Atlas Phẫu Thuật Thẩm Mỹ (Tập 2) – Atlas of Cosmetic Surgery

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Tumescent liposuction  •  Chapter 21
following 3–4 weeks. Compression is particularly important for
the neck, upper arms, upper inner thighs, and the abdomen.
If preoperative antibiotics were initiated, they are usually
continued for 5–7 days postoperatively. The patient is in­
structed not to shower for the first 24–48 hours to decrease
the risk of infection. For the same reason, the patient should
not bathe in a tub or sit in a jacuzzi until all incision sites have
healed. Patients should be informed of the signs of possible
infection, such as fever, chills, increased pain or redness and
told to notify the physician immediately if there is concern.
Since the lidocaine plasma peak level may actually occur
after the patient has left the office, it is imperative that the pa­
tient also be aware of the signs of lidocaine toxicity: difficulty
speaking, ringing in the ears, tremors or tingling around the
mouth, confusion. We prefer to have patients in the company
of another person for 12–24 hours after surgery so they are
not left unattended.
The patients are asked to not drink alcohol for 3 days after
surgery, refrain from smoking for as long as possible, and to
avoid strenuous activity for 1 week. They are encouraged to
drink fluids and have a soft diet for the first 24 hours, after
which they may resume their regular diet.
Edema, ecchymosis, dysesthesia, fatigue, and soreness are
common complaints which improve with time. Wearing the com­
pression garments will also improve these symptoms. For this rea­
son, some patients will choose to wear their garments for many
weeks after the procedure. Areas which become firm to the touch
can be gently massaged, twice a day for 10–15 minutes until they
resolve. This usually occurs between weeks 2–4. Dysesthesia of
the overlying skin tends to resolve over 1–3 months, and some
patients may complain of an ‘itchy’ sensation. It is important to
inform the patient that this is a normal phenomenon.
Development of a hematoma, seroma (Fig. 21-49), infection,
or drug reaction is indication to see the patient immediately. Early
intervention is key. Hematomas may require drainage, or even
surgical exploration. Seromas require aspiration, often serially
over several days. The physician must again confirm that the pa­
tient is being compliant with compression garment use, as poor
compliance is often a cause of hematoma or seroma formation.
Drug reactions may be confused with cellulitis, neither of which
should go untreated in the liposuction patient. Antibiotics should
be promptly changed if a drug reaction is suspected. Incision site
cultures, as wells as urine and blood cultures should be obtained
if systemic infection is suspected. Hospital admission should be
considered depending on the clinical scenario.
Some degree of entry site scars should be expected by the
patient, and followed clinically for improvements over a year. A
double-blind study evaluating the healing of cannula incisions
with and without sutures demonstrated that the sutured sites
healed more slowly and left more visible scars.60 Therefore,
it is recommended that incision sites are not sutured at the
conclusion of the procedure. In patients with light skin, inci­
sion sites initially turn red by 1–2 weeks, and fade completely
by 3–6 months, leaving a small porcelain-white scar 2–4 mm
in length. Patients with olive or dark skin should be told to
expect some degree of postinflammatory hyperpigmentation,
with resolution over 6–12 months.
Persistent edema and dysesthesia (usually hypoesthesia) can
be troubling to the patient. Lower leg edema is common, par­
ticularly following calf liposuction. Leg elevation and prop­
erly fitting compression garments are essential. Acute-onset
edema in the immediate postoperative period necessitates
an evaluation for deep venous thrombosis (DVT). Although
DVT is very uncommon in the postoperative period follow­
ing tumescent liposuction, women on oral contraceptives and
those with a family history of DVT may be particularly at
risk. Edema of the distal arm is occasionally seen after arm
liposuction, and is often due to garment constriction at the
forearm. A change in garments will usually correct this, along
with elevation of the affected limb.
After the initial dressing change on postoperative day 1, pa­
tients are seen again 1 week postoperatively to assess healing
and effectiveness of garments. Modifications can be made to
the postoperative plan as indicated, and patients are routinely
seen 1 month postoperatively, and then again at 3–6 months.
What the patient may notice most is any degree of asym­
metry, contour imperfections, or dimpling. Preoperative
photographs are essential for comparison during the postop­
erative period. Most patients are not symmetric prior to the
procedure, and this can be pointed out to the patient preop­
eratively. Minor irregularities may improve as the edema im­
proves. More noticeable contour imperfections may be best
served with a ‘touch-up,’ or additional liposuction to a limited
area. Dimpling of the skin can be caused by damage to the
Fig. 21-49  Seroma on postoperative day 3 following neck liposuction.

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Chapter 21
Cosmetic surgery procedures and techniques
reticular dermis, overaggressive suctioning of the deep fat, or
poor skin tone.
Patients are encouraged to wait a minimum of 3 months
before assessing surgical outcomes. This allows for postopera­
tive edema to resolve, and skin contraction to begin. Some
patients, especially younger patients with taught skin, will be­
gin to see their results on postoperative day 1. Others will see
their results evolve over weeks to months. Touch-up proce­
dures are performed in approximately 5–10% of patients, and
surgeons differ in their approach to touch-ups. Some prefer to
intervene early in the postoperative course, while others prefer
to wait until the final result has settled. While it is essential
to tailor decision-making on touch-ups to patient desires, it is
often advisable to wait as long as possible before performing
touch-ups. This is because skin retraction and redraping in the
postoperative period will often improve contours for months
after surgery, and an area that appears to need a touch-up
1 month after surgery may look superb at the 6-month mark
without any intervention.
In the event that surface irregularities do persist postopera­
tively, the surgeon has several options. A central premise to
liposuction surgery is that it is always easier to remove addi­
tional fat than it is to replace fat. Therefore, part of the treat­
ment of postoperative contour irregularities comes during the
initial surgical session in the form of conservative fat removal
in some areas. This is particularly important in challenging­
areas such as the inner/outer thighs and upper arms, or any
area where less than 100% fat removal is the goal. Since
­liposuction is a contouring procedure, the goal of treatment is
not always to remove 100% of the fat, but rather to leave just
enough fat to produce an aesthetically pleasing contour. If the
surgeon undertreats slightly, then it is possible to go back for
a touch-up procedure and remove additional fat to enhance
results. If the surgeon overtreats, then there is a need to either
replace fat with fat transplantation, or elevate the skin and
improve contours with alternate methods. Clearly, the method
of removing more fat is preferable if a touch-up is to be per­
formed. This point cannot be emphasized enough. Although
all surgeons strive to produce superb results each time a pro­
cedure is performed, it is the cautious surgeon who plans for
worst-case scenario.
When replacement of fat is needed, fat transplantation is
a good option. Fat can be harvested from other areas of the
body and moved to the area to be treated via this relatively
simple technique. The authors utilize a 12-gauge Klein can­
nula to harvest and implant the fat from a 10 cc syringe. It is
important to realize that fat will be less likely to maintain per­
manence in areas of high mobility, such as the outer thighs.
Also, some fat is likely to be absorbed during the healing phase,
so it is advisable to harvest more fat than is needed and freeze
some in the event a fat transplantation touch-up is indicated.
An alternative or complimentary solution to fat trans­
plantation is subdermal undermining. This is done with the
12-gauge Klein cannula, and can be performed alone or in
combination with fat transplantation. The cannula is inserted
in a piston-like motion similar to liposuction, and is directed to
bound-down or fibrous areas that are in need of elevation. By
releasing the tissue in these areas, it is possible to elevate and
improve its contours. The body’s natural response to injury
will cause an inflammatory response that ultimately produces
a fibrous reaction, which develops into a form of soft tissue
augmentation.
Summary
Liposuction is a challenging surgical procedure that can pro­
duce superb aesthetic results when performed properly. Care­
ful suctioning, use of the smart hand, triangulation, and fluid
management are all important parts of the liposuction pro­
cedure. Final outcomes depend on both the skill of the sur­
geon and the healing response of the patient. However, it is
the responsibility of the surgeon to have thorough knowledge
and training in the procedure to minimize the possibility that
surgical technique is the contributing factor to less than opti­
mal results. It is the blend of physician skill and artistry that
ultimately determines outcomes, and the surgeon can create
beautiful contours by managing the interplay of skin healing
dynamics, cannula motion and position, thoroughness of fat
removal, and body shape.
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Tumescent liposuction  •  Chapter 21
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22. Sifton DW ed. Epipen (Dey; Napa CA) Physician’s Desk Reference, 54th
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methodology in abdominoplasty and suction-assisted lipectomy. Aesth
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29. Matarasso A. Evaluation and classification in abdominal contour
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30. Bank DE, Perez MI. Skin retraction after liposuction in patients over the
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31. Glaser DA, Kaminer MS. Body dysmorphic disorder and the
liposuction patient. Dermatol Surg 2005; 31:559–561.
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33. Shippert RD. An ergonomic solution to surgeon fatigue and repetitive
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35. Thompson KD, Welykyj S, Massa MC. Antibacterial activity of
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38. Kiak GA, Koontz FF, Chavez AJ. Lidocaine inhibits growth of
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41. Hanke CW, et al. Infusion rates and levels of premedication in
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43. Colaric KB, Overton ST, Moore K. Pain reduciton in lidocaine
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45. Klein JA. Tumescent technique for local anesthesia improves safety in
large volume liposuction. Plast Reconstr Surg 1993; 92:1085–1098.
46. Lillis PJ. Liposuction: How aggressive should it be? Dermatol Surg
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47. Moreno A, Bell WH, Zhi-Hao Y. Esthetic contour analysis of the
submental cervical region. J Oral Maxiofac Surg 1994; 52:704–713.
48. Kamer FM, Lefkoff LA. Submental surgery: a graduated approach to
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50. Grazer, FM. Atlas of suction assisted lipectomy. New York: Churchill
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54. Cook WR Jr, Cook KK. Manual of tumescent liposculpture and laser
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of tumescent liposculpture. Derm Surg 1997; 23(12):1207–1211.
56. Troilius C. Ten year evolution of liposuction. Aesthetic Plas Surg 1996;
20(3):201–206.
57. Lillis PJ. Liposuction of the knees, calves and ankles. Dermatol Surg
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58. Habbema L, Hanke CW. Female breast reduction by liposuction using
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Appendix A
Medications Which Inhibit Cytochrome P450
Appendix B
Medications Which May Affect Bleeding
Generic name (Trade name)
Acebutolol (Sectral)
Acetazolamide
Alprazolam (Xanax)
Amiodarone (Cordarone)
Anastrazole (Arimidex)
Atenolol (Tenoretic)
Cannabinoids
Carbamazepine (Tegretol)
Cimetidine (Tagamet)
Chloramphenicol
Clarithromycin (Biaxin)
Ciclosporin (Neoral)
Danazol (Danocrine)
Dexamethasone (Decadron)
Diltiazem (Cardiazam)
Diazepam (Valium)
Erythromycin
Esmolol (Brevibloc)
Fluconazole (Diflucan)
Fluoxetine (Prozac)
Fluvoxamine (Luvox)
Norfluoxetine
Flurazepam
Indinivir (Crixivan)
Isoniazid (Rifamate)
Itraconazole (Sporanox)
Ketoconazole (Nizoral)
Labetolol (Normodyne, Trandate)
Methadone
Methylprednisolone (Solu-Medrol,
Depo-Medrol)
Metroprolol (Toprol-XL)
Metronidazole (Flagyl)
Mibefradil (Posicor)
Miconazole (Micatin)
Midazolam (Versed)
Nadolol (Corzide)
Naringenin (grapefruit juice)
Nefazodone (Serzone)
Nelfinavir (Viracept)
Nevirapine (Viramune)
Nicardipine (Cardene)
Nifedipine (Procardia)
Omeprazole (Prilosec)
Paroxetine (Paxil)
Pentoxifylline (Trental)
Pindolol
Propranolol (Inderal)
Propofol (Diprivan)
Quinidine (Quinaglute)
Remacemide
Ritonavir (Norvir)
Saquinavir (Invirase)
Sertinadole
Sertraline (Zoloft)
Stiripentol
Tetracycline (Achromycin, Sumycin)
Terfenadine (Seldane)(not available)
Thyroxine
Timolol (Blocadren, Cosopt, Timolide)
Triazolam (Halcion)
Troglitazon (Rezulin)
Troleandomycin (Tao)
Valproic Acid (Depakote)
Verapamil (Calan)
Zafirlukast (Accolate)
Zileuton (Zyflo)
Patient to avoid use of these agents 2 weeks prior to liposuction.
Accutane – Alert MD
Advil
Alka-Seltzer Tablets
Alka-Seltzer Plus Cold Medicine
Anacin Capsules and Tablets
Anacin Maximum Strength Capsules/Tabs
APC Tablets
APC with Codeine, Tabloyd Brand
Arthritis Formula by the makers of
Anacin Tablets
Ascodeen-30
Ascriptin
Aspirin
Modified from Shiffman M. Medication potentially causing lidocaine toxicity. Am J Cosmet Surg 1998:227–229. McEvoy GK,
ed. AHFS Drug Information. Bethesda, MD: 2000. Gelman CR, Rumack BH, Hess AJ, eds. Drugdex R. System. Englewood,
CO: Micromedex Inc; 2000.

363
Tumescent liposuction  •  Chapter 21
Aspergum
Aspirin Suppositories
Anarox
Bayer Aspirin
Bayer Children’s Chewable Aspirin
Bayer Children’s Cold Tablets
Bayer Timed-Released Aspirin
BC Powders
Buff-a Comp Tablets
Buffadyne
Bufferin
Bufferin Feldene
Butalbital
Cama Inlay Tablets
Cetased, Improved
Cheracol Capsules
Clinoril
Congespirin
Cope
Coricidin D Decongestant Tablets
Coricidin Medilets Tablets for Children
Darvon
Darvon with Aspirin
Darvon-N with Aspirin
Dristan Decongestant Tablets/Capsules
Duragesic
Ecotrin
Empirin
Emperin with Codeine
Emprazil-C Tablets
Equagesic
Excedrin
Fiorinal with Codeine
Four (4)-Way Cold Tablets
Gemnisyn
Goody’s Headache Powders
Ibuprofen
Indocin
Measurin
Midol
Momentum Muscular Backpain Formula
Monacet with Codeine
Motrin
Naprosyn
Norgesic/Norgesic Forte
Norwich Aspirin
Pabirin Buffered Tablets
Panalgesic/Percodan/Percodan Demi tabs
Persistin
Quiet World Analgesic/Sleeping Aid
Robaxisal Tablets
Salsalate
SK-65 Compound
St. Joseph’s Aspirin for Children
Sine-Aid
Sine-Off Sinus Medicine/Aspirin Formula
Stendin
Stero-Darvon with Aspirin
Sulindac
Supac
Synalgos Capsules
Tolectin
Triamcinilin
Verin
Viromed Tablets
Appendix C
Liposuction Consent Form
Patient Name: ________________________________
Date: _________________
Procedure: ___________________________________
Diagnosis: ___________________________________
Dr. _________________________ and/or the staff has explained the nature of my condition, the nature of the procedure, its
alternative treatments, and the risks/benefits to be reasonably expected compared with alternative approaches. This document is
a written confirmation of this discussion.
By placing my initials next to the following items, I clearly understand and accept the following.
_______ 1.  The goal of liposuction surgery, as in any other cosmetic procedure, is improvement, not perfection.
_______ 2.  The final results may not be apparent for 6–12 months postoperatively.
_______ 3.  In order to achieve the best possible result, a ‘touch up’ procedure may be required. There will be a charge for any
‘touch up’ operation performed.
_______ 4.  Areas of ‘cottage cheese’ texture, i.e. ‘cellulite,’ are unlikely to improve with the procedure.
_______ 5.  Liposuction surgery is a contouring procedure and not performed for purposes of weight reduction or skin
reduction.
_______ 6.  Strict adherence to the pre- and postoperative regimen (i.e. wearing garments for 4 weeks and following
instructions) is necessary in order to achieve the best possible results.

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Cosmetic surgery procedures and techniques
_______ 7.  I have not taken any aspirin or aspirin-containing products, nonsteroidal antiinflammatory drugs (i.e. Advil/Motrin
or Vitamin E) for 10 days prior to my surgery.
_______ 8.  The surgical fee covers the operation itself and subsequent postoperative office visits. There is no guarantee
that the expected or anticipated results will be achieved.
_______ 9.  I authorize the taking of photographs or films during the procedure and their use for teaching and research
purposes.
Although complications following liposuction are infrequent, by placing my initials next to the following, I understand that they
may occur:
_______ 1.  Skin irregularities, lumpiness, hardness and dimpling may appear postoperatively. Most of these problems
disappear with time and massage, but localized irregularities may persist permanently. If loose skin is present
in the treated area, it may or may not shrink back to conform to your new contour.
_______ 2.  Possible livedo pattern (mottled red and brown coloring) may occur following the procedure.
_______ 3.  Infection is rare, but should it occur, treatment with antibiotics and/or surgical drainage may be required.
_______ 4.  Numbness or increased sensitivity of the skin over the treated areas may persist for months. It is possible that
localized areas of numbness or increased sensitivity could be permanent.
_______ 5.  Objectionable scarring is rare because of the small size of incisions used in liposuction surgery, but scar formation
is possible.
_______ 6.  Dizziness may occur during the first week following liposuction surgery, particularly upon rising from a lying
or sitting position. If this occurs, extreme caution must be exercised while walking. Do not attempt to drive a car
if dizziness is present.
_______ 7.  Surgical bleeding is very rare, and theoretically could require hospitalization. It is possible that blood clots may
form under the skin and require subsequent surgical drainage.
_______ 8.  Although rare, injury to the facial nerve (for neck liposuction only) may occur.
_______ 9.  You have arranged for someone to bring you to the office and drive you home. We have cancelled surgeries
in the past if the patient didn’t have a ride.
_______ 10.  You have arranged for someone to stay with you for 24 hours after surgery.
_______ 11.  In addition to these possible complications, I am aware of the general risks inherent in all surgical procedures
and anesthetic administration.
_______ 12.  I am aware that unexpected risks or complications may occur and that no guarantee or promises have been made
to me concerning the results of any procedure or treatment.
My signature certifies that I have read and discussed the previous material thoroughly with my physician and/or his staff;
and that I understand the goals, limitations and possible complications of liposuction surgery and I wish to proceed with the
operation.
________________________________
_______________
Patient Signature
Date
I have explained the above statements to the patient and answered all questions.
________________________________
_______________
Clinical Staff Signature
Date
________________________________
_______________
Physician Signature
Date

Hair Transplantation
Walter P. Unger,
Robin H. Unger, and
Mark A. Unger
C H A P T E R
22
Key Points
n Follicular unit transplantation (FUT), when carried
out properly, can produce natural-looking results
after a single session in an alopecic area or an area
destined to become alopecic.
n Because each follicular unit (FU) contains only
1 to 4 hairs, usually between 1500 and 2500 FUs
must be obtained and transplanted during each
session to adequately treat an average-sized
frontal, ­midscalp, or vertex area in a single pass.
The authors believe that larger sessions (and their
attendant greater damage to the vascular bed)
should be suspected of resulting in unacceptable
levels of hair death, until proven otherwise.
n According to virtually all studies to date, FU densi­
ties that require greater than a total of 3.0 cm/cm2
of recipient site incisions can be expected to result
in unacceptably low hair survival rates in most
­offices. Hair density objectives per session should
therefore be limited for the preceding reason but
also because the more hair utilized in one area,
the less hair that will be left in reserve. This reserve
may be required to treat other areas of male pattern
baldness (MPB) currently present or destined to
develop over that individual’s entire lifetime.
n It is rare to encounter a male patient with a
donor rim that would yield less than two or three
­surgeries, each consisting of 1500–2500 FU. There­
fore, the frontal and midscalp areas can be treated
in almost all men. The authors believe that the
younger the patient the more caution should be
observed before hair restoration surgery is under­
taken. Nevertheless, given the preceding, a young
man should not be automatically precluded from
starting hair transplanting with an experienced and
skillful surgeon, if the physician limits treatment to
two sessions of FUT.
n While not all female patients with female pattern hair
loss (FPHL) or MPB are candidates for hair trans­
planting, in the authors’ experience the majority
of them can have at least one or two cosmetically
strategic areas treated. In some women, far more
can be possible.
n Determining the right location and size of the donor
strip, based on scalp laxity and the long-term size
of the ‘safe’ donor area, avoids the production of
unacceptably wide scars and ‘overharvesting’ that
results in noticeable scars. Excising any ­preceding
donor area scar(s) as part of any new harvest
ensures the preceding.
n FU, because of their small size and limited amounts
of surrounding protective tissue, are extremely
susceptible to lethal damage. (When these grafts
are closely trimmed to minimize any skin surface
change in the recipient area and to allow for smaller
recipient site incisions, they become more ­fragile.)
Usually, microscopic dissection is required to
produce FU without hair follicle transection. They
p a r t 2
(continued)

