The Art of Aesthetic Surgery_ Principles and Techniques -Foad Nahai, Farzad Nahai, Jeffrey Kenkel, Grant Stevens, William Adams Jr. (3 Volume Set)-Thieme (2020)

240
III Nonsurgical Cosmetic Treatments
>18@ Dierickx CC, Mazer -M, Sand M, .oenig S, Arigon V. Safety, tolerance,
and patient satisfaction with noninvasive cryolipolysis. Dermatol Surg
2013;39(8):1209–1216
>19@ Derrick CD, Shridharani SM, Broyles -M. The safety and efficacy of cryolipolysis: a
systematic review of available literature. Aesthet Surg J 2015;35(7):830–836
>20@ Duplechain -.. 1eck skin rejuvenation. Facial Plast Surg Clin North Am
2014;22(2):203–216
>21@ Few -:. Continuum of beauty: blending of surgical and nonsurgical cosmetic
medicine. Treatment Strategies, Dermatology 2012;2:29–31
>22@ Few -:. The beauty of blending: surgical and nonsurgical synergy. QMP Plastic
Surgery Pulse News 2012;4:1–4
>23@ Fry :-, :ulff V-, Tucker D, Fry F-. Physical factors involved in ultrasonically
induced changes in living systems: I. Identification of non-temperature effects. J
Acoust Soc Am 1950;22(6):867–875
>24@ Fry :-. Intense ultrasound; a new tool for neurological research. J Ment Sci
1954;100(418):85–96
>25@ Garibyan L, Sipprell :H III, -alian HR, Sakamoto FH, Avram M, Anderson RR.
Three-dimensional volumetric quantification of fat loss following cryolipolysis.
Lasers Surg Med 2014;46(2):75–80
>26@ Gliklich RE, :hite :M, Slayton MH, Barthe PG, Makin IR. Clinical pilot study of
intense ultrasound therapy to deep dermal facial skin and subcutaneous tissues.
Arch Facial Plast Surg 2007;9(2):88
>27@ Hu S, Chen MC, Lee MC, the treatment of atrophic facial acne scars in Asian skin. Dermatol Surg
2009;35(5):826–832
>28@ Ingargiola M-, Motakef S, Chung MT, Vasconez HC, Sasaki GH. Cryolipolysis for
fat reduction and body contouring: safety and efficacy of current treatment
paradigms. Plast Reconstr Surg 2015;135(6):1581–1590
>29@ -amshidian M, Tehrany EA, Imran M, -acquot M, Desobry S. Poly-lactic acid:
production, applications, nanocomposites, and release studies. Compr Rev Food
Sci Food Saf 2010;9:552–571
>30@ -ones DH, Carruthers -, -oseph -H, et al. REFI1E-1, a multicenter, randomized,
double-blind, placebo-controlled, phase 3 trial with ATX-101, an injectable drug
for submental fat reduction. Dermatol Surg 2016;42(1):38–49
>31@ .enkel -. Evaluation of the Ulthera system for improving skin laxity and tight-
ening. Abstract presentation. ASAPS Annual Meeting. Vancouver, Canada, May
3–8, 2012.
>32@ .lein .B, =elickson B, Riopelle -G, et al. 1on-invasive cryolipolysis for subcutane-
ous fat reduction does not affect serum lipid levels or liver function tests. Lasers
Surg Med 2009;41(10):785–790
>33@ .ulick M. Evaluation of a combined laser-radio frequency device (Polaris
:R) for the nonablative treatment of facial wrinkles. J Cosmet Laser Ther
2005;7(2):87–92
>34@ .ulick MI, Gajjar 1A. Analysis of histologic and clinical changes associated with
Polaris :R treatment of facial wrinkles. Aesthet Surg J 2007;27(1):32–46
>35@ Laubach H-, Makin IR, Barthe PG, Slayton MH, Manstein D. Intense focused ul-
trasound: evaluation of a new treatment modality for precise microcoagulation
within the skin. Dermatol Surg 2008;34(5):727–734
>36@ Liu TS, Owsley -4. Long-term results of face lift surgery: patient photo-
graphs compared with patient satisfaction ratings. Plast Reconstr Surg
2012;129(1):253–262
>37@ Manstein D, Laubach H, :atanabe ., Farinelli :, =urakowski D, Anderson RR.
Selective cryolysis: a novel method of non-invasive fat removal. Lasers Surg Med
2008;40(9):595–604
>38@ Manstein D, Herron GS, Sink R., Tanner H, Anderson RR. Fractional photother-
molysis: a new concept for cutaneous remodeling using microscopic patterns of
thermal injury. Lasers Surg Med 2004;34(5):426–438
>39@ Mendelson B, :ong CH. Anatomy of the aging face. In: 1eligan PC, :arren R-,
eds. Plastic Surgery Vol. 2: Aesthetic Surgery. 3rd ed. London, U.: Elsevier Saun-
ders, 2013:78–92
>40@ Metelitsa AI, Alster TS. Fractionated laser skin resurfacing treatment complica-
tions: a review. Dermatol Surg 2010;36(3):299–306
>41@ 1icolau P-. Use of suspension threads in facial rejuvenation. Prime. 2014 https://

Accessed October 10, 2019
>42@ Ogilvie MP, Few -: -r, Tomur SS, et al. Rejuvenating the face: an analysis of 100
absorbable suture suspension patients. Aesthet Surg J 2018;38(6):654–663
>43@ Oni G, Hoxworth R, Teotia S, Brown S, .enkel -M. Evaluation of a microfocused
ultrasound system for improving skin laxity and tightening in the lower face.
Aesthet Surg J 2014;34(7):1099–1110
>44@ Park E-, .im HS, .im M, Oh H-. Histological changes after treatment for localized
fat deposits with phosphatidylcholine and sodium deoxycholate. J Cosmet Der-
matol 2013;12(3):240–243
>45@ Rahman =, Alam M, Dover -S. Fractional laser treatment for pigmentation and
texture improvement. Skin Therapy Lett 2006;11(9):7–11
>46@ Rahman =, MacFalls H, -iang ., et al. Fractional deep dermal ablation induces
tissue tightening. Lasers Surg Med 2009;41(2):78–86
>47@ Reeds D1, Mohammed BS, .lein S, Boswell CB, tural effects of phosphatidylcholine and deoxycholate injections on subcutane-
ous fat: a randomized, controlled trial. Aesthet Surg J 2013;33(3):400–408
>48@ Rokhsar C., Fitzpatrick RE. The treatment of melasma with fractional photother-
molysis: a pilot study. Dermatol Surg 2005;31(12):1645–1650
>49@ Rose PT, Morgan M. Histological changes associated with mesotherapy for fat
dissolution. J Cosmet Laser Ther 2005;7(1):17–19
>50@ Rotunda AM, :eiss SR, Rivkin LS. Randomized double-blind clinical trial
of subcutaneously injected deoxycholate versus a phosphatidylcholine-de-
oxycholate combination for the reduction of submental fat. Dermatol Surg
2009;35(5):792–803
>51@ Rzany B, Griffiths T, :alker P, Lippert S, McDiarmid -, Havlickova B. Reduction
of unwanted submental fat with ATX-101 (deoxycholic acid), an adipocytolytic
injectable treatment: results from a phase III, randomized, placebo-controlled
study. Br J Dermatol 2014;170(2):445–453
>52@ Sadick 1. Tissue tightening technologies: fact or fiction. Aesthet Surg J
2008;28(2):180–188
>53@ Sadick 1S, Makino <. Selective electro-thermolysis in aesthetic medicine: a
review. Lasers Surg Med 2004;34(2):91–97
>54@ Salti G, Ghersetich I, Tantussi F, Bovani B, Lotti T. Phosphatidylcholine and sodi-
um deoxycholate in the treatment of localized fat: a double-blind, randomized
study. Dermatol Surg 2008;34(1):60–66, discussion 66
>55@ Sasaki GH, Tevez A. Clinical efficacy and safety of focused-image ultrasonogra-
phy: a 2-year experience. Aesthet Surg J 2012;32(5):601–612
>56@ Scheiner A, Baker SS. Laser management of festoons. In: Massry GG, Murphy MR,
Azizzadeh B, eds. Master Techniques in Blepharoplasty and Periorbital Rejuvena-
tion. 1ew >57@ Silhouette Lift Inc. Instruction Packet: I1STALIFT. 2015.
com. Accessed October 10, 2019.
>58@ Stuzin -M, Baker T-, Gordon HL, Baker TM. Extended SMAS dissection as an
approach to midface rejuvenation. Clin Plast Surg 1995;22(2):295–311
>59@ Suh DH, Shin M., Lee S-, et al. Intense focused ultrasound tightening in Asian
skin: clinical and pathologic results. Dermatol Surg 2011;37(11):1595–1602
>60@ Tan -, Lei <, Ouyang H:, Gold MH. The use of the fractional CO2 laser resurfacing
in the treatment of photoaging in Asians: five years long-term results. Lasers
Surg Med 2014;46(10):750–756
>61@ Tanzi EL, :anitphakdeedecha R, Alster TS. Fraxel laser indications and long-term
follow-up. Aesthet Surg J 2008;28(6):675–678, discussion 679–680
>62@ Tierney EP, Hanke C:. Ablative fractionated CO2, laser resurfacing for the neck:
prospective study and review of the literature. J Drugs Dermatol 2009;8(8):723–731
>63@ US Food and Drug Administration. 510(k) clearance .151179: CoolSculpting
System. 2015. Available from:
.151179.pdf. Accessed 1ovember 18, 2015.
>64@ :algrave SE, Ortiz AE, MacFalls HT, et al. Evaluation of a novel fractional resurfac-
ing device for treatment of acne scarring. Lasers Surg Med 2009;41(2):122–127
>65@ :hite :M, Makin IR, Slayton MH, Barthe PG, Gliklich R. Selective transcuta-
neous delivery of energy to porcine soft tissues using Intense Ultrasound (IUS).
Lasers Surg Med 2008;40(2):67–75
>66@ :einkle AP, Sofen B, Emer -. Synergistic approaches to neck rejuvenation and
lifting. J Drugs Dermatol 2015;14(11):1215–1228
>67@ :hite :M, Makin IR, Barthe PG, Slayton MH, Gliklich RE. Selective creation of
thermal injury zones in the superficial musculoaponeurotic system using intense
ultrasound therapy: a new target for noninvasive facial rejuvenation. Arch Facial
Plast Surg 2007;9(1):22–29
>68@ :ollina U, Goldman A. ATX-101 for reduction of submental fat. Expert Opin
Pharmacother 2015;16(5):755–762
>69@ =eltiq Aesthetics, Inc.

