Aesthetic Surgery Journal

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Hair Restoration Surgery : The State of the Art James E. Vogel, Francisco Jimenez, John Cole, Sharon A. Keene, James A. Harris, Alfonso Barrera and Paul T. Rose Aesthetic Surgery Journal published online 20 November 2012 DOI: 10.1177/1090820X12468314

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Aesthetic Surgery Journal Continuing Medical Education Article XX(X) 1–24 © 2012 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: Hair Restoration Surgery: The State of the Art http://www.sagepub.com/ journalsPermissions.nav DOI: 10.1177/1090820X12468314 www.aestheticsurgeryjournal.com James E. Vogel, MD; Francisco Jimenez, MD; John Cole, MD; Sharon A. Keene, MD; James A. Harris, MD; Alfonso Barrera, MD; and Paul T. Rose, MD, JD

Abstract Hair restoration is a highly sophisticated subspecialty that offers significant relief to patients with hair loss. An improved understanding of the aesthetics of hair loss and cosmetic hair restoration, hair anatomy and physiology, and the development of microvascular surgical instrumentation has revolutionized the approach to surgical hair restoration since the original description. Additional elements that contribute to the current state of the art in hair restoration include graft size, site creation, packing density, and medical control of hair loss. The results of hair restoration are natural in appearance and are provided with a very high level of patient satisfaction and safety. This aspect of cosmetic surgery is a very welcome addition to a traditional aesthetic practice and serves as a tremendous source for internal cross-referral. The future of hair restoration surgery is centered on minimal-incision surgery as well as cell- based therapies.

Keywords hair transplant, alopecia, follicular unit graft, hairline, CME

Accepted for publication September 28, 2012.

Alopecia, the term for generic hair loss, involves a diminu- have been reported with variant regions of the androgen tion of visible hair. There are numerous types of alopecia. receptor gene, which is located on the X chromosome. The most common form of surgically treatable alopecia is Epidemiologic surveys of AGA reveal the highest incidence androgenic alopecia (AGA). Throughout time, the pres- in Caucasians, followed by Asians and then Africans, with ence of scalp hair has represented attributes of health, the lowest incidence in Native Americans.4-8 vigor, vitality, and strength. Accordingly, loss of hair in For the purpose of hair transplantation, the scalp may men (MAGA, or male pattern androgenic alopecia) and be divided into the frontal, midscalp, vertex, and temporal especially women (FPHL, or female pattern hair loss) can areas (Figure 1A-C). Hair thinning and subsequent shed- have significant psychosocial effects. The overwhelming ding is due to gradual miniaturization of genetically majority of procedures for hair restoration are hair transplants, and the advent of microvascular surgical instru- Dr Vogel is Associate Professor, Department of Plastic Surgery, mentation as well as an improved understanding of the The Johns Hopkins Hospital and School of Medicine, Baltimore, anatomy and physiology of hair loss has revolutionized Maryland. Dr Jimenez is a hair restoration surgeon in private the art of surgical hair restoration since the original practice in Canary Islands, Spain. Dr Cole is a hair restoration description and early refinements.1-3 surgeon in private practice in Alpharetta, Georgia. Dr Keene is a hair restoration surgeon in private practice in Tucson, Arizona. Dr Harris is a Plastic surgeon in private practice in Greenwich Village, Anatomy, Genetics, and Physiology Colorado. Dr Barrerra is Clinical Assistant Professor of Plastic Surgery, Baylor College of Medicine, Houston, Texas. Dr Rose is a of Hair Loss hair restoration surgeon in private practice in Coral Gables, Florida.

Androgenic alopecia is characterized by progressive visible Corresponding Author: thinning of scalp hair in genetically susceptible men and Dr James E. Vogel, 4 Park Center Court, Owings Mills, MD 21117, in some women. The current scientific data support the USA. thesis that AGA is a polygenic trait. Significant associations E-mail: [email protected]

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Figure 1. Surgical anatomy of the scalp. (A) Frontal view emphasizing the level of the hairline, relationship to the temporal triangle, and the lateral canthal line. (B) Profile view to illustrate the relationship between the lateral hump and lateral aspect of the forelock. (C) Caudal view to illustrate the relationship with the lateral canthal line and lateral extent of the anterior hairline. marked hair follicles and represents shortening of the II 5α-reductase inhibitor.18 Balding scalp contains exces- anagen (growth) phase of the hair follicle with an increase sive concentrations of 5α-reductase, DHT, and the DHT in the telogen/anagen ratio of the affected scalp. An androgen receptor. The action of DHT is mediated by understanding of the normal hair follicle life cycle is criti- intracellular nuclear androgen receptors.19 cally linked to an appreciation of the physiology of hair In women, there is no consensus on whether hair loss loss.9-14 is truly androgen dependent. Most women with FPHL do Miniaturization results in the conversion of terminal not have biochemical hyperandrogenism. In fact, some (large) hairs into smaller, barely visible, depigmented vel- women without detectable circulating androgens may also lus hairs (Figure 2).15 At the cellular level, follicle minia- develop FPHL, suggesting a possible role for non-andro- turization is thought to be caused by a reduction in dermal gen-dependent mechanisms. Based on this evidence, it papilla volume, as a consequence of a decrease in the seems appropriate to replace the term androgenic alopecia number of cells per papilla. Nonetheless, hair follicles are in women with the previously mentioned, more contem- still present and cycling, even in bald scalps.16,17 Although porary and scientifically descriptive term female pattern testosterone is the major circulating androgen that causes hair loss (FPHL), to include this recognized heterogene- hair loss, to be maximally effective, it must first be con- ity.4,6-8,19-26 verted to dihydrotestosterone (DHT) by the enzyme On a macro level, the majority of human hair shafts 5α-reductase. The importance of DHT as an etiologic fac- emerge from the scalp as single-, 2-, and 3-hair groupings tor in male pattern hair loss is shown by the absence of (Figure 3). The groupings are the visible superficial por- AGA in men with congenital deficiency of type II tion of a distinctive histologic structure, known as the 5α-reductase and by varying amounts of hair regrowth in follicular unit (FU). Present-day hair transplants almost men with MAGA treated with finasteride, a selective type exclusively use follicular units as the transferred element

