With current techniques, hair transplants can look totally natural and without signs that a procedure has been performed.¹ Hair transplantation has, however, a poor reputation because so many patients in the past have had less than acceptable results.² Scalp reconstruction with flaps and excisions and the use of tissue expanders for male patients with genetic hair loss are now rarely used except in the management of difficult secondary cases.³^–²⁰

Improvements in results in the past 15 years are due to the work of many in the field, and in particular, Dr Carlos Uebel from Brazil,^21,²² who was one of the first to popularize the use of small natural-appearing grafts in large numbers performed at a single session. Today, rather than transferring a few hundred grafts at each session requiring numerous procedures, it is not unusual to transfer 1500, 2000, and even 3000 grafts in a single session.

Importance of Type of Graft and Design of a Natural Hairline

A discussion of transplantation usually refers to micro or mini grafts.²³ Current nomenclature uses the term follicular grafts,²⁴^–²⁶ which are clusters of one to three hairs that emerge from the scalp as a unit. Grafts often used to contain 10, 20, and even 40 hairs per each graft, so creating an unnatural appearance (Fig. 6.1A&B), and the hairline was often poorly designed. A successful and aesthetically pleasing hair restoration is as demanding as any other aesthetic facial procedure.

Fig. 6.1 Unsatisfactory hair transplants. A, Patient who had hair transplantation 20 years previously. The large plug grafts and hairline that is too straight create an unnatural result. B, Due to the natural progression of hair loss, the plug grafts placed 20 years previously are several centimeters in front of the receding hairline.

The frontotemporal recession is an important component of creating a mature natural hairline in males.²⁷ This anatomic landmark is formed by the junction of two lines, consisting of the frontal and temporal hairlines, which converge in an acute angle. It is critical in creating a natural-appearing male hair transplant to maintain this normal frontotemporal recession. In hair restorations where the frontotemporal angle is not created, the patient frequently has an un-natural result, creating either a feminine or immature male hairline.

Other important components of a natural hairline include the transition anteriorly from fine to thicker hair with increasing density, and a significant degree of irregularity along the hairline margin. Normal hairlines should not appear straight and regular. Perfectly straight hairlines are characteristic of unnatural-appearing hair transplants. Unsatisfactory results with hair transplants usually demonstrate a fundamental lack of knowledge of these critical points required to create a natural-appearing hairline.²⁸

Indications

Most patients seeking hair restoration due to genetic hair loss are male. Approximately 15% of patients who have primary alopecia in my current practice are women and demonstrate typical genetic pattern hair loss. The other main group of patients have had previous hair transplantation with poor results;²⁹^–³¹ these patients are more difficult to treat and fall into two groups:

• those who have been treated with unnatural large plug grafts;

• those in whom the hairline was poorly designed at the time of the original procedure (they are the most difficult to treat).

Most women with hair loss may not be good candidates for hair transplants and may suffer from metabolic autoimmune disorders

One of the main indications in women is secondary or traumatic alopecia after procedures such as facelifts or forehead lifts. In these patients hair loss results from excessive tension or undermining of the hair follicle.³² Such women are ideal for hair transplantation because scars or abnormally high hairlines can be readily corrected. The most common area needing hair transplantation is probably the temporal and preauricular area.

Male Androgenic Alopecia

In most men, hair loss is related to androgenic alopecia. This form of alopecia is a response to androgens, which reduce the rate of hair growth as well as the diameter of the hair shaft.³³ Also, the growth phase of hair referred to as anagen is shortened. It is believed that testosterone is converted by the enzyme 5-alpha reductase to dihydrotestosterone (DHT),³⁴ which targets the hair and causes genetic hair loss. In most men with hair loss, the hair follicles in the frontal and crown regions appear to be most susceptible to DHT, leading to androgenic alopecia. In most patients, 30–50% of the hair has been lost before it becomes apparent. As the average normal head has 100 000–150 000 hairs, a significant amount of hair loss is necessary before it becomes apparent.

Female Hair Loss

Female hair loss is frequently more diffuse, and many women are not good candidates for hair restoration because of a lack of good donor hair.³⁵ However, a subgroup of women present with hair loss similar to androgenic alopecia³⁶ and usually have good hair density in the lateral and posterior areas of the scalp. Many of these women have a history compatible with that seen in male pattern hair loss and report many family members with either thin hair or balding scalps.

Unlike male pattern hair loss of the genetic form, women with genetic hair loss tend to maintain a low frontal hairline with an anterior margin of hair (Fig. 6.2A&B). This is very different from men where there is progressive elevation of the frontal hairline and increasing temporal recession over time. Women, however, frequently maintain a frontal hairline for life, and this factor requires hair transplantation to be performed, beginning from the frontal hairline and continuing posteriorly to fill in the defect.