Part IV
Hair Transplantation
IV

(Trang không có chữ)

 ASSOied AnDWRmy in +Dir 7rDnVSODnWDWiRn
243
22 Applied Anatomy in Hair Transplantation
Alfonso Barrera
Abstract
:e review the importance of hair as well as its embryology and
histology, the phases of its growth cycle, and important details
about the importance of preserving complete anatomic intact-
ness and handling of follicular unit grafts to have optimal growth
at the time of hair transplantation.
Keywords
hair follicular units, anagen, catagen, telogen
22.1 Introduction
Historically, hair has been a source of pride to humans and serves
as a distinguishing feature that adorns as well as protects. It is
also one of our most variable characteristics. :ide differences
in color, density, texture, length, and style characterize differ-
ent 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 understanding 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, almost 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, axillae, chest, and pubis.
Vellus hair may become terminal hair and vice versa; for example,
facial vellus hair in adolescents may develop into a beard, and ter-
minal hair on the scalp may turn into vellus hair in male pattern
baldness and androgenic alopecia in women.
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 follicles 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 dermal papillae, the fibrous sheath of the
follicle, the blood vessels, and the arrector pili muscles originate
from the mesoderm.
The cells that form the hair matrix and the melanocytes are
of ectodermal origin. The melanocytes produce the pigment
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 arrector pili muscles.
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 pigment granules (melanin) that give hair its natural
color. As we age, the melanocytes cease functioning, resulting in
gray or white hair (Fig. 22.1).
22.2 Histology
To accomplish natural, aesthetic results in hair transplantation,
one must pay attention to many seemingly small details, starting
with the important histologic features of hair follicles (Fig. 22.2).
Transverse sections demonstrate that hair follicles grow in fol-
licular units. In his landmark 1984 article ´Transverse Microscopic
Anatomy of the Human Scalp,µ Headington described the follicular
unit as including one to four terminal hairs, one vellus hair (rarely
two), nine sebaceous glands, insertions of arrector pili muscles, a
perifollicular vascular plexus, a perifollicular neural network, and
perifolliculum (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 (Fig. 22.3).
22.3 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 posi-
tion of a mature hairline. Generally, the midline of the new hair-
line 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 (Fig. 22.4).
22.4 Growth Cycle
There are three life cycle phases of hair growth (Fig. 22.5). 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 directly
above the actively dividing cells. The living cells become dehydrated,
eventually die, and are ultimately 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 situated
just under the actively dividing cells of the follicle, plays an import-
ant role in the regulatory control of the hair’s growth cycle.

244
IV Hair Transplantation
The first phase, anagen, is the active growing phase in which the
follicular cells are actively multiplying and keratinizing. In a non-
balding scalp, approximately 90 of the hairs are in this phase, which
lasts about 3 years. During the second phase, catagen, 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 even-
tually connected to the dermal papilla only by a connective tissue
strand. This phase lasts 2 to 3 weeks. The third phase, telogen, is also
known as the ´resting phase.µ 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 months³and commonly occurs after hair trans-
plantation. For this reason, significant 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 WHORJHQ H̷XYLXP.
Approximately 10 of hair follicles in a nonbalding scalp are in
the telogen phase. :hen the rate of hair loss exceeds the rate of
growth, thinning and eventually baldness develop.
Fig. 22.1 Illustration of a hair follicle anatomy, showing the hair shaft, hair bulb, erector pili muscle, sebaceous gland, sweat glands, and a section of
the root sheath.
Fig. 22.2 Epidermis, dermis, dermal appendages, subcutaneous fatty
tissue, and hair follicles in vertical histologic sections of skin.

 ASSOied AnDWRmy in +Dir 7rDnVSODnWDWiRn
245
22.5 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 pattern 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 alope-
cia, occurs less frequently and is more diffuse. In women, the front
hairline is usually preserved. 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. Testosterone, secreted by the testes,
is the principal androgen circulating in plasma in men, whereas
in women the adrenal steroids dehydroepiandrosterone sulfate,
androstenediol sulfate, and 4-androstenedione are the most
abundant proandrogens³19-carbon steroids that are converted at
the target tissue into active androgen. The enzymatic reduction
of testosterone and the aforementioned androgens in females by
5-alpha-reductase into dihydrotestosterone is necessary for the
induction of androgenic hair loss both in men and women.
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. Depending on the genetic features
Fig 22.4 Design of a mature hairline.
Fig. 22.3 Histology of hair follicles as seen on horizontal sections. (a) Multiple follicular units of various sizes. (b) Close-up view. (c) Two-hair follicular
unit. (d) One-hair follicular unit.
a
c
b
d

246
IV Hair Transplantation
inherited, hairline recession may progress until only a temporal
and occipital fringe remains.
Although genetic predisposition is the cause for most forms of
hair loss, other sources of hair loss include the following (in order
of frequency in my practice):
• Hair loss associated with aesthetic facial rejuvenation surgery,
coronal, and endoscopic forehead lifts, such as loss of sideburns,
temporal hairline, and distortion of the retroauricular hairline
• Scalp and facial hair loss associated with burns or other trau-
matic injuries
• 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 tumors
of the skin or scalp
Surgeons must be equipped to restore sideburns, the temporal
hairline, the retroauricular hairline, eyebrows, eyelashes, mus-
tache, beard, and areas of the scalp. Many remedies have been
described over centuries to enhance and/or regrow hair³none 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
better, as demonstrated by Seager in 1997. Dissecting follicular
unit micrografts to the bare hair shaft may decrease the percent-
age of graft take. :hether 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, this result means
that hairs that were in the telogen phase were not initially counted
but ultimately grew hair. These hairs in the telogen phase are also
included when slightly chubby micrografts and minigrafts are
transplanted. This most not be misconstrued as requiring grafts
be too chubby, either. Additionally, when transplanting eyebrows
or eyelashes, we need very skinny grafts; we most gently trim
single-hair follicular units close to the hair shaft, as these areas
require ultrafine grafts (Fig. 22.6; Fig. 22.7).
Fig. 22.6 Illustration of ideal hair grafts (one- or two-hair follicular and
maximum three- to four-hair units).
Fig. 22.5 Hair growth cycle.

 ASSOied AnDWRmy in +Dir 7rDnVSODnWDWiRn
247
22.6 Anatomic Concepts to Keep in
Mind
:hen harvesting the donor ellipse, which generally is taken hor-
izontally from the occipital and sometimes extending to the tem-
poral areas, the surgeon must keep the incision superficial to the
fascia to preserve the occipital nerves and vessels. Dissection should
separate the plane between the subcutaneous tissue and fascia.
The elasticity of the scalp in the donor area is usually greatest in
the midline, and the scalp becomes less elastic laterally toward the
ears (especially above the mastoid area) and then often increases
toward the temporal areas.
The density of hair is usually greatest at the midline and dimin-
ishes as one proceeds laterally.
Minigrafts and micrografts should be inserted in the recipient
site following the same angulation and orientation of the residual
hair to mimic the natural direction of hair growth.
The epidermis of the graft should remain superficial to the epider-
mis 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 due to compression.
22.7 Concluding Thoughts
In recent years some physicians have been developing a pref-
erence for doing what is called follicular unit extraction (FUE),
which means extracting follicular units with a 0.8- to 1.0-mm
diameter punch directly from the donor area. Their reasons
include avoiding a horizontal scar on the donor area, quicker
recovery, and less postoperative pain and discomfort.
I am very familiar with the FUE technique. The main disad-
vantages to this, in my opinion, are that it is more predictable to
harvest intact follicular units by conventional strip harvesting and
then, under magnification, visualizing and dissecting the follicular
units, allowing for better quality of grafts as well as their growth.
Most physicians agree that the growth is stronger and more
predictable using strip harvesting. The scar is often minimally
detectable. However, in selected cases, I can see the benefit of FUE,
as in patients who wear very short hair (shaved or almost shaved),
such as men in the military; this way completely avoids the risk of
having a linear scar on the donor area.
Clinical Caveats
• It is imperative to do a very accurate dissection of the hair
follicles.
• Keep the grafts wet on chilled saline solution.
Suggested Reading
>1@ Harris -. Conventional FUE. In: Unger :, Shapiro R, Unger R, Unger M, eds. Hair
Transplantation, 5th ed. London, U.: Informa Healthcare; 2011:291–295
>2@ Headington -T. Transverse microscopic anatomy of the human scalp. A basis
for a morphometric approach to disorders of the hair follicle. Arch Dermatol
1984;120(4):449–456 PubMed
>3@ Orentreich D, Orentreich 1. Androgenic alopecia and its treatment. In: Unger :P.
Hair Transplantation, 3rd ed. 1ew >4@ Rassman :R, Bernstein RM, McClellan R, -ones R, :orton E, Uyttendaele H.
Follicular unit extraction: minimally invasive surgery for hair transplantation.
Dermatol Surg 2002;28(8):720–728 PubMed
>5@ Rose PT. The development, anatomy, and physiology of the hair follicle. Hair
Transplant Forum Int 1999;9:197
>6@ Seager D-. Micrograft size and subsequent survival. Dermatol Surg
1997;23(9):757–761, discussion 762 PubMed
>7@ Vallis CP. Hair replacement surgery. In: McCarthy -G. Plastic Surgery. Philadel-
phia, PA: :B Saunders; 1989:1519
Fig. 22.7 Photo of Ideal hair grafts (one-, two-, and three hair follicular
unit grafts).

248
IV Hair Transplantation
23 Clinical Decision Making in Hair Transplantation
Alfonso Barrera
Abstract
For hair transplantation, as with any surgical procedure, we must
evaluate each patient individually. There are various factors we
must consider, particularly the degree of hair loss as it relates to
the amount of donor hair available. To date we are not able to clone
hair follicles, so we can only work with the patient’s own existing
donor hair. All we do is redistribute the patients’ own existing,
durable hair roots from the donor area to the recipient area.
:e review the most frequent classification for male pattern
baldness and female pattern alopecia. :e show various exam-
ples of the most frequent cases we treat: correction of alopecias
secondary to previous surgery, cases of scarring alopecia, and
alopecia secondary to burn accidents (including scalp, mustache,
beard, eyebrows, and eyelashes).
Keywords
male pattern baldness, female pattern alopecia, scarring alope-
cia, mega session
23.1 Introduction
To date, we have no method for creating new hair where none
exists. All current techniques for hair restoration involve redis-
tributing the patient’s existing hair. Therefore, candidates for
hair transplantation are limited to those who have a favorable
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 attempt to clone hair follicles or cul-
ture and multiply hair follicles in the laboratory setting. :hen
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.
23.2 Hair Loss Patterns
The most frequent types of hair loss include male pattern
baldness, postsurgical alopecia, posttraumatic alopecia, and
congenital hair loss.
Male pattern baldness is by far the most frequent type of hair
loss, followed by androgenic (pattern) alopecia in women (Fig.
23.1; Fig. 23.2).
23.2.1 Male Pattern Baldness
The most commonly used classification system for male pattern
baldness is the one described by 1orwood (Table 23.1; Fig. 23.3).
Fig. 23.1 Typical case of male pattern baldness.
Fig. 23.2 Typical case of female androgenic alopecia.
Table 23.1 Norwood classification for male pattern baldness
Type I
There is minimal or no anterior hairline recession at the
frontotemporal areas.
Type II
Triangular, symmetrical frontotemporal recessions extend
posteriorly no more than 2 cm anterior to a coronal plane
drawn between 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
Telangiectatic matting
Type V
< 0.2 mm diameter network, bright red
Type VI
Venulectasis (usually protrudes above skin surface; distinguished
from telangiectasia by deeper color and larger diameter)
Type VII
1–2 mm diameter