366
Chapter 22
Cosmetic surgery procedures and techniques
History and Science
Background and history
The first published report of hair transplantation was a doc­
toral thesis written by J. Dieffenbach in 1822.1 His mentor,
Carl Unger, suggested the use of goose quills as trephines
to move small pieces of skin in order to investigate and suc­
cessfully prove the concept of auto-transplantation of hair,
feathers, and skin in animals and fowl. For approximately a
century after Dieffenbach’s early work, sporadic published
reports of hair transplantation in humans surfaced in the
­medi­cal literature of Germany, England, France, and Japan.
The majority of these reports described successful transposition
of large grafts or pedicle flaps.2 Two notable exceptions were a
­German article on eyelash transplantation of single hairs in
the early 1900s, and Okuda’s 1939 article on punch grafting
of hair into various areas of alopecia in the Japanese Journal of
Dermatology.3
This early work paved the road for the concept of hair
transplantation, but the idea of hair restoration surgery for
male pattern baldness (MPB) belongs to the American dermatolo­
gist, Dr. Norman Orentreich. Orentreich discovered and de­
fined the phenomenon of ‘donor dominance’ in MPB and, as
is often the case in medicine, came upon it by accident. While
investigating the pathogenesis of vitiligo, he noted that an au­
tologous punch graft from hair-bearing vitiliginous skin, when
placed into a non-hair-bearing area, grew hair at the new site.
In 1952, the first patient with frontal MPB was treated with 10
grafts harvested from the occipital area with a 4 mm diameter
round trephine. Orentreich’s classic 1959 paper4 reported the
successful transfer of hair to areas of MPB in this patient and
others, and opened the floodgates to a new field of cosmetic
surgery.
The ‘fathers’ of modern hair restoration surgery emerged
as a result of their relationships with Dr. Orentreich. They in­
clude Drs. Hiram Sturm, Jim Burks, Blu Stough, Jean Arouete,
Sam Ayres III, Robert Fosnaugh, Jay Pinski, Patrick Rabineau,
Robert Auerbach, Robert Berger, and Hillard Pearlstein. A sec­
ond and larger group of hair transplant surgeons came during
the late 1960s and early 1970s. Prominent among them were
O’Tar Norwood, Leonard Lewis, Sorrel Resnick, Walter Un­
ger, Rolf Nordstrom, Robert Limmer, Martin Unger, Manny
Marritt, Tom Alt, Patrick Frechet, Pierre Pouteaux, Ted Tro­
movitch, and Sam Stegman. To a large extent, it is they who
refined, taught widely, and popularized the technique of hair
transplanting as we currently practice it.
Further refinements over the past 10–15 years in donor
area harvesting and in transplanting techniques, including
‘minigrafting,’ ‘microslit grafting,’ and ‘follicular unit hair
transplanting’ (FUT), have revolutionized the approach to pa­
tients with MPB. An ever-expanding number of surgeons are
now able to consistently create remarkably natural-looking
results through the use of these techniques. One of the ad­
vantages of having so many skilled physicians performing hair
restoration surgery is the enormous potential for additional
innovations. What follows is the authors’ view of the optimal
approach to hair restoration surgery, as practiced today, and
the reasoning behind it. The reader is urged to remember that
there are many different techniques that can yield excellent
results and this chapter deals only with the personal approach
of these authors.
Studies
The major studies that merit mention in the limited space
available include early descriptive studies on the patterns
and frequency of MPB, pharmacologic studies with implica­
tions for surgical planning, and more recent studies that have
­analyzed particular aspects of surgical treatment. Research
horizons will also be briefly outlined.
Hair loss patterns
Early descriptive studies characterized evolving patterns of
hair loss, and the prevalence of those patterns. For males, the
Hamilton-Norwood classification established the standard
description of genetically based MPB (Fig. 22-1),5,6 while Lud­
wig classified female pattern hair loss (Fig. 22-2).7 Elise Olsen’s
1994 study of female pattern hair loss8 (FPHL) described a
second pattern distinct from that identified by Ludwig, the
‘Christmas tree’ pattern (Fig. 22-3), which in fact appears to
be more common than the Ludwig pattern. Two large studies
have been published that look at the prevalence of varying
degrees of MPB in men, at different ages. The results of these
studies can be seen in Tables 22-1 and 22-2. In females, it
should be noted that Hamilton found some degree of thinning
in frontotemporal triangles in 79% of post-pubertal ­females
and type IV MPB in, respectively, 25% and 50% of 50 year
old and 60 year old otherwise normal women. The planning
implications of these findings will be discussed later.
also must be stored and handled properly during
graft insertion. Technicians must be skilled as well
as both emotionally and physically able to perform
these tasks; they often require at least 6–12 months
of training and continuing intermittent supervision.
n As with all cosmetic procedures, hair restoration
surgery requires technical as well as aesthetic skills
that are honed by experience and time. Natural
results are achieved when appropriate decisions
are made with regard to hairline design, final objec­
tives, the placement of grafts with different numbers
of hairs, the graft density in different areas, and the
angle and direction of the hair in different sites.

367
Hair transplantation  •  Chapter 22
Medical treatment
The use of the 5α-reductase inhibitor, finasteride, at a dose of
1  mg orally per day, is particularly important as it pertains to
long-term planning in hair transplantation. In clinical stud­
ies, finasteride has been shown to be very effective in slowing
hair loss in the vertex area (88% of patients), and somewhat
effective in the midscalp area (60% of patients) (Fig. 22-4).
Sixty-six percent of patients also had some regrowth of hair in
the vertex area, and 39% had some regrowth in the midscalp
area.9 It is important to note that studies have never been pub­
lished to document the effect that finasteride has on the area
that hair restorations surgeons (HRSs) refer to as the ‘frontal
area,’ as shown in Figure 22-4.10 There is also no scientific
evidence that finasteride can be depended upon to permanently
III
III vertex
IV
V
VI
VII
I
II
Fig. 22-1  (A) The Hamilton-Norwood classification of the most common types of male pattern baldness (MPB). ����������
(cont’d)��

368
Chapter 22
Cosmetic surgery procedures and techniques
stop the progression of MPB in the vertex and midscalp. To
the contrary, even the hair counts of patients who grow more
hair in response to finasteride begin to steadily decline after
the second year of treatment (Fig. 22-5). Thus, while finas­
teride has an important role to play in postponing the surgical
treatment of the vertex and midscalp areas, long-term plans
should not be based on the assumption that finasteride can
permanently regrow hair or delay hair loss. Similarly, studies on
topical 2–5% minoxidil, alone or combined with finasteride,
have never been shown to permanently stop the progression
of MPB. Topical minoxidil can, however, produce longer,
higher-caliber hairs in some patients, especially in the vertex.
The earlier in the evolution of MPB in the area, the higher
the success rate.
Follicular unit hair transplanting
The reader should refer to Table 22-3 for a definition of the
graft terminology that will be used in this chapter. Current
hair transplanting in most offices is limited to transplant­
ing exclusively with follicular units (FUs) (Fig. 22-6). Bobby
­Limmer was the first hair restoration surgeon to realize the
clinical importance of FUs in hair transplanting,11 and his
approach has been refined and widely adopted. An initial
problem with follicular unit transplantation (FUT) was the
relatively low hair densities that were achieved when com­
pared with those created with the use of larger grafts. HRSs
have attempted to address this problem by steadily increasing
the number of FU/cm2 (and their attendant number of re­
cipient sites). ‘Dense packing’ of 40, 50, 60, and even greater
numbers of FU/cm2 has been the source of considerable con­
troversy, particularly with respect to the implications that this
practice may have for blood supply to the grafts, and hence
hair survival. Unfortunately, although a substantial number
of studies that quantify hair survival using different tech­
niques of FUT have been carried out, they are notoriously
Grade I
Grade II
Grade III
Fig. 22-2  Ludwig’s pattern of hair loss in females.
IIa
IIIa
IVa
Va
Fig. 22-1—cont’d  (B) The Norwood classification for type A
variant MPB.
• In a 5-year study, the benefits of using finasteride
were significant when compared to the effects of
a placebo and the differential in patient groups
increased each year. In addition, according to a
panel of judges, 90% of the finasteride patients
did not have any visible hair loss over the 5
years as compared to 25% of the patients in the
control group.
Pearls

369
Hair transplantation  •  Chapter 22
difficult to perform and interpret. This is because they have
always included too few patients. In addition, because 10–
15% of existing hair may be in a nonvisible telogen phase at
any given time12 the ‘before’ hair counts never include all of
the hair follicles in the transplanted tissue, but on the other
hand may include all of them in the ‘after’ counts, depend­
ing on when the counts are done. (In fact, hair counts in the
various studies have been done after differing time intervals,
resulting in yet another study variable.) The hair counts are
additionally complicated by the fact that patients in some of
these studies have not been completely alopecic in the study
area. Furthermore, ‘study’ sites, which are generally 1  cm2
‘boxes’ of grafts surrounded by intact skin, are hardly repre­
sentative of what one could clinically expect in today’s typi­
cal hair transplant. The latter often consists of 1000–2500
FU incision sites that would surround nearly all of such study
‘boxes,’ thereby decreasing the blood supply to the grafts
within them and probably affecting hair survival. Finally, the
results of one surgeon and the team of assistants cannot be
extrapolated to others because of a myriad of other variables
of technique from one office to another, most importantly,
the size of the recipient sites, the depth of the incisions, the
size of the grafts themselves, as well as the amount of graft
handling and dehydration.
A
C
B
Fig. 22-3  The ‘Christmas-tree’ pattern of hair loss as described by Olsen. (A) Mild; (B) moderate; (C) severe. (Photographs courtesy of
E. Olsen, MD).
Table 22-1  Norwood survey of incidences of different types of male pattern baldness at different ages
Age (years)
18–29
30–39
40–49
50–59
60–69
70–79
≥ 80
Type I
110 (60%)
60 (36%)
55 (33%)
45 (28%)
29 (19%)
18 (17%)
12 (16%)
Type II
52 (28%)
43 (26%)
38 (22%)
32 (20%)
24 (16%)
20 (19%)
11 (14%)
Type III
14 (6%)
30 (18%)
37 (20%)
34 (23%)
22 (15%)
16 (16%)
12 (16%)
(3V)a
(15V) a
(15V) a
(10V) a
(7V) a
(8V) a
Type IV
4 (3%)
16 (10%)
15 (10%)
21 (9%)
17 (12%)
13 (13%)
9 (12%)
Type V
3 (2%)
10 (6%)
13 (8%)
15 (10%
22 (15%)
13 (13%)
9 (12%)
Type VI
2 (1%)
4 (3%)
7 (4%)
10 (7%)
19 (13%)
11 (11%)
10 (13%)
Type VII
0
2 (1%)
5 (3%)
4 (3%)
16 (10%)
11 (11%)
14 (17%)
Total
185 (100%)
165 (100%)
165 (100%)
156 (100%)
149 (100%)
102 (100%)
77 (100%)
aNumbers in parentheses under type III represent type III vertex individuals.

370
Chapter 22
Cosmetic surgery procedures and techniques
With the above caveats in mind, several important studies
have concentrated on hair survival with different size grafts
and sites and different FU densities/cm2. Each has consist­
ently revealed better hair survival rates at 20 and 30 FU/cm2,
than at higher FU densities. In one of the most recent studies,
Mayer and colleagues looked at the effect of increasing FU
density when two-hair FU were inserted into minimal-depth
‘coronal’ recipient sites made by a 19 g hypodermic needle,
2 hours after the sites were made.13 The results at 9 months
revealed 95%, 76.6%, 70%, and 82% FU survival at, respec­
tively, 20, 30, 40, and 50 FU/cm2. A more recent study by the
same authors was presented at the 2005 annual meeting of
the International Society of Hair Restoration Surgery.14 The
results of this study are summarized in Table 22-4. Note that
at 50 FU/cm2, while 94% of the FUs survived, only 84% of
the hair survived, which is substantially lower than the 98%
hair survival that was achieved when 30 FU/cm2 were em­
ployed. Thus, while higher density was produced, it appeared
Table 22-2  Unger’s survey of incidences of different types of male pattern baldness at different ages
Age (years)
Type
65–69
70–74
75–79
80+
I
2 (3.6%)
5 (6.2%)
4 (5.5%)
2 (1.7%)
II
9 (16.4%)
7 (8.6%)
7 (9.6%)
12 (10.1%)
III
4 (7.3%)
15 (18.5%)
18 (24.7%)
11 (9.2%)
IV
10 (18.2%)
16 (19.8%)
8 (11.0%)
10 (8.4%)
V
6 (10.9%)
7 (8.6%)
10 (13.7%)
16 (13.4%)
VI
13 (23.6%)
19 (23.5%)
16 (21.9%)
37 (31.1%)
VII
11 (20.0%)
12 (14.8%)
10 (13.7%)
31 (26.1%)
Total
55 (100%)
81 (100%)
73 (100%)
119 (100%)
In age group 65–69 if one excludes types I and II, 33 of the remaining 44 (75%) have types III–VI (83.3% Norwood).
In age group 70–74 if one excludes types I and II, 57 of the remaining 69 (82.6%) have types III–VI (82.8% Norwood).
In age group 75–79 if one excludes types I and II, 52 of the remaining 62 (83.9%) have types III–VI.
In age group 80+ if one excludes types I and II, 74 of the remaining 105 (70.5%) have types III–VI (74.0% Norwood).
Present
superior
border of
rim hair
Intertragal
line
Fe
Vertex transition
point
Future superior
border of rim hair
Fe
High density
area
Ve
Ve
Me
Me
M
V
F
H
V = Vertex area
Ve = Evolving (future) vertex area
M = Midscalp area
Me = Evolving (future) midscalp area
Fe = Evolving (future) frontal area
F = Frontal area
H = Hairline zone
Fig. 22-4  A schematic showing frontal, midscalp, and vertex areas,
as well as evolving areas of MPB in a patient with type VI MPB. ­Ideally,
each of the three major areas is treated at the same time as the
evolving areas of MPB lateral to them. Typically, only one major area
and evolving area are treated during each session, though ‘touch-up’
thickening of previously transplanted sites may also be carried out
concomitantly. Recreating temporal ‘humps’ as shown, ­allows one to
place the lateral points of the hairline more superiorly on the ‘humps’
than would otherwise be possible (See also Fig. 22-11).
Mean hair count change from baseline
150
100
50
0
–50
–100
–150
–200
–250
–300
Fin→Fin
Baseline
Pbo→Fin
Fin→Pbo→Fin
Pbo→Pbo
6
12
24
36
48
60
Fig. 22-5  Hair count comparison of men taking finasteride versus
placebo over a 5-year period. The chart also shows crossover studies
of men who started on placebo and switched to finasteride, as well
as men who started on finasteride and switched to placebo. Note that
even in patients who grow more hair in response to finasteride, hair
counts begin a steady decline after the second year of treatment.

371
Hair transplantation  •  Chapter 22
to do so at the expense of hair survival. Hair survival of 98%
at 30 Fu/cm2 was also much better than the 76.7% hair sur­
vival Hayer had acheived in his 2003 study; hence the authors’
­increased enthusiasm for Fut begainning 2004-2005. Weonju
Lee et al. also have found hair survival is better at 30 FU/cm2
than at 40 and 50 FU/cm2.15 Thus far, the only study which
partially refutes such results was conducted by Beehner who
studied the effect of FU density in two recent patients (Table
22-5).16 In one man, at 17 months, there was 95% hair sur­
vival at 20 FU/cm2, but only 67% at 50 FU/cm2. The results
in the second patient contradicted those of the first one, with
hair survival of 87.5% at 20 FU/cm2 and 93% at 50 FU/cm2
(13 months postoperatively.) In addition to the methodological
concerns already mentioned, it should also be noted that any
interpretation of Beehner’s study is complicated by his use of
a 19 g needle to make the 20 and 30 FU/cm2 sites, but a 20 g
needle for the 40 and 50 FU/cm2 sites.
To preserve the integrity of the blood supply to the grafts
and hence maximize hair survival, the authors’ practice is to
primarily employ an 18 g or 19 g recipient site needle for an
FU graft density of no greater than 30–35 FU/cm2, and to
carry out sessions generally limited to a maximum of 2500 FU.
It may be possible to obtain good hair survival with larger ses­
sions (‘megasessions’) and higher densities of FU/cm2, for ex­
ample, by making smaller recipient site incisions or ­spreading
the grafts over a larger area, but thus far no hair survival stud­
ies have been done that confirm this possibility.
Table 22-3  Graft terminology
Graft type
Hairs
FUs
Recipient site
Cut ‘to size’ or cut
to ‘number of hairs’
Micrografts
Micrograft – (general term)
Follicular unit (FU) – (specific term)
Follicular family (FF)
1–4
1–4
5–6
1 or less
1
2
Needle/microslit
Needle/microslit
Needle/microslit
Cut to ‘number of hairs’
Cut to ‘number of hairs’
Cut to ‘number of hairs’
Multi-FU grafts
Microslit grafts
Double FU (DFU)
Triple FU (TFU)
Quadruple FU (QFU)
3–5
5–8
6–12
2
3
4
Slit
Slit
Slit
Cut to ‘number of hairs’ (FUs)
Cut to ‘number of hairs’ (FUs)
Cut to ‘number of hairs’ (FUs)
Traditional slit grafts
Small slit graft
Medium slit graft
Large slit graft
3–5
5–8
6–12
≈2
≈3
≈4
Slit
Slit
Slit
Cut to size
Cut to size
Cut to size
Traditional slit grafts
Small slot graft
Medium slot graft
Large slot graft
6–8
8–12
10–16+
≈4
≈6
≈8
Slot
Slot
Slot
Cut to size
Cut to size
Cut to size
Round grafts
Small round graft
Medium round graft
Large round graft (includes
‘standard’ punch grafts)
5–8
8–14
14–30+
2–3
4–5
4–5
Punch
Punch
Punch
Cut to size
Cut to size
• Because of the limited number of FU available
from any given patient, it would be unwise to
heavily concentrate the FU transplanted into
one area in most individuals. This inappropri­
ately limits the number of FU that would be left
in ­reserve for treating other alopecic areas that
might develop over time.
Pearls
• Increasing the size of sessions or the density of
recipient sites can reasonably be expected to
decrease blood supply and hence may decrease
graft hair survival. To optimize hair survival,
the authors recommend that sessions should
generally not exceed 2500 FU, and that total
recipient site incision length be no greater than
3.0 cm/cm2 – for example, 30–35 sites/cm2 made
with 19 g needles and sometimes 20 g needles.
Very good cosmetic results can be obtained with
FU densities of 25–35 FU/cm2. All of the patient
photographs of FUT included in this chapter
were treated in this manner.
Pitfalls

372
Chapter 22
Cosmetic surgery procedures and techniques
Other research
Briefly, two other recent focuses in research should be men­
tioned. The first is the development of a relatively new tech­
nique of FU harvesting usually referred to as follicular unit
extraction (FUE). The concept of FUE was first suggested and
practiced by an Australian physician and eventually described
in a published article written by Rassman et al.17 FUE can be
defined as the removal of one FU at a time from the donor
area (permanent hair-bearing areas of the scalp or body) us­
ing various sizes of small trephines. This approach obviates
the need to first excise a strip of donor tissue. It is a potentially
advantageous technique in a number of circumstances.
At this time, however, FUE has several significant problems
associated with it, most importantly, unacceptably high rates
of follicle transaction in some individuals, very lengthy surgical
­procedures and, because of the latter, very high costs/FU. In
addition, the small punctuate scars produced in the first sur­
gery may increase the significance of these drawbacks in any
­subsequent sessions. Hence, the authors do not currently recom­
mend its routine use in most individuals. FUE’s refinement, how­
ever, is continuing and, as implied above, involved practitioners
are even investigating the use of body hair transplantation to
the scalp, thus possibly providing additional donor hair in some
patients.18 One of the authors (WU) is ­ collaborating with a
group that believes it can construct a ­robot that will be able to
extract intact FU more consistently, and far faster than a human
operator can. If successful, this would certainly improve the
affordability and feasibility of good hair survival with FUE.
Secondly, research on hair stem cell therapy is ongoing.
­Jahoda et al. published the first report on such studies. They
were able to grow hair from cells obtained from rat vibris­
sae that were grown in a culture medium.19 Since that time,
however, progress on consistently growing human hair from
autologous cells has been disappointingly slow. The authors
have no doubt that eventually hair cell therapy will become
a reality. However, at the time of this writing (2008) the goal
seems little closer than it was several years ago.
Patient assessment and planning
The eight criteria of patient assessment

• The Long-Term Donor/Recipient Ratio: The larger the long-
term safe donor area, relative to the size of the long-term
area of alopecia, the higher the coverage and density
objectives ­possible.