Fig. 6.2 Female genetic-pattern hair loss: appearances before and after transplantation. A, Pre-transplantation. typical female hair loss pattern in 47-year woman, demonstrating maintenance of a frontal hairline fringe. B, Appearance 1 year after second session of transplantation with a total of 2000 grafts. The grafting began at the anterior hairline.

Most women who present with hair loss are not candidates for hair transplantation because the hair loss is usually caused by a metabolic disorder, autoimmune disease or other factors.

Patient Selection

One factor that makes hair restoration unique compared to other areas of aesthetic surgery is the unpredictability of future hair loss. Evaluation and prognosis of male pattern hair loss can be difficult. It is critical to take into consideration not only the family history, but also the patient’s age. Patients in their early 20s often have a significant amount of unpredictable future hair loss, and it is important to explain the possible effects of hair transplantation at too early an age:

• young patients often have the desire to create juvenile hairlines, which will be inappropriate as they age and cause problems;

• patients who have hair transplants too young, especially if the temporal recession is filled in, may be destined to wearing a hair piece as a result of progressive hair loss.

As in all areas of aesthetic surgery, realistic expectations of what can be accomplished with hair restoration are important.

Hair transplants to the existing hairline at a young age may cause significant undesirable patterns after the patient loses more hair at a later age.

Because hair loss is progressive, it is often better to wait until the third and fourth decades before considering transplantation. Also, as a young patient ages, there may also be recession of the hairline.

Another factor that must be carefully considered is hair transplantation of the occipital region. If the patient is relatively young or destined to have significant hair loss in the occipital area, overtransplantation centrally in the occipital area can lead to a bizarre appearance as he ages. Typically, there is hair loss in a coronal pattern around the area of transplantation, which leads to a halo of baldness. This will require further procedures to maintain a reasonable appearance. It is therefore important to evaluate the patient’s future hair loss based upon their hair characteristic and family history.

Preoperative History and Considerations

Hair normally passes through three cycles (Fig. 6.3A&B).³⁷

• Anagen is the growth phase. During this phase the follicular cells are actively reproducing. This growth phase lasts 2–5 years, and most of the hair is in this active phase.

• Catagen is the regression phase and lasts 2–3 weeks.

• Telogen is the final phase of hair growth and lasts approximately 3–4 months. During this phase, follicles are inactive and hair growth stops.

Fig. 6.3 Hair. A, Cycles of growth. B, Anatomy.

After the hair is transplanted, it goes into a telogenic phase for a period of 3–4 months. The patient should be informed about this.

Approximately 10% of hair is in the telogen phase at any one period. Therefore, most individuals with 100 000 or more hairs tend not to notice hair loss during the telogen phase. However, in the patient who has already lost a significant amount of hair, the telogen phase may be far more important.

After a hair transplant the hair transferred goes into a 3–4-month resting phase. It is important to inform patients that it will therefore take months to see the final result because of the delayed hair growth after transplantation.

Classification of Alopecia

The major classification of alopecia used by most physicians today is the Norwood classification, which is a modification of Hamilton’s original description (Fig. 6.4).³⁸ There are many other classifications, but most divide baldness into six to seven primary groups, with sub-groups included.^39,⁴⁰ These classifications can be useful, but most patients do not fit into a single specific classification or hair loss type exactly.

Fig. 6.4 Norwood classification of hair loss.

Ludwig has described a system for classifying androgenic alopecia in women.⁴¹

All techniques that attempt to classify hair loss have limitations and can only be used as guidelines, but can be useful tools in planning a hair restoration.

Hair Type

An important component of the initial patient evaluation includes an assessment of hair type. This includes the color, texture, density, and curling or straightness of the hair.

• The hair shafts are often thinner in fair skinned individuals and thicker in Asians and Africans. Thin hair gives less coverage, whereas thick hair gives greater coverage.

• Wavy hair has an oval appearance on cross-section under the microscope, whereas straight hair demonstrates a round appearance. In patients with curly hair, it is possible to get greater density or the appearance of greater density with fewer transplants because curly hair gives greater coverage of the scalp. Straight hair does not create as much density for coverage of the scalp.

• Hair density in a patient with male pattern or androgenic alopecia rapidly drops off with age and hair loss. Transplantation of large unnatural grafts containing 20–60 hairs looks unnatural in these patients because hair normally emerges from a single orifice as one to three hairs, and occasionally, four. A graft that has been transplanted with 20–60 hairs violates the basic principal of normal hair growth.