 &OiniFDO 'eFiViRn 0DNing in +Dir 7rDnVSODnWDWiRn
249
1orwood 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 (Fig. 23.4). The type a
anterior variance patterns are classified as described in Table 23.2.
23.2.2 Female Androgenic Alopecia
The most common classification system used for female andro-
genic alopecia is the Ludwig classification (Fig. 23.5). It is based
on three grades: I: mild, II: intermediate, and III: severe.
Thinning is usually more generalized than in male pattern
baldness, 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 den-
sity. :omen 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 receptors in the hair follicles
are hypersensitive to or have a greater binding affinity to dihydro-
testosterone, which may or may not be genetic in origin.
23.2.3 Other Causes of Hair Loss
After facial rejuvenation or craniofacial procedures, loss of side-
burns and of frontal, temporal, and/or retroauricular hair is not
uncommon. Posttraumatic alopecia includes hair loss from inju-
ries such as burns, traumatic injuries of the scalp and eyebrows,
and scalp avulsion (Fig. 23.6).
Examples of congenital hair loss include the absence of mustache
hair in cases of bilateral cleft lip (not obvious until after puberty),
triangular temporal alopecia, and nevus sebaceous of -adassohn.
Fig. 23.3 Example of scarring alopecia of the sideburn and temporal
hairline after a facelift procedure.
Fig. 23.4 Norwood classification, the most common classification used
for male pattern baldness. (Reproduced with permission from Norwood
OT, Shiell R. Hair transplant surgery. Charles C. Thomas; 1984.)
Fig. 23.6 The Ludwig classification, the most common classification system
used for female androgenic alopecia. (Reproduced with permission from
Ludwig E. Classification of the types of androgenetic alopecia (common
baldness) occurring in the female sex. Br J Dermatol. 1977; 97:247-254.)
Table 23.2 Norwood type a anterior variance patterns
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 denudation 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.
Fig. 23.5 Norwood classification anterior variance. A small percentage
of the cases of male pattern baldness affect primarily the front part of
the scalp, not affecting the crown. (Reproduced with permission from
Norwood OT, Shiell R. Hair transplant surgery. Charles C. Thomas; 1984.)

250
IV Hair Transplantation
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. To obtain the best result possible
often takes two sessions and in some cases three. In some cases, a
reasonable improvement can be obtained in just one megasession.
I have found that patients under 30 years of age are the most
demanding. They must understand that because they are young,
it is impossible to determine in advance the end point of their hair
loss. A conservative approach is recommended in these cases.
:hen patients receive proper instruction and have realistic
expectations, I have found that 97 are satisfied after a single
hair transplantation session. Moreover, the 3 of patients who
had been dissatisfied with their hair density after surgery subse-
quently underwent second sessions to improve the density and
were ultimately pleased with the results.
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 transferring 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 challenges encountered in a hair restoration practice.
The 32-year-old man shown in Fig. 23.7 had 1orwood type IV
male pattern baldness but good donor hair, which was coarse. He
underwent 1,500 follicular unit grafts in a single session, primar-
ily 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 available determined. The patient must understand
that because of his young age, further sessions will be needed in
the future as hair loss progresses.
The 53-year-old man shown in Fig. 23.8 was an ideal candidate,
because his pattern (1orwood type VI) was well established and was
not expected to change dramatically. In such cases a maximal density
procedure (2,000–2,500 follicular unit micrografts and minigrafts)
can be planned. His donor hair had good density and thickness, and
the entire area of baldness was grafted. A hairline pattern consistent
with the patient’s mature age is the preferred approach to produce the
most natural result. Thus, a slight frontotemporal recession was left.
The 56-year-old man in Fig. 23.9 had a more mature pattern of
baldness than the previous patient. Although his hair loss would
continue to progress, his future hair loss pattern could 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 2,040 follicular unit grafts in
one session (megasession).
The 43-year-old man in Fig. 23.10 had male pattern baldness
type IIIvertex without frontotemporal recession. The density and
thickness of his donor hair were excellent. The front part of his
scalp was covered with healthy, full hair. His pattern of baldness
was well established and limited to the crown. I recommended
two sessions of micrografts and minigrafts a year apart to achieve
an optimal result. The crown typically takes at least two sessions
to obtain reasonable coverage. Although the whirl can be recon-
structed by placing the grafts in a circular orientation, it probably
does not warrant the additional time and effort.
The 42-year-old man in Fig. 23.11 presented with male
pattern baldness type VII, the most severe 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 exten-
sive area of baldness. I advised a session of 1,300 follicular unit
micrografts and minigrafts but only to the median forelock area,
Fig. 23.7 This 32-year-old man with male pattern baldness type IV had
good donor hair; his hair was coarse, which could help to obtain nice
coverage in one session (left). He underwent 1,500 follicular unit grafts in a
single session, primarily to the frontal scalp and a few to the crown (right).
Fig. 23.8 This 53-year-old man with male pattern baldness type VI was
an ideal candidate, because his pattern of hair loss was well established
and probably would not change dramatically (top). He received a
maximal density procedure (2,000–2,500 follicular unit micrografts
and minigrafts) over the entire area of baldness (bottom), leaving a
slight frontotemporal recession consistent with his mature age.

 &OiniFDO 'eFiViRn 0DNing in +Dir 7rDnVSODnWDWiRn
251
the rhomboid-shaped area on the front part of the scalp, where
strategic transplantation would help frame his face even though
his crown would remain bare. One year postoperatively, the hair
on the top of his head blended naturally with the temporal fringes.
The 37-year-old man in Fig. 23.12 had male pattern baldness
type IV. His coarse, wavy donor hair would provide good coverage.
Because his hair loss was not very severe, approximately 700 to
800 follicular unit micrografts and minigrafts would be sufficient
to strengthen both the front scalp and crown. He must expect
further temporary thinning.
The 43-year-old woman in Fig. 23.13 had Ludwig grade II to III
female androgenic alopecia. Such patients tend to exhibit uniform
thinning over the entire scalp with preservation of the front hairline.
Fig. 23.10 This 43-year-old man had well-established male pattern
baldness type IIIvertex without frontotemporal recession, excellent
density and thickness of donor hair, and healthy, full hair on the front
part of his scalp. The author recommended two sessions of micrografts
and minigrafts a year apart to achieve an optimal result.
Fig. 23.11 This 42-year-old man presented with male pattern baldness
type VII, the most severe form of male pattern baldness, and insufficient
donor hair to transplant the entire area (left). A session of 1,300 follicular
unit micrografts and minigrafts to only the median forelock area (top
center) would help frame his face. One year postoperatively (right), the
hair on the top of his head blended naturally with the temporal fringes.
Fig. 23.9 This 56-year-old man with male pattern baldness type VI had
a more mature pattern of baldness than the patient in Fig. 23.8 did.
His expected hair loss pattern could be better determined, making a
more aggressive approach acceptable. He underwent 2,040 follicular
unit grafts in one session (megasession).

252
IV Hair Transplantation
Candidates for the procedure must have an area with good hair
quality and density, which tends to be in the occipital region. I
recommended that this patient undergo a megasession of 1,000 fol-
licular unit micrografts and minigrafts. The patient was forewarned
that she could expect further temporary hair thinning for the first
3 to 4 months in the area grafted (telogen ȩuvium). 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.
The 50-year-old woman in Fig. 23.14 was concerned about her
hair thinning on the front of her scalp. Because she had good density
on her remaining scalp, I recommended a session 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 post-
operative results are very natural, without any detectable scarring.
23.3 Preoperative Planning
23.3.1 Aesthetic Considerations
The appearance of fullness has to do with hair mass, which is
related to the number of hairs, the thickness of the individual
hair shafts, texture and color, and curliness. Furthermore, the
contrast of colors between the scalp and the hair has a significant
influence on the optical illusion of fullness. Most experts today
agree that the average healthy, nonbalding patient has one fol-
licular unit/mm2, and each unit contains an average of two hairs
(that is, a density of 2 hairs/mm2), giving a density of about 200
hairs/cm2 (range 130 to 280 hairs/cm2). Since an average scalp
has an area of approximately 500 cm2 (50,000 mm2), there are
approximately 100,000 hairs on the average head (Fig. 23.15).
However, most experts also agree that only 100 hairs/cm2 (range
Fig. 23.12 This 37-year-old man has male pattern baldness type IV. will
provide good coverage. Because his hair loss is not very severe, approxi-
mately 700 to 800 follicular unit micrografts and minigrafts of his coarse,
wavy donor hair should be sufficient to strengthen both the front scalp and
crown. The hair must be continuously parted as the grafts are inserted;
however, it is not necessary to shave the residual hair in the recipient areas.
He must be forewarned that there will be further temporary thinning.
Fig. 23.15 An average scalp has an area of 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), for approximately 100,000 hairs on the average head,
varying from patient to patient.
Fig. 23.13 This 43-year-old woman had Ludwig grade II to III female
androgenic alopecia, exhibiting uniform thinning over the entire scalp
with preservation of the front hairline as well as good hair quality and
density in the occipital region, supporting a megasession of 1,000
follicular unit micrografts and minigrafts. The patient was forewarned
to expect further temporary hair thinning for the first 3 to 4 months in
the area grafted (telogen ȩuvium) and advised to use 2% minoxidil
twice a day postoperatively to help preserve and thicken the existing
hair as well as the grafted hair.
Fig. 23.14 (a) This 50-year-old woman was concerned about her hair
thin-ning on the front of her scalp. She had good density on her remaining
scalp. (b) A session of 400 micrografts and minigrafts, under local anesthe-
sia with mild intravenous sedation, added hair precisely where needed. Her
postoperative results are very natural, without any detectable scarring.
a
b

