The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

Common indications for injection with duplex ultrasound visualization include the
following:
 Greater saphenous vein without junctional incompetence
 Lesser saphenous vein without junctional incompetence
 Truncal or tributary vessels with large failed perforating veins
 Varicosities with saphenofemoral incompetence
 Varicosities with saphenopopliteal incompetence
 Resistance to other techniques of sclerotherapy
 Nontruncal varicosities larger than 5 mm in diameter
 Venous component of arteriovenous malformations
 Varicosities eroding into soft tissues
 Vulvar or scrotal varices
 Varicosities with large open connections to the deep venous system
Although it is generally safe and effective, situations do arise in which sclerotherapy
is contraindicated. Any patient with a medical history significant for deep venous
thrombosis should be thoroughly evaluated with duplex examination of the deep
and superficial venous systems before treatment. Patients with a history of arterial
insufficiency or hypercoagulable states should not be considered candidates for treat-
ment. Additionally, sclerotherapy should not be performed on patients who are preg-
nant, bedridden, or severely diabetic.
Laser Treatment of Reticular Vessels and Telangiectasias
Although sclerotherapy and ambulatory phlebectomy remain the mainstay of treat-
ment of varicose and reticular veins, lasers certainly play a role in the treatment of
lower extremity telangiectasias. Upper extremity or dorsal hand varicose veins are
best treated with sclerotherapy. Lasers typically have no role in the treatment of up-
per extremity varicosities.
In general, treatment with lasers and light sources is more expensive, results are less
predictable, responses are more variable, and the risk of side effects is at least as high
as with sclerotherapy. Candidates suitable for laser or light source treatment are those
who are needle phobic, have failed sclerotherapy, or have developed untoward side
effects from sclerotherapy. Others suited for laser treatment are fair-skinned indi-
viduals who either have vessels smaller than the caliber of a 30-gauge needle or foot
and ankle vessels that are notoriously difficult to treat with sclerotherapy.
Lasers are typically reserved for the smallest telangiectasias of the leg, but newer
long-wavelength lasers can be useful for spider veins up to 2 mm in diameter.
Lasers have the greatest utility in vessels smaller than the diameter of a 30-gauge
needle. Additionally, lasers are a good option for treating vessels that are resistant to
sclerotherapy. There are instances in which laser and light source treatments should
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Chapter 17  Sclerotherapy and Laser Vein Treatment
be considered rather than superficial sclerotherapy, such as patients who are fearful
of needles or who do not tolerate sclerotherapy, patients whose vessels fail to re-
spond to sclerotherapy, and those who are prone to developing telangiectatic mat-
ting following sclerotherapy treatment. Additional carefully monitored controlled
studies are essential to better define the role of each of the available lasers and light
sources, and the optimal treatment parameters for leg telangiectasias.
Despite the fact that sclerotherapy has a long list of potential side effects, including
pain, swelling, urticaria, systemic allergic reaction, hyperpigmentation, telangiectatic
matting, skin necrosis, and phlebitis, it remains the treatment of choice for most leg
veins less than 4 mm in diameter.
TREATMENT OF LOWER EXTREMITY VENOUS DISEASE
0.2-0.4 mm telangiectasias
WITHOUT
REFLUX
Foam sclerotherapy using
0.1% foamed STS,
0.25% foamed polidocanol
0.1% STS,
0.25% polidocanol
72% Glycerin
0.1% STS,
0.25% polidocanol
Sclerodex
0.4-4 mm telangiectasias
Foam sclerotherapy using
0.1%, 0.2% foamed STS,
0.25% polidocanol
Duplex-guided
foam sclerotherapy using
0.2%-0.5% foamed STS,
0.5%-1% polidocanol
First treat blue or bluish-
green reticular veins in
the desired area
Telangiectasias with
feeding reticular veins
Telangiectasias without
feeding reticular veins
Documented greater saphenous vein or lesser
saphenous vein reflux by duplex ultrasound
Flush ligation and pin stripping
Endovenous laser ablation
Endovenous radiofrequency ablation
WITH
REFLUX
STS, Sodium tetradecyl sulfate.

Overview of Sclerotherapy Treatment Regimen
When sclerotherapy is planned to treat varicose disease, the first treatment session
is considered a test treatment and is usually limited to one or two sites. The goals of
this test are as follows:
 To observe the patient for any allergic reactions
 To determine the patient’s ability to tolerate the burning or cramping of a hy-
pertonic solution
 To judge the effectiveness of a particular concentration of sclerosing agent
 To observe any reactions to the tape used for compression
The patient returns 4 to 6 weeks later so the test site can be compared with pre-
treatment photographs. At each follow-up session the patient is asked if the painful
symptoms have decreased and if the appearance of the varicosities has improved.
When the symptoms have resolved, the physician can be confident that the treatment
has been successful, even before visual improvement is evident. Conversely, if visual
improvement is noted but the symptoms have not resolved, the source of reflux has
not been eliminated, and a recurrence in the treated area is highly likely.
The usual number of treatments is two to five per region, with a typical interval be-
tween treatments of 4 to 8 weeks. After a series of successful treatments, a rest pe-
riod of 6 months is preferred to observe for second-generation vessels and to allow
venous pressure to normalize. Reevaluation is done at 6 months if new or recurrent
vessels appear.
Patient Education
Before treatment is initiated, the patient is asked to view a sclerotherapy consulta-
tion video that explains the pathophysiology of spider veins, treatment options, pre-
operative and postoperative care, and the need for compression therapy among other
issues. After the test treatment and before the next treatment session, the patient is
instructed to eat beforehand to avoid a vasovagal response. Female patients are told
not to shave their legs or use moisturizers on the day of treatment, to wear shorts
during treatment sessions, and to bring support hose to the visit.
Compression therapy is very important to improve and maximize the results fol-
lowing sclerotherapy. External compression collapses and decreases blood flow in
the treated veins, allowing maximal sclerosant effects on the vessel walls. To achieve
adequate compression, it is recommended that patients use class I (20 to 30 mm Hg)
compression stockings for at least 2 weeks.
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Part III  Nonsurgical Cosmetic Treatments

It is not uncommon for patients to present for a treatment session and request that
lasers be used in place of sclerotherapy. Patients must be counseled that lasers are a
second-line treatment for spider and varicose veins. They are not as effective as con-
ventional sclerotherapy in their current technologic state. Treatment with currently
available lasers requires longer sessions, is generally more painful, and poses more
risk of causing harm.
TECHNIQUE
Glycerin Sclerotherapy
Glycerin is usually supplied in 100% or 72% solutions, in the chromated form. Be-
cause glycerin injected at 100% is painful and too viscous, it is usually diluted 2:1
volume/volume with 1% lidocaine with 1:100,000 epinephrine. It acts as an osmotic
corrosive agent, causing damage to the vessel wall directly, and works very well on
vessels 0.5 mm or smaller. To minimize the risk of hematuria, the use of more than
10 ml of glycerin per treatment is not recommended.
Lateral Thigh Telangiectasias
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Chapter 17  Sclerotherapy and Laser Vein Treatment
This 35-year-old woman presented with concerns about a spider vein on her right
thigh (arrow). The veins had appeared after the birth of her first child 4 years earlier
and persisted without worsening.
A clustering of 0.5 to 0.8 mm bluish-colored telangiectasias was evident on the right
anterior thigh. These vessels were associated with a 2 mm reticular vein, which was
injected. These associated telangiectasias were not located in the typical distribution
for the greater saphenous vein.