• The angle at which the hair exits the normal scalp varies. In the normal frontal area, the hair is angled slightly forward, while in the temporal area, it is angled slightly downward and backward, and in the posterior scalp, it is angled downward toward the neck. If the hair is put in at an unnatural angle, it will be obvious.

• In people with light hair and light scalps, or people with dark hair and dark scalps, a relatively moderate amount of hair in these patients may give adequate coverage. However, more hair may need to be transplanted to give a satisfactory result in patients who have dark hair with light scalps or patients with light hair and dark scalps, because of the greater color contrast. Variegated hair color, such as salt and pepper, gives a slightly more natural result because it creates irregularity based upon color variation (Fig. 6.5A&B).

Fig. 6.5 Appearances before and after transplantation. A, 52-year-old with salt and pepper colored hair (Norwood classification V). B, Result after 2550 grafts. The variegated color of the hair enhances the naturalness of the result. The greater the amount of gray hair, the less the color contrast between hair and scalp.

The less the color contrast between the hair and skin, the better the results.

Goals of Transplantation

On initial consultation, certain variables must be considered to assist the patient in making the appropriate decision and to set realistic goals concerning hair transplantation.

• Family history is useful, especially on the maternal side, but hair patterns are determined by a multifactorial inheritance. A strong history of hair loss among brothers, uncles, and grandfathers provides some ability to predict future hair loss.

• Another key factor is the availability of the donor hair. Patients may have only minimal hair loss but if they have little donor hair, the procedure and the final results can be limited. On the other hand, a patient with extensive hair loss who has extremely thick donor hair may be an excellent candidate for hair transplantation. The amount of hair in the donor area is quite variable and often ranges from 150 to 400 hairs/cm². The patient’s with greater hair density are more able to have future multiple procedures to continue transplantation as hair loss progresses. However, a conservative approach is necessary for the patient with limited donor hair, especially if the patient is relatively young.

• One of the most difficult areas to deal with is the occipital region if a halo of alopecia develops around previous transplants. Many therefore prefer not to be aggressive in transplanting younger patients in the occipital area until the area of hair loss is well demarcated or established. One method to reduce problems is to transplant only in the anterior area of occipital hair loss to limit the number of grafts required. Patients may elect to fill in the occipital area provided they understand the significance of this decision and that it will lead to the need for further grafting as hair loss progresses.

Hairline

It is important that the patient understands that the goal is to create a hairline that is harmonious with their facial characteristics and to create balance. One term that is frequently used is facial framing (Fig. 6.6A&B). This creates a more balanced appearance in the anatomic components of the face. Typically, the face can be divided into equal thirds, but in a patient who has a receding hairline, the eyes appear to have a more centralized appearance; creating a lower hairline produces better balance by framing the facial characteristics.

Fig. 6.6 Appearances before and after transplantation. A, A high forehead with temporal recession distorts the facial components, creating the illusion that the eyes are centrally located on the vertical plane. B, Transplantation of the anterior hairline and temporal areas create enhanced facial framing. Although the hairline has been lowered only 15 mm, there is a better aesthetic balance.

Patients in their 20s and 30s often dislike their bald appearance, not only because of the hair loss but also because they often look years or decades older than their actual age. Framing of the face improves the appearance, making the individual appear years younger.

Taking a family history and explaining to the patient what can be realistically accomplished with hair transplantation is important in achieving a successful outcome.

During the consultation, it is useful to draw the proposed transplantation pattern on the patient’s scalp and to allow the patient to see it (i.e. the most appropriate hairline) in a mirror. Patients given a marking pen will frequently draw the hairline in a relatively low position, which is usually not appropriate because a relatively youthful hairline now may lead to problems and dissatisfaction later. A demonstration of the Norwood classification allows patients to understand the normal nature of androgenic alopecia as hair recedes. A natural hairline will age appropriately with the patient as temporal recession and elevation in the frontal hairline progresses. For most patients the frontal hairline should be at least 8–10 cm above the glabella (Fig. 6.7A&B).

Fig. 6.7 Appearances before and after transplantation. A, Patient has Norwood III hair loss pattern. B, Result after 3200 follicular grafts in two sessions. The new hairline is 9 cm above the glabella. Also, an acute frontotemporal angle is maintained.

Appropriate angulation

It is critical when the hairs are transplanted to create the appropriate angulation in the different areas of the scalp. The frontal area should have slight anterior angulation, while the temporal area should have a slightly downward and posterior appearance. Creating angulation in any area of the hair restoration that is too oblique can produce an unnatural or inappropriate appearance.