 &OiniFDO 'eFiViRn 0DNing in +Dir 7rDnVSODnWDWiRn
253
65–140 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, and occasionally three, sessions may
be necessary to obtain the desired density. Often, however, signif-
icant improvement is seen after just one session, and results will
persist for years without a repeat procedure.
If the ratio of donor site area to recipient site area is favorable,
I transplant the entire area of baldness. If the ratio of donor site
area to recipient area is not favorable, I may transplant only the
front hairline or a median forelock. If it is clear that there is insuf-
ficient 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.
23.3.2 Donor Site Harvesting
The many variables encountered during donor site harvesting
test the surgeon’s clinical judgment. The size of the donor ellipse
will vary, depending on the number of grafts planned or the size
of the area to be grafted, as well as the hair 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 obtained for the number
of grafts planned and that the donor defect can be closed under
minimal tension.
The laxity of the scalp varies from person to person. The sur-
geon must be alert to the presence of scar tissue from previous
procedures, since this will result in reduced elasticity and pliabil-
ity of the donor scalp. Most patients’ scalps permit ellipses 1 to 1.5
cm wide (occasionally up to 2 cm) to be harvested with minimal
tension on closure. The surgeon must feel the donor scalp to assess
its laxity, elasticity, and pliability.
A long, narrow, horizontal donor ellipse is preferable to a short,
wide ellipse. Hair density and the elasticity of the donor occipi-
tal site are usually greater near the midline. The hair becomes
sparser and the scalp less elastic more laterally, particularly
over the mastoid area. The scalp above the ears is usually quite
inelastic. These factors must be taken into consideration so that
the ellipse can be designed to allow closure with minimal tension
(Fig. 23.16).
1ormally, as previously stated, 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.
Assuming a density of 150 hairs/cm2, an ellipse 10 by 1 cm will
yield approximately 1,500 hairs. 1aturally occurring follicular
units have one to four hairs per unit. These units must be kept
intact as much as possible. The exact number of grafts can be
determined only after dissecting the donor ellipse into grafts, but
an ellipse of this size will yield approximately 500 to 600 grafts
(Fig. 23.17).
If hair density is approximately 150 hairs/cm2, a horizontal,
occipital donor ellipse of 20 by 1 cm with 3,375 hairs will be
needed to produce 1,000 to 1,200 micrografts and minigrafts with
one to four hairs per unit (Fig. 23.18).
A maximal density procedure (2,000 to 2,500 grafts) in patients
with type VI or VII male pattern baldness makes harvesting
enough donor tissue a greater challenge. In these cases, we har-
vest a horizontal ellipse approximately 30 to 32 cm long and 1 to
1.5 cm wide at the midline (scalp elasticity permitting), gradually
Fig. 23.17 Assuming a density of 150 hairs/cm2, an ellipse 10 by 1 cm
will yield approximately 1,500 hairs. With one to four hairs per follicular
unit, an ellipse of this size will yield approximately 500 to 600 grafts.
Fig. 23.16 A long, narrow, horizontal donor ellipse is preferable to a
short, wide ellipse. Hair density and the elasticity of the donor occipital
site are usually greater near the midline, while the hair becomes
sparser and the scalp less elastic more laterally, particularly over the
mastoid area. The scalp above the ears is usually quite inelastic. These
factors must be taken into consideration so that the ellipse can be
closed with minimal tension.

254
IV Hair Transplantation
tapering the width laterally to 1 to 0.5 cm at the ends. In most
patients this yields approximately 2,000 to 2,500 follicular unit
micrografts and minigrafts containing between 5,000 and 6,000
hairs and allows closure with minimal if any tension (Fig. 23.19).
23.3.3 &DmRuÁDging SFDOS SFDrV
Patients are often seen with scars on the scalp or the front
hairline as a result of accidents, surgical interventions, or poor
healing after an aesthetic surgical procedure. Micrografts and
minigrafts 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 excellent solution for these deformities (Fig. 23.20;
Fig. 23.21). The technique is basically the same as that for male
pattern baldness or female androgenic alopecia, except that the
direction of the graft insertion may be more critical for controlling
the direction of hair growth.
:hen working on the temporal hairline, eyebrows, or mus-
tache, for example, the direction of the natural hair growth at the
respective sites must be followed. Micrografts or minigrafts can
be added at the newly closed wound suture line in hair-bearing
incisions. These small grafts thrive even if the blood supply is
precarious 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.
:hen feasible, it is best to make the micrografts and minigrafts
from hair-bearing areas surrounding the wound (local hair), espe-
cially for the eyebrows (the contralateral eyebrow or residual hair
from the same eyebrow), because they normally exhibit a very
different growth pattern from that seen in scalp hair.
Fig. 23.18 If hair density is approximately 150 hairs/cm2, a horizontal,
occipital donor ellipse of 20 by 1 cm, with 3,375 hairs, will be needed
to produce 1,000 to 1,200 micrografts and minigrafts (one to four
hairs per unit).
Fig. 23.19 A maximal density procedure (2,000 to 2,500 grafts)
requires harvest of 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 approximately 2,000 to 2,500 follicular unit micro-
grafts and minigrafts and allows closure with minimal if any tension.
Fig. 23.20 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.

 &OiniFDO 'eFiViRn 0DNing in +Dir 7rDnVSODnWDWiRn
255
23.3.4 Correction of Sideburns after
Facelift Procedures
Surgeons who perform facelift procedures acknowledge that
upward displacement of the sideburn, temporal hairline, and
retroauricular hairline is not uncommon, especially in patients
undergoing secondary facelifts. The sideburn is an important
aesthetic unit of the face.
Sideburn loss is a telltale deformity unique to facelift proce-
dures. Patients attempt to style their hair to camouflage the area,
but this may be futile if they live active outdoor lives. Such upward
displacement can often be prevented if prehairline incisions are
used. If sideburn loss does occur, it can be corrected with various
scalp flaps, but I prefer the use of micrografts and minigrafts for
several reasons:
1. A natural result can be achieved in just one session.
2. The direction of the hair can be controlled by angling the surgi-
cal blade.
3. The desired hairline design can be followed with precision.
4. A transition zone can be readily created that avoids a scar in
front, a common sequela of flap techniques.
An example of the results can be seen in Fig. 23.22.
23.3.5 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 transplanting 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 useful for restoring the eyebrows, mustache, and
beard. However, because the consistency 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.
On the face I personally prefer to make most of the recipient
sites first, allow a few moments for coagulation, and then insert
the grafts (Fig. 23.23; Fig. 23.24). For the eyebrows I prefer a to use
a 21-gauge needle to make the recipient sites; on the moustache
and beard, the 22.5 SharPoint (Surgical Specialties Corp., Reading,
PA) blades.
23.3.6 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 optimal 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 hos-
tile 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
(Fig. 23.25). 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
Fig. 23.21 Correction for the patient shown in Fig. 23.20. The area of
alopecia was excised, but an area of hair loss remained. Scar revision
by a plastic surgeon left a widened scar. The patient was referred to
the author for further revision and/or micrografting. The scar was
reexcised, and about 25 micrografts and minigrafts were placed at the
suture closure line and 25 around the closure.
Fig. 23.23 (a) This 20-year-old man presented with scarring alopecia
of his beard and moustache. (b) First all the recipient site incisions
were made before insertion of the grafts. (c) Immediately after
insertion of the grafts. (d) One year postoperative.
a
b
c
d
Fig. 23.22 (a) This 52-year-old woman came for a consultation 3 years
after a facelift. (b) 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. (c) Postoperatively,
blending of the grafts with the natural direction of hair growth is
evident.
a
b
c

256
IV Hair Transplantation
trauma before proceeding with hair transplantation, especially in
the case of burn alopecia, where tissue expansion may be neces-
sary first (Fig. 23.26; Fig. 23.27; Fig. 23.28).
23.3.7 Eyelash Reconstruction and
Augmentation
The eyelash of the upper eyelid is an important structure both
functionally and aesthetically. The upper eyelashes resemble
Fig. 23.24 (a) This 19-year-old woman presented with scarring alope-
cia of right eyebrow and upper lid eyelashes. (b) Follicular unit grafts in
place, and a strip (composite graft) for eyelash reconstruction). (c) One
year postoperative.
a
b
c
Fig. 23.25 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 micrografts 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 thus take 18 to 24 months to
complete. Scalp reduction was not an option, because her scalp was a bit
tight. Even though serial excisions might have improved the tightness,
they would have been repetitive and would have resulted in a hairless
scar line at best. Therefore the author recommended tissue expansion
with micrografts inserted between the sutures during closure.
Fig. 23.26 Tissue expansion was performed on the patient in Fig.
23.25 using a 350-mL crescent-shaped expander inflated to 210 mL.
The expander was removed after 3 months.
Fig. 23.27 With the patient in Fig. 23.25 and Fig. 23.26 under con-
scious sedation and local anesthesia, the areas of alopecia were excised
by tailoring the expanded scalp (left). The wound was closed with a
simple running 3–0 Prolene suture (center). Approximately 50 grafts
were placed between sutures to camouflage the closure further. Three
months postoperative, she shows excellent hair density (right).
Fig. 23.28 This 43-year-old man sustained 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 the
author for restoration of frontotemporal, left frontotemporal-parietal,
sideburn, and eyebrow hair. (a) He requested postponing eyelash
reconstruction. (b) He received a single session of 1,525 follicular unit
micrografts and minigrafts to both temples and the frontal hairline and
125 grafts to each eyebrow. (c) He returned 8 months postoperatively for
a second session to increase his hair density further.
a
b
c

 &OiniFDO 'eFiViRn 0DNing in +Dir 7rDnVSODnWDWiRn
257
an awning, 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 (Fig. 23.25). Eyelash reconstruction is suggested for
the following conditions:
• Congenital absence of eyelashes
• Eyelash loss from traumatic injury, burns, or dermatologic
disease
• Eyelash loss caused by oncologic surgery or radiotherapy
• Iatrogenic loss resulting from the use of silver nitrate to pre-
vent trachoma
Some anatomic features are especially noteworthy for
successful eyelash reconstruction. The central portion of the
orbicularis oculi muscle covering the eyelid is referred to as the
palpebral portion. This is further divided into the preseptal and
pretarsal muscles based on their relationship to the underlying
orbital septum and the tarsal plate, respectively (Fig. 23.29).
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 (of Moll) and sebaceous
glands (of =eis) 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 adherent to
the preseptal muscle (Fig. 23.30).
The patient in Fig. 23.31 requested restoration of the eye-
lashes over a small segment of the lower eyelid. I recommended
a strip graft and 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 follicular unit grafts, provides additional
control.
23.4 Choosing the Best Option
Recommended procedures for hair restoration in the various con-
ditions discussed in this chapter are summarized in Table 23.3.
Fig. 23.29 Anatomic features especially noteworthy for successful
eyelash reconstruction. The central (palpebral) portion of the orbicu-
laris oculi muscle covering the eyelid divided into the preseptal and
pretarsal muscles based on their relationship to the underlying orbital
septum and the tarsal plate, respectively.
Fig. 23.30 Sagittal section through the upper eyelid showing the
superficial and middle structures of the upper eyelid, including the
levator aponeurosis, preseptal and pretarsal portions of the orbicularis
oculi muscle, and eyelid skin. The drawing also demonstrates the
relationship of the pretarsal portion of the orbicularis oculi muscle,
eyelash hair follicle, and eyelid skin.
Fig. 23.31 (a) This 23-year-old man requested restoration of a small
segment of eyelashes in his left lower eyelid. A strip graft and a total
of five follicular unit micrografts to both the upper and lower eyelids
were recommended. (b) He had dense eyebrows, and since the area
of demand was small, a small donor strip was harvested from the
contralateral eyebrow in a spot that had good density with desirable hair
direction. (c) The strip was turned and positioned in the most desirable
orientation to mimic the missing eyelashes as best as possible. (d) He is
shown immediately after surgery with the scleral shield still in place and
(e) 1 year postoperatively.
d
a
e
b
c

