Phẫu Thuật Da Liễu: Khía Cạnh Ngoại Khoa (Surgery of the Skin)

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87. Dreizen NG, Framm L. Sudden unilateral visual loss after autologous
fat injection into the glabellar area. Am J Ophthalmol 1989;107:
85–87.
88. Teimourian B. Blindness following fat injections. Plast Reconstr Surg
1988;80:361.
89. Park SH, Sun HJ, Choi KS. Sudden unilateral visual loss after autolo-
gous fat injection into the nasolabial fold. Clin Ophthalmol 2008;2:
679–683.
90. Feinendegen D, Baumgartner R, Schroth G, et al. Middle cerebral artery
occlusion and ocular fat embolism after autologous fat injection the face.
J Neurol 1998;245:53–54.
91. Coleman SR. Avoidance of arterial occlusion from injection of soft tissue
fillers. Aesthetic Surg J 2002;22:555–557.
92. Wexler P. Tissue augmentation. Present and future. American Academy
of Dermatology Annual meeting. March 2000, San Francisco, CA.
93. Coleman S. Complications of fat grafts and structural fillers. In: Tech-
niques in minimally invasive aesthetic surgery. Los Angeles; 2002.
94. Von Heimburg D, Zachariah S, Heschel I, et al. Human preadipocytes
seeded on freeze-dried collagen scaffolds investigated in vitro and vivo.
Biomaterials 2001;22:429–438.
95. Von Heimburg D, Kuberka M, Rendchen R, et al. Preadipocyte loaded
collagen scaffolds with enlarged pore size for improved soft tissue engi-
neering. Int J Artif Organs 2003;26:1064–1076.
96. Yoshimura K, Shigeura T, Matsumoto D, et al. Characterization of
freshly isolated and cultured cells derived from the fatty and fluid por-
tions of liposuction aspirates. J Cell Physiol 2006;208:64–76.
97. Kurita M, Matsumoto D, Shigeura T, et al. Influences of centrifugation
on cells and tissues in liposuction aspirates: optimized centrifugation for
lipotransfer and cell isolation. Plast Reconst Surg March 2008;121:
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98. Moseley TA, Zhu M, Hedrick MH. Adipose-derived stem and progeni-
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99. Yoshimura K, Sato K, Aoi N, et al. Cell-assisted lipotransfer for facial
lipoatrophy: efficacy of clinical use of adipose-derived stem cells. J
Dermatol Surg 2008;34:1178–1185.
100. Fratila A. Autologous fat transplantation. My technique of lipofilling. In:
Baran R, Maibach H, eds. Textbook of cosmetic dermatology, 3rd edn.
London and New York: Taylor & Francis 2005; 629–640 (638).
71. Nguyen A, Pasyk KA, Bouvier TN, et al. Comparative study of survival
of autologous adipose tissue taken and transplanted by different tech-
niques. Plast Reconstr Surg 1990;85:378–386.
72. Kaminer MS, Omura NE. Autologous fat transplantation. Arch Derma-
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73. Chajchir A, Benzaquen I, Wexler E. Suction curettage lipectomy. Aes-
thetic Plast Surg 1983;7:195–202.
74. Perez M. Update on autologous fat transplantation. Cosmet Derm
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75. Fournier PF. Fat grafting: my technique. Dermatol Surg 2000;26:
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81. Butterwick KJ. Fresh versus frozen fat: a comparison of the longevity
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29
Follicular Unit Hair Transplantation
Robert M Bernstein MD
Summary box
 Follicular unit transplantation is a method of hair restoration
surgery that relocates hair in follicular units, its naturally
occurring groupings. The small size of the units allows for
tremendous versatility in their placement, the creation of hair
patterns that closely mimic nature, and the transplantation of
a large enough number of grafts so that a full restoration can
often be achieved in just one or two sessions.
 Follicular unit transplantation requires large numbers of grafts,
so it is important to accurately assess patients’ donor reserves
in the initial planning. Densitometry enables the physician
to estimate the total amount of movable hair, the size of the
individual follicular units, and the degree of miniaturization in
both the donor and recipient areas; scalp laxity assessment is
also crucial to the surgical planning.
 Great care should be taken to screen for patients who are too
young or whose hair loss may be diffuse, making the donor
supply inadequate for a hair transplant.
 Identifying androgenetic alopecia often proves difficult in
women as other medical conditions can have a similar
presentation. Options for medical treatment are more limited
in women and many experience diffuse hair loss, a relative
contraindication to surgery.
 Determining the right size and location of the donor strip
maximizes the yield and prevents problems such as widened
and/or visible scars.
 The follicular units obtained from donor strips are delicate
structures. Careful dissection, gentle handling, and adequate
hydration are essential to their survival. In order to dissect
and place the thousands of grafts often required in follicular
unit transplantation, the surgical team must be proficient in
stereomicroscopic dissection and insertion techniques – skills
that can take a year or more to develop.
 Follicular unit transplantation requires an astute aesthetic
sense for optimal hairline design, correct angling and
distribution of grafts, and the establishment of a master plan
that anticipates further hair loss and is consistent with the
long-term goals of the patient.
 INTRODUCTION
Within the past decade, follicular unit transplantation (FUT)
has transformed hair transplantation from a cosmetically
unpredictable procedure to one that can produce consistently
natural results. The key to its effectiveness lies in the fact
that scalp hair tends to grow in tiny bundles, called ‘follicular
units,’ rather than individually.1 By working with these natu-
rally occurring units, instead of larger or smaller grafts, FUT
creates as natural a look as possible while minimizing the
transplant wound size and accelerating postoperative healing.
Follicular units are made up of one to four terminal hairs,
one to two vellus hairs, their associated sebaceous glands,
neurovascular plexus, an erector pilorum muscle, and a cir-
cumferential band of adventitial collagen, the perifolliculum.2
The tendency of scalp hair to grow in this way, rather than
as single hairs, can be most easily demonstrated by clipping
the hair to approximately 1 mm in length and then viewing
it with a densitometer (Fig. 29.1) at ×30 magnification in a
10-mm field.3 What this also reveals is that these compact
units are surrounded by significant amounts of non-hair-
bearing scalp (Fig. 29.2).4 Including this extra skin in the
dissection – as do transplants with larger grafts, such as plugs
and mini-grafts – requires a larger recipient wound, as well
as risking visible scarring in the skin around the grafts and
distortions of the growing hair.
In FUT these naturally occurring units are used exclusively.
The FUT procedure takes advantage of the anatomic proxim-
ity of the hairs within each unit to:
• keep the recipient site wound size to a minimum
• prevent skin surface change in the recipient area
• facilitate postoperative healing
• enable grafts to be placed very close together
• permit large numbers of grafts to be safely transplanted
in a single session (because of the small recipient wound
size).1,5
The ability to insert up to four hairs in a tiny recipient site is
especially valuable cosmetically and has been instrumental
in eliminating the see-through quality of micrografting. In
the end, what this means is that the transplanted hair will
look natural – given that the transplant surgeon makes the
right aesthetic decisions about graft placement, angling, and
distribution.6,7
The higher precision of FUT as compared to mini-
micrografting is especially obvious when methods of harvest-
ing the grafts are compared. In FUT, once a strip of donor
tissue has been removed, follicular units are isolated through
careful stereomicroscopic dissection, avoiding injury to the
follicles.8,9 The grafts in mini-micrografting, on the other
hand, may or may not correspond to individual follicular
units. They are cut from the donor strip according to the
number of hairs they contain (optimally one to six, but often

486
Part 3  Aesthetic Surgical Procedures
surgical techniques used in FUT or of other hair restoration
methods. The chapter will not cover mini-micrografting,11 the
combining of large and small grafts,12 laser hair transplanta-
tion,13,14 scalp reductions,15,16 scalp lifts,17 or flaps.18 These
procedures are infrequently used today and have been detailed
in many excellent publications, as well as in two comprehen-
sive textbooks.11,19
When learning FUT, the importance of hands-on experi-
ence and beginning with small sessions until skills develop
cannot be overemphasized. Having a well-trained team of
assistants is also important to a successful outcome, particu-
larly for those procedures involving a large number of grafts.
Although simple in concept, FUT has many nuances and
complexities. Those wishing to perform FUT in their clinical
practice are encouraged to join the International Society of
Hair Restoration Surgery (ISHRS) and attend its annual
meeting, to subscribe to Hair Transplant Forum International
(the trade publication for hair restoration surgeons), and to
follow relevant medical literature. Although it is an independ-
ent board, certification by the American Board of Hair Res-
toration Surgery (ABHRS) indicates a basic competency in
the field. Certification requires 3 years of clinical experience
and passing both oral and written examinations. The process
of preparing for ABHRS certification is a worthwhile endeavor
and recommended for those serious about surgical hair
restoration.
Historical vignette
Reports of successful hair transplants appeared as early as
1930 in the Japanese literature, beginning with Sasagawa’s
hair-shaft insertion procedure20 and then Okuda’s technique
of using 2- to 4-mm punches for the treatment of various
alopecias of the scalp, eyebrows, and moustache. Okuda
made the important observation that using smaller punches
in the recipient area improved cosmetic results.21
By 1943, Tamura had treated 137 cases of non-androgenetic
alopecia of various etiologies using techniques very similar to
modern day hair transplantation.22 For instance, he harvested
donor grafts by making an elliptical incision that was sutured
closed, prepared recipient sites with a thick needle, stored
grafts in physiologic saline, and observed postoperative
telogen effluvium (shedding). Most significantly, Tamura
demonstrated that single-hair grafting resulted in growth
more) and/or the size of tissue required to fit into a given
recipient site – a process known as ‘grafts cut to size.’ Often
the dissection is performed without magnification, and it is
also common for the donor tissue to be removed with a
multibladed knife, rather than as a single strip, causing sig-
nificant destruction of follicles. Because the grafts may be too
large to fit into a slit incision, an excision (where recipient
tissue is removed, such as with a small punch) is sometimes
needed. In contrast, the recipient sites used for FUT always
consist of small incisional slits. The advantages of FUT over
mini-micrografting techniques have accounted for the shift
to FUT over the past decade.
In a new procedure called follicular unit extraction,10 the
need for a donor strip is eliminated entirely. In this proce-
dure, individual follicular units are removed (extracted)
directly from the donor area through a small circular incision
with or without microdissection. Although this procedure
obviates the need for a linear strip, it has limitations, par-
ticularly in the inability to efficiently utilize all the tissue in
the mid-portion of the permanent zone. As of this writing,
follicular unit extraction is used in only a small minority of
patients requiring surgical hair restoration. A description of
this procedure will be included in the section on donor
harvest under Techniques.
The purpose of this chapter is to describe the basic techni-
cal skills and aesthetic judgments involved in FUT. It should
be taken as a framework for physicians interested in learning
the procedure, not an exhaustive review of the various
A
B
Figure 29.1  (A) Hair densitometer. (B) Video-densitometer.
Figure 29.2  Natural hair groupings as seen through a
densitometer (magnification ×30).

487
Chapter 29  Follicular Unit Hair Transplantation
The term follicular unit transplantation should now be used
to encompass all hair restoration procedures that utilize nat-
urally occurring individual follicular units exclusively in the
surgery, regardless of how these units are harvested. The
caveat, of course, is that the harvesting technique must always
maintain the follicular unit’s integrity.
 PREOPERATIVE PREPARATION
Patient evaluation and surgical planning
Diagnosis and classification of
androgenetic alopecia
The diagnosis of androgenetic alopecia in men is usually
straightforward. It is made by observing a ‘patterned’ distri-
bution of hair loss. It is confirmed by the presence of mini-
aturized hairs in the areas of thinning. The diagnosis is
supported by both the inexorable progression of the hair loss
according to a recognizable pattern and a history of baldness
in the family.28 In women, the diagnosis is more complex
since the most common presentation, a diffuse pattern, can
be mimicked by a host of non-androgenetic etiologies.
Miniaturization – the progressive diminution of the hair
shaft’s diameter and length in response to androgens – can be
most readily observed with a densitometer,11 a hand-held
instrument that magnifies a small area of the scalp where the
hair has been clipped to about 1 mm. One type, the Rassman
densitometer,3 magnifies by ×30 in a visual field of 10 mm2,
making it easy to spot miniaturization and calculate hair
density (Figs 29.1–29.3). With video-densitometry (Fig
29.1B), the doctor can project the image onto a computer
screen so that it is immediately visible to the patient. It can
also provide a permanent digital record of the person’s density
and miniaturization status.29
When describing hair loss, particularly in the early phases,
it is preferable to think in terms of changes in volume rather
than density. Density is simply the number of hairs per unit
area, whereas volume reflects both hair shaft diameter as well
as the absolute numbers of hairs.30
A new device, called the Trichometer, takes both of these
factors into account by measuring the cross-sectional area of
a demarcated bundle of hair.31 The earliest sign of hair loss,
practically indistinguishable from naturally grown hair – and
much more natural looking than transplants using larger
grafts. Unfortunately, it took several decades before Western
surgeons would apply Tamura’s insights to their hair restora-
tion procedures.
The first hair transplant in the United States was per-
formed by Dr Norman Orentreich in 1952 with grafts meas-
uring 6–8  mm in diameter,23 significantly larger than those
of either Tamura or Okuda. At first, incredulous editors
rejected Orentreich’s work, not believing that hair trans­
plantation was even possible. In 1959, the Annals of the New
York Academy of Science finally agreed to publish his work.
The paper laid out the concept of ‘donor dominance’ – the
idea that grafts continue to show the characteristics of the
donor site after they have been transplanted to a new loca-
tion. This remains the basic tenet of all hair transplantation
surgery. Yet while donor dominance insured that transplanted
hair could grow, it did not guarantee that the results would
look natural.
Not until 40 years later would hair transplants in the United
States start to produce consistently natural-looking results
and promise predictable cosmetic improvements in most
patients. It was a slow evolution, but the large grafts used
throughout the 1960s and 1970s eventually gave way to
mini-grafts in the 1980s3 and mini-micrografting in the early
1990s.24 The stage was then set for FUT. First appearing in
the medical literature in 1995,1 it quickly emerged as the
standard in hair restoration – supplanting mini-micrografting
in the treatment of androgenetic alopecia and rendering other
well-established procedures such as scalp reductions, scalp
lifts, and flaps virtually obsolete.
So swift was the ascent of FUT that the two standard
textbooks on surgical hair restoration, published in 199525
and 1996,11 as well as the most comprehensive text on trich­
ology, published in 1997,26 make not one mention of the
terms ‘follicular unit’ or ‘follicular unit transplantation.’ At
the 1996 meeting of the ISHRS, three 7-minute presenta-
tions on the procedure were given; but at the 2002 meeting,
FUT was the subject of entire seminars and workshops and
suffused every aspect of the week-long gathering.
The follicular unit was first defined by Headington in
his landmark 1984 paper entitled ‘Transverse microscopic
anatomy of the human scalp.’2 Follicular unit transplantation
had its origins in the microscopic dissection techniques of Dr
Limmer in 1988 that was described in his paper ‘Elliptical
donor stereoscopically assisted micrografting as an approach
to further refinement in hair transplantation’ in 1994.8 The
term ‘follicular unit’ was introduced into the hair transplant
literature by Bernstein & Rassman in 1995. The conceptual
framework for FUT was mapped out by these authors in the
1995 publication ‘Follicular transplantation’1 and in the
paired articles ‘Follicular transplantation: patient evaluation
and surgical planning’ and ‘The aesthetics of follicular trans-
plantation’ in 1997.6,7
The name ‘follicular unit transplantation’ was formalized
by a group of hair restoration surgeons in 1998.27 In this
paper, the procedure was precisely defined and included the
two basic techniques, single-strip harvesting and stereomicro-
scopic dissection, as integral parts of the procedure. However,
because follicular units can now be harvested directly from
the donor area without the necessity of a strip incision (using
follicular unit extraction10), the original definition has become
too restrictive.
Figure 29.3  Histologic view of follicular units corresponding to
the natural hair groups observed on the scalp surface.
Transverse section taken at the level of sebaceous glands
(hematoxylin and eosin; original magnification ×40).2,5

488
Part 3  Aesthetic Surgical Procedures
zone. In DPA, the entire top of the scalp gradually mini-
aturizes without passing through the typical Norwood stages.
DUPA is also androgenetic but lacks a stable permanent zone
and affects men much less often than DPA. DUPA tends to
advance faster than DPA and eventuates in a horseshoe
pattern resembling the Norwood class VII. However, unlike
the Norwood class VII, the DUPA horseshoe can look almost
transparent due to the low density of the back and sides.
Differentiating between DPA and DUPA is very important
because DPA patients often make good transplant candidates,
whereas DUPA patients almost never do, as they inevita-
bly suffer extensive hair loss without a stable zone for
harvesting.6
The early warning signs of DUPA include:
• a rapid decrease in hair volume and a change in hair
texture at an early age, often in the teens
• the maintenance of an adolescent hair pattern and
persistent frontal hairline in spite of dramatic volume
change
• a see-through donor area (most easily visualized when
the hair is wet or lifted up)
• abnormal densitometry
• significant miniaturization of the donor area (greater
than 35%)
• a donor density of less than 1.5 hairs per mm2.
The sensitivity of densitometry in detecting early DUPA
justifies its routine use in the evaluation of hair loss. If a
diagnosis of DUPA is even remotely suspected, any decisions
regarding surgical hair restoration should be postponed. The
possibility of missing a DUPA diagnosis is one of the most
powerful arguments against performing hair transplantation
at an early age.
Both DPA and DUPA occur in women, but – in contrast
to men – DUPA is far more common. As with men, women
with DUPA do not make good transplant candidates (except
possibly when donor hair is used solely to soften the frontal
edge of a wig). Indeed, the higher DUPA incidence in women
explains why a smaller proportion of women than men qualify
as transplant candidates. Interestingly, the most common
classification used for women, the Ludwig classification, does
not differentiate between DPA and DUPA.34
Recently, a home test has been developed that screens for
variations in the androgen receptor gene on the X chromo-
some, a gene associated with male pattern hair loss. The
purpose is to identify persons at increased risk of developing
hair loss before it is clinically apparent so that medical inter-
vention can be started early, when it is most effective. The
presence of one of the variants indicates a moderately
increased risk for the development of androgenetic alopecia
that of miniaturization, results in volume changes caused by
the individual hair decreasing in size without a decrease in
their number. Only in more advanced balding will the actual
number of hairs start to decrease.1 This is why devices that
can assess hair shaft diameter are so useful for identifying
early hair loss.
The Norwood classification of male pattern hair loss, pub-
lished in 1975, remains the most widely used.32 It defines two
major patterns and several less common types (Fig. 29.4). In
the regular Norwood pattern, two areas of hair loss – a bitem-
poral recession and thinning crown – gradually enlarge and
coalesce until the entire front, top, and crown (vertex) of the
scalp are bald. A less common Norwood variety, Norwood
class A, is characterized by a distinctly anterior-to-posterior
progression, usually resulting in baldness on the front and top
of the scalp, but more limited loss in the crown. In both pat-
terns, the sides and back tend to resist androgenetic changes,
though the sides may exhibit significant thinning in senile
alopecia.
Two other types of genetic hair loss not emphasized in
the literature, diffuse patterned alopecia (DPA) and diffuse
unpatterned alopecia (DUPA), pose the greatest challenge
both for diagnosis and patient management. A thorough
familiarity with all of these patterns is essential for diagnosing
androgenetic alopecia and planning FUT (Table 29.1).
DPA is an androgenetic alopecia manifested as diffuse thin-
ning in the front, top, and vertex, with a stable permanent
I
II
III
III vertex
IV
V
VI
VII
Norwood classification
Figure 29.4  Norwood classification.32
Table 29.1  Classification of androgenetic alopecia
Norwood classes
Regular classes I to VII
Type A variant (IIA to VA)
Variations: persistent frontal forelock;33
persistent frontal hairline
Diffuse androgenic
alopecias
Diffuse patterned alopecia (DPA)
Diffuse unpatterned alopecia (DUPA)
Senile alopecia
Female pattern alopecia
Ludwig classes I to III

489
Chapter 29  Follicular Unit Hair Transplantation
if there is nothing to notice after the transplant matures,
why perform it in the first place? FUTs heal so quickly and
the hair growth is so gradual that, once the short postopera-
tive period ends, the process is almost always undetectable.
When hair loss is early, medical therapy is the treatment of
choice.
Patients seeking hair transplantation while still in their early
20s invariably wish to have their adolescent hairline and orig-
inal density restored. Since neither of these goals can be
achieved surgically without compromising the patient’s future
appearance, the procedure should not be performed at this
age. It should be explained that hair transplantation is a pro-
cedure that moves, rather than creates, hair. It does not
increase overall hair volume. In fact, the challenge is to have
the pattern of the transplanted hair take into account the
person’s ever-decreasing total hair mass. In other words,
patients who will have significant balding need to have built-
in temporal recession, and possibly a crown that is signifi-
cantly thinner than the surrounding hair, for the transplant
to look natural over time. Unfortunately, neither of these is
generally acceptable to a young man in his early 20s.
Another reason to postpone transplants for those under 25
years, or with only limited hair loss, is to give medications
– particularly finasteride – adequate time to work. As patients
may continue to show regrowth for 1–2 years after treatment
is initiated, they should in general take finasteride at least this
long before surgery is considered. It is inappropriate, there-
fore, to start younger patients on finasteride and schedule
surgery at the same time. Fortunately, finasteride works best
in younger patients, and especially those with large areas of
miniaturized scalp, rather than areas that are totally bald. On
the other hand, for older patients who would be taking fin-
asteride to maintain rather than regrow hair, and for those
whose advanced state of hair loss makes results from finas-
teride unlikely, the medication may be prescribed concomi-
tantly with surgery.
With the availability of finasteride, medication plays an
increasingly important role in the management of androge-
netic hair loss. Although the incidence is small (2–4%), the
stigma of possible sexual side effects has turned many against
this drug. Some also consider surgery a more conservative
form of treatment than the potential lifetime use of a drug.
Because of these concerns and the pressure from panicked
patients for surgery’s apparent ‘quick fix,’ the physician
should take time to thoroughly discuss the pros and cons of
medical therapy.
and the other indicates a substantially decreased risk of
becoming bald. A similar screening test is also available for
the detection of hair loss in women.35
It is important to realize that, at this point, these markers
just reveal an association with hair loss and that a cause and
effect relationship has not been proven. A danger is that
patients may overreact to this relatively incomplete informa-
tion. It is best to have the tests performed under a doctor’s
supervision so that the results can be put in the context of
other information that the physician gleans through a careful
history and physical and so that the patient may be properly
counseled.
It is important to emphasize that because a wide variety
of medical conditions can produce diffuse hair loss, a non-
androgenetic differential must be considered in all unpat-
terned alopecias. This is particularly relevant in evaluating
women in whom unpatterned hair loss is the rule rather than
the exception (Box 29.1). The following laboratory tests are
often useful when a non-androgenetic cause for diffuse hair
loss is suspected: chemistry screen, complete blood count,
serum iron, total iron-binding capacity, tri-iodothyronine,
thyroxine, thyroid-stimulating hormone, antinuclear anti-
body, and serologic test for syphilis.
In women, diffuse or patterned hair loss may be a sign of
excessive androgen production. A further medical evaluation
is indicated when the hair loss is associated with any of the
following: cystic acne, irregular menses, hirsuitism, viriliza-
tion, infertility, or galactorrhea. Serum levels of dehydroepi-
androsterone (DHEA) sulfate, androstenedione, total and
free testosterone, and prolactin can serve as a useful screen.36
When the diagnosis of androgenetic alopecia is uncertain,
further diagnostic information can be gleaned from a hair-pull
test for telogen effluvium, a potassium hydroxide mount and
culture for fungus, a microscopic examination of the hair bulb
and shaft, and a scalp biopsy (sectioned horizontally).37 A
dermatologic consultation is warranted whenever the diagno-
sis of hair loss is unclear.
Who is a candidate for hair transplantation?
In all cosmetic procedures, a successful outcome depends on
proper patient selection (Box 29.2). In surgical hair restora-
tion, proper timing is also crucial. There are no medical or
surgical advantages to transplanting at an early age. The
popular rationale that transplants should be performed at a
young age so that ‘no one will notice’ does not make sense:
Box 29.1  Non-androgenetic causes of diffuse
hair loss in women
 Anemia.
 Endocrine diseases (especially thyroid).
 Connective tissue disease.
 Obstetric/gynecologic conditions (e.g. postpartum, polycystic
ovarian disease).
 Weight loss (especially crash diets).
 Emotional and physical stress (e.g. surgery, anesthesia).
 Medications: oral contraceptives, thyroid drugs,
antihypertensives (especially β-blockers), psychotropics,
anticoagulants, antilipemics, gout therapy, prednisone,
excessive vitamin A or tryptophan use.
Box 29.2  Surgical patient selection for
androgenetic alopecia
 Age 25 years or older.
 Inadequate response to medication after 1 year.
 Significant hair loss: Norwood class III or greater.
 Diffuse patterned alopecia has been ruled out.
 Non-androgenetic causes of hair loss have been ruled out.*
 No medical contraindications to surgery (drug sensitivities,
keloids, connective tissue disease).†
 Reasonable patient expectations.
*Many non-androgenetic causes of hair loss can be treated with hair
transplantation.
†Some are relative contraindications.

