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

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Part IV  Hair Transplantation
This 52-year-old woman came for a consultation 3 years after a face lift. In a single
session, 850 follicular unit micrografts and minigrafts per side were transplanted to
restore the lost sideburns, temporal hairline, and some at the front hairline. Postop-
eratively, blending of the grafts with the natural direction of hair growth is evident.
Restoration of the Eyebrows, Mustache, and Beard
Fujita first described the use of single hair grafts to reconstruct the eyebrows in 1953.
This was the first mention of the use of micrografts since Tamura reported trans-
planting single hair grafts from the pubic area in 1943. It would be another four
decades before there was further experimentation with small grafts. More recently,
Gandelman published his superb results using micrografts and minigrafts to restore
the eyebrows.
Fortunately, micrografts and minigrafts grow anywhere on the face and thus are use-
ful for restoring the eyebrows, mustache, and beard. However, because the consis-
tency of facial skin is softer and more elastic than that of the scalp, the surgeon will
encounter more problems with grafts popping out when transplanting facial areas.
This 54-year-old man desired thicker eyebrows and more density in his frontotem-
poral region.

He underwent scar revision for a previous direct approach brow lift (done elsewhere)
plus a slight brow lift. I advised a session of 250 grafts to the frontotemporal reces-
sion areas and about 150 grafts to each eyebrow. Because of his thin eyebrows, donor
hair was taken from the lateral occipital area. He is shown 1 year postoperatively.
The density and natural direction of the hair and absence of scars are evident.
This case presented the challenge of choosing the optimal donor site for eyebrow
hair. If a patient has unilateral eyebrows with high contralateral density, donor hair
can be taken from the existing eyebrow. However, when the patient has thin eye-
brows bilaterally, other options such as axillary, pubic, and scalp hair must be ex-
plored. The caliber of individual axillary or pubic hair is generally too thick, and
both have textures different from eyebrow hair. Although it seems ideal to obtain
donor hair from the nape of the neck, the caudalmost part of the occipital area,
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Chapter 19  Clinical Decision-Making in Hair Transplantation

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Part IV  Hair Transplantation
I prefer not to harvest from this region because of the increased risk of hypertrophic
scarring. In addition, as we age, hair recedes from a caudal to a cephalic direction.
Therefore I look primarily at the lateral occipital area, not the retroauricular, as the
ideal potential donor site.
Treatment of Burn Alopecia
Various methods have been used for the treatment of burn alopecia, including punch
grafts, local scalp flaps, free scalp flaps, and tissue expansion. The fibrotic scar tissue
that normally forms after burn injuries has a precarious blood supply and is not an opti -
mal site for any type of graft. Single- and double-hair grafts (micrografts) and grafts
with three to four hairs (small minigrafts) have fewer metabolic requirements because
of their small size, which probably permits them to survive in this hostile environment.
Having seen these small grafts survive in patients with male pattern baldness who had
scarred scalps from previous surgical procedures, I decided to try them in patients with
burn alopecia. The success of this approach has been reported in the literature.
I think that it is important to allow sufficient time for the scalp to heal, soften, and
fully recover from the insult of surgery or trauma before proceeding with hair trans-
plantation, especially in the case of burn alopecia.
This 18-year-old woman developed chemical-burn alopecia after applying highlights
to her hair. She had very high density in the surrounding areas and requested quick
results, because she was leaving for college in a few months. Follicular unit micro-
grafts and minigrafts would have provided a nice result but would have taken at
least two sessions and perhaps three to blend reasonably well with the surround-
ing hair density. Furthermore, the sessions would have to be performed at least 6 to

8 months apart and would take 11⁄2 to 2 years to complete. Scalp reduction was not
an option, because her scalp was a bit tight. Even though serial excisions might have
improved the tightness, it would have been repetitive and would have resulted in a
hairless scar line at best. Therefore I recommended tissue expansion with micrografts
inserted between the sutures during closure.
Tissue expansion was performed using a 350 cc crescent-shaped expander inflated
to 210 cc. The expander was removed after 3 months.
With the patient under conscious sedation and local anesthesia, the areas of alope-
cia were excised by tailoring the expanded scalp. The wound was closed with a sim-
ple running 3-0 Prolene suture. Approximately 50 grafts were placed between su-
tures to further camouflage the closure. She is shown 3 months postoperatively with
excellent hair density.
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Chapter 19  Clinical Decision-Making in Hair Transplantation

This 43-year-old man sustained severe third-degree burns to his upper body, chest,
neck, face, and scalp. He underwent multiple surgical procedures, including rib-graft
ear reconstruction. He was referred to me for restoration of frontotemporal, left
frontotemporal-parietal, sideburn, and eyebrow hair. He requested postponing eye-
lash reconstruction. I recommended a single session of 1525 follicular unit micro-
grafts and minigrafts to both temples and the frontal hairline and 125 grafts to each
eyebrow. He is shown 8 months postoperatively. He returned for a second session
to further increase his hair density.
Eyelash Reconstruction and Augmentation
The eyelash of the upper eyelid is an important structure both functionally and aes-
thetically. The upper eyelashes resemble a cantilever, preventing the entrance of small
foreign bodies that may cause microtrauma to the conjunctiva and cornea. Eyelashes
contribute to the aesthetic appearance of the eyes and face. Lack of eyelashes can
result in a strange, owl-eyed appearance that is both embarrassing and damaging to
the self-esteem. Eyelash reconstruction is suggested for the following conditions:
1. Congenital absence of eyelashes
2. Eyelash loss from traumatic injury, burns, or dermatologic disease
3. Eyelash loss caused by oncologic surgery or radiotherapy
4. Iatrogenic loss resulting from the use of silver nitrate to prevent trachoma
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Part IV  Hair Transplantation