258
IV Hair Transplantation
Clinical Caveats
• The follicular units should be maintained as intact as is
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 occipital area; for eyelashes and eyebrows I
usually use scalp hair, but pubic hair may be considered for
eyebrow reconstruction.
Suggested Reading
>1@ Barrera A. Discussion of Seyhan A, tation into a newly closed wound to conceal the final scar on the hair-bearing
skin. Plast Reconstr Surg 2000;105:1871
>2@ Barrera A. Hair transplantation. In Lin S-, Mustoe TA, eds. Lin and Mustoe’s Aes-
thetic Head and Neck Surgery. McGraw-Hill Plastic Surgery Atlas. 1ew McGraw-Hill Professional; 2013:196–201
>3@ Barrera A. Hair Transplantation: The Art of Micrografting and Minigrafting.
St. Louis, MO: 4uality Medical Publishing; 2002
>4@ Barrera A. Micrograft and minigraft megasession hair transplantation results
after a single session. Plast Reconstr Surg 1997;100(6):1524–1530
>5@ Barrera A. Micrograft and minigraft megasession hair transplantation: review of
100 consecutive cases. Aesthet Surg J 1997;17(3):165–169
>6@ Barrera A. Reconstructive hair transplantation of the face and scalp. Hair resto-
ration: state of the art. Semin Plast Surg 2005;19:159–166
>7@ Barrera A. Refinements in hair transplantation: micro- and minigraft megases-
sion. Perspect Plast Surg 1998;11(1):53–70
>8@ Barrera A. Surgical correction of alopecia in the male patient. eLearning course. St
Louis, MO: 4uality Medical Publishing, 2010
>9@ Barrera A. Surgical correction of alopecia secondary to face lift procedures.
eLearning course. St Louis, MO: 4uality Medical Publishing, 2010
>10@ Barrera A. The use of micrografts and minigrafts for the correction of the post-
rhytidectomy lost sideburn. Plast Reconstr Surg 1998;102(6):2237–2240
>11@ Barrera A. The use of micrografts and minigrafts for the treatment of burn alope-
cia. Plast Reconstr Surg 1999;103(2):581–584
>12@ Barrera A, Phillips LG, Barrera FF. Hair grafts in lower leg reconstruction. Plast
Reconstr Surg 2007;120(2):22e–25e
>13@ Buhrer DP, Huang TT, Yee H:, Blackwell S-. Treatment of burn alopecia with
tissue expanders in children. Plast Reconstr Surg 1988;81(4):512–515
>14@ Cronin TD. Use of hair-bearing punch grafts for partial traumatic losses of the
scalp. Plast Reconstr Surg 1968;42(5):446–449
>15@ Fujita K. Reconstruction of eyebrows. Leprosy 1953;22:364
>16@ Gandelman M. Eyebrow transplantation. Hair Transplant Forum Int 1994;4:17–18
>17@ Gandelman M. Eyelash reconstruction. Hair Transplant Forum Int 1996;6:18
>18@ Giraldo F, Gonzilez C, Garnica I, Ferrón M, Rus -A. Sideburn reconstruc-
tion with an expanded supraauricular trapezoidal flap. Plast Reconstr Surg
1997;100(1):257–261
>19@ Harii K, Omori K, Omori S. Hair transplantation with free scalp flaps. Plast Recon-
str Surg 1974;53(4):410–413
>20@ Hata Y, Matsuka K. Eyelash reconstruction by means of strip skin grafting with
vibrissae. Br J Plast Surg 1992;45(2):163–164
>21@ Headington -T. Transverse microscopic anatomy of the human scalp. A basis
for a morphometric approach to disorders of the hair follicle. Arch Dermatol
1984;120(4):449–456
>22@ Hernindez-=endejas G, Guerrerosantos -. Eyelash reconstruction and aes-
thetic augmentation with strip composite sideburn graft. Plast Reconstr Surg
1998;101(7):1978–1980
>23@ Hudson DA, Grobbelaar AO. The use of tissue expansion in children with burns of
the head and neck. Burns 1995;21(3):209–211
>24@ Kasai K, Ogawa Y, Takeuchi E. A case of sideburn reconstruction using a temporo-
parieto-occipital island flap. Plast Reconstr Surg 1991;87(1):146–149
>25@ Leighton WD, -ohnson ML, Friedland -A. Use of the temporary soft-tissue ex-
pander in posttraumatic alopecia. Plast Reconstr Surg 1986;77(5):737–743
>26@ Lucas M:. Partial retransplantation. A new approach in hair transplantation. J
Dermatol Surg Oncol 1994;20(8):511–514
>27@ Norwood OT. Classification of male pattern baldness. In 1orwood OT, Shiell R,
eds. Hair Transplantation Surgery, 2nd ed. Springfield, IL: Charles C Thomas,
1984
>28@ Seyhan A, Yoleri L, Barutou A. Immediate hair transplantation into a newly closed
wound to conceal the final scar on the hair-bearing skin. Plast Reconstr Surg
2000;105(5):1866–1870, discussion 1871
>29@ Tamura H. Pubic hair transplantation. Jpn J Dermatol 1943;53:76
>30@ Uebel CO. Micrografts and minigrafts: a new approach to baldness surgery. Ann
Plast Surg 1991;27:476–487
>31@ Vogel -E. Correction of the cornrow hair transplant and other common problems
in surgical hair restoration. Plast Reconstr Surg 2000;105(4):1528–1536, discus-
sion 1537–1541
Table 23.3 Choosing hair restoration procedures
Condition
Scalp
)ROOiFuODr uniW miFrRgrDIWV
Rne Rr WZR KDirV
)ROOiFuODr uniW minigrDIWV
WKree Rr IRur KDirV
Strip
grDIWV
(yeErRZ
donor
Tissue
expansion
Male pattern baldness
ü
ü
Female pattern baldness
ü
ü
Lost sideburn and retroauricular area hair
ü
Scalp burn alopecia and scalp-scarring alopecia
ü
ü
ü
Eyebrow restoration*
ü
ü
Eyelash restoration
ü
ü
ü
Mustache and beard restoration
ü
ü
Pubic hair restoration
ü
ü
Body and lower leg
ü
ü
*In selected cases.

 +Dir 7rDnVSODnWDWiRn )ROOiFuODr 8niW 0iFrRgrDIWing Dnd 0inigrDIWing²&urrenW 7eFKniTueV Dnd )uWure 'ireFWiRnV
259
24 Hair Transplantation: Follicular Unit Micrografting and
Minigrafting–Current Techniques and Future Directions
Alfonso Barrera
Abstract
In this chapter we review a brief history of hair transplantation
and then a step-by-step description of my preferred technique
for hair transplantation, embodying what I have learned over
the last 25 years doing this procedure. I show you how to con-
sistently obtain natural and aesthetically pleasing results with
minimal scarring. It is a labor-intensive procedure and requires
a skillful team. My preferred technique is the ´stick and place,µ
in which the surgeon makes the small incision at the graft recip-
ient site and the assistant inserts the graft immediately. So far,
I have personally transplanted every single graft myself on all
my patients. I will describe the details of equipment, instrumen-
tation needed, and preferred surgical blades and microscopes.
The most frequent cases of hair loss in my practice include male
pattern baldness, female pattern alopecia, scarring alopecia
secondary to previous surgeries (postrhytidectomy sideburn and
temporal hairline alopecia). The future of hair transplantation is
focused on bioengineering and cloning hair follicles.
Keywords
follicular unit grafts, follicular unit transplantation (FUT), fol-
licular unit extraction (FUE), female pattern alopecia, scarring
alopecia
24.1 Brief Historic Review of Hair
Transplantation
:ith the advances in hair transplantation technique available
today, we can truly provide natural and aesthetically pleasing
results, using one- and two-hair follicular unit grafts (micro-
grafts) and three- and four-hair follicular unit grafts (minigrafts).
I have incorporated hair transplantation into my practice for 25
years, and it constitutes 60 of my practice. Initially I was treating
primarily male pattern baldness (MPB), but soon thereafter, I
started finding other applications, particularly enhancing aes-
thetics in reconstructive cases of the face and scalp: scar alopecia
after facial rejuvenation surgery (the loss of the temporal hairline
and sideburn); alopecia due to trauma, burns, radiation therapy,
or congenital defects (e.g., bilateral cleft lip on male patients). This
procedure in some cases helps correct untoward effects of surgery
and may help conceal some of the ramifications of congenital
deformities.
A complete historic review of hair restoration procedures
is beyond the scope of this chapter. Suffice it to say that 1.
Orentreich from 1ew by introducing the use of punch grafts (hair plugs) in 1959. In
addition, he described the concept of donor dominance over 40
years ago, which is key to successful hair transplantation: that
essentially each individual hair follicle contains its own unique
genetic makeup and that, when transplanted to another site,
these unique genetic properties are preserved regardless of the
transplantation site. The hair will grow at the recipient area with
the characteristics and longevity of the donor site. Fortunately,
most individuals with MPB tend to lose their hair only on the
top and crown, sparing the temporal and occipital areas. When
utilizing these areas as donor sites, we can expect the growth to
be as permanent at the recipient site.
The old punch graft, or hair plug, technique resulted in an
unnatural look, giving the appearance of clumpy grafts (often 4
mm) containing high-density hair follicles separated by empty
spaces. A movement toward smaller grafts allowed hair trans-
plantation to move toward a more natural look.
The use of single-hair grafts is not a new concept; it was
described as early as 1943 by Tamura, who transplanted in the
pubic area, and then Fujita, who described reconstructing the
eyebrows in 1953.
Our goal is to use our artistic, technical skills and expertise in
a way that provides a final outcome that has natural feathering of
boundaries without clumping of the follicles with an appropriate
density for the anatomic region.
Great advances toward a natural result in hair transplantation
techniques have occurred in the past 4 decades. Ideally, success in
hair transplantation required very small follicular unit hair grafts
in large numbers. This was first described by 1ordstrom in 1981,
who used a large number of single-hair grafts to the front hairline
of the scalp to camouflage the clumpy appearance of existing
punch grafts. It was a tedious, time-consuming effort, and at the
time it seemed unrealistic to think about transplanting the whole
top of the head in this fashion.
Subsequently, Carlos O. Uebel in Brazil in 1991 was the first to
report in the literature the use of follicular unit micrografts and
minigrafts to cover the entire area of baldness, doing well over a
thousand grafts in a single session. Based on his work, I started
doing hair transplantation.
The use of micro- and minigrafts produced a more natural
appearance, eliminating the clumpy and cobblestoned appear-
ance seen with punch grafts, row or strip grafts, flaps, or scarring
associated with these techniques. The use of follicular unit micro-
grafts (one- and two-hair grafts) and follicular unit minigrafts
(three- and four-hair grafts) has become my preferred method of
hair transplantation because of the predictability of the results
without visible scarring on the recipient scalp and minimal scar-
ring on the donor site.
:hen considering donor hair harvesting techniques, I prefer
the strip method, in which a horizontal 1-cm-wide strip is har-
vested from the occipital area, extending often into the temporal
areas (10 to 25 cm in length, or longer depending on the number

