A scalp may be divided roughly into two separate
areas. One is the area susceptible to balding and the other, of
course, is the area not. The horseshoe fringe of hair left behind
on a bald man’s scalp is the area from which hair can be safely
donated. Hair transplanted from this area of the scalp will not
be susceptible to balding even when it is placed right in the middle
of the bald scalp. This new hair maintains the same characteristics
of the hair left behind in the donor area no matter where it is
transplanted to the scalp. This is what is meant by donor dominance.
Figure 4-2. Different areas in the recipient
area. |
Multiple methods may be used to harvest this donor hair. In the
early days of hair transplantation, the hair was removed in 4 mm
plugs about the size of a pencil eraser. Multiple plugs were removed
simultaneously and the area was allowed to heal in by itself. Although
the healing areas were messy the first week because of the weeping
from the open wound, the areas tended to heal well. The primary
problem was the cobblestone scar pattern left behind. Eventually
the plugs were taken out in rows so that the edges could be sewn
together.
 Figure
4-3. Transplants were originally performed by removing
4 mm plugs from the shaved donor area and then transferring
them into 4 mm holes in the recipient area.
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This led to the idea of excising strips of tissue rather than
plugs. The open area left by the strip was more easily
sutured together. As the grafts that were transplanted became smaller,
physicians began to use multi-bladed scalpels. With a single pass
of a multi-bladed knife, they could produce multiple, thin strips
facilitating the quick dissection of grafts. Now, since the advent
of follicular unit transplantation, many physicians will excise
the strip with a single scalpel blade in order to minimize the transection
of the follicular units. Most follicular unit proponents feel that
the transection rate with a multi- bladed knife is unacceptably
high and could lead to reduced growth of the transplanted hair.
In regards to the recipient area, during the early days of hair
transplantation, the 4 mm plug removed from the back of the scalp
was then simply implanted intact into the balding area in the front
of the scalp. This certainly gave volume to the thinning hair but
at the unacceptable price of extreme “plugginess” as
the remainder of the preexisting hair eventually disappeared. Grafts
were gradually down-sized to quartered 4 mm plugs and then to minigrafts.
Minigrafts are small plugs of hair containing 3 to 10 hairs each.
They are produced by cutting the excised strip or strips down to
smaller sizes without magnification and without regard to follicular
units. This certainly reduces the harshness of the “plugginess”,
but by no means does it remove the problem entirely. Instead of
fewer, big plugs, there are numerous small plugs. Micrografts were
developed to hide this “plugginess” in the hairline.
Micrografts consist of 1 to 2 hairs dissected without magnification
and without regard to the follicular units. These are a tremendous
aid in helping to disguise the artificiality of minigraft hairlines.
 Figure
4-4. Hair transplants are now performed by excising
a strip from the donor area, suturing the open area shut, dissecting
the strip into small grafts, and then transferring them into
small holes in the recipient area. |
Follicular unit transplantation was the next major milestone in
hair transplantation. A follicular unit is the natural unit hair
grows in on the scalp. If the scalp is shaved and magnified, the
follicular units are evident as the 1 to 4 hair groupings exiting
the scalp from single points. Each individual follicular unit has
a single root system. Follicular unit transplantation is defined
as the dissection underneath a microscope of the individual follicular
units followed by the implantation of these single units into the
balding area. Emphasis is placed on not disturbing the root systems
while dissecting the 1 to 4 hair grafts. A microscope is required
for the adequate visualization necessary to avoid transection of
the follicular unit root system. Since these 1 to 4 hair grafts
are transferred individually, there should be no “plugginess”.
Figure 4-5. Close up of shaved scalp showing
the individual follicular units as bundles of 1 to 4 hairs. |
The recipient site in the front or top of the scalp must be prepared
to accept the various forms of grafts. The recipient site for the
4 mm plugs was simply a similar-sized hole created with a punch.
A punch is a small, circular, cookie-cutter type knife that creates
tiny, circular holes in the skin. The recipient sites for minigrafts
are made with either scalpel blade incisions or small 1.5 to 2.0
mm punches. Lasers have been utilized to create recipient sites
for minigrafts to no great advantage, but certainly at greater costs.
The recipient sites for follicular units are made by inserting small
needles into the scalp to create tiny holes.