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Figure 2. Progression of hair loss. In youth, testosterone is limited in concentration; however, during puberty and adulthood, testosterone is converted to dihydrotestosterone (DHT). Exposure of susceptible hair follicles to DHT results in miniaturization and ultimately hair loss. The enzyme 5α-reductase is responsible for the conversion of testosterone to DHT. Finasteride is an oral medication that blocks this pathway and prevents hair loss.

diffuse central thinning over the midfrontal scalp, as described and originally classified by Ludwig.36,37 Exceptions to these patterns occur. Some men will exhibit a Ludwig pattern of loss, and some women will display a typical Norwood pattern.

Nonsurgical Options for Treating Hair Loss

There are currently only 2 medications approved by the US Food and Drug Administration (FDA) to promote hair growth in the scalp. These medications are finasteride and minoxidil. Other options for medications claiming to treat hair loss are extensive but also of questionable value.38-40 Finasteride (Propecia; Merck & Co, Inc, Whitehouse Station, New Jersey) is a medication that lowers DHT Figure 3. Magnification view of in situ follicular units (FUs). through blockades to the 5α-reductase type 2 pathways A 4-hair FU has been scored in preparation for a follicular (Figure 2). In a prospective randomized study by the unit extraction (FUE) donor harvest. manufacturer, finasteride was shown to reduce hair loss or have positive effects related to hair growth in 90% of patients, and the drug’s safety and efficacy have also been of tissue, and thus the contemporary nomenclature for this reported by independent research.41 Propecia is FDA procedure is a follicular unit hair transplant (FUT).27-34 approved for men only. The FDA only allows the manufac- The clinically observed patterns of MAGA have been turer to make claims regarding growth in the vertex area well described by Norwood,35 after whom the most com- of the scalp, but many physicians have noted that this mon classification system for this condition is named. On medication has a global effect on the scalp hair. the other hand, hair loss patterns in women are typically Side effects reported with finasteride include a decrease characterized by maintenance of the anterior hairline and in libido, erectile dysfunction, testicular pain, and benign

Downloaded from aes.sagepub.com at ASAPS on December 12, 2012 4 Aesthetic Surgery Journal XX(X) growth in the male breast. The side effects associated with In women, the pattern of hair loss with FPHL, espe- the drug generally disappear with discontinuation of finas- cially in the early stages, can be mimicked by a variety of teride. Some controversy exists regarding its relation to other conditions. These include frontal fibrosing alopecia, breast and prostate cancer as well as the temporary nature diffuse alopecia areata, and telogen efluvium (acute and of sexual side effects.42,43 chronic).51-54 Women with bitemporal recessions, as seen Minoxidil (Rogaine; McNeil-PPC, Inc, Morris Plains, with male pattern baldness, should be screened for hor- New Jersey) has been available since 1988 as a topical monal imbalances. Finally, women with typical FPHL in a medication indicated to treat hair loss. It has been used in Ludwig pattern should be checked for iron deficiency as men and women. The mechanism of action is unclear, but well as thyroid function to rule out other causes of diffuse it is recognized that the vasodilatory effects of minoxidil hair loss.55 do not fully explain its positive action on hair growth. Observed benefits include increased proliferation of dermal papillae cells, increased hair caliber, and diminished Recipient Area telogen phase during the hair growth cycle. The first step in assessing the recipient area is to determine where to place the grafts. A conservative and princi- Evaluation and Planning pled surgical plan for the recipient site is an initial forelock Photography distribution hair transplant. The forelock is the area bounded anteriorly by the frontal hairline, posteriorly by Photography of the hair restoration surgery (HRS) result is the anterior crown region, and laterally by the parietal the principal measure by which results are objectively fringe (Figure 1). This is a commonly maintained, normal documented. The use of lighting and standard positions distribution of hair seen in male patients with mild hair for hair photography has been described.44 The use of a loss. A forelock pattern hair transplant is initially planned light gray or blue-colored background is recommended, so when there is anticipation of considerable future hair loss, that the top borders of dark hair will not blend into the especially in a young patient. For the same reason, this background. This background will also work for white and approach is also very appropriate for older patients who blond hair. present with extensive baldness and limited donor supply. The rationale for this approach is that the distribution of grafts in a forelock limits the requirements from the donor General Evaluation supply. Creation of a forelock pattern also provides an opportunity for a large, single-session procedure to achieve Young men and women are particularly distraught by the the 2 fundamental goals of hair restoration surgery— signs of hair loss.45,46 Low self-esteem and vulnerability to namely, to recreate a normal pattern of hair loss seen in a fantasized outcome place this subset of patients at par- nature and to create a frame of hair for the face (Figure ticular risk for quick decision making and unrealistic expec- 4).56-58 The beauty of this conservative and safe surgical tations. Managing these expectations and formulating a approach is that this graft distribution can be expanded realistic surgical plan for patients with hair loss is a critical posteriorly for additional crown coverage as desired. component to the long-term success of the procedure. Determining the number of grafts for the initial proce- A fundamental concept that physicians and patients are dure and over the lifetime of the patient is the next step in advised to maintain during the evaluation and planning recipient planning and evaluation. This assessment for HRS is that hair loss is progressive. The appearance of depends on a number of factors. These include current hair loss in the office during consultation is merely a snap- degree of baldness, donor hair characteristics, degree of shot along a continuum that began years earlier and will anticipated hair loss, patient’s goal for density and ulti- progress until death. Communication regarding the quality mate coverage, technical expertise of the hair transplant of the patient donor hair is also an additional essential team, and financial considerations of the patient. A good component in managing expectations. The qualities of the visual transplant result will be apparent with densities hair that should be reviewed include curl, hair shaft diam- between 25 and 40 FU/cm2. To put this into perspective, eter, color, texture, follicular unit density, and the telogen/ in adult men with no “visible” hair loss, the typical den- anogen ratio of in situ donor hair. These aspects of the sity in the frontal hairline ranges between 38 and 78 FU/ donor hair should be not only reviewed but also docu- cm2 (average 52 FU/cm2), whereas the average frontal mented as a means to predict how well the transplanted density of prepubertal males is approximately 80 to hair will camouflage areas of scalp alopecia. 100 FU/cm2.59 Lab tests for diagnosis are generally unnecessary in men with typical pattern AGA. However, a differential diagnosis for nonandrogenic causes for hair loss should be Donor Area maintained for consideration during the evaluation.47-50 Finally, most men younger than 60 years will also be It cannot be overemphasized to the patient that his or her encouraged to consider the use of finasteride, 1 mg daily, own intrinsic donor hair characteristics will dictate the to reduce crown hair loss. fullness of the hair transplant result. Patients with a thick