• Age: The older the patient, the safer the long-term donor/
recipient area prognosis. Patients less than 25 years of age
must be carefully screened on the basis of physical examina­
tion with wet hair, family history, and emotional need; with
rare exception they should only be transplanted with FU.

• Skin/Hair Color Contrast: In most instances the less contrast
between the hair and skin color, the thicker the hair
appears to be.

• Donor Hair Density: In Caucasians, 80 FU/cm2 or greater
is considered good density, 40 or less FUcm2 is poor.
Caucasians and Asians on average have 1 FU/mm2,
Africans have 0.6 FU/mm2, Asians have 0.7 FU/mm2.
Caucasians on average have 2 or more hairs/mm2,
Asians 1.7 hairs/mm2, Africans 1.6 hairs/mm2.

• Hair Shaft Caliber: The larger it is, the greater the coverage.
The hair caliber of Asians, on average, is greater than that
of Caucasians. The lower the caliber, the more natural
hair looks in the anterior hairline, especially in multihaired
FU with significant skin/hair color contrast.

• Hair Wave and Curl: The more hair wave and curl, the
thicker the hair will appear to be.

• Hair Frizziness: The more frizzy the hair, the thicker the
hair will appear to be.

• Patient Objectives: The patient must clearly understand and
accept the limitations imposed by the above criteria, most
specifically with regard to the percent of coverage of the
total eventual area of MPB, and the hair density that they
hope to achieve. Unrealistic expectations are the most
common cause of patient dissatisfaction and lawsuits.
Fig. 22-6  A relatively small number of single hairs emerge from
the scalp. Most often, hairs grow in small groupings of two to five
hairs, as shown here. These groupings are referred to as ‘follicular
groups’ or, more commonly, ‘follicular units’ (FUs). In follicular unit
transplanting (FUT), intact FUs are the only type of graft employed;
they are inserted into incisions made by needles or small blades.
(Photograph courtesy of Dr. Ron Shapiro.)
Table 22-4  Two hairs/FU; prepared with Meiji microscope; inserted into
19 g ‘coronal’ sites within 1.5 hours of harvesting using ‘stick-and-place’
6 months
1 year
Box 20 FU/cm2
20 FUs, 38 hairs
20 FUs, 38 hairs
% Yield:
100%, 95%
100, 95%
Box 30 FU/cm2
30 FUs, 59 hairs
30 FUs, 59 hairs
% Yield:
100%, 98%
100%, 98%
Box 40 FU/cm2
40 FUs, 67 hairs
38 FUs, 71 hairs
% Yield:
100%, 84%
95%, 90%
Box 50 FU/cm2
49 FUs, 82 hairs
47 FUs, 84 hairs
%Yield
98%, 82%
94%, 84%

373
Hair transplantation  •  Chapter 22
Male patients
As in all patients, appropriate planning is the key to achieving
an optimal outcome, and therefore the surgical design varies
considerably from patient to patient. It is also essential to rec­
ognize that MPB is a progressive disorder. If planning takes
this into consideration, it is not necessary to wait until MPB
is advanced or an area is completely alopecic before starting
hair transplanting. An ideal approach should not only ­consist
of grafting into alopecic areas but also into areas that are
still hair-bearing, but that can be reasonably expected to lose
hair in the future, thus avoiding a frustrating ‘chasing’ of an
enlarging alopecic area.
On the other hand, the ‘price’ for treating future areas of
alopecia at the same time as the more obvious areas of MPB
is that a smaller proportion of the currently alopecic or obvi­
ously thinning areas can be transplanted, unless one employs
more grafts. Patients will initially be more impressed with the
treatment of a larger proportion of the more obvious areas
of thinning, but in the long run the disadvantages of such an
objective will become evident.
Each patient should be assessed individually with regard
to the likely eventual extent of MPB, based on his age and
family history, as well as a physical examination of the scalp
hair, dry and wet. A suitable long-term, treatment plan can
then be established. However, perfect prognostication of
the degree of alopecia that any given patient will develop is
impossible. Therefore, a number of measures can be taken
to guard against the consequences of underestimating the size
of the eventual area of alopecia. These include:

• Utilize FU exclusively for most patients under the age of
40 years.

• Maintain a donor area ‘reserve’ of what is expected to be
permanent hair, especially in younger patients.

• If multi-FU grafts are being employed, construct the
lateral borders of the transplanted areas with FU so if one
should misjudge the ultimate limits of MPB, the patient
will be left with a larger than usual isolated frontal forelock
(IFF), which will look ‘natural’ standing on its own
(Figs 22-7, 22-8).

• Intentionally produce an IFF for some patients.20 (In the
opinion of the authors, this approach is overly conserva­
tive in a large majority of individuals with evolving MPB.)
It is important to again briefly review the implications of
finasteride treatment in planning. As was previously men­
tioned, finasteride has been shown to be very effective in slow­
ing hair loss in the vertex area and to a lesser degree in the
midscalp area; a smaller percentage of patients experience
hair regrowth in these regions. This allows HRSs to concentrate
initial transplanting on frontal and sometimes midscalp areas,
and to encourage patients to try a 1-year course of finasteride
for any vertex hair loss (and sometimes midscalp loss) before
committing to surgery at these sites.
Female patients
‘Androgenetic’ alopecia in females typically occurs in a differ­
ent form than that described for males, although as noted pre­
viously, some females also lose hair in a ‘male’ pattern.5 The
hallmarks of FPHL are the maintenance of at least some hair
in the hairline zone, with diffuse thinning more posteriorly,
punctuated intermittently by the presence of small round or
irregularly shaped alopecic areas. In addition to thinning over
the caudal scalp, a significant minority of women also develop
thinning in the potential donor areas. This minority of women
are not good candidates for hair transplantation. However, a
substantial majority of women can be improved with current
hair transplanting techniques.21
The key factor in planning in female hair transplantation is
to decide upon the most aesthetically strategic regions, and to
treat these sites first. Often, women have asked their hairstylists
which areas are the most important to thicken and therefore
they come to their surgeon with their own opinion. Neverthe­
less, the authors always suggest the area(s) they would treat if
it were ‘their head,’ and document this recommendation. In
many females, the most cosmetically important region is the
frontal area and in some it is also a predetermined ‘part’ line.
Fig. 22-7  This is a typical, natural IFF with surrounding MPB. Note
that the frontal border is not greatly receded from its original ­position.
Table 22-5  Hair survival in two patients (two-hair FU; ‘stick and place’)
Planting density
20 FU/cm2 (19 g)
30 FU/cm2 (19 g)
40 FU/cm2 (20 g)
50 FU/cm2 (20 g)
Patient #1 (DS)
17 mos. post-op
95%
93.30%
70%
67%
Patient #2 (RJ)
13 mos. post-op
87.50%
91.60%
100%
93%
Beehner M. Studying the effect of FU planting density on hair survival. Hair Transplant Forum International, Jan–Feb 2006: 247–248.

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Chapter 22
Cosmetic surgery procedures and techniques
Thus, transplanting is often limited to the frontal area and an
anteroposterior corridor that is 7.5–10 cm wide and extends
from the hairline zone as far posteriorly as is necessary and
possible, given the reality of limited donor reserves (Fig. 22-9).
The hair in these thickened areas is subsequently combed in
such a way as to produce the most effective coverage of areas
that cannot be treated because of the limited supply of grafts.
Provided that there are sufficient donor reserves, thinning or alopecic
frontotemporal triangles can also be transplanted. However,
both physicians and patients should understand that using grafts
to treat such commonly affected and generally easily camou­
flaged areas depletes donor tissue reserves that may be needed
to treat less easily camouflaged areas of future hair loss.
A
B
Fig. 22-9  (A) A 61-year-old female patient before hair transplanting with the recipient area outlined in black crayon demonstrating three
zones arranged in order of their treatment priority: (a) a ‘part-line’ corridor on her left side, going further posteriorly than the other two zones,
(b) an adjacent midline frontal zone, and (c) a zone further to the patient’s right side. (B) The same patient with the hair parted in a comparable
fashion to that shown in (A), 7 months after treatment with 1118 FUs.
• When presenting to the patient a description
of the expected degree of coverage, always
­underestimate. Also be certain to describe
the potential number of procedures that will
be required and clarify that any postoperative
loss of the ‘original’ hair in the recipient area is
temporary. Take many representative ‘before’
photographs. These clarifications will reduce
the likelihood of future disappointment and
­misunderstandings.
Pearls
A
B
Fig. 22-8  (A) A patient after four hair transplants with round grafts 30 years ago. (B) The same patient 24 years after (A). Note the marked
decrease of hair density in the ‘rim’ donor area. Decreased hair density in the round grafts has also decreased the original noticeability/
plugginess of the transplant. Note also the separation of the transplanted area from rim hair, creating a natural-looking IFF, due to the originally
unanticipated degree of progression of MPB. The grease pencil markings outline areas to be transplanted with FUs to reconnect the IFF to the
adjacent temporoparietal rim hair.

375
Hair transplantation  •  Chapter 22
The hairline
In males, the HRS needs to decide whether the ‘supratempo­
ral humps’ consist of permanent hair or whether, most com­
monly, they need to be recreated or reinforced with FU.22 The
midline point of the hairline should usually be located so that
when the hairline is completed and is viewed laterally, it runs
more or less horizontally. In addition, the most anterior point
of the hairline zone ideally lies in a transition area within which
the vertical aspect of the forehead becomes more parallel to
the ground in the caudal area. Most hairlines are designed in
a ‘bell shape’ which (together with the ­aforementioned ante­
rior midline point and reconstructed or permanent ‘temporal
humps’) allows the lateral points to be placed more superiorly
on the humps than they otherwise could be. All of the forego­
ing has the effect of decreasing the anteroposterior length of
the frontal area, while still maintaining a cosmetically advanta­
geous horizontal orientation to the hairline (Figs 22-10, 22-11).
In females, the hairline is flatter, with minimal frontotemporal
recessions and is usually created just posterior to the existing
hairline, which often becomes significantly sparser with the
passage of time but does not completely disappear.21,23
Alopecia reduction
The surgical correction of hair loss also can sometimes benefit
from alopecia reduction (AR), which is defined as the exci­
sion of an area of alopecia or future alopecia, in a single or
series of procedures. Because of improper planning and/or
inadequate surgical skill, in the past many patients have been
more hurt than helped by the inclusion of AR in their hair
­restoration ­ treatment plan. Such unfortunate results have
received widespread attention and the popularity of AR has
therefore plummeted to the point where it is rarely used to­
day. It will therefore not be discussed in detail in this chapter.
Nevertheless, if it is properly planned and executed, it can be
very useful (Fig. 22-12).24–27 Given that AR is still utilized by a
small number of HRSs, some admonitions and comments on
its role in planning are warranted here:

1. If the transplanting goal is maximum coverage, the
­surgeon should ideally consider the use of AR or plan to
use AR in the future (by leaving untransplanted zones that
can be excised at a later date).

2. Do not leave a scar in an area that one does not intend to
subsequently transplant.

3. If the alopecic area is large, do not attempt a complete exci­
sion. This will often result in an abnormal hair direction
at the midline, which has been referred to as the ‘parting
of the Red Sea’ effect. It is preferable to eliminate all but a
5–6 cm wide area of alopecia, and transplant this remain­
ing area with grafts that can by positioned to produce a
natural-looking gradual change of hair direction from left
to right or right to left.

4. The wider the area of alopecia removed, the sparser the
hair in the stretched ‘permanent’ fringe will become.
Fringe hair will also gradually become sparser with age,
A
B
Fig. 22-10  (A) A patient with relatively early MPB. The grease pencil line outlines the areas to be treated, including the supratemporal ‘humps’
that are currently hair-bearing but can reasonably be expected to lose their hair with the passage of time. Designing and transplanting these
‘humps’ has the advantage of allowing the lateral points of the new hairline to be placed more superiorly than they otherwise could be. This is
because if the ‘humps’ were not transplanted and proceeded to lose their hair, the new hairline would eventually end in alopecic areas. (B) The
same patient 6 months after the transplant which consisted of 2137 FUs. The hairline in this patient intersected the temporal ‘humps’ relatively
inferiorly and had a cosmetically advantageous horizontal orientation.. His family history and examination suggested that he would ultimately
develop type V or, at worst, type VI MPB and he had relatively dense hair in his donor area.
• A low hairline transplanted on a 25- or 30-year-
old male may look natural initially, but by the
time that individual is 60 or 70 years old it may
look very unnatural. A low hairline will also
consume a large number of FUs, leaving less
hair in reserve for transplanting further posteri­
orly as the MPB progresses over the patient’s
lifetime. Conservative hairlines are therefore
advisable in most circumstances.
Pearls

376
Chapter 22
Cosmetic surgery procedures and techniques
and this should be factored into the overall objectives.
Despite arguments to the contrary, if the patient has
normal healing, this thinning of the permanent rim
hair is the only negative consequence of AR that is not
completely avoidable.

5. When surgical technique is good, there is minimal ‘stretch­
back’ or loss of some of the gain obtained in the vast
majority of patients.25 More recently, the use of
nonabsorbable galeal ‘anchoring sutures’ has further
minimized this potential sequela of AR.26

6. AR is a very useful tool for the treatment of MPB
that has extended beyond its originally estimated
borders. It is generally unwise to expend a limited
supply of remaining donor tissue to treat unanticipated
new areas of alopecia if those areas can instead be
excised.25,27
Procedures and Techniques
Preoperative clinical ­considerations
Surgery is preceded by a complete personal medical history
to elicit any contraindications to the procedure. This includes
identification of possible drug interactions. Monoamine
B
A
C
Fig. 22-11  (A) A 67-year-old patient with type VII MPB and a relatively sparse donor area before treatment. The black crayon lines outline the
areas to be treated. Reconstruction of the supratemporal ‘humps’ will allow for a more superior than usual positioning for the new hairline that
decreases the anteroposterior length of the frontal area resulting in the consumption of fewer grafts for that zone; the hairline also can run par­
allel to the ground when viewed laterally. (B) A side view of the same patient 11 months after the second of two surgeries (one session to the
frontal area and one further posteriorly; a total of 3211 FUs). The advantages of recreating supratemporal ‘humps’ and a more superior than
usual hairline are more obvious for patients with type VII MPB (or destined to develop type VII MPB) than for patients with less severe MPB,
such as the one shown in Fig. 22-10. (C) A frontal view of the same patient as in (B). A third FUT session was carried out immediately after
these photographs were taken; it was done posterior to where the second session grafting had stopped.

377
Hair transplantation  •  Chapter 22
­oxidase inhibitors, for example, have been reported as causing
fatal reactions when combined with some local anesthetics.28
A baseline CBC is obtained, in addition to a screen for syphi­
lis, HIV, and hepatitis B and C viruses. Patients testing posi­
tive for any of these viruses must get medical clearance from
their treating physicians. This screening also allows the team
to protect themselves with immediate prophylactic treatment in
the case of accidental exposure to HIV or hepatitis B.
The preoperative instructions given to the authors’ pa­
tients have been included (Appendix A); thus, the authors will
highlight only a few points. Patients are asked to discontinue
any naturopathic regimens,29 medications, or other practices
that could result in excessive bleeding. In particular, patients
are asked to stop vitamin E supplementation for 3 weeks
­preoperatively, and that they avoid acetylsalicylic acid prepa­
rations and alcohol consumption for 1 week preoperatively.30
The hair is washed the night before and the morning of
surgery. Any shampoo may be used. Perioperative antibiotics,
usually cefdinir (Omnicef) 300  mg 1 hour before surgery and 6
hours later, have been used for many years, and have been asso­
ciated with an infection rate of less than 0.2%.30 To minimize
postoperative edema, the authors administer prednisolone ac­
etate (Depomedrol) 8  mg intramuscularly immediately prior to
surgery, and a 1-week tapering dose of prednisone beginning
on the first postoperative day (60, 30, 25, 20, 15, 10, 5  mg/day).
The authors are currently investigating the efficacy of an anec­
dotally beneficial homeopathic regimen of Arnica, Bromelain,
and vitamin C, for possibly reducing postoperative edema.
A
B
C
Fig. 22-12  (A) A 54-year-old gentleman, who was treated over 15 years ago, with an outline of the proposed area of alopecia reduction (AR)
that was, in fact, carried out 6 weeks before the first transplant in this area. (B) One year after the first transplant session to the vertex and the
midscalp. A combination of micrografts and ‘traditional’ slits grafts was used. The hair has been parted for critical evaluation. (C) A photograph
taken at the same time as that shown in (B) with the hair combed as normally worn. The frontal area had also been transplanted with three
­sessions consisting of a combination of micrografts and various types of minigrafts.

