair than skin
Moderate More skin than hair
Severe Much more skin than hair
No hair All skin
I. The KMI- Finger Mounted,

Rotating Graft Reservoir
Sharon Keene
Studies of graft survival point to graft dessication as one of the

most powerful destructive factors during the hair transplantation
procedure. Previously, it was necessary to leave grafts in a Petri
dish or other storage container to maintain graft hydration during
the graft placement process. Meanwhile, the person performing
graft placement had to repetitively ‘‘load’’ a limited number of Figure I-1A Photo of the cutting board, the rotating graft reser-
grafts onto their hand or finger which had to be rapidly placed voir, and backlight.
before dehydration occurred. During follicular unit megasessions
of over 1000 grafts this requires the graft placer (either doctor or
technical assistant) to turn and ‘‘load’’ grafts several times during
the procedure. The rotating graft reservoir was developed to main-
tain graft hydration, while allowing hundreds of grafts to be placed
literally on the fingertip (or hand) of the graft placer (Fig I-1A).
The small instrument mounts on the finger or hand, contains four
separate reservoir compartments, and has a placing ‘‘spout’’, that
allows it to be placed adjacent to the recipient site on the scalp
(Fig. I-1B). Finally, it rotates, allowing each reservoir, with various
size grafts, to be brought into close proximity with the recipient
site during graft placement (Fig I-1C). By eliminating the need to
repeatedly ‘‘load’’ grafts, it reduces placing time, and repetitive
movement that causes fatigue. It also improves graft hydration and
therefore, survival, during the placement process. The KMI reser-
voir is a tool which can be used for all types of grafts, to maintain
hydration during the graft placement portion of surgery. It is espe-
cially useful when used in conjunction with the reservoir cutting Figure I-1B The reservoir filled with grafts and sitting on the
board where it can be loaded during graft dissection. finger.
Figure I-1C Placement of the grafts in the vertex area employ-

ing the reservoir.
Figure J-1B Triangle outlined which will be excised.
J. Raising the Overly Flat Hairline

Michael L. Beehner
too ‘‘flat’’ for his liking, whether the result of transplanting or
Occasionally a patient will present with the complaint that pre- a flap. We use a technique whereby a narrow triangle of hair-
vious hair restoration surgery has resulted in a hairline that is bearing tissue in the front lateral portion of the offending hair
is excised. Along with this excision, a vertical incision down
into the anterior temple hair is also performed. The forehead
skin is then undermined down to the supraorbital region and is
then lifted up and sutured in place, using an inverted, interrupted
2-0 Vicryl ‘‘anchor’’ suture at the upper corner. A slight
Figure J-1A Frontal view of 35 y/o male who underwent 5

HT sessions, resulting in overly flat frontal hairline. Figure J-1C ‘‘Before’’ photo from left lateral side.
928 Chapter
Figure K-1B A 29 y/o male before HT surgery; Drawing

shows oval forelock area above and ‘‘scatter zone’’ between fore-
lock and low fringe; In this scatter zone area, we place a mirror
image of sparse hairs directed both superiorly and inferiorly.
Figure J-1D ‘‘After’’ photo from same side.
‘‘bunching’’ of the posterior aspect of the vertical temple inci-

sion, in relation to the anterior aspect of the incision (which
has been stretched upward some) is necessary, but usually heals
quite smoothly. Micrografting of these exposed areas is usually
necessary for a natural result. Figures J-1A–D show such a
procedure being performed on a flat transplanted hairline.
K. ‘‘Mirror Image’’ Concept in Hair

Transplantation
Michael L. Beehner
In transplanting many men, especially those who are young and

Figure K-1C Lateral view of the same patient after two hair
those who are extremely bald (Norwood Class VI or VII), I find
transplant sessions.
it valuable to construct the zones of transplanted hair laterally in

such a way that a mirror image is formed between the strong
hair of the inferior fringe and the strong hair of the oval ‘‘fore-
lock’’ hair above (Fig. K-1A). The intervening space and large
triangular area to the rear (a ‘‘scatter zone’’) is filled with more
sparsely spaced FUs (Fig K-1B–C). By creating such a gradient,
the surgeon ‘‘protects’’ the patient, in that later, should the
fringe recede further downward, all that is required is to lightly
‘‘touch up’’ this relatively sparse mirror image zone above and
below.
L. Hair Transplantation in Black

Patients
Figure K-1A Patient with natural ‘‘mirror image’’ formed by While there are no major biochemical differences in the hair
temporal fringe inferiorly and a natural oval forelock of density of Blacks, Caucasians and Asians, there are recognized morpho-
superiorly logical differences. Black hair is typically tightly coiled or
Table L-1 Racial Variations in Hair Characteristics various races (3). Sperling has also made pertinent observations
Caucasian Asian Black on racial differences in hair density and cycle stage (4). It is
important that all of the preceding data is known and understood
Hair structure Straight, Straight Tightly coiled, by hair restoration surgeons for appropriate planning in Blacks.
Wavy helical or Tables L-1, L-2, and L-3 summarize this data.
or helical spiraled Finally, while most discussions on hair transplanting in
X-section Round/oval Round, greater Elliptical, Blacks have concentrated on males, Valerie Callender presented
diameter flattened a thoughtful lecture on hair transplanting in Black females at
Hair follicle straight straight curved the 2003 annual meeting of the International Society of Hair
Restoration Surgery. She pointed out that 80% of African Amer-
ican Women (AAW) relax and ‘‘hot comb’’ their hair in order
to straighten it and achieve better manageability. As a result,
Table L-2 Racial Variations in Follicular Unit Density AAW may develop not only Female Pattern Hair Loss (FPHL)
but also traction alopecia (typically in the frontotemporal trian-
Caucasian Asian African Chinese gles and occipital hairline) and scarring alopecia from the use
of hot combs, as well as manipulations and chemicals used to
FU/mm2 1 1 0.6 0.7 straighten their hair. Thus, these external factors combine with
Average density 2 1.7 1.6 1.4 genetic factors in causing hair loss and must be stopped in order
hairs/mm2
to achieve good and more stable results with hair transplanting.
Predominate Two Two Three Two
She also recommended a postoperative regimen that, in her
hair grouping
experience, appears to minimize the likelihood of developing
Source: Bernstein RM. Dermatol Surg 1997. keloids in Black patients.
1. Use a mild potency topical corticosteroid in combina-
tion with Baciguent twice daily in the donor area, from
day 1 to day 14.
Table L-3 Racial Differences in Hair Density and Cycle 2. Apply a high potency topical corticosteroid twice daily
Stage to the donor area from the time the sutures are removed
Caucasians (12) Asians Blacks (22) to two weeks later.
3. Inject intra-lesional corticosteroids, for example, a
Hair density 35.5 (mean) — 21.4 3.33mg/cc solution of triamacinolone acetonide (Kena-
(No. follicles/4mm) log)—into the donor area scar, 20–30 days postsurgery.
No. terminal follicles 30.4 — 18.4 (WU)
No. anagen hairs 28.8 — 17.3
Source: Sperling LC. Arch Derm 1999
REFERENCES
1. O’Donoghue MN. Hair Cosmetics. Dermatol Clin 1987; 5(3):
‘‘curled,’’ helical or spiraled, and elliptical or ‘‘flattened’’ in 619–628.
X-section. Caucasian hair is typically straight, wavy or helical 2. Lindelof B, Forslind B, Hedblad MA, Kaveus U. Human hair
and, in X-section, is oval or round. Asian hair is typically form. Morphology revealed by light and scanning electron mi-
straight, has a greater diameter than the other races and, in X- croscopy aided three-dimensional reconstruction. Arch Dermatol
1988; 124(9):1359–1363.
section, is round (1). Lindelof et al concluded that it was the 3. Bernstein RM. The Aesthetics of Follicular Transplantation. Der-
shape and form of the follicle that determined the form of the matol Surg 1997; 23(9):785–799.
hair, rather than its X-section shape (2), while Bernstein tabu- 4. Sperling LC. Hair Density in African Americans. Arch Dermatol
lated and reported on the variations in follicular unit density in 1999; 135:656–658.
Index
ABHRS. See American Board of Hair Age of patient, 93, 109–110 [Alopecia reduction]
Restoration Surgery degree of androgenetic alopecia by, Frechet scalp extender, 734
Accidental exposure to pathogens, 201–202 51–56 galea fixation, 751–756
Acetaminophen, for pain control, 557 expectations and, 171 central scar slot, 754
Acetylsalicylic acid young patients, 171 complications, 753
avoiding preoperatively, 189–190 Alcohol historical background, 751–752
over counter medications containing, 216 avoiding preoperatively, 189, 190 immediate transplantation, 754
for pain control, 557 clotting and, 199 pericranial fixation, 753–754
Acitretin, hair loss with, 79 Allergic eczematous dermatitis, exchange stretch-back, 754–756
Acrodermatitis autografts in, 1 technique, 752–753
autograft dominance, 7 Allergic reactions, during procedure, 209 undermining, extensive, 754
exchange autografts in, 1 Alopecia galeal closure, tension of, 729–732
Actin iatrogenic, scalp expansion, 820–828 galeotomies, 730
alpha, smooth muscle, 43 new areas of, eliminating, 670 with graft transplantation, 731–732
beta, gene expression, 43 pedicle flaps in treatment of, 796–801 incisions, 709
gamma, gene expression, 43 traumatic, scalp expansion, 820–828 intervals between procedures, 731
Actinic keratoses, with squamous cell uncommon causes of, 77–78 major, 734–735
carcinoma, 74 Alopecia areata, 1–2, 3, 6, 72–73 minireductions, 732
Activities, postoperative, 564–565 autograft dominance in, 7 mobilization, 709–710
exercise, 564 Alopecia cicatrisata, 2, 3, 6 modified major reduction, 735–736
shampooing, 564–565 autograft dominance in, 7 operating room, 739–740
sports, 564 Alopecia prematura, 1, 3, 5, 6 patient selection, 712–714
work, 564
autograft dominance in, 7 age, 714
Adenosine, emergency use of, 207
Alopecia reduction, 145, 709–763. See also degree of alopecia, 714
Adrenaline. See Epinephrine
Scalp reduction general health, 712–714
Advanced life support, 205–206
advanced alopecia, 747–749 objectives, 714
Advertising, 21–22
before, during hair transplantation, psychological factors, 714
on Internet, 20–21
714–715 scalp laxity, 714
Aesthetic complications, 568–570
carbon dioxide laser, 731 patterns of, 715–721
delayed temporary marked thinning,
569–570 closure, 710 combined patterns, 721
poor growth, 568–569 complications, 736–737, 745, 749–751, lateral patterns, 718–719
postsurgical effluvium, 569 758 sagittal midline ellipse, 716
unnatural appearance, 570 dissatisfied patient, 750 U pattern, 719
Aesthetic principles, 91–92, 614–619 hematoma, 750 Y pattern, 716–718
detectability of graft, 614 infection, 750 Y pattern variations, 718
function, 92 photo documentation, 749–750 postoperative instructions, 744–745
micro-minigrafting, 428–432 postoperative edema, 751 preoperative instructions, 738–739
microstrip grafting, 614–619 scars, 750–751 recovery, 743–744
natural framing, 614–619 sensory nerve damage, 751 role of, 139–142
purpose of hair restoration surgery, 92 superficial catgut reaction, 750 combining hair transplantation and, 142
spacing between grafts, 614 wound dehiscence, 751 drawbacks, 139–140
African American patients. See Black consultation with patient, 738 planning, 140–142
patients design selection, 740–742 scalp extension, 765
931
932 Index
[Alopecia reduction] [Androgenetic alopecia] [Anesthesia]