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Figure 4. This 38-year-old man with male pattern hair loss requested hair restoration. He underwent a 2200–follicular unit forelock transplant in 1 session and is shown intraoperatively in part A. (B, D) Preoperative views. (C, E) At 10 months postoperatively, the patient’s face is framed with hair in a natural distribution. This result could be a stand-alone outcome or additional grafts could be added for more coverage as desired.

Downloaded from aes.sagepub.com at ASAPS on December 12, 2012 6 Aesthetic Surgery Journal XX(X) hair shaft (>80 microns) are better candidates than those Donor Site Harvest with narrow hair (<60 microns). Recently, a novel device In contemporary practice, follicular units can be obtained has been described to measure hair density and caliber.60 either through strip excision of the donor scalp with Even when transplanted densities are high (>40 FU/ subsequent microscopic tissue dissection26-28 or by cm2), individuals with fine, straight hair will have a more removal using a technique called follicular unit extrac- “see-through” result compared with those with coarse, tion (FUE).62-69 curly, and large-caliber hair transplanted at a lower den- Strip excision. In preparation for the strip harvest, the sity. In addition, patients with low follicular density (1-2 selected area of donor hair is trimmed to 4- to 5-mm length hairs/FU) will have a more sparse result than those with and the patient is positioned in a lateral decubitus posi- higher follicular density (3-5 hairs/FU). tion. An ellipse of donor scalp is outlined, and following In general, patients require a donor density of at least the administration of local anesthesia, tumescent saline 40 FU/cm2 to be considered for transplants. A higher den- solution is infiltrated. Tumescence in conjunction with pre- sity donor supply is extremely advantageous. To accu- cise knife blade angulation parallel to the hair shafts rately assess the size of the donor strip, required reduces follicle transection. Dissection level of the donor measurement of donor follicular unit density is performed strip should be at the superficial fat to avoid injury to the using one of several available specialized instruments occipital neurovascular bundle. The wound is closed in (hair densitometer, digital video camera, etc).61 Then the 2 layers, with an absorbable suture in the deep layer and a size of the donor strip can be determined according to the monofilament suture of choice at the level of the skin. Sta- desired number of follicular units to be transplanted. The ples or dissolving sutures are also options. region between the occipital protuberance and 1 cm above Trichophytic closure. With the advent of shorter hairstyles, the top of the ears is considered the “safest” physiological there has been an increased interest in minimizing (or maxi- place from which to harvest hair. In most patients, this mally concealing) the donor scar. The trichophytic closure area is approximately 5 to 6 cm in width. The higher area has been described to promote scar camouflage by allowing above the ear and below the occipital protuberance may hair growth through the scar.70,71 After the first layer of the thin over time and should be avoided, as this hair may be donor wound is closed, the entire lower edge of the incision susceptible to future AGA. epithelium is excised. The final running suture is then com- In women with a diffuse pattern, the quality of the pleted, with care taken to avoid deep “bites” of scalp that donor hair is often less than ideal. Clinical judgment and have the potential to damage underlying follicles (Figures the objective criteria listed above are components with 5A-F and 6A-C). This important anatomic detail is worth which to determine suitability for the procedure. emphasizing to maximize the results with the trichophytic closure technique. Deepithelization as well as suture depth should not exceed 1 mm, to avoid injury to the follicle Hair Transplant Technique “bulge” zone. Although the bulge was originally described as the portion of the hair follicle to which the arector pili As with any surgical procedure, the techniques of the (AP) muscle attaches, this important region has lately operation will vary based on personal preference and attained significant interest because it is where follicular clinical circumstances. Although the fundamental epithelial stem cells have been identified.9 The bulge region approach described herein is nearly universally applicable, starts at a depth of approximately 1 mm and extends down the specific techniques do reflect most closely the method- to 1.8 mm.29-31 Recently, a double-layer trichophytic closure ology preferred by the lead author (JEV). technique was described.72 Graft preparation. Once the donor tissue has been har- Anesthesia vested using the strip excision method, the tissue is Hair transplantation can be performed under local anes- immediately immersed in chilled isotonic saline or another thesia alone or with supplemental sedation. The local type of preferred “holding” solution. Graft preparation is per- anesthesia solution is a 40-mL mixture of 0.25% bupiv- formed using stereomicroscopes and microsurgical acaine with 1:200 000 epinephrine + 20 mL 1.0% lido- instrumentation. Initially, the donor strip is subsectioned into caine with 1:200 000 epinephrine. This solution is used in slivers, each being 1 FU in width (approximately 1-2 mm). the donor and recipient sites, and supplementation with Considerable skill and experience are required to avoid tran- additional bupivacaine 0.25% is performed in both regions section of grafts during slivering and at the same time of the scalp prior to discharge from the operating room. If maintaining an efficient pace of preparation. Each sliver is conscious sedation is included with the procedure, the then dissected into FU grafts (Figure 7). These grafts are patient is premedicated with 1 to 2 mg PO aprazolam. In placed back into a holding solution until they are planted. It the operating room, an intravenous cocktail of ketamine is imperative that these grafts stay moist in order for them to 5 mg/mL, midazolam 0.5 mg/mL, and fentanyl 10 mcg/ avoid desiccation. mL is titrated to achieve the desired level of sedation. All Follicular unit extraction. Follicular unit extraction is an patients receiving any type of sedation are continuously alternative method of donor harvest. This technique is monitored during the procedure with oximetry and receive essentially a refined “micropunch grafting” version of the supplemental nasal oxygen. older punch graft technique. Using the current technique