The angulation of the grafts is extremely important in achieving a natural outcome.

Special Cases

Isolated frontal forelock

An isolated frontal forelock is a characteristic hair pattern and in these patients connecting a frontal forelock with hair posteriorly can create an improvement with only a moderate amount of transplantation (Fig. 6.8A&B).

Fig. 6.8 Appearances before and after transplantation. A, Preoperative view of a patient with an isolated frontal forelock with posterior alopecia. B, By connecting the isolated forelock to the surrounding hair, even limited grafting can give significant improvement.

Norwood 6 or Norwood 7 hair loss

Because of the extent of the hair loss, it can be difficult to satisfy the expectations of patients classified as Norwood 6 or Norwood 7, even in those with a significant amount of donor hair.

Prevention of Complications

Patients are advised to avoid anything that could increase bleeding during the procedure, for example not to take aspirin or any aspirinrelated products for at least 2 weeks prior to the surgery. Also, patients with hypertension must be managed appropriately to reduce a hypertensive phase during the procedure, which can complicate the insertion of the graft or lead to a hematoma in the donor site.

Operative Approach

Surgical Anatomy

The concept of donor or recipient site dominance introduced by Orentrich in 1959 is important for successful hair transplantation. Donor dominant grafts maintain the characteristics of the donor site in the new recipient site. For example hair taken from the back of the scalp maintains its characteristics when it is moved to the frontal area and will continue to be relatively permanent hair in its new site because it is rare for men to lose hair in the very posterior scalp area.

Initially, Orentrich used large round punch grafts 3.5–5 mm in diameter. These grafts with multiple hairs in a clustered pattern created a doll’s hair or cornrow appearance. Over time, smaller plugs were developed containing 6–10 hairs, but these also resulted in an unnatural appearance. It was not until micrografting with one and two hairs per graft became the standard that more natural results were obtained.

Hair is now known to grow in follicular units in which there is a clustering of 1–4 hairs (Fig. 6.9). The number of hairs varies greatly, based on the patient’s hair type and hair characteristics. To create a natural result, it is critical to use these follicular units to avoid unnatural bunching of hair, and to use magnification during the dissection and preparation of these grafts to create appropriate follicular units (Figs 6.10 and 6.11). A team approach is therefore required with skilled individuals who cut the grafts and assist in their placement during procedures that often entail 2000–3000 grafts per session.

Fig. 6.9 Follicular units.

Fig. 6.10 Preparation of grafts. The grafts are prepared under magnification to ensure proper preservation of the follicular units. The quality of the grafts is crucial.

Fig. 6.11 Magnified view of prepared grafts on the tongue blade. The grafts will be transferred to a towel soaked in cool saline and sorted by size.

Surgical Technique

Although the equipment and instrumentation for hair transplant is relatively simple, the technique itself can be relatively complex, especially when large numbers of grafts are being transplanted at one time. The technique described here has been developed by Carlos Uebel of Brazil and has significantly simplified the performance of large transplantation sessions using small, natural-appearing grafts.

• Multi-blade knives used to harvest the donor tissue in the posterior scalp in the past often lead to significant transection rates of the grafts. Today, most surgeons remove the posterior scalp donor area as a single strip using a #10 knife. A key component is proper angulation of the blade to reduce follicle transection (Fig. 6.12).

• Strip width can vary by 1–2 cm. Most of the donor hair is obtained by taking relatively long strips 12–15 cm in length (Fig. 6.13). In most patients, a strip greater than 1.6–1.8 cm wide will require mobilization of the scalp for proper closure without tension. There is significant mobility of the posterior neck, which allows a relatively easy closure in most patients. Another important aspect is to harvest future donor strips using the same original incision to avoid multiple scars.

• Hemostasis of the scalp is relatively easy to obtain because the dissection is carried out just below the fatty area well above the galea, avoiding the occipital vessels and nerves (Figs 6.14 and 6.15). Injection of lidocaine with epinephrine as well as tumescent fluid aids in hemostasis of this area.

• Closure can be achieved in a variety of ways. My preferred technique is a double layer closure of 3–0 Vicryl sutures in the deep layer and 3–0 nylon on the surface (Figs 6.16 and 6.17). Although the staple will give a rapid closure, the resulting scar in the posterior scalp tends not to be as good as that resulting from a running surgical closure.

Fig. 6.12 Harvesting of the donor strip. The #10 knife blade is angled parallel to the hair shafts to reduce transection of the follicles during harvesting of the donor strip.