The patient underwent a test treatment with two different sclerosants: 72% glycerin
solution (compounded by the University Compounding Pharmacy, San Diego, CA)
and 0.1% sodium tetradecyl sulfate (STS) (Fibrovein; V.S. Ltd., Birmingham, Eng-
land) and wore compression stockings, 20 to 30 mm Hg, for the next 2 weeks to en-
sure the best results.
Treatment
The patient returned for a full sclerotherapy session 4 weeks after the test treatment.
The previously treated areas were evaluated and showed good resolution of vessels,
without evidence of hyperpigmentation.
The patient was placed in the supine position on a surgical table with a sclerotherapy
tray nearby. After wiping with isopropyl alcohol, a disposable 30-gauge needle con-
nected to a 3 ml syringe and filled with 1 ml of the 72% glycerin solution was used
to cannulate the vein. The needle was bent at a 30-degree angle to facilitate cannu-
lation. The solution was slowly injected into several places in the vein.
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Part III  Nonsurgical Cosmetic Treatments
Standard Sclerotherapy Tray Contents
 Cotton balls, dry and soaked with 70% isopropyl alcohol
 Protective nonsterile gloves
 30-gauge disposable plastic-hub needles
 Cotton balls or rolls for compression
 Transpore or paper tape
 Nitroglycerin paste for prolonged blanching
 Clearly labeled sclerosing solutions in 3 ml disposable latex-free syringes

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Chapter 17  Sclerotherapy and Laser Vein Treatment
On withdrawal of the needle, immediate but transient blanching of the telangiec-
tasias was noted. After treatment, mild erythema and urtication were noted along
the course of the treated vessels.
Foamed Sodium Tetradecyl Sulfate Sclerotherapy
Foamed sclerosant is an alternative to traditional liquid sclerosant; it offers several
advantages:
 Better displacement of the venous blood to allow intimate and prolonged con-
tact with the vessel wall
 Ability to maintain its concentration more than liquid sclerosant, which is di-
luted by venous blood
 Ability to travel farther along the vessel than liquid sclerosant
Currently, foam sclerotherapy is an off-label use.
Anterolateral Tributaries of the Greater Saphenous Vein
Foamed sclerosant was used to treat this patient,
who complained of a bulging varicose vein, ap-
proximately 7 mm, located on the lateral aspect of
her right thigh. To evaluate her problem, duplex
ultrasound evaluation was performed on the right
greater saphenous vein, with emphasis on the sa-
phenofemoral junction. This was found to be within
normal limits; however, the anterolateral branch
showed evidence of reflux along its course.

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Part III  Nonsurgical Cosmetic Treatments
Treatment
The patient was placed in the supine position on a surgical table with a sclerotherapy
tray nearby. A disposable 27-gauge needle connected to a 3 ml latex-free syringe was
used to canalize the vessels.
After flashback was visualized, the sclerosant solution, 0.5 ml of 1.0% foamed STS,
was slowly injected into the proximal varicosity.
On withdrawal of the needle, the areas treated were gently massaged in a proximal
direction. This process was repeated distally along the course of the vein, approxi-
mately every 4 to 5 cm. The patient is shown after treatment.
Dorsal Hand Veins
A foamed sclerosant was also used for hand sclerotherapy in patients who have cos-
metic problems on their enlarged dorsal hand veins.
Careful consideration during the medical examination includes any history of hand
trauma, weakness, carpal tunnel syndrome, need for frequent intravenous medica-
tions, and foreseeable need to canalize hand veins. Consent must include the fact that
the treated vein would no longer be usable in the future, in the event that it would
be needed as a route for intravenous access. During the physical examination, the
brachial and antecubital veins need to be identified, which could be accessible in the
event of a future need for intravenous access.

Treatment
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Chapter 17  Sclerotherapy and Laser Vein Treatment
The patient is placed in the supine position, and the arm and forearm on the side to
be treated should be placed along the bedside. A disposable 30-gauge needle con-
nected to a 3 ml latex-free syringe is used to canalize the vessels. The sclerosant so-
lution, 0.5% to 1.0% foamed STS, is commonly used for hand sclerotherapy. Alter-
natively, the newly FDA-approved sclerosant, 0.5% to 1.0% polidocanol (Asclera)
can also be used, foamed or nonfoamed. The sclerosant should be injected slowly
after confirming a flash of blood in the needle hub. Vein distention and mild blanch-
ing occurs while the foam is being injected.
This 49-year-old woman presented with cosmetic concerns about her hands. She
thought they looked old and “worn down.” She inquired about any treatments that
could revitalize the appearance of her hands. She was distressed about the dorsal
hand veins, which were especially prominent and had become more noticeable over
the past 5 years. On physical examination, a bluish superficial varicose vein of ap-
proximately 5 mm was noted on the dorsal aspect of the left hand.

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Part III  Nonsurgical Cosmetic Treatments
One year later, marked reduction of dorsal hand veins is seen on the left hand com-
pared with the untreated right hand.
Postoperative Care
The patient should elevate the treated hand immediately after injection to minimize
dilution of the foam sclerosant with venous blood and to maximize the contact of the
sclerosant with the vein walls. Compression wrapping or a gauntlet is placed on the
treated hand while the entire upper extremity is still elevated. The patient is instructed
to carefully monitor for any changes in sensation, temperature, color, and decreased
motion in the fingers on the treated hand. If these symptoms occur, the patient should
loosen the compression bandage; otherwise, it should be kept on overnight.
Duplex-Guided Foamed Sodium Tetradecyl Sulfate
Sclerotherapy
Volar Wrist Arteriovenous Malformation
The deep and superficial venous systems of the upper extremities are analogous to
those of the lower extremities. The deep venous system contains the majority of the
blood volume at any given time. Perforators connect the two systems, just as they do
in the lower extremities. Reflux of these perforators or in the superficial system itself
can cause a systematic weakening of the superficial vessel walls with distention and
pooling of blood. Congenital dysfunction in these systems predisposes to arteriove-
nous formation.

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Chapter 17  Sclerotherapy and Laser Vein Treatment
This 52-year-old man was seen for evaluation and treatment of a lifelong, intermit-
tently tender, protruding mass on the volar aspect of his left wrist. He noted that the
swelling and lumpiness had worsened with age and were associated with increased
sweating, redness, and heat sensation on his left hand in comparison to the right
hand. He had been evaluated 10 to 15 years earlier by radiologic examination and
was found to have an arteriovenous malformation. An approximately 5 cm spongy,
bluish-purple mass was noted on the flexor aspect of the left wrist, with extension
to the thenar and hypothenar eminences. The lesion blanched slightly with pressure.
The patient underwent a duplex ultrasound examination of the venous tributaries of
his left wrist, which revealed an incompetent, refluxing perforator communicating be-
tween the radial vein and the more superficial cephalic vein. Additionally, slow flow
was noted in the cephalic venous malformation. Duplex examination did not identify
any other communicating perforators or aberrant vascular structures. The patient
was willing to undergo duplex-guided sclerotherapy for treatment of the reflux.