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Figure 5. Donor site harvest and trichophytic closure technique. (A) Patient is shown in decubitus position with donor hair shaved to 4 mm. (B) Excised donor strip. (C) The first of the 2-layer donor site closure is complete. (D, E) The intraoperative technique is shown and illustrated, with deepithelization of the donor wound margin. (F) The final closure is shown, with superficial bites of 1 mm. Superficial needle entry into the scalp is performed to avoid injury to the follicle “bulge” zone. of FUE, 1 FU is removed at a time. There are several tech- matter which technique is employed, the net result is still niques and instruments to perform FUE. These include the isolation and removal of a single FU (Figures 3 and 7). manual, power-assisted, and automated methods. No The remaining puncture is left to heal by secondary

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Figure 6. A healed donor harvest site is shown after strip excision and closure with the trichophytic closure technique. (A) Eight months postoperatively. (B) Diagram of healed donor scar following trichophytic closure. (C) Reexcision of the donor scar shown in part A, illustrating hair growth through the initial closure site on tangential view of the specimen. intention. Some hair transplant surgeons choose to employ FUE on a selective basis for small cases (Figure 8), whereas others select this donor harvest technique for their larger sessions (Figure 9). The increased popularity of FUE has been linked to the development of power- assisted technology as well as a general trend toward minimally-invasive techniques. The indications, out- comes, and techniques for FUE as a donor harvest option are found elsewhere.62-69 Follicular unit extraction comprises approximately 22% of all hair restoration donor harvest procedures performed, as reported in a worldwide poll of hair restoration surgeons.73 As with any emerging technology, there is debate regarding this methodology. Controversy related to this donor technique includes the idea that this method is a return to earlier methods of punch harvesting, the specific indications, the ideal harvesting tools (blunt vs sharp), and the survival and growth of the grafts themselves as Figure 7. Microscopic dissection of donor “sliver” and compared with those obtained with strip harvesting. subdissected individual follicular units containing 1, 2, and Depletion of donor density as well as overharvesting of 3 hairs.

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Figure 8. Intraoperative view of small follicular unit extraction (FUE) donor harvest site. (A) Manual FUE harvest tool in use. (B) FUE donor harvest completed. (C) Donor site 8 months after initial harvest.

Figure 9. Large-session follicular unit extraction (FUE) donor harvest site. (A) Immediate intraoperative view upon completion of approximately 2500 FUE harvest. (B) Same donor area, 1 week postoperatively. hair vulnerable to AGA is also a concern with extensive interest and technical refinements. In fact, a novel robotic FUE harvesting. However, increased acceptance and popu- automation of the FUE technique is in the developmental larity of FUE are emerging as a result of evolving patient stage.74 Most hair restoration surgeons feel this donor