scalp lifting, extensive, 734–735 incidence, at various ages, 51–56 topical local anesthetics, 239
Shaw knife, 731 medical treatment, 60–64 warming, 238
standard reduction, 721–729 pathogenesis, 60–64 patient comfort, 225
anesthesia, 722 treatment, 62–64 patient safety, 225
preoperative information, 721–722 use of extender in, 773–774 peripheral nerve block, 239–240
preoperative preparation, 722 Anesthesia, 225–259, 628, 650–651, 655. notch injection, 239–240
surgical technique, 722–729 See also under specific procedure supraorbital/supratrochlear nerve block,
stretch back, 730–731 adverse reactions 239
surgery, 743 barbiturates, 232 three-finger rule, 240
sutures, interrupted, vs. continuous suture adverse reactions, 235 propofol, 232
closure, 729–730 long-acting barbiturates, 232 adverse reactions, 235
timing of procedure, 714–715 short-acting barbiturates, 232 recipient area, 639
tissue expansion with, 732–734 ultra-short-acting barbiturates, 232 routes of administration, 226
classic, continued tissue expansion, 732 benzodiazepines, 231–232 with scalp reduction, 722
intraoperative, rapid tissue expansion, adverse reactions, 235 systemically active agents, 226
732–733 diazepam, 231–232 tumescence, 243–245
presuturing, 733–734 midazolam, 232 saline tumescence, 243
Alprazolam, 194 conscious sedation, 235–237 tumescent anesthesia, 243
Alt, Tom, contributions of, 14 Dermojet, 238 Unger technique, 250–254
Alternative donor sites, 135 donor area, 637 Wolf technique, 243–245
Alternative therapy, 196, 199 epinephrine, 229–230 for donor area, 243
Ambien, 574 adverse reactions, 234–235 for recipient area, 243–245
American Board of Hair Restoration epinephrine/beta-blocker reaction, Aneurysm, cell therapy availability for, 44
Surgery, 22 234–235 Angina, during procedure, 208
Amide, versus ester local anesthetics, 227 concentrations of, 230 Angioedema, hereditary, 210
Amount of hair, moved per session, field blocks, 240–243 Angle of hair leaving scalp, illusion of
440–442 continuous-wheal technique, 240 density and, 443
Amyloidosis differences in donor, recipient areas, Angry patients, 95
exchange autografts in, 1 242–243 Annexin II, gene expression, 43
localized, autograft dominance in, 7 multiple-wheal technique, 240 Anterior temporal fringe, 91
Analgesics, 564 spinal-needle technique, 240–242 Antibiotics, 191–192, 195, 202–204, 564
drug interactions, 191 graft placement and, 535 drug interactions, 191
Anaphylactic reactions, during procedure, hair loss from, 68 Anticoagulants, effect of, 17, 189
209 hemostasis, 225 Antidepressants, hair loss with, 79
Anatomy of hair, 25–33 intravenous sedation, 651 Antihistamines, drug interactions, 191
Anatomy of head, 104 items used for, 837–838 Antineoplastic agents, hair loss with, 79
Anatomy of scalp, 33 local anesthesia, 226, 227–229 Antipsychotics, hair loss with, 79
arterial supply, 35–36 adverse reactions, 232–234 Anxiety disorder, 95
innervations, 36–37 systemic toxicity, 233–234 Aplasia cutis congenita, 77, 78
motor innervation, 36–37 true allergic reactions, 233 Aponeurotica
sensory innervations, 36 vasovagal reaction, 233 skin, 34
layers of scalp, 33–34 amide, versus ester local anesthetics, tensile strength of, 34
cross-section of, 33 227 Area ratio, donor/recipient, projected,
lymphatic drainage, 37 bupivacaine, 229 93–103
veins of scalp, 36 lidocaine, 227–229 Arouet, Jean, contributions of, 10
Androgenetic alopecia, 16, 49–66 mixtures of, 229 Arrhythmias, during procedure, 208
classification, 49–51, 894–897 prilocaine, 229 Arterial supply, scalp, 35–36
diffuse ropivacaine, 229 Arteriovenous anastomosis, postoperative,
patterned alopecia, 51 technique, 238–239 562–563
unpatterned alopecia, 51 medications, 226–227 Arteriovenous fistula, after transplantation,
Hamilton classification, 49–51, 53–56 nonpharmacological adjuncts to, 225–226 571
Norwood classification, 49–50 opioids, 230–231 Arthritis, cell therapy availability for, 44
persistent anterior fringe, 51 adverse reactions, 235 Artistic creativity, 635–641
with persistent mid-frontal forelock, 51 fentanyl, 231 anesthesia
senile alopecia, 51 meperidine, 231 donor area, 637
type A variant, standards for morphine, 231 recipient area, 639
classification, 50–51 optimal, benefits of, 225 donor area
clinical description, 61 oral sedation, 650–651 density, evaluation of, 636
correction, 679–680 pain of local anesthetic injection, limiting, selection of, 636–637
defined, 60–61 237–238 follicular unit extraction, 641
diagnosis, 62 buffering, 237–238 graded site preparation, recipient,
early stages of, 68 gate theory, 237 640–641
etiology, 61–62 needle size, 238 feathering zone, 640
hair loss unrelated to, 67–79 needleless injectors, 238 frontal density zone, 640
histopathology, 62 rate of administration, 238 vertex zone, 640–641
Index 933
[Artistic creativity] Banucci multi-graft dispenser, 848–849 Body dysmorphic disorder, 96, 166–169
graft preparation, 638–639 Barbiturates, 232 clinician-administered diagnostic module
harvesting, 637–638 adverse reactions, 235 for, 183
incisions, recipient site, 639–640 long-acting barbiturates, 232 litigation potential with, 166
expansion technique, 639 short-acting barbiturates, 232 Body Dysmorphic Disorder Questionnaire,
micropunches, 639–640 ultra-short-acting barbiturates, 232 182
slits versus holes, 639 Basal cell carcinoma, 75 Bonding with patient, 16
number of grafts, estimating, 636 hair loss from, 73, 74 Bone fractures, cell therapy availability for,
surgical refinements, 636–641 Basic life support, 205–206 44
Asian patients, 172, 591–595 Basic science, 25–48 Booklet for patient, 165, 176–181
alopecia reduction, 593 cell therapy, 44–48 Bretylium, emergency use of, 207
combination transplantation technique, gene expression, 42–46 Brochures
593 hair anatomy, 25–33 for marketing, 832
donor harvesting, 593 histology, 25–33 for patient, 17, 165, 176–181, 832
graft dissection, 593 scalp anatomy, 33, 37–42 Buddy technique, in graft placement, 538,
hair character, 592 BDD. See Body dysmorphic disorder 622
hair density, 592 Beard donor hair, 145 Buffering, pain, 237–238
hair transplantation, 593 Bedside manner, 16 Building of practice, 831–833
hair-bearing flap, 593 Benign growths, hair loss from, 73–74 brochures, 832
hairline, 592 Bent grafts, 534 change of address, 832
historical perspective, 594 Benzodiazepines, 231–232 computerized photography, imaging, 833
keloid formation in, 172 adverse reactions, 235 consultation with patient, 832–833
mini/micrografting vs. Choi implanter in diazepam, 231–232 Internet, 832
Asian patients, 595 midazolam, 232 lectures, 832
postoperative course, 593 Beta-blockers, 210–211 market, knowing, 831
recipient site, 593 epinephrine, reaction, 234–235 marketing
scar formation, 592 hair loss with, 79 external, 831
Aspirin, over counter medications Bilateral advancement transposition flap, internal, 832–833
containing, 216 813 media advertisement, 832
Assisting staff, capabilities, 102–103 Bimanual traction, epinephrine use and, 247 medical treatments, 833
Atenolol, hair loss with, 79 Binocular microscope, 351, 355–358 newsletters, 832
Atorvastatin, hair loss with, 79 Birth control pill, discontinuation of, hair niche marketing, 832
Atrophicans, exchange autografts in, 1 loss from, 68 phone book, 831–832
Atropine, emergency use of, 207 Black patients, 595–602 seminars, 832
Auranofin, hair loss with, 79 curl in hair, 595 staff, 832
Auriculotemporal nerve, 36 density, decreased, 595–595 videos, 832
Aurothioglucose, hair loss with, 79 donor harvesting, 595 Bulbous-peg stage, hair, 25
Autograft dominance, in dermatological graft preparation, 596–597 Bulge area, transection through, two equal
conditions, 7 hairline, 600 halves
Autoimmune disorders, hair loss from, hair/skin color contrast, 595 hair growth after, Mayer studies,
72–73 hot comb alopecia, 598 273–274
Automatic graft cutters, 842–843 keloid formation in, 172 Swinehart study, 274
Automatic graft placing devices, 849 poor donor-recipient ratio, 595–595 Bupivacaine, 229
Automation in office, 876–876 pseudofolliculitis barbae, 598 drug interactions, 191
Ayres, Sam, III, contributions of, 9–10 recipient area preparation, 597 for pain control, 557
scalp reduction, 598–600 Burns, cell therapy availability for, 44
Backlighting scarring, 598
loupe magnification, microscopic traction alopecia, 598 Caliber of hair, 96, 131
slivering, 363–372 Blades, for graft preparation, 842 decreased, 570
elliptical excision, total microscopic ‘‘Blamer’’ patient, 95 increased, 570
preparation of follicular units, Bleeding, 635 variations in, 32
367–368 after surgery, 570–571, 574 Cameras, 835, 861
follicular unit grafts vs. minigrafts, conventional medications causing, 215 digital, 872–874
364–365 conventional medications increasing, 197 Camouflage agents, 565–566, 664–666
susceptibility to transection, 364–365 hair loss from, 68 types of, 565–566
susceptibility to waste, 365 herbs/vitamins/minerals causing, 215 Cancer
microscope, backlighting, combined, during megasessions, 413 cell therapy availability for, 44
368–372 postoperative, 560 hair loss from, 73–74
multibladed harvest, 365–367 Blood pressure control, epinephrine, 246 Capsule, in long-term tissue expansion, 699
transection, waste with minigrafts cut Blood supply Captopril, hair loss with, 79
to size, 365 to hair, 30 Carbon dioxide laser, for scalp reduction,
systems for, 840–841 to scar, 607 731
Bacterial infection, hair loss from, 69 Blood vessels, damage to, 628 Cardiac anomalies, endocarditis prophylaxis
Baldness. See Alopecia Blood work, preoperative, 195 for, 203–204
Bandaging, 553–555, 574, 635 Blood-borne pathogens standards, OSHA, Cardiac arrest, during procedure, 208
removal of, 574 200–201 Cardiac defibrillator, 206
934 Index
Cardiomyopathy, endocarditis prophylaxis Closure of donor site, 328–330, 911–912 Congenital cardiac anomalies, endocarditis
for, 203–204 under tension, 332–337 prophylaxis for, 203–204
Cardiopulmonary resuscitation, 205–206 Clotting cascade, non-conventional products Conscious sedation, 235–237
Cardiovascular disease, cell therapy affecting, 198–199 Consent, informed, 193–194, 219, 757,
availability for, 44 Cobblestoning, after transplantation, 570 913–918
Cart, for emergencies, 207 Collagen Consultants, non-medical, 174–175
Catgut reaction, with alopecia reduction, graft healing, revascularization, growth disadvantages of, 175
750 factors, 289 hiring, 174
Cautery devices, 840 type 1, 43 postoperative phase, 175
Cefadroxil, 191 gene expression, 43 preoperative phase, 175
Cefdinir, 191 type VI, 43 rationale for, 173–174
Celestone soluspan, 564 Color of hair surgical phase, 175
Cell therapy, 44–48 contrast, illusion of density and, 443 Consultation with patient, 16–17, 165–188
conceptual framework, 45 donor harvesting and, 319–320 alopecia reduction, 738
disease states for which available, 44 skin, compared, 96–99 body dysmorphic disorder, 166–169
regulation of, 46 unnatural appearance of, 570 clinician-administered diagnostic
research, 45–46 Combination grafting. See also Minigrafts module for, 183
source of cells, 44 usage of term, 434 litigation potential with, 166
Celtic background, hair loss with, 74 vs. follicular unit transplanting, for repair, Body Dysmorphic Disorder
Centimeter boxes, for quality control, 654 670–674 Questionnaire, 182
Central centrifugal scarring alopecia, 77 Common hair-loss patterns, approach to, compatibility of patient, doctor, 165–166
Central necrosis, postoperative, 562 129–130 consent, issues, 193–194, 219, 757,
Cephalexin, drug interactions, 191 Compatibility of patient, doctor, establishing 913–918
Challenges threatening specialty, 20–21 at patient interview, 165–166 first, length of, 18
Change of address, for marketing, 832 Compazine, 574 general patient information, 165, 176–181
Charging for consultation, 18 Compliance with medical therapy, surgical goals, realistic, establishing, 165–166
Childbirth, hair loss from, 68 planning and, 146–147 Hair Evaluation Form, 186–187
Chlorpromazine, drug interactions, 191 Complications of transplantation, 568–577. hair transplantation principles, 165
Choi implanter, 537 See also under specific technique handout for patient, 165, 176–181
in Asian patients, 595 aesthetic complications, 568–570 information for prospective patient,
Cholesterol-lowering agents, hair loss with, delayed temporary marked thinning, 165–166
79 569–570 initial, 16–17
‘‘Christmas tree’’ pattern, hair loss, 57 poor growth, 568–569 marketing and, 832–833
Chronic atrophicans, exchange autografts in, postsurgical effluvium, 569 medical history form, 184–185
1 unnatural appearance, 570 number of sessions required, 167
Chronic folliculitis, after transplantation, arteriovenous fistula, 571 patient expectations, 170–173
571 bleeding, 570–571 patient questions, 170
Cicatricial alopecia areas, transplanting into, chronic folliculitis, 571 patient selection, 169
606 classification of, 568 photographs of treated patients, 167
blood supply, 607 cysts, 571 postoperative course, 165
scalp thickness, 607–608 epidermoid cysts, 571 negative aspects of, 168–169
scarring hypoesthesia, 572 purpose of consultation, 165–169
caused by inflammatory disease infection, 571–572 types of grafts, 165
process, 606–607 postoperative frontal central necrosis, Continuous-wheal technique, field blocks,
caused by physical trauma, 607 572 240
etiology of, 606–607 ingrown hairs, 571 Contour of frontal hairline, 111–113
surgical revision vs. hair transplantation, medical complications, 570–573 Cooling systems, 842
606 mushy dermis, 573 Core curriculum for training, 22
before transplanting, 606–608 neuralgias, 572 Coronal incision recipient site, 898–901
Cimetidine, hair loss with, 79 neuroma, 572 Coronary artery bypass procedures,
Classic microscope dissection, follicular pain, 572 endocarditis prophylaxis and,
units, 355–363 papules, 571 203–204
Classification of androgenetic alopecia, pustules, 571 Coronary heart disease, patient with, 17
49–51, 894–897 scarring, 572–573 Corticosteroids, 564
diffuse hyperfibrotic scarring, 573 systemic, 192
patterned alopecia, 51 hypertrophic scars, 573 Cosmetic problem correction, 663–687
unpatterned alopecia, 51 keloids, 573 alopecia, new areas of, eliminating, 670
Hamilton classification, 49–51, 53–56 wide scars, 573 camouflage, 664–666
Norwood classification, 49–50 wound dehiscence, 573 donor area, 685–687
persistent anterior fringe, 51 unnatural appearance planning errors, 686–687
with persistent mid-frontal forelock, 51 cobblestoning, 570 technical errors, 685–686
senile alopecia, 51 kinkiness, 570 scarring, 685–686
type A variant, standards for pitting, 570 excising inappropriate grafts, 666–670
classification, 50–51 tenting, 570 follicular unit transplanting vs.
Clofibrate, hair loss with, 79 Compression, tufting, 635 combination grafting, 670–674
Closed wound care, 556 Computerized photography, imaging, 833 limitations, 670
Index 935
[Cosmetic problem correction] Dehydration, 533 [Different-sized grafts]