Some anatomic features are especially noteworthy for successful eyelash reconstruc-
tion. The central portion of the orbicularis oculi muscle covering the eyelid is re-
ferred to as the palpebral portion. This is further divided into the preseptal and pre-
tarsal muscles based on their relationship to the underlying orbital septum and the
tarsal plate, respectively.
This illustration of a sagittal section through the upper eyelid shows the superficial
and middle structures of the upper eyelid, including the levator aponeurosis, presep-
tal and pretarsal portions of the orbicularis oculi muscle, and the eyelid skin. The
drawing also demonstrates the relationship of the pretarsal portion of the orbicu-
laris oculi muscle, eyelash hair follicle, and eyelid skin.
Superior tarsal plate
Palpebral portion of
orbicularis oculi muscle
Bony orbit
Orbital septum
Skin
Lateral palpebral
ligament
Levator
aponeurosis
Gray line
Orbicularis oculi
muscle
Orbital septum
Glands of Zeis
Levator
aponeurosis
Ciliary muscle of Riolin
Meibomian glands
Tarsal plate
Müller’s muscle
Glands of Moll
Skin
Pretarsal
muscles
Preseptal
muscles
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Part IV  Hair Transplantation
The pretarsal muscle is firmly attached to the underlying tarsal plate. However, the
upper part of the upper pretarsal muscle is attached to the levator aponeurosis and
thus is separated from the tarsus at that point. There are approximately 100 to 150
lashes on the upper eyelid. The eyelashes emerge in two to three irregular rows from
the eyelid margin anterior to the gray line (mucocutaneous junction). Sweat glands
(Moll) and sebaceous glands (Zeis) enter the follicular structure of the cilia. The skin
of the eyelids is the thinnest of the entire body. There is a thin fascial layer between
the skin and the orbicularis oculi muscle. There is virtually no subcutaneous fat in
this area, and the skin is tightly applied over the pretarsal muscle and loosely adher-
ent to the preseptal muscle.
This 23-year-old man requested restoration of a small segment of eyelashes in his
left lower eyelid. I recommended one strip graft and a total of five micrografts to
both the upper and lower eyelids. He had dense eyebrows, and since the area of de-
mand is small, I elected to harvest a small donor strip from the contralateral eye-
brow. I selected a spot that had good density with desirable hair direction. The strip
was turned and positioned in the most desirable orientation to mimic the missing
eyelashes as best as possible. He is shown immediately after surgery with the scleral
shield still in place and 1 year postoperatively.
I decided to choose eyebrow hair for the donor strip, because its features are similar
to those of eyelashes. Although it is a challenge to encourage transplanted eyebrow
hair to grow in the same direction as natural eyelashes, a strip graft, rather than fol-
licular unit grafts, provides additional control.

Clinical Caveats
 The follicular units should be maintained as intact as feasible.
 For patients with dark hair, 3.5 loupe magnification and background lighting are
sufficient to dissect most grafts as follicular units.
 For patients with light hair or gray hair, surgical microscopes and background
lighting may be needed for more accurate dissection.
 Always consider which donor area is most desirable. In most cases, it is the oc-
cipital area; for eyelashes and eyebrows I usually use scalp hair, but pubic hair
may be considered for eyebrow reconstruction.
Scalp
Choosing the Best Option
*In selected cases.
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Chapter 19  Clinical Decision-Making in Hair Transplantation
1-2 Hair
3-4 Hair
Follicular Unit
Follicular Unit
Strip
Eyebrow
Tissue
Micrografts
Micrografts
Grafts
Donor
Expansion
Male pattern baldness