Downloaded from aes.sagepub.com at ASAPS on December 12, 2012 10 Aesthetic Surgery Journal XX(X) technique is “here to stay,” and future refinements and grafted as indicated but should always be considered as an experience with FUE will solidify its indications. extension of the posterior forelock to maintain a natural distribution of hair (Figure 15). Hairline Design and General Recipient Area The first landmark that needs to be determined is the height Recipient Site Creation of the anterior hairline (AHL) (Figure 1). In most instances, There are numerous instruments and methods with which the location of the most anterior, midfrontal portion of the to create a site in which a hair graft is placed. The funda- hairline is between 7.5 and 9.5 cm above the glabella. The mental principles that should underlie any technique shape of the head, predicted future hair loss, and donor include matching the size of the individual recipient site capacity are factors to consider in this creative decision. One with the length and width of the patient’s FU. For example, must place the hairline in such a location that it will look if short, single hair grafts are placed at the anterior hairline natural as the patient matures and continues to lose hair. in a thin scalp, a smaller and more shallow site is created If the temporal point is expected to recede, a higher than would be required to accommodate a larger 3- to hairline should be considered because a low hairline with 4-hair FU placed in the thicker scalp. The most simple and a lost temporal point suggests a hairpiece. The temple cost-effective instrument for recipient site creation is a point should be even or slightly posterior to the frontal hypodermic needle. Needle sizes ranging from 23 to 18 hairline. Along with the aforementioned principles, a gen- gauge are typically used. A 19-gauge needle will produce a tly curving hairline should be created, with care taken to 1.1-mm slit that will accommodate the size of the majority always maintain a significant frontal-temporal recession. of FU of average density (Figure 16). Another popular Restoration of the temporal triangle is performed accord- instrument for site creation is the sharp-point, 22.5-degree ing to the personal preference of patient and surgeon. or the “mindi” knife. These instruments, as well as micro- The design should begin by ensuring the presence of a scopes designed for hair restoration surgery, are available lateral hump (Figure 1). If the lateral hump is absent, this through different vendors (Ellis Instruments, Madison, New should be designed first. The lateral hump is the superior Jersey; Tiemann-Bernsco & A to Z Surgical, Hauppauge, extension of the inferiorly directed hair of the temporopa- New York). Customized recipient blades can also be cut to rietal fringe. The superior extent of this important land- specific size from flat surgical prep blades using specialized mark is even with or just medial to a line drawn vertically cutting devices. In some circumstances, a 0.8-mm to 1.5-mm from the lateral canthus. This landmark is important hole punch might be utilized as well.81 because it represents the lateral extent of the AHL. The The angle of the recipient site should mimic the angles intersection of the lateral AHL and the lateral hump is the of the nontransplanted, existing hair growth. When hair apex of the frontotemporal recession and should always be is absent, a natural flow of hair is created. On most hair- convex in a male AHL design (Figure 10).75-77 lines, the angle of graft site creation should be approxi- The single most important component to achieving a mately 30 to 45 degrees anteriorly off the scalp. This natural appearance to the hair transplant is the creation of results in the illusion of more coverage as well as a natu- an outstanding AHL (Figure 11). This is accomplished ral angle. The hair on the left side of the hairline should through proper location and design of the hairline as well be angled anteriorly and toward the midline. As the hair as the use of large numbers of small grafts. The shape of progresses to the right side, a switch should be made so the frontal hairline should not be linear but should be that the hair on the opposite side is angled toward the broken up with major irregularities (triangles and gaps). midline. As mentioned above, a whorl is created at the The hairline should consist of a transition from the bald midpoint of the crown vertex area through a spiraling of forehead to a zone consisting of random placement of the angulation of recipient sites through a 360-degree single hair grafts from the softest hair available in donor rotation (Figure 15). supply.78,79 Typically, these single hairs are taken from the Most patients will require a follicular density of approx- temporal donor fringe. Posterior to the single hair grafts imately 25 to 40 FU/cm2 for satisfactory coverage. However, are FU containing 2 and 3 hairs with stronger physical as mentioned above, the individual hair characteristics characteristics (Figure 12). Recreating a female hairline play an important role in this regard. Although highly requires a design that includes a more rounded temporal variable between surgeons, the typical density of site infill and lower hairline than the one normally created for packing in a completely bald scalp is approximately 25 to men (Figures 13 and 14).80 35 sites/cm2/hair transplant session. The density for opti- When a forelock pattern is created, the rear border mal site packing as well as the use of “skinny” (closely should be located somewhere along the midscalp. Whether trimmed) or “chubby” (containing more fat and sebaceous or not there is a plan to graft the vertex, the rear hairline tissue) grafts is controversial. The considerations in this should be constructed with an irregular border of small debate are based on limited reports of survival at different grafts. The lead author prefers to create a tapered posterior densities, surgeon’s preference, and also the skill of the forelock pattern of trailing design that renders the crown transplant team.82-85 less circular and mimics a natural variation on the balding process (Figure 15). A distribution of grafts recreating a Graft Planting natural whorl pattern can be constructed at the posterior As with site creation, numerous techniques and instru- aspect of the forelock. The crown area can be further ments are available for graft placement. The different

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Figure 10. This 58-year-old man with male pattern alopecia who underwent a 2500-graft follicular unit hair transplant is shown during immediate preoperative planning (A, C) and immediately postoperatively (B, D, E). Note the design of the posterior forelock taper and fill of the temporal hump.

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Figure 11. (A, C) This 63-year-old man with male pattern alopecia requested restoration of his anterior hairline. (B, D) Eight months after receiving 3200 grafts in 2 sessions. forceps used for planting are essentially adaptations of Conclusion of Procedure, Postoperative Care, and those used in microvascular surgery. The fundamental Emergence of Results principles of this aspect of the procedure include gentle Hair transplants are lengthy procedures. A typical session of grasping of the grafts, maintenance of graft hydration, 1500 to 2500 grafts utilizing 4 assistants will last approxi- placement of grafts in the identical angle of site creation, mately 6 to 7 hours. The procedure is conducted using a and also maintaining appropriate rotation of the natural clean technique with sterilized or disposable instruments. curvature of the hair graft. As with graft preparation, con- Postoperatively, the recipient sites and donor area are typi- siderable skill is required to perform this delicate task in cally not bandaged, and perioperative antibiotics are not a repetitive, atraumatic, and efficient manner. Frequently, prescribed on a routine basis. Patient instructions include several “planters” work simultaneously to complete the head elevation and icing of the forehead and donor area, procedure in an efficient manner. An experienced assis- along with analgesics. Aloe ointment administration to the tant or physician can plant 200 to 300 grafts per hour. grafted area and gentle shampooing in the shower should Typically, the recipient sites are designed first and the commence on postoperative day 2. Most of the recipient site grafts are placed as a following step. However, another eschars are gone by day 10, and donor sutures are removed technique known as the “stick-and-place” method incor- on day 14. Although there are exceptions to the rule, most porates both maneuvers in a sequential manner. The grafts enter a telogen phase for the first 3 months prior to “sticker” creates the site with a blade of choice, and the entering their anagen phase. Full growth and evaluation of “placer” inserts the graft immediately before the next slit transplant results cannot reliably be assessed for 8 to 12 is developed. months following the procedure (Figure 17).

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Figure 12. This 48-year-old man demonstrates the irregularity required for graft distribution at the anterior hairline. (A) The patient is shown intraoperatively, after a single session of 2200 grafts. Note the distribution of grafts containing 1 and 2 hairs per follicular unit at the leading edge of the hairline and larger grafts posteriorly. (B) The patient’s hairline is shown preoperatively. (C) Eight months after grafting, the irregularity and distribution of graft size clearly contribute to the natural appearance of the patient’s transplanted hairline.