260
IV Hair Transplantation
of grafts intended), allowing a tension-free closure, resulting in
minimal scarring. This method allows the preservation of at least
95 of the hair follicles harvested. Using 3.5ð loupe or 10ð micro-
scope magnification including background lighting translumina-
tion, intact follicular unit grafts can be incised parallel to the hair
shafts on both edges. The donor site is camouflaged immediately
by combing the hair down (hair is trimmed only on the donor
strip itself).
Recently another technique for donor hair harvesting has been
described: follicular unit extraction (FUE). This technique consists
of shaving a wide area of donor hair and using 0.8- to 1-mm
diameter sharp punch knives, either manually or with rotation
power or robotics, extracting the grafts individually. This can
be technically demanding, requiring great skill to avoid wastage
of hair follicles, of which in some cases up to 30 to 40 may be
wasted. The challenge lies in precisely incising the grafts parallel
to the hair shafts along their entire length. Additionally, the donor
site cannot be immediately camouflaged, as a large area of hair is
shaved.
Other surgical techniques described in the past to treat areas of
baldness include the following:
• Scalp reduction
• Scalp flaps
• Tissue expansion
These techniques are seldom used except in select cases where
tissue expansion and serial excisions may be beneficial.
Currently, we can only redistribute the patient’s own existing
hair roots (follicles), so a prerequisite to be a candidate for this
procedure is having a sufficient supply of donor hair. For success,
it is imperative to maintain a good supply and demand ratio.
:hen the ratio is unfavorable, we have to select what area of the
scalp is most important to transplant and leave some baldness in
a less important area. Alternatively, the patient could be deemed
not a candidate for hair transplantation. In our opinion, the front
hairline is more important than the crown area. It is important to
understand that as we age, the area of demand enlarges and the
area of supply shrinks.
24.2 Essentials for a Natural Result
in Hair Transplantation
Surgery
1. Small grafts: Graft individual follicular units: one- and two-hair
follicular unit grafts at the front hairline, two-, three- or four-
hair follicular unit grafts posterior to that.
2. Level of the hairline: There are no standardized measurements
for the ideal hairline in patients. These vary from person to per-
son, and we must aim for the most aesthetically pleasant level
and plan for the long term (6–9 cm from the eyebrows).
3. Design: There should be a slight irregularity to the hair pattern
to mimic nature.
4. Density: Sufficient density is needed to blend naturally with the
neighboring areas, generally a minimum of 70 to 100 hairs per
square centimeter.
5. Direction of hair growth: The direction of the hair and its growth
should be consistent with residual native hair, particularly at the
boundaries of the affected areas. Anteriorly at the front hairline,
the follicles are oriented at a 30ƒ angle and a slight left or right
direction. This can vary and may be straight on the sideburns.
At the temporal areas the most optimal direction often is in a
downward position, but it can be in a diagonal, posterior direc-
tion or occasionally a straight, posterior direction (Fig. 24.1).
6. Absence of detectable scarring: Of course today’s techniques
enable us to perform hair transplantation without visible scar-
ring. This is accomplished by using ultrafine scalpels, such as the
Fig. 24.1 The importance of the direction of hair growth, showing a case of scarring alopecia of the sideburn area, (a) before and (b) after
transplantation.
a
b

 +Dir 7rDnVSODnWDWiRn )ROOiFuODr 8niW 0iFrRgrDIWing Dnd 0inigrDIWing²&urrenW 7eFKniTueV Dnd )uWure 'ireFWiRnV
261
15ƒ or 22.5ƒ SharPoint blades (Surgical Specialties Corp., Read-
ing, PA) for transplantation of the hair follicular units, and doing
a slight trichophytic closure of the donor site and closing with-
out tension.
24.3 Technique for the Treatment of
Male Pattern Baldness
and Female Pattern Alopecia
24.3.1 Anesthesia and Preparation
The patient is placed in the supine position, under intravenous
(IV) sedation with midazolam (Versed) and fentanyl (Sublimaze)
as well as occipital and supraorbital nerve blocks with 0.5 bupi-
vacaine (Marcaine) with epinephrine 1:200,000 (Fig. 24.2a, b).
Once the area is locally well anesthetized, we use tumescence
infiltration along the donor ellipse, allowing for hemostasis
and ease of graft dissection (Fig. 24.2c). Our wetting solution
consists of the following:
• 120 mL of normal saline with 20 mL of 2 plain Xylocaine
• 1 mL of epinephrine 1:1000
• 40 mL of triamcinolone (.enalog)
The same solution is used to infiltrate both the donor and the
recipient area. By adding .enalog, we have found significantly less
postoperative pain and edema. :e generally use a total of about
150 mL of tumescence solution throughout the procedure at both
the donor and recipient sites.
24.3.2 Donor Ellipse Harvest
A horizontal ellipse of scalp is harvested from the occipital
area, often extending to the temporal areas, frequently from
above the ear on one side to above the ear on the other side.
The ellipse will vary in dimensions depending on the number of
grafts planned and the density of the donor site. :hen we plan
on 2,000 or more grafts, the ellipse will measure 20 to 25 cm ð 1
cm. It is imperative to avoid tension at the closure, allowing for
Fig. 24.2 Anesthesia preparation and donor strip harvest. (a) Supraorbital and supratrochlear nerve blocks with 0.5% bupivacaine (Marcaine) with
epinephrine 1:200,000. (b) Reinforcing the block just in front of the proposed hairline. (c) Infiltration of the donor ellipse, starting at the caudal
margin. (d) Making incision using a no. 10 scalpel blade, incising parallel to the hair shafts. (e,f) One side of donor site closed with 3–0 Prolene simple
running suture. (g) The head is turned to the right to enable harvest of the other half of the donor strip. (h) Donor site closed on the left side (3–0
Prolene simple running suture).
a
d
g
b
e
h
c
f

262
IV Hair Transplantation
optimal healing and preservation of donor site hair. :e begin by
harvesting the right half of the donor ellipse under 3.5ð loupe
magnification. Incisions are made precisely parallel to the hair
shafts (Fig. 24.2d, e).
The plane of dissection is just deep to the hair follicles and
superficial enough to avoid injury to significant vessels and sen-
sory nerves. This results in the preservation of a small amount
of subcutaneous fatty tissues over the galea or fascia. The site is
closed without the need to undermine using a continuous running
suture of 3–0 Prolene. The contralateral side is then harvested
and closed while assistants dissect grafts from the right side (Fig.
24.2f; Fig. 24.2g; Fig. 24.2h).
24.3.3 Graft Dissection
The assistants work under microscope at 10ð magnification
(Fig. 24.3a). Using background lighting and a transparent sterile
silicone block is important for increased visualization of the
follicular units (Fig. 24.3b). Using a no. 10 blade and jeweler’s
forceps, the assistants process the donor ellipse into 1.5- to
2-mm-thick slices and subsequently dissect it into follicular unit
grafts as the surgeon continues the donor site harvesting and
closure (Fig. 24.3c). The harvested scalp and all slices and grafts
are kept chilled in normal saline until transplanted (Fig. 24.3d).
The thin slices are next dissected into one- and two-hair fol-
licular unit micrografts and three- and four-hair follicular unit
Fig. 24.3 Dissection of follicular unit grafts from the donor strip. (a) Use of 10ð magnification with microscope. (b) Use of background lighting and
a transparent sterile silicone block is important for increased visualization of the follicular units. (c) Notice a needle securing the tail of the strip,
allowing for traction and countertraction, facilitating the dissection. (d) The harvested scalp and all grafts are kept chilled in normal saline until
transplanted. (e) Dissection of the thin slices into one- and two-hair follicular unit micrografts and three- and four-hair follicular unit minigrafts with
background lighting and use of no. 10 scalpel blades and magnification. (f) Close-up view of one-, two-, and three-hair follicular unit grafts. (g) Lining
up the grafts in groups of 10 by 10 (groups of 100).
a
d
f
b
e
g
c

 +Dir 7rDnVSODnWDWiRn )ROOiFuODr 8niW 0iFrRgrDIWing Dnd 0inigrDIWing²&urrenW 7eFKniTueV Dnd )uWure 'ireFWiRnV
263
minigrafts, again using background lighting, no. 10 scalpel blades,
and magnification (Fig. 24.3e). This is the most tedious part of the
procedure but one of the most important steps. The grafts must
be handled gently and atraumatically. The darker and thicker the
individual hair shafts, the easier it is to dissect the grafts. The ideal
grafts have intact hair shafts all the way from the subcutaneous
fatty tissue to the scalp surface and contain from one to four hairs
each, as they come in nature (Fig. 24.3f). Several hundred grafts
will have been dissected at this point. They are lined up in rows on
a wet green or blue surgical towel and are ready for insertion (Fig.
24.3g). The process of graft dissection and insertion continues
until all the grafts are transplanted. It is imperative to keep the
grafts wet, as desiccation damages the hair bulbs.
24.3.4 Graft Insertion
Our team uses a stick-and-place technique. Infiltration of tumes-
cent solution into the recipient area is important for several
reasons, the most important of which are to promote hemostasis
and to produce temporary edema of the scalp, which facilitates
graft insertion. The surgeon makes the small incision, and then
the assistant slides the graft into position with the use of jewel-
er’s forceps (Fig. 24.4; Fig. 24.5).
Due to the nature of these procedures, it is very important to
have a good surgical team, enabling cases to go smoothly and
obtain optimal results. :e have two registered nurses (R1s) and
one surgical assistant on the team, with me personally inserting
every single graft on all my patients.
One R1, under my supervision, administers the IV sedation
(midazolam and fentanyl as stated previously) and circulates
while I harvest the donor strip with one assistant. :hile the
assistants are preparing the grafts, I see office patients for about
an hour and then return to begin transplanting the first 500 grafts.
I select where each graft goes and its orientation, making the
incision with the blade in the desired direction of growth. This is
followed by insertion of the graft by one of the assistants. This is
repeated until the procedure is complete. This is a time-consuming
process and often takes our team 4 to 6 hours depending on the
number of grafts being performed. Most of our sessions range
from 1,500 to 2,800 grafts per session (Fig. 24.6).
24.3.5 Postoperative Care
For dressing we use Adaptic (-ohnson -ohnson, 1ew Brunswick,
1-) impregnated with bacitracin/polymyxin B ointment (Polysporin,
-ohnson -ohnson, 1ew Brunswick, 1-), .erlex bandages (Cardinal
Fig. 24.4 Stick-and-place technique. The surgeon makes the small
incision, and the assistant slides the graft into position with the use of
jeweler’s forceps. (Reproduced with permission from Barrera A, Uebel
CO. Hair Transplantation: The Art of Follicular Unit Micrografting and
Minigrafting. 2nd ed. St Louis MO: 4uality Medical Publishing; 2014.)?
Fig. 24.5 Graft insertion. (a) Using the 22.5° SharPoint blade ready to create a recipient site. (b) Now creating the recipient site, angling the blade in
the desired direction for the hair growth. (c) Graft being inserted by the assistant with jeweler’s forceps. (d) The tip of the SharPoint blade holds the
graft in place as the jeweler’s forceps come out. (e) SharPoint blade.
a
d
b
e
c