low donor area hair density, 670 effects on graft, 285–287 micrograft survival over time,
low hair caliber, 670 during megasessions, 413 Limmer study, 263–264
planning errors, 678–685 tissue stretch, 702–703 perigraft tissue, higher hair counts,
androgenetic alopecia, 679–680 Demerol, for pain control, 556 Seager and Beehner studies, 263
frontotemporal recessions, incorrect Dense packing planting densities, FU growth,
filling of, 679 in follicular unit hair transplantation, compared, Mayer study, 267–268
hairline 411–412 vertically, horizontally cut grafts vs.
too high, 679 in hair transplant plan, 144 intact FU, Martinick study,
too low, 678–679 Densitometers, 836 268–270
insufficient number of grafts used, 679 Density of hair large standard grafts, 261–262
recipient area, 674–685 creating illusion of, 442–443 minigrafts, 262–263
‘‘Barbie-doll’’ appearance, 676 follicular unit transplantation alone vs. Beehner study, 262–263
cobblestoning, 674–678 with multi-follicular unit grafts, Unger study, 263
compression, 674–676 439–445 overview conclusions of hair growth
dimpling, 674–676 gradient between adjacent zones, 131 studies, 272–273
hyperfibrotic healing, 677 inadequacy of, in follicular unit hair Different-sized recipient sites, graft survival,
inappropriate grafts, 676–676 transplantation, 408 295
incorrect hair direction, angle, 677–678 measurement of, 876–880 Diffuse hair patterns
poor hair yield, 676 variations in, 32 frontal scalp, 152
scarring, 677 Density packed megasessions, in follicular patterned alopecia, 51
stubble, 678 unit hair transplantation, 412 unpatterned alopecia, 51
technical errors, 674–678 Dental syringes, 837 Digital cameras, 835
scalp mobility, 670 Depression, after surgery, 575 Digital micrometer, 836
scarring, 670 Dermal papilla Digital photography, 870–876
spacing at repair session, 670 cells, 43 35-mm, compared, 860–861
vertex, 674 gene expression, in bald, non-bald, 42–46 computer files, 872–874
Coup de sabre morphea, 70 terminal hair follicle, 27 database, 872–874
Coupled follicular unit. See also Micro- Dermatitis, eczematous, allergic, autograft database software, 871–872
minigrafting dominance in, 7 digital camera, 872–874
usage of term, 434 Dermis, in long-term tissue expansion, 699 digital imaging, 871–872
Cox 2 inhibitors. See Cyclooxygenase-2 DermoJet, 238, 838 lighting, 874
inhibitors Dexamethasone, 192 making transition, 874
‘‘Crash’’ dieting, hair loss from, 68 DFU. See Double follicular unit office automation, 876–876
Crease area, transplanting, 128 Diabetes, cell therapy availability for, 44 Dilators, 536
Creep of tissue, intraoperative, 702–703 Diagnostic procedure form, 219 Diltiazem, emergency use of, 207
Crown of scalp, 87 Diameter of hair shaft, 312–315 Disclosure to patient, medico-legal issues,
effect of medical therapy on surgical classification of, 315–316 913–916. See also Consent
planning, 147 Diazepam, 194, 231–232, 564 Discoid lupus erythematosus, 70, 71–72, 77
Crusting, postoperative, 560–561 emergency use of, 207 Dislodging grafts, postoperative, 561
Curlers, traction alopecia secondary to use Didanosine, 202 Division of labor, surgical assistants,
of, 75 Dieffenbach, J., contributions of, 8 851–852
Curly hair, 99
Diet, after surgery, 574 Doctor-patient relationship, with younger
in Black patients, 595
Different-sized grafts, 297 patient, 130
harvesting, 327
survival studies, 261–279 Donor area, 628
illusion of density and, 443
additional studies, 273–277 closure, 911–912
Custom blade cutter, 844–847
growth of follicular units, 2-mm [Donor area]
Cutting grafts to ‘‘number of hairs,’’ 83
grafts in same patient, Unger and Cole approach, 342–347
Cutting surfaces, 841
Seager study, 274–276 density, evaluation of, 636
Cyclooxygenase-2 inhibitors, for pain
control, 557 hairless grafts, Jerzy Kolasinski local anesthesia, 652
Cyclophosphamide, hair loss with, 79 study, 276–277 necrosis, in follicular unit hair
Cyclosporine, hair loss with, 79 multibladed harvesting, grafts transplantation, 410
Cysts, after transplantation, 563, 571 obtained with, Reed study, 272 postoperative care, 557–558
transection through bulge area cold application, 558
Danshen, 198 Mayer studies, 273–274 dressings, 557–558
Darvocet, for pain control, 557 Swinehart study, 274 gels, 557
Database software, digital photography, criteria for studies, 261 ointments, 557
871–872 follicular units, microminigrafting, suture removal, 558
Decision to undergo transplant, 92 compared, 270–272 preparation, 349–382
Deep temporal gulf pattern, 118–119 one to three-hair micro-minigrafts vs. problem correction, 685–687
Deep vein thrombosis, during megasessions, FU, Reed study, 270 planning errors, 686–687
413–414 1.3-mm minigrafts after 1–3 sessions technical errors, 685–686
Defibrillators, endocarditis prophylaxis and, vs. FU, Beehner study, 270–272 scarring, 685–686
203–204 follicular units/micrografts, 263–270 selection of, 636–637
Degree of androgenetic alopecia, by age, intact vs. nonintact follicular unit suture material, 345–346
51–56 graft, Beehner studies, 264–266 Unger approach to, 337–342
936 Index
Donor dominance, discovery of, 8 Elevation, postoperative, 559–560 Environmental emergencies, 207
Donor harvesting, 301–347, 350, 637–638, Ellipse, vs. multibladed harvest, 434–435 Epicranium, skin, 34
651–652 Elliptical excision, total microscopic Epidermis, in long-term tissue expansion,
closure of donor site, 328–330, 652 preparation of follicular units, 698–699
curly hair, 327 367–368 Epidermoid cysts, after transplantation, 571
donor site preparation, 321–322 Embarrassment of patient, regarding hair Epinephrine, 194, 210–211, 229–230,
donor strip dimensions, 651 loss, 16 245–250
donor strip removal, 327–328 Embryology, hair, 25–26 adverse reactions, 234–235
estimating required tissue, 311–312 bulbous-peg stage, 25 epinephrine/beta-blocker reaction,
Chang method, 311 first primordial hair, 25 234–235
Farjo method, 311–312 germ stage, 25 beta-blocker reaction, 234–235
excision of donor strip, 323–324 hair-peg stage, 25 bimanual traction, 247
grafts larger than follicular units, tissue pregerm stage, 25 blood pressure control, 246
for, 312 Emergency airway device, 206 concentrations of, 230
hair body, 320 Emergency cart equipment, 207 emergency use of, 207
hair color, 319–320 Emergency interventions, 204–211 gravity, 246
hair density in donor area, 305–310 advanced life support, 205–206 headband of patient, 249
calculated density, 307–308 allergic reactions, 209 medical interactions, 191
follicular unit density, 308–310 anaphalactoid reactions, 209 predisposing agents, discontinuance of,
hair shaft diameter, 312–315 anaphylactic reactions, 209 246
classification of, 315–316 basic life support, 205–206
hemostasis, 652 premade recipient sites, 247
beta-blockers, 210–211 preoperative evaluation and, 246
instrumentation, 652 cardiac arrest, 208
items used for, 838–840 recipient site size, 247–249
cardiac arrhythmias, 208
local anesthesia of donor area, 652 ring block anesthesia, 246–247
cardiac defibrillator, 206
physical examination, 305 scattering sites, 247
emergency airway device, 206
problem donor areas, 331–332 smoking, 249
emergency cart equipment, 207
safe area, 301–305, 651 tumescence, 247
environmental emergencies, 207
scalp depth, 320–321 donor area tumescence, 247
epinephrine, 210–211
scalp laxity, 316–319 recipient area tumescence, 247
equipment, 206–207
scars, 330–331 visibility, 247
evidence-based medicine, levels of
site closure under tension, 332–337 Epithelium, removing, 536
evidence, 205
follicular unit extraction, 334–337 hereditary angioedema, 210 Equipment for emergencies, 206–207
strip harvesting, 652 hypoglycemia, 209–210 Ergonomics in graft preparation, 349–350
temporal hair, 327 hypovolemia, 208 Erythromycin, drug interactions, 191
tumescence of donor area, 322–323 incidental asymptomatic hypertension, ESHRS. See European Society of Hair
virgin midline elliptical donor areas, 208–209 Restoration Surgery
previous harvests, positioning, intravenous access supplies, 206 Esthetic considerations, scalp extension,
326–327 malignant hyperthermia, 210 780–781
wave, 320 medication interactions, 210–210 Estimating required donor tissue, 311–312
width of donor strips, 324–326 monitoring tools, 206 Chang method, 311
old scars, 325–326 monoamine oxidase, 211 Farjo method, 311–312
Donor strip dimensions, 651 Ethnic groups, rounded hairlines, 113
myocardial ischemia, 208
Donor supply Ethnicity, 171–172
oxygen delivery device, 206
economizing, 396–398 African Americans, 171–172
patient transfer to another facility, 207
limited, implications of, 439–440 keloid formation in, 172
pharmacologically related emergencies,
Double follicular unit, 82 Asians, 172
210–211
Dressings, 556 keloid formation in, 172
pharmacology, 207
cons of, 556 European Society of Hair Restoration
preparation for, 205–207
occlusive, 556 Surgery, 22
pros of, 556 reviewing medical information, grading
system for, 205 Evidence-based medicine, levels of
Dry wound care method, 555
seizures, 210 evidence, 205
Eczematous dermatitis, allergic specific emergency situations, 207–210 Evolving male pattern baldness, 133–135
autograft dominance in, 7 team approach, 207 Exchange autografts, overview, 1
exchange autografts in, 1 vasovagal reactions, 209 Excising inappropriate grafts, 666–670
Edema, after alopecia reduction, 751 Emergency situations, 220–221 Excision of donor strip, 323–324
Effluvium of preexisting hair, postsurgical, Emollients, application of, for wound care, Exercise, after surgery, 564, 575
562 555 ‘‘Exogen’’ follicles from donor tissue, loss
Ehlers-Danlos Syndrome, 77 Emotional, physical illness, hair loss from, of, 424–427
Eicosapentanoic acid, preoperative ingestion 68 Expanded scalp flap technique, 812–820
of, 190 Employee satisfaction, 854 bilateral advancement transposition, 813
Elastic limit of skin, 41–42 Empty graft sites, 534 case reports, 819–820
Elastin component of skin, 41 Endocarditis, prophylaxis, 192, 203–204 evolution of, 813
Electron microscopy Endocrine disease, cell therapy availability planning for, 813–814
follicular unit grafting, 279–281 for, 44 triple advancement transposition flaps,
in long-term tissue expansion, 700 Entrepreneurial model of medicine, 21 813
Index 937
Expectations of patient, 170–173 [Flap procedures] [Follicular unit transplantation]

realistic, establishing, 165–166 hair loss, 829 large sessions, transplanting follicular
unrealistic, 95 hematoma, 829 units in, rationale for, 392–399
Eyebrow transplantation, 579–580 infection, 829 donor supply, economizing, 396–398
Eyelash transplantation, 580 scar, 829 graft sorting enhancement, 398–399
expanded scalp flap technique, 812–820 social, 393–395
Factors contributing to hair transplantation, historical perspective, 795 telogen effluvium, 395–396
92–93 Juri flap, 795–796 lasers, rationale for not using, 392
Fainting, during procedure, 209 microsurgical free flaps, 801–808 mini-micrografting, rationale for not
Family history, male pattern baldness, 103 temporo-parieto-occipital flap, 808–812 using, 403
Females pedicle flaps, treatment of alopecia, with multi-follicular unit grafts, 475–478
hair transplantation in, 516–524 796–801 coronal vs. sagittal, 487
planning, 142–144 density, 479–492
technical considerations, 795–796
Ludwig’s pattern of hair loss in, 53–56 graft detectability, advantage of, 489
traumatic, iatrogenic alopecia, scalp
stanozolol, hair loss with use of, 79 hair direction, 486–489
expansion for, 820–828
Fentanyl, 231 hair survival, 489–492
Flared hairline, 111–112
Ferritin, light polypeptide, gene expression, rationale for, 478–479
Flucosanol, emergency use of, 207
43 round grafts, 492–503
Fever Fluoxetine, hair loss with, 79
Follicles, iatrogenic injury of, 279–281 naturalness, 445–448
endocarditis prophylaxis and, 203–204 pitfalls, 408–418
hair loss from, 68 Follicular family grafts, 82–84
Follicular unit constant, rationale for, dense packing, 411–412
Feverfew, 198 density packed megasessions, 412
FFs. See Follicular family grafts 399–401
Follicular unit density, donor area, 308–310 donor area necrosis, 410
Fibronectin, gene expression, 43 inadequate density, 408
Fibrosing alopecia, 72 Follicular unit grafts, 30, 82, 83. See also
megasessions, 413–418
Field blocks, 240–243 Follicular unit transplantation
bleeding, 413
continuous-wheal technique, 240 anatomically precise, hair groupings,
deep vein thrombosis, 413–414
differences in donor, recipient areas, compared, 363
dehydration, 413
242–243 to create extended hairline area, step-by-
hypoglycemia, 413
multiple-wheal technique, 240 step systemic approach, 460–465
lidocaine toxicity, 414–415
spinal-needle technique, 240–242 extraction, 641
nausea, 415–416
Film, photography, 864 closure of donor site under tension,
orthostatic hypotension, 415–416
Financial capability of patient, 104 334–337 popping, 413
Finasteride, effect on surgical planning, light, electron microscopy, 279–281 staff, practical problems, 413
146–151 microminigrafting, compared, 270–272 vomiting, 415–416
First consultation with patient, 16–17, one to three-hair micro-minigrafts vs. necrosis in recipient area, 409–410
165–188, 193–194, 219, 757, FU, Reed study, 270 poor growth, 408
913–918 1.3-mm minigrafts after 1–3 sessions staff recruitment, training, 412
body dysmorphic disorder, 166–169 vs. FU, Beehner study, 270–272 stretched donor area scars, 410
litigation potential with, 166 microscope dissection, 355–363 technical difficulties, 410–411
charging for, 18 binocular stereoscopic dissecting unsuitable hair characteristics, 411
compatibility of patient, doctor, 165–166 microscope, 355–358 preserving follicular unit, 388–390
goals, realistic, establishing, 165–166 general principles, 355 rationale for, 388
hair transplantation principles, 165 graft cutting, 362 single-strip harvesting, 402–403
information for prospective patient, natural hair groupings, anatomically
165–166 small recipient sites, 390–392
precise follicular units, compared, sorting follicular units, 392
length of, 18
363 stereomicroscopic dissection, 403
number of sessions required, 167
sizing grafts, cutter discretion in, vs. combination grafting, for repair,
patient questions, 170
362–363 670–674
patient selection, 169
slivering techniques, 361–362 vs. with multi-follicular unit grafts,
photographs of treated patients, 167
stereoscopic dissection of donor hair, 435–469
postoperative course, 165
negative aspects of, 168–169 disadvantages of, 358–360 clinical significance of study results,
purpose of consultation, 165–169 stereoscopic dissection of follicular 439
types of grafts, 165 units, instrumentation, 360–361 comparison of techniques, 438–439
First primordial hair, 25 vs. minigrafts, 364–365 controversy regarding, 435–436
Fixed medication eruption susceptibility to transection, 364–365 density, 439–445
autograft dominance in, 7 susceptibility to waste, 365 extended hairline area, 460–465
exchange autografts in, 1 Follicular unit micrografting technique, hair characteristics, 438
Flap procedures, 795–830 383–388 variety of, 438
basic science, 689–707 Follicular unit transplantation, 132, 388, in hairline, other areas, 454–460
biomechanical considerations, 796 445–451, 654–657 heterogeneity, 438
complications of, 796, 828–830 exclusive, vs. micro-minigrafting, 132 learning curve, in transplant
‘‘dog-ear,’’ 829 follicular unit constant, 399–401 procedures, 438
ear discomfort of, 828 hairline, 454–460 levels of skill, 438–439
ecchymosis, 828 individual follicular units, transplanting, multiple follicular unit grafts, 451–454
frontal edema, 828 390 patient follow-up, 438
938 Index
[Follicular unit transplantation] [Future of hair restoration surgery] [Graft]