Special Considerations surgery, burns, radiation, trauma, and congenital deformi- Body Hair as Donor ties.90-93 Hair transplants do grow in scar as well as radi- ated tissue; however, the survival rate is lower than in Body hair is useful to treat areas of hair loss when the noninjured recipient beds. Formal studies on this topic scalp donor area supply is near or at exhaustion. The have not been published (Figure 18). results of body hair transplants are impossible to predict In the case of hairline reconstruction for female-to- with certainty because of the intrinsic physical and short male gender reassignment, androgen supplementation life cycle characteristics of this type of hair. In general, the and ensuing temporal recession or thinning is generally beard is the best source of body hair because its intrinsic all that is necessary. In male-to-female reassignment, the life cycle and physical characteristics most closely resem- hairline design includes a typical rounded temporal infill ble that of scalp hair.86-89 Follicular unit extraction as a and the lower hairline described earlier for restoring donor technique is particularly well suited to the submen- FPHL (Figure 14). tal area when beard hair is harvested. Flaps/Scalp Reduction/Expanders Reconstructive Applications In contemporary practice, hair-bearing scalp flaps and Hair transplantation can have a significant role in correct- alopecia reductions for elective aesthetic hair restoration ing alopecia associated with scars from previous aesthetic surgery are primarily of historic interest. A comprehensive

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Figure 13. (A, C) This 68-year-old woman with typical female pattern hair loss presented for hair restoration. (B, D) Eight months after undergoing a second treatment session, for a total of 3300 total grafts.

review of the previous use of these techniques in the treat- the incidence of primary surgical problems is estimated to ment of AGA can be found in 2 studies.94,95 In some cases, be less than 2% to 3% and includes bleeding, arteriovenous these procedures have resulted in an excellent outcome for fistula, cysts, pustules, infection, frontal necrosis, neurosen- the patient. However, as a result of poorly designed surgi- sory changes, and scarring.96 Primary aesthetic complica- cal incisions as well as naive surgical planning in the face tions include poor growth of grafts, postsurgical effluvium, of progressive hair loss, the long-term results of these and unnatural appearance. The incidence of poor growth procedures have also resulted in exposed, unattractive ranges from 0% to 25%, but this number is highly subjec- scars as well as misdirection of hair flow. The use of tive. These complications and other patient safety concerns scalp expanders, reductions, and flaps for reconstruction have been reviewed in detail elsewhere.97 of traumatic hair-bearing scalp defects remains well entrenched in the scalp surgeon’s armamentarium. Surgical Complications

Complications and Patient Safety Folliculitis/Cysts/Pustules A variety of cysts and pustules can present within the first Fortunately, the incidence of complications in HRS is quite few weeks or months following a transplant. They can be low. Unfortunately, there are no published reports of sig- isolated or occur as clusters of diffuse lesions. The causes nificant size detailing the frequency of complications in are not clear. Theories include “ingrown” hair, foreign large series. Nevertheless, the types of complications seen body reactions, epithelium logged into slit sites during have been well described and can be categorized into surgi- recipient site creation, piggybacked grafts, and the “idio- cal and aesthetic complications. In contemporary practice, pathic” intrinsic properties of the host scalp. In the majority

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Figure 14. A female hairline design is shown in a 32-year-old genetic male, transgender patient seeking a feminine appearance. (A) Preoperative markings are shown following healing of a previous forehead-lowering procedure by another surgeon. (B) The patient is shown intraoperatively. (C, D) Eight months after a third treatment session and a total of approximately 4700 grafts. of cases, a pathogen cannot be cultured from the lesions, keloid scarring is rare in the donor site and interestingly has but a secondary, uncultured bacterial agent cannot be never been reported as occurring in the recipient area. excluded as having a secondary role in pathogenesis. Oral Reduction in donor density secondary to extensive punctate antibiotics, warm compresses, and unroofing of the cysts scarring is a potential risk of FUE harvesting. are the mainstays of treatment.

Neurosensory Complications Aesthetic Complications A certain amount of pain, especially in the strip harvested donor site, is to be expected. Occasionally, some patients Poor Growth will experience severe pain in the donor site, requiring It is unrealistic to expect 100% of grafts to survive. prolonged periods of narcotics. Although some patients Accurate measurement of growth requires precise hair report headaches following the transplant procedure, there counts using magnification, scalp tattooing, and macro- have been reports of a decrease in this symptom as well. photography. Studies of this caliber are small in size and Neuralgias and hypoesthesia symptoms are uncommon very limited. However, most would agree that growth rates and almost always resolve within the first 6 to 8 months. less than 85% to 90% would be considered poor growth. Neuromas have been rarely reported and are treated with Causes for poor growth are numerous but generally focus steroid injection or excision. on follicular trauma and dehydration during the different stages of the lengthy procedure. Some limited studies on Scarring out-of-body time indicate that graft growth is not effected Scarring in the donor area remains the primary concern, even until 6 to 8 hours following harvest.82,83 Different holding with modern strip harvesting techniques. The advent of the solutions are being investigated to maximize graft integ- trichophytic closure technique and the awareness of the rity. Other factors for poor growth include host factors critical importance of avoiding tension in donor site closure such as vascularity of scalp, smoking, and the presence of have reduced the incidence of donor scar complications. True scar tissue.

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Figure 15. (A) This 43-year-old man with primary alopecia in the crown region presented for hair restoration. (B) Eight months after posterior forelock grafting and creation of crown whorl pattern with approximately 2000 grafts.

an anagen or a telogen effluvium and typically takes place 2 to 6 weeks following the transplant procedure. This situ- ation most frequently occurs in female patients with diffuse pattern hair loss but can be seen in men as well. In addition, effluvium can also be seen in the donor harvest sites. Fortunately, the effluvium is usually temporary. In some instances, the hair will grow back with a more narrow caliber or not at all. To reduce the likelihood of effluvium, the surgeon can minimize the number of recipient sites, as well as their size, and also consider the use of minoxodil (Rogaine) or finasteride (Propecia) during the perioperative period.