490
Part 3  Aesthetic Surgical Procedures
surgery is approximately one unit per mm2.7 In the first pro-
cedure, therefore, the donor area should yield approximately
one follicular graft per mm2 of scalp, provided there is no
significant wastage during surgery. The average yield declines
when longer strips are taken because density decreases
towards the sides. In some people, density varies dramatically
throughout the donor area, but this is the exception rather
than the rule.
Since the number of follicular units per unit area stays
relatively constant, donor density is an indication of the
average number of hairs per graft. For example, if a patient
has a density of two hairs per mm2, the donor area will gen-
erally contain one follicular unit per mm2 and the grafts will
consist of a combination of one-, two-, and three-hair units,
with the average being two hairs per graft. With a density of
2.3 hairs per mm2, there will still be one follicular unit per
mm2, so the same number of grafts will be harvested per unit
donor area, but the grafts will have an average of 2.3 hairs
per mm2 and consist of a mix of fewer one-hair units and a
larger percentage of three- and four-hair units.7
Follicular unit density varies according to race; therefore
the number of grafts obtained per unit area of donor tissue
will exhibit racial variability and must be accounted for in the
surgical planning.6
If the scalp has been stretched from previous transplants,
scalp reductions, or scalp lifts, the follicular units will be
spaced further apart, making it necessary to actually measure
the density of follicular units to accurately estimate the
number of grafts obtainable from the strip (as the density of
follicular units will now be less than one per mm2).
Donor scarring from previous surgeries will also signifi-
cantly diminish the donor yield. All donor harvests, no matter
how perfectly executed, entail some loss of hair. In addition,
the angle of the hair surrounding the scar will be altered
slightly, creating more transection in any subsequent harvest.
A person can lose a substantial amount of hair volume –
either due to actual loss of hair or to miniaturization – before
it becomes noticeable. When the hair is blonde or white it
takes longer for thinning to show, while it is evident sooner
for those with black hair and white skin. For those with
average density and average hair attributes, approximately
half of the hair in the donor area may be moved without a
significant change in appearance.
Scalp laxity
Scalp laxity (looseness) is an important factor in determining
a person’s total available donor hair. There appears to be two
main factors that contribute to laxity: redundancy and dis-
tensibility. Redundancy is simply extra scalp skin. Distensibil-
ity is the ability of the scalp to stretch. In those with lax
scalps due to redundancy, harvesting the donor strip merely
removes some of the extra scalp tissue while only slightly
affecting density (hairs per mm2); therefore, the yield can be
high over several procedures. With little redundancy,
however, each procedure stretches the skin, measurably
decreasing density. The limitations of a tight scalp are usually
not apparent in the initial surgery, but in subsequent proce-
dures it can become much harder to perform a non-tension
closure or, in the face of decreased density, to harvest a sig-
nificant amount of hair. Therefore, the long-term goals of
those with tight scalps must reflect a more limited donor
supply.
In the Norwood classification, class I represents a normal
adolescent pattern and class II a normal non-balding adult.
Therefore, as a minimum, patients should qualify as class III
before transplants are contemplated. Early class III patients
will often benefit from medication alone, so this should be
considered first.
Although the opportunities for a complete restoration in a
person who is extensively bald (i.e. a Norwood class VII) is
limited, extensive balding is not necessarily a contraindication
to surgery. If the person’s donor zone is stable (miniaturiza-
tion of less than 20%) and the patient’s expectations are
commensurate with his or her limited available donor supply,
a hair transplant may be considered. As long as the patient is
in good health, there is no upper age limit for surgery. In fact,
older patients tend to have the most reasonable expectations
and are often the most satisfied. Even a small amount of hair
can make a dramatic improvement in the appearance of a
person who has been bald for many years.
There are few absolute medical contraindications to sur­
gical hair restoration, particularly because it is an outpatient
procedure not requiring general anesthesia. Relative con­
traindications include: bleeding disorders, drugs that increase
bleeding such as clopidogrel (Plavix), immunodeficiency,
unstable arrhythmias, chronic obstructive pulmonary disease,
sensitivity to local anesthetics or epinephrine, a history of
keloid formation or connective tissue disease, and major psy-
chiatric disorders. When in doubt about the patient’s medical
condition, it is always best to get medical clearance from their
primary physician.
Patients should be able to tolerate being in the surgical chair
for a good part of the day; consequently, back and neck
problems as well as claustrophobia can sometimes make the
procedure problematic. Special care should be taken when
evaluating patients with significant psychiatric problems, par-
ticularly depression, trichotillomania, body dysmorphic dis-
order, or severe obsessive compulsive disorder. In such cases,
a psychiatrist or psychologist should participate in the
decision-making process.
Possibly the most difficult aspect of the consultation is
managing patients’ expectations. It is almost a cliché to say
that they must have ‘reasonable expectations,’ but ensuring
this is the essence of the evaluation. The surgeon cannot
stress strongly enough that because hair restoration proce-
dures move rather than create hair, the resulting transplanted
density will be significantly less than the person’s non-balding
density. It is also important to emphasize that it is the
patient’s own hair from the sides and back of the head that
will be transplanted. Therefore, the final result can be best
described with reference to the texture, color, curl, and other
qualities of the person’s existing hair. In addition to a thor-
ough discussion, it is also helpful to provide prospective
patients with printed material and photos, and to make past
patients available for them to meet.
Assessing the patient’s donor supply
The main factors in determining total donor reserves are
donor density, scalp laxity, and the physical size of the donor
area.
Donor density
The number of follicular units in the mid-portion of the
donor area of a normal Caucasian man who has not had

491
Chapter 29  Follicular Unit Hair Transplantation
as producing very high densities. In addition, popping becomes
less of a technical issue when the same number of grafts are
placed over a larger area. However, transplanting large number
of grafts (in ‘mega-sessions’) poses its own challenges, such
as increasing the time the grafts remain outside the body,
requiring more staff, contributing to patient and staff fatigue,
and creating organizational issues. As with dense packing, the
use of very large sessions should be reserved for only the most
experienced surgical teams.
Though the amount of hair needed to cover the front and
top of the patient’s scalp will vary, an attempt should be
made to achieve this coverage, if only lightly, in the first
session. Crown coverage should not be a goal of the first
session unless the patient has an above-average donor supply;
if it is attempted in the first session, the patient’s options will
be more limited and the chances for an aesthetically balanced
transplant may be permanently compromised.
Table 29.2 offers general guidelines as to the number of
follicular units recommended for the first hair transplant
procedure.
Planning a second session
Timing of the second session
Transplanted hair sheds around 2–6 weeks after the proce-
dure and the first signs of new growth occur on average in
approximately 10 weeks, though the onset can vary consider-
ably, taking as long as 4–6 months or more. Hair gradually
increases in both thickness and in length, so that the initial
growth is often not indicative of the final result. In less than
5% of patients, hair grows unabated after surgery, without
shedding.
One should generally wait 10–12 months to best appreciate
the cosmetic impact of the procedure. During this time, the
continued increase in the hair’s diameter and length strikingly
alters the appearance of the restoration. Once the hair reaches
styling length, both the patient and physician can make aes-
thetic judgments about the desirability of an additional treat-
ment session.
It will also be advantageous to delay the second procedure
to maximize the donor harvest. Although each procedure
results in a potentially tighter scalp, some of the preoperative
donor laxity returns in the months following the surgery.
Although, the major change will occur during the first month
Patients with very loose scalps, due to increased distensibil-
ity, tend to heal with widened scars and so often make poor
candidates for procedures using a linear incision. Some, in
fact, may have undiagnosed connective tissue disease.38 Fol-
licular unit extraction should be considered in cases of both
very loose and very tight scalps.10
Donor dimensions
The mid-portion of the harvestable donor zone generally lies
over the occipital protuberance and extends laterally to
within 3 cm of the temple hairline on either side. This dis-
tance is approximately 32–34 cm. Recession at the temples
can signal extensive balding and portends a limited donor
supply. The height of the permanent zone can vary markedly
from person to person and should be carefully measured. Hair
should be harvested only where it is stable, that is where it
lacks significant miniaturization. An often overlooked sign is
the ‘ascending’ hairline, characterized by miniaturization in
the lower margin of the permanent zone. Both receding
temples and an ascending posterior hairline indicate a shrink-
ing donor zone and mandate conservative surgical planning.
Planning the first hair transplant session
Ideally, the main goals of the first transplant session should
be:
• to establish the frontal hairline and frame the face
• to provide coverage to all bald areas of the scalp, from
the frontal hairline to the vertex transition point39
• to create sufficient density so that the results will look
natural after one session, though additional sessions may
be desired.6
These goals should be the ultimate aim of those performing
hair restoration surgery, but may not be achievable with a
small or inexperienced surgical team. In this author’s opinion,
there is little medical or aesthetic justification for performing
the surgery in arbitrarily small sessions. It is preferable that
each procedure cover the entire area of hair loss intended to
be treated and be designed to ‘stand alone.’6,7
In an alternate approach to surgical planning, the objective
is to achieve final density in a one-pass procedure by creating
high density in a more limited area and then transplanting
another area in a subsequent session. This is accomplished in
part by using very small recipient sites, limiting graft size to
three hairs and using the stick-and-place method, in which
grafts are inserted as soon as the recipient sites are made.40
As the number of grafts placed per unit area (density) rises,
so too does the risk of vascular compromise that may result
in suboptimal graft growth. Technical problems of popping
that may cause the grafts to become desiccated or that expose
the grafts to mechanical injury on reinsertion also become
more likely. Proper patient selection and technical expertise
help avoid such problems, but the risks are increased never-
theless. It certainly behoves those with more limited experi-
ence to be conservative when determining the number of
grafts to be transplanted.
Because the blood supply to the scalp is extensively col-
lateralized,41 the risk of vascular compromise is related more
to the density of grafts in a specific area and the size of the
recipient wounds, than the absolute numbers of grafts placed.
For this reason, the transplantation of a large number of grafts
over a broad area does not seem to pose the same problems
Table 29.2  Number of grafts in first follicular unit transplant
session
NORWOOD
CLASS
FOLLICULAR
UNITS
TOTAL UNITS
WITH CROWN
III
800–1200+
–
III Vertex
800–1200+
1200–1800+
IIIA
1300–1700+
–
IV
1500–1800+
1800–2200+
IVA
1700–2100+
–
V
1500–1900+
1900–2400+
VA
2000–2400+
–
VI
2000–2400+
2400+
VII
2400–2800+
2800+

492
Part 3  Aesthetic Surgical Procedures
in, however, many people will feel comfortable committing
to a specific grooming pattern. If this is the case, then the
second procedure may be used to complement a specific way
of styling the hair. For example, if a man is relatively certain
that he will continue to comb his hair from left to right, then
the transplant can be left-weighted to enhance the appear-
ance of density when the hair is groomed in this manner. If,
however, the person prefers to comb his hair straight back,
or wants to vary his look, then the second transplant should
be symmetrical like the distribution of the first.
Subsequent transplant sessions
The surgeon should make every attempt to accomplish the
restoration in as few sessions as possible, rather than putting
patients through an unnecessarily protracted course of mul-
tiple surgeries that can adversely affect their donor area and
lifestyle. The number of grafts required to achieve patient
satisfaction varies widely due to the great variability in hair
characteristics. Moreover, because hair loss patterns form a
continuum, while the Norwood classes are discrete, even the
transplant size necessary for each class can vary significantly.
Table 29.3 shows the approximate number of follicular unit
grafts necessary for a complete restoration, with and without
crown coverage.
The patient
Doctors commonly place patients on finasteride before
surgery to minimize the chance of postsurgical effluvium
(shedding). Although there are no scientific studies confirm-
ing that it is effective for this purpose, it would seem that if
the goal is to prevent postsurgical shedding, the medication
should be prescribed at least a month before the procedure.
If, however, the intent is to postpone or obviate the need for
surgery, then it should be taken for a minimum of 1 year to
allow sufficient time for the patient’s hair to regrow.
Patients using topical minoxidil are advised to discontinue
its use several days before surgery (because of its vasodilator
properties) and wait until a week after the procedure before
resuming (to avoid the irritating effects of the alcohol in the
2% solution or the propylene glycol in the 5% solution).
Although we suggest minoxidil in combination with finas-
teride for patients with early hair loss, we generally do not
recommend the use of minoxidil after a hair transplant,
as the edema and inflammation subside, further loosening
occurs as the scalp stretches over the next 12 months.
In the uncommon event of telogen effluvium occurring in
the donor area, the telogen follicles may not be easily iden-
tifiable in the dissection. Since recovery in the donor area
may take up to a year, it is essential that patients wait until
complete regrowth has taken place before a second session is
performed. In rare cases, if the closure is too tight, the efflu-
vium may eventuate in permanent hair loss.
Goals for the second session
The main goals of the second session are:
• to add density to areas transplanted in the first session
• to refine the hairline
• to follow the progression of the hair loss (if necessary)
• to extend the transplant into the crown (when
appropriate)
• to complement a specific grooming pattern.
In general, most patients require two sessions to achieve
adequate density. When seen at 1-year follow up, approxi-
mately 50% of patients are satisfied with the density achieved
in the first session. However, if the first session is planned as
a stand-alone procedure, the patient who does want more
density does not need to have this second session in order to
look natural. Of the 50% that do want further density, many
postpone the next procedure due to either financial or time
constraints and have it performed at a time that is convenient
for them.
The hairline can often benefit from a little ‘tweaking’ to
make the leading edge softer and more irregular. Placing the
hairline too low is a common mistake, but so is placing it too
high, something often done with the intention of bringing it
down on the second session, once the patient can see how it
looks. It is better to try to get the hairline position right in
the first session; lowering it later often leaves the leading edge
too thin.
The decision regarding crown coverage is important because
it is the least visible of the balding regions, but can potentially
occupy a very large surface area, producing an almost inex-
haustible demand upon the donor supply.
If extensive balding appears likely and the patient has a
modest donor supply, the crown should be treated as an
extension of the top, rather than an isolated region. This will
help to ensure that the patient will not be short of hair if the
intervening bridge between the front and crown were to
require additional grafts. Unless the patient’s history, age, and
physical examination indicate limited balding, it is particu-
larly important to avoid creating high density in the crown,
as subsequent balding could leave an isolated island of hair.
A useful alternative to covering the crown with trans-
planted hair is to end the transplant at the vertex transition
point.39,42 The patient can then groom the hair back to conceal
the non-transplanted area. This is recommended when direct
crown coverage is not realistic or it is too early in the balding
process to determine whether significant crown coverage will
be possible in the future. Another advantage of sparing, or
lightly covering, the crown is that donor reserves may be
saved to address further diminution of the lateral donor
fringe.
Particularly when a person has been bald for many years,
it is not known how the person will want to groom his/her
hair after the restoration. Once the first procedure has grown
Table 29.3  Total number of follicular unit grafts for
complete restoration
NORWOOD
CLASS
FOLLICULAR
UNITS
TOTAL UNITS
WITH CROWN
III
1000–1600
–
III Vertex
1000–1600
1600–2200
IIIA
1400–2200
–
IV
1400–2200
2200–3000
IVA
1800–3600
–
V
2000–3000
3000–4200
VA
2400–4400
–
VI
2200–4600
4200–5600
VII
2200–4800
4400–6600

493
Chapter 29  Follicular Unit Hair Transplantation
unless it is being used in an area other than that which was
transplanted (such as the crown). We feel that minoxidil has
little added value for the average post-transplant patient. We
do, however, encourage the continued use of finasteride to
help retard further balding. Those who do not plan to use
minoxidil after surgery should discontinue it immediately, so
that any of its beneficial effects may be reversed by the time
of surgery.
Patients are advised to avoid products that are used to
thicken the hair or that stain the scalp for 3 days before the
procedure, as these often take several days to completely
wash out of the scalp. Their presence during surgery can
decrease visibility and make placing more difficult. Hair
systems should be removed before surgery and be replaced
with, or converted to, a clip-on system. The front edge of the
piece can be kept in place with a stiffening rod, obviating the
need for tape or glue. However, any form of attachment at
or near the frontal hairline risks dislodging grafts. Patients are
encouraged to permanently discontinue the system after the
procedure, but those who feel the need to use them until
their hair grows in should wait at least 5 days post-op.
Systemic antibiotics are not indicated for clean surgical
wounds in healthy patients, so their routine use in hair trans-
plantation is not necessary; however, many doctors routinely
use them. Because there are no specific guidelines for antibi-
otic prophylaxis in hair transplantation for patients with a
history of endocarditis or mitral valve prolapse, the decision
to use them must be based on the individual patient’s risk
factors.43
The other preoperative instructions are relatively straight-
forward and will depend to some degree on the preferences
of the operating surgeon. Patients should be notified well in
advance of the procedure date regarding the need to discon-
tinue certain medications, to stop smoking, and abstain from
alcohol before surgery. Box 29.3 is a summary of the main
preoperative instructions.
All patients undergoing hair transplantation should be
treated with universal precautions. Although there is no con-
sensus on the need to perform routine blood tests before the
procedure, the following tests provide an additional level of
safety:
• Complete blood count.
• Hepatitis B surface antigen and antibody.
• Hepatitis C antibody.
• HIV screen.
One should obtain medical clearance for HIV-positive
patients to make sure that they are immunocompetent
enough to withstand a potential series of procedures. With
the hepatitis antigen-positive patient, there is a concern about
active disease and one should inform the patient’s primary
physician of a positive screening. Other tests, such as a plate-
let count and prothrombin and thromboplastin times, are
performed only if warranted by the history and physical.
The surgical consent form should be given to patients to
read at their leisure well in advance of the procedure and
should be signed by the patient before any medications that
can cause drowsiness or impair judgment have been given.
The exact time of signing should be indicated. The major
elements of the consent form are listed in Box 29.4.
Although not universally recommended, some doctors have
the patient shower the morning of surgery using a chlorhexi-
dine surgical scrub as shampoo. Though it does not sterilize
Box 29.3  Preoperative instructions
 Continue medications currently prescribed by the physician,
particularly those for high blood pressure. Those taking
broad β-blockers (such as propranolol) should switch to
selective β-blockers, as the former may interact with
epinephrine. This should be done under a doctor’s
supervision.
 Discontinue topical minoxidil and avoid products used to
thicken the hair or stain the scalp 3 days before the
procedure.
 In order to minimize bleeding, avoid the following before
surgery: aspirin or other anti-inflammatory medications (1–2
weeks), vitamin B or vitamin E (1 week), and alcoholic
beverages (3 days). Do not drink coffee or any other
caffeinated beverages on the day of the procedure as these
substances will increase sensitivity to medications such as
epinephrine.
 Do not smoke tobacco products for at least 24 hours before
the procedure and at least 1–2 weeks after. Smoking will
slow down healing and heighten the chances of wound
infection and scarring.
 On the morning of the procedure, take a bath or shower and
wash the hair thoroughly using a surgical scrub (containing
3% chloroxylenol).
 In the weeks prior to surgery, if possible, leave the hair long
in the back and on the sides to cover the sutures.
 Wear clothes that do not need to be pulled on over the head;
this will help keep bandages in place and avoid any damage
to the grafts immediately after surgery.
 Eat breakfast in the morning if the surgery is scheduled in the
afternoon, have a light lunch before arrival.
 Because medications given during the procedure can make
people drowsy, it is not wise to drive home following the
surgery. If necessary plan to have a driver or take public
transportation. Please let the doctor know ahead of time.
Box 29.4  Elements of consent form for
hair transplant
 Nature of the procedure, with specific reference to its
cosmetic nature.
 Indications for surgery.
 Risks: reactions to anesthetics; allergic reactions; sterile
folliculitis, infection; cyst formation at graft site; scarring in
donor area; hair loss related to the procedure; hair texture
changes; failure of transplanted hair to grow; numbness;
paresthesia; temporary swelling or bruising.
 Benefits.
 Alternatives: doing nothing, change hair styles (e.g. lightening
or keeping hair very short); medical therapy; another form of
hair restoration surgery (e.g. mini-micrografting); wearing a
hairpiece.
 Results are not guaranteed.
 Consent for photograph as part of the medical record.
 Caution about driving under the influence of medication.
 Statement that the above are understood and all questions
have been answered.
 Signature of the patient with date and time (before the
administration of drugs), countersigned by the operating
physician and witnessed by a staff member.

494
Part 3  Aesthetic Surgical Procedures
donor area, as they can be angled to illuminate the posterior
scalp of the seated patient.51
The Petri dishes containing grafts pending placement
should be kept on a stable, wall-mounted surface to keep
them from being inadvertently knocked over (Fig. 29.6). The
typical operating room Mayo stand is not stable enough.52
Normal saline is the most frequently used holding solution
for grafts, but we prefer the more physiologic lactated
Ringer’s. Limmer has shown a high survival rate for grafts
kept in chilled saline for up to 8 hours.53 More exotic solu-
tions with potential graft-sustaining properties, such as plate-
let-rich plasma, have been developed, but they are not widely
used.54–56
Grafts should be refrigerated when they are outside the
body. Approximately 1 hour before placement, we remove a
portion of the grafts from refrigeration and put them into
Petri dishes which are resting on ice packs that maintain the
Ringer’s solution at 59°C. This is set on a wall-mounted stand
conveniently located at the head of the operating chair.
It is preferable to have all the dissection performed in the
operating room. In addition, a small refrigerator used solely
for graft storage should be located in each room. Performing
all the dissection and storing the grafts in the same room
eliminates the risk of inadvertently placing grafts in the wrong
patient. This is particularly important in a busy practice
where more than one person is being operated on per day.
The minimum room size for a physician and five staff members
to work comfortably is approximately 15.5 square meters.
In advance of the procedure, it is helpful to set up complete
surgical trays, including the local anesthetic mixtures pre-
drawn into syringes. This serves a number of purposes: it
the scalp, the chlorhexidine binds to the stratum corneum,
decreasing transient and pathogenic microorganisms and res-
ident skin flora. Caution is advised as it can be toxic to the
middle ear and irritating to the eyes. In our practice, we
advise patients to use a simple baby shampoo. After shower-
ing, the patient should dress in comfortable clothes and wear
a button-down shirt.
 THE OPERATING ROOM
FUT is typically performed in an outpatient office setting.
The guidelines of care for office surgical facilities delineated
by the American Academy of Dermatology should be reviewed
before setting up facilities.44,45 Though major complications
occur only rarely, protocols should be in place to handle
emergencies such as hypersensitivity reactions or anaphylaxis,
stroke, seizures, arrhythmias, acute myocardial infarction,
and hypertensive crisis. At the very least, specific arrange-
ments should be made with a local Emergency Medical Serv-
ices (EMS) facility to take care of distressed patients.46
The medical staff should be comfortable dealing with
problems such as bleeding, syncope, petit mal episodes, and
anxiety reactions. The medical staff should be certified in
cardiopulmonary resuscitation (CPR), and at least some in
advanced cardiac life support (ACLS). The amount of in-
office emergency equipment will depend on staff capability
and training, and proximity to an EMS unit. Basic equipment
includes portable oxygen, an automated defribrillator, intra-
venous setup, and an oral and nasopharyngeal airway.46
Because of the scalp’s abundant vascular supply and relative
resistance to infection, it is common practice for doctors’
technique to be aseptic, rather than sterile. And because the
scalp is not usually shaved and prepped, strict sterile tech-
nique is not practical. However, at least until the donor area
is sutured closed, a sterile environment should be maintained.
This issue is discussed in greater detail by Sebben.47,48
The single most important instrument for FUT is the dis-
secting stereomicroscope,8,49 which is available with either a
binocular view or an LCD screen. There should be one micro-
scope for each member of the surgical team performing dis-
section. Experienced teams generally require one staff
member per 500–750 grafts (for graft dissection and placing),
so that a typical 2000-graft procedure would necessitate
three or four staff members in addition to the physician,
though this will vary considerably among practices. Less
experienced teams may require more people. The staff’s
other responsibilities, as well as possible absenteeism, must
also be taken into account.
Regular operating room tables are generally inadequate.
Rather, the tables must be contoured and provide some
lumbar support when patients are sitting. They also need to
be low to the ground, with the seat not more than 56 cm
from the floor, so the staff can work comfortably around the
head while the patient is seated.
Equally important are comfortable working areas for the
staff. Dissecting tables with a bull nose, rather than squared
edge, are easier on their arms, and adjustable seating saves
them from bending over to look into the microscopes (Fig.
29.5). The long duration of the surgery makes meticulous
attention to ergonomic issues all the more crucial.50 Bright
fluorescent ceiling lighting is preferable to surgical operating
room lights because it generates less heat. We use high-
intensity surgical lights only for working on the patient’s
Figure 29.5  Dissecting stereomicroscopes on cutting table.
Figure 29.6  Wall-mounted placing stand for ice blocks, grafts,
and instruments.52