264
IV Hair Transplantation
Health, Dublin, OH) and a 3-inch Ace bandage (3M, St. Paul, M1)
for the first 48 hours (Fig. 24.7), then allow the patient to shampoo
gently daily. The sutures are removed on the 10th day.
The after care is simple and safe, reinforcing to the patient the
need to be gentle with the scalp for the first 2 weeks. A large portion
of the transplanted hair will go into telogen (rest phase) and will
shed in the first 2 to 3 weeks. It is very important that the patient
understands the natural evolution of the grafts. At 12 to 14 weeks
the follicles shift into anagen (growth phase) and the hair begins
to grow, most noticeable by the third or fourth month. During the
ensuing 6 to 10 months the hair will gain length and thickness,
with the final result evident at 1 year following the procedure. If the
patient desires greater hair density, additional sessions can be done.
24.3.6 Examples
Example 1
The 60-year-old man with MPB, 1orwood type VI, shown in Fig.
24.8a received a single session of 1,500 follicular unit grafts to
the front scalp area. Minimal grafting was done to the crown
because he had limited donor hair. Simply restoring the front
hairline produced a significant degree of aesthetic improvement
and rejuvenation, as seen 1 year later in Fig. 24.8b.
Example 2
The 61-year-old man with MPB type V in progress to type VI
shown in Fig. 24.9 received a single session of 2,600 follicular
unit grafts.
Example 3
The 52-year-old man with MPB type II shown in Fig. 24.10
desired to have his front hairline brought forward 1.5 cm and as
dense as possible. It took four sessions of follicular unit grafting
to get the degree of density shown, comprising approximately
2,800 grafts total, all in the front.
Example 4
The 29-year-old man with MPB type II shown in Fig. 24.11
desired his front hairline to be moved anteriorly 2.5–3 cm. He
received approximately 1,000 follicular unit grafts.
Example 5
The 59-year-old woman with female androgenic alopecia (FAA)
Ludwig type II shown in Fig. 24.12 received a single session of
1,800 follicular unit grafts.
Fig. 24.6 (a) The author personally inserts every single graft. (b) End of surgery, view from the head of the table. (c) End of surgery front view. (d)
End of surgery, left side view.
a
c
b
d

 +Dir 7rDnVSODnWDWiRn )ROOiFuODr 8niW 0iFrRgrDIWing Dnd 0inigrDIWing²&urrenW 7eFKniTueV Dnd )uWure 'ireFWiRnV
265
24.4 Correction of Scar Alopecia
Secondary to Facelift
Procedure
Facelift incisions may result in a variable degree of cephalic and
posterior advancement of the temporal hairline and sideburn,
creating an unsightly stigma of a poorly performed facelift.
Other areas that may be distorted following rhytidectomy pro-
cedures may include alopecia of the retroauricular hairline and
elongation of the forehead following brow lift procedures.
These deformities can predictably and consistently be cor-
rected by using follicular unit hair transplantation techniques. :e
first reported our technique for the correction of this condition
in 1998. It is essential to place very small single- and double-hair
grafts in a natural direction, downward or posterior, to match the
patient’s hairline.
For the treatment of sideburn alopecia we prefer to use the
occipital area for the donor site. Most patients have sufficient
donor hair to restore the sideburns and the temporal and retroau-
ricular hairline, as it is not a large area, but confirmation should be
done to ensure the supply-to-demand ratio is favorable.
Expectations must be realistic, and the patient should be aware
that a second session may be required to obtain sufficient hair
density.
For these deformities we may utilize between 300 and 1,500
grafts per session, depending on the degree of alopecia and the
size of the area to be covered. :e address this area just as in cases
of MPB and FAA (Fig. 24.13).
24.5 Complications
:hile hair transplantation is a very safe procedure, minor com-
plications can sometimes occur.
Fig. 24.7 Postoperative dressings. (a) Several layers of Adaptic impregnated with Polysporin ointment, anterior view. (b) Adaptic impregnated with
Polysporin, lateral view. (c) On top of the Adaptic are two Kerlex bandages and a 3-inch Ace bandage; anterior view. (d) Kerlex and Ace bandages,
lateral view.
a
c
b
d

266
IV Hair Transplantation
Fig. 24.8 Man aged 60 with Norwood type VI male pattern baldness, (a) before and (b) a year after a single session of 1,500 follicular unit grafts
to the front scalp area. By simply restoring the front hairline a significant degree of aesthetic improvement and rejuvenation was accomplished.
(Procedure by Alfonso Barrera, M.D.).
a
b
Fig. 24.9 A 61-year-old man with male pattern baldness type V in progress to a VI (a,c,e,g,i,k) before and (b,d,f,h,j,l) a year after a single session of
2,600 follicular unit grafts. If the patient desires further hair density, a second session can be done any time after a year postoperatively.
a
e
i
b
f
j
c
g
k
d
h
l

 +Dir 7rDnVSODnWDWiRn )ROOiFuODr 8niW 0iFrRgrDIWing Dnd 0inigrDIWing²&urrenW 7eFKniTueV Dnd )uWure 'ireFWiRnV
267
24.5.1 Ingrown Hairs and Cysts
The most frequent complication after hair transplantation is
ingrown hairs and cysts. This may occur when the grafts are
placed too deep, which allows the recipient scalp to heal on top
of the graft, creating a cyst. :hen doing large procedures such as
2,000 grafts, one may encounter a few cysts in the postoperative
period. If mild they are self-resolving, eventually erupting and
draining spontaneously. Occasionally treatment may require
digital compression or an 18-gauge needle to facilitate drainage.
24.5.2 Widening of the Donor Site Scar
Widening of the donor site scar is due to tension at the closure
and incisions that were not parallel to the hair shafts (resulting on
excision of hair roots at the closure). This can usually be avoided
by accurate dissection and closure with minimal tension.
Fig. 24.10 (a,c,e) A 52-year-old man with type II male pattern baldness
desired the front hairline brought forward 1.5 cm and as dense
as possible. (b,d,f) It took four sessions of follicular unit grafting,
including approximately 2,800 grafts total, all in the front, to get this
degree of density.
a
c
e
b
d
f
Fig. 24.11 This 29-year-old man with male pattern baldness type II
desired his front hairline to be moved anteriorly 2.5–3 cm. (a) Before.
(b) Immediately post approximately 1,000 follicular unit grafts. (c)
Ten days postoperative; usually most or all of the scabs have come off
by then. (d) Six months postoperative, showing nice improvement,
but the final result takes a year. (e) One year postoperative. Optionally
more grafts can be added after this.
a
c
e
b
d
Fig. 24.12 This 59-year-old woman presented with female androgenic alopecia Ludwig type II. (a) Before and (b) a year after a single session of 1,800
follicular unit grafts.
a
b

268
IV Hair Transplantation
24.5.3 Keloids
.eloids are extremely rare; harvesting too caudally (near the
lower boundary of the occipital hairline) is more prone to this
complication.
24.6 Future Directions
The idea of replication of a single hair into thousands of hairs
suitable for transplantation remains an exciting frontier for hair
transplantation. Many bioengineering centers worldwide con-
tinue trying to clone hair follicles. There are many patients with
limited or almost no available donor hair who would immensely
appreciate this technique when it becomes possible.
24.7 Concluding Thoughts
The use of follicular unit grafts, both micrografts and minigrafts,
for hair transplantation is a safe and predictable procedure to
help correct male pattern baldness, female pattern alopecia,
and hair loss secondary to facial rejuvenation surgery as well as
many other types of scarring alopecias. These procedures result
in high patient satisfaction.
Clinical Caveats
• Make sure to spend the necessary time to explain to the
patient what is possible and what is not. Make sure realistic
expectations are established.
• More than a single session may be required for optimal
correction.
• It is important for both the surgeon and patient to under-
stand the supply and demand ratio. It is ideal to have a high
hair density donor area and a limited area of hair loss.
• If there is limited or not enough hair density, it is better not to
do the hair transplantation.
• The future of hair transplantation lies with cloning and bioen-
gineering of grafts.
Suggested Reading
>1@ Barrera A. Micrograft and minigraft megasession hair transplantation: review of
100 consecutive cases. Aesthet Surg J 1997;17(3):165–169
>2@ Barrera A. Micrograft and minigraft megasession hair transplantation results
after a single session. Plast Reconstr Surg 1997;100(6):1524–1530
>3@ Barrera A. Refinements in hair transplantation: micro- and minigraft megases-
sion. Perspect Plast Surg 1998;11(1):53–70
>4@ Barrera A. Hair Transplantation: The Art of Micrografting and Minigrafting, 1st ed.
St. Louis, MO: 4uality Medical Publishing; 2002
Fig. 24.13 This 59-year-old woman had scarring alopecia secondary to a facelift procedure. (a,d) Preoperative. (b) Preoperative marking, right side.
(c,e) Six months post single session of 1,200 follicular unit hair grafts between both sides.
a
d
b
e
c

 +Dir 7rDnVSODnWDWiRn )ROOiFuODr 8niW 0iFrRgrDIWing Dnd 0inigrDIWing²&urrenW 7eFKniTueV Dnd )uWure 'ireFWiRnV
269
>5@ Barrera A, Uebel CO. Hair Transplantation: The Art of Follicular Unit Micrografting
and Minigrafting, 2nd ed. St. Louis MO: 4uality Medical Publishing; 2014
>6@ Barrera A. The use of micrografts and minigrafts for the correction of the post-
rhytidectomy lost sideburn. Plast Reconstr Surg 1998;102(6):2237–2240
>7@ Barrera A. Correcting retroauricular hairline deformity after face lift. Aesthet Surg
J 2004;24(2):176–178
>8@ Harris -A. Follicular unit extraction (FUE). In: Unger :, Shapiro R, Unger
M, Unger R, eds. Hair Transplantation, 5th ed. London, U.: Informa Health-
care;2010:23–34
>9@ Headington -T. Transverse microscopic anatomy of the human scalp. A basis
for a morphometric approach to disorders of the hair follicle. Arch Dermatol
1984;120(4):449–456
>10@ 1ordstr|m REA. ´Micrograftsµ for improvement of the frontal hairline after hair
transplantation. Aesthet Plast Surg 1981;5:97–101
>11@ Orentreich 1. Autografts in alopecias and other selected dermatological condi-
tions. Ann N Y Acad Sci 1959;83:463–479
>12@ Uebel CO. Micrografts and minigrafts: a new approach for baldness surgery. Ann
Plast Surg 1991;27(5):476–487