Unachieved Patient Expectations As in any type of aesthetic surgical procedure, the expectations of the patient need to be realistic. However, unique for the hair restoration patient is the importance of appre- Figure 16. Relationship of size between 1-, 2-, and 3-hair ciating the progressive nature of nontransplanted hair loss follicular unit grafts and the 19-gauge and 1.0-mm blades used over time, the inherent qualities of their donor hair as a to create recipient sites. It is important to create recipient sites source for scalp coverage, and their individual limitation with a depth and width that match the graft size. in donor supply.

Poor Cosmetic Appearance of the Transplant Postsurgical Effluvium The expected outcome using contemporary techniques of Occasionally there can be a shedding of the in situ, non- hair transplantation is a result that is generally indistin- transplanted hair. This postsurgical shedding can be either guishable from the appearance of native scalp hair.

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Figure 17. (A, C, E) This 28-year-old man with male pattern alopecia presented for hair restoration. (B, D, F) Eight months following a single session of hair grafting with 2500 grafts placed in a forelock distribution. Note the beneficial effect from finasteride in the nontransplanted posterior crown region. The benefit to forelock grafting is that additional grafts can be placed in the crown region if desired or the result can stand alone.

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Figure 18. (A) This 28-year-old man presented for beard reconstruction after a burn injury and secondary chin reconstruction. (B) Twelve months after placement of approximately 1000 grafts in 2 sessions. Reprinted with permission from Barrera A. The use of micrografts and minigrafts in the aesthetic reconstruction of the face and scalp. Plast Reconstr Surg. 2003;112(3):883-890.

Unfortunately, older techniques as well as some poorly to a patient whose life has been undesirably transformed by performed recent transplants have not resulted in a natu- the initial hair transplant procedures (Figure 19). ral appearance. As a consequence, there are a considerable number of patients who bear the visual and psychological burden of an unnatural hair transplant. A complete review The Future of Hair Transplantation of these types of problems and their management was FUE published elsewhere.98-105 The most frequent type of cosmetic problems following Currently, a minority of hair transplant surgeons provide hair transplants are FUE for all patients. Most practices use FUE for selected indications. However, the future direction appears to be 1. Unsightly appearance of plugs moving toward a greater interest in and application of 2. Wide scars in the donor area FUE. Improved instrumentation, automation, and an ever- 3. A poorly designed hairline increasing interest in minimally-invasive techniques are 4. Errors in surgical planning and inappropriate dis- driving this trend. tribution of grafts at a young age, in which the progressive nature of hair loss was not considered Cell-Based Therapy All of the above cosmetic complications result in the In the foreseeable future, hair restoration surgery will be same fundamental problem for the patient: an unnatural intermingled with some type of cell-based therapy. The appearance to the scalp hair that yields a strange and concept of the hair follicle as a mini-organ is recognized unnatural appearance. Patients are plagued with these by cell biologists pursuing hair replication research. unnatural results, which become worse over time as their Biotech and basic research labs are currently investigating surrounding hair recedes and thus further exposes the pathways for hair induction, hair development, and hair original unnatural hair grafts. Understandably, these follicle regeneration. The results of this research will patients are angry with the original surgeon and themselves undoubtedly make their appearance into clinical trials for submitting to the original transplant; they often wish and, theoretically, daily practice. It should be recalled that they could trade the unnatural appearance for simple bald- androgenic alopecia is, at least in principle, a reversible ness. Correction of these tragic results is difficult and time- condition. Although the terminal hairs have become min- consuming, requires a special relationship of trust between iaturized beyond recognition by the naked eye, the same the surgeon and patient, and often requires 3 or more surgi- hair follicles (with fully intact stem cell machinery) con- cal procedures. The techniques and approach for correction tinue to be present in the balding scalp. The ultimate solu- of these challenging cases are beyond the scope of this cur- tion to finding a cure for androgenic alopecia would be rent review. The references cited in this section provide the a product that is able to switch on the differentiation principles and fundamental techniques for restoring normalcy mechanism from vellus to terminal hair. The ability to

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Figure 19. (A) The patient’s preoperative markings are shown prior to the first procedure. The dots indicate the location where plugs are to be removed and recycled into new follicular unit grafts for immediate grafting. The irregular anterior hairline was also marked for creation of a new leading edge hairline. Dome marking in the area of the lateral hump above the ears indicates planned distribution of grafts to fill in bald “alleys” of scalp. (B, D, F) This 38-year-old man had previously undergone a hair transplant at age 20 but was cosmetically dissatisfied with the appearance of his scalp. The patient had experienced progressive hair loss with resulting exposure of previously transplanted 4-mm “plug” grafts. In addition, progressive hair loss above his ears resulted in “alleys” of baldness. He desired correction of this unnatural appearance. (C, E, G) Eight months after the third procedure; all procedures consisted of primary hair grafting from the occipital donor site, plug reduction, and recycling of 4-mm plug grafts. In total, the patient underwent removal and recycling of approximately 252 four-mm previously grafted transplant “plugs” and 2000 follicular unit grafts over a 2-year period. The patient was also maintained on finasteride oral medication.