Female pattern baldness


Lost sideburn and retro-

auricular area hair
Scalp burn alopecia and


*
scalp-scarring alopecia
Eyebrow restoration*

*
Eyelash restoration

*
*
Moustache and beard


restoration
Pubic hair restoration


Body and lower leg



Suggested Readings
Barrera A. Discussion of Seyhan A, Yoleri L, Baructu A. Immediate hair transplantation into
a newly closed wound to conceal the final scar on the hair-bearing skin. Plast Reconstr
Surg 105:1871, 2000.
Barrera A. Hair transplantation. In Lin SJ, Mustoe TA, eds. Lin and Mustoe’s Aesthetic Head
and Neck: An Operative Atlas. New York: McGraw-Hill Professional, 2009.
Barrera A. Hair Transplantation: The Art of Micrografting and Minigrafting. St Louis: Qual-
ity Medical Publishing, 2002.
Barrera A. Micrograft and minigraft megasession hair transplantation: results after a single
session. Plast Reconstr Surg 100:1524-1530, 1997.
Barrera A. Micrograft and minigraft megasession hair transplantation: review of 100 con-
secutive cases. Aesthet Surg J 17:165-169, 1997.
Barrera A. Reconstructive hair transplantation of the face and scalp. Hair restoration: state
of the art. Semin Plast Surg 19:159-166, 2005.
Barrera A. Refinements in hair transplantation: micro- and minigraft megasession. Perspect
Plast Surg 11:53, 1998.
Barrera A. Surgical correction of alopecia in the male patient. eLearning course. St Louis:
Quality Medical Publishing, 2010.
Barrera A. Surgical correction of alopecia secondary to face lift procedures. eLearning course.
St Louis: Quality Medical Publishing, 2010.
Barrera A. The use of micrografts and minigrafts for the correction of the postrhytidectomy
lost sideburn. Plast Reconstr Surg 102:2237-2240, 1998.
Barrera A. The use of micrografts and minigrafts for the treatment of burn alopecia. Plast
Reconstr Surg 103:581-584, 1999.
Barrera A, Phillips LG, Barrera FF. Hair grafts in lower leg reconstruction. Plast Reconstr
Surg 120:22e-25e, 2007.
Buhrer DP, Huang TT, Yee W, et al. Treatment of burn alopecia with tissue expansion in chil-
dren. Plast Reconstr Surg 81:512-515, 1988.
Cronin TD. Use of hair-bearing punch grafts for partial traumatic losses of the scalp. Plast
Reconstr Surg 42:446-449, 1968.
Fujita K. Reconstruction of eyebrows. Leprosy 22:364, 1953.
Gandelman M. Eyebrow transplantation. Hair Transplant Forum Int 4:17-18, 1994.
Gandelman M. Eyelash reconstruction. Hair Transplant Forum Int 6:18, 1996.
Giraldo F, Gonzalez C, Garnica I, et al. Sideburn reconstruction with an expanded supra-
auricular trapezoid flap. Plast Reconstr Surg 100:257-261, 1997.
Harii K, Ohmori K, Ohmori S. Hair transplantation with free scalp flaps. Plast Reconstr
Surg 53:410, 1974.
Hata Y, Matsuka K. Eyelash reconstruction by means of strip grafting with vibrissae. Br J
Plast Surg 45:163-164, 1992.
Headington JT. Transverse microscopic anatomy of the human scalp. Arch Dermatol 120:449-
456, 1984.
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Part IV  Hair Transplantation

Hernández-Zendejas G, Guerrerosantos J. Eyelash reconstruction and aesthetic augmenta-
tion with strip composite sideburn graft. Plast Reconstr Surg 101:1978-1980, 1998.
Hudson DA, Grobbelaar AO. The use of tissue expansion in children with burns of the head
and neck. Burns 21:209-211, 1995.
Kasai KI, Ogawa Y, Takeuchi E. A case of sideburn reconstruction using a temporoparietal-
occipital island flap. Plast Reconstr Surg 87:146, 1991.
Leighton W, Johnson M, Frieland J. Use of temporary soft tissue expansion in posttraumatic
alopecia. Plast Reconstr Surg 77:737-743, 1986.
Lucas MW. Partial retransplantation: a new approach in hair transplantation. J Dermatol
Surg Oncol 20:511-514, 1994.
Norwood OT. Classification of male pattern baldness. In Norwood OT, Shiell R, eds. Hair
Transplantation Surgery, 2nd ed. Springfield, IL: Charles C Thomas, 1984.
Seyhan A, Yoleri L, Baructu A. Immediate hair transplantation into a newly closed wound to
conceal a final scar on the hair-bearing skin. Plast Reconstr Surg 105:1866-1870, 2000.
Tamura H. Pubic hair transplantation. Jpn J Dermatol 53:76, 1943.
Uebel CO. Micrografts and minigrafts: a new approach to baldness surgery. Ann Plast Surg
27:476-487, 1991.
Vogel JE. Correction of the cornrow hair transplantation and other common problems in
surgical hair restoration. Plast Reconstr Surg 105:1528-1536; discussion 1537-1541,
2000.
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Micrograft and Minigraft
Megasessions in Hair Transplantation:
Current Techniques and Future Directions

CARLOS OSCAR UEBEL
CHAPTER 20

H
air loss, whether partial or complete, is the cause of significant concern to
both men and women, who view it as unaesthetic and a visible sign of aging.
Consequently, as our population ages and techniques for hair transplanta tion im-
prove, the demand for hair restoration has grown significantly. Today surgical re-
placement of the hair has become an increasingly common and popular procedure
in the field of male plastic surgery; it has been embraced by politicians, movie stars,
and businessmen alike as they seek to reverse the progressive hair loss associated with
the aging process. Women are also requesting this procedure to ad dress alopecia and
to correct deformities secondary to face-lift procedures. In the first part of this chap-
ter I describe the basic techniques currently performed; the second part focuses on
new developments and the potential role for platelet-rich plasma growth factors.
Evolution of Technique
The beginnings of modern hair transplantation procedures can be traced back as
early as 1943, when Tamura of Japan successfully transplanted pubic hair; this was
followed by Fujita in 1953, who transplanted hair for eyebrow reconstruction. How-
ever, it was not until 1959 that hair transplantation became popular when Oren-
treich introduced the use of punch grafts. He also introduced the concept of donor
dominance, which is central to hair transplantation. This concept asserted that in-
dividual hair follicles had their own hereditary characteristics that are preserved af-
ter transplantation, enabling the hair to grow at the recipient site with its inherent
characteristics preserved. Although the punch procedure provided a mechanism for
hair transplantation to address male pattern baldness, the results were often unnat-
ural and obvious.
In an effort to improve the aesthetic appearance of transplanted hair, temporopari-
etooccipital (TPO) flaps were introduced by Juri, with subsequent improvements by
Chajchir et al and Uebel. Although scalp pedicle flaps from the parietal and occipi-
tal areas produced acceptable aesthetic results in patients with male pattern bald-
ness, there were two distinct disadvantages. Even though it was well integrated, the
flap was visible as a camouflaging patch, and the residual scar at the border of the
hairline was con spicuous. It was not until the 1980s, with the introduction of the
micrograft con cept by Nordström and Marrit, that these problems were solved and
surgeons were able to create a more natural-appearing hairline. This served as the
basis for further advances and refinements, culminating in the intro duction of mi-
crograft and minigraft megasessions in 1986. I published reports on this technique
in 1989 and 1991, which I called the micropunctiform tech nique; I have been per-
fecting this procedure since its introduction. Today this technique has become widely ac-
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Part IV  Hair Transplantation