Fig. 6.13 A typical donor site measuring 1.6 × 16 cm. The lower edge of the donor site is 6 cm above the posterior hairline margin. A donor site of this dimension can be closed with minimal tension.

Fig. 6.14 Donor strip dissection. Care is taken by staying just deep to the fatty layer containing the hair follicles. The deep structures, including the occipital neurovascular bundles, are avoided.

Fig. 6.15 Entire donor strip has been removed. Hemostasis is obtained with limited use of the cautery to reduce damage to the remaining follicles.

Fig. 6.16 Temporary stay sutures align the donor site closure. A deep layer of 3-0 Vicryl is followed by a running 3-0 nylon.

Fig. 6.17 Completed donor site closure. In most patients, the donor site is concealed by the patient’s hair. Sutures are removed 10 days postoperatively.

The most important factor in harvesting the donor site is appropriate angulation of the knife blade to reduce transection of hair follicles.

• After the strip has been removed (Fig. 6.18), it is cut horizontally in a bread loaf fashion into cross-sectional segments several mm wide (Fig. 6.19). These are cut by the assistants (Box 6.1) into the individual grafts under magnification (Fig. 6.20). Each graft should contain the hair shaft, follicle and surrounding fat, and should be kept on ice-chilled moist saline towels and trays to prevent desiccation (Fig. 6.21). The hair follicles are then viable for several hours.

• Prior to insertion of the grafts the recipient area is infused with tumescent fluid. This elevates the soft tissues off the scalp, making insertion easier and also creates appropriate hemostasis.

• A #11 blade is used to make a small slit in the recipient area and the opening is held open while an assistant places the graft along the edge of the blade, and then like a piston, the blade is partially withdrawn (Fig. 6.22).

• The graft is positioned and then pushed in into the appropriate depth (Fig. 6.23). Placing the graft too deep will result in inclusion cysts. Proper placement, rotating the graft into its proper alignment, is also important. The slits are made at a specific angle to allow growth of the hair in the appropriate direction and angulation. I make a slight modification of the #11 blade to approximate the size of the graft to reduce popping out (Fig. 6.24). The graft is held in place initially by only a little thrombin, and the more that the graft is equivalent to the size of the slit made by the #11 blade, the less the grafts pop out and the better the fixation.

• As the grafts are placed from anterior to posterior, initially creating the anterior hairline, they are placed as close as possible to create maximal density. In patients with thick scalps with no previous scarring, this can frequently be done at 1 mm intervals or less.

• The transfer of large numbers of small grafts at one time is the key to a successful procedure. Once the grafts have been inserted, an appropriate dressing is applied and then removed the next day.

• Most patients can wash their hair the next day, and the donor site sutures are removed at approximately 10 days.

Fig. 6.18 The harvested donor strip. This is ready to be cut into individual thin cross-sections.

Fig. 6.19 Under magnification, the donor strip is cut into cross-sections or bread loaf segments. The segments are then cut into the individual grafts. Cutting these cross-sectional pieces at the proper angle reduces follicle transection.

Box 6.1 Logistics of hair transplantation

• Although hair transplantation is relatively simple, the logistics of setting up a hair transplant service can be quite complex.

• Most plastic surgeons do not carry out hair transplants for logistic reasons.

• Successful hair transplantation requires a team approach with highly skilled individuals.

Creating an appropriate environment

• In a procedure of 2000 grafts, typically four skilled people are preparing and cutting the grafts while one is assisting the surgeon in graft insertion.

• It frequently takes at least 6 months for a person to become skilled at cutting follicular grafts at a reasonable rate (i.e. 100–150 grafts per hour) to make large volume procedures possible.

• Maintaining a large team of individuals skilled in hair transplantation in the office when other procedures are being performed is not financially feasible unless the skilled staff are primarily maintained on call for the procedure and used only during the actual hair transplantation process.

Starting a hair transplantation service

• Start with relatively limited numbers of grafts: carrying out 2000 grafts as a first procedure would cause significant frustration.

• One way to begin is to deal with patients who have had limited hair loss after cosmetic surgery, where 500–700 grafts will provide a significant improvement.

Fig. 6.20 Division into individual follicular units. The bread loaf segments positioned for division into the individual follicular units.

Fig. 6.21 Prepared grafts awaiting transplantation are kept on chilled saline-soaked towels. During the insertion process, the assistant holds the towel in one hand and picks up the individual grafts near the follicle with fine pickups in the other hand. The assistant then holds the grafts against the #11 blade for insertion.

Fig. 6.22 Insertion of graft 1. A modified #11 blade makes a small slit in the scalp and the blade tip is used to open the slit while partially removing the blade. Several hundred grafts have already been inserted.