378
Chapter 22
Cosmetic surgery procedures and techniques
Procedural techniques
Anesthesia
The anesthetic regimen includes administration of diazepam
(Valium) 20 mg orally 30 minutes before surgery to minimize
anxiety, but more importantly to decrease the possibility of
local anesthetic toxicity.31 The donor area is then anesthe­
tized in a ‘skipped’ fashion by infiltrating individual wheals
at approximately 4 cm intervals along the inferior edge of the
proposed excision area, using a solution of 2% lidocaine with
1/100 000 epinephrine in a 3 mL syringe with a 30 g needle.
After waiting approximately 2 minutes, these wheals are then
extended laterally in both directions, via needle entries into
the already anesthetized areas, until a solid line of anesthe­
sia is produced. Thus a complete field block is created with
­minimal discomfort to the patient.32
Occasionally it is necessary to reinforce ‘hot spots’ using lido­
caine 3% or 4% with 1/50 000 epinephrine. Some patients
also require similar additional anesthesia along portions of or
all of the superior edge of the proposed donor site; these are
usually patients who have had several prior hair restoration
surgeries. Approximately 6 cc of a 1/50 000 epinephrine in
saline solution is infiltrated into the donor area, superior to the
field block to maximize hemostasis.
Once the donor area has been harvested and sutured, three
injections of 2% lidocaine with 1/100 000 epinephrine are
made along the hairline with a 30 g needle, one in the midline
and one in the middle of the proposed left and right hairline
(Fig. 22-13). These wheals are intermittently extended to com­
plete the field block, with minimal discomfort, in much the
same manner as described above for the donor area. If this
is done slowly enough, the patient only feels the initial three
injections.
Ten to fifteen minutes after completion of the recipient area
field block, the proposed hairline region is infiltrated superfi­
cially with a saline solution containing epinephrine 1/50 000
to minimize intraoperative bleeding. A total of 10–20 mL of
the epinephrine solution is used intermittently and in small doses
to provide improved hemostasis throughout the recipient area
during the course of treating it.
The field blocks are reinforced approximately every
2.5–3 hours with 2–4% (as needed) lidocaine with 1/50 000
­epinephrine, or with 0.5% bupivicaine (Marcaine) with
1/200 000 epinephrine. At the end of the procedure the donor
area is reinforced again, this time always with the longer-acting
bupivacaine solution. An intramuscular injection of ketorolac
tromethamine (Toradol) 30–60 mg is usually administered. In
most patients, the latter eliminates virtually all postoperative
pain for 3–5 hours. It should not be used in patients with a
history of asthma or gastrointestinal ulcers. It has been used
in over 4000 of the authors’ surgeries and has not produced
a significant increase in postoperative bleeding. There is now
one case of which the authors are aware in which a single dose
of Toradol may have caused acute glomerulonephritis, one of
its most serious potential complications (Dorin R, personal
communication 2006).
Propofol and ketamine, administered by an anesthesi­
ologist, can also be employed in individuals who are very
• If patients are known to be particularly difficult
to anesthetize, perform the recipient field block
with 3% or 4% lidocaine with 1/50 000 epine­
phrine. Alternatively, create a supraorbital nerve
block utilizing 0.5% bupivicaine (Marcaine) with
1/200 000 epinephrine.33
Pearls
Wheals at initial
injection sites of
anesthetic
Proposed
hairline
Fig. 22-13  A schematic showing the wheals raised by anesthetic
injection in the midline and in the middle of the left and right hairline.
The most lateral wheals are produced immediately after the donor
area has been anesthetized, usually approximately 30 minutes
before anesthetizing of the recipient area begins. The wheals shown
above are gradually extended to complete a field block.
• To minimize patient discomfort caused by
­injection of local anesthetic, a solution of lido­
caine is prepared on the morning of surgery by
adding 0.1  mL of 1/1000 epinephrine to 10  mL
of stock lidocaine 2%. This avoids the acidic
pH of the stock solutions of 2% lidocaine with
1/100  000 epinephrine. It is this acidity that
­produces much of the ‘stinging’ sensation
associated with the preserved solutions.
Pearls

379
Hair transplantation  •  Chapter 22
­apprehensive about ‘needles.’ In these cases, both donor and
recipient-area field blocks are completed in the initial 10–15
minutes, while the patient is unconscious. Anesthesiologists
are also present if the authors are operating on patients with
medical histories that raise special concerns.
Donor area harvesting
The ‘permanent’ or ‘safe’ donor area was defined in a study
of 328 men aged 65 or older, and includes regions with hair
­densities of 8 or more hairs per 4 mm circle.34 Figure 22-14 is
a schematic drawing of this area. In over 80% of the ­patients
in the aforementioned study, the donor was an average of
69 mm high in the midline of the occipital area; thus, a sub­
stantial ‘margin of error’ is present if even 50 or 60 mm is
eventually excised from this area in the form of, for example,
five or six 10 mm wide donor strips. Note also that it is wid­
est in the parietal areas, where it averages 80 mm, so ellipti­
cal excisions should ideally not have their widest aspects in the
midline of the occipital area where the ‘safe’ donor area is in
fact narrower. Sites with fewer than 8 hairs per 4 mm circle,
located superior and inferior to the ‘permanent’ donor zone,
can also be used to a limited extent for strip or FUE harvesting
if that becomes necessary.35
In preparation for harvesting, a 10–15 mm wide zone
of hair in the densest area of the rim hair is trimmed with
Metzenbaum scissors to a 1–3 mm length. This zone is usu­
ally midway between the superior and inferior borders of
the rim hair. The anesthetized donor area is maximally
tumesced with saline and a rectangular strip with tapered
ends is then excised. In a patient with previous donor har­
vesting, the old scar(s) should ideally be included in this
strip. Such an ­approach maximizes blood supply to both
edges of the new wound, and can result in better drain­
age of postoperative ­donor site edema. A single donor area
scar also maximizes how much hair can be removed from
the donor area without scarring in that area becoming
­noticeable.36
If the patient has multiple scars, for example as occurred
with older methods of harvesting, the authors try to excise two
rows of scars within the new donor strip and convert them
into a single fine scar, while concurrently obtaining a reason­
able amount of hair from the intervening tissue.27,37
The donor strip is excised with a double-bladed scalpel ex­
cept for the tapered ends that are incised with a single blade.
Scalpels are always held at the same angle as the hair exits
the scalp. The chosen width of the strip is determined by a
number of variables, the most important of which is scalp
laxity. This varies from patient to patient and within the same
patient from one area to another, as well as from one surgery
to the next. In the authors’ office, the most common distance
between the double blades is 8–10 mm.
Because scalpel blades are always held at the same angle as
the hair exits the scalp, it is important to note that in certain
circumstances the width of the excised strip may differ from
the actual distance between the blades. This phenomenon is
particularly important when the hair angle is very acute, ne­
cessitating holding the scalpel blades at a very acute angle. In
such circumstances the width of the strip and the wound will be
wider than expected (given the actual distance between the
blades of the double-bladed scalpel). This will result in more
closing wound tension and increases the chance of producing
a less than optimal scar.
Once the donor strip has been removed, any large bleed­
ing vessels are cauterized with a Hyfrecator set at unipolar
delivery and 80 to 90 watts. The wound is usually closed with
a running single-layer suture technique using 2-0 Supramid
(nylon) on a CL-30 reverse cutting needle, and loops are nor­
mally placed 3–4 mm apart. The suture needle enters the
skin approximately 2–3 mm inferior to the inferior incision,
is usually brought through the mid to deep dermis, and exits
3–4 mm superior to the superior incision.
In the authors’ practice, the resulting scar is typically
0.2–1.5 mm wide, regardless of the number of sessions that
Zone of lowest
density hair
Lateral and posterior
borders of area of MPB
‘Safe’ donor area
50 mm
Ear
80 mm
Zone of lowest
density hair
70 mm
80 mm
Midline of
occipital area
50 mm
Ear
Fig. 22-14  The shaded area is Unger ‘safe’ donor area (containing
eight or more hairs/4 mm diameter circle) for more than 80% of
patients under the age of 80 years, as determined from studies
of 328 men aged 65 years or older.
• The authors spend 5–10 minutes, after the
suturing has been completed, to flip hairs that
have been trapped beneath the suture loops
into their normal position. These hairs, if left
under the sutures, cause greater crust ­formation
and may accidentally get pulled when the hair
is combed during the postoperative period.
Care is also taken to check the wound edge
­approximation at the same time.
Pearls

380
Chapter 22
Cosmetic surgery procedures and techniques
have been carried out (Fig. 22-15). Occasionally, wider than
usual scars occur, for which the following reasons are most
common:

• Healing characteristics intrinsic to the patient: one such
characteristic is extreme laxity in the donor region. The
authors have found that an inherent tendency to wide
scars can be improved upon by leaving the sutures in place
for 2 weeks postoperatively, instead of the usual 8 days.

• Excessive tension upon wound closure.

• Poor blood supply, most commonly seen in ‘repair’
patients who have multiple rows of scar tissue superior
and/or inferior to the new excision site.

• Excessive wound tension one to several days after closure,
secondary to excessive postoperative edema.
As indicated above, excessive tension at closure is one
of the most common reasons for increased scar width, and
thus an attempt should be made to minimize tension in all
­circumstances. A stepwise approach to closure of wounds
with excessive tension can be seen in the summary below; the
best approach of course is to avoid this, and the ­possibility
of ­creating wide scars, by taking a narrower donor strip than
one actually thinks is possible. (The authors try to choose
strip widths that are 1–2 mm narrower than they believe
could maximally be excised while still closing the wound with
­essentially no tension.) Any patient with a high-tension wound
closure should be carefully followed to ensure that healing is
progressing appropriately.
After closure, the length and width of the donor strips, clos­
ing tension (rated from 1 for least to 10 for extreme tension),
and the numbers and types of grafts obtained are noted on
the operative record as a guide for what amount of donor
tissue should be excised in future sessions.
The relative indications for FUE donor graft harvesting
have already been briefly discussed in the section entitled
‘Studies.’ To elaborate briefly, in FUE, a small-bore trephine,
usually 1 mm or less in diameter, is used to incise around an
individual FU to the high- to middermis level. The FU is then
gently eased out of its site with a combination of traction and
pressure with a blunt trephine,18 or peripheral 27 g needle
punctures17 intended to sever its fibrous attachments. If one
incises too superficially or the patient’s tissue is more friable
than usual, the follicles are torn apart as traction is exerted.
If one incises too deeply, the follicles are transected as they
splay in the subcutaneous tissue. Practice and skill are neces­
sary to incise to just the right depth, at just the right angle
and direction, and to apply the optimal amount of traction.
It is not surprising that few practitioners have been able to
master FUE.
Stepwise approach to possible or actual high-tension
wound closure

• Excise any previous scar tissue from the base and sides
of the wound, to eliminate any unnecessary bulk and
‘tethering’ which it may cause.

• Use interrupted instead of continuous sutures.

• If necessary, use 3-0 Vicryl galeal sutures.

• Undermine the superior wound edge, as a last resort.

• Inject small amounts of a solution of 3.33 mg triamcino­
lone acetonide superior to the wound immediately after
closure in order to minimize local postoperative edema.
Graft preparation and insertions
Hairs emerge from the scalp as single hairs or, far more fre­
quently, groupings of 2–3 or 4–5 closely associated hairs (see
Fig. 22-6).38 As mentioned earlier, these ‘follicular groups’ or
‘follicular units’ have become the basic building block of most
modern hair transplantation and of current terminology (see
Table 22-3). Donor strips are kept moist in cooled saline, prior
to being carefully sectioned, using small jeweler’s forceps and
super-sharp razor blades and 6× to 10× magnification, into
‘slices,’ much as one would slice a loaf of bread. For FUT,
microslit and slot grafts, the slices are made one or two FU
wide (Fig. 22-16). They are then sectioned into pieces contain­
ing the desired numbers of FUs or hairs. A small amount of
subcutaneous tissue is left below the level of the deepest hair
bulbs. Grafts ideally should be grasped by this subcutaneous
‘tag’ when they are being inserted into recipient sites. Most
of the alopecic skin and subcutaneous tissue is sectioned off
as part of the ‘cleaning’ process for FUs. Removal of all, or
more commonly, most of the epidermal portion of each FU is
optional but the authors prefer a ‘tear-shaped’ graft with lim­
ited tissue at the epidermal end and more tissue to cushion the
bulb area at the proximal end of the hairs (Fig. 22-17). Every
effort is always made to avoid follicle transection.
With the exception of dehydration, it appears that a great
deal of abuse must be administered to the follicle to actually
impair hair growth.39 Even intentional mutilation of follicles
will often not deter growth. Kim and Choi demonstrated 80%
regrowth of hair when the distal third of the follicle was inten­
tionally removed (hair survival drops to 60% if the proximal
third is removed).40 Limmer has shown somewhat lower rates
of hair survival with similar injuries, while Mayer has demon­
strated that if follicles are divided into distal third and proximal
two-thirds fragments, and these are then transplanted, one can
achieve a total of 133 hairs from every 100 hairs transplanted
(though these hairs often have a finer texture).41,42 Regardless
of the variable percentage rates of survival, it is clear that sub­
stantial damage can be done to follicles without death of the
hair, and that the instinct for preserving intact FU may be more
emotional than necessary. Minor ­follicular injuries during graft
• If a patient has white hair, briefly ­submerge
slices in a dilute solution of methylene blue.
This solution is ­prepared by adding varying
amounts of normal saline (from 20–30 cc) to 2%
methylene blue 1 cc. Each ­technician finds the
concentration felt to be most effective to outline
the follicles and reduce the possibility of follicle
­transection. These grafts should also be trimmed
less than usual, again to ­preserve the integrity of
the follicle.
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381
Hair transplantation  •  Chapter 22
A
B
C
E
D
Fig. 22-15  (A) A patient before transplanting. (B) Nine months after the second of two sessions to the frontal area (2970 FUs). (C) The vertex
area before transplanting. (D) Six months after his first transplant to the vertex. (Full growth will take an additional 6 months.) Because this patient
was in his early 50s, and had a relatively small area of MPB, at this stage in his life, the author was able to treat his entire area of alopecia, as
frontal and posterior areas (plus adjacent evolving areas), in two zones instead of the more usual three zones (plus adjacent evolving areas)
shown in Fig. 22-4. (Patients with advanced type VI or type VII MPB would usually be treated in four or even five zones plus adjacent areas.) He
had returned for a second session to the vertex. (E) The hair was clipped short in the donor area prior to the fourth session. The narrow scar that
can be seen in this photograph, in the middle of the clipped zone, is the only scar he had after three sessions as the authors nearly always excise
any scar(s) from prior surgery as part of any subsequent donor strip. Scars are typically 0.2–1.5 mm wide regardless of the number of strips that
have been excised because the authors always try to choose a strip width that creates a wound that will close with what they call minus 1 (−1) to
minus 2 (−2) tension; that is, they believe they could have taken a strip that was 1.0–2.0 mm wider than what was actually taken.

382
Chapter 22
Cosmetic surgery procedures and techniques
preparation appear to be far less important than, for example,
excessive handling/dehydration of FUs during ‘dense packing.’
Occasionally, unseen telogen follicles can be mistakenly dis­
carded as part of the ‘garbage’ between FUs when microscopic
dissection of donor tissue is used to remove essentially every­
thing but the visible anagen hairs in FUs.43 Some evidence
lends credence to this possibility, with one study showing that
when ‘chubby’ rather than ‘skinny’ FUs are transplanted, 33%
more hair may grow than is originally counted.44 Therefore,
it would seem wise to leave a cushion of tissue around each
FU during dissection, rather than to make them as ‘skinny’
as possible. The latter practice nearly always attends ‘dense
packing’ and is another reason why dense packing may not be
as advantageous as it may first seem to be.
The FUs, after preparation, are placed in the ‘wells’ of a
sterilized ceramic escargot dish filled with saline. They are also
kept cool by placing the dishes on a ‘Lepaw graft cooler,’ a Py­
rex container filled with ice (Fig. 22-18). The individual ‘wells’
of the escargot dishes are labeled and are used to sort grafts by
the number of hairs they contain, as well as the color, texture,
and caliber of the hairs. Differences in caliber are ­particularly
important to recognize as, has been noted ­earlier, even slight
variations in hair caliber can have a marked ­effect on perceived
naturalness and hair density or hair ‘bulk.’ Fine-textured hair
is ideal for hairlines, while coarser hairs are more suitable for
creating density. Cole has pointed out that a ‘mere’ 0.01 mm
increase in the diameter of an average hair can produce a 36%
increase in hair volume. The latter explains the sometimes
Fig. 22-17  Pear-shaped, ‘chubby’, one-haired, two-haired, three-
haired, and four-haired follicular units. Note the intact sebaceous
glands and the fat pads below the dermal papillae. (Photograph
courtesy of Dr. David Seager.)
• Keep grafts immersed in saline or at least very
wet at ALL times.
Pearls
Fig. 22-18  An escargot dish is used to hold the prepared grafts.
Each escargot well is filled with a sufficient amount of saline solution
to completely immerse the grafts that will be put into it. The wells are
also marked with a grease pencil indicating the number of hairs in
each graft and the hair texture. The initials of the technician who has
prepared the grafts are written on the escargot dish handle. The dish
is then placed on an ice-filled Pyrex container.
Fig. 22-16  The donor strip is carefully incised into slices that are
only one or sometimes two FU wide. These are then subdivided into
sections containing a single FU or, if two of the FUs are very close to
each other, into a ‘follicular family’ of two FUs that still can be inserted
into a small needle hole. (Photograph courtesy of Dr. David Seager.)
• A tendency to create ‘skinny’ FUs will probably
result in the loss of unseen telogen follicles.
Avoid this problem by favoring the preparation
of more tear-shaped, ‘chubby’ grafts.
Pitfalls

383
Hair transplantation  •  Chapter 22
­remarkably ‘full’ look achieved with FUT in some patients de­
spite relatively low numbers of hairs per square centimeter (Fig.
22-19).36,45 Sorting grafts at the time of their preparation not
only facilitates the consideration of caliber during implantation,
but also the other variable hair characteristics noted above.
The ideal technician has the following characteristics:
1. Technical expertise to create grafts with the correct
amount of surrounding tissue and (somewhat less impor­
tantly) to do so quickly.
2. The physical and mental ability to concentrate intensely and
for long periods on a repetitive, demanding task and to emo­
tionally accept the necessary ongoing quality control oversight.
3. A personality that enables her or him to work harmoni­
ously with a large number of other technicians for long
periods of time.
Finding a sufficient number of such individuals is the most
difficult, time-consuming, and expensive task necessary in a
practice which incorporates FUT.
Inserting grafts into recipient sites by starting in the posterior
aspects of the area being treated and moving anteriorly will
tend to minimize ‘popping’ of grafts that have been previously
inserted in that same general area. The technician must try to
envision the angle and direction at which the recipient site was
made and to insert the graft in one smooth action by following
those perceived parameters. The best technicians can do this
remarkably quickly and without multiple tries, just as some
technicians can very quickly and accurately ‘sliver’ the strips
into one FU wide slices. Each office must identify the techni­
cians that are best at accomplishing these specific goals.
Multi-unit grafts
If microslit grafts are being employed for multi-unit grafts
(MUGs), making them only one FU wide and two to three FU
long eliminates the possibility of ‘compression’ of hair into
dense unsightly lines. Slot grafts are made three FU long and
are prepared from ‘slices’ that are two FU wide.46 Grafts that
A
B
C
Fig. 22-19  (A) Black crayon markings outline the areas to be transplanted. Note that the temporal ‘humps,’ where there is temporarily
persisting hair, are included in the treatment plan. (B) The same patient after one session of FUT to the frontal area and one to the midscalp
area (4095 FUs at 25 FU/cm3 density). (C) Frontal view of the patient at the same time as shown in (B).

384
Chapter 22
Cosmetic surgery procedures and techniques
are intended to fill holes made with 1.3–2.0 mm trephines are
prepared from the donor strip by slicing it into approximately
2 mm2 grafts, and those that will be inserted into holes made
with 3.0–3.25 mm diameter punches are generally 3.5 mm2 in
size. The first few MUGs are tested in the recipient sites to be
certain their size is appropriate before many of them are pro­
duced. Placement should result in a ‘snug’ fit, but not so tight
as to produce compression of the hair within the graft.
The recipient area
Presenting or potential type V to VI MPB is conceptually di­
vided into four zones: the frontal (F), midscalp (M), vertex (V),
and future areas of loss of each of the three aforementioned
regions (Fe, Me, and Ve, respectively) (see Fig. 22-4). The fron­
tal area extends from the hairline to a modified coronal line
drawn perpendicularly from the left to right tragus. The ver­
tex (‘crown’) area begins at a point that Beehner has called the
‘vertex transition point,’47 where the more or less horizontal
caudal aspect of the skull starts becoming more vertical, and
extends posteroinferiorly to the limits of the alopecic area.
The midscalp consists of the region between the frontal and
vertex areas. If hair is transplanted as far posteriorly as the
‘vertex transition point,’ the individual will look like he has full
coverage when viewed frontally and almost full coverage when
viewed laterally, despite the presence of an untransplanted
alopecic ‘crown.’ In most type V to VI MPB patients, one
FUT session in the F/Fe area and one in the M/Me area will
produce very acceptable cosmetic results (see Fig. 22-19).
With rare exception, the authors believe that one should
not attempt to transplant the entire, ultimate area of MPB un­
less the patient is willing to undergo transplanting exclusively
with FUs and/or to undergo AR at some point during the
course of treatment. Exceptions to this general rule include
older patients in whom the authors can be more certain of
the long-term extent and pattern of hair loss; those who are
seeking relatively lower-density coverage of larger areas; and
those with an exceptionally good prognosis based on family
history and physical examination. Even in the latter group, ac­
ceptance of perhaps less dense coverage should be anticipated
as a possible necessity.
As implied from the preceding, for the majority of patients
in whom AR will not be used, limiting transplanting to the
frontal and midscalp areas is a more reasonable and cos­
metically very acceptable goal. The posterior border of the
­midscalp should be completed with FUs in a posterior ‘hair­
line zone’ fashion and should be curved so as to leave a nor­
mal, oval, or round shape to the remaining alopecic ‘crown’
area (see Fig. 22-4). Despite the foregoing, occasionally for
individuals with large current or future areas of alopecia, the
authors have opted to transplant the periphery of the entire
vertex area in order to create a ‘bald spot’ in a natural-looking
more caudal position. Such peripheral vertex transplantation
(PVT) (Fig. 22-20) is utilized in patients who have an especially
low inferior border in the vertex and who have donor tissue
reserves which are insufficient to allow for transplantation of
the entire vertex area, but are adequate for this more limited
goal.48
Follicular unit hair transplanting (FUT)
The recipient area can be treated in one of two different
general ways: (1) FUT or (2) FUT combined with MUGs.
Approximately, 95% of the authors’ patients and 100% of the
patients of most HRSs are currently treated with FUT. The
authors use FUT in: (1) the anterior hairline zone in all pa­
tients (all of the hairlines in the photos shown in this chapter
were created with FUs), (2) patients who have sparse temporal
A
B
Fig. 22-20  (A) Occasionally, patients present with very large alopecic vertex areas (as shown here) or likely future very large areas of vertex
alopecia. Because there is an inadequate supply of donor tissue to transplant the entire vertex, some patients can be satisfied by transplanting
the periphery of the vertex area in order to create a smaller ‘bald spot’ in a more natural-looking, more caudal position. (B) The same patient
as in (A), 9 months after a single session of 1805 FUs to the periphery of the vertex. The remaining area of alopecia is now located in a more
aesthetically satisfactory, more caudal position.