The implanting of the grafts is considered the most technically
difficult portion of the procedure. As the grafts have become smaller,
the skill required to gently insert them with a fine pair of forceps
(tweezer-like instruments) has greatly increased. These grafts must
be grasped and inserted without traumatizing the tissue, or poor
growth is risked. This gentleness combined with the close-spacing
of the grafts makes a planter with good hands, patience, and a sense
of perfectionism, critical.
But does it hurt? The skin of the donor and recipient areas is anesthetized
with local numbing shots. Most surgeons will either have their patients
take pills to help them relax, such as Valium or Xanax, or inject
medicines intravenously to put them to sleep before beginning the
numbing shots. Although the intravenous medicines sound appealing
since the patient is asleep, the patient and the surgeon must assume
an increased level of risk. It is possible for the patient to stop
breathing for himself, and monitoring equipment is required to check
the patient’s status. The risk of severe complications seems
to be quite small, but from a personal standpoint, that risk is
not justified in my patients. In no way am I suggesting that the
use of I.V. medicines is inappropriate. It is, simply, my experience
that a patient who has taken something orally to help him relax
and who is treated with gentleness and care does just as well, without
the increased risk.
Various agents can be applied to the skin prior to the injections
to reduce the sensation of the needle stick. Injection techniques
such as tumescent anesthesia and nerve blocks further facilitate
patient comfort. Tumescent anesthesia involves the injection of
dilute anesthetics into the deeper, fatty tissue first. The fatty
tissue is far less sensitive to injection pain than the skin. After
it has been numbed, the skin injections are much less tender. Nerve
blocks involve the injection of anesthetic around the bases of the
nerves that supply the front of the scalp. These are located right
above each eyebrow. Once the bases of these nerves are numbed, work
in the central-frontal scalp is painless. The primary reason injections
anywhere on the body hurt is due to the anesthetic being pushed
into the skin too rapidly because either the person performing the
injection is impatient or uncompassionate.
But, again, does it hurt? My answer is that if the procedure is
performed by an experienced, gentle, and caring surgeon, it will
hurt very little. After almost every procedure, I hear the same
thing, “If I would have known how easy this was, I would have
done it a long time ago”. On the other hand, if the surgeon
lacks these qualities, (whether done under I.V. sedation or not)
yes, it can hurt.
Very few hair transplants are performed by the physician alone.
With the advent of minigrafts, and then, especially, follicular
units, the amount of work required to prepare and implant the grafts
has increased logarithmically. Surgeons working alone would only
be able to perform small follicular unit transplantation sessions.
Most surgeons plan the procedure, perform the excision and repair,
and then oversee a team of technicians who dissect the grafts and
then implant them. In my office, a typical follicular unit transplantation
session will take six to ten hours and require four technicians,
two dissecting and two planting. During the majority of the procedure,
the patient relaxes in a reclined position. He may pass the time
by watching television or movies, listening to music, chatting with
the staff, or simply napping.
After the transplant is completed, bandaging of the head is usually
unnecessary. On occasion, if a patient is oozing a little from the
donor area, a bandage will be applied like a headband for several
hours. Patients leave wearing a baseball cap to hide what has been
done. Sutures or staples are removed in about ten days from the
donor area. There are no sutures in the recipient area.
The transplanted hair shaft typically falls out during the first
month after surgery. The root system is still present just as if
the hair had been plucked. The new hair starts to grow in three
to five months. This transplanted hair is now permanent hair not
susceptible to the progressive nature of male pattern baldness.
This hair may thin out when the patient reaches seventy to eighty
years of age, but this is a general thinning known as senile alopecia
which causes hair over the entire scalp to begin to disappear. Otherwise,
the new hair is permanent. The transplanted hair occasionally grows
in a little kinky and coarse during the first year, but it will
ultimately appear just like the hair in the donor area. It will
grow and need to be cut probably more frequently then any surrounding
miniaturized preexisting hair. It can be colored and styled any
way the patient likes. If another transplant is desired, usually
I will ask my patients to wait a minimum of six months so that I
will know where the new growth is and I can transplant between the
previous grafts.
Next Topics:
Follicular Unit
Hair Transplants
Considering a Hair Transplant?
After the Hair Transplant
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