Fig. 6.23 Insertion of graft 2. The assistant slides the graft along the tip of the #11 blade toward the opening. At the same time, the surgeon inserts the grafts controlling depth and orientation.

Fig. 6.24 #11 blade with notch cut into side opposite the cutting surface. This changes the blade tip from a wedge to a cylindrical configuration, matching the shape of the graft. This creates a slit matching the size and depth of the grafts. (Blade design, Val Lambros, MD)

Once the Uebel technique has been mastered by two individuals working together, 600–700 grafts can be inserted per hour.

The best techniques require the simplest instrumentation. The use of punches and electrical coring devices to create punch grafts are no longer considered acceptable because of the size of the grafts obtained and the final appearance of the result.

Anesthesia

Hair transplantation can be carried out in the office with local anesthesia and acquiring good anesthesia is relatively simple. Knowledge of the anatomy of the nerves in the scalp allows a satisfactory level of local anesthesia in both the donor and the recipient areas (Fig. 6.25).

Fig. 6.25 Nerve and blood supply of the scalp.

Anesthesia is achieved with a dilute epinephrine solution, initially blocking the occipital nerves posteriorly in the donor site (Fig. 6.26). This is followed by tumescence of a very dilute solution in the area to distend the posterior scalp off the galea.

Fig. 6.26 Anesthesia. Initially the occipital nerves are blocked, followed by a ring block using diluted lidocaine with epinephrine. The donor tissue is then tumesced to facilitate elevation along the fatty layer containing the follicles deep to the skin. Tumescence in the proper plane aids dissection and enhances hemostasis.

In the recipient area anteriorly, anesthesia is accomplished with both a ring block and occasionally, supraorbital nerve blocks, which facilitate the injection of the ring block.

Because the anatomy of the scalp nerves is so predictable, it is relatively easy to gain rapid anesthesia during these procedures.

Occasionally, the patients can be given a small dose of oral diazepam; however, most patient are completely comfortable during the procedure once the blocks and tumescent fluid are inserted. The addition of bupivacaine can extend the duration of anesthesia to the scalp area, especially when large numbers of grafts (2000–3000) are done during a single procedure.

Scalp Excisions

In general, scalp excisions are now primarily used for difficult or secondary cases, and few patients receive a scalp excision in the standard management of male pattern baldness.

In the past, however, scalp excisions were often performed in conjunction with hair transplantation42–45 to reduce the total surface that required transplantation. The most frequent technique was midline excision of non-hairbearing scalp with advancement of the lateral hairbearing scalp flaps toward the midline. Usually this only partially reduces the area requiring transplantation and creates several problems. Advancing lateral flaps superiorly creates an abnormal hair pattern with divergence of the hair away from midline, resulting in a midline scar, which creates a slot deformity; even with aggressive mobilization there is significant stretch back, leading to a wide scar, with hair diverging away from the scar.⁴⁶ The final result was often far less than optimal. Attempts have been made to reduce the amount of stretch back or scar widening using various techniques^47,48 by reducing the tension of the incision closure with unique sutures and elastic membranes internally.

Scalp excisions for secondary alopecia

Scalp excisions are particularly useful in secondary cases. Patients who have had large plug grafts placed too low on the forehead or temporal region cannot usually be treated with just further hair grafting. Patients who have had plug grafts can be treated with:

• regrafting using small grafts between the larger ones for camouflage;

• excision of selective plugs with recycling of the hairs for further grafting.

In selected patients, the best option is complete excision of the unsightly anterior plugs with superior advancement of the forehead followed by regrafting (Fig. 6.27A-D). At the time of the excision, the large plug grafts are recut into micrografts and reinserted at the same time.

Fig. 6.27 Complete excision of the unsightly anterior plugs with superior advancement of the forehead followed by regrafting. A, Complete excision of anterior scalp containing large unsightly plugs. B, The excised strip will be divided into cross-sections followed by dissection into individual grafts. C, Mitek sutures placed into the outer table of the skull for suture elevation of the forehead. Four Miteks were placed for incision closure. D, Closure of defect using Mitek sutures with insertion of recycled grafts into scalp.

Secondary procedures consist of further grafting to conceal the scar and to thicken up the transplanted hair. This excisional technique combined with forehead advancement can give dramatic results. To prevent widening of the scar and to stabilize the forehead position, it is helpful to use bony fixation.

The procedure requires mobilization of the entire forehead to the level of the eyebrows. Unlike a forehead lift, however, where the goal is elevation of the eyebrows, the goal is elevation of the abnormally low hairline leaving the eyebrows in their original position. Several methods are used to accomplish bony fixation, including bony tunnels, Mitek sutures, and Endotyne devices. All these work well to maintain forehead elevation.