584
Part III  Nonsurgical Cosmetic Treatments
At the follow-up visit 5 weeks later, the patient noted a mild decrease in the lesion
size and was treated again with 1.5 ml of 0.5% STS, resulting in the improvement
shown.
Postoperative Care
In the immediate postoperative period, the patient’s arm was elevated and the wrist
massaged from the proximal to distal direction. A compression dressing was placed
on the area and secured with Coban wrap. The patient was told to remove this dress-
ing the following day. No further care was needed.
Treatment
Under duplex guidance, a solution of 0.1% foamed STS was slowly injected with a
27-gauge 1-inch needle after withdrawing slightly to visualize blood flashback in the
needle hub. A total of 1.5 ml of foamed STS was injected during the first visit. Foamed
STS was achieved using the Tessari technique, in which 1 ml of the sclerosant in a
latex-free syringe was mixed with 2 cc of air in an empty syringe using a one-way
stopcock. Foam position was verified with duplex as being confined to the superfi-
cial cephalic vein, with little to no foam traveling to the deeper radial vein. In addi-
tion, firm pressure was applied just distal to the injection site to better localize the
sclerosant. Immediate blanching and slight spasm of the vessel was noted after treat-
ment. The patient had no complaints of pain at the conclusion of the treatment.

585
Chapter 17  Sclerotherapy and Laser Vein Treatment
It is likely that the 1064 nm laser achieves its vasodestructive effects by penetrating
deeply enough to cause complete, circumferential thermal damage to the vessel wall.
For patient comfort and epidermal sparing, some type of cooling must be employed,
whether in the form of contact cooling, cryogen cooling, or ice-cold gel.
Long-Pulse Laser Therapy
Long-pulse Nd:YAG 1064 nm lasers have been developed in an effort to target deep
relatively large-caliber cutaneous vessels. The primary benefit of this wavelength is
its capacity for relatively deep penetration to approximately 0.75 mm in human skin,
allowing targeting of vessels in the middermis. The wavelength is well absorbed by
water and hemoglobin, but not by melanin, thus allowing treatment even in deeply
pigmented individuals. However, high energies must be used for adequate penetra-
tion in these individuals. Only with sufficient fluence and facilitation of heat dissi-
pation can the posterior wall of a larger diameter (1 to 2 mm) vessel filled with de-
oxygenated hemoglobin be reached and heated.
The newer pulsed 1064 nm lasers have pulse durations between 1 and 200 msec and
are capable of more than 350 J/cm2 at small spot sizes. In general, treatment with
long-pulse 1064 nm laser light is relatively painful and requires cooling and topical
anesthesia. Large-caliber vessels greater than 0.5 mm in diameter respond best. Ves-
sels up to 3 mm can be treated with long-pulse Nd:YAG lasers. Some of the effects
of hydrostatic pressure may be addressed by treating these larger vessels, although
the pain experienced by patients significantly increases beyond a 2 mm vessel. Re-
cent data suggest that by using smaller spots and even higher fluences, even small
vessels respond.

She agreed to undergo a series of test pulses with the long-pulsed Nd:YAG 1064 nm
laser (Laserscope Gemini) to a small segment of the veins. She underwent a duplex
examination of the right greater saphenous vein and right saphenofemoral junction,
which revealed no abnormalities. Duplex examination did reveal enlarged antero -
superior branches of the lateral subdermic venous system. The patient was unwill-
ing to undergo duplex-guided sclerotherapy for the reflux and instead opted for
1064 nm laser treatment of her spider veins. She was informed that the results of this
treatment would likely not be permanent.
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Part III  Nonsurgical Cosmetic Treatments
This 41-year-old woman presented with a 5-year history of anterior right thigh telan-
giectatic vessels. She had long wished to be rid of the unsightly, asymptomatic veins
but had an overriding fear of needles, which prevented her from seeking treatment.
Anterior Thigh Telangiectasias

587
Chapter 17  Sclerotherapy and Laser Vein Treatment
Treatment
A grouping of telangiectasias on the patient’s thigh were selected and treated at a
constant fluence of 120 J/cm2 with a spot size of 2.5 mm and varying pulse dura-
tions from 10 to 40 msec. Ice-cold gel was applied to the skin before laser treatment.
A pulse duration of 30 msec produced the best immediate contraction, as illustrated
by handheld digital microscopy.
Postoperative Care
The patient requires minimal care in the postoperative period. He or she should be
made aware of the potential for posttreatment hyperpigmentation, which results
from the hemosiderin degradation products of blood trapped in the vessel during
and after treatment. The larger the treated vessel, the more likely the chance that hy-
perpigmentation will occur. Most hyperpigmentation resolves spontaneously within
3 to 6 months.
Before treatment
Immediately after treatment
10 minutes after treatment
1 week after treatment
Courtesy Girish S. Munavalli, MD

588
Part III  Nonsurgical Cosmetic Treatments
Concluding Thoughts
Sclerotherapy is a safe, effective treatment for leg and hand varicosities. The surgeon
must recognize various patterns of varicose veins, thoroughly understand the perti-
nent anatomy, be familiar with sclerosants and injection techniques, and the use of
compression therapy; these are the key to successful treatment. Underlying superfi-
cial or deep venous insufficiency requires management before one attempts to treat
clinically apparent reticular or spider veins to avoid failure of the sclerotherapy and
potential complications.
Clinical Caveats
Sclerotherapy
 Be aware of your body position; avoid neck and back strain.
 Avoid halogen surgical lighting—indirect lighting is best.
 Use magnification (1.5 to 33).
 For smaller matting, use double-polarized light.
 Apply alcohol to decrease white scale reflection.
 Stretch the skin taut for easier cannulation.
 Bend the needle 30 degrees.
 Obtain 30-gauge disposable needles with a plastic hub (needles are available at
); the needle should be changed frequently if it dulls.
 Do not attempt to withdraw blood into the hub with vessels less than 0.55 mm in
diameter; intravascular placement cannot be confirmed except by the smooth flow
of solution.
 Before solution is injected, producing a tiny air bubble (approximately the volume
in the hub) may be helpful to clear the existing blood.
 Inject very slowly, with little pressure, 0.1 to 0.3 ml at each site.
 For immediate pressure, apply cotton balls and tape for 24 hours.
 Advise the patient to wear compression hose (20 to 30 mm Hg) for 2 weeks after
treatment.
Foam Sclerotherapy
 Be aware of the anatomy and orientation of each individual patient.
 Use latex-free syringes when using STS.