385
Hair transplantation  •  Chapter 22
hair and/or are aiming for less than high density, (3) most pa­
tients who present with totally alopecic recipient areas, (4) most
patients under the age of 40 years, and (5) as discussed above,
patients whose goal is to cover the majority or all of the alo­
pecic areas that will develop over their lifetime. As techniques
have improved, the disadvantage of relatively low hair density
with FUTs has been overcome, and its cosmetic efficacy has
increased dramatically (Fig. 22-21).
As described earlier, the goal of FUT is to divide the en­
tire donor strip into FUs, discarding what is viewed as excess
alopecic tissue between the FUs. The FUs are then inserted
into small holes or incisions made by various-sized needles
or small blades, thus attempting to recreate hair distribution
similar to that which is seen in nature. While FUT can pro­
duce the appearance of remarkable hair density in relatively
early stages of MPB (Figs 22-22, Fig. 22-23; see Fig. 22-10),
the most important advantage of FUT is that a single ses­
sion can stand completely on its own and look natural in an
area that is totally alopecic, or that is destined to become
alopecic. Thus, a larger proportion of any area of alopecia
that might develop can be treated by transplanting each area
only one time. In contrast, if MUGs are utilized each area
must be treated at least twice in order to produce natural-
looking coverage.
In addition, for most alopecic patients the ability to avoid
the temporary but usual noticeability of MUGs between the
first and second sessions (in the same area) is more important
than the somewhat denser result that can be produced with
MUGs. As described earlier, an additional important attribute
of FUT is that if the MPB extends beyond the initial prog­
nosis, the then isolated transplanted area will be transformed
into a natural-looking IFF.
A
B
Fig. 22-21  (A) A patient before transplanting. (B) One year after one FUT session (1947 FUs). This unusually dense result with FUT is mostly
due to the patient’s relatively high-caliber and wavy hair.
Fig. 22-22  (A) A 42-year-old man with mild-to-moderate thinning of his hair in the frontal area before transplanting. The site has been wiped
with a Betadine solution just prior to surgery for antisepsis and to clarify thinning areas. (B) Seven months after a single FUT session (2282 FUs).

386
Chapter 22
Cosmetic surgery procedures and techniques
It has been previously noted that the authors always con­
struct the hairline zone with FUT. This is done in a ‘two-
step’ fashion, first creating a single line of recipient sites
that follows the line drawn preoperatively and then creat­
ing irregularly shaped mounds of grafts anterior to that line
(Fig. 22-24).49 The authors have found Parsley’s descrip­
tion of patterns of normal hairlines50 to be especially help­
ful in designing ‘mounds’ of appropriate sizes and locations.
FUs containing the finest single hairs are used most anteri­
orly, two to three rows deep, at a density of approximately
30 FU/cm2. The recipient sites are made with a 19–20 g hy­
podermic needle to allow for easy graft insertion, and a ‘snug’
fit, while minimizing vascular damage. FUs containing two
fine-textured hairs are transplanted for two to three rows pos­
terior to the single hair FU and at initially similar or slightly
higher densities.
Characteristics of a natural appearing hairline

• Irregular anterior zone consisting of 1- and 2-haired FUs

• Irregular hair density

• Hairs that grow in the original hair angle and direction

• Finer hairs most anterior and coarser ones further
­posteriorly

• Single, fine-textured ‘sentinel’ hairs scattered irregularly
anterior to the bulk of the hairline zone
As one moves progressively more posteriorly, the FU
­density per square centimeter decreases slightly and FUs
with more than two hairs and of greater caliber are utilized;
these sites are made with a 19–18 g needle. The authors and
many other FUT practitioners also treat an anterior mid­
line oval zone, ‘the egg,’ with FUs containing three or more
usually high-caliber hairs,51 at a density of approximately
30–35 FU/cm2 (see Fig. 22-4). Virtually all of the recipient
sites for these somewhat larger FUs are also made with an
18 g needle.
Creating good tissue turgor is as important in the recipient
area as it is in the donor area in order to minimize injury to
hair adjacent to the recipient sites being incised during any
given session. The more fluid infiltrated, the farther the exist­
ing FUs in the recipient areas are spread apart, and thus the
less likely injury to the FUs becomes. As the fluid dissipates,
recipient sites also move closer together, thereby increasing the
FU/cm2 density. Effective hemostasis is likewise an important
component of creating ideal densities, distributions, angles,
and directions of recipient sites. Good control of bleeding can
be achieved with mechanical pressure produced manually or
with large amounts of saline and periodic infiltration of small
amounts of a saline solution with a 1/50 000 concentration
of epinephrine. In a small percentage of patients a 1/25 000
epinephrine concentration may be required to produce
adequate hemostasis.
One of the most important factors contributing to a natural-
­looking final result is the angle and direction of the transplanted
hair. If recipient sites are made too obtusely, leading to hairs
that are ‘standing straight up,’ or do not mimic the existing flow
A
B
Fig. 22-23  (A) A 32-year-old male patient with moderately advanced hair loss in deep frontotemporal triangles before transplanting.
(B) The same patient 9 months after a session consisting of 1625 FUs. Starting transplanting at earlier stages of hair loss is advantageous in
that postoperative camouflaging of the grafting is easier, there is less obvious alteration of the appearance to friends and associates, and the
patient avoids going through the embarrassment of ever being totally alopecic.
• The higher the FU density, the more important
it becomes that the transplanting be carried out
using the smallest incisions while still allowing
for atraumatic graft insertion. High FU density
should ideally be performed using a ‘stick and
place’ technique, in which each graft is inserted
immediately after each recipient site is incised,
so as to minimize trauma to the grafts.51
Pearls

387
Hair transplantation  •  Chapter 22
of hair, the transplant looks artificial, regardless of the size of
the grafts utilized or the density of the transplanted hairs. Mak­
ing these sites at the correct angle and direction also eliminates
possible lethal injury to any existing hair in the area. Although
various general directions and angles of hairs in different areas
of the scalp have been described, implicitly none of these gen­
eralities applies to all patients. In fact, hair directions and angles
can change dramatically and in unexpected ways in some pa­
tients (Fig. 22-25). Therefore, the surgeon should follow what
he or she sees rather than any general ‘rule.’ The more pre-
existing hair, the more important correct angling and direction
becomes. The authors quite frequently spend 90–150 minutes
just to make 1500–2500 recipient site incisions.
FUT combined with multi-follicular unit grafts
As indicated earlier, in the frontal area, approximately 5% of
the authors’ male patients are treated with MUGs in combina­
tion with FUs. Space does not allow for a full discussion of the
various options and purposes of such combinations, but com­
plete descriptions are available elsewhere.49,51–53 The main
benefit of using mixed grafting is that, in the authors’ hands,
higher densities can be achieved than with FUT alone, with­
out compromising the natural appearance of the final result
and without using FU densities/session that increase the risk
of lower hair survival (Figs 22-26, 22-27). The decision to use
‘mixed grafting’ is taken only after a number of conditions
are met.
A
B
C
D
Fig. 22-24  (A) After having tried numerous approaches, the authors find it most helpful to create a hairline by starting with a straight line of
recipient sites 2–3 mm superior to where they decide the ultimate hairline zone should appear to be. The photograph shows this relatively
straight line that is produced with a 20–19 g needle for one-haired FU. A small widow’s peak was also created in this individual in the anterior
midline. (B) Beginning at the lateral ends of the hairline, the authors create more or less triangular mounds of recipient sites anterior to the
straight line; the job now is to simply make the original straight line irregular, by producing, at various points, small and large mounds of
triangles anterior to it. (C) The irregularities are complete along the entire straight line, and the authors now produce a wider hairline zone,
making five to six sites posterior to the original straight line. This process is shown beginning on the right side of the photograph.
(D) The hairline zone is now complete. It has an irregular anterior border and a depth of approximately 10 FU sites.

388
Chapter 22
Cosmetic surgery procedures and techniques
As per usual, a hairline area consisting of seven to ten rows
of FUs is constructed; however, DFUs may be used posterior
to this zone. If slot grafts or round grafts are employed, they
are positioned in three to four rows, posterior to the DFUs,
or sometimes posterior to a wider zone of FUs instead of the
DFU zone. The frontal area is completed with DFUs, FUs,
or a combination of both, posterior to the zone treated with
larger MUGs (see Figs 22-26B, 22-27). Slot grafts and round
grafts are especially advantageous for producing hair density as
they reduce the surface area of the current or future alopecic
site and replace it with FUs spaced more densely than they were
in the donor area. If slot or round grafts are employed, the
second session should ideally occur 5–6 months after the first
one in order to fill the spaces between the prior session’s grafts
sufficiently well to minimize the possibility of temporary graft
noticeability. A third and usually final session in the area often
includes FUs scattered between the MUGs to create a back­
ground of diffuse hair in any remaining untransplanted areas.
The authors primarily employ FUs and DFUs in female
patients, unless the area to be transplanted is only an extended
hairline zone, in which case FUs are utilized exclusively.
Hair restoration surgery in the vertex area
Hair restoration surgery in the vertex (‘crown’) area is consid­
erably more demanding than frontal and midscalp transplant­
ing. Hair direction and angling are more difficult to mimic if
there is existing hair, or to recreate in a natural pattern if the
area is alopecic or nearly so. In addition, the ‘shingling’ or
overlapping of hairs, which helps create the appearance of
higher density in the frontal and midscalp areas, is not present
in most of the vertex with its whorl-like direction of hair.
The authors utilize only FUs in the vertex because most
patients do not have enough donor reserve to transplant the
entire crown more than once (in addition to the frontal and
midscalp areas once or twice each), and FUT is the only type
of grafting that looks natural after a single session. Often, a
limited area at the center of the whorl can be transplanted
a second time, usually concomitant with transplanting else­
where, in order to create the appearance of a similar density
to that seen in the rest of the crown area where shingling is
A
B
Fig. 22-26  (A) This patient with an excellent donor/recipient area ratio and relatively dense temporal hair wanted denser hair growth in the
frontal area than can usually be produced using FUs exclusively. (B) He agreed to undergo two sessions, 5 months apart, using a combination
of FUs, DFUs, and slot grafts as shown above during his first session.
Fig. 22-25  Although various general directions and angles of hairs
in different areas of the scalp have been described, implicitly none of
these generalities applies to all patients. Hair directions and angles
can change dramatically in relatively small areas, as indicated in this
photograph showing needles inserted at the angle and direction of
hair at each of the locations. The surgeon should follow what he or
she sees rather than any general rule.
• It is easiest to determine the proper direction for
hair orientation in the vertex area if the surgeon
begins at the center of the whorl and works
outwardly.
Pearls
(continued)

389
Hair transplantation  •  Chapter 22
C
D
Fig. 22-26­—cont’d  (C) The same patient 9 months after his second session. This type of hair density cannot be produced with two FUT ses­
sions unless the FUs are placed closer together than the authors feel is acceptable for optimal hair survival. The option of grafting with multi-unit
grafts is reserved for only a small percentage of the authors’ patients whose long-term donor/recipient area ratio is excellent, and whose tempo­
ral hair is also expected to remain fairly dense over the long term. (D) Close-up view of the hairline zone (created with FUs) for critical evaluation.
A
B
C
D
Fig. 22-27  (A) A patient prior to transplanting. (B) The patient shown after three surgeries of mixed grafting including FUs, DFUs, and
standard 4 mm round grafts. His hair is parted to reveal lack of any pluggy appearance. (C) The same patient with his hair as worn normally.
(D) The same patient showing close-up of the hairline.

390
Chapter 22
Cosmetic surgery procedures and techniques
present. In very rare instances, there are sufficient reserves of
grafts to treat the entire vertex two or even three times.
As has been noted previously in this chapter, unless the
patient is past middle age and/or has a particularly advanta­
geous family history and physical examination, the authors
do not generally transplant the vertex until the frontal and
midscalp areas, and adjacent future areas of loss, have been
satisfactorily completed. At that stage, they will treat the ver­
tex region if they believe a minimum of two sessions are still
available from the ‘permanent’ donor area (one for the ver­
tex and one to treat areas of unexpected future loss). Rare
exceptions are made for individuals who are more concerned
about their vertex hair loss than their frontal loss, and for
those who will be satisfied with reducing the size of the ver­
tex alopecia with peripheral transplanting as described ear­
lier (see Fig. 22-20), provided that they have enough donor
tissue to fulfill that objective but insufficient amounts for total
vertex coverage. All patients are also advised that because
there is little opportunity for overlapping of hair in the crown
region, they should be prepared to accept the appearance
of a somewhat lower density at that site than in frontal and
midscalp areas.
The repair of cosmetically unsatisfactory transplanting
There are many individuals who have walked around for years
with peculiar hairlines, ‘pluggy’-looking grafts and a separa­
tion of previously transplanted areas from receding fringes of
hair. These are the most prominent, but by no means the only,
tell-tale signs of the potential drawbacks of older forms of hair
transplanting. Fortunately, many patients with these problems
can be greatly improved with the techniques that are currently
available (Figs 22-28, 22-29). An exhaustive discussion of this
subject is not possible in the limited space allowed, but it is
available elsewhere.27 The following points summarize several
of the most important components of ‘repair’ sessions:

• If grafts have been placed into areas that are anterior to
a reasonable frontal hairline, they should be excised by
punching them out with a trephine or by block exci­
sion. This may be performed in one session or in staged
sessions. Such excisions can be carried out in a separate
surgery; however, it is preferable to combine this step with
more substantial corrective transplantation at the same
time. Any hair obtained from the excised grafts should
always be retransplanted concurrently rather than being
discarded.

• If the grafts have been transplanted into reasonable loca­
tions, but are noticeably pluggy, either because the hair
within them is very dense or very coarse or has high color
contrast to the surrounding skin color, they should be
excised partially or completely. Such excisions can be
single or multiple (typically with 3-month intervals)
and may or may not be done before substantial hair
transplanting is carried out.

• The authors believe that the reluctance of most practi­
tioners to utilize alopecia reductions is an over-reaction
to the past problems associated with improperly planned or
performed AR. Any scars remaining from such procedures
should be transplanted with grafts if sufficient donor hair
is available.

• Most or all of the transplanting in corrective procedures
should be done with FUs. This is because, as noted many
times before, a single session will look natural standing on
its own in an alopecic area. It is therefore the most graft-
­economical way to utilize the limited reserves of donor
A
B
Fig. 22-28  (A) This 56-year-old gentleman had undergone hair transplanting 15 years ago prior to seeing us. He had fine-textured, reddish-
to-blonde colored hair. The transplanted area was moderately pluggy-looking and would have appeared much worse had his hair not been so
fine and relatively light-colored. The density in the transplanted area was also relatively low. In addition to the preceding, his MPB was obviously
extending further laterally and he had lost all of the hair behind the transplanted zone. He was basically left with a pluggy-looking, unsatisfactory
isolated frontal forelock, as is shown in the photo. The authors designed lateral ‘humps’ for completion of the frontal-third of the area of MPB and
a new hairline zone in front of the old one. The black crayon line delineates these objectives. (B) The same patient shown in (A) 9 months after
a first repair session that consisted of 1270 follicular units, 105 double follicular units, and 21 2  mm2 grafts.

391
Hair transplantation  •  Chapter 22
tissue that is always a major hurdle to overcome in repair
cases. A larger area can be transplanted more lightly and
will look more natural than if multi-FU grafts were uti­
lized. In some instances, multi-FU grafts are preferable in
strategic areas, but the explanation of when this approach
is appropriate is quite complex. The reader is referred
elsewhere for further information.27

• The most important objectives of repair transplanting,
in order of priority, are:

1. To create a new hairline anterior to the old grafts
and to make this FU zone as wide as possible; keep­
ing in mind aesthetic considerations and donor tissue
limitations.

2. To fill the alopecic spaces between the older grafts.

3. To treat new or additional areas of alopecia. The goal
should be to join old transplanted areas to the adjacent
rim hair and to ideally transplant as far posteriorly as
the middle of the midscalp or, even better, the anterior
border of the vertex.

4. To remove as much donor area scar as possible when
excising donor tissue for the repair session. The overall
scalp hair to scar ratio should improve with each repair
session rather than worsen. As noted earlier in this
chapter, both objectives are most often met by excising
two scars and a hair-bearing area between them during
each session.
Because blood supply to the new wound is nearly always
reduced by surrounding old scars it is best to close with less
tension than one aims for in non-repair situations. In these cir­
cumstances both the amount of closing tension will be greater
than expected in normal tissue and postoperative edema will
diffuse more slowly; neither are conducive to optimal healing.

• The repair sessions should ideally be separated by intervals
of 6–9 months. This allows the operator to better assess
A
B
C
Fig. 22-29  (A) This 38-year-old patient demonstrates a number of problems: (1) obvious spaces between previously transplanted round grafts
with dense dark hair, (2) progression of his MPB beyond the originally treated area, and (3) varying textures and densities of hair within the
old grafts. Fortunately, most of the old transplanting was done in an area well posterior to where a hairline zone could have been placed, so it
was easy to produce a new and more natural-looking hairline zone anterior to the old grafts. (B) The grafts at the midline anterior border of the
transplanted area were partially excised and moved further posteriorly, as were those containing hair that was excessively coarse or dense. Dur­
ing the same sessions, a new hairline zone was created, grafts were added to previously untreated areas in the lateral frontal areas and to the
previously treated ones. The anterior aspect of the midscalp was also transplanted during two of the three repair sessions. A total of 623 FUs,
203 small slit grafts, 837 medium slit grafts, 268 2 mm round grafts and 23 standard grafts were utilized in three sessions. (C) The photograph
shows natural-looking and denser appearing results, 12 months after the third session.

392
Chapter 22
Cosmetic surgery procedures and techniques
areas that do or do not need more grafting at the same
time as new areas are transplanted. It also provides more
time for donor area laxity to improve.