studies on survival, density, insurance premiums, 20–21 wound healing, revascularization, growth
unreliability of, 439 Internet advertising practices, 20–21 factors, 287–294
trends in controversy regarding, 436 litigation, 20–21 Graft cutting, 362
variety of patients, 438 marketing environment, 21–22 Graft insertion, placement, 533–552
when to use, 451 opportunities, 22 Graft placement, 533–539, 633–635
Follicular units/micrografts, 263–270 professionalism, 20–21 anesthesia, 535
hair growth studies, 263–270 right to practice cosmetic surgery, bent grafts, 534
intact vs. nonintact follicular unit graft, regulation of, 21 buddy technique, 538
Beehner studies, 264–266 self-regulation, 22 dehydration, 533
micrograft survival over time, Limmer trepidation regarding, 20–21 dilators, 536
study, 263–264 empty sites, 534
perigraft tissue, higher hair counts, Seager Galea aponeurotica, scalp, 38 factors influencing placing, 535–538
and Beehner studies, 263 Galea fixation, alopecia reduction, 751–756 graft sizing, 536
planting densities, FU growth, compared, central scar slot, 754 graft spacing, 536
Mayer study, 267–268 complications, 753 grafts placed too deeply, 534
vertically, horizontally cut grafts vs. intact historical background, 751–752 hemostasis control, 535
FU, Martinick study, 268–270 immediate transplantation, 754 hydration control, 536
Folliculitis decalvans, 69, 70 pericranial fixation, 753–754 improper direction, orientation of grafts,
Follow-up of patients, 905–911 stretch-back, 754–756 534
Forceps technique, 752–753 incision depth, limited-depth incisions,
for graft preparation, 841 undermining, extensive, 754 536
placing, 848 Galeal closure, tension of, with scalp looking away from recipient site, 535
Forelock designs, 138–139 reduction, 729–732
magnification loupes, 535
Frechet, Patrick, contributions of, 15 Galeotomies, scalp reduction, 730
mechanical implanter devices, 537
Frechet scalp extender, 734 Gandelman, Marcelo, contributions of,
Choi implanter, 537
Frechet three hair-bearing flap transposition 12–13
hair implanter pen, 537
procedure, 775–782 Garlic, 197
mechanical measures, 535
Free radical formation, 192 preoperative ingestion of, 190
Gastrointestinal disease, cell therapy mechanics of ‘‘gentle’’ graft insertion,
Fringe hair, quality of, 103 537
Frizziness, 100 availability for, 44
Gate theory, pain, 237 missed sites, 534
Frontal fibrosing alopecia, 70–71, 71 physical trauma, 533–534
Frontal forelock, 90–91, 137–138 Gels, application of, for wound care, 555
Gemfibrozil, hair loss with, 79 piggybacking, 524
candidates for, 137
Gender, expectations of patient and, 172 popping, 534
designs, 88, 137–138
Gene expression, 43–44 preexisting conditions, 535
isolated, frontal scalp, 152–153
in bald, non-bald dermal papillae, 42–46 preoperative measures, 535
Frontal hairline, microcontouring, 114–142
Genitourinary disease, cell therapy problems, 533–534
pitfalls, 114–116
availability for, 44 prolonged time out of body, 534
Frontal hairs, setting angle, 116–118
Germ stage, hair, 25 quality control, 538
Frontal scalp, 87, 152–153
Ginger, 197 removing epithelium, 536
diffuse patterns, 152
Ginkgo biloba, 197–198 with scalp reduction, 731–732
hair patterns, 155–158
Ginseng, 198 ‘‘stick and place’’ vs. ‘‘making all
isolated frontal forelock, 152–153,
Glyceraldehyde-3-phosphate dehydrogenase, incisions first,’’ 537–538
157–158 gene expression, 43
recession patterns, 152 advantages of, 538
Gold-based agents, hair loss with, 79 disadvantages of, 538
whorl patterns, 153, 158 Governmental regulation of right-to-practice,
Frontal tuft, 90, 456 tumescent, epinephrine solutions, 535
20–21 visualization, 535
Frontal-midscalp forelock, 137, 138 Graded site preparation, recipient, 640–641
Frontotemporal recession, 90 Graft preparation, 349–382, 628–633,
feathering zone, 640 638–639
incorrect filling of, correction, 679 frontal density zone, 640
Fungal infections, hair loss from, 69 classic microscope dissection, follicular
vertex zone, 640–641
FUs. See Follicular unit grafts units, 355–363
Grading system for reviewing medical
Future hair styling preference, 105–106 ergonomics in, 349–350
information, 205
Future of hair restoration surgery, 20–22 harvesting, 350
Graft
advertising, 21–22 cut ‘‘to size,’’ vs. ‘‘number of hairs,’’ impulsive force graft preparation,
American Board of Hair Restoration 81–82 372–376
Surgery, 22 dehydration magnification methods, 351
challenges, 20–21 effects of, 285–287 microscopic slivering, with backlighting,
core curriculum for training, 22 hydrogen peroxide, 286 loupe magnification, 363–372
entrepreneurial model of medicine, 21 preservation time, temperature, 286 multifollicular unit grafts, 380–382
European Society of Hair Restoration larger than follicular units, tissue for, 312 planting, 654–657
Surgery, 22 partial follicle survival, pluripotent stem follicular unit transplantation, 654–657
governmental regulation of right-to- cells, melanocyte reservoir, local anesthesia, 655
practice, 20–21 281–285 recipient sites, 655–657
group practices, high-volume, 21 used at hairline, 111 slivering of donor strip, 350–355
Index 939
Graft shedding, postoperative, 562 [Growth factors] [Hair patterns]

Graft size, 131, 628 histological stains, 287–288 mounds, 155–157
Graft sorting enhancement, 398–399 photographic observations, 288 natural patterns, 152
Graft spacing, 131 revascularization, 291 patterns to guide hair transplantation,
Graft storage, containers, 842, 848–849 tissue markers, 287–288 155–158
Graft survival, 261–297 Growth of follicular units, 2-mm grafts in temple, 155
different rows within pattern, insertion of same patient, Unger and Seager temporal scalp, 158–161
grafts on, 296–297 study, 274–276 vertex, 153–155, 158
different-sized grafts, 261–279, 297 Hair physiology, 31–32
additional studies, 273–277 Hair anatomy, 25–33 Hair restoration, personal technique,
growth of follicular units, 2-mm Hair characteristics, 96–102 Tykocinski, 620–626
grafts in same patient, Unger and caliber of hair, 96 chubby grafts, 624
Seager study, 274–276 color contrast, hair to skin, 96–99 density, 622
hairless grafts, Jerzy Kolasinski curl, 99 follicular groupings, 624–626
study, 276–277 frizziness, 100 density, 626
multibladed harvesting, grafts intrinsic beauty, 100–102 forceps, 624
obtained with, Reed study, 272 wave, 99 graft organization, 620–621
transection through bulge area Hair color, 32 graft type, 620
Mayer studies, 273–274 donor harvesting and, 319–320 grafts insertion, 624
Swinhart study, 274 unnatural appearance of, 570 loading grafts, 622
criteria for studies, 261 Hair counts, graft survival, 294–297 number of blades, 624
follicular units, microminigrafting, Hair cover of relatives, patient information recipient site, 621
compared, 270–272 about, 17 rhythm, 624
one to three-hair micro-minigrafts vs. Hair curl, illusion of density and, 443 two-person stick-and-place technique, 622
FU, Reed study, 270 Hair curlers, traction alopecia secondary to Hair shaft
1.3-mm minigrafts after 1–3 sessions use of, 75 diameter, 312–315
vs. FU, Beehner study, 270–272 Hair cutting, styling equipment, 836 classification of, 315–316
follicular units/micrografts, 263–270 Hair cycle, 32–33 terminal hair follicle, 27–28
intact vs. nonintact follicular unit Hair density in donor area, 305–310 cortex, 28
graft, Beehner studies, 264–266 calculated density, 307–308 cuticle, 28
micrograft survival over time, follicular unit density, 308–310 medulla, 27–28
Limmer study, 263–264 Hair Evaluation Form, 186–187
perigraft tissue, higher hair counts, Hair survival studies, different-sized grafts,
Hair follicle transection rates, 421–424 261–279
Seager and Beehner studies, 263 Hair groupings, 30
planting densities, FU growth, additional studies, 273–277
anatomically precise follicular units, growth of follicular units, 2-mm grafts
compared, Mayer study, 267–268 compared, 363
vertically, horizontally cut grafts vs. in same patient, Unger and Seager
Hair growth characteristics, influence of
intact FU, Martinick study, study, 274–276
recipient site, 56–60
268–270 hairless grafts, Jerzy Kolasinski study,
Hair growth cycle, autograft dominance in,
large standard grafts, 261–262 276–277
7
minigrafts, 262–263 multibladed harvesting, grafts obtained
Hair growth studies
Beehner study, 262–263 with, Reed study, 272
criteria for, 261
Unger study, 263 transection through bulge area, two
in large standard grafts, 261–262
overview conclusions of hair growth equal halves
in minigrafts, 262–263
studies, 272–273 Hair histology, 25–33 hair growth after, Mayer studies,
different-sized recipient sites, 295 Hair implanter pen, 537 273–274
hair counts, 294–297 Hair loss Swinehart study, 274
nevus flammeus, donors from, 295–296 laboratory investigation of, 79 criteria for studies, 261
rapid transfer of grafts from donor area to medications associated with, 79 follicular units, microminigrafting,
recipient area, effect of, 295 unrelated to androgenetic alopecia, 67–79 compared, 270–272
Graft terminology, 81–83 variant pattern of, 118 one to three-hair micro-minigrafts vs.
cutting grafts to ‘‘number of hairs,’’ 83 Hair loss profile, 887–892, 894–897 FU, Reed study, 270
grafts cut ‘‘to size,’’ vs. ‘‘number of Hair Magic, 565 1.3-mm minigrafts after 1–3 sessions
hairs,’’ 81–82 Hair morphology, 31–32 vs. FU, Beehner study, 270–272
GraftCyte, for wound care, 555 Hair patterns, transplant goals and, 151–164 follicular units/micrografts, 263–270
Gravol, 574 frontal scalp, 152–153, 155–158 intact vs. nonintact follicular unit graft,
Greater auricular nerve, 36 diffuse patterns, 152 Beehner studies, 264–266
Group practices, high-volume, increase in, isolated frontal forelock, 152–153, micrograft survival over time, Limmer
21 157–158 study, 263–264
Growth factors, graft healing, recession patterns, 152 perigraft tissue, higher hair counts,
revascularization whorl patterns, 153, 158 Seager and Beehner studies, 263
acute healing phases, 290–291 general patterns, 152–153 planting densities, FU growth,
biopsy observations, 289–290 hairline shapes, 153 compared, Mayer study, 267–268
collagen activity, 289 large patterns, 153 vertically, horizontally cut grafts vs.
cytometry, 288 small patterns, 153 intact FU, Martinick study,
growth factor activity, 288–289 midscalp, 155 268–270
940 Index
[Hair survival studies, different-sized grafts] Hepatic failure, cell therapy availability for, [Incisions]
large standard grafts, 261–262 44 expansion technique, 639
minigrafts, 262–263 Hepatitis, 202 micropunches, 639–640
Beehner study, 262–263 laboratory testing, 192, 193, 200, 201 slits versus holes, 639
Unger study, 263 patient with, 17 Inderal, drug interactions, 191
overview conclusions of hair growth Herbal remedies, 196 Individual follicular units, transplanting, 390
studies, 272–273 Hereditary angioedema, 210 Indomethacin, hair loss with, 79
Hairless grafts, Jerzy Kolasinski study, Herpes simplex, hair loss from, 69 Infarction, myocardial, during procedure,
276–277 Herpes zoster, hair loss from, 69 208
Hairline, 91, 904–905 Hiccups, postoperative, 563 Infection
design, for Norwood class VI, VII, High hairline, correction, 679 after surgery, 562, 571–572, 575
653–654 High-volume group practices, increase in, postoperative frontal central necrosis,
extended, follicular unit, step-by-step 21 572
systemic approach, 460–465 HIP. See Hair implanter pen with alopecia reduction, 750
follicular unit transplantation in, 454–460 Histology hair loss from, 69–70
adjusting hairline downward, 460 hair, 25–33 Inferior segment, terminal hair, 27
angle, 460 terminal hair follicle, 27–30 Inflammatory disease
anterior border of hairline, proper Histopathology, androgenetic alopecia, 62 hair loss from, 70–72
placement of, 459 History of hair transplantation, 1–23 process scar, transplanting into, 606–607
defined zone, 456 HIV. See Human immunodeficiency virus Information for prospective patient provided
direction, 460 Hot comb alopecia, 598 at interview, 165–166. See also
donor strip, excision, 458 Human immunodeficiency virus, 192 Initial interview with patient
early graft testing, 458 laboratory testing for, 192, 200–201 Informed consent, 193–194, 219, 757,
follicular pairing, 458 Hydration control, during graft placement, 913–918
follicular unit micrografts, 458–459 536 Infundibulum, terminal hair, 26
frontal tuft, 456 Hydrocodone/acetominophen, drug Ingrown hairs, after transplantation, 571
lateral border of hairline, proper interactions, 191 Inhalation administration of anesthetics, 226
placement of, 459 Hydrogen peroxide, graft dehydration, 286 Initial interview with patient, 16–17,
selective separation, distribution, 458 Hyperfibrotic scarring, after transplantation, 165–188, 173–175, 193–194, 219,
transition zone, 454–456 573 757, 913–918
trimmed follicular unit micrografts, Hyperidrosis, exchange autografts in, 1 body dysmorphic disorder, 166–169
456–458 Hypertension, asymptomatic, 208–209 clinician-administered diagnostic
medical therapy, surgical planning and, Hyperthermia, during procedure, 210 module for, 183
147–151 Hypertrophic cardiomyopathy, endocarditis litigation potential with, 166
multi-follicular unit graft, 503–504 prophylaxis for, 203–204 Body Dysmorphic Disorder
planning, 106–114 Hypertrophic scars, after transplantation, Questionnaire, 182
Hairline height 573 charging for, 18
high, correction, 679 Hypoesthesia, after transplantation, 561, 572 compatibility of patient, doctor, 165–166
low, correction, 678–679 Hypoglycemia, 209–210 general patient information, 165, 176–181
Hairline placement, 652–654 Hypoparathyroidism, cell therapy goals, realistic, establishing, 165–166
Hairline shapes, 153 availability for, 44 Hair Evaluation Form, 186–187
large patterns, 153 Hypotension, during megasessions, 415–416 hair transplantation principles, 165
Hypothyroidism, hair loss from, 68
small patterns, 153 handout for patient, 165, 176–181
Hypovolemia, during procedure, 208
Hair-mass index, 878–880 information for prospective patient,
Hair-peg stage, 25 Iatrogenic alopecia, scalp expansion, 165–166
Hairpieces, 136, 565 820–828 length of, 18
Hamilton classification, androgenetic Iatrogenic injury of follicles, 279–281 medical history form, 184–185
alopecia, 49–51, 53–56 Ibuprofen number of sessions required, 167
Handout for patient, 165, 176–181 drug interactions, 191 patient expectations, 170–173
Harvesting. See Donor harvesting over counter medications containing, 216 patient questions, 170
Head dressings, 556 Idiopathic scarring alopecia, 76–77 patient selection, 169
cons of, 556 Illusion of density photographs of treated patients, 167
pros of, 556 creating, 442–443 postoperative course, 165
Headband of patient, epinephrine use and, factors affecting, 443 negative aspects of, 168–169
249 Imaging software, 835 purpose of consultation, 165–169
Heart valve disease, cell therapy availability Immunodeficiency, 17 types of grafts, 165
for, 44 cell therapy availability for, 44 Inner root sheath, histology, 28–29
Height of frontal hairline, 108–111 Immunosuppressant agents, hair loss with, Innervations, scalp, 36–37
Hematoma, with alopecia reduction, 750 79 motor innervation, 36–37
Hematopoietic disease, cell therapy Impulsive force graft preparation, 372–376 sensory innervations, 36
availability for, 44 Inadequate density, in follicular unit hair Insertion of graft, 549–552
Hemophilia, patient with, 17 transplantation, 408 Instrumentation in hair restoration surgery,
Hemostasis Incidence of antrogenetic alopecia, by age, 835
anesthesia and, 225 51–56 Insufficient number of grafts used,
in donor harvesting, 652 Incisions, 633, 639–640 correction, 679
in graft placement, 535 depth of, limited-depth incisions, 536 Insurance premiums, 20–21
Index 941
Intact vs. nonintact follicular unit graft, Lasers Magnification, 840