 Produce a small bolus of air or foam preceding injection of the sclerosant when
possible.
 Draw venous blood (low pressure and darker) freely back into the syringe before
injection.
 Visualize the initial injection of foam or sclerosant.
 Stop if distention or bulging around the vein occurs.
 Stop if the patient complains of discomfort at the first moment of injection.
 Note immediate vessel contraction as a treatment endpoint.
Duplex-Guided Sclerotherapy
 Try to identify reticular veins, which may be difficult to clinically appreciate but
feed smaller vessels; if they are identified, treat those first.
 Draw venous blood (low pressure and darker) freely back into the syringe before
injection.
 Visualize the initial injection of several drops of foam or sclerosant.
 Stop if distention around the vein is seen on ultrasound.
 Stop if the patient complains of discomfort at the first moment of injection.
 The proper endpoint is total contraction.
 Foam resting in the vein is often seen on duplex imaging.
Long-Pulse Laser Therapy
 Use 1064 nm laser for treatment of leg telangiectasias.
 Always check that safety glasses are in use by all.
 Target only superficial reticular and telangiectatic vessels.
 Use long-pulse laser therapy for vessels larger than 0.5 mm.
 If the vessel is 0.5 mm or larger, start with a modest fluence of 60 to 80 J/cm2 at
a pulse duration of 30 msec (given a 2.5 cm spot size) and gradually increase the
fluence.
 If the vessel is 0.5 mm or smaller, start with a pulse duration of 15 to 16 msec.
 Have ice-cold gel on hand to decrease the sensation of pain and avoid epidermal
injury.
 Strongly avoid double-pulsing or pulse-stacking the laser at these settings; vessels
can be re-treated after several minutes if the settings need to be modified.
 After successful treatment, note the vessel contraction, perivessel erythema, and
edema.
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Chapter 17  Sclerotherapy and Laser Vein Treatment

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Part III  Nonsurgical Cosmetic Treatments
Annotated Bibliography
Bowes LE, Goldman MP. Sclerotherapy of reticular and telangiectatic veins of the face, hands,
and chest. Dermatol Surg 28:46-51, 2002.
Prominent, tortuous veins of the face and hands may result from the process of aging
and constitute a source of distress for many patients. Marked telangiectases of the chest
and face are similarly distressing to some patients. In this article the authors discuss the
safety and efficacy of sclerotherapy for telangiectatic veins of the face and chest, and
varicose veins of the hands.
Cabrera J, Cabrera J Jr, Garcia-Olmedo MA, et al. Treatment of venous malformations with
sclerosant in microfoam form. Arch Dermatol 139:1409-1416, 2003.
Treatment of congenital venous malformations poses a major clinical challenge. Sur-
gery is difficult and frequently unsuccessful, radiologic intervention with embolization
has an ill-defined role, and conventional sclerotherapy has little to offer. The authors
evaluate the efficacy and safety of sclerosant in microfoam form for treating congenital
venous malformations.
Duffy DM, Garcia C, Clark RE. The role of sclerotherapy in abnormal varicose hand veins.
Plast Reconstr Surg 104:1474-1479, 1999.
Large, tortuous veins involving the dorsa of the hands often become more prominent
with the passage of time and are a common source of patient dissatisfaction. This arti-
cle evaluates the results of sclerotherapy for the management of unsightly varicose veins
of the dorsum of the hand. Adverse events are also discussed.
Tessari L, Cavezzi A, Frullini A. Preliminary experience with a new sclerosing foam in the
treatment of varicose veins. Dermatol Surg 27:58-60, 2001.
Recently a new method of using a foam sclerosing agent for the treatment of leg veins
has been described. The authors present a pilot study of Tessari’s technique for pro-
ducing the sclerosing and its use in sclerotherapy of major and minor varicosities. The au-
thors evaluate the safety and efficacy of different doses and concentrations of the drug,
as well as different methods of preparing the foam. The results of this technique are also
evaluated.
Suggested Readings
Albanese AR, Albanese AM, Albanese EF. Lateral subdermic varicose vein system of the legs.
Its surgical treatment by chiseling tube method. Vasc Surg 3:81-89, 1969.
Bergan JJ, Weiss RA, Goldman MP. Extensive tissue necrosis following high-concentration
sclerotherapy for varicose veins. Dermatol Surg 26:535-541, 2000.
Boyd AM. Treatment of varicose veins. Proc R Soc Med 41:633-639, 1948.
Callam MJ. Epidemiology of varicose veins. Br J Surg 81:167-173, 1994.
Engel A, Johnson ML, Haynes SG. Health effects of sunlight exposure in the United States.
Results from the first National Health and Nutrition Examination Survey, 1971-1974.
Arch Dermatol 124:72-79, 1988.

Glassberg E, Lask GP, Tan EM, et al. The flashlamp-pumped tunable 577-nm pulsed tunable
dye laser: clonal efficacy and in vitro studies. J Dermatol Surg Oncol 14:1200-1208,
1988.
Goldman MP, Bergan JJ, Weiss RA. Varicose Veins and Telangiectasias: Diagnosis and Treat-
ment, 2nd ed. St Louis: Quality Medical Publishing, 1999.
Goldman MP, Fronek A. Anatomy and physiology of varicose veins. J Dermatol Surg Oncol
15:138-145, 1989.
Ibegbuna V, Delis K, Nicolaides AN. Effect of lightweight compression stockings on venous
haemodynamics. Int Angiol 16:185-188, 1997.
Merlen JF. Red telangiectasias, blue telangiectasias. Soc France Phlebol 22:167-174, 1970.
Raju S, Fredericks R. Venous obstruction: an analysis of one hundred thirty-seven cases with
hemodynamic, venographic, and clinical correlations. J Vasc Surg 14:305-313, 1991.
Redisch W, Pelzer RH. Localized vascular dilations of the human skin: capillary microscopy
and related studies. Am Heart J 37:106-111, 1949.
Thibault P, Bray A, Wlodarczyk J, et al. Cosmetic leg veins: evaluation using duplex venous
imaging. J Dermatol Surg Oncol 16:612-618, 1990.
Weiss RA, Dover JS. Leg vein management: sclerotherapy, ambulatory phlebectomy, and laser
surgery. Semin Cutan Med Surg 21:76-103, 2002.
Weiss RA, Feied CF, Weiss MA. Vein Diagnosis and Treatment: A Comprehensive Approach.
New York: McGraw-Hill, 2001.
Weiss RA, Sadick NS, Goldman MP, et al. Post-sclerotherapy compression: controlled com-
parative study of duration of compression and its effects on clinical outcome. Dermatol
Surg 25:105-108, 1999.
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HAIR
TRANSPLANTATION
PART IV

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Applied Anatomy in Hair
Transplantation

ALFONSO BARRERA
CHAPTER 18

H
istorically, hair has been a source of pride to humans and serves as a distin-
guishing feature that adorns as well as protects. It is also one of our most vari-
able characteristics. Wide differences in color, density, texture, length, and style char-
acterize different races and ethnic groups. Hairstyling and adornment have evolved
throughout the ages. Today men as well as women place a premium on hair fashion
and products to enhance their appearance. Considering its significance, it is easy to
understand why hair loss often causes severe emotional distress and why people seek
hair restoration.
For a surgeon performing hair transplantation, it is important to have a basic un-
derstanding of anatomy and aesthetics to obtain optimal results. The character and
texture of hair vary, depending on its stage of development and location. Lanugo
hair is the soft, fine, and usually clear, nonpigmented hair that covers the fetus and
generally sheds around the eighth gestational month. Vellus hair is the fine, clear, al-
most invisible hair seen on the forehead. Terminal hair, which is coarse, long, and
of variable pigment, characterizes the adult years. Subtypes of terminal hair are found
on the scalp, eyebrows, upper lip, chin, axillas, chest, and pubis. Vellus hair may be-
come terminal hair; for example, facial vellus hair in adolescents may develop into
a beard, and terminal hair on the scalp may turn into vellus hair in male pattern
baldness and androgenic alopecia in females.
In an embryo, the hair follicles originate from both ectoderm and mesoderm in the
third gestational month and continue to develop over the next 3 months. Hair folli-
cles develop from microscopic indentations of ectoderm, the outermost of the three
embryonic tissue layers. These indentations meet and combine with small elevations
of mesoderm, the middle layer of embryonic tissue. The cells that form the hair der-
mal papillae, the fibrous sheath of the follicle, the blood vessels, and the erector pili
muscles originate from the mesoderm.
The cells that form the hair matrix and the melanocytes are of ectodermal origin.
The melanocytes produce the color granules in the central, hollow core of the hair
shaft that give hair its natural color. The cells from the matrix divide and are pushed
upward; they are continuously replaced by new cells forming beneath them. Later,
two buds are formed from special cells to create the sebaceous glands and the erec-
tor pili muscles.
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As the matrix cells continue to be pushed up and outward and become dehydrated by
an extrusion process, they form a tubular hair shaft of dead protein called keratin.
This hollow tube is then filled with color granules (melanin) that give hair its natu-
ral color. As we age, the melanocytes cease functioning, resulting in gray or white hair.
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Sebaceous gland
Erector pili
muscle
Epidermis
Hair shaft
Hair bulb
Papilla
(containing
capillary loops)
Sweat glands
Medulla
Cortex
Dermis
Cuticle
Outer root sheath
Glassy membrane
Fibrous sheath
Inner root
sheath
Henle’s
layer
Huxley’s
layer