495
Chapter 29  Follicular Unit Hair Transplantation
density is checked to confirm the measurement taken at the
initial consultation. If the number differs or it appears that
density varies in the donor area, multiple measurements are
taken. Scalp laxity is also reassessed and recorded on the
operative report.
Patients are given cotton surgical gowns to wear and their
pictures are taken with a digital camera against a light-blue
background. Next, the hairline and other important land-
marks, such as the vertex transition point and crown swirl,
are marked in gentian violet and shown to the patient using
two mirrors. If the patient approves of the hairline design,
additional pictures are taken, this time of the marked scalp,
usually from the front and aerial views. Three-quarter and
close-up photos are sometimes taken to illustrate particular
cosmetic issues. Occasionally pictures are taken during and
after the operation for teaching purposes. All photos are kept
as part of patients’ permanent medical records.
Typically, for a procedure of 1500 grafts or more, patients
are premedicated with oral diazepam 5–15 mg and intramus-
cular midazolam 2–4 mg about 15 minutes prior to surgery.
Dosing will depend upon the patient’s body weight, age, sex,
and past sedative/analgesic use. Long-acting sedatives are not
given to patients who will be driving themselves home from
the procedure. Intramuscular methylprednisolone 80 mg is
given to reduce postoperative swelling. Oral antibiotics are
not routinely given, but are considered in patients with
implanted prosthetic devices, valvular heart disease, and
other medical conditions requiring prophylaxis.
Donor harvest
In preparation for the donor harvest, patients are seated
upright on the operating table. The hair in the donor area
(that covering the donor strip plus the 0.5  cm beyond its
perimeter) is then cut to 1–2 mm using electric clippers (the
extra 0.5  cm is to facilitate suturing). The trimmings are
thoroughly vacuumed away and the hair above the strip is
held back with paper tape, fully exposing the donor area. A
gauze headband is placed around the patient’s head just below
the clipped area and sterile drapes are taped to the headband.
In the first session, in a patient with average scalp laxity,
we generally harvest a donor strip that is 1–1.3 cm wide. In
calculating the length, we use the general rule of 90–100 fol-
licular units per cm2.5 For example, if a 1500-follicular unit
graft hair transplant is planned for a Caucasian with average
density, a 1–1.1-cm-wide strip would need to be 18 cm in
length (15 cm plus 3 cm for tapering). People of African and
Asian descent characteristically have a lower follicular unit
density and a strip of this dimension will yield a lower number
of follicular unit grafts.7
Local anesthesia
A ring block is established using an anesthetic mixture of
lidocaine, bupivacaine, and epinephrine (see Table 29.4). The
anesthetic solution is injected into the subcutaneous fat layer
approximately 1 cm below the lower portion of the clipped
area and extending several centimeters past it on either side.
In addition to buffering the anesthetic, already discussed,
discomfort from the injections can be reduced by pressing a
vibrating hand massager to the skin below the area of inser-
tion of the needle. The sting of the injection can also be
reduced by a device that controls the flow of the anesthetic
solution.61
makes it easier to keep track of how much anesthetic is used
in each part of the procedure, it helps to ensure that safe dose
limits are not exceeded,57 and it minimizes the risk of needle-
stick injury, because the preparation takes place before the
operating room begins to bustle.
Local anesthesia is administered with a ring block consisting
of lidocaine, bupivacaine, and epinephrine buffered with
sodium bicarbonate. Lidocaine, the major component, is used
for its safety and quick onset. Bupivacaine is added to increase
the duration of anesthesia, but in smaller quantities to limit
its potential cardiac toxicity.58 Epinephrine increases the
anesthetic duration while decreasing its toxicity and provid-
ing some hemostasis – although its vasoconstrictive action is
relatively short lived.
Sodium bicarbonate can be added to bring the acidic pH
of the epinephrine-containing solution closer to 7.4, lessening
its sting.59 This is particularly useful for injections at the
hairline, where the scalp tends to be most sensitive. It is
important to stress that the combined use of epinephrine and
broad β-blockers (e.g. propranolol) can result in potentially
life-threatening reactions.60
The anesthetic solution used for a typical 2000-graft session
is listed in Table 29.4. The anesthetic is drawn into 13 5-mL
syringes then fitted with 27-gauge needles. The tumescent
mixture consists of three 10-mL syringes with 25-gauge
needles. These quantities are preprinted on the operative
report and circled as each syringe is used. If the patient
requires additional anesthesia, the medication is drawn up
and the additional doses are recorded.
 TECHNIQUES
On arriving at the office, patients sign the consent form which
was given to them well in advance. The surgical plan is
reviewed and any last-minute questions are answered. Next,
Table 29.4  Anesthetic mixture
Ring block
COMPONENT
CONCENTRATION
AMOUNT IN
MIXTURE
Lidocaine
0.50%
≈60%
Bupivacaine
0.25%
≈40%
Sodium bicarbonate*
8.40%
1 : 10
Epinephrine
–
1 : 200 000
VOLUME†
INITIAL QUANTITY
BOOST
Donor area
20 cc
10 mL
Recipient area
25 cc
10 mL
Tumescent mixture for donor harvest
COMPONENT
CONCENTRATION
AMOUNT IN
MIXTURE
Lidocaine
0.17%
≈100%
Epinephrine
–
1 : 600 000
VOLUME†
QUANTITY
Donor area
30 cc
*Used prn.
†Volume of mixture typically used in 2000-graft session.

496
Part 3  Aesthetic Surgical Procedures
Donor closure
The most common types of closures include metal staples,
a running non-absorbable suture, or a running absorbable
suture.64–66 If staples are used to close the wound edges, it is
important to be certain that the wound edges are flush before
the staples are applied. The edges can be approximated by
grasping the lower edge with a skin hook and using rat-
toothed forceps to hold and slightly evert the upper edge (this
requires the help of an assistant) (Fig. 29.9). The staples
should then be placed approximately 0.6 cm apart. Staples
have virtually no tissue reactivity, but they make flush appo-
sition of wound edges difficult and can be uncomfortable in
the postoperative period and sometimes painful to remove.64
In the author’s practice, we routinely remove alternating
staples at 9–10 days and the remainder at 18–20 days post-
operatively. We feel that leaving in staples for this longer
period of time leads to a finer donor scar, particularly in
patients with tighter than average closures. This opinion has
yet to be confirmed in controlled studies.
Non-absorbable sutures, of either nylon or polypropylene,
are usually placed using a single running stitch and are
removed in 10–14 days. A problem is that if they are placed
too far from the wound edge, they entrap hair follicles and
this may result in the destruction of donor hair if there is
Approximately 0.75  mL of anesthesia is used per centi­
meter of donor area, so that a 25-cm long incision would
require slightly less than 20 mL of anesthetic solution. It is
important to avoid injecting into the muscle, as epinephrine
will cause vasodilatation, due to the action on β2-receptors,
quickly dissipating the local effects of the anesthetic and
increasing its toxicity.62
The ring block takes approximately 15 minutes to induce
anesthesia. As soon as the donor-area skin becomes numb,
tumescent anesthesia is administered by injecting larger quan-
tities of a more dilute lidocaine–epinephrine solution into the
mid-fat to make the area firm. The tumescence serves six
purposes: 1) to widen the distance from the follicles residing
in the upper fat to the nerves and larger blood vessels lying
just above the fascia; 2) to increase the rigidity of the donor
area; 3) to decrease follicular transection; 4) to decrease
bleeding; 5) to produce more uniform anesthesia; and 6) to
reduce the amount of anesthetic required.
Tumescence can be achieved using a dilute solution of
epinephrine and lidocaine (see Table 29.4) in somewhat
higher concentrations than used in liposuction surgery, as this
will provide additional anesthesia that is particularly impor-
tant in repeat procedures, or for patients with significant
donor scarring.63 In situations where there is prior surgery,
direct cutaneous innervation to the donor area from the
occipital branches can be blocked by scar tissue, so that
innervation to the donor area arrives in a rostral–caudal direc-
tion, rendering inferiorly placed ring block anesthesia ineffec-
tive. At times, when there is an excessive amount of donor
scarring, the anesthetic mixture must be injected above or
directly into the scarred area to make it numb.
Strip excision
The ideal position for the donor incision is in the mid-portion
of the permanent zone. This generally lies at the level of the
external occipital protuberance. The donor strip can be excised
using two parallel blades set 1.0–1.5 cm apart or the strip can
be harvested using a single blade. When using the parallel blade
technique, a convenient harvesting device is the Rassman
handle that is loaded with two #10 blades. The handle holds
the blades at an angle of 30°, making them parallel to the
emergent hair. The handle should hold the blades in a pre­
angled position to allow both blades to lie flush with the skin
surface when aligned with the hair follicles; otherwise, the
surgeon may cut too superficially with the upper blade and too
deep into the scalp with the lower (Fig. 29.7). Once the main
parallel portion of the incision is complete, a single scalpel
blade is used to taper the ends into an ellipse. In general, the
length of each tapered end should measure at least 1.5 times
the width of the strip, so that the ends lie flat (Fig. 29.8).
Alternatively, the entire excision can be performed with a
long free-hand ellipse after the skin is marked.8 This allows
the angle of the blade to be adjusted as each edge is cut. On
the other hand, this technique makes it harder to keep the
width uniform, which is necessary for predictable graft yields.
Cutting the second edge also becomes more difficult because
the rigidity of the tumescence is lost. The first incision renders
the second wound edge mobile and there is more distortion
of the wound edge and hair follicles due to the relative elas-
ticity of the dermis compared to the epidermis and fat.
Once the strip is removed it is immediately placed into a
chilled Ringer’s lactate solution.
Figure 29.7  Donor-strip harvesting using two parallel blades on
a Rassman handle preangled at 30° to allow both blades to lie
flush against the scalp.
Figure 29.8  Dissection at the tapered corner of the strip in a
mid-subcutaneous plane, just below the follicles.

497
Chapter 29  Follicular Unit Hair Transplantation
Graft dissection
Once the donor strip is removed, it is immediately placed
into lactated Ringer’s, or similar holding solution, and passed
to the surgical team leader stationed at a stereomicroscope
(Fig. 29.12). The strip dimensions are measured and recorded.
The next step is performed under strict stereomicroscopic
control in a process called ‘slivering.’27,40
In one method of slivering, the donor strip is placed on its
side, on a wooden tongue-depressor blade, soaked in Ringer’s,
with the hair pointing away from the dissector and the convex
surface of the strip facing upward. For a right-handed person
performing dissection, the left end of the strip is held with
rat-toothed forceps in the dissector’s left hand. An assistant
applies tension to the strip, holding it a few centimeters away
from the area being cut with rat-toothed forceps held in the
right hand. Using a Personna #10 blade on a #3 blade handle
held in the right hand, the dissector begins to cut the strip
into 2–2.5-mm wide sections, by guiding the blade between
follicular units using a one-directional fillet-like movement
from the epidermal side to the subcutaneous surface. A back-
and-forth sawing motion should be avoided as it will increase
the risk of transection (Figs 29.13 and 29.14). The pieces
generated are then passed along to the other members of the
surgical team who complete the dissection. In the last step,
the individual pieces are placed on their sides, stabilized with
straight jeweler’s forceps, and then dissected under the ster-
significant postoperative edema. If placed too close to the
wound edge, they can become buried and difficult to remove.
These two problems are avoided with the use of staples and
speak in part as to why staples are used by many hair trans-
plant surgeons in spite of the preference that patients have
for the more comfortable sutured closure.
Absorbable sutures should be placed close to the wound
edge (Fig. 29.10). This will tend to minimize the amount of
suture material used, decrease the entrapment of follicles and
avoid strangulation if there is significant postoperative edema.
To further limit damage to follicles, the sutures should be
placed approximately 4.5 mm apart and the suture should be
advanced on the surface, rather than under the skin, as this
will minimize the amount of suture in contact with the fol-
licles (Fig. 29.11). With this technique, the needle should be
passed through the full thickness of the dermis and exit the
wound edge, just below the level of the bulbs, without incor-
porating any significant amount of subcutaneous tissue. The
needle track must be kept parallel to, and within, 1.5 mm of
the wound edge. Particular attention should be paid to placing
the needle parallel to the upper wound edge where the angle
is very acute. Basic guidelines for using poliglecaprone 25
sutures can be found in Box 29.5.
Figure 29.9  Stapling technique illustrating very controlled
apposition of wound edges, using skin hooks for the lower
edge, and forceps to evert the upper.64
Figure 29.10  Suturing the donor area using absorbable
sutures. Note the needle track is parallel and very close to the
wound edges.64
4.5 mm
1.5 mm
Suturing technique for donor scalp
Figure 29.11  Schematic of the suturing technique
recommended for closing the donor scalp. The spacing
between loops is 4.5 mm.64
Box 29.5  Guidelines for use of poliglecaprone
25 sutures
 Plan width of donor strip so that there is little or no tension
on closure.
 Use tumescent anesthesia to harvest donor strip in mid-fat.
 Use sutures no heavier than 5-0.
 Use a simple running stitch, advance each loop on the skin
surface.
 Keep needle parallel to and within 1.5 mm of wound edge.
 Incorporate epidermis and dermis only.
 Use 4.5-mm spacing between loops.

498
Part 3  Aesthetic Surgical Procedures
number of grafts (several hundred) have been dissected, they
are put into secure plastic specimen containers and refriger-
ated.
An alternate slivering method involves dissecting the donor
strip into slivers as wide as one follicular unit, approximately
1 mm. The units are then isolated from the very thin strip.
The key to either method is that every step is performed
under stereomicroscopic control, which keeps the units intact
and avoids follicular transection. It is also vital that all the
eomicroscope with a scalpel into individual follicular units of
one to four hairs (Figs 29.15 and 29.16).
Next, the units are sorted according to the number of hairs
they contain into separate Petri dishes held on ice blocks and
filled with Ringer’s lactate (Fig. 29.17). When a substantial
Figure 29.12  Close-up view of a donor strip showing the
natural hair groupings at the surface, the slightly curved path of
the hair through the dermis, and the random distribution of
bulbs in the fat. It is this unique anatomy that makes
stereomicroscopic dissection essential in preventing follicular
transection.
Figure 29.13  ‘Slivering’ the donor strip into sections.
Figure 29.14  Stereomicroscopic dissection of one section into
smaller pieces.
Figure 29.15  The final step of the dissection: generating
individual follicular units.
Figure 29.16  Dissected one-hair, two-hair, three-hair, and
four-hair follicular units.
Figure 29.17  Petri dishes with one-hair to four-hair follicular
units immersed in Ringer’s lactate.

499
Chapter 29  Follicular Unit Hair Transplantation
that FUE techniques and instrumentation continue to improve
and some progress has been made towards automating the
extraction procedure using robotics.69
Recipient sites
The way recipient sites are prepared determines the most
critical aesthetic aspects of the transplant: the angle at which
the new hair grows, its distribution, its density, and how
natural the hair will look as it emerges from the scalp. A
thorough discussion of site creation is beyond the scope of
this chapter, but the four basic elements will be reviewed
briefly. These are recipient site size, hair direction, site
density, and graft distribution, and they are covered in greater
detail in ‘The Aesthetics of Follicular Transplantation’ by
Bernstein & Rassman.7
pieces of the strip remain in chilled Ringer’s lactate except
when they are being cut. While under the microscope they
should be kept well hydrated using 10-mL syringes containing
Ringer’s lactate that is kept at each cutting station.
Follicular unit extraction
Follicular unit extraction (FUE)10 is a conceptually simple
procedure, where individual follicular units are harvested
through small circular incisions created by a trephine or
similar instrument. The punch cuts into the reticular dermis
and the remainder of the follicular unit is literally extracted
from the scalp. The advantage of this procedure is that it
obviates the need for a linear incision. Difficulties lie in the
intrinsic variability of each patient with respect to the ease
of extraction, the increased risk of follicular transection com-
pared to other techniques, the inability to harvest all the hair
from the mid-portion of the donor area, and the organiza-
tional limitations of not being able to have multiple persons
(more than two) working in parallel, as can be done with the
microscopic dissection of a harvested strip.
FUE is appropriate for patients who have limited hair loss
and who want to wear their hair so short that a linear donor
scar might become visible. The procedure is also useful in
patients who have healed poorly, or who have very tight scalps.
An important application of this technique is to camouflage
a linear donor scar from prior hair transplant procedures.10
FUE’s main limitation is that it is less efficient in harvesting
hair than FUT performed with strip harvesting. In FUT, all
the hair from the optimal (central) part of the donor region
can be removed and transplanted, and the resulting defect is
sewn closed. In contrast, the FUE defects remain open to
heal by second intention with significant amounts of interven-
ing hair left behind and, therefore, a much larger region of
the scalp must be accessed to harvest the necessary amount
of donor hair. The greater area required greatly increases the
risk of harvesting hair from non-permanent areas of the scalp.
Figure 29.18 shows the donor area immediately after the
extraction of 600 follicular units and the same area at 6 and
13 days postoperatively.
With FUE, the second intention healing causes microscopic
fibrotic changes in the donor area, distorting adjacent follicu-
lar units and making subsequent sessions more difficult. As
mentioned, transection during the harvest is greater than
stereomicroscopically-controlled FUT. Taken together, these
factors limit the total amount of hair that can be accessed
through FUE, rendering it a less robust procedure than FUT.
In a procedure where a finite donor supply is the main con-
straint, the inefficient use of donor tissue poses a significant
problem. Table 29.5 summarizes the pros and cons of FUE.
The ability to perform FUE with minimal transection varies
significantly among patients. Because of this, a test measuring
the ease of extraction (the FOX Test)10 should be performed
prior to recommending the procedure. Patients undergoing
FUT should also be tested for FUE at the time of surgery, in
case the latter procedure is considered at a future date.
A significant advance in the technique of FUE is to first
score the top of the follicular unit with a sharp punch and
then use a blunt instrument to separate the follicular unit
from the surrounding tissue, thereby minimizing follicular
transection. The main limitations of this technique are the
increased incidence of buried grafts and increased surgical
time in an already very laborious process.67,68 It is encouraging
A
B
C
Figure 29.18  Donor area in follicular unit extraction.
(A) Immediately after harvesting 600 grafts. (B) Six days
postoperatively. (C) Thirteen days postoperatively.

500
Part 3  Aesthetic Surgical Procedures
of a sagittal orientation are: greater visibility of sites; ease of
graft placement; less trauma to existing hair; and less lateral
(radial) splay of hair. Because coronal incisions provide better
coverage and a slightly more natural look, they are currently
used by the majority of hair transplant surgeons.
Hair direction
Hair should be placed into the scalp at the angle it originally
grew, not in the direction that it is to be groomed. However,
there are some exceptions. Whorls at the frontal hairline
should not be mimicked with a hair transplant, nor should
hair at the hairline be planted in a radial direction, even if
some of the original hair grew that way. In general, hair ante-
rior to the vertex transition point should point forward, with
the angle becoming more acute as it reaches the anterior
hairline – where it is essentially horizontal to the ground –
regardless of the slope of the forehead. By planting the hair
in the frontal hairline in a forward direction (rather than
radially), the transplanted hair will act more as a unit and
hold together when it is groomed (Fig. 29.19).7 At the
temples, the forward-pointing hair makes an abrupt transition
to a downward direction. Hair at the temples should be
transplanted at a very acute angle, that is lying as close to the
surface of the skin as possible.
Recipient site density
The average non-balding scalp has 90–100 follicular units per
cm2. Approximately 50% may be lost before there is any
noticeable thinning. It would be wasteful for more than 50%
to be replaced, especially since hair transplants are always
performed in the face of diminished total hair volume. We
generally recommend transplanting up to 25–30 follicular
units per cm2 into the frontal area of a balding scalp in the
first session. If the larger three-hair and four-hair units are
placed in select areas, more than 25% of the initial density
can be achieved in one pass. The ideal transplant density can
be achieved in many patients with two procedures.7
Some physicians advocate a ‘one-pass’ procedure to achieve
the final density.40 Although this may be appropriate for some
patients, the increased incidence of graft popping and desic-
Recipient site sizes and orientation
The sites should provide a snug fit for the graft: just large
enough to accommodate a follicular unit, but not so small
that insertion is difficult or traumatic.1 Numerous instru-
ments have been developed to create recipient sites. The
main aspect to consider in choosing one is its diameter.70
Although there are many viable options, the following are
used by many practitioners:
• 21-gauge hypodermic needle for one-hair follicular unit
grafts.
• 20-gauge for thin two-hair follicular unit grafts.
• 19-gauge needle for thick two-hair and all three- and
four-hair follicular unit grafts.
• 18-gauge for three-hair grafts in African races with very
kinky hair.
These needles can be fitted on 1- or 3-mL syringes for ease
of use, obviating expensive handles. Some physicians advo-
cate smaller recipient sites, but this may require dividing
four-hair follicular units – a technique that this author does
not recommend.40 For very fine hair, or in special situations
like transplanting eyebrows, a 22-gauge (or finer) needle can
be used.
As an alternate to using hypodermic needles, some physi-
cians use a blade breaker that enables a straight blade to be
custom cut into chisel-shaped cutting instruments of various
sizes. It is this author’s opinion that hypodermic needles,
which spread apart the skin as the wound is created, tend to
cause less tissue injury than chisel-shaped blades, which cut
through the skin.
Most instruments used to make sites create tiny slits as
they cut through the skin and these slits can have either a
coronal (horizontal) or sagittal (vertical) orientation. The
advantages of coronal incisions are: a more natural appear-
ance, since the original orientation of most follicular units
seems to be coronal; a fuller look; and less tendency of the
growing hair to elevate in the vertical plane. The advantages
Table 29.5  Pros and cons of follicular unit extraction
PROS
CONS
No linear scar
Useful when the patient wants
(or needs) to wear the hair
styled back from the face and
with the sides very short
Provides an alternative when
the scalp is too tight for a
primary closure or when the
patient heals with widened
scars
Ideal for camouflaging donor
scars that cannot be excised
Makes it possible to harvest
non-scalp hair (e.g. beard or
body hair)
Requires multiple sessions to
equal the size of a single
follicular unit transplantation
procedure
Takes longer to perform and is
more expensive than follicular
unit transplantation
Risks the eventual loss of
transplanted grafts by harvesting
from outside the ‘sweet spot’ of
permanent hair in the donor zone
After large numbers are
harvested, fine stipple scars may
become visible due to thinning of
the donor area
Scarring and distortion of follicles
may make further harvesting by
follicular unit extraction difficult
Maximum possible yield lower
than with follicular unit
transplantation
A
B
Normal direction of hair growth
Figure 29.19  Normal hair direction. (A) Top view and (B) side
view.7

501
Chapter 29  Follicular Unit Hair Transplantation
cation, insertion injury, and possible vascular compromise
may lead to poor growth. For very bald patients, very dense
packing does not allow coverage of an entire bald area.
Transplants of more than 3000 follicular unit grafts may
necessitate that the grafts be out of the body so long that
their survival may be diminished. In addition, the large donor
strip required to harvest graft numbers of this magnitude
increases the incidence of a widened donor scar. Further-
more, for procedures of 3000 or more to be practical, the
recipient area should be shaved, a condition unacceptable to
many patients. It is this author’s view that covering the entire
bald area and then increasing density in a subsequent session
is a better goal for the majority of patients.
Graft distribution
For simplicity, the area of the scalp subject to androgenetic
change can be divided into three regions: the frontal region
that includes the frontal hairline; the top or mid-scalp; and
the vertex or crown. The vertex transition point separates the
top of the scalp from the crown (Fig. 29.20).38 As most social
interaction takes place face to face, and people generally view
themselves from the front, the overall impact of the trans-
plant is essentially defined by the position of the frontal
hairline and density of the frontal region of the scalp.
For most patients who are moderately or extensively bald,
or for those who are destined to be, the limitations of the
donor supply make restoring the entire bald scalp to ideal
density impossible. Consequently, creating the greatest
density in the frontal forelock area of the scalp produces the
best cosmetic result. This ‘forward weighting’ can be accom-
plished by putting recipient sites closer together, placing
larger follicular units (i.e. those with three and four hairs) in
those sites, or by a combination of both.
In general, recipient site density should be the highest in
the front part of the scalp and gradually tapered toward the
crown. In contrast, the largest follicular units should be
Vertex
(crown)
Mid-scalp
(top)
Front
Frontal hairline
Vertex transition
point
Regions of the scalp
Figure 29.20  Regions of the scalp.
placed in the forelock region of the scalp. This overlapping
distribution of sites and follicular unit grafts may be visualized
in Figure 29.21. It is explained in greater detail in ‘The Aes-
thetics of Follicular Transplantation’ by Bernstein & Rassman.7
The pattern serves two functions: 1) it creates a natural
central-forelock density without the need for spacing sites
closer towards the mid-scalp, where the blood supply can
most easily be compromised; and 2) it insures the most
natural look by placing the larger follicular units in a forward-
central position, but away from the frontal hairline. Density
in the forelock area brings about a ‘patterned look’ and avoids
the diffuse thinning that often results when small grafts are
evenly distributed over the scalp.
Practically every patient has enough donor hair to provide
at least light coverage extending to the vertex transition
point. This is a natural stopping point because even if the
crown continues to enlarge, transplants performed to this
point will continue to look natural without additional surgery.
Transplants should be extended past the vertex transition
point into the crown only when there is adequate hair to
create a swirl and follow the hair loss if the balding progresses.
The indications for transplanting the crown are discussed in
detail in ‘Follicular transplantation: patient evaluation and
surgical planning’ by Bernstein & Rassman.6
The distribution of grafts in the first transplant session
should, in general, be symmetric. However, once the first
transplant has had a chance to grow and the patient is willing
to commit to styling his/her hair in a specific pattern, ‘side
weighting’ may be considered. This is accomplished either by
placing a greater proportion of the grafts on the parted side
of the scalp, using larger follicular units on that side, or doing
both. It results in increased fullness when one’s hair is combed
to the side. In situations where there is a great imbalance in
the supply:demand ratio, such as after scalp reductions or old
plug procedures, a more exaggerated form of ‘side weighting’
should be considered. In this case, the follicular unit grafts
Forward weighting
Figure 29.21  Schematic of ‘forward weighting,’ achieved by
close placement of recipient sites (shaded dark grey), and
central density, accomplished by placing larger follicular units in
the forelock area (dark brown oval).