Beehner studies, 264–266 rationale for not using, 392 methods of, 351
Intensity of lighting, illusion of density and, for scalp reduction, 731 Magnifiers, 351
443 use of, 524–528 Male pattern baldness. See Androgenetic
Internet, marketing via, 20–21, 832 Laxity, scalp, 41, 105, 714 alopecia
Intervals between scalp reductions, 731 classification of, 697–698 Malignant growths, hair loss from, 73–74
Intervals between transplant sessions, donor harvesting and, 316–319 Malignant hyperthermia, during procedure,
136–137 Layers of scalp, 33–34 210
Intestinal failure, cell therapy availability cross-section of, 33 Malignant tumors, hair loss from, 73–74
for, 44 Learning curve, in transplant procedures, Mantis microscope, 351
Intramuscular administration of anesthetics, 438 MAO. See Monoamine oxidase
226 Lectures, for marketing, 832 Market, knowing, 831
Intravenous access supplies, 206 Lenses, 861–862 Marketing
Intravenous administration of anesthetics, Lesser occipital nerve, 36 external, 831
226 Levodopa, hair loss with, 79 internal, 832–833
Iron deficiency, hair loss with, 79 Lichen planopilaris, 70, 72, 77 Marketing environment, 21–22
Ischemia reperfusion injury, 192 Lichen simplex chronicus, 76 Marking pens, 836
Isocarboxazid, drug interactions, 191 Lidocaine, 227–229, 557 Marritt, Manny, contributions of, 15
Isolated frontal forelock, frontal scalp, drug interactions, 191 Mass, hair, measurement of, 876–880
152–153 emergency use of, 207 Matrix cells, terminal hair follicle, 27
Isomorphic phenomenon of Koeber, 7 toxicity, during megasessions, 414–415 Mature part, 106–108
Isotretinoin, hair loss with, 79 Light, electron microscopy, follicular unit Maximum usage of donor hair, 627
Isthmus, terminal hair, 26–27 grafting, 279–281 Means of camouflage available, 105
Lighting Measurement, hair density, mass, 876–880
digital photography, 874 Mechanical implanter devices, 537
Juri flap, 795–796 illusion of density and, 443 Choi implanter, 537
photography, 862–863 hair implanter pen, 537
Keloid formation standardized photography, 862–863 Media advertisement, 832
in African Americans, 172 Limited total donor supply, implications of, Medical complications after transplantation,
after transplantation, 573 439–440 570–573
in Asians, 172 Limmer, Robert, contributions of, 14–15 Medical health of patient, 94
Keloidlike reaction, donor site, 3 Lithium, hair loss with, 79 Medical history form, 184–185
Keratinization, 30 Litigation by patient, 19–20, 20–21, Medical history of patient, 17
Kerion, 69 913–916. See also Consent anticoagulant medication, 17
with body dysmorphic disorder, 166 coronary heart disease, 17
Ketorolac tromethamine, for pain control,
Load cycling, tissue stretch, 702–703 hemophilia, 17
557
Local anesthetics, 226, 227–229 hepatitis, 17
Kinkiness, after transplantation, 570
adverse reactions, 232–234 immune deficiency disorders, 17
systemic toxicity, 233–234 past surgery, 17
Laboratory tests, 200–202 true allergic reactions, 233 Medical therapy, effect on surgical
epidemiology, 200 vasovagal reaction, 233 planning, 146–151
hepatitis, 192, 193 amide, versus ester local anesthetics, 227 compliance, 146–147
human immunodeficiency virus, 192 bupivacaine, 229 crown, 147
preoperative, generally, 192–193 drug interactions, 191 hairline, 147–151
Lamivudine, after accidental exposures, 202 lidocaine, 227–229 motivation, 147
Landmarks, scalp, 90–91 mixtures of, 229 short-term therapy, 147
anterior temporal fringe, 91 prilocaine, 229 stabilization, effect of, 147
frontal forelock, 90–91 ropivacaine, 229 timing of benefits, 147
frontal tuft, 90 technique, 238–239 Medical treatment of androgenetic alopecia,
frontotemporal recession, 90 Long frontal region, 113 60–64
hairline height, 91 Long-acting barbiturates, 232 clinical description, 61
occipital fringe, 91 Loose connective tissue (subgalea fascial) of diagnosis, 62
parietal fringe, 91 scalp, 34 etiology, 61–62
superior temporal fringe, 91 Loratadine, hair loss with, 79 histopathology, 62
temporal point, 90 Lotions for camouflage, 565 treatment, 62–64
Langer’s lines, scalp, 39 Loupe magnification, backlighting, Medication eruption, fixed
Large round graft, 82, 85 microscopic slivering, 363–372 autograft dominance in, 7
Large sessions, transplanting follicular units Low hairline, correction, 678–679 exchange autografts in, 1
in, rationale for, 392–399 Lupus erythematosus Medications. See also specific medication
donor supply, economizing, 396–398 autograft dominance in, 7 emergencies related to, 210–211
graft sorting enhancement, 398–399 exchange autografts in, 1 hair loss with, 68, 79
social, 393–395 hair loss with, 79 interactions, 191, 210–210, 215–218
telogen effluvium, 395–396 Lymphatic drainage, scalp, 37 for postoperative use, 564
Large slit graft, 82, 84 Medico-legal issues, 913–916. See also
Large slot graft, 82, 85 Magnesium, 198 Consent
Large standard graft, 261–262 emergency use of, 207 Medium round graft, 82, 85
942 Index
Medium slit graft, 82, 84 [Micro-minigrafting] Mini-micrografting, 403

Medium slot graft, 82, 85 recipient area treatment, 428 Minoxidil, 146–151, 194
Megasessions, 413–418 size of recipient area, 428 effect on surgical planning, 146–151
for follicular unit hair transplantation, surface deformity of recipient area, 428 Missed sites, in graft placement, 534
413–418 vascular injury to recipient area, 428 Mitral regurgitation, previous episodes of,
bleeding, 413 recipient vasculature, 432–433 203–204
deep vein thrombosis, 413–414 stem cell, 427–428 Mitral valve prolapse prophylaxis, 192,
dehydration, 413 stereoscopic dissecting microscope, 203–204
hypoglycemia, 413 ellipse, 427 Mixed grafting, follicular units, with multi-
lidocaine toxicity, 414–415 subtlety, 430–432 follicular unit grafts, 475–478
nausea, 415–416 transitional plugginess, 434 coronal vs. sagittal, 487
orthostatic hypotension, 415–416 usage of term, 434 density, 479–492
popping, 413 Micropunches, 639–640 graft detectability, advantage of, 489
staff, practical problems, 413 Microscopic slivering, 355–363 hair direction, 486–489
vomiting, 415–416 with backlighting, loupe magnification, hair survival, 489–492
363–372 rationale for, 478–479
staff, practical problems with, 413
elliptical excision, total microscopic round grafts, 492–503
Melanocyte reservoir, partial follicle
preparation of follicular units, Monitoring equipment, 206, 836–837
survival, graft, 281–285
367–368 Monoamine oxidase, 191, 194, 211
Meperidine, 231
follicular unit grafts vs. minigrafts, drug interactions, 191
Metabolic disorders, hair loss from, 67–69
364–365 Monosodium glutamate, preoperative
iron deficiency, 67 susceptibility to transection, 364–365
polycystic ovary syndrome, 67–68 ingestion of, 190
susceptibility to waste, 365 Morphea
telogen effluvium, 68–69 microscope, backlighting, combined, autograft dominance in, 7
thyroid disease, 67 368–372 exchange autografts in, 1
Methotrexate, hair loss with, 79 multibladed harvest, 365–367 Morphine, 207, 231
Methylprednisone acetate, 564 transection, waste with minigrafts cut Morphology of hair, variations in, 31–32
Microblades, 843 to size, 365 Motor innervation, scalp, 36–37
Microcontouring frontal hairline, 114–142, binocular stereoscopic dissecting Mounds, use in transplantation, 155–157
116 microscope, 355–358 Multibladed harvesting, 365–367
pitfalls, 114–116 general principles, 355 grafts obtained with, Reed study, 272
Micrografts, 82, 83–84 graft cutting, 362 Multi-bladed knife handles, 838
follicular family grafts, 83–84 natural hair groupings, anatomically Multifollicular unit graft, 84–85, 451–454,
follicular unit grafts, 83, 263–270 precise follicular units, compared, 503–516
intact vs. nonintact follicular unit graft, 363 density, 452–454
Beehner studies, 264–266 sizing grafts, cutter discretion in, follicular unit transplantation alone vs.
perigraft tissue, higher hair counts, 362–363 with multi-follicular unit grafts,
Seager and Beehner studies, 263 slivering techniques, 361–362 451–454
planting densities, FU growth, stereoscopic, 358–360, 360–361 follicular units with, 475–478
compared, Mayer study, 267–268 Microslit grafting, 82, 84–85, 504–511 coronal vs. sagittal, 487
survival over time, Limmer study, Microstrip grafting, 611–619 density, 479–492
263–264 aesthetic principles, 614–619 graft detectability, advantage of, 489
vertically, horizontally cut grafts vs. detectability of graft, 614
hair direction, 486–489
intact FU, Martinick study, donor area, 612
hair survival, 489–492
268–270 graft insertion ergonomics, 614
rationale for, 478–479
Micro-minigrafting, 418–435. See also microstrip grafts, 612–613
round grafts, 492–503
Coupled follicular unit characteristics of, 612–613
hairline zone, 503–504
aesthetically pleasing results, 428–432 natural framing, 614–619
insertion of, 549–552
density, hair volume, 428–430 recipient area, 613–614
large round grafts, 85
donor tissue use, 421–428 slits, creating, 614
spacing between grafts, 614 large slit grafts, 84
hair follicle transection rates, 421–424 large slot grafts, 85
Microsurgical free flaps, 801–808
ellipse, vs. multibladed harvest, 434–435 maximum density, 424
flap suited for transplantation, 801–802
‘‘exogen’’ follicles from donor tissue, medium round grafts, 85
microsurgical vascular anastomosis, 802
loss of, 424–427 medium slit grafts, 84
temporo-parieto-occipital, 808–812
follicular units, 419–421 medium slot grafts, 85
design, 808–809
compared, 270–272 surgical technique, 809–812 microslit grafts, 84–85, 504–511
one to three-hair micro-minigrafts vs. transfer, 801–808 ‘‘minigraft,’’ history of term, 84
FU, Reed study, 270 Midazolam, 232 minigrafts, 454
1.3-mm minigrafts after 1–3 sessions Midscalp balding, 87 naturalness, 451–452
vs. FU, Beehner study, 270–272 Minigrafts, 262–263 preparation, 380–382
gradient, graft density, 434 Beehner study, 262–263 round grafts, 380–381
graft orientation, 433 hair growth study, 262–263 slit grafts, 380–382
hairline design, 428 history of term, 84 slot grafts, 380–382
minigrafts, exogen follicles, 433–434 Unger study, 263 proposed terminology, 84
multihair follicular unit grafts, maximum usage of term, 434 round graft, 85, 511–516
density, 424 micro-minigrafting, 434 insertion of, 550–552
Index 943
[Multifollicular unit graft] [Natural hair patterns, transplant goals and] Notch injection, 239–240
slit graft, insertion of, 549–550 temple, 155 No-touch technique, 657–662
slot graft, 85, 511 temporal scalp, 158–161 donor harvesting, 657–658
insertion of, 549–550 vertex, 153–155, 158 graft preparation, 657–658
small round grafts, 85 Naturally maturing hairline, 106 incisions, recipient, 658
small slit grafts, 84 Nausea, postoperative, 562 placing, 658–660
small slot grafts, 85 Near syncope, during procedure, 209 NSAIDs. See Nonsteroidal anti-
‘‘traditional’’ slit grafts, 84 Necrosis, 562 inflammatory drugs
vs. follicular unit transplantation alone, in donor area, in follicular unit hair Number of grafts, estimating, 636
435–469 transplantation, 410 ‘‘Number of hairs,’’ cutting grafts to, 83
clinical significance of study results, in recipient area, in follicular unit hair Number of sessions required, informing
439 transplantation, 409–410 patient of, in initial interview, 167
comparison of techniques, 438–439 Needle holders, 839 Numbness, after surgery, 575
controversy regarding, 435–436 Needle size, pain of local anesthetic
density, 439–445 injection, 238 Occipital artery, 35
extended hairline area, 460–465 Needleless injectors, 238 Occipital fringe, 91
hair characteristics, 438 Needles, 843, 847 Occlusive dressings, 556
variety of, 438 Negative connotations, words with, Occupational Safety and Health
in hairline, other areas, 454–460 avoidance of, 17 Administration, 200–2002
heterogeneity, 438 Neoplastic disorders, hair loss from, 72–73 Office, setting-up, 831–885
learning curve, in transplant Nerve block, 239–240, 254–259 building practice, 831–833
procedures, 438 supraorbital nerve, 254–255 digital photography, 870–876
levels of skill, 438–439 supratrochlear nerve, 254 instrumentation, 835–840
multiple follicular unit grafts, 451–454 Nervous system disease, cell therapy office automation, 870–876
patient follow-up, 438 availability for, 44 phototrichogram, 857–860
studies on survival, density, Neuralgia, postoperative, 561, 572 standardized photography, 860–870
unreliability of, 439 Neuroma, after transplantation, 572 supplies, 835–840
trends in controversy regarding, 436 Nevus flammeus, donors from, 295–296 surgical assistants, 851–856
variety of patients, 438 Newsletter surgical suite, 833–835
Multiple-wheal technique, field blocks, 240 clinic, 18 Office automation, 876–876
Multi-recipient-site scalpels, 847 for marketing, 832 Office design, 833
Murmurs, nonpathologic, endocarditis Niacin, preoperative ingestion of, 190 Ointments, application of, for wound care,
prophylaxis not recommended, Nialamide, drug interactions, 191 555
203–204 Niche marketing, 832 Omega-3 fatty acids, preoperative ingestion
Muscle, in long-term tissue expansion, 699 Nicotine, avoiding, preoperatively, 190 of, 190
Musculoskeletal disease, cell therapy Nifedipine, emergency use of, 207 One to three-hair micro-minigrafts vs.
availability for, 44 Nitroglycerine spray, emergency use of, 207 follicular unit, Reed study, 270
Mushy dermis, after transplantation, 573 Nitrous oxide, 195 1.3-mm minigrafts after 1–3 sessions vs.
Mustache transplantation, 580–581 delivery machines, 838 follicular unit, Beehner study,
Myocardial infarction, cell therapy Nocturnal sedation, 192 270–272
availability for, 44 Non-conventional medications, 196–199 Open method of wound care, 555
Myocardial ischemia, during procedure, 208 Non-narcotics, postoperative, 557 Opioids, 230–231
Nonpathologic murmurs, endocarditis adverse reactions to, 235
Naloxone, emergency use of, 207 prophylaxis and, 203–204 fentanyl, 231
Naproxen, hair loss with, 79 Nonpharmacological adjuncts to anesthesia, meperidine, 231
Narcotics, postoperative, 556–557 225–226 morphine, 231
Nataf, Jules, contributions of, 13–14 Non-physician interviews, 174–175 Optical mechanism, in creation of illusion
Natural course of hair grafts, 555 advantages of, 173–175 of fullness, 443–445
Natural hair groupings, anatomically precise disadvantages of, 175 Optimal anesthesia, benefits of, 225
follicular units, compared, 363 ethical control, 173–175 Oral administration of anesthetics, 226
Natural hair patterns, transplant goals and, hiring, 174 Oral contraceptives, hair loss with, 79
151–164 postoperative phase, 175 Oral finasteride, combining hair
frontal scalp, 152–153, 155–158 preoperative phase, 175 transplantation with, 145
diffuse patterns, 152 rationale for, 173–174 Orentreich, Norman, contributions of, 8–9
isolated frontal forelock, 152–153 surgical phase, 175 Orientation of hair, illusion of density and,
isolated frontal forelocks, 157–158 Nonsteroidal anti-inflammatory drugs, 189 443
recession patterns, 152 avoiding preoperatively, 189–190 Orthostatic hypotension, during
whorl patterns, 153, 158 hair loss with, 79 megasessions, 415–416
general patterns, 152–153 for pain control, 557 OSHA. See Occupational Safety and Health
hairline shapes, 153 Nordstrom, Rolf, contributions of, 14 Administration
large patterns, 153 Norwood, O’Tar, contributions of, 11–12 Osteonectin, gene expression, 43
small patterns, 153 Norwood classification, 49–50, 653–654 Outer root sheath, histology, 29–30
midscalp, 155 type III-vertex, 129 Oxycodone, 194
mounds, 155–157 type IV pattern, 129 Oxygen delivery device, 206
natural patterns, 152 type V pattern, 129
patterns to guide hair transplantation, type VI pattern, 129, 653–654 Pacemakers, endocarditis prophylaxis and,
155–158 type VII pattern, 129–130, 653–654 203–204
944 Index
Pain control, 194–196, 237–238, 556–557, [Photography] [Pitfalls of follicular unit hair
572, 574, 772 accessories, 863–864 transplantation]
Pain of local anesthetic injection, 237–238 background, 863 nausea, 415–416
buffering, 237–238 camera, 861 orthostatic hypotension, 415–416
gate theory, 237 digital, 35-mm, compared, 860–861 popping, 413
needle size, 238 digital photography, 860–861 staff, practical problems, 413
needleless injectors, 238 film, 864 vomiting, 415–416
rate of administration, 238 lenses, 861–862 necrosis in recipient area, 409–410
topical local anesthetics, 239 lighting, 862–863 poor growth, 408
warming, 238 photographic session, 865 staff recruitment, training, 412
Papules, after transplantation, 571 photography room set-up, 864 stretched donor area scars, 410
Parietal fringe, 91 standardized views, 864—865 technical difficulties, 410–411
Parkinson’s disease, cell therapy availability Photography room set-up, 864 unsuitable hair characteristics, 411
for, 44 Phototrichogram, 857–860 Pitting, after transplantation, 570
Part, mature, 106–108 other photographic techniques compared, Placement of graft, 533–548, 633–635
Partial follicle survival, graft 858–859 anesthesia, 535
melanocyte reservoir, 281–285 potential problems, 858 bent grafts, 534
pluripotent stem cells, 281–285 uses of, 857 buddy technique, 538
Patent ductus arteriosus, endocarditis Physical examination of donor area, 305 dehydration, 533
prophylaxis and, 203–204 Physical trauma scar, transplanting into, 607 dilators, 536
Pathogenesis, androgenetic alopecia, 60–64 Physician-patient relationship, 16–20 empty sites, 534
clinical description, 61 bedside manner, 16 factors influencing placing, 535–538
diagnosis, 62 bonding with patient, 16 graft sizing, 536
etiology, 61–62 graft spacing, 536
brochure, 17
histopathology, 62 grafts placed too deeply, 534
charging for consultation, 18
treatment, 62–64 hemostasis control, 535
continuation process, 18
Patient questions, in initial interview, 170 hydration control, 536
embarrassment of patient, 16
Patient transfer to another facility, improper direction, orientation of grafts,
first consultation, 16–17
procedures during emergency, 207 534
length of, 18
Patients’ preferences, goals, 94 incision depth, limited-depth incisions,
hair cover of relatives, information about,
Pedicle flaps, in treatment of alopecia, 536
17
796–801 looking away from recipient site, 535
Percocet, for pain control, 556 litigation, 19–20 magnification loupes, 535
Performance review, for surgical assistants, medical history, 17 mechanical implanter devices, 537
854 anticoagulant medication, 17 Choi implanter, 537
standards for, 855 coronary heart disease, 17 hair implanter pen, 537
Pericranium, 34, 40 hemophilia, 17 mechanical measures, 535
Perigraft tissue, higher hair counts, Seager hepatitis, 17 mechanics of ‘‘gentle’’ graft insertion,
and Beehner studies, 263 immune deficiency disorders, 17 537
Peripheral nerve block, 239–240 past surgery, 17 missed sites, 534
notch injection, 239–240 negative connotations, words with, 17 physical trauma, 533–534
supraorbital/supratrochlear nerve block, photographs, before/after, 17 piggybacking, 524
239 positive phrases, use of, 17 popping, 534
three-finger rule, 240 postoperative instructions, 18 preexisting conditions, 535
Permission form for operative and/or postoperative review, 18 preoperative measures, 535
diagnostic procedure, 759–760 PowerPoint presentation, 17 problems, 533–534
Perphenazine, drug interactions, 191 preliminary phase, 16 prolonged time out of body, 534
Persistent anterior fringe, 51 psychological problem, missing hair, 17 quality control, 538
Persistent mid-frontal forelock, androgenetic receptionist, skills of, 16 removing epithelium, 536
alopecia with, 51 sales consultants, role of, 18 ‘‘stick and place’’ vs. ‘‘making all
Phenothiazines, drug interactions, 191 Physiology, hair, variations in, 31–32 incisions first,’’ 537–538
Phenytoin, emergency use of, 207 ‘‘Picker’s nodule,’’ 76 advantages of, 538
Phone book, for marketing, 831–832 Piggybacking, in graft placement, 524 disadvantages of, 538
Photographic consent form, 757 Pilar cyst, hair loss from, 73 tumescent, epinephrine solutions, 535
Photographs, of treated patients, 17, 167 Pinski, James Bernard, contributions of, 11 visualization, 535
Photography Pitfalls of follicular unit hair transplantation, Planting densities, FU growth, compared,
digital, 870–876 408–418 Mayer study, 267–268
computer files, 872–874 dense packing, 411–412 Plasminogen activator inhibitor 1, 43
database, 872–874 donor area necrosis, 410 Platelet function, non-conventional products
database software, 871–872 inadequate density, 408 affecting, 197–198
digital camera, 872–874 megasessions, 412, 413–418 danshen, 198
digital imaging, 871–872 bleeding, 413 feverfew, 198
lighting, 874 deep vein thrombosis, 413–414 garlic, 197
making transition, 874 dehydration, 413 ginger, 197
office automation, 876–876 hypoglycemia, 413 ginkgo biloba, 197–198
standardized, 860–870 lidocaine toxicity, 414–415 ginseng, 198
Index 945
[Platelet function, non-conventional [Postoperative period] Preoperative phase, 189–224, 194–196