Excisional technique for a temporal alley

These excisional techniques can be used elsewhere on the scalp to reduce areas of alopecia that develop years after hair transplantation. One of the more common types is referred to as a temporal alley. This is a gap that occurs over time in the temporal region as the height of the temporal hair recedes inferiorly, while the area of previous transplantation above remains constant. The two options are:

• further grafting if donor hair is adequate to reconnect the previously transplanted area to the receding hairline;

• excision of the intervening area of alopecia to reconnect the transplanted superior area to the residual hair inferiorly (Fig. 6.28A&B).

Fig. 6.28 Reconnecting a transplanted superior area to residual hair. A, Previous hair transplants on top of scalp. Over time, the lateral hair has receded inferiorly, creating a temporal alley or gap. B, The area of alopecia was excised and Mitek sutures used to reduce stretch back of the closure.

Tissue Expansion in Alopecia Management

Tissue expansion is no longer considered to be a primary modality for the treatment of male pattern baldness, and is mainly used for reconstructed scalp surgery. Although several authors have developed specific expanders for hair restoration and specific flaps to be used in conjunction with the expansion process (Fig. 6.29A&B), none of these techniques are in mainstream use.

Fig. 6.29 Flaps used in conjunction with the expansion process. A, Expanded bilateral advancement transposition (BAT) flaps created with tissue expanders laterally and posteriorly. B, Result after removal of expanders and flap advancement superiorly and anteriorly. (Photos courtesy of Dr Robin Andersson.)

Optimizing outcomes

Two major factors are key to a successful hair transplant

• Use of small, natural-appearing grafts of one to three hairs.

• Designing a natural-appearing hairline appropriate for the patient’s face (Table 6.1).

Table 6.1 Management of alopecia (primary vs secondary)

Primary Hair Transplantation: Case Study 1 (Figs 6.30 and 6.31A-C)

Fig. 6.30 Case study 1. A, Norwood IV hair loss pattern with isolated frontal forelock. B, Result after 3200 grafts in two sessions. C, Hairline is 9 cm above glabella.

Fig. 6.31 Case study 2. A&B, 58-year-old woman with high anterior hairline and marked temporal recession. C&D, The anterior hairline on frontal view has been lowered 15 mm. The temporal area has been filled in creating a rounded margin.

Preoperative considerations

• 38-year-old male with a Norwood IV hair loss pattern and an isolated frontal forelock.

• The patient has excellent donor hair density and reports minimal advancement of the degree of alopecia over the past 4 years.

• Family history is important: he reports most males in his family have a limited degree of alopecia.

• The patient is on finasteride (a DHT blocker) to reduce the rate of future hair loss.

Operative Approach

• To optimize this patient’s outcome it is imperative to create a high hairline with temporal recession. A low hairline in this patient would look artificial. Many patients with this type of hair loss pattern have had a high hairline with significant temporal recession, even in their youth. A discussion of this patient’s hairline as a young man as well as photos can be very useful. A patient with this hair pattern, who requests a low rounded hairline and filling in at the temporal recession, is not suitable for the procedure. As with any aesthetic procedure, realistic expectations are critical. The hairline should be at least 8–10 cm above the glabella.

• In this patient, the anterior extent of the hairline has already been created by his frontal forelock. No hair transplants should be placed anterior to this forelock. The vertical anterior temporal line is left alone and the transplants connect the isolated forelock to the temporal hair at a high and acute angle. In this patient a total of 3200 grafts in two sessions were placed to give him this excellent result.

Primary Hair Transplantation: Case Study 2 (Fig. 6.31A-D)

Preoperative considerations

• 58-year-old woman with a high anterior hairline and marked temporal recession (Fig. 6.32A&B), creating distortion of normal facial components.

• Typically, the face can be divided into thirds. The lower third is between the inferior aspect of the chin and the base of the nose. The middle third extends from the inferior nose to the eyes, while the upper third extends from the eyes to the hairline. This relationship is distorted if there is excessive temporal recession and a high anterior hairline, especially in women.

Fig. 6.32 Case study 3. A&B, Patient had large plug grafts in his early 20s. These grafts were placed in a straight line and too low. The frontotemporal angle is obliterated. Over time, he went bald behind the plug grafts, creating a bizarre appearance. C, Final result after excision of the anterior scalp with the plug grafts. The forehead was advanced superiorly with boney fixation of the scalp. The patient also had two large sessions of grafting to create the final result. A normal frontotemporal angle was created, producing a more aesthetic result.