cepted by surgeons and patients as a simple and safe procedure that recreates pre-
dictably natural and aesthetic hairlines for most patients with various degrees of hair
loss. The unnatural clumps, rows, strips, or flaps so typical of early procedures have
now been replaced with ran dom-pattern hairlines with feathered, natural borders.
We have truly entered a new age of hair transplantation that offers the surgeon a
valuable tool for address ing male and female pattern baldness, as well as other hair
loss problems associated with disease or aesthetic surgery.
Indications and Contraindications
Although male pattern baldness is often associated with the aging process, it can also
occur in younger patients, beginning as early as 16 years of age. It results from three
main factors: heredity, androgenic hormones, and age. It is progressive in nature, and
its growth cycle becomes more evident after age 30. In women, hair loss seems to oc-
cur more frequently during menopause, but androgenic female alopecia can occur
at an earlier age.
Hair restoration procedures are appropriate for men and women of all ages and in pa-
tients with partial or moderate balding. Careful patient selection and good commu-
nication are crucial. Patients must have realistic expecta tions of what can be achieved.
Because there is no means of creating new hair, they must understand that hair trans-
plantation is ultimately a method for redistributing their available hair, and the suc-
cess of the procedure depends on the condition of the donor area as well as on the
density and quality of the hair to be transplanted.
The micrograft/minigraft technique is very effective in older patients in helping them
to achieve a younger look. The new hairline reframes the patient’s face with a natu-
ral, elegant profile. In women, this technique is indicated for androgenic baldness; it
is also very effective in patients undergoing secondary face and forehead lifts for re-
con structing sideburns and improving the temporal recesses.
I prefer to operate on patients who are at least 24 years old, because by that age they
are more aware of the progressive nature of their hair loss, are truly certain of what
they want, and are usually mature enough to understand that they may need to un-
dergo one or more additional procedures in the future. Patients should always be
honestly informed of the necessity for any reoperative procedures to maintain hair
density. Surgery is not recommended for patients with diabetes or coagulation dis-
orders as evidenced by a prothrombin level of less than 75%.
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Part IV  Hair Transplantation
Preoperative Assessment
History and Testing
As is standard with all operative procedures, a complete history is obtained, in cluding
previous illnesses and surgeries. After the patient has been assessed and a surgical
plan defined, the following laboratory tests are performed:
 Complete blood cell count
 Glucose test
 Coagulation test
 Electrocardiogram for patients over 50 years of age
We do not require any complementary examinations, because hair transplantation
procedures are performed on an outpatient basis with the use of local anesthetic and
sedation.
Evaluation of Hair Characteristics
Hair can be divided into different categories to help the surgeon assess each pa tient’s
requirements and develop a realistic plan for hair restoration. Griffin established the
following four important characteristics for evaluating the hair in pa tients under-
going hair transplantation:
1. Color: black, brown, red, blond, or gray
2. Texture: coarse, medium, or fine
3. Skin-to-scalp contrast:
– High contrast: black hair on fair skin
– Low contrast: red hair on ruddy skin
– Medium contrast: brown hair on olive skin
4. Degree of curl: kinky, curly, or straight
Norwood added two more factors for proper patient assessment:
5. Density
6. Size of donor area
To these classifications, I have added two other hair types that are very common in
patients of European descent and in the patients I see from southern Brazil:
7. White hair
8. Wavy hair

Hair Density
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Chapter 20  Micrograft and Minigraft Megasessions in Hair Transplantation
Hair density is an important factor in hair restoration. As can be seen in these three in-
dividuals, density varies from one patient to another; the younger the patient, the denser
the hair. One of the best techniques for improving hair density is to place additional
grafts in between the remaining hair. Patients are satisfied with the results and are able
to change hairstyles and color. In the third patient, the natural aging progression of fol-
licular units is demonstrated. He is seen preoperatively at age 42, 3 years after trans-
plantation at age 45, and 13 years after the procedure at age 57.

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Part IV  Hair Transplantation
Hair Thickness
Hair thickness must also be considered. Coarse hair usually covers baldness more
effectively than fine hair does; however, the shafts of thick hair tend to be more vis-
ible and detectable. With fine shafts we can achieve a better hairline, although it is
less dense, often making repeat procedures necessary. Wavy and kinky hair works
well in hair restoration and provides better coverage of the bald area.
Hair Color
Special care is needed when transplanting black hair, especially if it is coarse and im-
planted on a bright, oily surface. In these cases the contrast is high, which results in
an artificial appearance. A random distribution of implants is recommended, and
the temple recessions should be maintained to create a natural appearance. Patients
who have thick, dark hair are encouraged to modify their hairstyles by combing the
hair to the front or to the side.