502
Part 3  Aesthetic Surgical Procedures
the recipient hole can serve as a ‘shoehorn’ to help guide the
graft into the site. The advantage of this method is that it
eliminates the possibility that sites may be left unfilled or that
two grafts may be placed into one site (piggy-backing). It also
moves the surgery along faster, since other members of staff
do not need to wait for the surgeon to make the sites and
they do not need to search for the sites that are empty.
On the other hand, there is more bleeding when sites are
made concomitantly with graft placement (decreasing visibil-
ity) and there is an increased risk of the grafts popping and
then drying out on the surface of the scalp. In addition, the
staff must make judgments regarding the angling and distribu-
tion of the sites they are creating at a time when they must
also be focusing on the technical aspects of graft insertion.
This leaves many of the aesthetic decisions in the hands of
the technicians, who are actively engaged in stick and place,
rather than with the physician, who could take a more stra-
tegic view of the procedure.
Patient disposition
After graft insertion is complete, the scalp is cleaned with
distilled water, bacitracin zinc ointment is applied to the
sutures, and a headband-type pressure dressing is placed over
the donor area. The transplanted area is covered with a sur-
geon’s cap. Prior to leaving, patients are given verbal and
printed postoperative instructions, a neck pillow, and medica-
tions for sleep and pain (Table 29.6). Patients leave the office
wearing a bandana covering the cap and the headband. It is
worth stressing that patients given sedatives or pain medica-
tion should not drive after surgery.
 OPTIMIZING OUTCOMES
Transition zones
A soft natural hairline is the hallmark of the ideal hair
transplant. However, careful observation of a normal frontal
hairline reveals that there is no actual ‘line,’ but rather an
irregular, slightly asymmetric ‘transition zone’ or gradation of
follicular units of increasing size and density. This is what
should be replicated in the transplant (Fig. 29.24). Transition
zones are not limited to the frontal hairline; they must be
recreated wherever the edge of the transplanted area is
are concentrated on the front and parted side of the scalp,
but widely scattered on the top and back (Fig. 29.22).7
When the follicular units are completely dissected and
grouped in Petri dishes, they are placed at the head of the
operating table on ice blocks. Graft placement, carried out in
a front-to-back pattern, begins at the frontal hairline starting
with one-hair follicular units. In a typical transplant, approx-
imately 250 one-hair units are used for the leading edge of
the frontal hairline, immediately followed by two-hair grafts.
Three-hair to four-hair units are concentrated in the forelock
area, while toward the back and sides the pattern is reversed
so that the three-hair and four-hair units are always central
to the one-hair and two-hair units.
Approximately 20–30 grafts are transferred at one time
from the dish to the index finger, held on the finger in a
droplet of Ringer’s solution. The grafts are inserted using
curved jeweler’s forceps (Fig. 29.23). A small Band-Aid should
be worn on the finger under the area the grafts will sit to
decrease the incidence of a stick injury from the forceps. Each
graft should be carefully grasped by the fat at its bottom or
at its edge, not at the germinative center. In the two-handed
technique, gauze – held between the free fingers of the hand
holding the grafts – is used to keep the partially inserted grafts
in place as the forceps are repositioned higher along the length
of the graft, to facilitate the last phase of insertion. This is a
particular useful technique when there is popping (the ten-
dency of grafts to lift up as they are being placed.)
Most physicians make the majority of recipient sites prior
to graft placement. This allows the doctor to concentrate on
the angle and distribution of sites without having to worry
about actual graft placement. It also allows the team to
easily clean the recipient area without having to be concerned
about dislodging grafts. In addition, it gives time for some
coagulation to occur and for the sites to become more ‘sticky’
as this holds the grafts in place and reduces the incidence of
popping.
In an alternative method, termed ‘stick and place,’ the
grafts are inserted at the same time that the recipient sites
are made.40 In this technique, the needle that is used to make
Side weighting
Figure 29.22  Left shows schematic view of left-to-right ‘side
weighting.’ Right shows extreme side weighting employed when
the donor supply is severely diminished.
Figure 29.23  Staff using loop magnification and curved
jeweler’s forceps to place follicular unit grafts into premade
recipient sites.

503
Chapter 29  Follicular Unit Hair Transplantation
visible. In Figure 29.24C, one notes that transition zones have
been created at the frontal hairline, sides, and vertex transi-
tion point leading to the crown.
Although there are an infinite number of ways to create a
transition zone at the frontal hairline, the placement of
Table 29.6  Common medications in hair transplant
CLASS
MEDICATION
USE
Topical
antibacterials
Hibiclens
Preoperative
Systemic antibiotics
Dicloxacillin,
cephalosporin
Intraoperative
prophylaxis*
Sedatives/
hypnotics
Diazepam,
aprazolam71
Intraoperative sedation
Corticosteroids
Betamethasone
Postoperative swelling
Topical antibiotics
Bacitracin
ointment
Postoperative care,
donor area
Opiates
Hydrocodone
postoperative pain, prn
Antihiccup agents
Chlorpromazine
Hiccups, prn
Analgesics
Nitrous oxide62
During injections prn†
Wound healing
promoters
Copper-peptide
Postoperative healing†
Hair-growth
promotors
Finasteride,
minoxidil
Pre- and
postoperative*
* See text.
†Not used in our practice.
approximately 75–100 single follicular units in front of a band
of staggered single units, one to three rows deep, will usually
achieve the appropriate softness. This should be followed by
two-, three-, and eventually four-hair units, but the larger
units should be more centrally located (Fig. 29.24B). With
finer hair, larger units may be placed closer to the hairline. It
is important to limit the depth of the single hair units, or the
zone will appear too thin.
Visibility
Premaking all the recipient sites before graft insertion helps
to control bleeding and limits the need for epinephrine (Fig.
29.24C). It initiates the ‘extrinsic pathway’ so that coagula-
tion can begin before the grafts are introduced and allows for
easy cleaning of the recipient area of any blood or coagulum,
without the risk of dislodging grafts. It also makes it possible
to place sites close together without a concern for grafts
in adjacent sites popping. Most importantly, it provides
maximum visibility in the placing phase of the procedure.51
If the initial sites are scattered, they tend to cause the
cutaneous vasculature of the scalp to ‘clamp down,’ increasing
visibility for subsequent passes and allowing the skipped areas
to be filled in. When premaking sites, the logistics of match-
ing the number of sites to the number of grafts can be solved
by making ‘projections’ of the anticipated number of grafts
while the dissection phase is still in progress.
Recipient site influences
Some hair characteristics, such as waviness, are governed by
the recipient site. When individual follicular units are placed
A
B
C
D
Figure 29.24  (A) Before and (D) 1 year after two sessions totaling 4295 follicular unit grafts. (B) Preoperative markings of the
planned procedure. (C) First session just before placement, showing the distribution of 2355 recipient sites.

504
Part 3  Aesthetic Surgical Procedures
Hairline placement
If it is to look natural throughout the patient’s life, the trans-
planted hairline must simulate that of a mature adult. In the
adolescent male, the frontal hairline touches the top crease
of the brow when the eyebrows are raised (that is, the hair
begins at the upper border of the frontalis muscle). In a
mature adult, the mid-portion of the frontal hairline rests
approximately one fingerbreadth (1.5–2 cm) above the brow
crease. Although the degree of temple recession can vary
dramatically in the normal adult hairline, the mid-part of the
frontal hairline is crucial in framing the face.1,7 Significant
bitemporal recession was built into the restoration of the
patient in Figure 29.27, yet the forward-placed mid-portion
sets his facial features in the correct proportions.
Forelock integration
A persistent frontal forelock poses an interesting dilemma.
When hair is transplanted around the forelock, the patient
into very small wounds, there is little fibrotic reaction to the
grafts and the recipient area can exert its influences on hair
growth. In Figure 29.25, note the delicate wave produced by
the recipient scalp. It sometimes takes a year or more for the
hair character to return to normal.
Hair direction
When the hair is planted at the frontal hairline in its natural
forward-pointing direction, combing it back causes it to bow,
giving it the appearance of fullness. A common mistake is to
point the hair in the direction that the patient plans to comb
their hair; this makes the hair lie flat and bodiless when
groomed. On the other hand, as the frontal hairline approaches
the temples, the hair direction should be abruptly changed,
so that it is angled downward and lying very flat on the scalp.
Perfect integration of the frontal hairline with hair on the
sides and temples is essential if the transplant is to look
completely natural (Fig. 29.26).
A
B
Figure 29.25  Norwood class VI, with
very fine, blonde hair, and a donor
density of 2.5 hairs per mm2. (A) Before
and (B) 1 year after two sessions of 2678
and 1836 follicular unit grafts.
A
B
Figure 29.26  Early Norwood class VI. (A)
Before and (B) 1 year after one session
of 2520 follicular unit grafts.

505
Chapter 29  Follicular Unit Hair Transplantation
density significantly greater than if the grafts were evenly dis-
tributed. This is possible because the compactness of the fol-
licular unit allows four-hair grafts to be placed into very small
sites.5,7 In certain instances, follicular units may contain more
than four hairs, and adjacent follicular units are occasionally so
close together that they can fit into a small recipient site.72,73
However, as long as these ‘grouped grafts’ are placed in a
central location and the recipient wounds are kept small, this
technique can add density without risking an unnatural look.
It is important to keep in mind that ultimate density depends
on the absolute number of hairs moved rather than the size of
the grafts.74 Using grafts larger than follicular units always risks
that the transplant may look unnatural. The patient in Figure
29.29 achieved a very dramatic frontal density in two sessions
using the technique of follicular unit sorting.
may be left with a gap in his frontal hairline if the forelock
eventually disappears. On the other hand, it is wasteful to
add hair to a forelock with adequate density that may persist
for years. The solution is to check for miniaturization with
a densitometer. The patient in Figure 29.28 had miniaturiza-
tion in his forelock greater than 50%, suggesting that it would
not be stable over time. Two sessions were used to integrate
transplanted hair into the resident terminal hair of the fore-
lock, producing a central density that will be permanent.
Optimizing density
One of the advantages of FUT over micrografting techniques
is follicular unit sorting, the ability to sort the three-hair and
four-hair units and place them in the forelock area, creating a
A
B
Figure 29.27  Early Norwood class V.
(A) Before and (B) 1 year following two
sessions of 2105 and 1665 follicular unit
grafts.
A
B
Figure 29.28  Norwood class V.
(A) Before procedure. (B) Integrating
hair with a persistent frontal forelock
(1 year following two sessions of 2133
and 1171 follicular unit grafts).

506
Part 3  Aesthetic Surgical Procedures
A
B
Figure 29.29  A 46-year-old early Norwood class IVA with wavy medium-coarse hair. (A) Before transplant. (B) After two sessions of
2085 and 1438 follicular unit grafts.
A
B
Figure 29.30  (A) Before transplant, showing large grafts forming a literal wall of plugs. (B) Camouflage from one session of 1818
follicular grafts.
Creating camouflage
A sizable part of many practices involves repairing transplants
performed with older techniques. FUT is ideal for this because
of the small size of follicular units and high hair count.75,76
Often fixing a ‘pluggy’ look requires graft excision with reim-
plantation, before the actual transplant. Although the patient
in Figure 29.30 had a row of plugs set far enough back from
his frontal hairline that camouflage with follicular units alone
was sufficient for the repair, in general it is better in the long
run to excise and redistribute questionable grafts as individual
follicular units than to attempt to camouflage them.
Eyebrow transplantation
Eyebrows are perhaps more important to one’s appearance
than scalp hair, as eyebrows are in a more central position on
the face and serve to frame the eyes. Unlike the loss of scalp
hair, the loss of one’s eyebrows is not viewed as a natural
process and is, therefore, not cosmetically acceptable. Because
eyebrows have their own unique attributes, eyebrow trans-
plants require techniques different from hair transplants on
the scalp: 1) eyebrow hairs grow as individual strands, there-
fore multi-hair follicular units should be divided into 1-hair
micrografts before planting; 2) eyebrow hair must be planted
at a very acute angle so that the hair grows flat to the skin’s
surface; 3) subtle angle changes are required to recreate the
fan-like splay of hair at the medial aspect of the brow; 4) the
hair must be planted in a criss-cross growth pattern that
causes the hairs in the middle of the eyebrows to converge
and form a subtle natural elevation; and 5) since the hair cycle
of scalp hair (3–7 years) is longer that eyebrow hair (4
months), the eyebrow hair (after a transplant from the scalp)
must be periodically trimmed.77
Eyelash transplants
The donor hair used in an eyelash restoration must match, as
closely as possible, the original eyelash. Hair suited for this
purpose includes the fine short hairs at the nape of the neck,
hair from behind the ears or the eyebrows. The incision made
into the lid margin should be made with a curved instrument
and the hair should be rotated to follow the curvature of the
original lashes.78 In a very elegant procedure, scalp hairs are
threaded onto a crescent needle and then introduced into the
eyelid through an incision made on the inside of the lid
margin. The hairs are then cut to the appropriate length.79
Long hair transplants
Transplanting long hairs, instead of the traditional 1–2-mm
clipped hairs, allows the patient to temporarily see the actual

507
Chapter 29  Follicular Unit Hair Transplantation
At 10–12 months postoperatively, all patients return to the
office so that we can assess growth, take photos, and discuss
the possibility of additional surgery. Those with questions or
concerns are seen as frequently as needed. Box 29.6 sum-
marizes typical postoperative instructions.
 PITFALLS AND THEIR MANAGEMENT
A number of problems arising in hair transplant surgery have
been well described in the literature. These are summarized
in Table 29.7, along with their most likely cause, although
some etiologies may be multifactorial. The table also sum-
marizes and methods for preventing and managing them
should they occur.11,96,97
Although FUT eliminates many of the shortcomings of
the older techniques, such as a ‘pluggy’ look, a ‘moth-eaten’
donor area, or midline scalp reduction scars, poor aesthetic
judgment and techniques that compromise graft growth can
still lead to problems. Perhaps because FUT requires large
numbers of grafts (using a significant portion of the donor
area at one time), because so many staff members are involved
in the process, and because some of the problems of small-
graft procedures are very difficult to correct, improperly per-
formed FUT can sometimes pose a greater risk to patients
than traditional grafting. The problem is compounded by the
fact that many physicians perceive FUT as a safe, risk-free
procedure and describe it to patients as such.
The remainder of this section will focus on some of the
most common mistakes made by FUT practitioners, particu-
larly in the areas of planning, transplant design, and handling
large numbers of small grafts. These problems and how they
may be avoided are summarized in Box 29.7.
Operating on patients that are too young or
before medical therapy
Patents in their early 20s have their flat adolescent hairline
and original density fresh in their memory. A transplant
designed with enough frontal and temporal recession to look
good for one’s entire life will rarely satisfy a younger patient.
Creating a density that suits a younger person will not leave
enough hair in reserve when their hair loss progresses. In
addition, at this age, the extent of future balding is very dif-
ficult to anticipate. For these reasons, surgery should rarely
be considered in patients with androgenetic alopecia who are
younger than 25 years of age.
Often doctors begin medical therapy and schedule surgery
at the same time. However, if there is a possibility that using
medication, such as finasteride and minoxidil, can make
transplantation unnecessary, then the medication should be
used for at least a year before any decision on surgery is
reached. Medication should be the first line of therapy for all
younger patients with androgenetic alopecia, regardless of the
degree of their hair loss.
Failing to identify low donor density
before surgery
Earlier in this chapter the importance of assessing patient’s
donor supply with densitometry was stressed. A low donor
density, generally less than 1.5 hairs per mm2, usually indi-
cates that donor supply is insufficient to create adequate
density or coverage and is a relative contraindication to
surgery. An exception might be an older person with very
results immediately upon completing the procedure. In this
technique, the donor hair is left long (up to 25 cm) through-
out the harvesting, dissecting, and placing steps. As with
traditional hair transplants, the hair is shed about 4 weeks
after surgery. Although the procedure gives the patient an
early view of the results and eliminates the problems of piggy-
backing and buried grafts, it is technically more laborious and
requires more meticulous postoperative care.80,81
Trichophytic donor closure
A trichophytic closure is a way of improving the appearance
of the linear donor scar from strip harvesting. A trichophytic
closure involves trimming the upper or lower edge of the
incision and then closing the wound in such a way that the
hair near the edge can grow toward or through the scar. This
has the potential to produce a donor scar that is virtually
undetectable.82
Automation
Short of cloning follicular units in a Petri dish, the future in
FUT optimization lies in the development of robotic devices
that can harvest the donor strip, isolate individual follicular
units, create recipient sites, and insert grafts – all without the
risk of human variability or error. A number of creative instru-
ments have been designed toward this end, but thus far their
success has been limited.83–86 Much of the difficulty lies in the
inherent variability of the human scalp and the follicular unit
itself. The full automation of a procedure that is labor inten-
sive, organizationally complex, and dependent on the aes-
thetic judgment of the surgeon remains a formidable challenge.
Hair cloning
The ability to clone human follicles will revolutionize surgical
hair restoration as this will provide an unlimited supply of
donor hair. Cloning will potentially allow older patients to
enjoy a full head of hair and younger patients to have their
adolescent density and hairline restored. One of the most
promising areas of research is follicular cell implantation
(FCI). FCI is based on the ability of the dermal papilla cells
(fibroblasts), found at the bottom of hair follicles, to interact
with the keratinocytes and stimulate new hairs to form.
Dermal papilla cells can be grown and multiplied in culture,
so that a very small number can theoretically produce enough
follicles to cover an entire bald scalp.87
There are a number of obstacles that still need to be over-
come before cloning can be a viable option for patients. First,
fibroblasts seem to lose their inductive properties when they
are cultured over multiple generations; secondly, the produc-
tion of cosmetically useful hair – which depends on the
interaction between the various cell types – is not yet pos-
sible; and thirdly, the research is in its preclinical phases, with
US Food and Drug Administration (FDA) approval still many
years away.
 POSTOPERATIVE CARE
Patients are called at home the day after the procedure.
Those with a stapled closure are seen in our office 10 days
postoperatively to have alternating staples removed. They
return again 7–10 days later to have the remainder of the
staples removed. Patients in whom we have used sutures
return for only one visit 7–10 days postoperatively.

508
Part 3  Aesthetic Surgical Procedures
conservative goals. High miniaturization in the donor area,
particularly in a person under the age of 30, suggests DUPA
and is, in this author’s opinion, a contraindication to surgery.6
Transplanting young patients with low donor density will
not only insure a poor cosmetic result but also will risk a
visible scar if the hair is worn short. FUE, which is sometimes
considered in such cases, is not appropriate because it further
limits the total available hair. In fact, because the contrast
between bald and non-balding scalp in patients with low
donor density is naturally low, their best option tends to be
wearing their hair short, to decrease the contrast further
(rather than having surgery).
Failing to identify a tight scalp
Assessing scalp laxity is an underappreciated aspect of the
patient evaluation, probably because it is difficult to quantify.
However, a tight scalp severely limits the total amount of
harvestable donor hair and can constitute a contraindication
to surgery, except when patients have extremely conservative
goals or are expected to experience only limited balding. The
constraints that poor scalp laxity impose generally manifest
themselves after the first transplant session. Though laxity
should be judged in the preoperative evaluation, the intraop-
Box 29.6  Summary of instructions following follicular unit transplantation
Care of transplanted area
Shampoo every 3–4 hours the day following surgery and then
twice daily until the 1-week postoperative visit. Be especially
careful when cleaning the transplanted site in the first few days so
that the grafts will not be dislodged. However, a thorough but
gentle rinsing of the recipient area will minimize crusting and
make the transplant less noticeable. When shampooing and
rinsing the transplanted area, be gentle for the first 2 weeks
following surgery. Do not rub, pick, or scratch, as this may
dislodge grafts.
Care of sutured area and non-transplanted parts
of scalp
Gently wash the sutured area with your fingertips using a
copper-peptide-containing shampoo. Shower water may hit the
sutured area in the back of the scalp directly. A hair dryer may be
used when set on warm, but not hot. Do not use any scalp- or
hair-coloring agents for at least 2 weeks after the surgery.
Postoperative medications
After surgery, sleeping medication and medication for pain may
be given.
Itching
There may be some itching either in the transplanted area or
sutured area following surgery. Hydrocortisone ointment may be
applied locally to the areas that itch as needed, up to four times a
day.
Swelling
An injection of cortisone may be given during the procedure to
decrease swelling after surgery. If there is significant swelling, it
usually occurs around the second to fifth postoperative day and
should not be cause for concern. It resolves by itself after a few
days and does not require any special treatment. Cool, wet
dressings may be placed over the swollen area, but make sure
they do not touch the grafts.
Bleeding
Before leaving the office, all bleeding will be controlled. Rarely
some bleeding may occur after the procedure. If this happens,
apply firm continuous pressure on the area. If it is impossible to
contact the office, go to the nearest emergency room and show
these instructions to the physician on duty.
Exercise, alcohol, smoking, and other restrictions
Avoid direct trauma to the head for 2 weeks after the procedure,
and abstain from sexual intercourse, alcohol use, and smoking for
3 days after the procedure. After 2 weeks, normal daily activities
may be resumed. However, be careful not to stretch the donor
area until instructed by the physician.
Sun
Avoid unprotected exposure to sunlight for 3 months. Wear a hat
when going outside or use a strong sunscreen with a sun
protection factor of 30+.
Infection
Redness, swelling, and slight tenderness are to be expected for
the first few days after a procedure. Persistent swelling, pain, or
tenderness in the sutured area may be a sign of infection. Fever
and/or chills are indications of infection as well. There also may
be a discharge or pus in the suture line. If any of these conditions
should occur, please contact the office.
Numbness
Scalp numbness, tingling, or similar sensations may occur
temporarily. This generally disappears within a few weeks to
months, as nerve endings regrow.
Hair-loss medications
Minoxidil 5%: If the plan is to continue this medication, resume it
1–2 weeks after the procedure.
Finasteride 1 mg: This medication should not be discontinued
for the surgery.
Box 29.7  Twelve common pitfalls in follicular
unit transplantation
1. Operating on patients that are too young or prior to trying
medical therapy.
2. Failing to identify low donor density prior to surgery.
3. Failing to identify a tight scalp.
4. Harvesting a donor strip that is too wide.
5. Placing the donor incision too low or too high.
6. Using a multibladed knife.
7. Crushing grafts during insertion.
8. Allowing grafts to dry.
9. Placing the frontal hairline too far forward.
10. Creating a hairline that is too broad.
11. Angling hair in the wrong direction.
12. Attempting to cover an area that is too large.
erative assessment, made while suturing, is most accurate in
predicting future difficulties. Therefore, every operative
report should include a record of the ease of closure and
intraoperative suture tension.6
A tight scalp can be loosened by placing the palm of the
hands on the back/sides of the head with the fingers pointing

509
Chapter 29  Follicular Unit Hair Transplantation
Table 29.7  Pitfalls of follicular unit hair transplantation and their management
PROBLEM
CAUSE
PREVENTION
TREATMENT
Syncope
Anxiety, vasovagal reaction
Premedicate with diazepam
or atropine, administer local
anesthesia with patient lying flat
Lie patient supine and elevate
legs
Anxiety, palpitations
β1- and α-adrenergic effects of
epinephrine
Administer epinephrine slowly,
premedicate with diazepam
Patience (the half-life of
epinephrine is short); lidocaine
for arrhythmias
Hypertension, bradycardia
Epinephrine interaction with
β-blocker
Use selective β1-blockers
α-Adrenergic blockers; treat as
cardiac emergency
Agitation, confusion,
perioral numbness
Lidocaine toxicity
Use more dilute anesthetic mixture,
use ring blocks rather than local
infiltration
Intravenous fluids, oxygen,
ventilate, diazepam; treat as
cardiac emergency
Pruritus, urticaria,
angioedema
Allergic reaction or anaphylaxis
to drugs or food
Careful history
Oxygen, epinephrine
subcutaneously
Excessive bleeding
Elevated blood pressure,
non-steroidal anti-inflammatory
agents
Discontinue antiplatelet agents
before surgery, continue
antihypertensive medications on
day of surgery, pulse oximetry
Operate with patient seated;
with elevated blood pressure,
consider antihypertensives
Postoperative edema
Surgical trauma, buffered
anesthetic
Keep recipient sites small,
preoperative and postoperative
systemic corticosteroids
Head elevation, additional
postoperative corticosteroids
Sterile folliculitis
Growing hair trapped by
epidermal overgrowth
Keep grafts slightly elevated
Resolves spontaneously; incision
and drainage if persistent
Cyst formation at graft site
Foreign body reaction to
imbedded graft
Avoid piggy-backing one graft over
another in the same site
Incision and drainage, topical
and/or systemic antibiotics
Bacterial folliculitis
Picking, scratching, poor
hygiene, secondary to infected
sterile folliculitis or cyst
Frequent postoperative showering,
topical corticosteroids for pruritus
Topical and systemic antibiotics
Infected donor wound
Suture bites too large or tight;
with postoperative edema,
causes vascular compromise
Harvest a narrower donor strip
under less tension, change suturing
technique
Systemic antibiotics; if severe,
leave portion of donor area to
heal by second intention, watch
for MSRA88
Widened scar in donor
area
Donor strip too wide or placed
too low, patient tendency to
heal with stretched scar
Careful history, conservative donor
strip located at level of occipital
protuberance
Excision ± (can worsen scar),
follicular unit extraction
Raised donor scar
History of keloids, racial
susceptibility, incision placed
too low
Careful history, patient selection,
test biopsy
Intralesional corticosteroids
Persistent numbness or
paresthesias in the back
of the scalp
Transection of branches of the
occipital nerves
Limit donor depth to deep
subcutaneous layer, use tumescent
anesthesia
Subsides spontaneously if the
cut nerve branches were small
Hiccups
Possible injury to C2–C4
indirectly stimulating the vagus
or diaphragmatic nerves
Limit donor depth to deep
subcutaneous layer, use tumescent
anesthesia
Chlorpromazine
Hair texture changes
Trauma to grafts, sebaceous
glands removed in dissection
Careful atraumatic dissection and
placing, avoid trimming follicular
units too close
Usually resolves spontaneously
Skin texture changes
Recipient wounds too large
Make wounds no larger than the
equivalent size of a 19-gauge
needle at the frontal hairline
Add coverage with one- and two-
hair follicular units at the frontal
hairline using very small sites
Hair loss in recipient area
related to the procedure
Telogen effluvium89
Possibly effective: small surgical
wounds, limit epinephrine, pretreat
with finasteride
Terminal non-miniaturized hair
should return spontaneously,
finasteride
Hair loss in donor area
Strangulation of follicles by
sutures, transection of follicles
during harvest
Narrower donor strip, meticulous
suturing techniques
Follicular unit transplantation,
follicular unit extraction, local
excision
Failure of transplanted
hair to grow
Desiccation,90 crush injury,91
transection,92–95 grafts out of the
body too long53
Keep grafts well hydrated in
an isotonic solution, careful
microscopic dissection and
handling
None
MRSA, methicillin-resistant Staphylococcus aureus.