products affecting] GraftCyte, for wound care, 555 acetaminophen, 194
magnesium, 198 Hair Magic, 565 acetylsalicylic acid, 189–190
saw palmetto, 198 hairpieces, 565 adverse interactions with medications,
vitamin E, 198 head dressings, 556 191, 194, 215–218
Pluripotent stem cells, partial follicle cons of, 556 alcohol, 190
survival, graft, 281–285 pros of, 556 alprazolam, 194
Polycystic ovary syndrome, hair loss with, hiccups, 563 antibiotics, 191–192, 195
79 hypoesthesia, 561 anxiety control, preoperative medication,
Poor growth, in follicular unit hair infection, 562 194–195
transplantation, 408 lotions for camouflage, 565 aspirin, over counter medications
Positive phrases, physician’s use of, 17 narcotics, 556–557 containing, 216
Posterior auricular artery, 35 natural course of hair grafts, 555 beta blockers, 194
Postoperative instructions, 18, 574–575 nausea, 562 bleeding
alopecia reduction, 744–745 negative aspects of, informing patient of, conventional medications causing, 215
Ambien, 574 168–169 herbs/vitamins/minerals causing, 215
bandage, 574 neuralgia, 561 blood work, 195
bandage removal, 574 non-narcotics, 557 cefadroxil, 191
bleeding, 574 occlusive dressings, 556 cefdinir, 191
Compazine, 574 ointments, application of, for wound care, check list, 189, 212
depression, 575 555 clothing, 195–196
diet, 574 pain, 556–557 comfort considerations, 195–196
exercise, 575 powder cakes, camouflage, 565 confirmation letter, 189, 213
Gravol, 574 problems consent to operate form, diagnostic
infection, 575 common, 560–561 procedure form, 219
numbness, 575 uncommon, 561–563 coordination, 189
pain management, 574 pruritus, 560 dexamethasone, 192
Serax, 574 pustules, 563 diagnostic procedure form, 219
shampooing, 575 recipient site, 558–559 diazepam, 194
suture removal, 575 dressings vs. no dressings, 558 endocarditis prophylaxis, 192
swelling, 574–575 gels, 558 epinephrine, 194
transplanted hair growth, 575 GraftCyte, 558–559 free radical formation, 192
vitamins, 575 minoxidil, 559 hair care, styling, 195
Postoperative period, 553–577 ointments, 558 hair length, styling, 193
activities, 564–565 vitamin E oil, 559 informed consent, 193–194, 219, 757,
exercise, 564 rest, 560 913–918
shampooing, 564–565 review, 18 instructions for patient, 189, 214
sports, 564 sedatives, 564 ischemia reperfusion injury, 192
work, 564 sprays for camouflage, 565–566 laboratory tests, 192–193, 200–202
analgesics, 564 Super Million Hair, 565 hepatitis B, laboratory testing, 192, 193
antibiotics, 564 sweating, 563 hepatitis C, laboratory testing, 192
arteriovenous anastomosis, 562–563 syncope, 562 human immunodeficiency virus,
laboratory testing for, 192
bandaging, 553–555 systemic medications, 564
medications, drug interactions, 217–218
bleeding, 560 Toppik, 565
minoxidil, 194
camouflage agents, 565–566 trauma, avoidance of, 560
mitral valve prolapse, 192, 203–204
types of, 565–566 wound care methods, 555–556
monoamine oxidase inhibitors, beta
central necrosis, 562 Postsurgical effluvium, 569
blockers, 194
complications during, 568–577 Pouteaux, Pierre, contributions of, 11
nicotine, 190
corticosteroids, 564 Powder cakes, camouflage, 565
nitrous oxide analgesia, 195
crusting, 560–561 PowerPoint presentation for patient, 17 nocturnal sedation, 192
cysts, 563 Pre-anesthesia, 628 nonsteroidal anti-inflammatories, 189–190
dislodging grafts, 561 Prednisone, 192 oxycodone, 194
donor site, 557–558 emergency use of, 207 pain, preoperative medication, 194–195
cold application, 558 medical interactions, 191 prednisone, 192
dressings, 557–558 Pregerm stage, hair, 25 preoperative check list, 189, 212
gels, 557 Preliminary phase of physician/patient preoperative medications, 191–192
ointments, 557 relationship, 16 preoperative package, 189
suture removal, 558 Preoperative check list, 189, 212 substances to be avoided, 189–191, 194
dry wound care method, 555 Preoperative confirmation letter, 189, 213 supplies for postoperative period, 196
effluvium of preexisting hair, Preoperative information, with scalp systemic corticosteroids, 192
postsurgical, 562 reduction, 721–722 travel, 196
elevation, 559–560 Preoperative instructions, 189, 214 trimethoprim-sulfamethoxazole, 192
general care, 559–560 with alopecia reduction, 721–722, vitamin K, 191
giving patient information regarding at 738–739 vitamins, 190
initial interview, 165 Preoperative laboratory testing, 202 Von Willebrand’s factor deficiency, 192
graft shedding, 562 Preoperative medications, 191–192 warfarin coumadin, 190
946 Index
Preparation of donor site, 321–322 Realistic goals, establishing, in initial [Recipient site]
Preservation time, graft preservation and, interview, 165–166 frizziness, 100
286 Receptionist, skills of, 16 intrinsic beauty, 100–102
Preserving follicular unit, 388–390 Recession patterns, frontal scalp, 152 wave, 99
Prilocaine, 229 Recipient site, 81–146, 652–654, 904 hair growth characteristics and, 56–60
Primordial hair, 25 aesthetic principles, 91–92 hairline design, 652–654
Procainamide, emergency use of, 207 function, 92 for Norwood class VI, VII, 653–654
Prochlorperazine purpose of hair restoration surgery, 92 hairline placement, 652–654
drug interactions, 191 age of patient, 109–110 hairpiece, patients with, 136
emergency use of, 207 alopecia reductions, 145 height of frontal hairline, 108–111
Professionalism, 20–21 role of, 139–142 incisions, 383–531
Promazine, drug interactions, 191 combining hair transplantation and, intervals between transplant sessions,
Promethazine, drug interactions, 191 142 136–137
Propecia, 146–151 drawbacks, 139–140 limited dense packing into hair transplant
Prophylaxis, 202–204 planning, 140–142 plan, 144
Propiomazine, drug interactions, 191 alternative donor sites, 135 long frontal region, 113
Propofol, 232 anatomy of patient’s head, 104 mature part, 106–108
Propranolol angry patients, 95 means of camouflage available, 105
drug interactions, 191 anxiety disorder, 95 medical health of patient, 94
hair loss with, 79 background factors, 92–93 microcontouring frontal hairline, 114–142
Propylthiouracil, hair loss with, 79 age, 93 pitfalls, 114–116
Prospective forelock approach, to younger factors contributing to hair micrografts, 83–84
patient, 130 transplantation, 92–93 follicular family grafts, 83–84
Prosthetic valves, endocarditis prophylaxis initial decision, 92 follicular unit grafts, 83
for, 203–204 beard donor hair, 145 multi-follicular unit grafts, 84–85
Prurigo nodularis, 76 ‘‘blamer,’’ 95 large round grafts, 85
Pruritus, postoperative, 560 body dysmorphic disorder, 96 large slit grafts, 84
Pseudoephedrine, emergency use of, 207 caliber of hairs, 131 large slot grafts, 85
Pseudofolliculitis barbae, 598 capabilities of surgeon, assisting staff, medium round grafts, 85
Pseudopelade of Brocq, 76–77 102–103 medium slit grafts, 84
Psoriasis, 2, 3, 78 centimeter boxes, for quality control, 654 medium slot grafts, 85
autograft dominance in, 7 common hair-loss patterns, approach to, micro-slit grafts, 84–85
Psychiatric illness, hair loss from, 68 129–130 ‘‘minigraft,’’ history of term, 84
Psychological problems, from missing hair, contour of frontal hairline, 111–113 proposed terminology, 84
17 current hair loss treatment strategy of round grafts, 85
Psychological state of patient, 94–96 patient, 105 slot grafts, 85
Pubic hair transplantation, 581–584 deep temporal gulf pattern, 118–119 small round grafts, 85
Punch handles, 847 density gradient between adjacent zones, small slit grafts, 84
Punches, used for donor harvesting, 131 small slot grafts, 85
839–840 ethnic groups, rounded hairlines, 113 ‘‘traditional’’ slit grafts, 84
Punctiform technique, 641–650 evolving male pattern baldness, 133–135 naturally maturing hairline, 106
anesthesia, 641–642 family history of male pattern baldness, Norwood III-vertex, type IV or V pattern,
complications, 646–650
103 129
follicular units, preparing, 643–645
financial capability of patient, 104 Norwood type VI pattern, 129
hair-bearing ellipse, harvesting, 642–643
flared hairline, 111–112 Norwood type VII pattern, 129–130
hairline creation, 641–642
follicular unit transplanting, exclusive, vs. oral finasteride, combining hair
implantation, 646
micro-minigrafting, 132 transplantation with, 145
preoperative procedure, 641–642
forelock designs, 138–139 organization of, 81–146
hairline creation, 641–642
fringe hair, quality of, 103 patients’ preferences, goals, 94
Purpose of hair restoration surgery, 92
Purpose of initial interview with patient, frontal forelock, 137–138 planning hairline zone, 106–114
165–169 candidates for, 137 planning of, 81–146
Pustules designs, 137–138 position of temporal hair, 110
after transplantation, 571 frontal hairs, setting angle, 116–118 postoperative care, 558–559
postoperative, 563 frontal-midscalp forelock, 137, 138 dressings vs. no dressings, 558
Pyruvate kinase M2, gene expression, 43 future hair styling preference, 105–106 gels, 558
graft size, 131 GraftCyte, 558–559
QFU. See Quadruple follicular unit graft spacing, 131 minoxidil, 559
Quadruple follicular unit, 82 graft terminology, 81–83 ointments, 558
Quality control, in graft placement, 538 cutting grafts to ‘‘number of hairs,’’ 83 vitamin E oil, 559
grafts cut ‘‘to size,’’ vs. ‘‘number of problem correction, 674–685
Rabineau, Patrick, contributions of, 10–11 hairs,’’ 81–82 ‘‘Barbie-doll’’ appearance, 676
Racial variations, in hair, 32. See also under grafts used at hairline, 111 cobblestoning, 674–678
specific race hair characteristics, 96–102 compression, 674–676
Radiation, hair loss from, 76 caliber of hair, 96 dimpling, 674–676
Rapid transfer of grafts from donor area to color contrast, hair to skin, 96–99 hyperfibrotic healing, 677
recipient area, effect of, 295 curl, 99 inappropriate grafts, 676–676
Index 947
[Recipient site] Recombinant follicular units, 469–475 [Scalp]