Brown hair is usually found on young patients with incipient baldness. It is easier to
work with than black hair. Its contrast against the scalp is lower, and the result is
aesthetically more natural. This type of hair will gray with age, improving the sur-
gical result.
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Chapter 20  Micrograft and Minigraft Megasessions in Hair Transplantation

Gray hair is typically found on patients over 60 years of age. In older patients the
hair becomes fine, and its contrast with the scalp is minimal. Hair transplanted from
the neck is usually darker, and this mixture of gray and dark hair produces a more
youthful appearance.
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Part IV  Hair Transplantation
Red hair is rare; it maintains its color or lightens with age, giving patients a youth-
ful appearance. In most cases, red hair is accompanied by ruddy skin and scalp. These
patients are often freckled.

Blond hair offers the best results in hair restoration. It is usually fine, and its con-
trast to the scalp is minimal. In most cases, to achieve good density, two or three
transplant procedures must be performed.
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Chapter 20  Micrograft and Minigraft Megasessions in Hair Transplantation
The root of white hair is very difficult to work on, because the absence of melanin
in the hair bulb and shaft make the root almost imperceptible when the follicular
units are being prepared. However, the aesthetic result is very pleasing.

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Part IV  Hair Transplantation
Texture
Coarse hair is very good for transplantation. The preparation of follicular units is
easy, and the desired density often can be achieved in the first procedure. A natural
hairline is often difficult to obtain. Therefore the texture of the donor area needs to
be assessed, and the patient must be aware of this tendency. Care should be taken to
implant the hairs one at a time and in an irregular dispersal pattern to achieve a nat-
ural result.

Fine hair is sometimes found on young patients but is more frequently found on in-
dividuals 40 years of age and older. The aesthetic result is better than with coarse
hair, although the hair density is lower. A second replacement procedure after 1 year
is essential.
Skin-to-Scalp Contrast
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Chapter 20  Micrograft and Minigraft Megasessions in Hair Transplantation
Black hair on fair skin has a high contrast. This is usually seen in patients with oily
skin. The surgeon should be honest and explain that even after two or three re-
placements are performed, the results will be detectable. Patients in this category are
instructed to wash their hair with a shampoo for oily hair to keep the hair as oil free
as possible. Some patients use skin blush to diminish the high contrast.

Degree of Curl
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Part IV  Hair Transplantation
Kinky and curly hair is typically found on individuals of African descent, Arabs, and
people of Middle Eastern origin. It is more difficult to separate the follicular units
because of their curly form; however, this hair type covers and protects the scalp bet-
ter than other kinds of hair. The density and aesthetic result are superior to what is
achieved with other hair types.

Wavy hair provides the patient with different hairstyle options and good natural
density.
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Chapter 20  Micrograft and Minigraft Megasessions in Hair Transplantation

The aesthetic result from straight hair is good, but maintaining a hairstyle often
proves difficult. Usually two replacement procedures are required to achieve natural
density. We recommend that patients use gel to hold the hairstyle in place.
Photographic Documentation
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Part IV  Hair Transplantation
Pictures are very important at all stages of hair restoration surgery. We take color
photographs (ISO 100/21 degrees) and digital photographs with a 5.0-megapixel
camera. Preoperative images are taken with the patient sitting and the head posi-
tioned at a 45-degree angle. The front and right and left sides are photographed, and
when the crown area is included, a picture is taken from behind. These images help
the surgeon evaluate the new hairline, assess the area of bald ness, and estimate the
quantity of hair to be replaced.

Postoperative pictures are usually taken 8 months after the transplantation proce-
dure for men and 12 to 15 months after transplantation for women. It is important
to allow enough time to pass so that the final result can be adequately estimated.
Postoperative photographs must be of the same quality as those taken preoperatively.
It is very important for the photographer to maintain the same distance from the pa-
tient and to duplicate the views and angles of the preoperative images so the post-
procedure images are comparable. When in doubt, the preoperative photos should
be reviewed.
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Chapter 20  Micrograft and Minigraft Megasessions in Hair Transplantation

The proper preoperative and postoperative views and positions are demonstrated.
A close-up view of the hairline using a macro lens is helpful to detail the new hairline
(see p. 648). A complementary photograph taken from behind showing the hori-
zontal scar and donor area can be included if necessary for planning a second re-
placement procedure.
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Part IV  Hair Transplantation

Patient Education
Each step of the procedure is explained to the patient. Surgeons should always be
honest when discussing the positive and negative aspects of hair replacement. Bald-
ness is progressive in nature, and the transplanted hair will undergo the same aging
process as the hair of the donor area, becoming finer and changing color. It is espe-
cially important to make the patient aware that a second procedure may be neces-
sary to maintain the new hairline. Honesty will increase the patient’s confidence, and
he or she will become an ally and collaborator in establishing the surgical plan.
Pertinent Anatomy
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Chapter 20  Micrograft and Minigraft Megasessions in Hair Transplantation
The growth cycle of hair is divided into three distinct phases: anagen, catagen, and
telogen. Anagen, the adult phase, lasts approximately 6 years. In this phase, hair
grows exuberantly and naturally. Catagen, the involution and loss of hair, lasts 2 to
3 weeks. In this stage, hair is lost on pillows, on combs, and in the shower. Average
hair loss during this phase is approximately 100 hairs per day. After the involution
of the follicle, the telogen phase begins and lasts from 3 to 6 months. This is the prepa-
ration phase for new hair. During this phase, fine hair begins to grow and lasts for
6 years. Implanted hair, with its preserved genetic characteristics, maintains this cycle.
Connective
tissue sheath
TELOGEN
Resting
phase
(3-6 mo)
Return to
ANAGEN
phase
CATAGEN
Involution
phase
(1-2 wk)
ANAGEN
Active growing
phase
(2-6 yr)
Cortex
Cuticle
Secondary
germ cells
Club
hair
Dermal
papilla
Hair matrix
forming
new hair
Dermal
papilla
Outer root sheath
Inner root sheath
Bulge area
with stem cells