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Part IV  Hair Transplantation
The anatomy details of the hair follicles are clearly seen in these photos. The epi-
dermis, dermis, and almost immediately deep to that a slight brown bulging struc-
ture can be seen. This corresponds to the sebaceous glands. The hair shaft continues
deep to the hair bulb, surrounded by subcutaneous fatty tissue.
Histology
To accomplish natural, aesthetic results in hair transplantation, one must pay at-
tention to many small details, starting with the important histologic features of hair
follicles.
Epidermis, dermis, dermal appendages, and subcutaneous fatty tissue can be seen
on vertical histologic sections of skin taken for skin biopsies or when checking tis-
sue margins after excision of skin lesions.

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Chapter 18  Applied Anatomy in Hair Transplantation
Multiple follicular units of various sizes
Close-up view
Two-hair follicular unit
One-hair follicular unit
Sebaceous gland
Maximum number
of hairs in graft
IDEAL HAIR GRAFTS
Subcutaneous fat
Follicular unit micrograft
(one or two hairs)
Follicular unit minigraft
(three or four hairs)
Transverse sections demonstrate that hair follicles grow in follicular units. In his land-
mark 1984 article, Headington described the follicular unit as including one to four
terminal hairs, one vellus hair (rarely two), nine sebaceous glands, insertions of erector
pili muscles, a perifollicular vascular plexus, a perifollicular neural network, and peri -
folliculum (a circumferential band of fine adventitial collagen that defines the unit).
This suggests that a unit constitutes at least to some degree a physiologic entity.
Follicular Units
When planning hair transplantation, it is important to maintain the follicular units
as intact as possible. As long as the surgeon uses grafts with no more than four hairs
per graft, the appearance of clumpiness (the “plug” look) can be avoided altogether.

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Two two-hair follicular units may be used together as one graft, or one one-hair fol-
licular unit may be used with a two-hair follicular unit as one graft. In selected ar-
eas it may be desirable to use primarily one- or two-hair follicular units (micrografts),
as in the front hairline. In other areas a mixture of one- or two-hair follicular units
and three- or four-hair follicular units (minigrafts) are desirable. In yet other areas,
such as behind the front hairline, three- or four-hair follicular units are ideal, be-
cause they provide more density.
Design of the Hairline
The design of the hairline or the area to be transplanted is crucial, the idea being to
mimic nature as much as possible. The position of the front hairline is critical for a
natural result; conservatism is in order. The goal is to achieve a mature hairline. The
size and shape of the head vary from person to person, as does the position of a ma-
ture hairline. Generally, the midline of the new hairline is approximately 8 cm from
a horizontal line immediately above the eyebrows. In some patients a slightly longer
or shorter distance is appropriate, depending on the specific facial features, shape,
and size of the head as well as the interrelationship and proportions of the face and
skull.
Irregular
design
8 cm
Maintain
mature
hairline

Growth Cycle
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There are three life cycle phases of hair growth. The living cells at the base of the
hair follicle first show active, mitotic growth, eventually forming a compact column
that extends toward the surface of the skin. A zone of keratinization then forms di-
rectly above the actively dividing cells. The living cells become dehydrated, eventu-
ally die, and are converted into a mass of keratin. The keratin filaments are finally
cemented together by a matrix rich in cystine. The average rate of growth of scalp
hair is approximately 0.35 mm/day or 1 cm/month. The dermal papilla, which is sit-
uated just under the actively dividing cells of the follicle, plays an important role in
the regulatory control of the hair’s growth cycle.
The first phase, anagen, is the active growing phase in which the follicular cells are
actively multiplying and keratinizing. In a nonbalding scalp, approximately 90% of
the hairs are in this phase, which lasts about 3 years. During the second phase, cata-
gen, the base of the hair becomes keratinized, forming a club, and separates itself
from the dermal papilla. It then moves toward the surface and is eventually connected
to the dermal papilla only by a connective tissue strand. This phase lasts 2 to 3 weeks.
Secondary
germ
lengthens
Epidermal
strand
TELOGEN
(10% of hairs)
EARLY ANAGEN
3-4 months
CATAGEN
2-3 weeks
ANAGEN
3 years
(90% of hairs)
Papilla
New hair
Secondary
germ
Club