incorrect hair direction, angle, 677–678 theoretical framework, 470–471 vascular considerations, 37–38
poor hair yield, 676 Reduction of treatment area, 627–628 subgaleal layer/space of scalp, 39–40
scarring, 677 Refinements, surgical, 636–641 undermining for wound closure, 42
stubble, 678 Regulation of right to practice cosmetic Scalp depth, donor harvesting and, 320–321
technical errors, 674–678 surgery, future developments, 21 Scalp elasticity, laxity, 105
projected donor/recipient area ratio, Regulation of tissue engineering, 46 Scalp expansion, for traumatic, iatrogenic
93–103 Relatives, hair cover of, patient information alopecia, 820–828
psychological state of patient, 94–96 about, 17 Scalp extension, 765–793
rounded hairline, 112–113 Removal of donor strip, 327–328 alopecia reduction, 765
scalp elasticity, laxity, 105 Renal failure, cell therapy availability for, compared, 772–773
scalp landmarks, 90–91 44 androgenetic alopecia, use of extender in,
anterior temporal fringe, 91 Rest, postoperative, 560 773–774
frontal forelock, 90–91 Retinoids, hair loss with, 79 beginners’ tips, 782–785
frontal tuft, 90 Revascularization, graft, growth factors, compression, alopecic scalp, 769
287–294 description, 766
frontotemporal recession, 90
Reviewing medical information, grading esthetic considerations, 780–781
hairline height, 91
system for, 205 extensive alopecia, 770–771
occipital fringe, 91
Rheumatic valvular diseases, endocarditis Frechet three hair-bearing flap
parietal fringe, 91
prophylaxis for, 203–204 transposition procedure, 775–782
superior temporal fringe, 91
Right to practice, governmental regulation complications following, 779–780
temporal point, 90 of, 20–21
scalp lesions, 137 newer types of extenders, 774–775
Ring block anesthesia, epinephrine use and, novice, tips for, 782–785, 785–793
scalp thickness, 103–104 246–247 complications, 791–793
scatter zones, 138–139 Rogaine, 146–151 drawing, for scalp reduction, position
selective transplanting of specific zones, Ropivacaine, 229 of extender, 787
131 Round graft, 82, 85, 511–516 Frechet’s skin extender, sub-galeal
side-to-side hairstyle, 112–113 insertion of, 550–552 positioning, 787
size of, 390–392 multi-follicular unit grafts, follicular units indication for surgery, 785
supporting temporal hair, 104 with, 492–503 motivated patient, 785
transplant philosophy, 144 Round punches, 843–844 scalp reduction plan, 787
transplanting crease area, 128 Rounded hairline, 112–113 sub-galeal positioning of Frechet’s skin
transplanting frontal region, 118–120 Routes of administration, anesthetics, 226 extender, 787
transplanting midscalp region, 120–122 Rows, insertion of grafts on within given surgery plan, 785–787
transplanting temporal region, 128 pattern, graft survival, 296–297 transposition flaps, planning slot
transplanting vertex, 122–128 correction with, 787
full density vertex, 128 Sagittal midline ellipse, scalp reduction, 716
operative technique, 766–769
graft selection, 126–127 Sales consultants, role of, 18
extender removal, 767–769
vertex hair, as tacking hair, 127–128 Saline compresses, sprays, 555
insertion of extender, 766–767
whorl’s center point, 127 Saline tumescence, 243
scalp stretching, parietal, occipital areas,
trichotillomania, 95 Sarcoidosis, 71
770
types of grafts employed in hair Saw palmetto, 198
side effects, 771–772
transplantation, 131–132 Scalp
infection, 771–772
typical transplant candidate, 128–129 anatomy of, 33. See also Scalp, surgical
morphological changes, 771
unrealistic expectations, patients with, 95 anatomy
arterial supply, 35–36 postoperative pain, nausea, 772
variant pattern of hair loss, 118 time with extender in situ, 770
innervations, 36–37
whisker hair, 105 Scalp landmarks, 90–91
motor innervation, 36–37
women, planning of hair transplantation anterior temporal fringe, 91
sensory innervations, 36
in, 142–144 frontal forelock, 90–91
layers of, 33–34
younger patient, 130–131 frontal tuft, 90
cross-section, 33
doctor-patient relationship, 130 frontotemporal recession, 90
lymphatic drainage, 37
minimum age for transplanting, 131 veins, 36 hairline height, 91
prospective forelock approach, 130 subgalea fascial, 34 occipital fringe, 91
zones of balding scalp surgical anatomy, 37–42 parietal fringe, 91
frontal forelock design, in biomechanics, 41–42 superior temporal fringe, 91
transplanting, 88 elastic limit of skin, 41–42 temporal point, 90
frontal hairline zone, 88 elastin component of skin, 41 Scalp laxity, 41, 105
frontal region, 87 galea aponeurotica, 38, 39 classification of, 697–698
lateral crease zones or ledges, 88–89 Langer’s lines, 39 donor harvesting and, 316–319
midscalp, 87 incisions/excisions, 41 Scalp lesions, 137
nomenclature system, 85–90 Langer’s lines, 39 Scalp mobility, correction, 670
posterior parietal triangle zones, 89–90 pericranium, 40 Scalp reduction, 710–737
sub zones within three major zones, scalp laxity, 41 before, during hair transplantation,
88–90 skin, 37 714–715
vertex (crown), 87 subcutaneous tissue, 37 carbon dioxide laser, 731
vertex transition point, 87–88 neurological considerations, 38 complications, 736–737
948 Index
[Scalp reduction] [Scar tissue, transplanting into] Skin of scalp, 37

with deep plane fixation, 695 inflammatory disease process scar, stretch, 698–706
Frechet scalp extender, 734 606–607 anatomy of, 698
galeal closure, tension of, 729–732 physical trauma scar, 607 pathophysiology of, 698
galeotomies, 730 scalp thickness, 607–608 Slit grafts, insertion of, 549–550
with graft transplantation, 731–732 scarring, etiology of, 606–607 Slivering, microscopic, 363–372
intervals between procedures, 731 surgical revision vs. hair transplantation, elliptical excision, total microscopic
major, 734–735 606 preparation of follicular units,
minireductions, 732 before transplanting, 606–608 367–368
patient selection, 712–714 Scarring, 635 follicular unit grafts vs. minigrafts,
age, 714 after transplantation, 572–573 364–365
degree of alopecia, 714 hyperfibrotic scarring, 573 susceptibility to transection, 364–365
general health, 712–714 keloids, 573 susceptibility to waste, 365
objectives, 714 wide scars, 573 microscope, backlighting, combined,
psychological factors, 714 wound dehiscence, 573 368–372
with alopecia reduction, 750–751 multibladed harvest, 365–367
scalp laxity, 714
in Asian patients, 592 transection, waste with minigrafts cut to
patterns of, 715–721
in Black patients, 598 size, 365
combined patterns, 721
correction, 670 Slivering boards, 841
lateral patterns, 718–719
donor harvesting and, 325–326, 330–331 Slivering of donor strip, 350–355
sagittal midline ellipse, 716
stretched donor area, in follicular unit Slivering techniques, 361–362
U pattern, 719 hair transplantation, 410
Y pattern, 716–718 Slot grafts, 82, 85, 511
Scatter zones, 138–139 insertion of, 549–550
Y pattern variations, 718 Scissor-sharpening equipment, 847 multifollicular unit graft preparation,
scalp extension, novice, tips for, drawing Scleroderma, exchange autografts in, 1 380–382
for, 787 Sebaceous nevus, 74 Slot punch, 844
Shaw knife, 731 Secundum atrial septal defect, endocarditis Small recipient sites, rationale for, 390–392
standard, 721–729 prophylaxis and, 203–204 Small round grafts, 85
anesthesia, 722 Sedation, 564, 650–651 Small slit graft, 82, 84
preoperative information, 721–722 intravenous sedation, 651 Small slot graft, 82, 85
preoperative preparation, 722 oral sedation, 650–651 Smoking, epinephrine use and, 249
surgical technique, 722–729 Seizures, during procedure, 210 Smooth muscle protein SM22, alpha, gene
stretch back, 730–731 Self-regulation of practice, 22 expression, 43
sutures, interrupted, vs. continuous suture Seminars, for marketing, 832 Sodium bicarbonate, emergency use of, 207
closure, 729–730 Senile alopecia, 51 Soft tissue defects, cell therapy availability
timing of procedure, 714–715 Sensory innervations, scalp, 36 for, 44
tissue expansion with, 732–734 Sensory nerve damage, 751 Sorting follicular units, 392
classic, continued tissue expansion, 732 with alopeia reduction, 751 Spacing at repair session, 670
intraoperative, rapid tissue expansion, Serax, 574 Specific zones, selective transplanting of,
732–733 Setting-up office, 831–885 131
presuturing, 733–734 building practice, 831–833 Spinal cord injury, cell therapy availability
Unger-modified major reduction, digital photography, 870–876 for, 44
735–736 instrumentation, 835–840
Spinal-needle technique, field blocks,
Scalp reductions, basic science, 689–707 office automation, 870–876
240–242
Scalp surgery, 689–697 phototrichogram, 857–860
Sports, postoperative, 564
analysis, 695 standardized photography, 860–870
Sprays for camouflage, 565–566
excisions, 689 supplies, 835–840
Squamous cell carcinoma, 74
incision, 689 surgical assistants, 851–856
actinic keratoses with, 74
median pericranial flap, wound anchorage surgical suite, 833–835
hair loss from, 73
to, 694–695 Shampooing, after surgery, 564–565, 575
Shaw knife, for scalp reduction, 731 Staff members, qualifications of, 852
mobilization, 691–692 Staff recruitment, training, for follicular unit
Shepherd’s-crook type hairs, 4
modifications, 695–696 hair transplantation, 412
Shiell, Richard, contributions of, 12
neurological considerations, 691 Staff requirements, 635, 853–854
Short-acting barbiturates, 232
pericranium, 692–694 Standard punch grafts, 82
Short-term medical therapy, effect on
procedure, 695 Standardized photography, 860–870
surgical planning, 147
reconstruction, 691–692 Shunts, systemic-pulmonary, endocarditis 35-mm compared, 860–861
scalp reduction, with deep plane fixation, prophylaxis for, 203–204 accessories, 863–864
695 Side-to-side hairstyle, 112–113 background, 863
statistics on, 696 Single-bladed scalpel, 838 camera, 861
vascular considerations, 690–691 Single-strip harvesting, rationale for, digital photography, 860–861
Scalp thickness, 103–104 402–403 film, 864
scarring and, 607–608 Size of recipient area, 428 lenses, 861–862
Scalpel, 838 Sizing grafts, cutter discretion in, 362–363 lighting, 862–863
Scalpels, multi-recipient-site, 847 Skin disease photographic session, 865
Scar tissue, transplanting into, 606 cell therapy availability for, 44 photography room set-up, 864
blood supply, 607 hair loss from, 68 standardized views, 864—865
Index 949
Stanozolol, hair loss with, 79 Supraorbital nerve, 36 Syncope