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Part IV  Hair Transplantation
Hair shafts
Residual
fibrous tract
Arrector pili muscle
Sebaceous gland
Perifolliculum
Vellus pilus
FOLLICULAR UNIT
An anatomic/histologic structure of the scalp was described by Headington. It usu-
ally consists of two to four terminal follicles, one to two vellus follicles, sebaceous
glands, and insertions of the arrector pili muscles. Surrounding this structure is the
perifolliculum, which is formed by reticular dermis collagen fibers.
The key to successful graft survival and ultimate hair growth is knowledge of this
anatomy and an understanding that chubby grafts and intact follicular unit grafts
have far greater potential for survival than bare hair shafts.
Preoperative Planning
When a new hairline is being designed, the donor area, its density and hair type, and
the bald area are evaluated to ensure that there are no dermatologic lesions. The pro-
gression of the patient’s baldness is also assessed.

Hairline Design
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The new hairline is discussed with the patient in front of a mirror, and the new hair-
line is drawn on the scalp. An irregular frontal hairline will create a more natural
and aesthetic result. Temple recessions are maintained to create a more natural ap-
pearance. Normally we begin with a perpendicular line from the tail of the eyebrow
to the upper scalp, reaching the temple recession area. From this point we mark the
frontal hairline.
In young patients it is important to project the definitive frontal hairline. I normally
draw a line 2 or 3 cm beyond the original hairline, estimating the future frontal and
temporal recesses. In older patients (more than 60 years of age), a more poste rior
hairline is suggested, sometimes with a design such as a frontal forelock.
Over the years I have established some important parameters for the frontal hair-
line. The midpoint of the forehead is normally 8 cm from the glabella, varying from
7 to 9 cm, depending on the individual patient’s facial contours. I draw a perpen -
dicular line from the brow–lateral canthus up to the temporal recesses. This lateral
point will connect with the middle point in a VW irregular line. If necessary, the thin
hair and effluvium are raised to make the surgery more effective.

Operative Technique
Donor Area Preparation
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The donor area is shaved and the ellipse is marked. The hair follicles are harvested
from the posterior cervical area where the hair density is greatest and the quality is
best; this is normally 6 to 8 cm from the nape of the neck. I plan to remove a hair-
bearing ellipse that correlates to the size of the area of baldness; this area may be
small, medium, or large and can vary from 10 by 2 cm to 20 by 3 cm, where 500 to
1500 follicular units can be obtained.
I never count the exact number of hairs to be replaced. Some patients have less den-
sity per square centimeter than others, so it is useful to harvest a larger hair-bearing
ellipse.

Anesthesia
During the procedure the patient must be kept calm and quiet and in a reclining po-
sition. The operation takes approximately 2 to 3 hours, so the patient should be po-
sitioned comfortably. Both the surgeon and the patient should be relaxed. A well-
trained team is requisite for a good result. Anesthesia is divided into three stages:
sedation, nerve blockage, and scalp ballooning.
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I normally use midazolam 5 to 10 mg and fentanyl citrate 1 to 2 ml to sedate the pa-
tient, and 20 ml levobupivacaine chloride 0.5% with epinephrine 1:200,000 to block
the supraorbital nerves and the coronal area 1 cm in front of the hairline.
Scalp ballooning is a procedure that I described in 1991. It is designed to increase
the edema of the scalp and to achieve ischemia, which aids in the implantation of
the follicular units. The scalp is infiltrated with 160 ml of saline solution containing
epinephrine 1:160,000.

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All layers of the scalp are infiltrated, from the subgalea to the dermis. This maneu-
ver is important to prevent bleeding during surgery and to maintain the grafts in side
the punctiform incision. We wait 5 to 10 minutes before we begin and repeat the in-
filtration every 30 minutes as necessary.
We also use levobupivacaine 0.5% at the donor site to block the occipital nerve
branches and the entire ellipse. The scalp-ballooning technique is also performed at
the donor site. The objective of this infiltration is to make the scalp tumescent, thus
easing the separation of the follicular units. It also reduces bleeding in this area.

Harvesting the Donor Ellipse
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The hair-bearing ellipse is cut with a single No. 10 blade at an oblique angle to avoid
damaging the hair follicles. This incision is quite superficial; the flap is raised from
the subcutaneous fat layer, with care to avoid dividing the sensitive branches of this
region. It is important to avoid causing posterior paresthesia or painful processes
such as sensitive neuroma, which may last for months. The galea aponeurotica must
remain intact.
In the past we attempted to use multiblades and punches in the donor area, but we
found that we damaged many of the hair follicles. This in turn made it more diffi-
cult to harvest the area during a second replacement procedure.
To achieve a natural closure, it is very important to undermine the superior and in-
ferior edges of the ellipse, taking care not to damage the occipital vessels and nerves
located at the ends of the ellipse. The scalp does not tolerate stretching, so closure
must be done gently.

Subcutaneous sutures are placed, and a running superficial cutaneous suture is used
to close the defect.
Preparing the Follicular Units
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The hair-bearing ellipse is placed on a hard wooden or acrylic surface and cut into
several slices, 3 to 4 mm wide, with a No. 22 or No. 10 blade. The movement for cut-
ting the grafts must be fast and precise, maintaining a direction parallel to the shafts
and follicles. The subcutaneous fat is removed from the follicles, but care is taken to
maintain a small amount around the bulbs. This remaining fat will pro vide nour-
ishment and protect the bulbs during the grasping maneuver.