510
Part 3  Aesthetic Surgical Procedures
to transplant permanent donor hair into a high scar should be
approached with caution, as progressive balding may isolate
the hair-bearing scar, presenting new cosmetic problems.
In the case of young patients with traumatic scars and
hair-loss patterns that are still unclear, FUE can function as
a hedge against this risk. If the hair is harvested from the
immediate vicinity of the scar, any future balding will affect
the transplanted hair in the scar at the same rate as the hair
surrounding it.
Using a multibladed knife
In order to save time, doctors performing large transplants
may use a multibladed knife (one with three or more blades)
for harvesting donor tissue. The resulting presliced multiple
thin strips are much easier to work with than a single intact
strip. Unfortunately, harvesting this way causes unacceptable
levels of follicular transection and destroys naturally occur-
ring follicular units. This technique is incompatible with
FUT.27
Crushing grafts during insertion
Proper placing technique necessitates the use of forceps to
grasp the graft by the fat below the bulb or by the dermis
alongside the hair shaft in order to avoid damaging the ger-
minative components of the follicle. Though placers often
exercise enormous care while initially grasping the graft,
there is a tendency to become rougher when repositioning
the forceps for further inserting, replacing a popped graft, or
transferring grafts from the holding solution to the fingers. As
follicular units and other small grafts are particularly suscep-
tible to crush injury, improper handling can more than negate
the benefits of careful stereomicroscopic dissection.91,92
Allowing grafts to dry
A study using electron microscopy has shown that desiccation
is by far the most significant form of injury to grafts and that
this makes them much more susceptible to other forms of
injury, such as mechanical trauma and warming. Grafts
should therefore be kept well hydrated with chilled isotonic
solution (such as Ringer’s lactate) from the moment the
tissue is harvested until the time they are reinserted into the
scalp.90
Placing the frontal hairline too far forward
(too low)
Despite the fact that individual follicular units at the hairline
in themselves look natural, their proper placement is no less
important than in traditional grafting. The frontal hairline
should be placed no lower than 1.5 cm above the upper brow
crease.1,7 If the underlying skin is normal, follicular units
placed too low can be removed with an alexandrite (755 nm)
or diode (800 nm, 810 nm) laser. Electrolysis is more difficult
and time-consuming with transplanted follicles, but should
also be considered. Punch excision is too imprecise for very
small grafts, and FUE with wounds left to heal by secondary
intention risks visible scarring.
Creating a hairline that is too broad
Since significant temporal recession is characteristic of a
normal adult man’s hairline, a broad, flat transplanted hairline
upwards and thumbs pointing towards each other. The scalp
is then moved up and down as vigorous as possible using the
palms and thumbs, with the fingers resting stationary on the
top of the scalp. The exercise should be performed for a total
of 15 minutes every evening at bed time. One should try to
begin the exercise at least 8 weeks prior to surgery and con-
tinue the exercise up to the day before the procedure.98
Harvesting a donor strip that is too wide
In large sessions, it can be tempting to take a slightly wider
donor strip in order to conserve on length. A strip that is
25 cm by 1 cm, for instance, can be shortened by 6 cm if
widened by just 3 mm and yield the same amount of hair.
However, a wide strip puts unnecessary tension on the donor
closure and is probably the most common iatrogenic cause of
widened scars. If larger sessions are appropriate, and the scalp
lacks adequate mobility, the surgeon should consider a longer
incision rather than a wider one.
If a wide donor strip has been identified as the likely cause
of a stretched scar, it is advisable to wait at least 8 months,
to give the scar a chance to mature and regain some of its
original laxity. When the next excision is made, the strip
should measure at least 3–6 mm narrower than the previous
one. Attempts to remove the entire width or length of the
old scar invariably lead to a recurrence, or worsening, of the
old scar. To facilitate healing, the new excision should extend
to the patient’s hair-bearing edge, and be significantly shorter
than the old incision.
Unfortunately, attempts to re-excise scars commonly result
in either no improvement or an even wider defect. For this
reason, we have been using FUE to place hair directly into
the scar as a primary treatment. It is has been our experience,
however, that transplanted hair will not grow in a thickened
scar; therefore any hypertrophic scars should be thinned with
intralesional corticosteroids prior to implantation and then a
small test area should be transplanted first, to see if the hair
will grow and to make sure that the scar doesn’t thicken from
the grafting.76
Placing the donor incision too low
The ideal position for the donor incision is in the mid-portion
of the permanent zone that lies, in most people, at the level
of the external occipital protuberance and the superior nuchal
line. The muscles of the neck insert into the inferior portion
of this ridge, so an incision below this anatomic landmark will
be impacted by the muscle movement beneath it. A stretched
scar in this location is extremely difficult to repair because
re-excision, even with undermining and layered closure,
tends to heal with a wider scar. In addition, one is more likely
to cut through fascia with a low donor incision; and once the
fascia has been violated, the risk of widening the scar rises
considerably.41 To compound the problem, some patient’s
nuchal hair thins dramatically over time, rendering low donor
scars visible.
Harvesting hair too high in the donor area risks lack of
permanence of the transplanted hair because this hair may be
subject to androgenic alopecia. The donor scar may also
become visible if the donor fringe narrows further. In addi-
tion, a high donor scar has a greater risk of widening compared
to one placed at the level of the occipital protuberance. Inci-
sions made too high are best left untreated, unless poor surgi-
cal technique has been identified as the cause. The temptation

511
Chapter 29  Follicular Unit Hair Transplantation
vate a keen aesthetic sensibility with regard to transplant
design and graft placement.
In view of the psychological aspects of hair loss, FUT
requires a thorough preoperative assessment to understand
the patient’s expectations, a careful examination to determine
if surgery is appropriate, and, most importantly, the establish-
ment of realistic goals. If the surgical route is chosen, meticu-
lous attention to detail is required in every aspect of the
procedure, so that these goals may be realized. It is a daunting
task for the hair restoration surgeon and team to develop the
necessary expertise for perfecting FUT; but when they do,
the procedure can benefit patients for their lifetime.
 REFERENCES
1. Bernstein RM, Rassman WR, Szaniawski W, et al. Follicular transplanta-
tion. Int J Aesthetic Rest Surg 1995;3:119–132.
2. Headington JT. Transverse microscopic anatomy of the human scalp.
Arch Dermatol 1984;120:449–456.
3. Rassman WR, Pomerantz MA. The art and science of minigrafting. Int J
Aesthetic Rest Surg 1993;1:27–36.
4. Limmer B. Thoughts on the extensive micrografting technique in hair
transplantation. Hair Transplant Forum Int 1996;6:16–18.
5. Bernstein RM, Rassman WR. The logic of follicular unit transplantation.
Dermatol Clin 1999;17:277–295.
6. Bernstein RM, Rassman WR. Follicular transplantation: patient evaluation
and surgical planning. Dermatol Surg 1997;23:771–784.
7. Bernstein RM, Rassman WR. The aesthetics of follicular transplantation.
Dermatol Surg 1997;23:785–799.
8. Limmer BL. Elliptical donor stereoscopically assisted micrografting as an
approach to further refinement in hair transplantation. Dermatol Surg
1994;20:789–793.
9. Seager D. Binocular stereoscopic dissecting microscopes: should we use
them? Hair Transplant Forum Int 1996;6:2–5.
10. Rassman WR, Bernstein RM, McClellan R, et al. Follicular unit extrac-
tion: minimally invasive surgery for hair transplantation. Dermatol Surg
2002;28:720–727.
11. Stough DB, Haber RS, eds. Hair replacement: surgical and medical. St
Louis: Mosby; 1996.
12. Unger WP. Different grafts for different purposes. Am J Cosmet Surg
1997;14:177–183.
13. Unger WP. Laser hair transplanting 1997. Am J Cosmet Surg 1997;
14:143–148.
14. Bernstein RM, Rassman WR. Laser hair transplantation: is it really state
of the art? Lasers Surg Med 1996;19:233–235.
15. Norwood OT. Scalp reductions: are they necessary? Hair Transplant
Forum Int 1993;3:1–7.
16. Bernstein RM. Are scalp reductions still indicated? Hair Transplant
Forum Int 1996;6:12–13.
17. Swinehart JM, Brandy DA. Scalp lifting: anatomic and technical consid-
erations. J Dermatol Surg Oncol 1994;20:600–612.
18. Epstein JS, Kabaker SS. Scalp flaps in the treatment of baldness: long-
term results. Dermatol Surg 1996;22:45–50.
19. Unger WP, Shapiro R. Hair transplantation, 4th edn. New York: Marcel
Dekker; 2004.
20. Sasagawa M. Hair transplantation. Jpn J Dermatol 1930;30:473 (in
Japanese).
21. Okuda S. Clinical and experimental studies of transplantation of living
hairs. Jpn J Dermatol Urol 1939;46:135–138 (in Japanese).
22. Tamura H. Pubic hair transplantation. Jpn J Dermatol 1943;53:76 (in
Japanese).
23. Orentreich N. Autographs in alopecias and other selected dermatologic
conditions. Ann NY Acad Sci 1959;83:463–479.
24. Rassman WR, Carson S. Micrografting in extensive quantities; the ideal
hair restoration procedure. Dermatol Surg 1995;21:306–311.
25. Unger WP. Hair transplantation, 3rd edn. New York: Marcel Dekker;
1995.
26. Camacho F, Montagna W. Trichology: diseases of the pilosebaceus fol-
licle. Madrid: Aula Medica; 1997.
27. Bernstein RM, Rassman WR, Seager D, et al. Standardizing the classifica-
tion and description of follicular unit transplantation and mini-micro-
grafting techniques. Dermatol Surg 1998;24:957–963.
28. Kuster W, Happle R. The inheritance of common baldness: two B or not
two B? J Am Acad Dermatol 1984;11:921–926.
29. Bernstein RM, Rassman WR. Densitometry and video-microscopy. Hair
Transplant Forum Int 2007;17:1, 49–51.
will not age well and can cause cosmetic problems if baldness
becomes extensive. The treatment is the same as with low
hairlines, but if grafts larger than follicular units were used,
and/or if there is scarring of the recipient skin, punch excision
with reutilization of the hair should be considered.
Angling hair in the wrong direction
As noted earlier, in the front and top part of the scalp, hair
grows in a distinctly forward direction, changing to a radial
pattern as it approaches the crown. Hair emerges from the
scalp at an acute angle, with the hair lying practically flush to
the skin at the temples.
There has been a tendency among some hair restoration
surgeons to transplant grafts perpendicular to the skin – prob-
ably due to the fact that the mechanics of the old plug pro-
cedures made sharp angling technically difficult. The cosmetic
consequence of this is most apparent at the frontal hairline.
When the hair is perpendicular, the viewer’s eye is guided to
the base of the hair shaft where it inserts into the skin; con-
versely, when hair is transplanted in its natural, forward-
pointing position, it is bowed by grooming and the eye settles
on the body of the hair shaft.
When grafts at the frontal hairline are transplanted in a
radial direction, combing the hair in any style becomes prob-
lematic as the transplanted hair fans outward and becomes
unmanageable. When the hair is pointed forward, it can be
groomed as a single unit increasing the illusion of fullness. As
with low or broad hairlines, hair that is angled in the wrong
direction, particularly in the frontal hairline, should often be
removed rather than camouflaged.
Attempting to cover an area that
is too large
Attempting to cover an area greater than the donor supply
can adequately fill may leave cosmetically important areas
thin or untransplanted. As a general guide, the first region of
the scalp to bald is generally the area where you should be
most hesitant to transplant. Recession at the temples and
thinning in the crown are usually the earliest manifestations
of baldness, but they are acceptable, especially as a person
ages, so these areas may be left untransplanted. The central
forelock region, however, is generally late to bald, but when
balding occurs the patient loses the frame to his face and its
restoration becomes essential.6
Whether or not these areas need coverage at the time of
the initial transplant, an adequate amount of hair must always
be reserved for critical areas, such as the forelock and top of
the scalp. If donor reserves are limited, the transplantation
of less critical areas should be postponed or avoided all
together.6
 SUMMARY
Developed within the past decade, FUT has emerged as the
‘gold standard’ in surgical hair restoration. In conserving
donor hair, achieving optimal coverage, and creating a natural
look, FUT represents a significant advance over earlier
methods of hair restoration. Appropriately, it also demands
considerably more from its practitioners. Surgical teams must
develop the skill and stamina for the delicate handling of large
numbers of follicular unit grafts, while surgeons must culti-

512
Part 3  Aesthetic Surgical Procedures
65. Bennett RG. Selection of wound closure materials. J Am Acad Dermatol
1988;18:619–637.
66. Moy RL, Waldman B, Hein DW. A review of sutures and suturing tech-
niques. J Dermatol Surg Oncol 1992;18:785–795.
67. Harris JA. The SAFE system: new instrumentation and methodology to
improve follicular unit extraction. Hair Transplant Forum Int 2004;14:
157, 163–164.
68. Bernstein RM. New instrumentation for three-step follicular unit extrac-
tion. Hair Transplant Forum Int 2006;16:229, 237–239.
69. Canales MG. The age of surgical robotics. Hair Transplant Forum Int
2008;18:95–96.
70. Arnold J. Mini-blades and a mini-blade handle for hair transplantation.
Am J Cosm Surg 1997;14:195–200.
71. Weber P, Weber R, Dzubow L. Sedation for dermatologic surgery. J Am
Acad Dermatol 1989;20:815–826.
72. Seager D. Dense hair transplantation from sparse donor area – introducing
the ‘follicular family unit.’ Hair Transplant Forum Int 1998;8:21–23.
73. Tykocinski A. A one-year study of using exclusively ‘follicular grouping
grafts’ in specific areas to increase hair density and volume during FUT.
Hair Transplant Forum Int 2003;13:366, 369–700.
74. Limmer BL. The density issue in hair transplantation. Dermatol Surg
1997;23:747–750.
75. Bernstein RM, Rassman WR, Rashid N, et al. The art of repair in surgical
hair restoration – part I: basic repair strategies. Dermatol Surg 2002;28:
783–794.
76. Bernstein RM, Rassman WR, Rashid N, et al. The art of repair in surgical
hair restoration – part II: the tactics of repair. Dermatol Surg 2002;
28:873–893.
77. Epstein JS. Eyebrow transplantation. Hair Transplant Forum Int 2006;
16:121–123.
78. Jazayeri K. Eyelash transplantation using eyebrow-derived single-hair
grafts: a case report. Hair Transplant Forum Int 2008;18:134–135.
79. Caputy GG, Flowers RS. The ‘pluck and sew’ technique of individual
hair follicle placement. Plast Reconstr Surg 1994;93:615–620.
80. Bouhanna P. Long hair grafts: 20 years of experience. Hair Transplant
Forum Int 2007;17:127–128.
81. Pitchon M. Preview. Long-hair follicular unit transplantation: an immedi-
ate temporary vision of the best possible final result. Hair Transplant
Forum Int 2006;16:114, 118–119.
82. Marzola M. Trichophytic closure of the donor area. Hair Transplant
Forum Int 2005;15:113, 116–117.
83. Rassman WR, Bernstein RM. Rapid fire hair implanter carousel: a new
surgical instrument for the automation of hair transplantation. Dermatol
Surg 1998;24:623–627.
84. Choi YC, Kim JC. Single hair transplantation using Choi hair trans-
planter. J Dermatol Surg Oncol 1992;18:945–948.
85. Boudjema P. A new hair graft implanter: the hair implanter pen. Hair
Transplant Forum Int 1998;8:1–4.
86. Rassman WR, Bernstein RM. The automation of hair transplantation:
past, present, and future. In: Harahap M, ed. Innovative techniques in
skin surgery. New York: Marcel Dekker 2002; 489–502.
87. Teumer J. Strategies for follicular cell implantation. Hair Transplant
Forum Int 2008;18:97–98.
88. True R. Hair restoration in the age of MRSA. Hair Transplant Forum Int
2008;18:121, 129, 130.
89. Headington JE. Telogen effluvium: new concepts and review. Arch Der-
matol 1993;129:356–363.
90. Gandelman M, Mota AL, Abrahamsohn PA, et al. Light and electron
microscopic analysis of controlled injury to follicular unit grafts. Derma-
tol Surg 2000;26:31.
91. Greco J. The H-factor in micrografting procedures. Hair Transplant
Forum Int 1996;6:8–9.
92. Cooley J, Vogel J. Loss of the dermal papilla during graft dissection and
placement: another cause of X-factor? Hair Transplant Forum Int 1997;
7:20–21.
93. Limmer BL, Razmi R, Davis T, et al. Relating hair growth theory and
experimental evidence to practical hair transplantation. Am J Cosmet
Surg 1994;11:305–310.
94. Bernstein RM. Blind graft production: value at what cost? Hair Transplant
Forum Int 1998;8:28–29.
95. Benstein RM, Rassman WR. Follicular unit graft yield using three differ-
ent techniques. Hair Transplant Forum Int 2001;11:1, 11–13.
96. Meza DP. Complications in hair restoration surgery. Hair Transplant
Forum Int 2000;10:145.
97. Fader DJ, Johnson TM. Medical issues and emergencies in the dermatol-
ogy office. J Am Acad Dermatol 1997;36:1–16.
98. Mohebi P, Pak J, Rassman W. How to assess scalp laxity. Hair Transplant
Forum Int 2008;18:161, 167.
30. Bernstein RM. Measurements in hair restoration. Hair Transplant Forum
Int 1998;8:27.
31. Walsh N. Trichometer coming soon to quantify hair loss. Skin & Allergy
News 2008;11:14.
32. Norwood OT. Male pattern baldness: classification and incidence. South
Med J 1975;68:1359–1365.
33. Marritt E, Dzubow L. The isolated frontal forelock. Dermatol Surg
1995;21:523–538.
34. Ludwig E. Classification of the types of androgenetic alopecia (common
baldness) occurring in the female sex. Br J Dermatol 1977;97:247–
254.
35. Keene S. A genetic test for androgenetic alopecia. Hair Transplant Forum
Int 2008;18:91–93.
36. Olsen EA. Female pattern hair loss. J Am Acad Dermatol 2001;45:
S70–S80.
37. Chartier MB, Hoss DM, Grant-Kels JM. Approach to the adult female
patient with diffuse non-scarring alopecia. J Am Acad Dermatol 2002;
47:809–818.
38. Bernstein RM, Rassman WR. The scalp laxity paradox. Hair Transplant
Forum Int 2002;12:9–10.
39. Beehner M. Nomenclature proposal for the zones and landmarks of the
balding scalp. Dermatol Surg 2001;27:375–380.
40. Seager, D. The ‘one-pass hair transplant’ – a six-year perspective. Hair
Transplant Forum Int 2003;12:176–178, 194–196.
41. Salasche SJ, Bernstein G, Senkarik M. Surgical anatomy of the skin.
Norwalk, CT: Appleton & Lange 1988;151–162.
42. Beehner M. Where is thy crown, your majesty? Hair Transplant Forum
Int 1998;8:18–19.
43. Haas A, Grekin R. Antibiotic prophylaxis in dermatologic surgery. J Am
Acad Dermatol 1995;32:155–176.
44. Drake LA, Ceilley RI, Cornelison RL, et al. Guidelines of care for office
surgical facilities, part I. J Am Acad Dermatol 1992;26:763–765.
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surgical facilities, part II. Self-assessment checklist. J Am Acad Dermatol
1995;33:265–270.
46. Fader DJ, Johnson TM. Medical issues and emergencies in the dermatol-
ogy office. J Am Acad Dermatol 1997;36:1–16.
47. Sebben, JE. Survey of sterile technique used by dermatologic surgeons.
J Am Acad Dermatol 1988;18:1107–1112.
48. Sebben, JE. Sterile technique in dermatologic surgery: what is enough? J
Dermatol Surg Oncol 1988;14:487–489.
49. Bernstein RM, Rassman WR. Dissecting microscope versus magnifying
loupes with transillumination in the preparation of follicular unit grafts:
a bilateral controlled study. Dermatol Surg 1998;24:875–880.
50. Blugerman G, Schavelzon D. Ergonomics applied to hair restoration. Hair
Transplant Forum Int 1996;6:1–14.
51. Bernstein RM, Rassman WR. Limiting epinephrine (adrenaline) in large
hair transplant sessions. Hair Transplant Forum Int 2000;10:39–42.
52. Bernstein RM, Rassman WR. Wall mounted placing stand. Hair Trans-
plant Forum Int 1997;7:17–18.
53. Limmer BL. Micrograft survival. In: Stough DB, Haber, RS, eds. Hair
replacement: surgical and medical. St Louis: Mosby 1996; 147–149.
54. Raposio E, Cella A, Panarese P, et al. Power boosting the grafts in hair
transplantation surgery. Evaluation of a new storage medium. Dermatol
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55. Krugluger W, Moser K, Hugeneck J, et al. New storage buffers for
micrografts enhance graft survival and clinical outcome in hair restoration
surgery. Hair Transplant Forum Int 2003;13:325, 333–334, 343.
56. Greco J, Brandt RJ. Preliminary experience and extended applications
for the use of autologous platelet-rich plasma in hair transplantation
surgery. Hair Transplant Forum Int 2007;17:131–132.
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Dermatol 1988;19:599–614.
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7:178–189.
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1996;22:520
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anesthetic delivery vs. traditional syringe technique: subjective pain
response. NY State Dent J 1997;63:24–29.
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tion: poliglecaprone 25. Dermatol Surg 2001;27:5–11.