Operative Approach

• Optimizing results in this situation entailed filling in the temporal recession and creating a rounded temporal margin, which is normally seen in women (Fig. 6.31C&D).

• To balance the face the anterior frontal hairline was lowered 1.5 cm with transplants.

Discussion

• Postoperatively the patient has had a dramatic change in both frontal and side appearance.

• A key factor in obtaining a successful outcome includes adequate donor hair. Many middle-aged women with this type of hair appearance have limited donor hair, making the transplantation procedure or process difficult. Fortunately, this patient had excellent donor density.

• Another fact enhancing the result is the light color of the hair. Hair color and skin color contrast are important components of a successful result. The less the contrast, the better the final appearance.

Secondary Hair Transplantation: Case Study 3 (Fig. 6.32A-C)

Preoperative considerations

• This patient demonstrates many important components of an unsatisfactory hair transplant:

• large plug grafts inserted at a young age

• grafts placed too low and too straight

• altered frontotemporal angle resulting in an unnatural appearance.

This patient had to wear a hairpiece to cover his scalp.

• Numerous factors must be assessed before embarking on this difficult case.

Is there adequate donor hair?

• Patients who have had previous plug grafts have significant scarring at the donor site. The technique that was used consisted of coring out the plug grafts from the donor site with a punch device. The donor sites were left open to heal by secondary intention, resulting in significant scarring. It is therefore imperative to first confirm the presence of adequate donor hair.

Need for multiple procedures

• In the preoperative discussion with this patient it is important for him to thoroughly understand the surgical process. A single procedure will not give the final result. This situation requires multiple procedures over an extended period of time.

Operative Approach

• The first operation requires a radical excision of the anterior hairline, including the previously inserted plug grafts, with recycling of the plugs into small micrografts.

• Next, after the scalp has healed, approximately 6–8 months later, further grafting is performed: in this case, it consisted of two separate graft sessions to create the final result.

• The patient now has a properly contoured hairline with a normal temporal recession and removal of the unsightly plug grafts.

Secondary Hair Transplantation: Case Study 4 (Fig. 6.33A&B)

Fig. 6.33 Case study 4. A, Patient had a previous facelift with loss of hair behind the ear and elevation of the temporal-preauricular hairline. Tattooing the area did not improve the appearance. B, Postoperative appearance after grafting in the postauricular area and the temporal and preauricular area, creating a more natural hairline.

Preoperative considerations

• This patient has the typical problem with hair loss and hairline elevation seen after a facelift.

• Previous attempts to camouflage these areas in front of and behind her ears with tattooing have made the areas of hair loss even more noticeable.

Operative Approach

• Improvement is relatively easy to obtain because only limited hair transplantation is required.

• The most important factor is proper angulation of the grafts in these two sites:

• in the frontotemporal area and extending down toward the preauricular area, hairs normally grow downward and posteriorly – it is imperative to place the grafts at these acute angles in these areas to create a natural result

• behind the ears, the grafts must be angled downward and slightly posteriorly to follow the normal pattern.

With proper attention to the angle of the grafts, the appearance can be dramatically improved.

Complications and Side Effects

Hair transplantation has a low incidence of complications when properly performed.

Donor Site Complications

Hematoma is rare and can be managed with simple aspiration unless there is a significant amount of blood and/or recurrence of the bleeding.

Other problems are associated with the neurovascular bundles, primarily in the posterior neck area. The occipital nerves run directly at a right angle to the donor site excision. It is important during the donor site excision to stay superficial to the occipital nerves, otherwise there will be numbness in the posterior scalp area. The use of tumescent fluid just deep to the fatty layer will separate the hair follicles and underlying fat from the underlying neurovascular pedicle. Dissection is then performed just along the deep portion of the fatty layer with care taken to protect follicles but staying superficial to the occipital nerve and vessel.

All patients have a degree of superficial numbness above the incision due to division of superficial cutaneous nerves. This usually resolves after several months. If the occipital nerves are completely divided the patient may have an area of permanent numbness.

Recipient Site Complications

Complications in the recipient site are minimal. The most common problem is the development of an inclusion cyst if the grafts are placed too deep. This occurs when the epithelium of the scalp covers the epithelium of the graft prior to the hair growing above the surface of the scalp. Usually, these can be treated by simply opening any developing cysts.

Other Complications

Other risks or complications result from creating an abnormal hairline or using large grafts (Fig. 6.34). The use of large plug grafts is no longer acceptable and the surgeon performing the hair transplant must be knowledgeable about creating a normal-appearing hairline.