Patients with less hair density will present with larger interstices of reticular dermis
and connective fibers surrounding the grafts. This tissue is trimmed away during graft
preparation so the follicular units may be placed closer together in the recipient area
to create density with a significant amount of connective tissue surrounding the grafts
that needs to be trimmed away.
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In this transverse section of the scalp, at the level of the sebaceous glands in the
low reticular dermis, follicles are seen separated by a large fibroconnective tissue
(hematoxylin-eosin stain; original magnification 50). This tissue is trimmed away,
“cleaning” the units for transplantation. Other areas have a density greater than
1 follicular unit/mm2.
In this histologic specimen, we see a normal
density of follicular units (hematoxylin-
eosin stain; original magnification 50).

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Grafts can be separated without magnification or with three-dimensional stereo-
scopic viewing. The use of magnification in the preparation of follicular units has
contributed to improved graft quality. Highly skilled and experienced assistants are
essential in the preparation of the follicular units. With good lighting and sharp
blades, they can accurately prepare 100 to 1000 grafts within an hour.
Three hair shafts
FOLLICULAR UNIT
Three bulbs
The grafts are divided into two groups: micrografts consisting of one or two bulbs,
and minigrafts consisting of three or four bulbs. Both are called follicular units.

In preparing the grafts, it is important not to cut the epidermis. We have found that
buried grafts produce more cysts and granulomas after the third month, when the hair
starts to grow. For the past 12 years we have preferred to maintain the epidermis.
After the grafts are prepared, they are placed on gauze moistened with saline solu-
tion and brought to the recipient site immediately; there is no need to place them in
solution or wet dishes. To maintain good histologic condition, grafts should be trans-
planted within 20 minutes of being divided. Through studies described by Limmer,
we know that the grafts can be kept out for a period of up to 2 hours without waste.
After that, they lose their quality and the yield will be jeopardized. This is an im-
portant part of our technique, which allows the grafts to be implanted immediately.
As the follicular units are being prepared by two assistants, the surgeon and another
assistant are immediately implanting them.
Implantation of the Follicles
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The bald recipient area should be swollen and ischemic; it is important to work with-
out bleeding and to maintain the grafts inside the orifices. To achieve this scalp bal-
looning, I perform tumescent infiltration of all layers of the scalp. As mentioned pre-
viously, this can be repeated every 30 minutes, whenever the tumescence and ischemia
diminish. It is important to inject the dermal surface immediately be fore transplan-
tation to achieve a sympathetic and microvascular plexus of the area, which is demon-
strated by “white marbling.” The area is then ready to re ceive the micrografts with-
out bleeding.

To perform the punctiform incision, we use a No. 11 sharp blade, or a microsurgi-
cal blade (Beaver 6500-BD). An angular microsurgical forceps is useful to grasp the
follicular units and bring them to the slit.
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I normally prefer to begin the punctiform incision from the middle and work toward
the front. To create a natural hairline, the incision is made vertically in the middle
and then a little obliquely as it approaches the forehead. The incision is 3 to 4 mm
deep, which is a sufficient depth to gently place the graft. Care must be taken not to
cut the galea aponeurotica, because doing so would cause more bleeding and the
graft could be totally buried.

When I have made the incision with a No. 11 blade or microsurgical blade, the as-
sistant picks up the graft from the moist towel with an angled microsurgical forceps
and gently inserts it into the slit. The blade is then removed to help with insertion.
This maneuver, which we call stick-and-place, is performed simultaneously.
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New hairline
Transplants placed
Remaining hair (not grafts)
STICK-AND-PLACE PUNCTIFORM TECHNIQUE
WITH FOLLICULAR UNITS

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The stick-and-place procedure is repeated, maintaining a space of 4 to 5 mm be-
tween each unit so the implanted grafts are not dislodged. If greater density is de-
sired, I wait 15 to 20 minutes before introducing another graft between the newly
implanted units. During this time the fibrinogen inside the skin becomes fibrin and
surrounds the grafts like glue, causing them to adhere in place. When the anterior
region of the forehead is reached, I implant single hairs in an irregular pattern for
an effect that is vital to achieving a natural-looking final result. It usually takes
2 hours to place 1500 follicular units; we do not recommend exceeding this amount.
It is preferable to perform a second replacement procedure after 8 months, if neces-
sary, at which time another quantity of grafts can be successfully implanted. Trans-
planted units are like plants in that we need to keep a distance of 2 to 3 mm between
them so that they will grow with greater vitality.
When transplantation is complete, a simple dressing of gauze moistened in saline so-
lution is applied over the implanted area, and a bandage is kept in place for 24 hours
to protect the area.