The third phase, telogen, is also known as the “resting phase.” During this phase the
attachment at the base of the follicle becomes weaker until the hair finally sheds.
During this period the follicle is inactive and hair growth ceases. This phase lasts 3 to
4 month—and commonly occurs after hair transplantation. For this reason, signifi-
cant growth of the hair grafts is not seen until this phase is over. In addition, some
of the native hair often goes into the catagen phase and then into the telogen phase
from the insult of the surgery; this is called telogen effluvium.
Approximately 10% of hair follicles in a nonbalding scalp are in the telogen phase.
When the rate of hair loss exceeds the rate of growth, thinning and eventually bald-
ness develop.
Applied Anatomy
Male pattern baldness is a gradual conversion of hairs from the terminal (healthy,
thick) to the vellus (clear, microscopic) state. In the most common type, male pat-
tern baldness primarily affects the top of the head while the hair on the temporal
and occipital areas is preserved. Hair loss in women, female androgenic alopecia,
occurs less frequently and is more diffuse. In women, the front hairline is usually pre-
served. Both of these are naturally occurring and have primarily a genetic origin.
This is a hereditary condition that appears to be controlled by a single, dominant,
sex-linked autosomal gene. The expression of this gene is dependent on the level of
circulating androgens. The initial signs of thinning clearly correlate with puberty in
males, when the levels of androgens (testosterone) start to rise, gradually converting
terminal hair into vellus hair. Initially this results in a receding hairline and, de-
pending on the genetic features inherited, may progress until only a temporal and
occipital fringe remains.
Testosterone secreted by the testes is the principal androgen circulating in plasma in
men, whereas in women the adrenal steroids dehydroepiandrosterone sulfate, an-
drostenediol sulfate, and 4-androstenedione are the most abundant proandrogens.
A proandrogen is a 19-carbon steroid that is converted at the target tissue into ac-
tive androgen. The enzymatic reduction of testosterone and the previously mentioned
androgens in females by 5-alpha reductase into dihydrotestosterone is necessary for
the induction of androgenic hair loss in both men and women.
Although genetic predisposition is the cause of most forms of hair loss, other sources
of hair loss include (in order of frequency in my practice):
 Hair loss associated with aesthetic facial rejuvenation surgery, coronal and en-
doscopic forehead lifts, such as loss of sideburns, temporal hairline, and dis-
tortion of the retroauricular hairline
 Scalp and facial hair loss associated with burns or other traumatic injuries
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Chapter 18  Applied Anatomy in Hair Transplantation
 Congenital abnormalities of the face or scalp, such as vascular malformations
and melanotic nevi that require surgical excision
 Postoncologic resections resulting from the excision of skin or scalp tumors
Surgeons must be equipped to restore sideburns, the temporal hairline, the retroau-
ricular hairline, eyebrows, eyelashes, mustache, beard, and areas of the scalp. Many
remedies have been described over the centuries to enhance and/or regrow hair—
none of which has been truly effective. However, as we have learned more about the
anatomy and physiology of the hair, it has become clear that optimal graft survival
and ultimate hair growth depend on transplanting more than just the bare hair shafts.
Slightly chubby grafts and intact follicular unit grafts thrive much better, as demon-
strated by Seager in 1997. Dissecting a micrograft to the bare hair shaft deprives it
of vital structures that ensure its survival. Whether it is the perifollicular vascular
plexus, the sebaceous glands, or other appendages that are necessary for survival is
unknown. Seager reported 113% hair survival and growth with follicular unit grafts.
Presumably, hairs that were in the telogen phase were not initially counted but ulti-
mately grew hair. These hairs in the telogen phase are also included when slightly
chubby micrografts and minigrafts are transplanted.
Concluding Thoughts
It is extremely important that all surgical assistants have a clear understanding of
the anatomy of the hair follicles. The ultimate result of hair transplantation will de-
pend to a great extent on the accuracy of their dissection of the donor strip into
grafts. Minimizing transactions of hair follicles and hair shafts is very important,
and they must be handled atraumatically.
Clinical Caveats
 When harvesting the donor ellipse, the surgeon must keep the incision superficial
to the fascia to preserve the occipital nerves and vessels. Dissection should sepa-
rate the plane between the subcutaneous tissue and fascia.
 The elasticity of the scalp in the donor area is usually greatest in the midline and
becomes less elastic laterally toward the ears and temple.
 The density of hair is usually greatest at the midline and diminishes as one pro-
ceeds laterally.
Continued

Clinical Caveats—cont’d
 Minigrafts and micrografts should be inserted in the recipient site following the
same angulation and orientation of the residual hair to mimic the natural direc-
tion of hair growth.
 The epidermis of the graft should remain superficial to the epidermis of the scalp
to avoid ingrown hairs and epidermal inclusion cysts.
 Minimal incisions at the recipient site will avoid detectable scarring.
 Grafts larger than one follicular unit will produce an unnatural appearance be-
cause of compression.
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Part IV  Hair Transplantation
Annotated Bibliography
Barrera A. Hair restoration. Clin Plastic Surg 32:163-170, 2005.
This article summarizes the aesthetic and reconstructive applications of hair transplan-
tation.
Shapiro R, Rose P, Morgan M. Hair anatomy and histology. In Unger W, Shapiro R, eds.
Hair Transplantation, 4th ed. New York: Marcel Dekker, 2004.
Another point of view on the histology and anatomy of the scalp.
Thomas JF. Transverse sectioning of the scalp (Headington technique) in the 19th century.
J Cutan Pathol 35:82-85, 2008.
The article provides information of historical interest concerning two slides of human
scalp that were prepared in the latter half of the nineteenth century and recently became
available. Dr. Thomas details the methods of preparation and their similarity to today’s
methods.
Suggested Readings
Headington JT. Transverse microscopic anatomy of the human scalp. Arch Dermatol 120:449,
1984.
Orentreich D, Orentreich N. Androgenic alopecia and its treatment. In Unger WP, ed. Hair
Transplantation, 3rd ed. New York: Marcel Dekker, 1995.
Rose PT. The development, anatomy, and physiology of the hair follicle. Hair Transplant Fo-
rum Int 9:197, 1999.
Seager DJ. Micrograft size and subsequent survival. Dermatol Surg 23:757-761; discussion
762, 1997.
Vallis CP. Hair replacement surgery. In McCarthy JG, ed. Plastic Surgery. Philadelphia: WB
Saunders, 1989.

Clinical Decision-Making
in Hair Transplantation

ALFONSO BARRERA
CHAPTER 19

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T
o date, we have no method for creating new hair where none exists. All cur-
rent techniques for hair restoration involve redistributing the patient’s existing
hair. Therefore candidates for hair transplantation are limited to those who have a fa-
vorable donor site surface area and hair density relative to the size of the area to be
transplanted. Several centers worldwide are working on tissue engineering in an at-
tempt to clone hair follicles or culture and multiply hair follicles in the laboratory
setting. When this is successful, we will be able to treat patients with limited donor
hair and will need only harvest a sample of hair follicles.
Unfortunately, male pattern baldness is a progressive condition. However, the rate
of hair loss may slow down after an individual is about 40 years of age, although it
never stops completely. Thus the preoperative plan must ensure a natural-looking,
long-term result.
Preoperative Assessment
Careful patient selection and good communication are essential. Patients must have
realistic expectations about the result that can be achieved. They must understand
that the procedure involves redistributing their existing hair and that currently there
is no method for creating new hair. Therefore there are limits to the hair density that
can be expected. To obtain the best result possible often takes two sessions and in
some cases three; however, a reasonable improvement can often be obtained in just
one megasession.
I have found that patients under 30 years of age are often the most demanding. They
must understand that because they are young, it is impossible to determine in ad-
vance the endpoint of their hair loss. A conservative approach is recommended in
these cases.
When patients receive proper instruction and have realistic expectations, I have found
that 97% are satisfied after a single hair transplantation session. The 3% of patients
who have been dissatisfied with their hair density after surgery have subsequently
undergone second sessions to improve the density and were ultimately pleased with
the results.
Hair-Loss Patterns
The most frequent types of hair loss include male pattern baldness, postsurgical
alopecia, posttraumatic alopecia, and congenital hair loss.

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Chapter 19  Clinical Decision-Making in Hair Transplantation
Male pattern baldness is by far the most frequent type of hair loss, followed by an-
drogenic (pattern) alopecia in females.
Postsurgical alopecia (left) may occur after oncologic resection of the scalp or eye-
brows. After facial rejuvenation or craniofacial procedures, loss of sideburns and of
frontal, temporal, and/or retroauricular hair is not uncommon. Posttraumatic alope-
cia (right) includes hair loss from injuries such as burns, traumatic injuries of the
scalp and eyebrows, and scalp avulsion.
Examples of congenital hair loss include the absence of mustache hair in cases of bi-
lateral cleft lip (not obvious until after puberty), triangular temporal alopecia, and
nevus sebaceous of Jadassohn.