• Consider employing FUE, scalp-to-scalp or body-to-scalp,
if required donor hair is not available in the scalp, or
scarring in the donor area is too severe to allow for further
strip harvesting or the latter results in more scarring than
usual or expected. If one is not an expert at FUE, it is best
to refer the patient to a more experienced practioner.
Transplanting into scar tissue
Contrary to a persisting belief held by many physicians, hair
can be successfully transplanted into scar tissue (Fig. 22-30).54,55
The requisites for a positive outcome are:

• Excise as much of the scar as possible before transplant­
ing hair into it. Once again, the width of excision should
allow closure with low tension.

• Use only FUs.

• Use a lower FU per square centimeter density than in nor­
mal skin. Generally, 15 FU/cm2 should be a maximum.

• Surgeries into the same scarred areas should be scheduled
at least 6 months apart.

• When repairing scars subsequent to rhytidectomy,
the authors often will also construct new anterior
temporal hairlines and sideburns at the same time
(Fig. 22-31).
A
B
Fig. 22-30  (A) A patient before transplanting into scarred areas of temple subsequent to a car accident. The black lines denote the limits of
the areas to be treated. (B) Nine months after the second session of a combination of FUs and DFUs. Hair transplanted into scar tissue will
survive if appropriate graft densities and time intervals between sessions are utilized.
A
B
Fig. 22-31  (A) A 55-year-old female post-rhytidectomy 5 years previously. The surgical plan included transplantation to temple recessions, and
pre- and supra-auricular area scars, from the cosmetic surgery. (B) Results 11 months post-surgical. Surgery consisted of 1252 FUs
(199 × 1 hair, 599 × 2 hairs, 454 × 3+ hairs).
• Ask ‘repair’ patients to massage their donor
areas for 15–30 minutes three or four times a
day for several months prior to strip harvest­
ing, in order to improve the scalp laxity in those
areas.
Pearls

393
Hair transplantation  •  Chapter 22
Postoperative care and course
The authors are one of the minority of HRSs who continue
to encourage patients to wear a turban-like bandage overnight
after surgery.56 This is done because all of the wound healing
studies of which they are aware have shown faster healing of
wounds that have been occluded for the first 12–24 hours as
compared to those left open to the air. Patients are informed
of this rationale and if they still prefer to have no postop­
erative bandage they are kept in the office for an extra 30–60
minutes after the surgery is completed, to assure good hemos­
tasis, and then allowed to leave.
All patients return to the office the following morning for
bandage removal (if they have one), checking of graft placement,
and careful shampooing of the scalp and hair, as well as blow-
drying and styling the hair. Patients are advised to wash their
own hair once or twice a day, after soaking their scalp in a bath
for 10–15 minutes, until the sutures are removed in 8–10 days.
This accelerates the shedding of surgical crusts. Twice-daily ap­
plications of a 3.5% solution of minoxidil (equal parts 2% and
5% solutions) is recommended for ­donor and ­especially recipi­
ent areas, for the first 5 postoperative weeks. There is reason to
believe that: (1) this accelerates and may improve wound heal­
ing, and (2) decreases the amount of any postoperative telogen
effluvium of pre-existing hair in recipient and donor areas.57,58
In addition to the postoperative corticosteroids described
earlier, patients are told to sleep at a 45-degree angle for the
first 5 days (and are given Zolpidem [Ambien] 10 mg to help
them sleep). Both measures should reduce the frequency and
severity of postoperative edema in donor and recipient areas.
For those who find it practical, lying flat on their back or side
for the first 48 hours encourages edematous fluid to drain pos­
teriorly instead of towards the forehead and face, due to the
effects of gravity. This position is therefore more helpful than
lying at a 45-degree angle.
The hair in the grafts is usually shed during the first 2–4
postoperative weeks. Most hairs typically regrow by 2–4
months after surgery, though new hairs continue to sprout in
the recipient area for up to 18 months after surgery.59 Patients
are told to expect a nice improvement at 6 months and essen­
tially full growth at 1 year. Transplanted hairs will last in the
recipient area for as long as they would have in the donor area
from which they are removed.
Significant complications in hair transplanting are ex­
tremely uncommon and are almost always easily managed.60
In particular, infection and postoperative bleeding occur in
only a small fraction of 1% of surgeries.
Conclusion
Modern hair transplanting can help more patients with MPB
and FPHL than ever before. Results can be expected to be
far more natural, after fewer surgeries, than previously. On
the other hand, the need for appropriate long-term planning,
artistry, and meticulous technique are as or more demanding
than in the past.
REFERENCES
  1. Dieffenbach JF. Nonulla de regeneratione et transplantatione.
Disseration inauguralis, 1822. Wurzburg.
  2. Davis JS. Scalping accidents. Bull Johns Hopkins Hosp 1911; 16:257.
  3. Okuda S. Klinische und experimentelle untersuchungen uber die
transplantation von lebenden haaren (in Japanese). Jpn J Dermatol
1939; 40:537.
  4. Orentreich N. Autografts in alopecias and other selected dermatological
conditions. Ann NY Acad Sci 1959; 83:463.
  5. Hamilton JB. Patterned loss of hair in men: types and incidence. Ann
NY Acad Sci 1951; 53:708–728.
  6. Norwood OT. Classification and incidence of male pattern baldness.
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Springfield: Charles C Thomas; 1984:3–14.
  7. Ludwig E. Classification of the types of androgenetic alopecia (common
baldness) occurring in the female sex. Br J Dermatol 1977; 97:247–254.
  8. Olsen EA. Androgenetic alopecia. In: Olsen EA, ed. Disorders of hair
growth: diagnosis and treatment. New York: McGraw-Hill; 1994:
257–283.
  9. The Finasteride Male Pattern Hair Loss Study Group: long term (5 year)
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10. Unger W, Shapiro R. Commentary on Ruseell Knudsen’s Effect of
medical therapy on surgical planning. In: Unger WP, Shapiro R, eds.
Hair transplantation. 4th edn. New York: Marcel Dekker; 2004:
148–151.
11. Limmer B. Bob Limmer does it all one hair at a time. Hair Transplant
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12. Kligman AM. The human hair cycle. J Invest Dermatol 1959; 33:307.
13. Mayer M, Keene S. FU growth with different planting densities. In:
Unger WP, Shapiro R, eds. Hair transplantation, 4th edn. New York:
Marcel Dekker; 2004:921.
14. Mayer M, Keene S, Perez-Meza D. FU growth with different planting
densities, Annual Meeting of the International Society of Hair
restoration Surgery, Sydney, Australia, August 27, 2005.
15. Weonju L, Seokjong L, et al. Survival rate according to grafted hair density
of Korean one-hair follicular units with a hair transplant implanter:
experience with four patients. Dermatol Surg 2006; 32:815–818.
16. Beehner M. Studying the effect of FU planting density on hair survival.
Hair Transplant Forum International. 2006; 16(1):247–278.
17. Rassman WR, Bernstein R, McLellan R, et al. Follicular unit extraction:
minimally invasive surgery for hair transplantation. Dermatol Surg
2002; 28:698–703.
18. Harris JA. New methodology and instrumentation for follicular unit
extraction (FUE): lower follicle transection rates and expanded patient
candidacy. Dermatol Surg 2006; 32:56–62.
19. Jahoda CAB, Reynolds AJ, Oliver RF. Induction hair growth in ear
wounds by cultured dermal papilla cells. J Invest Dermatol 1993;
101:584–590.
20. Beehner M. The frontal forelock, concept in hair transplantation.
Am J Cosmet Surg 1997; 14:125–132.
21. Unger WP, Unger RH. Hair transplanting: an important but often
forgotten treatment for female pattern hair loss. J Am Acad Dermatol
2003; 49(5):853–860.
22. Shapiro R. Principles and techniques used to create a natural hairline in
surgical hair restoration. Facial Plastic Surg Clin N Am 2004; 12:
201–217.
23. Cotterill P. Hair transplantation in females. In: Unger WP, ed. Hair
transplantation, 3rd edn. New York: Marcel Dekker; 1995:287–292.

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24. Unger M, Marzola M, Cattani R, et al. Alopecia reduction procedures.
In: Unger WP, Shapiro R, eds. Hair transplantation, 4th edn. New
York: Marcel Dekker; 2004:709–751.
25. Unger MG. Alopecia reduction and stretch-back. Clin Dermatol 1992;
10:345.
26. Nordstrom REA. The ‘Nordstrom Suture’ for scalp reduction. Fifth
Annual Meeting of the International Society of Hair Restoration
Surgery, Barcelona, 1997, October 15–19.
27. Unger WP. Corrections of cosmetic problems in hair transplanting. In:
Unger WP, Shapiro R, eds. Hair transplantation, 4th edn. New York:
Marcel Dekker; 2004:663–689.
28. Farber GA. Anaesthesia for skin surgery. Skin surgery, 4th edn. 55
Springfield: Charles C. Thomas, 1977:55.
29. Nelson JL. Conventional and non-conventional medications in hair
transplantation. In: Unger WP, Shapiro R, eds. Hair transplantation,
4th edn. New York: Marcel Dekker; 2004:196–199.
30. Unger WP. Preoperative preparation and instructions. In: Unger WP,
Shapiro R, eds. Hair transplantation, 4th edn. New York: Marcel
Dekker; 2004:189–194.
31. Abadir AR. Use of local anesthetics in dermatology. J Dermatol Surg
Oncol 1975; 1:65–70.
32. Unger WP. Unger’s technique for anesthesia. In: Unger WP, Shapiro R,
eds. Hair transplantation, 4th edn. New York: Marcel Dekker;
2004:250–254.
33. Seager D, Simmons C. Supraorbital and supratrochlear nerve blocks.
In: Unger WP, Shapiro R, eds. Hair transplantation, 4th edn. New
York: Marcel Dekker; 2004:254–258.
34. Unger WP. The donor site. In: Unger W, ed. Hair transplantation, 3rd
edn. New York: Marcel Dekker; 1995:183–212.
35. Unger WP, Cole J. The safe donor area. In: Unger WP, Shapiro R, eds.
Hair transplantation, 4th edn. New York: Marcel Dekker; 2004:301–305.
36. Unger WP, Cole J. Donor harvesting. In: Unger WP, Shapiro R, eds.
Hair transplantation 4th edn. New York; Marcel Dekker; 2004:301–349.
37. Unger WP. Correction of poor hair transplanting. In: Unger WP, ed.
Hair transplantation, 3rd edn. New York: Marcel Dekker; 1995:375–388.
38. Headington JT. Transverse microscopic anatomy of human scalp. Arch
Dermatol 1984; 120:449–456.
39. Gandelman M, Abrahamson PA. Light and electron microscopic
analysis of controlled crushing injury of micrografts. Abstract from
1997 Annual Meeting of the International Society of Hair Restoration
Surgery. Dermatol Surg 1998; 24:789.
40. Kim JC, Choi YC. Regrowth of grafted human scalp hair after removal
of the bulb. Dermatol Surg 1995; 24:312–313.
41. Limmer B. On follicular unit hair transplanting. Hair Transplant Forum
International 1998; 8:1–6.
42. Mayer MA. Follicular regeneration. Presented at the Annual Meeting of
the International Society of Hair Restoration Surgery, Washington, DC,
September 17, 1998.
43. Unger WP. The telogen war: the ‘condemned’ replies. Hair Transplant
Forum International 1999; 9(1):22–24.
44. Beehner M. A comparison of hair growth between follicular unit grafts
trimmed skinny vs. chubby. Hair Transplant Forum International 1999;
9(1):16.
45. Cole J. Mathematics of follicular hair transplantation. Sixth Annual
Meeting of the International Society of Hair Restoration Surgery,
Washington, DC, September 16–20, 1998.
46. Unger W. Preparation of multifollicular grafts. In: Unger WP, Shapiro R,
eds. Hair transplantation, 4th edn. New York: Marcel Dekker; 2004:
379–381.
47. Beehner M. A nomenclature system for the zones and landmarks of the
balding scalp. In: Unger WP, Shapiro R, eds. Hair transplantation, 4th
edn. New York: Marcel Dekker; 2004:261–279.
48. Unger R. Crown transplantation: peripheral vertex hair transplantation.
Presented at the 13th Annual Scientific Meeting of the International
Society of Hair Restoration Surgery, August 2005, Sydney, Australia.
49. Unger WP. How I use multi-FU grafts. In: Unger WP, Shapiro R, eds.
Hair transplantation, 4th edn. New York; Marcel Dekker; 2004:
475–516.
50. Parsley WM. Hair transplant goals based on natural hair patterns. In:
Unger WP, Shapiro R, eds. Hair transplantation, 4th edn. New York:
Marcel Dekker; 2004:151–165.
51. Shapiro R. How to use follicular unit transplantation in the hairline
and other appropriate areas. In: Unger WP, Shapiro R, eds. Hair
transplantation, 4th edn. New York: Marcel Dekker; 2004:454–469.
52. Unger WP. Why ‘mixed grafting’: follicular units with multi-follicular
unit grafts. In: Unger WP, Shapiro R, eds. Hair transplantation, 4th
edn. New York: Marcel Dekker; 2004:475–503.
53. Shapiro R. Follicular unit transplantation alone or follicular units with
multi-FU grafts: why, when, how? In: Unger WP, Shapiro R, eds. Hair
transplantation, 4th edn. New York: Marcel Dekker; 2004:435–469.
54. Rose P, Shapiro R. Transplanting into scar tissue and areas of cicatricial
alopecia. In: Unger WP, Shapiro R, eds. Hair transplantation, 4th edn.
New York: Marcel Dekker; 2004:606–609.
55. Brandy D. The exclusive use of slit mini-micrografting for the correction
of a large fronto-parietal scalp defect. Am J Cosm Surg 1993; 10:
111–115.
56. Unger WP. Postoperative phase: bandaging. In: Unger WP, Shapiro R,
eds. Hair transplantation, 4th edn. New York: Marcel Dekker; 2004:
553–554.
57. Eremia S, Umar SH, Li CY. Prevention of temporal alopecia following
rhytidectomy: the prophylactic use of minoxidil: A study of 60 patients.
Dermatol Surg 2002; 28:66–74.
58. Avram CY. The potential role of minoxidil in the hair transplanting
setting. Dermatol Surg 2002; 28:894–900.
59. Beehner M, Martinick J. Study of intact FU vs. vertically and
horizontally cut grafts. In: Unger WP, Shapiro R, eds. Hair
transplantation, 4th edn. New York: Marcel Dekker; 2004:268–270.
60. Cooley J. Complications of hair transplantation. In: Unger WP, Shapiro R,
eds. Hair transplantation, 4th edn. New York: Marcel Dekker; 2004:
568–573.

395
Hair transplantation  •  Chapter 22
Appendix A
Hair Transplantation Preoperative Instructions
3 Weeks before surgery
• Notify us about your medications

At least 3 weeks before your surgery date, you must inform our office if you are using any prescription medications and/or
over-the-counter medications. Some may have to be discontinued or an alternate drug may have to be substituted.
• Drugs and herbs to avoid

See the attached list of conventional medicines and herbs, minerals, and supplements that may cause bleeding (Appendix B).
• Stop taking vitamin E

Eliminate intake of vitamin E capsules or vitamin pills containing vitamin E.
• Make arrangements to be on time

If you live out of town, make arrangements to stay overnight in a hotel near our office, as traffic and/or weather could delay your arrival
at our office. If you arrive late, your appointment may have to be postponed. The day after surgery, do not book flights before 12:00 noon.
1 Week before surgery
• Stop drinking alcohol

DO NOT drink any alcohol – INCLUDING wine, beer, or liquors. Even one drink causes excess bleeding.
• Stop using drugs

DO NOT use marijuana or any non-approved drugs.
• Stop taking aspirin

DO NOT take any ASPIRIN (ASA) or any drugs containing aspirin. (Read the label of over-the-counter cold remedies to make
sure they don’t contain aspirin.) You may use Tylenol.
1 Day before surgery
• Ibuprofen and Naproxen should be discontinued. Trade names of products containing these medications can be found on the
attached sheet (Appendix C).
The night before surgery
• Get a full night’s sleep.
• Shampoo and rinse your hair well with any shampoo. If you have long hair, please use a cream rinse.
The day of surgery
• Take the first dosage of antibiotics 2 hours before the scheduled time of your surgery – unless otherwise directed by our office.
• Shampoo your hair well with any shampoo.
• Please make sure that you have a full breakfast.

EXCEPTION: Patients having intravenous sedation by the anesthetist are not to eat anything after midnight the night before
surgery. A small amount of clear liquids is permitted when you wake up on the morning of surgery.
• Eating for afternoon surgery

Please eat a full breakfast and lunch.
• What to wear

On day of surgery, do not wear any clothing that must be pulled over your head to be removed. Wear shirts/sweaters/jackets with
buttons or zippers that open completely – it could be a hooded sweater or jacket to cover the bandage. We suggest that women
patients bring a scarf to cover the bandage. The same scarf may be used the next day after bandage removal and hair washing.

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Other important instructions
• Notify us about antibiotic allergies

If you are allergic to Erythromycin or Eryc (Polymer-Coated Erythromycin), Cefadroxil or Penicillin, confirm with our office that
you have notified us of the allergy and you will receive a different antibiotic.
• Do not take M.A.O. inhibitors

DO not take any M.A.O. inhibitor, including Parnate, Marplan, or Niamid.
• Arrangements for accommodations

If you live outside the area, please make arrangements to stay for two nights – the evening before your surgery and the evening of your
surgery. You will return to our office the morning after surgery for hair washing and a check-up of the donor and recipient areas.
Please do not plan on departing before 12:00 noon the day after surgery.
• Make arrangements to be picked up

The drugs administered during the procedure will significantly impair your driving ability; consequently, you will not be able
to drive after your surgery. Ideally, you should plan to take a taxi or arrange to have someone pick you up and remain with you
overnight.
For your comfort
• Hair length, perms and colouring

You should let your hair grow to a length of 2½ to 3 inches in the back and on the sides of your head (this allows for easy coverage
of donor areas after surgery). Permanents and/or hair coloring may be done up to 2 days before surgery. After surgery, it should not
be done until all of the crusts have fallen off, generally, within 1 to 3 weeks.
• Hair care products

Use gentle shampoos and conditioners. Light hair sprays, gels, and mousses may be used when you begin shampooing your hair,
(the 2nd morning after surgery) but preferably as little as possible for the first week and they must be washed off daily. Any hair
spray that has a non-alcohol base may be used.
• Camouflage

If you have an important meeting or function you must attend, following your surgery, you can camouflage the recipient area grafts
for a few hours by using any oil-free, water-based, makeup foundation available from any large department store or pharmacy.
Whichever cover-up method you use, shampoo and remove it as soon as possible after the function.
• Favorite music

Our operating rooms are equipped with stereo equipment so please feel free to bring the kind of music you would like to listen to.
• Minoxidil

Female patients are to use a twice-daily application of 3% minoxidil (Rogaine) to the recipient area for one week before surgery.
See instruction sheet inside your package.