513
30
Laser Hair Removal
Sandy S Tsao MD, George J Hruza MD, C William Hanke MD MPH FACP, and William G Stebbins MD
Summary box
 Lasers and light sources can provide temporary hair reduction
for all individuals.
 At present, permanent hair reduction is possible only in
individuals with pigmented terminal hairs.
 Proper patient selection is vital to ensure effective treatment
with minimal side effects.
 A thorough knowledge of laser–tissue interactions is
mandatory to minimize side effects.
 Treatment outcome is optimized by understanding the
attributes of specific laser and light systems.
 Close follow-up care is necessary to provide optimum patient
outcome.
 INTRODUCTION
Excessive and unwanted body hair is a common frustration
for many individuals, and despite the many etiologies, the
desire for permanent removal remains universal. Before
the development of lasers and light sources, treatments for
the removal of unwanted hair were tedious, generally tempo-
rary in nature, and often associated with significant side
effects. The ability to selectively target and destroy hair fol-
licles with lasers and light sources has revolutionized the
ability to eliminate unwanted hair temporarily and perma-
nently in many individuals. As laser technology advances, the
ability to treat individuals of all skin types and all hair colors
broadens.
Proper patient selection and laser and light source selection
are key to the success of laser treatment. An understanding
of hair anatomy, growth, and physiology, together with a
thorough understanding of laser–tissue interactions, in par-
ticular within the context of designing optimal laser param-
eters for effective laser hair removal, must be acquired before
using lasers for hair removal.
Hair anatomy
The hair follicle is a complex, hormonally regulated structure
with a cyclical growth pattern. Each follicle is formed through
an interaction between dermal and epidermal components.
In the pre-germ stage, there is an accumulation of basal
cells and associated mesenchymal cells, which form the prim-
itive hair germ. A solid column of epidermal cells progres-
sively penetrates into the dermis to form a rudimentary hair
follicle. The broad tip becomes concave and encloses the
dermal papilla, which is a neurovascular structure that sup-
plies the cells of the rapidly dividing proliferating matrix
forming the hair shaft.
Two swellings appear at the posterior edge of the follicle,
with the upper swelling representing the future sebaceous
gland and the lower bulge representing the site of attachment
of the arrector pili muscle. The hair emerges from the surface
at an angle such that the arrector pili muscle and bulge are
on the deeper aspect of the follicle.
The first hair follicles are formed at the end of the second
and beginning of the third month of gestation in the eyebrow,
upper lip, and chin regions, with further hair growth in a
cephalad to caudal direction during the fourth to fifth months
of gestation. No further follicular neogenesis occurs after
birth.1
The hair follicle is divided into three anatomic units:
infundibulum, isthmus, and inferior segment (Fig. 30.1). The
infundibulum includes the region from the hair follicle orifice
to the sebaceous duct entrance. The isthmus includes the
region between the entrance of the sebaceous duct and the
arrector pili muscle. The inferior segment extends from
the insertion of the arrector pili muscle to the base of the
follicle, including the hair bulb.
The hair bulb is composed of matrix cells interspersed with
melanocytes. The matrix cells differentiate along separate
pathways and form, from the outside inward, the outer root
sheath, the three layers of the inner root sheath (Henle,
Huxley, and cuticle), and the three layers of the hair shaft
itself (cuticle of the hair shaft, cortex, and medulla).
Hair growth
Each hair follicle consists of a permanent and non-permanent
part, with the lowermost aspect of the permanent part at the
level of the insertion of the arrector pili muscle (the follicu-
lar bulge).
All hair undergoes intrinsic cyclical growth, consisting of
three phases (Fig. 30.2). In periods of active growth (anagen),
the rapidly developing bulbar matrix cells differentiate into
the hair shaft and inner root sheath, both of which migrate
outward as the hair lengthens. Anagen bulbs are 2–7  mm
below the skin surface. A transition period follows in which
the bulbar part of the hair follicle, including matrical melano-

514
Part 3  Aesthetic Surgical Procedures
The duration of each of these growth phases varies accord-
ing to the body site (Table 30.1). Body sites with long hair
(e.g. scalp) have a prolonged anagen phase, whereas areas
with short hair (e.g. female upper lip) have short anagen and
prolonged telogen phases. The duration of anagen growth of
the upper lip is typically 16 weeks, catagen 1 week, and
telogen 6 weeks. The duration of anagen growth on the scalp
is generally 150 weeks, catagen 1–3 weeks, and telogen 12
weeks. The rate of hair growth is approximately 0.44 mm/
day on the scalp and 0.27  mm/day for the beard region.
Seasonal variation does exist, with a higher rate of growth
during the summer months and slower growth during the
winter months. This variability correlates with fluctuations in
androgen levels, with higher levels of testosterone noted
during the summer. Any method of hair treatment that
induces telogen can produce a prolonged absence of hair
growth that may not represent permanent hair loss. It is
critical in the management of patients with excess hair growth
to understand the variability of these growth phases to
provide effective treatment and follow-up expectations with
predictable outcomes.
Hair type
Hair can be classified according to its texture and length, with
the three main types being defined as lanugo, vellus, and
terminal hairs. Hair features such as the amount of pigment
and hair shaft diameter increase from lanugo to terminal
hairs. Hair diameter is determined by the size of the papilla
and hair bulb. Lanugo hairs are soft, fine hairs that cover a
fetus and are shed before or shortly after birth. Vellus hairs
are non-pigmented, with a diameter of 30 mm or less. Sec-
ondary vellus hairs represent miniaturized or hypoplastic ter-
minal hairs and have the same diameter as vellus hairs, but
are pigmented. Terminal hair shafts range from 200 to
300 mm in cross-sectional diameter. Both vellus and terminal
hairs go through all stages of follicular growth, but the dura-
tion of anagen is much shorter for vellus hairs. The type of
hair produced by an individual follicle may change, as observed
by the replacement of vellus by terminal hairs at puberty or
the conversion of terminal to secondary vellus hairs with
androgenetic alopecia. Vellus hair bulbs extend to a depth of
less than 1 mm into the skin, whereas telogen hair bulbs may
extend 2–7 mm into the skin. The bulge maintains a constant
depth throughout the hair cycle.3
Hair color
Hair color is genetically determined and is dependent on the
amount of pigment in the hair shaft.4 Follicular melanocytes
cytes, is almost totally degraded through apoptosis (catagen).
The follicle decreases to approximately one-third of its
former length, with its lowermost part coming to lie at the
level of attachment of the dermal papilla. A resting phase
(telogen) ensues. With new regrowth in early anagen, new
epithelial cell division occurs near the arrector pili insertion,
a new matrix develops, and hair growth resumes.
The hair follicle is self-renewing, with a population of stem
cells capable of regenerating the follicle within or near the
hair bulb matrix. Another population of slow-cycling stem
cells has been defined in the follicular bulge arising off the
outer root sheath at the site of arrector pili muscle attach-
ment, approximately 1  mm below the skin surface. This
region represents the lower end of the permanent part of the
hair follicle. It is postulated that during late telogen to early
anagen, these follicular bulge stem cells are activated by
dermal papillary signals to proliferate briefly to form more
differentiated follicular cells before returning to their non-
cycling state in mid-anagen.2
Anatomy of the hair follicle
Bulge region
Papilla/matrix
Epidermis
Stratum
corneum
Hair shaft
Arrector pili
muscle
Sebaceous
gland
Figure 30.1  Anatomy of the hair follicle.
Table 30.1  Hair growth table
BODY SITE
TELOGEN
DURATION
(MONTHS)
ANAGEN
DURATION
(MONTHS)
Upper lip
1–2
3–4
Axillae
3–4
3–6
Pubic area
3–4
3–6
Lower limbs
5–6
4–5
Scalp
3–4
35–40

515
Chapter 30  Laser Hair Removal
Excessive terminal hair growth in androgen-dependent
areas, including the upper lip, chin, chest, lower abdomen,
and thighs is classified as hirsutism. Other cutaneous signs
that may be associated with hirsutism include acne, acantho-
sis nigricans, striae distensae, and androgenetic alopecia.
Systemic signs of virilization such as a voice deepening, hyper-
tension, increased muscle bulk, and clitoromegaly may
indicate a hyperandrogenic state, such as polycystic ovarian
syndrome,
21-hydroxylase-deficient
non-classic
adrenal
hyper­plasia, insulin-resistant acanthosis nigricans, androgen
drug intake, or an androgen-secreting neoplasm.6 Appro-
priate laboratory tests, including tests for free testosterone
and dehydroepiandrosterone sulfate (DHEA-S), should be
obtained to exclude elevated androgen levels as a cause of
hirsutism.
Traditional treatment modalities
Numerous treatment modalities exist for the removal of hair.
Temporary hair removal is obtained by shaving, tweezing,
bleaching, waxing, and employing chemical depilatories.
Though inexpensive and easy to perform, many women
loathe shaving because of the masculine connotations associ-
ated with the procedure or the mistaken belief that shaving
will coarsen hair or make it grow faster.6 Tweezing and waxing
provide temporary hair loss for several weeks; however, these
techniques are painful and may result in undesired side
effects such as postinflammatory hyperpigmentation, ingrown
hairs, folliculitis, and scarring. Bleaching provides a lightening
of treated hairs, masquerading their presence. This technique
is most effective for light-skinned individuals. Chemical
depilatories commonly contain thioglycolates that dissolve
hairs by disrupting disulfide bonds. The resultant hair removal
includes some of the hair shaft below the skin surface.7
Although effective for temporary hair removal, they are
messy to use and can provide significant irritation, especially
when used on the face.
produce two types of melanin – eumelanin, a brown–black
pigment, and pheomelanin, a red pigment. They are biologi-
cally related and share a common metabolic pathway, in
which dopaquinone is a key intermediate. Pheomelanin
absorption is 30 times lower than eumelanin at 694 nm and
is poorly absorbed at wavelengths longer than 700  nm.5
Melanocytes occur in the upper part of the hair bulb and
outer root sheath of the infundibulum with a 1 : 5 ratio of
melanocytes to keratinocytes. Melanogenesis is halted during
catagen and reinitiated during early anagen. Pigment transfer
is halted during telogen, resulting in an unpigmented telogen
bulb. Hair varies in its type of melanin – black and brown
hair contains ellipsoidal heavily melanized eumelanosomes;
red hair contains spherical pheomelanosomes; blond hair con-
tains incompletely melanized melanosomes or fewer melano-
somes; gray hair-producing follicles contain few melanocytes,
with poorly melanized melanosomes; while white hair-
producing follicles contain no dopa-positive melanocytes.
Classification of excess hair
The removal of unwanted hair is a daily challenge for many
men and women. Two main groups of individuals seek hair
removal – individuals with increased hair in undesirable loca-
tions secondary to an underlying medical condition or genetic
predisposition, and individuals with hair in areas considered
to be normal in density and distribution, but for social, emo-
tional, or other reasons is not desired.
Individuals with increased hair density are classified as
having hypertrichosis or hirsutism. Hypertrichosis is defined
as localized or excessive hair at any body site in a male or
female and may develop as a result of a drug interaction to
certain medications such as cyclosporine, phenytoin, and ana-
bolic steroids. Internal malignancy, trauma, malnutrition,
patients with a hair-bearing skin graft, endocrine distur-
bance, and a genetic or ethnic predisposition have also been
implicated.6
Stages of hair growth
A
B
C
Figure 30.2  Stages of
hair growth: (A) anagen;
(B) catagen; (C) telogen.

516
Part 3  Aesthetic Surgical Procedures
be fully defined before treatment initiation. Treatment risks
and benefits must be thoroughly reviewed and understood.
A review of a patient’s past medical history should include
the presence of any underlying medical conditions (Box
30.1). Even though no scientific evidence exists to suggest
that laser hair removal penetrates deep enough to injure a
fetus, the treatment of a pregnant woman is best avoided in
our litigious society. The presence of any underlying condi-
tions that may cause hirsutism requires further work-up
before laser treatment. A past history of herpes simplex virus
at or near the treatment site requires prophylactic antiviral
therapy. A history of keloids or hypertrophic scar formation
may preclude the use of lasers for hair removal. Documenta-
tion of past hair removal treatment modalities, including
method, frequency, date of last treatment, and response is
essential. Treatment should be avoided in patients taking
photosensitizing medications or isotretinoin within the previ-
ous 6 months, past or current use of gold therapy, underlying
photosensitizing conditions such as lupus erythematosus, or
koebnerizing conditions such as psoriasis.
Fitzpatrick skin phototype classification is used to assist in
the determination of eligibility (Table 30.2). The ideal can-
didate for laser hair removal is fair-skinned (skin types I and
II) with dark terminal hair. Less ideal are patients with darker
skin (skin types III and VI) and dark hair. Patients with blond,
gray, red, or white hair need to be aware that it is unlikely
that laser treatment will result in permanent hair removal.
Patients with skin types V and VI have an increased risk for
side effects, and as such may not be optimal candidates for
laser hair removal.
Absence or presence of a tan should be noted. If an active
tan is present or there is recent sun exposure, laser treatment
should be postponed up to 6 weeks, depending on the degree
of tan, to allow the tan to lighten to minimize potential side
Antiandrogenic medications, including oral contraceptives
for hormonal suppression and spironolactone, flutamide, and
cyproterone acetate for peripheral androgen blockade, have
been employed for the treatment of hirsutism with variable
success. They provide only partial and temporary hair loss
and are associated with significant side effects, which warrant
monthly monitoring.
Attempts to delay hair growth have been performed. There
are three ways to slow down hair growth – decrease the
anagen phase, delay the onset of anagen, or prolong the
telogen phase. To date, pharmacological prolongation of
the telogen phase or anagen onset is not possible. It is,
however, possible to decrease the anagen phase. Eflornithine
hydrochloride 13.9% cream (Vaniqa, Bristol-Myers Squibb)
was approved by the Food and Drug Administration (FDA)
in August 2000 as the first topical prescription treatment for
the reduction of unwanted facial hair in women. It acts as an
irreversible inhibitor of ornithine decarboxylase (ODC), an
enzyme that is critical for the biosynthesis of cationic
polyamines which are necessary for cell growth. ODC is
abundantly expressed in the proliferating bulb cells of anagen
follicles. When ODC is decreased, anagen is reduced with
subsequent hair growth delay. The mean percutaneous
absorption for eflornithine 13.9% cream is less than 1%. It is
not metabolized and is excreted unchanged in the urine.8 Two
multicenter, double-blind, vehicle-controlled, randomized
studies were carried out, with twice-daily application of the
creams for 24 weeks, followed by 8 weeks of no treatment,
to the chin and upper lip. Statistically and clinically significant
hair growth delay was noted in the eflornithine group when
compared to the vehicle. Hair growth was noted to approach
pretreatment levels within 8 weeks of treatment withdrawal.9
Applied twice daily, eflornithine hydrochloride 13.9% cream
is effective in slowing facial hair regrowth temporarily and
may complement other hair removal methods. Skin-related
side effects include stinging, burning, tingling, acne, and fol-
liculitis at the treatment site. It is classified as a pregnancy
category C agent.8
For several decades electrolysis was the only available
means of achieving safe, permanent hair removal. Two types
of electrolysis have been employed for hair removal: galvanic
electrolysis and thermolysis. During galvanic electrolysis, a
needle carrying direct electric current is inserted into each
individual hair follicle. The current destroys the follicle by
producing sodium hydroxide within the follicle. Thermolysis
generates a high-frequency alternating current through a
needle inserted into the follicle, which destroys the hair fol-
licle through heat production.10 Both forms of electrolysis can
provide permanent hair removal. However, the process is
tedious, time-consuming, costly, painful, and can result in
postinflammatory hyperpigmentation, hypopigmentation,
and ice-pick scarring; and the results are variable, with effi-
cacy of 30–40% for destroying individual hair follicles. It is
not a practical means of hair removal for individuals with
extensive hair or large areas to treat.
 PREOPERATIVE PREPARATION
Preoperative preparation for laser hair removal requires a
pretreatment consultative visit to determine eligibility. A
thorough history and physical examination are paramount for
treatment success. Patient and physician expectations must
Table 30.2  Fitzpatrick skin phototype
SKIN TYPE
SUNBURN AND TANNING HISTORY
I
Extremely fair skin – always burns, never tans
II
Fair skin – always burns, sometimes tans
III
Medium skin – sometimes burns, always tans
IV
Olive skin – rarely burns, always tans
V
Moderately pigmented brown skin – never
burns, always tans
VI
Markedly pigmented black skin – never burns,
always tans
Box 30.1  Pertinent history in patient
selection for laser hair removal
 Underlying endocrine disorders.
 Hypertrophic or keloidal scarring.
 Intake of isotretinoin within the past month.
 Koebnerizing dermatologic disorder.
 Herpes simplex infection.
 Recurrent skin infection.
 Gold therapy.
 Recent suntan or exposure to tanning booths.

517
Chapter 30  Laser Hair Removal
thermal damage must be confined to the hair follicle alone to
avoid non-specific tissue injury.
Chromophores
The endogenous chromophore targeted for selective destruc-
tion of hair follicles is melanin, although water has also been
used as a chromophore with minimal success to date (Box
30.2). Melanin is in the hair shaft, the outer root sheath of
the infundibulum, and the matrix area.18 It functions as a
natural chromophore over a wide range of wavelengths, up to
1100  nm19 (Fig. 30.3). Most lasers and non-coherent light
sources with cut-off filters used for hair removal deliver
energy at red or near infrared wavelengths, which target
melanin within the hair follicle. The amount and type of
melanin within the follicle determines the amount of follicu-
lar damage possible. Red and near infrared wavelengths are
poorly absorbed by competing chromophores such as hemo-
globin and are able to penetrate into the deep dermis.
Exogenous chromophores have been employed when hairs
lack significant pigment as a target. The first FDA-approved
method of laser hair removal employed the use of a
Q-switched neodymium : yttrium aluminum garnet (Nd : YAG)
laser with topically applied carbon particles suspended in
mineral oil massaged into hair follicles.20 Even though this
method did not provide permanent hair removal, the con­
cept has been expanded to include the use of other exoge-
nous chromophores. Liposomal targeting of melanin to hair
effects. Patients are instructed to avoid excessive sun expo-
sure for a month before and during the entire treatment
course. Documentation of existing tattoos, nevi, and scars
within treatment areas is critical in managing treatment
outcome. Patients with numerous lentigines should be aware
that laser hair removal might result in permanent removal of
these freckles.
Patients must fully understand the risks and benefits of
treatment, as well as the long-term results. Patients should
be aware that laser hair removal offers a method to signifi-
cantly delay hair growth. After multiple treatments, the
treatment areas will have less hair growth and finer hair
growth.11 Temporary hair loss is achievable for all patients.
Hair loss in patients with blond, red, gray, or white hair can
be maintained by treatment at approximately 3-month inter-
vals. Long-term hair reduction is strongly correlated with hair
color, skin color, and tolerated fluence.12 In general, a 20–30%
hair loss has been observed with each treatment when effec-
tive fluences can be used in patients with fair skin and dark
hair.13 With the use of lower fluences, as are needed for Fitz­
patrick skin types III or greater, the percentage of hair loss
is decreased, and complete permanent hair removal is unlikely.
Treatment risks for all patients include blistering, ulceration,
scar formation, folliculitis or acne flare, hyperpigmentation,
hypopigmentation,
increased
hair
growth,
poor-to-no
response, and recurrence. These risks should be addressed
before each treatment and informed consent obtained.
Pretreatment instructions include strict sun avoidance for
6 weeks before treatment and daily use of a broad-spectrum
sunscreen throughout the treatment course. A bleaching
cream such as 4% hydroquinone with or without 0.025%
retinoic acid and 2% hydrocortisone can be prescribed for
patients with Fitzpatrick skin types III or greater and for
patients with recent sun exposure. Side effects after treat-
ment have been reported to be reduced with the pretreat-
ment use of sunscreens and bleaching creams.14 Plucking,
waxing, and electrolysis are to be avoided to maintain an
intact hair shaft. Shaving, bleaching, and depilatory creams
may be used.
 TECHNIQUES
Several components are necessary to selectively damage a hair
follicle with a laser or light source, including a chromophore
in the follicle, a laser or light source that selectively targets
the chromophore, and appropriate parameters that selec-
tively damage the hair follicle. At present, it is understood
that it is necessary to damage stem cells in the bulge area at
the interface of the outer root sheath and the connective
tissue sheath, or irreversibly damage a hair follicle at the level
of the dermis by replacing it with connective tissue.15 Damage
to the bulb area is also likely to be critical.
Laser hair removal was first applied non-specifically for the
removal of hair from flaps and grafts16 and to treat trichiasis.
Most recently, laser-assisted hair removal has been based
on the principle of selective photothermolysis – confining
thermal injury to the targeted chromophore.17 This selective
thermal destruction by light occurs when energy is delivered
at a wavelength of light well absorbed by the hair follicle
within a time period less than or equal to the thermal relax-
ation time (TRT) of the follicle. When the proper pulse
duration, wavelength, and energy fluence are used, selective
damage to the hair follicle occurs. During laser treatment,
Absorption spectrum of various substances
300
400
500
600
700
800
900
1000
2000
Wavelength (nm)
Absorption
Ultraviolet
Visible
Near infrared
Scatter
Melanin
Ruby
Alexandrite
Diode
Nd:YAG
H2O
Oxyhemoglobin
Figure 30.3  Absorption spectrum of various substances. Laser
targeting of these substances is wavelength dependent.
Nd : YAG, neodymium : yttrium aluminum garnet.
Box 30.2  Chromophores for hair removal
with lasers and light sources
Endogenous
 Melanin.
Exogenous
 Aminolevulinic acid.
 Carbon particles.
 Meladine.