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Part IV  Hair Transplantation
Classification
The most commonly used classification system for male pattern baldness is the one
described by Norwood:
Type I
There is minimal or no anterior hairline recession at the fronto -
temporal areas.
Type II
Triangular, symmetrical frontotemporal recessions extend poste-
riorly no more than 2 cm anterior to a coronal plane drawn be-
tween the external auditory canals.
Type III
The frontotemporal recessions extend posteriorly beyond 2 cm
anterior to a coronal line drawn between the external auditory
canals.
Type IIIvertex
Hair loss is primarily in the vertex area but may be accompanied
by a frontotemporal recession that does not exceed that described
for type III.
Type IV
The frontotemporal recession is more severe than in type III. Hair
is absent or sparse hair in the vertex area, but both areas are sep-
arated by a band of moderately dense hair that goes across the
top of the head.
Type V
Hair loss in both the frontotemporal and vertex areas is more ex-
tensive and is only separated by a narrower and sparser band of
hair across the top.
Type VI
The band of hair that separated the frontotemporal area and ver-
tex is gone. The two areas are interconnected. The entire area has
extended laterally and posteriorly.
Type VII
This is the most severe form of male pattern baldness. There is
only a narrow horseshoe-shaped band of sparse, fine hair.
NORWOOD CLASSIFICATION—MALES

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Chapter 19  Clinical Decision-Making in Hair Transplantation
Norwood also described a less common variant (type a) that applies to about 3%
of cases of male pattern baldness; in this variant the baldness starts at the anterior
hairline without a peninsula of hair and advances in a posterior direction. The type
a anterior variance patterns are classified as follows:
Type IIa
The entire anterior hairline is high on the forehead. The midfrontal
peninsula is represented only by a few sparse hairs. The area of de-
nudation extends no farther than 2 cm from the midfrontal line.
Type IIIa
The area of denudation essentially reaches the midcoronal line.
Type IVa
The area of alopecia extends posterior to the midcoronal line.
Type Va
This is the most advanced degree of alopecia and extends farther
posteriorly. If it progresses, it may be indistinguishable from types V
and VI.
The most common classification system used for female androgenic alopecia is the
Ludwig classification, grades I through III. Thinning is usually more generalized, in
most cases sparing the front hairline, with significant thinning of the vertex, temple,
and parietal areas. The occiput tends to be the only area of reasonably good hair
quality and density. Women who develop androgenic alopecia do not necessarily
have an abnormal increase in circulating androgens or hormonal imbalances; many,
in fact, have normal adult female androgen levels. It may be that the androgen re-
ceptors in the hair follicles are hypersensitive to or have a greater binding affinity to
dihydrotestosterone, which may or may not be genetic in origin.
NORWOOD CLASSIFICATION—MALES
LUDWIG CLASSIFICATION—FEMALES

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Part IV  Hair Transplantation
Indications and Contraindications
Based on the principles we have learned for the treatment of male pattern baldness,
and with slight modifications, we are able to help most cases of hair loss by trans-
ferring primarily micrografts (one- and two-hair follicular unit grafts) and minigrafts
(three- and four-hair follicular unit grafts). In select cases, flaps or tissue expansion
may be used. The following patient examples represent the range of clinical chal-
lenges encountered in a hair restoration practice.
Patient Profiles
This 32-year-old man with male pattern baldness type IV had good donor hair; his
hair is coarse, which can help to obtain nice coverage in one session. He underwent
1500 follicular unit grafts in a single session, primarily to the frontal scalp and a
few to the crown.
Further grafting to the crown should be deferred until the patient is older, when his
hair loss pattern can be more accurately assessed and the amount of donor hair avail-
able determined. The patient must understand that because of his young age, fur-
ther sessions will be needed in the future as hair loss progresses.

This 53-year-old man with male pattern baldness type VI is an ideal candidate, be-
cause his pattern of hair loss is well established and will probably not change dra-
matically. In such cases a maximal density procedure (2000 to 2500 follicular unit
micrografts and minigrafts) can be planned. His donor hair has good density and
thickness, and the entire area of baldness will be grafted. A hairline pattern consis-
tent with the patient’s mature age is the preferred approach to produce the most nat-
ural result. Thus a slight frontotemporal recession will remain.
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This 56-year-old man with male pattern baldness type VI had a more mature pat-
tern of baldness than the previous patient. Although his hair loss will continue to
progress, his hair-loss pattern as he ages can be better determined, making a more
aggressive approach acceptable. He had a reasonably good, dense donor area and a
well-established pattern of baldness. He underwent 2040 follicular unit grafts in one
session (megasession).
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Chapter 19  Clinical Decision-Making in Hair Transplantation

This 43-year-old man has male pattern baldness type IIIvertex without frontotempo-
ral recession. The density and thickness of his donor hair are excellent. The front
part of his scalp is covered with healthy, full hair. His pattern of baldness is well es-
tablished and limited to the crown. I recommended two sessions of micrografts and
minigrafts a year apart to achieve an optimal result. The crown typically will take
at least two sessions to obtain reasonable coverage. Although the whirl can be re-
constructed by orienting the grafts in a circular orientation, it probably does not
warrant the additional time and effort.
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Part IV  Hair Transplantation

This 42-year-old man presented with male pattern baldness type VII, the most se-
vere form of male pattern baldness. There was insufficient donor hair to transplant
the entire area. Flaps, tissue expansion, and scalp reduction were treatment options
because of the sparse donor hair and extensive area of baldness. I advised a session
of 1300 follicular unit micrografts and minigrafts only to the median forelock area,
the rhomboid-shaped area on the front part of the scalp. Even though his crown will
remain bare, strategic transplantation to this area will help frame his face. He is
shown 1 year postoperatively. The hair on the top of his head blends naturally with
the temporal fringes.
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This 37-year-old man has male pattern baldness type IV. His coarse, wavy donor
hair will provide good coverage. Because his hair loss is not very severe, approxi-
mately 700 to 800 follicular unit micrografts and minigrafts should be sufficient to
strengthen both the front scalp and crown. He must be forewarned that there will be
further temporary thinning. The hair must be continuously parted as the grafts are in -
serted; however, it is not necessary to shave the residual hair in the recipient areas.
This 43-year-old woman had Ludwig grade II to III female androgenic alopecia. Pa-
tients such as this tend to exhibit uniform thinning over the entire scalp with preser-
vation of the front hairline. Candidates for the procedure must have an area with
good hair quality and density, which tends to be in the occipital region. I recom-
mended that this patient undergo a megasession of 1000 follicular unit micrografts
and minigrafts. The patient was forewarned that she could expect further tempo-
rary hair thinning for the first 3 to 4 months in the area grafted (telogen effluvium).
I recommend that female patients use 2% minoxidil twice a day postoperatively to
help preserve and thicken the existing hair as well as the grafted hair.