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Figure 19. (continued) (A) The patient’s preoperative markings are shown prior to the first procedure. The dots indicate the location where plugs are to be removed and recycled into new follicular unit grafts for immediate grafting. The irregular anterior hairline was also marked for creation of a new leading edge hairline. Dome marking in the area of the lateral hump above the ears indicates planned distribution of grafts to fill in bald “alleys” of scalp. (B, D, F) This 38-year-old man had previously undergone a hair transplant at age 20 but was cosmetically dissatisfied with the appearance of his scalp. The patient had experienced progressive hair loss with resulting exposure of previously transplanted 4-mm “plug” grafts. In addition, progressive hair loss above his ears resulted in “alleys” of baldness. He desired correction of this unnatural appearance. (C, E, G) Eight months after the third procedure; all procedures consisted of primary hair grafting from the occipital donor site, plug reduction, and recycling of 4-mm plug grafts. In total, the patient underwent removal and recycling of approximately 252 four-mm previously grafted transplant “plugs” and 2000 follicular unit grafts over a 2-year period. The patient was also maintained on finasteride oral medication.

Downloaded from aes.sagepub.com at ASAPS on December 12, 2012 Vogel et al 21 enhance hair graft growth and survival through the use of hair are the key elements the hair restoration surgeon uti- platelet-derived growth factors is an additional area for lizes to artistically craft the transplant. The future of HRS research and development.106 and the treatments for alopecia are centered on minimal- incision surgery as well as cell-based therapies.

Cloning Disclosures

Initial enthusiasm for replication of a single hair into thou- The authors declared no potential conflicts of interest with respect sands of hairs suitable for transplantation has been tem- to the research, authorship, and publication of this article. pered by the difficulties of culturing and replicating hair in vivo. Even when this biological task has been minimally Funding accomplished, the effective number of viable hairs created as well as the subsequent delivery techniques into tissue The authors received no financial support for the research, has been disappointing thus far. authorship, and/or publication of this article.

References Incorporating HRS Into Plastic Surgery Practice 1. Okuda H. The study of clinical experiments of hair transplantation. [in Japanese]. Jpn J Dermatol Urol. 1939;46:1-11. A traditional aesthetic surgery practice that includes hair 2. Orentreich N. Autografts in alopecias and other selected restoration surgery enjoys excellent internal marketing conditions. Ann N Y Acad Sci. 1959;83:463. opportunities and patient crossover between the 2 prac- 3. Uebel CO. Micrografts and minigrafts: a new approach for tices. For this and other reasons, HRS often piques the baldness surgery. Ann Plast Surg. 1991;27(5):476-487. interest of plastic surgeons. However, lack of exposure to 4. Ellis J, Stebbing M, Harrup S. Polymorphism of the HRS in plastic surgery residency training renders this field androgen receptor gene is associated with male pattern difficult to fully incorporate into practice. The fact is that baldness. J Invest Dermatol. 2001;116:452-455. HRS is a “subspecialty” in itself and does not exclusively 5. Blume-Peytavi U, Blumeyer A, Tosti A, et al. Guidelines reside within the domain of any one of the specialties for diagnostic evaluation in androgenetic alopecia in men, endorsed by the American Board of Medical Specialties women and adolescents. Br J Dermatol. 2011;164(1):5-15. (ABMS). The International Society of Hair Restoration 6. Hillmer A, Hanneken S, Ritzmann S, et al. Genetic varia- Surgery is the largest organization dedicated to education tion in the human androgen receptor gene is the major and training in HRS. Six- and 12-month fellowships in HRS determinant of common early onset androgenetic alope- as well as annual educational meetings and local surgical cia. Am J Hum Genet. 2005;77:140-148. workshops are offered through this organization. Although 7. Levy-Nissenbaum E, Bar-Natan M, Pras E. Confirmation of the not recognized by the ABMS, the American Board of Hair association between male pattern baldness and the andro- Restoration Surgery does offer an excellent educational cur- gen receptor gene. Eur J Dermatol. 2005;15(5):339-340. riculum leading to certification. This later curriculum is a 8. Sinclair R, Greenland KJ, van Egmond S, Hoedemaker C, particularly good educational track for a board-certified Chapman A, Zajac JD. Men with Kennedy disease had plastic surgeon to expand his or her knowledge base in this a reduced risk of androgenetic alopecia. Br J Dermatol. field. However, establishing a practice setup, training hair 2007;157:290-294. transplant technicians and front office staff, and develop- 9. Paus R, Cotsarelis G. The biology of hair follicles. N Engl ing a marketing program in this subspecialty require a J Med. 1999;341:491-497. disciplined and multifaceted, long-range business plan. 10. Ansell DM, Kloepper JE, Thomason HA, Paus R, Hard- man MJ. Exploring the “hair growth–wound healing connection”: anagen phase promotes wound healing re- Conclusions epithelialization. J Invest Dermatol. 2011;131:518-528. 11. Driskell RR, Clavel C, Rendl M, Watt FM. Hair follicle der- Hair restoration surgery has developed into a highly sophis- mal papilla cells at a glance. J Cell Sci. 2011;124:1179-1182. ticated subspecialty that offers significant relief to patients 12. Woo WM, Oro AE. Snapshot: hair follicle stem cells. Cell. with hair loss. This aspect of cosmetic surgery is a very 2011;146:334. welcome addition to a traditional aesthetic practice and 13. Fujiwara H, Ferreira M, Donati G, et al. The basement serves as a tremendous source for patient satisfaction and membrane of hair follicle stem cells is a muscle cell internal cross-referral. The results of contemporary hair niche. Cell. 2011;144:577-589. restoration are natural, enduring, and are performed with a 14. Hsu YC, Pasolli HA, Fuchs E. Dynamics between very high level of patient safety. This degree of refinement stem cells, niche and progeny in the hair follicle. Cell. has been established through an improved understanding 2011;144:92-105. of hair biology and physiology as well as the incorporation 15. Jahoda CAB, Reynolds AJ. Hair follicle dermal sheath of standard microsurgical techniques. The combination of cells: unsung participants in wound healing. Lancet. graft size, site creation, packing density, and selected donor 2001;358:1445-1448.

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