Male patients will ONLY use it following surgery.
Appendix B
Conventional medications that can cause bleeding
Acetaminophen
Acenocoumarol
Acetylsalicylic acid (aspirin)
Aggrenox
Alprostadil
Amoxicillin
Amtolmetin
Anagrelide
Anisindione
Ardeparin
Ascriptin
Auranofin
Carbenicillin
Chlorphenesin
Chlorpheniramine
Cholestyramine
Choline salicylate
Ciprofloxacin
Clopidogrel
Dalteparin
Danaparoid
Danazol
Dantrolene
Darvon

397
Hair transplantation  •  Chapter 22
Soma
Sotalol
Sulindac
Suprofen
Tiaprofenic acid
Ticlopidine
Tinzaparin
Tolmetin
Tranexamic acid
Tretinoin
Trimethadione
Vicoprofen
Warfarin
Herbs, vitamins and minerals that can
cause bleeding
Angelica root
Anise
Asafetida
Bogbean
Borage seed oil
Capsicum
Celery
Chamomile
Clove
Co-enzyme
Danshen
Devil’s claw
Dong quai
Fenugreek
Feverfew
Flaxseed
Fish oil
Garlic
Ginger
Ginkgo biloba
Ginseng
Green tea
Guggul
Horse chestnut
Licorice root
Lovage root
Lucid ganoderma
magnesium
Meadowsweet
Onion
Papain
Papaw
Parsley
Passionflower herb
Poplar
Quassia
Quinine
Dexchlorpheniramine
Diclofenac
Dicumarol
Diflunisal
Digitoxin
Dipyridamole
Donepezil
Emperin
Enoxaparin
Ethacrynic acid
Etodolac
Etretinate
Felbamate
Fenoprofen
Fiorinal
Fluoxetine
Flurbiprofen
Fluvoxamine
Ibuprofen
Indinavir
Indomethacin
Indoprofen
Interferon beta-1b
Isosorbide mononitrate
Isotretinoin
Ketoprofen
Ketorolac
Levodopa
Levonorgestrel
Lopinavir/ritonavir
Magnesium
Meloxicam
Methimazole
Methotrexate
Mycophenolate mofetil
Nabumetone
Naproxen
Nelfinavir
Nimodipine
Nitroglycerin
Norgesic
Oxaprozin
Paramethadione
Paroxetine
Penicillin G
Pentoxifylline
Percodan
Piroxicam
Propylthiouracil
Reserpine
Reviparin
Robaxisal
Salsalate
Sertraline
Sodium salicylate

398
Chapter 22
Cosmetic surgery procedures and techniques
Q10
Red clover
Rue
Saw Palmetto
Sweet clover
Szechuan pepper-plant bark
Turmeric
Umbelliferae
Vitamin E
Willow bark
Some trade names of products
containing ibuprofen and naproxen
Ibuprofen: Advil, Vicoprofen, Dristan-sinus, Pseudofed, Sinus
advance
Naproxen: Advil, Motrin, Anaprox, Naprosyn, Naprox,
Synflex, Naxen
Contain aspirin:
Alka-Seltzer Pain Reliever & Antacid
Alka-Seltzer Plus Cold Medicine
Anacin Analgesic Capsules and Tablets
Arthritis Bayer Timed-Release Aspirin
Arthritis Pain Formula by the makers of Anacin
Arthritis Strength Bufferin
Ascriptin
Aspergum
Bayer Aspirin & Children’s Chewable Aspirin
Bayer Children’s Cold Tablets
Bufferin
Cama Inlay-Tabs
Congespirin
Coricidin D Decongestant Tablets
Coricidin Demilets & Medilets for Children
Coricidin Tablets for Adults
Ecotrin Tablets
Empirin (Pu mo uglis Iveilcome)
En Tab-650 Tablets
Excedrin
Extra-Strength Bufferin Capsules & Tablets
4-Way Cold Tablets
Goody’s Headache Powders
Medipren
Momentum Muscular Backache Formula
Midol
Norwich Aspirin & extra-strength aspirin
Panalgesic (poythress)
St. Joseph Aspirin for Children
St. Joseph Cold Tablets for Children
Sine-Off Sinus Medicine Tablets-Aspirin
Triaminic Tablets
Vanquish
Contain ibuprofen:
Advil
Motrin
Appendix C
Some Over-The-Counter Medications To Avoid Before Surgery
Which Contain Aspirin (Acetylsalicylic Acid) Or Ibuprofen

color can also range from mildly erythematous to vivid pur­
ple, while older scars may become hypo- or hyperpigmented.
Keloids tend to have a thick, ropelike surface; whereas, hyper­
trophic scars tend to have a smoother surface. Associated
pruritus, dysesthesia, and pain, as well as restricted range of
motion and contracture formation may be observed with both
keloids and hypertrophic scars, but tend to be more common
with keloids. Unlike keloids, hypertrophic scars tend to regress
over time. Within 6–12 months of scar onset, the erythema of
a hypertrophic scar may begin to subside, with incremental
softening and bulk reduction occurring later.1 Keloids tend to
persist over time and may continue to enlarge.
The earliest existing written description of keloids dates to
1700 BC in the Smith Papyrus.2 In 1802, Jean Louis Alibert
coined the term cheloides to describe a keloid’s tendency toward
lateral growth and claw-like extension into normal tissue. He
noted a distinction between keloids and scars that remained
within the confines of the initial trauma, currently referred to
as hypertrophic scars.3
The incidence of keloids and hypertrophic scars varies
with age, race, anatomic location, and the inciting trauma.
Patients with the highest incidence of keloid development
are between the ages of 10 and 30 years.4 Though the exact
prevalence of hypertrophic scars and keloids is unknown, the
male-to-female ratio is approximately 1:1. Blacks and Asians
are affected more often than Caucasians, with comparable
incidence ­ratios between 5:1 and 15:1.4 An incidence of be­
tween 4.5% and 16% in a predominantly black and Hispanic
population has been reported.5
The risk of keloids varies anatomically.6 The highest-risk
regions of the body include the presternal area, anterior chest,
back, shoulder, and posterior neck. The ears, abdomen, and
beard area are also susceptible to keloid formation. Keloids
rarely develop on the palms, soles, mucous membranes, scalp,
or genitalia. Hypertrophic scars do not appear to have a re­
gional predisposition. Though keloidal and hypertrophic scars
may arise even after minor trauma, they are more common in
sites of increased motion or tension, or in response to a nidus
of prolonged inflammation such as an infection or foreign
body response.
Scar Management: Keloid,
Hypertrophic, Atrophic,
and Acne Scars
Sonia Batra, Cicely Chen and
Thomas E. Rohrer
C h a p t e r
23
Key Points
n Abnormal scars can generally be classified as
excessively raised (keloids and hypertrophic scars)
or depressed (atrophic or acne scars).
n While no scar can be completely erased, scar
management employs a variety of techniques
to improve the aesthetic appearance of abnormal
scars.
n Realistic patient expectations and detailed informed
consent are critical prior to any attempt at scar
management.
n For keloidal and hypertrophic scars, first-line therapies
include intralesional corticosteroid injections and laser
surgery such as the pulsed dye laser.
Other therapies include pressure, silicone gel
sheeting, cryosurgery, interferon, other pharmaco­
logic therapies, and incisional or excisional surgery.
n For atrophic and acne scars, combination therapy
generally yields the best results.
Techniques include surgical excision, subcision,
laser surgery, autologous fat transplantation,
fillers, dermabrasion, and dermasanding.
p a r t 2
HISTORY AND SCIENCE
Keloidal and hypertrophic scars
Though keloidal and hypertrophic scars are always raised, their
appearance can vary significantly. Such scars range from firm
papules, nodules, or plaques with telangiectases and a pearly
atrophic surface to soft, doughy, pendulous nodules. Their

400
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Cosmetic surgery procedures and techniques
Histologically, keloids are characterized by haphazard
deposition of thick, hyalinized eosinophilic collagen bun­
dles within the dermis, forming nodules that contain an
abundance of eosinophils, mast cells, plasma cells, and lym­
phocytes.7,8 These nodules are encircled by numerous small
vessels. Hypertrophic scars also demonstrate increased col­
lagen bundles histologically. The collagen lies parallel to the
epithelial surface, as observed with normal skin, but is flatter
and less clearly demarcated. In hypertrophic scars, nodules
are not present and the collagen lacks the hyalinized appear­
ance noted with keloids.8 More fibroblasts are present and
­microvasculature occlusion is noted. Foreign body reactions
are frequently detected.
At a cellular level, keloid-derived fibroblasts produce in­
creased amounts of collagen per cell in comparison to normal
fibroblasts and appear to function autonomously.9 Initially,
collagen synthesis is approximately 20 times greater in kel­
oids than in normal skin,10 but this rate approaches normal
scar levels within 2–3 years after the initial injury. Elevated
levels of chondroitin 4-sulfate,11 which acts to make collagen
fibers resistant to collagenase degradation, as well as elevated
levels of collagenase inhibitors such as α1-antitrypsin and
α2-macroglobulin12 have been detected in keloids.
Keloid formation has been associated with abnormal func­
tion of the hypothalamus, thyroid, and parathyroid glands.
An underlying mechanism may be an increase in melanocyte-
stimulating hormone (MSH). This is supported by the higher
incidence of keloids in darker-skinned individuals, a greater
distribution of melanocytes present in high-risk anatomic sites,
and an increased incidence of keloid formation at puberty and
during pregnancy, when levels of MSH are elevated.
Genetic determinants of keloids have been described. Both
autosomal recessive13 and autosomal dominant14 patterns
of inheritance have been reported for keloids. A predisposi­
tion for keloid formation has been noted in individuals with
­human leukocyte antigens (HLA) B14, BW16,15–17 and blood
type A.18 The spontaneous development of multiple keloids
has been recognized in genodermatoses such as Rubenstein-
Taybi, progeria, Ehlers-Danlos, pachydermoperiostosis, osteo­
genesis imperfecta, and trichorhinophalangeal syndrome.
Atrophic and acne scars
Atrophic scarring is a well-recognized consequence of acne
vulgaris and varicella infection. It is the result of an inflamma­
tory response to an initial lesion, which terminates in fibrotic
scar tissue formation. Trauma, infection, and long-standing
epithelial cyst formation are processes that can also lead to
atrophic scarring. The dermal nature of the scar produces
a bound-down, often angular scar with an indented or in­
verted center. Although the shape of the final defect may vary,
the underlying etiology is similar: fibrosis. It is unclear why
certain individuals will heal with atrophic scars, while others
with a similar-appearing clinical lesion will heal without any
evidence of scarring.
Development of acne scarring is multifactorial, including
a genetic predisposition, delay in treatment administration,
and a tendency toward scarring. The gamut of acne scarring
­includes both contour irregularities and surface discoloration. A
reddish-brown macular hue may develop at the site of a resolved
acneiform lesion. This represents postinflammatory hyperpig­
mentation and erythema. This change is usually temporary
but may persist in some patients for up to 8–12 months.
There are three basic types of textural acne scars: box­
car, ice pick, and rolling scars (Fig. 23-1). Perhaps the most
common acne scar is the depressed, crateriform boxcar scar.
It generally measures 3–4  mm or less in diameter and is
similar in appearance to a varicella scar. A fibrotic lesion is
present, with extension of the fibrosis into the dermis and
subcutaneous fat resulting in a firm, semirigid scar. The
deeper the scar, the more visible the scar becomes due to its
exaggerated demarcated edges and resultant shadow forma­
tion. Ice pick scars (Fig. 23-2), or deep pitted scars, exhibit
a narrow opening with a 0.5  mm or greater extension into
the dermis, resembling a small hole. Rolling scars (Fig. 23-3)
are soft, distensible, depressed scars, with a slightly wrinkled
Skin
surface
Laser
SMAS
Icepick
Rolling
Boxcar
Fig. 23-1  Acne scar subtypes. The three main acne scar subtypes
– ice pick, rolling, and boxcar – are depicted in schematic cross-
section. White lines represent fibrous tethers that produce rolling
scar bound-down appearance. Pink line indicates depth achievable
with laser resurfacing. Dashed line indicates level of SMAS.
Fig. 23-2  Perioral ice pick scars. Arrows indicate individual scars.

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Scar management: keloid, hypertrophic, atrophic, and acne scars  •  Chapter 23
superficial base. These scars present as shallow undulations
and may be subtle, but often become more noticeable with
lighting changes or as the patient moves his or her head. Roll­
ing scars can be small (less than 1  cm) or large (greater than
1  cm). Often, patients will have several individual rolling scars
that coalesce to form a larger area of scarring. An individ­
ual may present with one type of scar or a combination of
scar types. Treatment must be tailored to the type of scarring
present.
Procedures and Techniques
Scar types
Scar formation is a necessary process in wound repair. The
spectrum of resultant scars range in appearance from nearly
imperceptible to excessively raised or depressed. Abnormal
scars can be divided into two basic categories: (1) keloidal
and hypertrophic scars and (2) atrophic scars. Keloidal and
hypertrophic scars represent examples of exuberant scarring.
Keloids are characterized by scar tissue that extends beyond
the confines of the original wound, while hypertrophic scars
are confined to the original injury and increase in size by
pushing outward but not by invasion.19 Atrophic or depressed
scars result from localized, exaggerated dermal and subcu­
taneous fibrosis and/or collagen destruction due to inflam­
mation. Various management techniques can be employed
to improve the cosmetic appearance of abnormal scars, and
treatment is driven in large part by the underlying anatomy
and the cause of the defect.
General preprocedure considerations
Prior to any attempt at scar management, a preoperative con­
sultation is essential to educate the patient regarding realis­
tic expectations from the procedure. While any scar with a
suboptimal appearance can be revised and improved, the scar
itself can never be completely erased. Informed consent that
details the risks, benefits, possible side effects, and the alterna­
tives to the procedure should always be obtained. Pre- and
postprocedure photographs are also invaluable in document­
ing response to therapy.
A detailed medical history should be recorded, including
onset or inciting factor for scarring, endocrine/hormonal ab­
normalities and treatments received for these abnormalities,
current and prior medications, especially use of isotretinoin
within the preceding year, and prior treatment attempts. A
surgical procedure should not be performed within 1 year
of the last dose of isotretinoin, as this may lead to delayed
postprocedural wound healing and risk of hypertrophic
scarring.20
Prophylactic antibiotics may be administered to patients
with certain predisposing medical conditions. Patients should
avoid anticoagulant medications as medically appropriate in­
cluding voluntary aspirin, nonsteroidal analgesic medications,
oral vitamin E and C supplements, and alcohol for a mini­
mum of 1 week before a procedure to help prevent postproce­
dure ecchymoses and hematoma formation.
Fig. 23-3  Young man with rolling scars on bilateral cheeks.
• Take a good medical history and provide
a thorough consultation to give patient realistic
expectations.
• Take preoperative photographs.
Pearls
• Be sure patients have been off isotretinoin
for 1 year prior to the planned procedure.
• Have patients avoid anticoagulants for 1 week
prior to the surgery.
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Keloidal and hypertrophic scars
Keloidal and hypertrophic scars remain a management chal­
lenge. Numerous treatment modalities have been employed
with varying degrees of success. Three distinctly different
therapeutic approaches can be taken that target different
mechanisms based on current understanding of keloidal and
hypertrophic scar formation: (1) manipulation of the me­
chanical properties of wound repair; (2) correction of the ab­
normal balance of collagen synthesis and degradation; and
(3) alteration of the immune/inflammatory response. Multi­
ple modalities are often utilized concurrently or sequentially
to manage these scars successfully.
Intralesional Corticosteroid and 5-fluorouracil
Injections
Preoperative considerations
Intralesional corticosteroid injections are a first-line treatment
for hypertrophic scars and keloids. Corticosteroids appear to
act by degrading collagen. Corticosteroid injections alone will
improve but may not eliminate a keloid. Enhanced ­ results
may be achieved when intralesional corticosteroid injections
are combined with other treatment modalities (e.g. laser or
cryosurgery) or initiated after surgical excision. Similarly,
5-fluorouracil (5-FU) may be diluted into a suspension of
­corticosteroid prior to injection and may be combined with
other treatment modalities to enhance results.
Techniques
Varied intralesional corticosteroid preparations may be used
in the treatment of hypertrophic scars and keloids. One ap­
proach is to start with triamcinolone acetonide, 10  mg/mL.
If no improvement is noticed after one or two treatments, the
concentration should be doubled with each treatment to a
maximum concentration of 40  mg/mL. An alternate therapy
is the use of triamcinolone diacetate, 25  mg/mL.
Steroid preparations may be diluted with 1% lidocaine
with or without epinephrine (1:100  000). The use of lidocaine
reduces the pain of multiple injections, as well as the pain in­
curred immediately post-treatment. The vasoconstrictive prop­
erties of epinephrine may allow for prolonged presence of the
steroid at the treatment site. An alternative diluent is buffered
sterile saline. Regardless of which diluent is used, the contents
within the syringe must be mixed continuously throughout the
treatment in order to ensure an even concentration of the mix­
ture throughout the syringe. A 1  mL or 3  mL Luer-Lok syringe
should be used to prevent the needle hub from dislodging with
the high pressure associated with keloid injections. A 0.5  inch or
1  inch 27- or 30-gauge needle is generally used. A larger-bore
needle may be required for more fibrotic scars.
The corticosteroid preparation is injected directly into the
bulk of the keloid or hypertrophic scar. It is vital to ensure
that the needle is within the body of the scar and not above or
below it in order to decrease the risk of side effects.21 If cor­
rectly placed, a whitening of the scar will be observed as the
preparation is injected. Injection into the scar is often difficult
because of the resistance from scar fibrosis. If the injection
appears easy to perform and there is little resistance to the in­
jection, the needle may be placed too low in the subcutaneous
tissue. With improper placement, subcutaneous ­atrophy may
result. To facilitate injection, the needle should be advanced to
create a tract, and the corticosteroid should be injected while
the needle is withdrawn. Some pressure should be applied
during the advancement of the needle to help prevent scar
tissue from entering the needle opening and blocking the flow.
An alternative method is to treat the scar with cryosurgery
for 15–30 seconds prior to the injection. This allows for tissue
edema and subsequent softening of the scar prior to intral­
esional corticosteroid injection.22
Intralesional 5-fluorouracil (5-FU) has been successfully
utilized at a concentration of 50  mg/mL in the manage­
ment of hypertrophic scars23 and keloids. The addition of
triamcinolone acetonide at a final concentration of 1  mg/mL
to 5-FU (i.e. dilution of nine parts 50  mg/mL 5-FU to one
part 10  mg/mL triamcinolone acetonide) increases the effi­
cacy of this treatment when employed on a monthly basis.
Postoperative considerations
Intralesional corticosteroids have an approximately 30–40-day
duration of action. Injections are therefore administered at
­intervals of 4–6 weeks to limit side effects (Box 23-1). Therapy
may require repeated treatments over several months.24
• Start with lower concentrations and build up
strength.
• Use a Luer-Lok syringe to prevent the needle
hub from dislodging with high pressure of keloid
injections.
• Diluting with lidocaine containing epinephrine
constricts vessels and prolongs steroid ­presence
in area.
• Inject directly into scar if possible. Apply some
pressure while inserting needle to prevent
scar tissue from entering the needle hub
and blocking it.
• Scar tissue may be softened by treating with
liquid nitrogen prior to injection.
• Fifty mg/mL 5-fluorouracil mixed with steroid
may also be used in the treatment of resistant
keloids. Mix nine parts 50  mg/mL 5-FU with one
part 10  mg/mL triamcinolone acetonide.
Pearls
• Steroid injection may lead to atrophy, hypopig­
mentation, and telangiectasia formation.