This 50-year-old woman was concerned about her hair thinning on the front of her
scalp. Because she had good density on her remaining scalp, I recommended a ses-
sion of 400 micrografts and minigrafts. This treatment added hair precisely where
needed and was easily performed with the patient under local anesthesia with mild
intravenous sedation. I would not advise scalp flaps, strip grafts, or tissue expansion
in such a case. These treatments would have been excessive, causing a scar at the
front hairline, and she would have had to endure an unpleasant expansion phase.
Her postoperative results are very natural, without any detectable scarring.
Preoperative Planning
Aesthetic Considerations
An average scalp is approximately 500 cm2 (50,000 mm2). The normal nonbalding
scalp has one follicular unit/mm2, and each unit contains an average of two hairs
(that is, a density of 2 hairs/mm2), so there are approximately 100,000 hairs on the
head. Of course, this varies from patient to patient.
500 cm2
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The appearance of fullness has to do with hair mass, which is related to the num-
ber of hairs, the thickness of the individual hair shafts, texture and color, and curli-
ness. Furthermore, the contrast of colors between the scalp and the hair has a sig-
nificant influence on the optical illusion of fullness. Most experts today agree that
the average healthy, nonbalding patient has a density of about 200 hairs/cm2 (range
130 to 280 hairs/cm2) and that only 100 hairs/cm2 (range 65 to 140 hairs/cm2) are
needed to give an appearance of normal density.
Realistically, this number of micrografts and minigrafts can be transplanted in two
sessions. To obtain a surgical result that mimics nature, a large number of randomly
transplanted small grafts (follicular unit–sized grafts) is essential, providing a result
unmatched by any other method of hair restoration. Patients should be advised that
two sessions and occasionally three sessions may be necessary to obtain the desired
density. Often, however, significant improvement is seen after just one session, and
results will persist for years without a repeat procedure.
If the ratio of donor site to recipient area is favorable, I transplant the entire area of
baldness. If the ratio of donor site to recipient area is not favorable, I may only trans-
plant the front hairline or a median forelock. If it is clear that there is insufficient
donor hair, it is better not to proceed with transplantation. It is a judgment call.
When feasible, I prefer to transplant the entire bald area, with a focus on providing
the greatest density possible at the front hairline. Patients can style their hair so that
it layers farther back to give the visual appearance of density in the back.
1
19-1 Hair
transplantation with
micrografts and
minigrafts

Design of the Hairline
The design of the hairline or the area to be transplanted is crucial, the idea being to
mimic nature as much as possible. The position of the front hairline is critical for a
natural result; conservatism is in order. The goal is to achieve a mature hairline. The
size and shape of the head vary among individuals, as does the position of a mature
hairline. Generally, the midline of the new hairline is approximately 8 cm from a
horizontal line immediately above the eyebrows. In some patients a slightly longer
or shorter distance is appropriate, depending on the facial features, shape, and size
of the head as well as the interrelationship and proportions of the face and skull.
Donor Site Harvesting
The many variables encountered during donor site harvesting test the surgeon’s clin-
ical judgment. The size of the donor ellipse varies, depending on the number of grafts
planned or the size of the area to be grafted, as well as the density of the donor site
and the pliability and elasticity of the donor scalp. Only the amount of scalp needed
should be harvested, yet the surgeon must ensure that enough donor scalp is ob-
tained for the number of grafts planned and that the donor defect can be closed un-
der minimal tension.
The laxity of the scalp varies from person to person. The surgeon must be alert to
the presence of scar tissue from previous procedures since this will result in reduced
elasticity and pliability of the donor scalp. Most patients’ scalps permit ellipses 1 to
1.5 cm wide to be harvested with minimal tension on closure. The surgeon must feel
the donor scalp to assess the laxity, elasticity, and pliability.
Irregular
design
8 cm
Maintain
mature
hairline
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A long, narrow, horizontal donor ellipse is preferable to a short, wide ellipse. Hair
density as well as the elasticity of the donor occipital site is usually greater toward the
midline. The hair becomes sparser and the scalp less elastic more laterally. The scalp
above the ears is usually quite inelastic. These factors must be taken into considera-
tion so that the ellipse can be designed to allow closure with minimal tension.
Normally the hair density in the donor area is approximately 200 hairs/cm2 (range
130 to 280 hairs/cm2). The diameter of the individual hair shafts varies from 0.06
to 0.14 mm.
10 cm
1 cm
Hair density is
greater medially
Hair density
is sparser
laterally
Area of greater
elasticity
Area of less
elasticity
0.5 cm
1 cm
0.5 cm
1 cm
1.5 cm
MIDLINE
Assuming a density of 150 hairs/cm2, an ellipse 10 by 1 cm
will yield approximately 1500 hairs. Naturally occurring
follicular units have 1 to 4 hairs per unit. These units must
be kept intact as much as possible. The exact number of
grafts can only be determined after dissecting the donor
ellipse into grafts, but an ellipse of this size will yield ap-
proximately 500 to 600 grafts.

20 cm
1 cm
0.5 cm
1 cm
0.5 cm
1 cm
1-1.5 cm
30-32 cm
Donor Site Dimension Guidelines
Micrograft and
Minigraft Follicular Units
(number of hairs)
150 (low)
200 (average)
201-250 (high)
500-600 (1500 hairs)
10  1 cm ellipse
6-7  1 cm ellipse
5  1 cm ellipse
1000-1200 (3000 hairs)
20  1 cm ellipse
15  1 cm ellipse
10  1 cm ellipse
1500-1800 (4500 hairs)
25  1 cm ellipse
20  1 cm ellipse
15  1 cm ellipse
2000-2500 (6000 hairs)
30  1.5 cm ellipse
30  1 cm ellipse
25  1 cm ellipse
Hair Density (hairs/cm2)
NOTE: All ellipses 1.0-1.5 cm in width, tapering only at the 1.0-0.5 cm ends.
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Chapter 19  Clinical Decision-Making in Hair Transplantation
If hair density is approximately 150 hairs/cm2, a
horizontal, occipital donor ellipse of 20 by 1 cm
with 3375 hairs will be needed to produce 1000 to
1200 micrografts and minigrafts (1 to 4 hairs per
unit).
A maximal density procedure (2000 to 2500 grafts)
in patients with types VI or VII male pattern bald-
ness makes harvesting enough donor tissue a greater
challenge. In these cases I harvest a horizontal ellipse
approximately 30 to 32 cm long and 1 to 1.5 cm
wide at the midline (scalp elasticity permitting),
gradually tapering the width laterally to 1 to 0.5 cm
at the ends. In most patients this yields approxi-
mately 2000 to 2500 follicular unit micrografts and
minigrafts and between 5000 and 6000 hairs.

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Camouflaging Scalp Scars
Patients are often seen with scars on the scalp or the front hairline as a result of ac-
cidents, surgical interventions, and poor healing after an aesthetic surgical proce-
dure. Micrografts and minigrafts alone can frequently benefit such patients.
Even when incisions are made parallel to the hair shafts on the scalp or on the hair-
bearing skin (eyebrows, beard, or mustache) and closed without significant tension,
a fine hairline scar is often inevitable. These scars are sometimes detectable because
of the absence of hair at the scar line. Micrografting and minigrafting offer an ex-
cellent solution for these deformities. The technique is basically the same as that de-
scribed earlier except that the direction of the graft insertion may be more critical
for controlling the direction of hair growth.
When working on the temporal hairline, eyebrows, or mustache, for example, the
direction of the natural hair growth at the respective sites must be followed. Micro-
grafts and/or minigrafts can be added at the newly closed wound suture line in hair-
bearing incisions. These small grafts thrive well even if the blood supply is precari-
ous and will help minimize hair loss at the incision site. The use of atraumatically
dissected micrografts and minigrafts and closure under minimal or no tension are
key to the success of this approach.
When feasible, it is best to make the micrografts and minigrafts from hair-bearing
areas surrounding the wound (local hair), especially for the eyebrows (the contralat-
eral eyebrow or residual hair from the same eyebrow), because they normally ex-
hibit a very different growth pattern than that seen in scalp hair.
This 15-year-old girl had an otoplastic procedure performed. A tight dressing placed
around the head and knotted at the front hairline level resulted in a pressure sore
and loss of hair in an area about the size of a half dollar.