518
Part 3  Aesthetic Surgical Procedures
600 and 1064 nm (see Fig. 30.3). Melanin is the dominant
chromophore at these wavelengths, with an optical window
between 600 and 1100 nm. Shorter wavelengths are associ-
ated with increased light scatter, limiting beam penetration.
Using longer wavelengths of light, 800 nm or greater, allows
deeper penetration into the skin. The ratio of energy depos-
ited in the dermis compared to the epidermis is greater
because of this increased penetration. At longer wavelengths,
higher fluences are required for follicular destruction as a
result of decreased melanin absorption.
The optimal wavelength for hair removal is dependent on
the color contrast between the epidermis and hair shaft
(Table 30.3). Individuals with light skin and dark hair can
tolerate all wavelengths of light with minimal risk of epider-
mal damage. The use of a shorter wavelength (694  nm,
755 nm) is well tolerated in these individuals. For darker skin
and dark hair, longer wavelengths (800 nm and greater) are
essential for epidermal protection. Red and red–brown hairs
absorb 800–1100  nm light poorly, thus requiring shorter
wavelengths. Blond, white, and gray hairs require the shortest
wavelength possible (694 nm) to allow for maximum melanin
absorption.
Pulse duration
Q-switched lasers produce instantaneous hair shaft vaporiza-
tion and a photoacoustic effect through the delivery of very
short pulses. Separation of the shaft from the surrounding
tissue and alteration of the optical thermal properties of the
shaft lead to a compromise in further laser energy absorption
and less effective treatment. When longer pulse durations are
used, more efficient heat transfer occurs. The most selective
damage is obtained when the pulse duration is equal to or
less than the TRT of the hair follicle, which is estimated to
be 40–100  ms for terminal hairs with a diameter of 200–
300 µm25 (Table 30.4). In addition, the pulse duration should
exceed the TRT of the epidermis (estimated to be 3–10 ms)
follicles has been achieved in the scalp and the ability to color
hair with melanin has been demonstrated.21 A topical mela-
nin-encapsulated liposomal spray has been FDA approved to
enhance the effects of lasers in non-pigmented hair (Mela-
dine, Creative Technologies, Inc, Chesapeake, VA). It con-
tains water, glycerol, melanin, natural soy lecithin, and
2-phenoxyethanol, is odorless and non-toxic, and requires
refrigeration when opened. It must be applied twice daily to
the treatment site(s) up to 4–6 weeks in advance of treat-
ment, with six to eight coatings used with each application.
Its long-term efficacy for permanent hair removal has not
been documented in formal studies to date.
Site-specific microsphere targeting of both hydrophilic and
lipophilic particles may also be used. A particle bead size
between 3 and 7  µm in diameter is necessary for optimal
deposition within the hair follicle, with larger and smaller
particles depositing preferentially in the stratum corneum
and skin surface. Methylene blue has been demonstrated to
selectively deposit within pilosebaceous units using 5-mm
porous nylon microspheres22 in hairless rats. Human applica-
tions derived from this work will be beneficial in the treat-
ment of non-pigmented hair.
Light can also be used to photochemically activate an exog-
enously administered or induced photosensitizer within hair
follicles, a technique known as photodynamic therapy (PDT).
Aminolevulinic acid (ALA) is the most commonly used drug.
When applied topically, ALA is absorbed by hair follicles over
several hours and converted to the photosensitizing com-
pound protoporphyrin IX. Red light near 635  nm is then
applied to the surface, activating protoporphyrin IX, resulting
in singlet oxygen production and follicular cell destruction.
PDT has been reported to induce temporary hair loss for 3
months, depending on the ALA concentration used and light
dose applied. An advantage of PDT is that hair color and skin
color are not important variables for treatment success.23
Optimal target
Bulbar stem cells were originally thought to be the key
follicular target for laser hair removal. With the discovery
of stem cells in the bulge area,15 it is likely that both the
bulge and bulb are important for permanent hair follicle
destruction.
The influence of hair cycle growth on laser-induced hair
removal is not completely understood. The depth and pig-
mentation of the bulb are dependent on the hair cycle stage.
Telogen hair bulbs are unpigmented and thus not active
targets for light absorption. Melanogenesis resumes during
early anagen. At this stage the bulb is more superficial in the
dermis in close proximity to the bulge and the bulge stem
cells are actively dividing. It is at this stage that cells are more
susceptible to injury. As anagen progresses, the bulb and
papillae descend into the deep dermis and subcutis, and the
bulge cells become quiescent. It is therefore believed that
follicles in early anagen are more responsive to laser and light
treatment. Attempts to synchronize hair growth to early
anagen by waxing 6–8 weeks before laser hair removal have
demonstrated only a modest increase in permanent hair
reduction.24
Wavelength
Most present strategies for laser hair removal employ the use
of visible and near infrared light, with wavelengths between
Table 30.3  Optimal wavelengths for hair removal
HAIR COLOR
FITZPATRICK
SKIN TYPE
WAVELENGTH
(nm)
Brown
I, II
694, 755, 800
Brown, black
III, IV, V
800, 1064
Red, gray
I, II
694, 755
Blond, white
I, II
694
Table 30.4  Thermal relaxation time (TRT) for various
follicular structures
STRUCTURES
TRT (ms)
Whole epidermis
10
Hair shaft, mid-dermis
3–5
Epidermal basal layer
0.1
Hair follicle, mid-dermis
40–100
Individual melanosome
0.001
Hair bulb
20–40

519
Chapter 30  Laser Hair Removal
receive less fluence. Slight overlapping of treatment pulses
helps to reduce this occurrence.
Fluence
Temporary hair removal is possible with all devices at any
fluence (Table 30.5). A critical threshold fluence is needed
to obtain long-term hair removal.12 Because there is evidence
that sublethal laser doses induce catagen and telogen, it may
be possible to synchronize follicular growth to some degree
using lower fluences. Once the follicles are in early anagen,
larger fluences with longer pulse durations could be used to
destroy the follicle.
Cooling
For many skin types, the threshold light energy required to
maximally damage the hair follicle for permanent hair removal
also produces maximum melanin absorption by the epidermis
with resultant injury to the overlying skin. This precludes the
use of higher fluences in darker-skinned individuals, which
limits the possibility of permanent hair reduction. To mini-
mize this occurrence, selective epidermal cooling is employed
– a component that is especially critical in the treatment of
darker-skinned individuals (Fig. 30.5).
to minimize epidermal damage. The optimal pulse duration
for permanent hair reduction while minimizing epidermal
injury is between 10 and 50 ms. Longer pulse widths allow
for higher tolerated fluences for all skin types (see Table
30.3).
Altshuler et  al.26 have proposed an expanded theory of
selective photothermolysis to take into consideration the
variability in heat absorption between the high heat absorb-
ing, melanin-bearing structures including the hair shaft and
matrix cells, and the bulge and bulb, both containing stem
cells, which are the targets for follicular destruction, but
lacking sufficient chromophore for heat absorption. These
weakly absorbing targets have to be damaged by heat diffu-
sion from the highly pigmented, strongly absorbing regions.
The delay between chromophore heating and distant target
heating is referred to as thermal damage time (TDT) and is
the time required to irreversibly damage the target with
sparing of the surrounding tissue. The TDT may be signifi-
cantly longer than the TRT of the target. Pulse widths within
or below the TDT may allow for maximal efficacy as well as
optimized epidermal cooling. With laser hair removal, the
chromophore is melanin within the hair follicle, whereas the
ultimate target is the follicular stem cell, which is located in
the bulb or bulge. The time required to transfer heat from
the hair follicle to the bulb or bulge is referred to as the TDT.
Spot size
Optical scattering by dermal collagen causes light to diffuse
as it penetrates into the dermis. Photons that are scattered
out of the beam are essentially wasted because they do not
carry enough thermal energy to cause significant thermal
damage.27 A larger spot size (>9 mm) (Fig. 30.4) allows for
a greater likelihood that photons will be scattered back into
the incident collimated beam with resultant beam broaden-
ing. This greater photon density results in deeper energy
penetration. A larger spot size also allows for faster adminis-
tration of treatment. Note that even for large spot sizes, there
are edge effects, with variability in treatment success based
on the location of the spot. Areas near the edge of the beam
Beam diameter and effective skin penetration
Wide beam
Narrow beam
Skin
surface
Figure 30.4  Effect of beam diameter
on effective laser penetration. Optical
scattering by dermal collagen causes light
to diffuse as it penetrates into the dermis.
A larger spot size allows for a greater
likelihood that photons will be scattered
back into the incident collimated beam
with resultant beam broadening at any
given depth and greater energy delivery.
Table 30.5  Fluences for minimal side-effect profile
FITZPATRICK
SKIN TYPE
Pulse duration (J/cm2)
30 ms
100 ms
200 ms
I
>60
>60
>60
II
>45
>60
>60
III
>45
>60
>60
IV
<30
<45
<45
V
<15
<30
<45
VI
Cannot safely
treat
<15
<15

520
Part 3  Aesthetic Surgical Procedures
of laser–tissue coupling may increase backscatter with the
technique.
Forced air cooling with air at −5°C or colder effectively
reduces the epidermal temperature, thus protecting the epi-
dermis, reducing the pain of treatment, and eliminating the
noxious odor of singed hair.
The epidermal protection afforded by the use of surface
cooling allows for increased tolerated fluences for all skin
types.
Histology
Biopsies obtained immediately after laser treatment demon-
strate selective thermal damage to pigmented hair follicles,
with vaporization of hair shafts and apoptosis of follicular
epithelial cells. Patients with permanent hair loss demon-
strate a reduction in the number of terminal hairs and an
increase in vellus-like hairs without fibrosis30 (Fig. 30.6).
These findings most closely resemble the histologic picture
of androgenetic alopecia.
Specific laser systems
The first laser-assisted hair removal device was marketed in
1996. The FDA has since approved numerous laser and light
sources for this use (Table 30.6).
Ruby laser
The normal-mode ruby laser (694  nm) was the first laser
employed that demonstrated both temporary and perma-
nent hair reduction. Grossman et  al.25 reported selective
injury to hair follicles using the long-pulsed ruby laser in 13
patients with fair skin and brown or black hair. Treatment
sites were shaved or wax-epilated before delivery of a
single laser treatment using a 6-mm spot size, fluences of
20–60 J/cm2, and pulses of 0.27-ms duration. Hair growth
delay lasting 1–3 months was noted in all patients. Biopsies
immediately after treatment showed selective thermal
damage to pigmented hair follicles. Long-term follow up of
seven of the 13 patients after 1 or 2 years revealed permanent
hair loss only in the shaved areas at all fluences.30 Skin sites
treated at the highest fluence (60 J/cm2) revealed the great-
est hair loss.
Although the ruby laser is an effective method of hair
removal, there are significant dose-related side effects. High
epidermal melanin absorption may result in epidermal injury,
manifested as acute vesiculation, crusting, or pigmentary
change. Even though these changes may be observed with any
laser system, they are more commonly observed with the
ruby laser. Use of the ruby laser should be avoided in patients
with a history of persistent postinflammatory hyperpigmenta-
tion, darkly tanned skin, or skin type darker than Fitzpatrick
type III. A relative disadvantage is that the two commercially
available ruby lasers (Epilaser, Palomar Medical, Lexington,
MA; Epitouch, Lumenis, Israel) each have a slow pulse rep-
etition rate, making it time-consuming to treat large body
sites.
Alexandrite laser
Several long-pulsed alexandrite lasers (755 nm) are available
for hair removal. These include the Apogee series (Cynosure,
Chelmsford, MA), EpiCare (Light Age), and GentleLASE
(Candela, Wayland, MA). The longer wavelength allows for
Five types of cooling systems have been devised in conjunc-
tion with laser hair removal:
1. Passive cooling with an aqueous gel.
2. Active contact cooling with water encased in a glass
housing.
3. Active contact cooling with water encased in a sapphire
housing.
4. Dynamic active cooling with a cryogen spray.
5. Forced air cooling.
The use of a water-based gel works to hydrate the stratum
corneum, improving the thermal conductivity at the skin
surface. The effect is temporary with only a small amount of
heat extracted because the temperature is not maintained. A
sapphire window circulates water at approximately 2–6°C,
resulting in expedient heat extraction. This allows for rapid
movement of the laser hand piece with adequate cooling.
Applying the window for more than 0.5 seconds may result
in undesirable levels of bulbar and shaft cooling. The index
of refraction obtained with the sapphire window optimizes
laser–tissue coupling with reduced backscatter. Water surface
condensation may result in beam attenuation with the use of
either a sapphire or glass window.
Evaporative cooling systems typically employ a cryogen
spray delivered before the laser pulse. This generates greater
epidermal protection with less inadvertent dermal cooling.
An FDA-approved cryogen uses tetrafluoroethane as a surface
cooling agent, with a boiling point of −26.2°C. It is non-toxic,
non-flammable, and environmentally safe.28 Irregularities in
cryogen droplet size may lead to variable cooling. A cryogen
film left on the skin surface may result in laser light attenu-
ation as a result of increased surface reflection and scattering.
Measurement of laser light attenuation following cryogen
spray cooling has been examined. A minimum average trans-
mittance value of approximately 97% was measured using a
30-ms spurt duration and 30-ms delay, thus showing negligi-
ble light attenuation at the two wavelengths studied.29 A lack
Without cooling
With cooling
Figure 30.5  Effect of epidermal cooling. Areas treated using
similar fluences and pulse durations, with and without cooling.
No epidermal damage is noted with pretreatment cooling.
Postoperative vesiculation is noted without cooling. (Courtesy of
C Dierickx.)

521
Chapter 30  Laser Hair Removal
the long-pulsed alexandrite laser at pulse durations of 5, 10,
and 20 ms.32 Longer pulse durations provided more effective
epidermal protection.
Diode laser
The introduction of diode lasers (800–810  nm) further
expanded the laser hair removal market because they are
less costly to produce, reliable, and compact in size. Advan-
tages of the diode laser include longer pulse durations
and longer wavelength, allowing for the treatment of Fitz-
patrick skin type III and IV patients because there is less
epidermal melanin absorption. Long-term results (>12
months) suggest that the pulsed 800-nm diode laser is as
effective as the long-pulsed ruby laser in the removal of dark,
terminal hair.33,34
Nd : YAG laser
Long-pulsed 1064-nm Nd : YAG lasers have deeply penetrat-
ing wavelengths. Reduced melanin absorption at this wave-
length requires the use of higher fluences for adequate follicle
injury. This laser is not as effective in treating patients with
lighter hair. It is a safe treatment option for patients with
Fitzpatrick skin types III–V.35
Q-switched Nd : YAG lasers are available for hair removal.
Although capable of treating darker skin types and inducing
delayed regrowth, these systems do not produce long-term
hair removal.
Intense pulsed light
Intense pulsed (non-laser) light (IPL) sources that emit non-
coherent, multiwavelength light are being used for hair
removal. The output spectrum extends across the 500–1000-
nm range. Filters are placed to allow more selective treat-
ment. Shorter wavelengths are blocked for Fitzpatrick skin
types III and darker to avoid excessive epidermal heating.
Shorter wavelengths are used for Fitzpatrick skin types I and
II for maximal energy delivery.36 A disadvantage of IPL
systems is that most devices use large rectangular spots, cre-
ating difficulty in the treatment of convex or concave hair-
bearing areas.
Microwave technology
A microwave-based hair removal system (Microwave
Delivery System, MW Medical, Scottsdale, AZ) has been
FDA approved for hair removal in all body sites except the
face. Pulses of microwave energy are delivered to the skin in
conjunction with a coolant spray. No published data are avail-
able to assess the efficacy of this technology.
Treatment delivery
Treatment can be initiated after a consultative appointment
has been performed and the risks and benefits of laser hair
removal reviewed. An oral antiviral medication is initiated 24
hours before the laser procedure and continued for a total of
7 days in patients with a history of herpes simplex virus near
the laser treatment site. Each patient signs an informed
consent on the day of service. Preoperative pictures are rec-
ommended to monitor patient progress.
To minimize treatment discomfort, a topical anesthetic
cream may be applied. We recommend LMX 4 (4% lido-
caine cream) or LMX 5 (5% lidocaine cream) (Ferndale
A
B
C
Figure 30.6  Skin biopsies of a hair follicle using a normal-
mode ruby laser. (A) Pretreatment. Intact follicles penetrate
deeply into the deep dermis and subcutis. (B) Immediately
following treatment. Thermal damage to the follicles is
observed, with hair shaft vaporization and follicular cell
apoptosis noted. (C) Six months after treatment. A reduction in
terminal hairs and an increase in vellus-like hairs are seen. No
fibrosis is observed. Hematoxylin and eosin stain, original
magnification ×32. (Courtesy of T Flotte.)
a slightly greater depth of penetration. There is also a lower
risk of epidermal damage because of the slightly lower
melanin absorption at this wavelength. McDaniel et  al.31
showed a 40–50% hair reduction at 6 months after one treat-
ment with the variable-pulsed alexandrite laser. Nanni &
Alster demonstrated equivalent long-term hair removal with

522
Part 3  Aesthetic Surgical Procedures
Table 30.6  Lasers and light sources for hair removal
LASER/
LIGHT
SOURCE
WAVELENGTH
(nm)
SYSTEM NAME
PULSE
DURATION
(ms)
FLUENCE
(J/cm2)
SPOT
SIZE
(mm)
OTHER
FEATURES
Long-pulsed
ruby
694
Epilaser (Palomar, Burlington,
MA)
3
10–40
7,10
Epiwan
Epitouch (Sharplan, Allendale,
NJ)
1.2
10–40
3–6
Dual mode, also
Q-switched
Long-pulsed
alexandrite
755
Apogee 5500, 6200, 9300
(Cynosure, Chelmsford, MA)
5–40
50
10, 12.5, 15
Smartcool cold
air
Arion (Cynosure)
1–15
5–140
60 × 65
Skin cooling (air)
EpiCare SP, LP, LPX, 2H, 4H
(Light Age, Somerset, NJ)
3–300
12–100
7, 9, 12, 15
Smartscreen
user interface
GentleLASE plus (Candela,
Wayland, MA)
3
10–100
10, 12, 18
Dynamic cooling
Photogenica LPIR (Cynosure)
5, 10, 20
25–40
7, 10
Cooling tip
available
Diode
800–810
Apex 800 (Iridex, Mountainview,
CA)
5–100
5–60
1–5, 10
Adjustable hand
piece
F1 Diode (Opusmed, Montreal,
Canada)
10–100
10–40
5, 7, 10
Air cooling
Lightsheer ET, ST, XC (Lumenis,
Santa Clara, MA)
5–400
10–100
9 × 9, 12
× 12
Chill-tip hand
piece
SLP100 (Palomar)
50–1000 ns
Up to 575
Three contact
cooling hand
pieces
Nd : YAG
1064
Acclaim7000; SmartEpil II
(Cynosure)
0.4–300
16–300
2, 5, 5, 7, 10
Smartcool cold
air
Coolglide Classic, Excel, XEl,
Vantage (Cutera, Brisbane, CA)
0.1–300
10–300
Multiple
Gentle YAG (Candela)
3
10–100
10, 12
Lyra (Laserscope, San Jose, CA)
20–100
5–900
1–5, 10
Adjustable hand
piece
Mydon (Wavelight, Erlangen,
Germany)
20–200
15–50
60 × 65, 3
Air or contact
cooling
Profile (Sciton, Palo Alto, CA)
0.1–200
4–400
Scanner up
to 31 × 31
Contact cooling
Softlight (Telsar, Wood River, IL)
12–18
2–3
Q-switched;
patented carbon
lotion
Intense-pulsed
light source
525–1200
Estelux Y, R, Rs, Medilux Y, R
(Palomar)
10–100
Up to 15–30
16 × 46,
12 × 28
400–1200
PhotoLight (Cynosure)
5–50
3–30
46 × 18,
46 × 10
550–900
Prolite (Alderm Irvine, CA)
10–50
10 × 20,
20 × 25
510–1200
Quadra Q4 (DermaMed, Lenni,
PA)
48
10–20
Closed cooling
system
400–1200
Spectraclear (Symedex LLC,
Minneapolis, MN)
34
10–50
55 × 22
Five small area
adapters
Fluorescent
pulsed light
615–920
OmniLight (Medical Bio Care,
Newport Beach, CA)
2–500
Up to 45
Photothermal
400–1200
Skin Station (Radiancy,
Orangeburg, NY)
35
3–10
22 × 55
Optical energy
combined w/RF
electrical energy
580–980
Aurora DS, DSR (Syneron,
Richmond Hill, Canada)
Up to 100
10–45 optical;
5–25 J/cm3
RF
8 × 12
Contact cooling
Diode combined
w/RF electrical
energy
800
Polaris DS (Syneron)
Up to 100
Up to 25
optical, up to
20 J/cm3 RF
8 ×12
Contact cooling
w/RF, with radiofrequency.

523
Chapter 30  Laser Hair Removal
light transmission to the hair follicles. Applying gentle skin
traction decreases the relative depth of the bulb and bulge
relative to the skin surface.
The treated skin is monitored for a 5-minute interval after
initiation of treatment for the desired erythema and perifol-
licular edema. If any whitening, vesiculation, or forced epi-
dermal separation (positive Nikolsky’s sign) are noted, the
fluence must be decreased and repeat monitoring observed at
the lower energy. In general, the treatment fluence should be
at 75% of the Nikolsky’s sign threshold fluence. Treatment
sites bearing tattoos should not be treated to avoid alteration
of the tattoo pigment. With direct contact cooling systems,
the laser hand piece should be wiped clean every 10–20
pulses to remove debris. The laser hand piece must be disin-
fected with Virex II (Johnson Wax Professional, Sturtevant,
WI) or a similar agent between patients to minimize
contamination.
 OPTIMIZING OUTCOMES
The optimal candidate for laser hair removal is the individual
with fair skin (skin type I or II) and dark terminal hair
because maximal follicular pigment is vital for permanent hair
reduction and minimal epidermal pigment is desired to min-
imize side effects (Fig. 30.7). Individuals with red, gray, or
white hair may lack sufficient follicular melanin to allow for
permanent hair reduction. Individuals with darker skin
present with an increased risk of side effects at any given
energy, although longer wavelengths offer some degree of
protection of epidermal melanin.
To achieve maximum benefit, an appropriate wavelength,
pulse duration, and fluence must be tailored to each indi-
vidual. Using the highest tolerated fluence and largest spot
size allows for more effective hair removal.
The complicating factor in selecting follicular melanin as
the target for laser hair removal is that melanin is also found
in the epidermis. With laser treatment, epidermal damage
may occur as a result of absorptive interference by epidermal
melanin. Darker-skinned individuals (Fitzpatrick skin types
III–V) benefit from longer pulse durations (>30 ms) because
this allows for the simultaneous cooling of the band of melanin
at the dermoepidermal junction, and more time for heat
Labo­ratories, Ferndale, MI), an over-the-counter mixture to
be applied 30–45 minutes before the procedure without
occlusion. Alternatively, EMLA (eutectic mixture of 2.5%
lidocaine/2.5% prilocaine; Astra Pharmaceuticals, Westboro,
MA) is applied 1–1.5 hours before the procedure under
plastic wrap occlusion. Each cream should be applied as a
thick layer to the entire treatment site to maximize efficacy.
The anesthetic cream is removed immediately before laser
treatment.
Patients are instructed to clip or shave the treatment site
1 day before treatment. Shaving may be performed by the
staff immediately before treatment if patients are reluctant
to shave. The hair should be cut to approximately 1 mm in
length to minimize plume and prevent hair char and subse-
quent epidermal damage. All make-up should be removed
before treatment to allow for maximum laser energy delivery
and to minimize light scatter.
Patients are positioned comfortably on a surgical table to
permit maximum accessibility to the targeted surfaces. All
staff and the patient must wear protective glasses or goggles
with a minimum optical density of 5 specific for the wave-
length of light being used. A polarizing headlamp with mag-
nifying loupe may be used (Seymour light, Syris Scientific,
Gray, ME) for improved visibility of treatment sites. The
plume generated by vaporized hair shafts has a sulfur smell
and in large quantities can be irritating to the respiratory
tract, not to mention bothersome to the patient because of
malodor. Use of a smoke evacuator and good room ventilation
are recommended except with the cold air blowing system,
which disperses the odor from the area. If the device is not
equipped with a cooling device, an ice-cold cooling gel is
generously applied before laser treatment for epidermal
cooling. With dynamic cooling, short bursts of cryogen are
emitted before the delivery of the laser pulse. With contact
cooling, the chilled hand piece is applied firmly to the skin
before pulse delivery.
Laser parameters are tailored to each patient and each
device to ensure maximum efficacy with minimal side effects.
The highest tolerated fluence and the largest spot size should
be used to obtain the best results. Mild traction on the skin
with slight pressure may help to provide uniform illumination
and prevent capillary blood flow, which may interfere with
A
B
Figure 30.7  Laser hair removal. (A) Pretreatment: neck area of a patient with Fitzpatrick skin type II. (B) Noted hair reduction after
three treatments using an 800-nm diode laser, 20-ms pulse duration, 42 J/cm2 and contact cooling.

524
Part 3  Aesthetic Surgical Procedures
quently, perifollicular crusting lasting 7–10 days may occur.
Twice-daily application of topical petrolatum or topical anti-
biotic ointment is recommended until the scabbing has com-
pletely resolved. Any trauma such as picking or scratching of
the area must be avoided. Purpura is rarely observed, resolv-
ing over 2 weeks when noted. Analgesics are generally not
required unless extensive areas are treated.
Patients should be informed that the treated hair will con-
tinue to ‘grow’ for 1–2 weeks after treatment, until each hair
is expelled from the skin surface. Patients can shave, tweeze,
or wax these treated hairs to expedite their removal once all
inflammation has resolved. Depending on the treatment site,
patients will note hair regrowth of those hairs not in anagen
during treatment within 2–6 weeks thereafter.
Strict photoprotection is stressed for the duration of the
treatment course. Treatment is to be avoided if an active tan
is noted. Patients are instructed to complete their antiviral
medication, when appropriate. Treatment intervals are site
dependent. In general, treatments are spaced every 6–8
weeks for the face, axillae, and bikini areas where regrowth
is faster, and every 12–16 weeks for the legs, chest, arms, and
back where regrowth is slower.
 PITFALLS AND THEIR MANAGEMENT
extraction from the skin surface (Fig. 30.8). This reduces the
risk of epidermal injury. Cooling allows higher fluences to be
used for more permanent hair removal. Patients with Fitz-
patrick skin type III or greater should not be treated with a
long-pulsed ruby laser to minimize side effects. The alexan-
drite and long-pulsed Nd:YAG lasers and IPL sources operat-
ing at near infrared wavelengths and long pulse durations have
been safely used to treat these patients. Patients with an
active tan should not be treated.
A laser test spot should be considered for any patient in
whom there is a concern about the potential for side effects.
This test spot should be performed within or adjacent to the
proposed treatment site if possible. The treatment site should
be observed immediately and 1 week after treatment to
assess for any adverse reaction. Treatment can be initiated at
the 1-week follow-up visit if no side effects are noted.
It is best to avoid the treatment of vellus hairs, in particu-
lar of the jawline, because new hair growth may be induced
as a result of sublethal laser doses, with resultant induction
of terminal hair.37 This has been reported to occur more com-
monly in females of Mediterranean descent. For highly dense
hair-bearing areas, such as the back and chest, it is imperative
to use lower fluences to prevent non-selective damage through
excessive heat diffusion. Appropriate laser safety precautions
must be followed (see Chapter 32).
 POSTOPERATIVE CARE
Laser-treated sites generally demonstrate perifollicular edema
lasting up to 48 hours, and erythema which may persist for
up to 1 week. Ice is applied to the treatment sites immedi-
ately on treatment completion to minimize these effects and
reduce postoperative discomfort. If the erythema persists
beyond 10 days, a low to mid-potency corticosteroid cream
may be applied twice daily until the redness subsides. Infre-
Figure 30.8  Epidermal protection using longer pulse durations
in the treatment of a Fitzpatrick skin type V patient. The
patient’s right submental area was treated with a Nd : YAG laser
using a 30-ms pulse duration and 30 J/cm2 with immediate
vesiculation and skin sloughing. The patient’s left submental
area was treated using a 100-ms pulse duration and 30 J/cm2
without complication. (Courtesy of E Battle.)
Pitfalls and their management
 Adverse reactions may occur – patients should be made
aware of what to expect postoperatively and instructed to
notify the office as soon as possible if an adverse reaction
occurs.
 Potential pigmentary changes include postinflammatory and
temporary or permanent hypopigmentation. They generally
resolve slowly over months to years. Strict sun avoidance is
mandatory. Twice-daily application of a bleaching cream to
hyperpigmented areas helps lighten the affected sites.
 Hair thinning is common, with an associated fading and
lightening of the hair color.38 Conversion of vellus hairs to
terminal hairs may also occur. Use of the highest tolerated
fluence minimizes these occurrences.
 Temporary or permanent leukotrichia after IPL and laser hair
removal therapy is avoided by using sufficient fluences to
induce germinative cell death concurrently with melanocyte
death.
 If patients are properly selected during the consultation, few
adverse events should be observed. Patients should be made
aware of what to expect postoperatively and instructed to
notify the office as soon as possible if an adverse reaction
develops to allow for proper management and follow up.
Pigmentary changes that can occur include postinflammatory
hyperpigmentation and temporary or permanent hypopig-
mentation (Figs 30.9 and 30.10). This occurs most frequently
in patients who do not avoid sun exposure before or after
treatment and in patients with Fitzpatrick skin type III or
greater. These pigmentary changes generally resolve slowly
over time, but may take months to years for full resolution.
Strict sun avoidance is mandatory to avoid further tanning of
the affected sites. Twice-daily application of a bleaching
cream to hyperpigmented areas helps to lighten the affected
sites. Patients must be aware that topical hydroquinone
creams rarely cause an irritant dermatitis with long-term use.