Postoperative Care
After the surgery, someone should accompany the patient home. Patients may return
to their professional activities the day after surgery. I recommend the use of an anal-
gesic to relieve discomfort in the donor area, which is common 6 to 8 hours after surgery.
I do not recommend the routine use of antiinflammatory medication or antibiotics.
During the first 24 to 48 hours, it is important for the patient to sleep with the head
elevated at no more than a 30-degree angle to avoid swelling in the forehead, which
may occur as a result of the scalp ballooning. Swelling of the forehead occurs in 25%
of patients and may, after the second day, move down to the eyelids and even the
cheeks. Cool compresses are helpful for reducing the swelling, but steroids do not
bring significant improvement.
The tumescent technique produces swelling in the scalp that lasts for approximately
2 days and can affect the face and upper eyelids for up to 3 days. I recommend that
the patient not drive during the first 24 hours and sleep in a dorsal or lateral decu-
bitus position at a 30-degree angle for the first 48 hours.
The patient removes the dressing at home on the second postoperative day and show-
ers, gently cleansing the scalp with an antiseptic shampoo. Patients should try to re-
move only the dry blood but not the crusts, which will slough off within 8 to 15 days.
If the patient dislodges any of the implants, there will be some bleeding, which can
be stopped by pressing the loca tion for 3 to 5 minutes.
There is a transition phase, catagen, 1 to 3 weeks after surgery, in which the implanted
hair grows to 3 or 4 mm. During this stage, the patient can touch the implanted area
and feel hair beginning to grow. After this period, the telogen phase be gins, during
which almost every implanted hair falls out. This phase lasts approximately 6 to
9 weeks, and the patient may worry whether the surgery was a success. After the te -
lo gen phase, the anagen phase begins, and new hair will be gen erated from the re-
maining matrix. The new hair growth initially comes in very thin and delicate. The
final result will be visible after 6 to 8 months in men and 10 to 12 months in women.
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This 42-year-old patient shows the progression of hair growth in the first 8 months
after hair transplantation.
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6 months
7 months
8 months
Preoperative
3 months
4 months
5 months

The same patient is shown preoperatively and 1 year postoperatively.
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Patient Instructions Following Hair Transplantation
 Plan on relative rest for the first 72 hours. During this period always lie with your head
elevated at a 30-degree angle.
 After the second day, swelling may occur in the eyelids and the forehead region. If this
occurs, apply cold compresses soaked in saline solution or boric acid dissolved in
water. The swelling will decrease within 48 hours.
 The dressing should be removed on the second postoperative day, and your head must
be washed with antiseptic shampoo, taking care to remove only the dried blood, not
the crusts. The antiseptic shampoo must be used for a week.
 After the dressing has been removed, we recommend covering the implanted area for
protection with sterile gauze and a hat or cap.
 We advise against any of the following:
– The use of hair dye
– Driving while the eyelids are swollen
– Smoking or drinking alcoholic beverages during the first postoperative week
– Playing sports or exerting yourself during the first 2 postoperative weeks
– Exposure to the sun or intense heat for at least 3 weeks
 The stitches in your head must be evaluated on the third postoperative day and re-
moved on the seventh postoperative day. The small crusts from the follicular units will
fall off by themselves approximately 10 days after surgery, along with some implanted
hair. Do not worry about the hair loss; the implants are still intact.
 It is common for cysts to appear after the third month; these should be ruptured with a
sterilized needle or forceps, and the scalp should be cleansed with antiseptic solution.
 Hair growth will begin 90 to 120 days after surgery, and the final result will be visible
within 6 to 8 months in men and within 10 to 12 months in women.
 If a second implant procedure is necessary, this can be performed 1 year after the ini-
tial transplantation.
 Surgical scars remain for an indefinite period and their quality is unpredictable, de-
pending on characteristics of your skin.

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Female Pattern Baldness
Although male pattern baldness is more prevalent, millions of women also experi-
ence hair loss. The most common cause of hair loss in women is androgenic alope-
cia, which usually occurs when an individual enters menopause. The operative tech-
nique for treating female pattern baldness is similar to that described for men, with
a few modifications. Because women’s hair is finer than that of men, we prefer to im-
plant more minifollicular units containing three to four shafts rather than microunits
with one or two shafts. We begin the replacement procedure in the posterior region
and work forward toward the anterior region. When we need to implant grafts into
the anterior hairline, we transplant microunits containing one or two hair shafts. Fi-
nal results can be expected approximately 15 months after the procedure. Patients are
advised not to color their hair until 1 month after surgery, because hair-coloring prod-
ucts can be abrasive to the newly implanted bulbs. If additional hair density is de-
sired, a second replacement procedure can be performed 15 months later.
This 58-year-old woman presented with androgenic female baldness and was treated
with one follicular unit replacement session. She is shown 14 months postoperatively.

This 62-year-old patient has typical temporal hair loss (telogen effluvium) as a re-
sult of an endoscopic brow lift. She is shown 11 months after transplantation of fol-
licular unit micrografts.
Complications
The complications associated with hair transplantation are rare and minor compared
with those of other techniques. The most common complication is forehead and eye-
lid edema, which appears 2 to 4 days postoperatively. Application of a 10% solution
of boric acid dissolved in water or cool chamomile compresses can help reduce the
swelling.
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For patients at high risk for keloid scars, a trial procedure is recommended, during
which approximately 10 follicular units are implanted. The donor and recipient sites
are observed for 6 to 12 months to ascertain that the healing process is complete be-
fore proceeding with the full hair transplantation.
Temporary alopecia around a tight donor site closure (the telogen phase induced by
ischemia) has been observed, but the hair usually regrows within 3 to 4 months. This
is more likely to occur in patients who have scars from prior procedures.
Results
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This young patient had incipient baldness; we increased his hair density. After
2 years, he enhanced his hairstyle with some blond highlights.

This 41-year-old patient with androgenic female baldness was treated with a single
session of follicular unit implantation. She is shown 2 years postoperatively.
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This 48-year-old man had hair loss and gray hair; he is shown initially at 15 months
after transplantation. He is then seen 4 years postoperatively; he had changed his
hair color to a slightly bluish cast.
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