DO NOT INJECT SOONER THAN 4–6 WEEK
INTERVALS
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Scar management: keloid, hypertrophic, atrophic, and acne scars  •  Chapter 23
For 5-FU, frequent initial injections (one to three times
weekly) are employed, with a reduction to weekly or monthly
injections as improvement is noted. A major disadvantage to
the use of intralesional injections of 5-FU or ­corticosteroids
is pain during injection, which may lead to patient
noncompliance.
Laser surgery
Debulking of a keloid may be performed with a CO2 laser.
For hypertrophic and keloid scars, the pulsed dye lasers
can be a first-line treatment. The carbon dioxide laser is still
used occasionally for ablation, but may soon be supplanted
by newer technologies such as fractional resurfacing (Fraxel,
Reliant Technologies, Palo Alto, CA; Star-Lux, Palomar
Technologies, Burlington, MA) or plasma resurfacing (Reliant
Technologies).25
Pulsed dye laser
Preoperative considerations  In 1993, Alster first described
an improvement in atrophic and hypertrophic scars26 with the
use of a 585  nm pulsed dye laser. By targeting treatment to the
vascular component of the scars, the pulsed dye laser induced
a reduction or elimination of the erythema. In addition,
normal skin markings often returned and a flattening of the
elevated portions of the scars was observed. No recurrence of
the scars was noted at 4-year follow-up.
The pulsed dye laser’s mechanism of action on scar
­improvement is likely multifactorial. The laser’s vascular
specificity may lead to direct microvasculature damage, with
resultant ischemia and subsequent collagen degradation.
Thermal damage to collagen fibers may also result in di­
rect dissolution of disulfide bonds. Histologic examination
of laser-treated hypertrophic scar implants evidenced sig­
nificant vessel wall necrosis, suggesting that the primary tar­
get is the microvasculature.27 There may also be release of
a variety of chemical mediators that induce both collagen
production and collagen destruction, resulting in significant
remodeling.
The optimal time for the initiation of pulsed dye laser treat­
ment of hypertrophic scars and keloids has not yet been de­
termined. Fibroblasts in evolving keloids do not deviate from
their normal growth pattern for at least 3 weeks after surgery.28
Therefore, treatment initiated within this first 2–3-week post­
operative period may serve as preventative ­ management.
Nouri et al. showed that treatments initiated at the time of
suture removal and continued for several months significantly
improved the appearance of scars.25
Techniques  Laser-specific protective eyewear with side
shields must be worn by all persons involved in treatment. The
treatment site is cleaned with a noninflammatory cleanser to
remove any makeup and debris present. A water-based lubri­
cant is applied to moisten any potentially combustible mate­
rials that will fall within the laser treatment field, including
patient hair.
The need for anesthesia depends on the size and location of
the lesion to be treated, as well as the age and pain tolerance
of the patient. In general, treatment discomfort is short-lived
and is tolerated without the need for pretreatment anesthesia.
Topical anesthetic cream (EMLA, AstraZeneca, Wilmington,
DE, LMX-4) may be applied under occlusion to the scar(s)
2 hours before treatment. Also, 1% lidocaine with or without
epinephrine (1:100  000) intralesionally or via a regional nerve
block may be used.
Treatment parameters are determined by the location
and appearance of the lesion. Lesions of the face can toler­
ate higher fluences than the neck and chest. The Fitzpatrick
skin type of the patient must also be considered, as melanin
interferes with absorption of the pulsed dye laser energy.
Skin types IV and greater are treated with lower energy flu­
ences in order to decrease the risk of epidermal blistering,
pigmentary change, and scarring. Recommended pulsed
dye laser treatment parameters for hypertrophic scars and
keloids include energy fluences of 4–7.5  J/cm2 utilizing a
7–10  mm spot size and a 3–6  ms pulse duration (VBeam,
Candela Corp., Wayland, MA) at treatment intervals of
4–8 weeks.
Postoperative considerations  A cool hydrogel or ­compress
may be applied immediately after treatment to decrease
patient discomfort. Aquaphor Healing Ointment (Biersdorf,
Wilton, CT) or an equivalent emollient can be applied over
the subsequent 2–3 days following treatment to minimize
­epidermal crusting. Side effects are listed in Box 23-2.
Box 23-1  Side effects of intralesional corticosteroid
­injections
• Skin atrophy
• Hypopigmentation or hyperpigmentation
• Telangiectasia formation
• Necrosis or ulceration
• Subepidermal white deposits that resolve slowly over time
• Systemic response to corticosteroids ­(extremely rare)
Box 23-2  Side effects of pulsed dye laser treatment
• Transient purpura, lasting up to 2 weeks (This discoloration
is deep purple and difficult to camouflage with cosmetics.)
• Short-lived sharp, stinging pain, compared to the snap
of a rubber band, followed by a sensation of heat
• Pigmentary alteration, including temporary postinflamma­
tory hyperpigmentation and permanent hypopigmentation
(extremely rare)
• Blistering and partial-thickness burns
• Infection (extremely rare)
• Scar formation (extremely rare)

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Chapter 23
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Carbon dioxide laser
Preoperative considerations  The carbon dioxide 10  600  nm
laser was one of the first lasers to be employed in the treat­
ment of keloids and hypertrophic scars. More recent advances
in laser technology have generated two new categories, the
short-pulsed and scanned carbon dioxide lasers, which offer
an alternative treatment modality in the surgical ablation of
keloids. These lasers produce tissue vaporization with mini­
mal coagulation, as they exceed the vaporization threshold of
tissue, 5  J/cm2, while also limiting the tissue exposure time
(pulse duration) to less than 1  ms, which is the thermal relaxa­
tion time of the skin. Temporary side effects include erythema
in all scars lasting 2–4 months and slight hypopigmentation
in approximately 10%. Long-term follow-up regarding keloid
recurrence has not been reported.
Techniques  The treatment area is first draped with fire-
resistant materials (i.e. moistened towels) and anesthetized
locally with 1% lidocaine with or without epinephrine
(1:100  000) or via a regional nerve block to eliminate patient
discomfort during treatment. Protective eyewear, masks, and
continuous suction are employed during the entire procedure
to minimize exposure to the continuous plume of smoke and
debris that is emitted during treatment.
Scar ablative treatment may be initiated with the carbon
dioxide laser set in a continuous-wave mode utilizing a power
of 10 watts and with a 1, 2, or 3 mm spot handpiece. With
the parameters set, aim the laser beam at a tongue depres­
sor and test for laser function and alignment. Beam target
distance greatly affects the power delivered to the skin. The
laser should be aimed at the scar to deliver an impact spot of
3–4 mm. A single-pulse setting or repeat-pulse setting can be
utilized to ensure precise treatment of the affected areas. The
perimeter of the scar is traced in a continuous burst to define
the treatment area, then the remainder of the tissue surface is
vaporized. Once an entire pass has been completed, the char
is gently removed with saline-moistened gauze. This cycle
is repeated until the scar has been ablated. As the lesion is
­debulked, a lower power and increased target distance should
be used to avoid excessive treatment.
Postoperative considerations  Immediately after ­treatment
the area should be covered with antibiotic ointment. Wound
care consists of cleansing the treatment areas with moist
­compresses two to three times a day to remove any formed
crust, followed by the application of an emollient such as
Aquaphor Healing Ointment (Biersdorf, Wilton, CT). This
should be continued until complete reepithelialization has
occurred.
Postoperative pain is generally limited. Analgesic use should
be titrated both to the extent of the surgery and to the patient’s
subjective experience. In general, use of acetaminophen is
generally sufficient for pain relief.
Incisional/Excisional surgery
Preoperative considerations
Recurrence rates for simple surgical excision of keloids
alone vary from 50% to 80%.29 Therefore, if an excision is
performed, at least one other treatment modality should be
utilized to minimize recurrence. Certain keloids display a
greater tendency to recur, even with adjuvant therapy. These
scars are in areas of high skin tension, such as the presternal
area. These scars are generally dumbbell shaped with clawlike
lateral extensions. Surgical revision is not recommended for
these scars.
Techniques
Several surgical approaches are available. A simple excision
and closure with meticulous surgical technique can produce
acceptable results for small keloid scars in areas with mini­
mal skin tension (Fig. 23-4). Care must be taken to remove
all sources of residual inflammation, including trapped hair
follicles, epithelial cysts, and sinus tracts, which may act as
­potential sources of fibroblast stimulation. It is also impor­
tant to reorient scars parallel to lines of skin tension, when
possible.
For larger scars, tension-relieving procedures should be
employed. Skin flaps and grafts may be necessary. Of con­
cern is the risk of keloid formation at both the recipient and
graft donor sites, which has been observed in 50% of cases. A
technique to avoid this complication is to use the epidermis
and upper dermis overlying the keloid as a skin graft30 or skin
flap.31 This skin is usually unaffected by the under­lying scar.
For a flap, an incision is made extending about halfway
around the base of the affected tissue. The tissue is lifted back
and the keloid scar tissue is shelled out and removed from the
dermis down without damaging the overlying tissue. Palpation
of the affected tissue will provide an estimation of complete
scar removal. The remaining attached epidermis and dermis
is then sutured into the surgical defect using interrupted epi­
dermal sutures. Subcutaneous suture use is limited to avoid
foreign body reaction to the absorbable sutures.
For a graft, the overlying epidermis and dermis are carefully
removed from the underlying keloid. The keloid is resected
and the preserved tissue is sutured into the surgical defect as
a free full-thickness graft. This may provide sufficient micro­
vasculature to allow for decreased angiogenesis and fibroblast
proliferation. It is important to note that failure to remove the
entire keloid can lead to rapid recurrence, making these tech­
niques particularly challenging.
• Early treatment with pulsed dye laser may not
only serve to reduce erythema, but also inhibit
fibroblast proliferation and subsequent scar
formation.
• Although higher fluences with pulsed dye lasers
are more effective in the reduction of erythema,
lower fluences may work better for inhibition of
scar tissue.
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Management of earlobe keloids requires evaluation of the
extent of keloid spread. If isolated only to the anterior or
posterior aspects of the ear, a simple excision of the keloid
or keloid flap is often sufficient. If the keloid is an anterior-
posterior keloid with a fibrous tract extending through the
earlobe, all scar tissue must be removed in order to avoid
a nidus for future keloid formation. Both the anterior and
posterior keloids as well as the tract may be removed at the
same time via a dumbbell-shaped through-and-through exci­
sion. A 3–4  mm punch biopsy tool is useful for excising the
anterior earlobe hole and keloid. A side-to-side closure or
a keloid flap is then performed. An alternative technique is
to excise the keloid on each side separately using the flap
technique, taking care to remove the fibrous tract with one
of the incisions.
Scar irregularization techniques such as a Z-plasty or
W-plasty, while helpful for contracted or webbed scars, are not
recommended for hypertrophic or keloidal scars due to the
high risk of recurrence along the lengthened scar.
Postoperative considerations
A pressure dressing is left in place for at least 24 hours
after these surgical techniques to minimize the risk of bleeding
into the wound. Immediate postoperative intralesional ster­
oid injections are generally avoided for the first week to avoid
wound dehiscence.32 Steroid injections (triamcinolone aceto­
nide, 10–40  mg/mL) are initiated at the time of suture re­
moval and monthly thereafter for a minimum of two to three
intralesional steroid injections or until the keloid is clinically
resolved. Following this treatment, patients are informed to
return if induration is palpated or if pain or pruritus devel­
ops. Patients must be aware of a risk of hypopigmentation,
atrophy, and telangiectasia formation with intralesional corti­
costeroid injections. The adjunctive use of radiation therapy
following excision has also been successfully utilized.
Pressure
Preoperative considerations
Pressure therapy is useful for therapy of established keloids
and hypertrophic scars as well as for prevention. The use of
pressure in the prevention and treatment of keloids after burn
injury became standard in the late 1960s.33 No study has been
able to fully elucidate the mechanism by which pressure alters
scars, but all have shown it to be beneficial.
Techniques
For treatment to be effective, the pressure applied must ex­
ceed the inherent capillary pressure of 24  mmHg.34 Pressure
should be maintained for a minimum of 8–12 hours a day for
A
B
Fig. 23-4  Patient with hypertrophic scar. (A) Preoperative appearance. (B) At 2 months after excisional surgery. Note orientation of corrective
scar to skin tension lines.
• To minimize tension on a keloid excision, do
not extend the excision beyond the keloid, shell
out the keloid, and use the overlying skin of the
keloid as a pseudoflap/graft.
• Remove entire keloid and sinus tract to avoid
a nidus for future keloid formation.
• Limit use of subcutaneous sutures to avoid
foreign body reactions.
• Use pressure and/or silicone dressings and
inject intralesional steroids at suture removal
and at monthly intervals thereafter.
Pearls
• Excision alone has a recurrence rate of 50–80%.
• Keloids in the presternal areas and dumbbell-
shaped keloids have the highest rate of recur­
rence.
• Avoid use of scar irregularization procedures
such as Z-plastys and W-plastys.
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4–6 months.35 Careful consideration to avoid further trauma
and excessive tension with the use of the materials available for
treatment is vital. These materials include compression wraps
(Coban bandages, 3M, St. Paul, MN; Expandover Medical
Elastic Adhesive Bandages, Sherwood, St. Louis, MO), tubu­
lar support bandages (Jobskin PPS, Jobst, Toledo, OH), pre­
sized garments (Jobst, Toledo, OH), pressure earrings (Padgett
Instruments, Kansas City, MO), molded splints (Silastic elas­
tomer, WFR Aquaplast, Wyckoff, NJ), and self-adhering poly­
urethane sponges.
Postoperative considerations
There are no noted physiologic complications to pressure.
­Patient compliance is the limiting factor, given the need for
long-term pressure application for success.
Silicone gel sheeting
Preoperative considerations
Silicone gel sheeting, a 3.5  mm soft, adherent, semiocclusive
covering made from medical-grade, cross-linked silicone poly­
mers, is thought to act through scar hydration and decreased
evaporative water loss. It is theorized that this hydration
­results in decreased capillary flow, with a reduction in collagen
deposition due to decreased circulating proinflammatory
­cytokines. Various investigators have demonstrated significant
keloid and hypertrophic scar improvement following silicone
gel sheeting application.36
Techniques
A silicone gel sheet is trimmed to fit the dimensions of the scar
and is applied to the scar for a minimum of 12 hours daily.
Paper tape may be used to secure the sheeting. Silicone cream
occlusive dressing may also be used, which may be especially
helpful in children due to its ease of application.37 The same
sheet may be used on a continuous basis until it begins to show
evidence of wear. Silicone gel sheeting provides symptomatic
relief with decreased pruritus and pain. Scar pigmentation
and scar elevation generally remain the same.
Postoperative considerations
Side effects of silicone gel application are limited to localized
irritation. No release of silicone material into skin has been
documented to date.

• Silicone sheets must be kept in place for 12 hours a day
and may be used until they show signs of wear.

• Silicone cream occlusive dressing may be used in children
where it is more difficult to keep a dressing in place.
Cryosurgery
Preoperative considerations
Cryosurgery utilizes a cryogenic agent or cryoprobe to cause
direct cell and microcirculatory damage. The resulting stasis,
thrombus formation, and subsequent anoxia leads to tissue necro­
sis and sloughing, followed by tissue flattening.38 Cell destruction
is somewhat selective, leaving fibroblasts intact for reepitheliali­
zation of the wound. Cryotherapy alone can result in complete
keloid flattening in 51–74% of patients and, in combination with
intralesional steroids, can yield an 84% response rate.39
Techniques
Liquid nitrogen is the coldest cryogen available and is the pre­
ferred method for cryotherapy. Without cryoprobes, it is not
possible to know the exact depth of freezing that occurs below
the surface of a treated area. For keloids and hypertrophic
scars, treatment is gauged by the freezing time, determined
by the time it takes for the treatment site to become frozen
white. With these scars, the physician must limit the amount
of lateral spread of whitening in order to avoid damaging sur­
rounding tissue (Box 23-3).
The cryogun operates via a trigger mechanism to deliver a
continuous spray, allowing for controlled delivery. Treatment
usually involves one freeze-thaw cycle lasting from 10 to 30
seconds at each treatment session to achieve keloid flattening.
Generally 2 to 10 sessions, separated by 20 to 30 days, are
required. Lack of efficacy of cryosurgery may be due to inad­
equate freeze times or the failure to continue treatment when
initial results are not impressive.
Postoperative considerations
Postprocedure care may include application of antibiotic oint­
ment followed by the placement of a bandage on the treated
area. Silicone gel sheets may be used to enhance the improve­
ment attained with cryotherapy.
Interferon
Preoperative considerations
The use of interferons in the treatment of keloids and hyper­
trophic scars has been investigated because of their effects on
collagen synthesis. Interferons alpha (IFN- α), beta (IFN-β),
Box 23-3  Side effects of cryosurgery
• Permanent pigmentary alteration
(hypopigmentation, hyperpigmentation)
• Blistering
• Intradermal hemorrhage
• Postoperative infection
• Postoperative pain
• Scar formation
• Neuropathy
• Pressure should be maintained for a minimum
of 8–12 hours a day for 4–6 months.
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Scar management: keloid, hypertrophic, atrophic, and acne scars  •  Chapter 23
and gamma (IFN-γ) inhibit types I and III collagen synthesis
by dermal and synovial fibroblasts and type II collagen
­synthesis by chondrocytes in a dose-dependent fashion via
a reduction in cellular ribonucleic acid.40
Techniques
Intralesional injections of 10–200  μg of interferon gamma are
made into the keloid twice weekly for 4 weeks.
Postoperative considerations
Overall, intralesional injections of interferon gamma are well
tolerated. However, injections tend to be painful, and patients
may require regional anesthesia prior to treatment. A flulike
syndrome, characterized by myalgia, headaches, and low-
grade fever (37.5°C) may persist for 6–48 hours after the int­
ralesional injection. The use of acetaminophen may be useful­
in managing these symptoms. No significant biochemical,
­hematologic, or renal abnormalities have been reported.
Other pharmacologic therapies
Novel approaches to treating keloids and hypertrophic scars
are being utilized as knowledge of the underlying factors lead­
ing to their formation is revealed. Many treatments are anec­
dotal to date. The efficacy of the treatments listed below will
require further confirmation via controlled studies.
Topical retinoic acid is thought to act via an inhibitory ef­
fect on fibroblast DNA synthesis to reduce the size of keloids.
Application of 0.05% retinoic acid solution in the treatment of
28 keloids and hypertrophic scars produced improved colora­
tion, symptomatic relief, and some flattening of the lesions.41
The irritating nature of retinoic acid may limit its long-term
use in certain anatomic areas.
Intralesional verapamil and other calcium-channel antagonists
have been employed in the management of keloids due to their
ability to inhibit extracellular matrix proline incorporation.42
Imiquimod 5% cream induces TNF- α, IFN- α and IFN-γ,
and IL-1, 6, 8, and 12 as well as alters expression of apoptotic
markers. Recent studies have demonstrated reduced rates of
recurrence after surgical excision of keloids with postopera­
tive application of imiquimod 5% cream.43,44
Fibroblasts in keloids overexpress the oncogene Gli-1.45
This finding has prompted investigation of topical application
to keloids of tacrolimus and rapamycin, immunomodulators
that inhibit TNF-α and Gli-1.46
Atrophic and acne scars
When evaluating a patient with atrophic scarring, one must
assess multiple aspects of the patient’s background prior to
developing a treatment plan. In addition to the types of scars
present, the wide range of skin types and anatomic locations
in which these scars occur is paramount to consider in the se­
lection of treatment modalities. Frequently, several treatment
modalities are sequentially performed to achieve the maximal
degree of cosmetic improvement (Table 23-1).
Surgical excision
Preoperative considerations
Various excisional techniques are available for the effective
treatment of atrophic scars. Each technique utilizes similar
equipment to perform the procedure. In all cases, the scars
are outlined with a marking pen. The treatment areas are ster­
ilely prepped and draped. The areas are then infiltrated with
1% lidocaine with epinephrine (1:100  000) and the patient is
allowed to sit for 5–20 minutes prior to the procedure to
allow for the vasoconstrictive effects of the epinephrine.
Techniques
Punch excision  Ice pick scars and deep boxcar scars can
often be excised with a 1.5–3  mm punch tool. By placing
outward traction on the punch site at the time of excision,
the circular wound is changed into an ellipse. To ensure that
the ellipse runs parallel to the skin lines, the outward traction
should be applied perpendicular to the relaxed skin tension
lines. The scar tissue is removed and the wound sutured with
one to three interrupted sutures using 6-0 nylon or Prolene
(Ethicon, Somerville, NJ). If the punch excision is 2.5  mm or
greater, a 6-0 Vicryl (Ethicon, Somerville, NJ) subcutaneous
suture can be placed prior to epidermal closure. This absorb­
able deep suture helps to promote wound edge eversion and
facilitates proper healing.
Punch elevation   Wide boxcar scars (greater than 3  mm)
are the type of scars most amenable to punch elevation
treatment. A punch that is exactly sized to match the inner
diameter of the crateriform scar is selected for treatment.
The punch is performed using a quick, rotating motion. This
releases the bound-down scar. The plug is elevated with for­
ceps and carefully freed from the underlying tissue. The plug
Table 23-1  Therapy of atrophic scars
Scar type
Excision
Punch
elevation
Subcision
Ablative CO2/
Er:YAG laser
Nonablative
lasers
Fillers
Derma­
brasion
Ice pick
+++
−
−
−
−
−
−
Superficial
boxcar
+
+
−
+++
++
+
+++
Deep boxcar
+++
++
−
++
−
+
+
Rolling
−
+
+++
++
++
++
++