270
IV Hair Transplantation
25 5eRSerDWiRn 5eÀnemenW Dnd 7reDWmenW RI &RmSOiFDWiRnV
after Hair Transplantation
Jack Fisher
Abstract
This chapter analyzes the many factors that can lead to an
unsuccessful hair transplant. Once the source of the problem
has been identified, the next step is planning and executing a
solution. These two basic steps³proper analysis of the etiology
of the problem and creating a solution³are both critical in order
to resolve the unsatisfactory hair transplant.
Sources of failure are described, including improper patient
selection, inappropriate hairline design, and failure to evaluate the
patient’s family history. Some patients were poor candidates for a
hair transplant and should not have had the procedure originally.
Poor surgical technique and surgical complications are further
possible causes.
Another critical factor in reducing potential complications
in the long term is designing a hairline that is both age- and
gender-appropriate. Extremely low hairlines in men frequently
lead to problems as they age. Also, a curved or rounded hairline
usually creates a feminizing appearance. Another obvious prob-
lem is an extremely straight hairline without irregularity or
feathering, creating an artificial appearance. Methods to correct
these untoward outcomes surgically are discussed in detail.
In the final analysis, an ideal hair transplant should not be iden-
tifiable but should enhance the facial aesthetics of the patient,
whether male or female.
Keywords
patient selection, hairline, family histories, age-appropriate, fol-
licular units, hair angulation, graft excision, traumatic hair loss
25.1 Introduction
Hair transplantation is one of the most frequently performed
aesthetic surgery procedures in men today. The goal is hair
restoration that is natural and virtually imperceptible. A poorly
designed or executed procedure will result in a highly visible and
unnatural hairline. Despite its popularity, this procedure often
results in unsatisfactory aesthetic outcomes. The causes of these
problems and solutions for addressing them are the focus of this
chapter.
Before defining the problems that create bad results in hair
transplantation, one must identify the components of a natural
hairline. :ithout knowledge of what defines the normal, it is dif-
ficult to discuss the abnormal. A successful hair transplant should
look totally natural, with a hairline that is irregular, feathered, and
age-appropriate.
When considering a patient for hair transplantation, the
surgeon must realize that hair loss is progressive. Probably no
single factor is as important or has led to so many poor results as
when the progressive nature of hair loss is ignored. The location
of the frontal hairline is another key factor. :hat looks good
in an 18-year-old young man will usually not be appealing in a
45-year-old. Therefore, it is important to design a frontal hairline
that will be aesthetically acceptable over a long period as the
patient’s face matures and hair loss continues. High hairlines
rarely look bad, but extremely low hairlines can be a disaster. One
of the most critical anatomic components of a natural hairline
is the frontotemporal angle. Rounding off this angle with hair
transplants usually leads to a bizarre appearance, especially as
the patient ages.
Aesthetic surgeons frequently place a high premium on obtain-
ing symmetrical results in most procedures. However, in hair
transplantation, a perfectly straight, symmetrical hairline, even
with the use of micrografts, is destined to look artificial, as can
be seen in the patient in Fig. 25.1, who had a large number of
transplants placed in an extremely straight line. Irregularity and
asymmetry are the hallmarks of a natural-appearing hairline.
25.2 Common Problems Requiring
Reoperation
Unsuccessful hair transplants generally share similar charac-
teristics:
• The hairline is too even and straight.
• The frontotemporal angle has been blunted.
• Large plug grafts have been used.
• The transplanted hair fails to grow.
• The hairline is too low.
• The hair has been transplanted at an incorrect angle.
Transplants done with large plug grafts represent a major
problem (Fig. 25.2; Fig. 25.3). Unfortunately, many individuals
have undergone these procedures over the past three decades.
Careful analysis is required to correct or improve these difficult
cases. Often there is significant scarring in the donor site, because
a coring device was used to remove grafts containing 10 to 40
hairs at a time. Frequently the donor site was allowed to heal by
secondary intention, resulting in significant scarring. Many of
these patients have little if any available donor hair remaining for
further grafting.
In individuals with adequate donor hair, a significant improve-
ment can be achieved by excising the old plugs, recutting and
recycling this hair, and using small one- to three-hair grafts for
further transplantation. This improvement, however, can be
accomplished only if sufficient residual donor hair is available.
Scalp excisions and forehead advancement procedures are
important adjuncts in these difficult secondary cases.

 5eRSerDWiRn 5eÀnemenW Dnd 7reDWmenW RI &RmSOiFDWiRnV DIWer +Dir 7rDnVSODnWDWiRn
271
Another problem is the failure of transplanted grafts to take.
In healthy patients, the graft-take rate should exceed 90. Small
one- to three-hair grafts, properly created, will rapidly undergo
neovascularization, and in a healthy patient most of this hair
should grow. However, if the grafts are poorly prepared, the
success rate falls off drastically. It takes a considerable amount of
time and experience for a surgeon to be able to create these small
grafts, and a well-trained team is critical for a successful outcome.
One of the most difficult problems to correct successfully is
a hairline that has been placed too low. As the patient ages, the
hair recedes, leaving a bizarre, isolated frontal hairline. Often the
only solution is an aggressive procedure that involves resection
of these grafts combined with a forehead lift with regrafting
(Fig. 25.4).
Finally, there is the group of patients who have had cosmetic
surgery and experienced secondary hair loss, such as after a
facelift or a coronal brow lift. In a patient who has undergone a
facelift, temporal hair loss is the most common; it is caused by
either excess skin tension or superficial undermining with direct
damage to the hair bulbs. Hair loss is usually related to tissue isch-
emia. In many of these patients, the hair will regrow after 6 to 9
months, and a conservative approach is best. In some individuals
the hair fails to regrow, and transplantation is an ideal solution.
Traumatic alopecia, which usually occurs from hair bulb ischemia,
may be caused by factors other than cosmetic surgery. Prolonged
pressure on the scalp, such as in a comatose patient, can also
lead to hair loss without ischemia of the scalp. The skin is more
tolerant of ischemia than the hair bulbs are.
25.3 Evolution of Technique
In 1959 Orentreich published a landmark report on the use of
punch grafts to treat male pattern baldness, thereby establishing
punch grafts as the standard treatment for almost three decades.
Fig. 25.1 A perfectly straight, symmetrical hairline, even with the use
of micrografts, is destined to look artificial.
Fig. 25.2 This patient had plug grafts to thicken his frontal hairline in
his early 20s. As the hair surrounding the unsightly plugs fell out with
aging, the large plug grafts became exposed, creating this noticeable
deformity.
Fig. 25.3 A common problem when a young patient undergoes a
hair transplantation procedure at too early an age is the creation of a
permanent frontal fringe with extensive baldness behind it. The use of
large plug grafts makes the deformity even more noticeable.
Fig. 25.4 One of the most difficult problems to correct successfully is
a hairline that has been placed too low. As the patient ages, the hair
recedes, leaving a bizarre, isolated frontal hairline. Often the only
solution is an aggressive procedure that involves resection of these
grafts combined with a forehead lift with regrafting.

272
IV Hair Transplantation
Although results achieved with this technique may have been
reasonable at that time, the abnormal ´cornrowµ appearance they
produced was far from aesthetic. These grafts were harvested
with a 3.5- to 5.0-mm punch, producing plugs containing a large
number of hairs. This technique created two major problems: (1)
a severely scarred donor site in the posterior scalp, because the
donor holes were allowed to heal by secondary intention, and (2)
an unnatural recipient site with the classic cornrow appearance.
Eventually, smaller plugs containing six to eight hairs were
used, but this still resulted in an unnatural appearance. It was
not until the early 1990s that physicians began to recognize that
donor grafts containing the follicular units (naturally occurring
clusters in which hair grows) of one to three hairs were the key
to producing natural results. By transplanting the hair in these
smaller units, the cornrow appearance is avoided.
The other great advance in the evolution of hair transplantation
occurred with the development of the technique for transplanting
large numbers of hairs in one session. Pioneers such as Carlos
Uebel and others developed techniques whereby 1,000 to 2,000
follicular units could be transferred at one time. Thus, the com-
bination of small grafts composed of anatomically correct one- to
three-hair units and the ability to transfer a large number of grafts
rapidly in a single ´megasessionµ produced a revolution in hair
transplantation.
25.4 Indications and
Contraindications
The patient’s age, family history of hair loss, current hair pattern,
amount of hair remaining, and expectations are all important
factors in selecting potential candidates for reoperative hair
transplantation. Patients with minimal hair loss are the best
candidates for primary³and, in particular, secondary³hair
transplantation procedures and are much more likely to be
satisfied after hair transplantation.
Patients in their late or early 20s and those in their teens are
rarely appropriate candidates. These young patients often develop
a receding hairline later in life and may wish to fill in the anterior
hairline they previously had. Such a procedure is usually a major
mistake, because with progressive hair loss the patient will be
left with an isolated frontal fringe with balding areas behind the
transplanted rows. An attempt to create a juvenile hairline by
rounding off the temporal recession is also a mistake in a young
patient. Patients who demand an inappropriate hairline should be
excluded from surgery; otherwise, both the patient and the doctor
at some time in the future will regret the procedure (Fig. 25.2).
Another common problem when a young patient undergoes a
hair transplantation procedure at too early an age is the creation of
a permanent frontal fringe with extensive baldness behind it. The
use of large plug grafts makes the deformity even more noticeable
(Fig. 25.3). However, in this patient, even if small natural grafts
had been inserted originally, the effect would still look unnatural
because of the extensive baldness that evolved over the years
behind the grafts. The major point demonstrated by this case is
not to perform transplantations too early.
A patient with extensive hair loss with only a thin posterior and
lateral remaining fringe is also a poor candidate for reoperative
hair transplantation. Such a patient can be given a frontal hairline,
but if complete coverage of the area of alopecia is the goal, the
patient will likely be disappointed after the procedure. Caution
should also be exercised when attempting hair transplantation
in the occipital area. In young patients or those with extensive
hair loss, overly aggressive transplantation in this region can
lead to a strange ´haloµ pattern, with a permanent tuft of central
occipital hair surrounded by a bald ring or halo that progresses
as the patient ages and hair recedes. It is important to explain to
the patient the possible ramifications of overly aggressive hair
transplantation in this area. Thus, in younger patients it is prudent
to graft the frontal and superior regions of hair loss initially and
to observe over time the evolution of the patient’s hair loss. If a
young patient with fairly extensive hair loss rejects a high hairline
with temporal recession, this patient is not a good candidate for
transplantation.
As in all aesthetic surgery procedures, it is essential that the
patient be fully informed to ensure ultimate patient satisfaction.
This is even more important in an unhappy patient who has had
a poor result and wants revision. Realistic expectations must be
established before the surgeon considers reoperating on such
patients, based on the results of previous surgery and what
available donor hair tissue remains. The patient with a poor result
from 20 years ago who expects a miracle should be excluded from
surgery. Some of these patients must resign themselves to wearing
a hairpiece either to cover up a poor result in the recipient area or
to cover excessive scarring in the donor site from previous punch
grafting. In other areas of cosmetic surgery, such as a facelift, the
procedure can be repeated over time. However, a patient with
male pattern baldness has limited donor hair; therefore, it is crit-
ical to set appropriate goals with the patient based on this simple
anatomic fact.
25.5 Preoperative Assessment
Preoperative assessment focuses on the recipient site to evaluate
the results of the transplantation, as well as the donor site to
assess residual scarring and the amount of available donor hair.
The recipient site should be examined to determine whether the
hairline was placed in the correct location³not too high or too
low³and whether it was properly created. That means it has
an irregular line with a natural temporal recession. A common
problem after hair transplantation, especially in the past, was
creation of a straight hairline. Hairlines need to be irregular;
even a properly located hairline with small grafts in the correct
location will look unnatural if it is perfectly straight.
After assessing the recipient area, the physician must critically
evaluate the potential donor site if further grafting is to be con-
sidered. In the past, donor grafts were harvested with punches,
and the residual donor area was allowed to heal by secondary
intention, creating a significant amount of scar tissue. Eventually,
physicians began to use linear excision of the donor site with
primary closure. This became the standard, which significantly
reduced scarring in the donor area. Unfortunately, in the past and
even today, some surgeons make multiple parallel incisions each
time they harvest donor hair, which results in multiple transverse
scars in the posterior recipient area. This technique is rarely
necessary. Most patients can undergo at least two or three repeat
procedures over time using a single donor site and creating a