Staphylococcal infection, hair loss from, 69 Supraorbital nerve block, 254–259 postoperative, 562
Staple device, 839 additional innervation, 255 during procedure, 209
Stavudine, 202 anatomy, 254, 255 Systemic corticosteroids, 192
Stem cell transplantation, 427–428 complications, 257 Systemically active anesthetics, 226
Stereomicroscopic dissection, rationale for, supraorbital nerve, 254–255
403 supratrochlear nerve, 254 Team approach to emergency situation, 207
Stereoscope dissection surface anatomy, 255 Technical difficulties, in follicular unit hair
donor hair, disadvantages of, 358–360 technique, 255–256 transplantation, 410–411
follicular units, instrumentation, 360–361 Supratrochlear artery, 35 Telogen effluvium, 395–396
Stereoscopic dissecting microscope, ellipse, Supratrochlear nerve, 36 common causes of, 68
427 Supratrochlear nerve block, 239, 254–259 Temperature, graft dehydration and, 286
Stick and place method, 537–548, 622 additional innervation, 255 Templates, 835–836
advantages of, 538, 543–544 anatomy, 254, 255 Temple, 155
epinephrine, 543 complications, 257 Temporal hair, donor harvesting and, 327
graft density, variation of, 543 supraorbital nerve, 254–255 Temporal point, scalp, 90
local anesthetic, 543 supratrochlear nerve, 254 Temporal point transplantation, 584–591
needle sites, 544 surface anatomy, 255 postoperative care, 586–587
piggybacking, elimination of, 543–544 technique, 255–256 surgical technique, 584–586
recipient site size, variation of, 543 Surgical anatomy of scalp, 37–42 temporal point recession, classification of,
smaller recipient sites, 543 biomechanics, 41–42 584
delegation of procedure, 545 elastic limit of skin, 41–42 Temporal scalp, hair patterns, 158–161
advantages, 545 elastin component of skin, 41 Temporary marked thinning, after
disadvantages, 545 galea aponeurotica, 38, 39 transplantation, 569–570
ethical issues, 545–547 Langer’s lines, 39 Temporo-parieto-occipital flap,
disadvantages of, 538, 544–545 incisions/excisions, 41 microsurgical, free, 808–812
increased cost, 544 pericranium, 40 Tenting, after transplantation, 570
management costs, 544 scalp laxity, 41 Terminal hair
minimal, no-charge training sessions, skin, 37 anatomy, 26–27
544 subcutaneous tissue, 37 inferior segment, 27
needlestick injuries, 544 neurological considerations, 38 infundibulum, 26
quality control, 544–545 vascular considerations, 37–38 isthmus, 26–27
recruitment costs, 544 subgaleal layer/space of scalp, 39–40 histology of, 26–27
slower planting, 544 undermining for wound closure, 42 vellus, contrasted, 31–32
training costs, 544 Surgical assistants, 851–856 Terminal hair follicle, histology, 27–30
fine-tuning, 465 division of labor, 851–852 dermal papilla, 27
incomplete growth, 541–542 employee satisfaction, 854 hair shaft, 27–28
legal implications, 546–547 hiring, 852 hair shaft cortex, 28
summary of technique, 542–543 performance review, 854 hair shaft cuticle, 28
Stough standards, 855 hair shaft medulla, 27–28
Blu, contributions of, 10 staff members, qualifications, 852 inner root sheath, 28–29
Dow, contributions of, 15 staffing requirements, 853–854 matrix cells, 27
Stress relaxation, tissue stretch, 702–703 training, 852–853 outer root sheath, 29–30
Stretched donor area scars, in follicular unit for graft placement, 853 TFU. See Triple follicular unit
hair transplantation, 410 for graft preparation, 853 Thinning, temporary, after transplantation,
Strip harvesting, 652 for OR assistant, 853 569–570
Sturm, Hiram, contributions of, 9 Surgical interventions, hair loss from, 68 Thioridazine, drug interactions, 191
Subaortic stenosis, endocarditis prophylaxis Surgical scissors, 838 Three-finger rule, peripheral nerve block,
for, 203–204 Surgical suite, 833–835 240
Subcutaneous administration of anesthetics, Surgical systemic-pulmonary shunts, Thyroid disease, hair loss with, 79
226 endocarditis prophylaxis for, TI. See Transplant Index; Transplant index
Subcutaneous layer of skin, scalp, 34 203–204 Tissue engineering, 44–48
Subcutaneous tissue, scalp, 37 Surplus skin, 700–701 conceptual framework, 45
neurological considerations, 38 biological origin, 700 disease states for which available, 44
vascular considerations, 37–38 proliferation, 700 regulation of, 46
Subgaleal layer/space of scalp, 34, 39–40 mechanical origin, 700–701 research, 45–46
Subgaleal positioning of Frechet’s skin tissue-expanded skin, 700–701 source of cells, 44
extender, scalp extension, 787 Survival of hair transplants, 261–297 Tissue expansion, 698–706
Super Million Hair, 565 Suture material, 345–346, 838 long-term, 698–700
Superficial catgut reaction, with alopecia Sutures capsule, 699
reduction, 750 removal, 575 dermis, 699
Superficial temporal artery, 35 with scalp reduction, 729–730 electron microscopy, 700
Superior temporal fringe, 91 Sweat ducts, 34 epidermis, 698–699
Supplies in hair restoration surgery, 835 Sweating, postoperative, 563 fat, 699
Supporting temporal hair, 104 Swelling, after surgery, 574–575 muscle, 699
Supraorbital artery, 35 Synchronization, 569–570 with scalp reduction, 732–734
950 Index
Tissue forceps, used in donor harvesting, Tufting, 635 Vitamin B complex, preoperative ingestion
838 Tumescence, 243–245, 322–323 of, 190
Tissue stretch, intraoperative, 701–704 anesthesia, 243 Vitamin E, 198
creep, 702–703 epinephrine use and, 247, 535 preoperative ingestion of, 189, 190
intraoperative tissue stretch, surplus skin, donor area tumescence, 247 Vitamin K, 191
stretch-back, 703–704 recipient area tumescence, 247 Vitamins
load cycling, 702–703 items used for, 837–838 after surgery, 575
stress relaxation, 702–703 Tumescent syringe, 837–838 avoiding, preoperatively, 190
surplus skin, 702–703 Tumors, hair loss from, 73–74 increased bleeding with, 198
mechanical origin, 701–702 Turban-induced traction alopecia, 75 Vitiligo, 2, 4, 7
tissue dehydration, 702–703 Tylenol, for pain control, 557, 564 autograft dominance in, 7
viscoelastic properties of skin, 701–702 Type A variant, androgenetic alopecia, exchange autografts in, 1
Topical local anesthetics, 239 standards for classification, 50–51 Vomiting, postoperative, 562
Toppik, 565 Types of grafts employed in hair Von Willebrand’s factor deficiency, 192
Traction alopecia, 75, 598 transplantation, 131–132
Warfarin coumadin, avoiding,
secondary to use of hair curlers, 75 Typical transplant candidate, 128–129
preoperatively, 190
Traditional slit grafts, 82, 84 Wave of hair
Training of physicians, core curriculum for, U pattern, scalp reduction, 719 donor harvesting and, 320
22 Ulcers, cell therapy availability for, 44 recipient area considerations, 99
Training of surgical assistants, 852–853 Ultra-short-acting barbiturates, 232 Wet hair, illusion of density and, 443
for graft placement, 853 Undermining, for wound closure of scalp, Whisker hair, 105
for graft preparation, 853 42 White hair growth, 73
for OR assistant, 853 Unger Whorl patterns, frontal scalp, 153
Tranquilizers, drug interactions, 191 Carl, contributions of, 8 Whorl’s center point, transplanting vertex,
Transcutaneous administration of Martin, contributions of, 14 127
anesthetics, 226 Walter, contributions of, 13. See also Wide scars, after transplantation, 573
Transection through bulge area, two equal within specific area of hair Width of donor strips, donor harvesting and,
halves transplantation 324–326
hair growth after, Mayer studies, Unnatural appearance after transplantation, old scars, 325–326
273–274 570. See also aesthetic Women
Swinehart study, 274 complications hair transplantation in, 516–524
Translation elongation factor 1 alpha, 43 cobblestoning, 570 planning of, 142–144
Transplant consent, 193–194, 219, 757, kinkiness, 570 Ludwig’s pattern of hair loss in, 53–56
913–918, 917–918 pitting, 570 stanozolol, hair loss with use of, 79
Transplant Index, 878 Unrealistic expectations, patients with, 95 Woolly hair nevus, 2, 3
documentation of, 878 Unsuitable hair characteristics, in follicular Work, postoperative, 564
Transplant philosophy, 144 unit hair transplantation, 411 Wound care methods, 555–556
Transsexual male, 602–606 Urinary reflux, cell therapy availability for, Wound dehiscence
approach to, 603 44 after transplantation, 573
baldness, future progression of, 603–606 with alopecia reduction, 751
donor site, 603 Wound revascularization, growth factors,
Vacuum devices, 840 287–294
financial considerations, 603
Vallis, Charles, contributions of, 12
hairline design, 603 Y pattern scalp reduction, 716–718
Valvular dysfunctions, endocarditis
Tranylcypromine, drug interactions, 191 Younger patients, 130–131
prophylaxis for, 203–204
Trauma, avoidance of, postoperatively, 560 Vasovagal reactions, during procedure, 209 doctor-patient relationship, 130
Traumatic alopecia, 75–76 Veins of scalp, 36 expectations of, 171
physical injury, 76 Vellus, terminal hair, contrasted, 31–32 minimum age for transplanting, 131
radiation, 76 Verapamil, emergency use of, 207 prospective forelock approach, 130
scalp expansion, 820–828 Vertex, 153–155, 158
traction alopecia, 75 ZDV. See Zidovudine
of balding scalp, 87 Zidovudine
trichotillomania, 76 transition point, 87–88
Travel, preoperative, 196 after accidental exposures, 202
problem correction, 674 Zolpidem tartrate, 564
Trepidation regarding, 20–21 Vertex transplant, 122–128 Zones of balding scalp
Triamcinolone acetonide, 564 full density vertex, 128 frontal forelock design, in transplanting,
Triangular alopecia, 77 graft selection, 126–127 88
Trichodensitometry, 876–878 vertex hair, as tacking hair, 127–128 frontal hairline zone, 88
occipital donor area, 876–878 whorl’s center point, 127 frontal region, 87
recipient area, 878 Vertically, horizontally cut grafts vs. intact lateral crease zones or ledges, 88–89
transplanted area, 878 FU, Martinick study, 268–270 midscalp, 87
Trichotillomania, 76, 95 Videomicroscope, 351 nomenclature system, 85–90
Trifluoperazine, drug interactions, 191 Videos, for marketing, 832 posterior parietal triangle zones, 89–90
Trimeprazine, drug interactions, 191 Virgin midline elliptical donor areas, sub zones within three major zones,
Trimethoprim-sulfamethoxazole, 192 previous harvests, positioning, 88–90
Triple advancement transposition flaps, 813 326–327 vertex, 87
Triple follicular unit, 82 Visualization, in graft placement, 535 vertex transition point, 87–88
Tufted folliculitis, 69, 70 Vitamin A, hair loss with, 79 Zygomatic nerve, innervation by, 36
About the Editors
WALTER P. UNGER is Clinical Professor of Dermatology, Mount Sinai School of Medicine, New York, New York, as well as Visiting
Professor, Dermatology, Johns Hopkins School of Medicine, Baltimore, Maryland, and Assistant Professor of Medicine, University
of Toronto, Ontario, Canada. The author of numerous articles and chapters in medical journals and texts, he has been invited to
deliver scientific papers at medical meetings throughout the world. He is the recipient of the Golden Follicle Award (1995) and
the Manfred Lucas Award (2003) from the International Society of Hair Restoration Surgery and was one of only three physicians
recommended for hair transplantation in The Best Doctors in America. Dr. Unger is a member of the American Board of Hair
Restoration Surgery and the American Society of Dermatologic Surgery, among many other professional organizations. He received
his M.D. degree from the University of Toronto, Ontario, Canada.
RONALD SHAPIRO is Founder and Director, The Shapiro Medical Group, Minneapolis, Minnesota. The author of numerous journal
articles and professional publications, he is one of a select group of world-renowned physicians regularly honored with invitations
to demonstrate his technique at major conferences around the world. He has been elected by his peers to be on the Board of
Governors to the International Society of Hair Restoration Surgery and is Board Certified in Internal Medicine, Emergency Medicine,
and Hair Transplant Surgery.

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No claim to original U.S. Government works

International Standard Book Number-13: 978-1-4200-3035-8 (eBook - PDF)

James Arnold, M.D.

Foreword James Arnold iii

1. History and Patient Relationship 1

4. Hair Loss Unrelated to Androgenetic Alopecia Eric L. Eisenberg 67

5. Basic Principles and Organization 81

6. The Initial Interview 165

7. Preoperative Phase 189

9. Graft Survival, Growth, and Healing Studies 261

10. Donor Harvesting 301

11. Graft Preparation 349

12. Recipient Site Grafts and Incisions 383

13. Graft Insertion and Placement 533

14. Postoperative Phase 553

15. Transplanting Areas That Need Special Consideration 579

16. Personal Techniques 611

17. Correction of Cosmetic Problems in Hair Transplanting Walter P. Unger 663

ALOPECIA REDUCTION AND FLAPS

18. Basic Science and Principles of Reductions and Flaps 689

19. Alopecia Reduction Procedures 709

20. Scalp Extension 765

21. Flap Procedures 795

22. Setting Up an Office 831

23. Some Things New, Some Things Old 887

Epilogue: Addendums to Chapters and Recent Developments 921

Catello Balsamo, M.D. Private practice, Modena, Italy

Guillermo Blugerman, M.D. Private practice, Buenos Aires, Argentina

Mont J. Cartwright, M.D. Private practice, Abilene, Texas, U.S.A.

Yung-Chul Choi, M.D. Togo Clinic, Seoul, Korea

Jerry E. Cooley, M.D. Private practice, Charlotte, North Carolina, U.S.A.

Paul C. Cotterill, B.Sc., M.D. Private practice, Toronto, Ontario, Canada

Shanee Courtney, R.N. Private practice, Littleton, Colorado, U.S.A.

Patrick Frechet, M.D. Private practice, Paris, France

Victor Hasson, M.D. Private practice, Vancouver, British Columbia, Canada

Kenichiro Imagawa, M.D. Private practice, Yokohama, Japan

Sajjad Khan, M.D. Private practice, San Diego, California, U.S.A.

Shagufta Khan, M.D. Private practice, San Diego, California, U.S.A.

Moon-Kyu Kim, M.D. Kyungpook National University, Taegu, Korea

Russell Knudsen, M.B., B.S. Private practice, Sydney, Australia

E. Antonio Mangubat, M.D. Private practice, Seattle, Washington, U.S.A.

Mario Marzola, M.B., B.S. Private practice, Adelaide, Australia

Konstantinos J. Minotakis, M.D. DHI Medical Group, Athens, Greece

Frank G. Neidel, M.D. Private practice, Düsseldorf, Germany

Carlos Puig, D.O. Private practice, Houston, Texas, U.S.A.

Patrick Rabineau, M.D. Private practice, Paris, France

William H. Reed, II, M.D. Private practice, La Jolla, California, U.S.A.

Arturo Sandoval-Camarena, M.D. Private practice, Guadalajara, Mexico

Diego Schavelzon, M.D. Private practice, Buenos Aires, Argentina

Gerard E. Seery, M.D., F.R.C.S. Private practice, Carmichael, California, U.S.A.

Richard C. Shiell, M.B., B.S. Private practice, Melbourne, Australia

Martin E. Tessler, M.D. Private practice, Southfield, Michigan, U.S.A.

Arthur Tykocinski, M.D. Private practice, São Paulo, Brazil

Bradley R. Wolf, M.D. Private practice, Cincinnati, Ohio, U.S.A.

Figure 1A-3 This is a patient with alopecia areata: (a) an ‘‘alo-