525
Chapter 30  Laser Hair Removal
Blistering may occur, requiring localized wound care and use
of a mid-potency corticosteroid cream. Scar formation is
extremely rare.
Hair thinning is observed frequently, with an associated
fading and lightening of the hair color.38 This may represent
partial rather than complete destruction of germinative cells
at the bulge and bulb regions. Hair growth induced by laser
hair removal has also been reported.37 This is especially seen
in people with darker skin types, possibly due to sublethal
fluences used that paradoxically increase hair growth. Con-
version of vellus hairs to terminal hairs may also occur in this
setting. Use of the highest tolerated fluence minimizes these
occurrences. On the other hand, significant pain needs to be
tended to and may be a warning that fluences are unduly high
and causing tissue destruction.
Temporary or permanent leukotrichia may develop follow-
ing IPL and laser hair removal therapy. This likely represents
the destruction of the melanocytes within the hair follicles
Figure 30.9  Transient hypopigmentation 4 weeks after
treatment.
Figure 30.10  Transient blistering and hyperpigmentation 2
days after treatment. The patient was treated with a long-pulsed
Nd : YAG laser, 100 ms, 20 J/cm2.
without destruction of the germinative cells. Temporary leu-
kotrichia may represent a temporary arrest in melanin syn-
thesis by damaged, but viable, melanocytes. The melanocytes
may become functional after a while, leading to the restora-
tion of hair color. Hair color restoration occurs more fre-
quently in younger patients, whose melanocytes may be less
susceptible to permanent thermal damage. In patients with
permanent depigmentation of their treated hair, permanent
melanocyte destruction may occur. Permanent leukotrichia
was reported in 29 of 770 patients of skin types I–IV treated
primarily for unwanted facial and submental hair using a non-
coherent IPL system with a 650-nm flashlamp filter. The
white hairs were found to be as thick as the pretreatment
black hairs.39 The use of sufficient fluences to induce germina-
tive cell death concurrently with melanocyte death is critical
in avoiding this side effect.
 SUMMARY
Numerous laser and light sources are available for rapid, safe,
and effective hair removal. Temporary hair removal can be
achieved with all systems regardless of hair color. Numerous
published studies have confirmed the long-term efficacy of
laser and flashlamp technology. The ability to achieve long­
lasting hair removal depends on hair color, skin type, and
treatment fluence. Uniform permanent hair reduction has
proven difficult, probably because of the broad distribution
of pluripotential cells, as well as the hardiness of the hair
follicle. To date, no laser-specific parameters provide predict-
able permanent hair follicle destruction. The number of treat-
ments needed to obtain complete permanent hair removal for
different anatomic sites varies and is unknown.
The benefits of this technology have largely been limited
to patients with fair skin and dark hair. Studies using devices
with longer wavelengths, longer pulse durations, and epidermal
cooling have shown that it is possible to safely and effectively
treat darker-skinned individuals. The remaining challenge is
to develop a means to eliminate light and non-pigmented hair.
Advancing technologies and broadening understanding of fol-
licular biology and growth will allow for improved means of
hair removal.
The treatment of blonde, red, white, and gray hair may be
possible with the use of combined IPL and radiofrequency
devices such as the Aurora (Syneron, Israel) by directing the
radiofrequency current to the hair follicle through heating of
the follicle with the IPL. Heating reduces impedance, result-
ing in concentration of the radiofrequency to the follicular
target. In addition, the hair shaft with its low water content
and high impedance encourages the electrical current to
become concentrated around the hair shaft in the hair follicle,
resulting in further localized follicular heating. Another alter-
native is the use of PDT. In a pilot study, ALA combined
with red light photodynamic therapy has shown promise in
hair reduction. Using ALA eliminates the need for pigment
in the hair follicle.
Dermatologists are seeing an increasing number of compli-
cations from laser/light hair reduction by non-dermatologists
and non-physicians.40–42 State laws and regulations determine
who can perform laser/light hair reduction in a given locality.
Patient safety is maximized when a physician determines the
diagnosis and appropriateness of the patient for laser/light
hair reduction. Depending upon the state laws, the proce-
dure itself can be delegated to an appropriately trained and

526
Part 3  Aesthetic Surgical Procedures
22. Mordon S, Sumian C, Devoisselle JM. Site-specific methylene blue deliv-
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24. Lehrer MS, Crawford GH, Gelfand JM, et al. Effect of wax epilation
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25. Grossman M, Dierickx C, Farinelli W, et al. Damage to hair follicles by
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26. Altshuler GB, Anderson RR, Manstein D, et al. Extended theory of selec-
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31. McDaniel DH, Lord J, Ask K, et al. A review and report of the use of
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33. Dierickx CC, Grossman MC, Farinelli WA, et al. Comparison between
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34. Grossman MC, Dierickx CC, Quintana A, et al. Removal of excess body
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36. Gold MH, Bell MW, Foster TD, et al. Long-term epilation using the
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37. Hirsch R, Farinelli WA, Dover JS, et al. Hair growth induced by laser
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39. Radmaneshi M, Mostaghimi M, Yousefi I, et al. Leukotrichia developed
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supervised non-physician. The physician should be present
on-site during the procedure. If complications occur, the
physician is the best trained medical professional to provide
treatment.
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using a topical carbon-based solution and 1064 nm Q-switched
neodymium:YAG laser energy. Arch Dermatol 1997;133:1546–1549.
21. Hoffman RM. Topical liposome targeting of dyes, melanins, genes and
proteins selectively to hair follicles. J Drug Target 1998;5:67–74.

527
31
Microdermabrasion and Dermabrasion
James M Spencer MD MS and Christopher B Harmon MD
Summary box
 Microdermabrasion is the second most widely performed
cosmetic procedure in the United States and is commonly
offered at spas and beauty salons.
 Microdermabrasion is used to treat photodamage,
dyschromias, acne scars, and stretch marks.
 Studies indicate that changes in the epidermis and dermis
can be measured objectively after microdermabrasion, and
that patients and physicians alike perceive a clinical benefit.
 Mechanical dermabrasion with a rotating diamond fraise or
wire brush is one of the most effective means for resurfacing a
variety of skin defects and blemishes.
 The most common indication for dermabrasion is facial acne
scars.
 INTRODUCTION
It has been known for centuries that abrading the superficial
portion of the skin produces a wound that heals with new
skin having an enhanced cosmetic appearance. The deeper
the dermal wounding, the greater the cosmetic improvement;
however, wounds need to be limited to a mid-reticular dermal
depth as wounding deeper than this results in surface changes
that are perceived as a scar. Traditional dermabrasion utilizes
a wire brush or diamond fraise on a rotary hand engine to
mechanically remove tissue and has been widely utilized since
its development in the 1950s. This technique can produce
outstanding results, but it creates a significant wound that can
require weeks to heal, and aerosolizes blood into the operat-
ing room during the procedure. It is quite operator dependent
and requires hands-on learning and significant experience.
Scarring, dyspigmentation, and infection are potential com-
plications of any deep abrasion procedure.
A resurfacing procedure that is blood free, safer, and with
less healing time than dermabrasion has been a goal. In 1985,
Marini & Lo1 developed microdermabrasion as an abrasive
resurfacing technique that would fulfill these goals.
Microdermabrasion
Microdermabrasion has been widely utilized to treat photo-
damage, dyschromias, acne, scars, and stretch marks. Despite
the widespread use of microdermabrasion, surprisingly little
is known about its clinical efficacy.
In 1995, Tsai et al.2 reported the treatment of 41 patients
with acne, traumatic, varicella, and burn scars with microder-
mabrasion. These investigators used an aggressive vacuum
setting of 76 mmHg and performed multiple treatments. The
authors reported ‘good to excellent’ clinical improvement
after a mean of 9.1 treatments; acne scars required a mean
of 15.2 treatments for improvement. Mild postinflammatory
hyperpigmentation was the only side effect. A limitation of
this study was the lack of objective evaluation of efficacy. The
outcome was measured solely by the physician’s subjective
visual evaluation. The human eye has a remarkable sensitivity
to mild aesthetic improvements; thus we can see if someone
‘looks better.’ However, objectively quantifying aesthetic
outcomes is difficult scientifically. Subsequently, others tried
to solve the problem of evaluating cosmetic treatments.
Shim et al.3 combined the patient’s and physician’s subjec-
tive evaluation with histology. Fourteen patients with photo-
aging were treated once every 2 weeks at a mild vacuum
setting for a total of six to seven treatments. Eleven of the
14 patients also had comedomal acne or milia, and three had
acne scarring. Following the series of treatments, patients
completed a questionnaire to evaluate their perception of
the potential benefit of the procedure. Patients perceived
improvement in overall complexion, skin roughness, and
mottled pigmentation. They did not perceive an improve-
ment in fine wrinkles, comedomal acne, or milia. An unblinded
physician investigator subjectively evaluated before and after
photographs of the three patients with acne scars. The acne
scars were treated much more aggressively than the photo-
damage patients, usually with more than 20 passes each
session. One patient was considered to have ‘good’ improve-
ment, one ‘fair’ improvement, and one no improvement. The
authors report pinpoint bleeding, petechiae, and even purpura
when 20 passes are performed on acne scars. This implies
that injury, in the form of suction or abrasion, extends to the
papillary dermis where the blood vessels are located.
This study also includes limited histologic evaluation.3 First,
a single piece of excised abdominal skin was treated with 20
passes of microdermabrasion at settings of −12 inHg (inches
Hg). Permanent histologic sections were prepared and stained
with hematoxylin and eosin. Surprisingly little effect of the
abrasion was seen, with only partial ablation of the stratum
corneum and compaction of the remaining stratum corneum.
No epidermis below the stratum corneum was affected. They
performed in-vivo histologic evaluation of three patients. The
dorsal forearm was treated once every 2 weeks for a total of

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Part 3  Aesthetic Surgical Procedures
lar inflammation, were noted. Clinically, the treated areas
developed significant erythema and overall improvement
which lasted a week (Fig. 31.1). The authors speculated that
these changes were unlikely to result from the impact of the
aluminum oxide crystals (abrasion) and more likely to result
from the effects of suction on dermal vasculature.
Then Tan et al.6 treated 10 subjects with facial photodam-
age with weekly microdermabrasion for five to six sessions.
The vacuum line was set to a moderate level (30 mmHg), as
per the manufacturer, and each patient received four passes
per session. One week after the last treatment session, most
patients subjectively reported at least a mild improvement in
the appearance of the skin. Similarly, blinded physician eval-
uators also subjectively rated pre and post photographs as
showing at least a mild improvement in most patients. The
investigators utilized objective measurements with a sebum-
eter to quantify surface sebum levels, silicone replicas to
measure skin topography (i.e. wrinkling), and an advanced
cutometer to measure skin biomechanical properties (i.e. skin
integrity). Sebumeter readings showed a significant decrease
in surface sebum levels immediately following each treat-
ment. However, this effect was gone by 1 week. Silicone
impressions revealed a temporary increase in skin roughness
and a mild flattening of some wrinkles immediately after
treatment, consistent with abrasion of the stratum corneum.
This effect disappeared 1 week after treatment, and maybe
earlier as the 1-week evaluation was the earliest one per-
formed. However, in the two patients who showed the great-
est increase in surface roughness immediately after treatment,
a significant decrease in skin roughness was seen 1 week after
the final session.
The biomechanical analysis of the skin by cutometer
revealed the most interesting findings. The device used was
a BTC 2000 (SRLI, Nashville, TN). This device applies
suction to the skin through a plastic tube. Infrared light is
utilized to measure how much the skin moves over a range
of negative pressures. Once the suction is released, the device
also measures the return to presuction position. Skin elastic-
ity, stiffness, and compliance can thus be calculated. It was
found there was a significant decrease in skin stiffness and
increase in skin compliance on the cheek. This effect per-
sisted for 1 week after the final session, which is consistent
with increased edema and hydration of the skin. One can
think of this as a stiff, dry sponge becoming soft and compli-
ant as it is hydrated. This finding is consistent with the edema
and vasodilatation seen from the forearm biopsies.
Two patients agreed to preauricular biopsies before and 1
week after the final treatment. There was an increase in
orthokeratosis, mild flattening of the rete ridges, and most
significantly, persistent dermal edema, vascular ectasia, and
perivascular inflammation extending to the upper reticular
dermis. Thus, microdermabrasion can produce persistent
dermal edema, vasodilatation, and perivascular inflammation
with essentially no abrasion or wound formation. This edema
makes the skin plumper and softer.
Objective confirmation of a biologic effect due to micro-
dermabrasion from a wholly different perspective was pro-
vided by Rajan & Grimes.7 In this study, epidermal barrier
function was assessed by measuring transepidermal water loss
(TEWL), stratum corneum hydration, skin surface pH, and
sebum content. Patients were treated with conventional alu-
minum oxide microdermabrasion on one side of the face, and
a similar device using sodium chloride as an abrasive on the
six treatments. Ten passes were performed at each session
at a setting of −16  inHg. Following completion of six
treatments, after-treatment biopsies were compared to
before-treatment biopsies. In these three subjects, six micro-
dermabrasion treatments produced thickening of the epider-
mis with no change in the stratum corneum. Fontana-Masson
staining revealed a more regular distribution of melanosomes
and less melanization of the epidermis. There was an increase
in elastin content in two of the three subjects, and no consist-
ent change in mucin or collagen content of the papillary
dermis.
Freedman et  al.4 evaluated the histologic changes in ten
patients who received a series of six microdermabrasion
treatments. The posterior auricular area was biopsied before
treatment, and after three and six treatments. There was
thickening of both the epidermis and papillary dermis after
three and six treatments. As compared to controls, there was
flattening of the rete pegs, and normalization of the stratum
corneum. In the dermis, collagen fibers showed hyalinization
with thicker, horizontally-oriented collagen bundles that
were more tightly packed when compared to controls. An
improvement in the appearance of the elastic fibers was
noted, as well as increased dermal inflammatory activity.
Hernandez-Perez & Ibiett5 confirmed most of these obser-
vations in a study of seven patients with facial photodamage
who received five weekly microdermabrasion treatments of
three passes each. The subjective evaluation of the appear-
ance of the skin was assessed by recording the patient’s,
nurse’s, and physician’s evaluation of the degree of skin oili-
ness, porosity, sebaceousness, fine wrinkling, and overall
appearance (oily skin, dilated pores, thick skin, fine wrinkles,
and general appearance). As in other reports, patients and
operators alike perceived a benefit with microdermabrasion.
Patients and clinicians (doctors and nurses) alike reported
subjective improvement in all parameters assessed. All
patients underwent biopsies of the left malar region before
and after treatment. Similar to other report, there was an
increase in epidermal thickness, and additionally, an improve-
ment in the polarity of epidermal cells and a decrease in basal
cell liquefaction. There were dermal changes, including a
decrease in solar elastosis, and a slight improvement in the
degree of dermal telangiectasias, edema, and inflammation.
These studies using different microdermabrasion equip-
ment with different vacuum settings and treatment protocols
come to the same general conclusions. Taken together, these
studies suggest the following.
• Most patients are somewhat pleased with the results of
a series of microdermabrasion treatments.
• Physicians perceive at least some degree of benefit.
• Very subtle histologic changes are noted in the
epidermis and the dermis following a series of
treatments.
Tan et  al.6 used subjective and objective measures to shed
some light on the question of how histologic changes in the
dermis are produced in the absence of significant epidermal
changes. First, two patients received four microdermabrasion
passes at an aggressive setting of 60–65 mmHg to one forearm
with biopsies both before treatment and immediately after
treatment. In both patients, aggressive microdermabrasion
produced only thinning of the stratum corneum, with no
abrasion of the viable epidermis. However, dermal changes,
which included dermal edema, vasodilatation, and perivascu-

529
Chapter 31  Microdermabrasion and Dermabrasion
other side. TEWL scores increased on both sides 24 hours
after the procedure, suggesting disruption of barrier function.
However, TEWL scores decreased when measured after 7
days, suggesting an improvement in barrier function. Stratum
corneum hydration increased on both sides 24 hours after the
procedure, and stayed increased on the sodium chloride side
at 7 days. There was no sustained change in surface pH or
sebum content. This study suggests microdermabrasion pro-
duces changes in epidermal barrier function which are sus-
tained for at least 7 days, and the authors speculated these
changes could be responsible for the perceived clinical benefit.
Another biochemical analysis of photodamaged forearm
skin after microdermabrasion with three passes of a coarse-
grit diamond-studded hand piece resulting in mild erythema
demonstrated induction of a wound healing response with
increased cytokeratin 16 and activation of activator protein
(AP)-1 transcription factor in the epidermis.8 The wound
healing response was characterized by dermal remodeling
with induction of types I and III procollagens and induction
of collagen-production enhancers heat-shock protein 47
(HSP47) and prolyl-4-prolase. Dermal remodeling was not
achieved with a medium-grit hand piece.
In their prior rigorous study, Karimipour et al.9 elegantly
showed measurable dermal molecular changes following a
single treatment. Forty-nine patients received a single treat-
ment on the buttock with the device set at its most aggressive
setting for three passes. Following treatment, 4-mm punch
biopsies were obtained from treated and untreated control
sites at various time points after treatment, ranging from 15
minutes to 16 days post treatment. Specimens were analyzed
histologically with monoclonal antibodies to detect enzyme
expression, and reverse transcriptase polymerase chain reac-
tion (PCR) was used to analyze mRNA expression. First,
histology with Nile acid red, a stain that highlights keratin,
showed no thinning or ablation of the stratum corneum.
There was no upregulation of acetyl CoA carboxylase or
HMG-CoA reductase, enzymes involved in barrier repair,
further supporting the observation there was no injury to the
stratum corneum. However, molecular changes that could
bring about remodeling of the dermal matrix were observed.
Specifically, there was increased expression of transcription
factors AP-1 and nuclear factor (NF)-κB, primary cytokines
interleukin (IL)-1β and tumor necrosis factor (TNF)-α, three
matrix degrading enzymes, and a trend toward increased
type I procollagen expression that did not reach statistical
significance.
This group of investigators explored the mechanism that
produces this molecular cascade.8,10 Since there is little to no
actual abrasion of the stratum corneum, let alone the epider-
mis itself, could it be the mechanical action of the suction
alone on the skin? In this study, 10 patients were treated once
on the forearm at an aggressive negative pressure setting
(suction) with and without aluminum oxide crystals. Simi-
larly, six patients were treated on the buttock with negative
pressure and aluminum oxide crystals for 3 seconds, while
negative pressure alone was applied elsewhere for 10, 20, and
30 seconds. The specimens were then analyzed molecularly
in a fashion similar to their prior study. Combined negative
pressure and aluminum oxide crystal abrasion produced sig-
nificantly increased expression of the c-Jun component of
AP-1, primary cytokines IL-1β and TNF-α, and three matrix
degrading enzymes. Negative pressure alone produced a sig-
nificant elevation of the matrix degrading enzymes, but of a
A
B
C
Figure 31.1  (A) Normal skin of the forearm before
microdermabrasion. (B) The same area after four passes of
microdermabrasion at an aggressive setting. Only the stratum
corneum is abraded: there is no abrasion of viable epidermis.
(C) The treated area showing marked erythema that persisted
for 1 week. Despite a lack of any true abrasion, a visible clinical
response is readily noted.

530
Part 3  Aesthetic Surgical Procedures
Rhinophyma responds well to dermabrasion. The nodules
of rhinophyma can be debulked and the shape of the nose
recontoured with dermabrasion. The sebaceous nature of rhi-
nophymatous tissue allows a significant volume of excessive
growth on the nasal tip to be removed with minimal risk of
scarring. Initially it is difficult to debulk these large nodules
with a pulsed or scanned CO2 laser alone. Mechanical der-
mabrasion can efficiently remove the build up of connective
tissue and sebaceous glands, after which the natural shape of
the nasal bulb and ala can be restored with one or two CO2
laser passes, which will symmetrically contract the dermis.
Epidermal nevi, seborrheic keratoses, syringomas, angiofi-
bromas, and trichoepitheliomas can be dermabraded with
good results, as described by Roenigk.23 Similarly decorative
tattoos can be abraded followed by the application of 1%
gentian violet directly to the abraded surface and dressed
with Adaptic gauze (Johnson & Johnson, New Brunswick,
NJ). The gentian violet is thought to promote the removal of
tattoo pigment by stimulating phagocytes to carry away the
abraded pigment.24 Deeply placed tattoo pigment, which can
be resistant to the selective photothermolysis of alexandrite,
neodymium (Nd):YAG, and Q-switched ruby lasers can
often be removed with this technique. However, in non-facial
sites, the risk of hypopigmentation is significant.
Traumatic and surgical scars can also be greatly improved
with programmed dermabrasion performed as early as 6–8
weeks following injury or surgery.21,25 Dermabrasion has been
shown to be more effective than 5-fluorouracil in removing
precancerous actinic keratoses.26 In fact, superficial basal cell
carcinoma and squamous cell carcinoma in situ can also be
treated with dermabrasion with reasonable outcomes.
 HISTORICAL VIGNETTE
Since ancient times it has been appreciated that producing a
partial-thickness wound on the skin results in healing with
new skin that has an enhanced cosmetic appearance. The
ancient Egyptians used salt, alabaster, and animal oils as an
abrasive, whereas a mixture of urine and pumice was used in
India. When ancient Egyptian women bathed in sour milk,
they were in fact performing a light chemical peel with lactic
acid. In Turkey, fire was used to lightly singe the skin in an
effort to perform a thermal exfoliation, a technique that finds
modern expression in laser resurfacing.
Over the past century, the ancient idea of creating a con-
trolled partial-thickness abrasion for cosmetic enhancement
of the skin has been refined and widely accepted in medical
practice. In general, the deeper the wound created (to a
point), the greater the cosmetic benefit. Skin can be removed
to the level of the mid-reticular dermis and heals with
improved appearance. Wounding deeper than this level
results in scar formation. Partial-thickness wounds can be
created with acids (which produce a controlled chemical burn
wound) and lasers (which vaporize tissue thermally), and by
mechanical removal of tissue by dermabrasion.
 PREOPERATIVE PREPARATION
A comprehensive resurfacing evaluation includes three main
components: discussion of the patient’s goals and objectives
within the bounds of reasonable surgical outcomes; careful
examination of the skin and its defects, as well as a complete
smaller magnitude than the combined treatment. There was
a trend toward increase in the other measured parameters
that did not reach statistical significance. In sum, while there
is a measurable response to negative pressure alone, there is
a much greater response to negative pressure and aluminum
oxide abrasion.
These studies show that molecular changes associated with
dermal remodeling occur following microdermabrasion. As
microdermabrasion continues to grow in popularity, users
will find ways to expand its applications. Certainly the most
interesting such expansion is the enhanced delivery and
penetration of topical medications. In a nutshell, the idea is
that prior microdermabrasion increases the penetration and
effectiveness of subsequent topical medication. This has
been convincingly demonstrated for the topical application of
5-aminolevulinic acid (ALA) for photodynamic therapy
(PDT).10–13 Microdermabrasion immediately followed by
topical application of ALA resulted in greater penetration of
the drug into the skin, and ultimately a more vigorous response
to the PDT protocol. Cosmetic enhancement is claimed
when cosmeceuticals are given in conjunction with microder-
mabrasion,14 but documentation of enhanced cosmetic
outcome is not available.
Dermabrasion
Mechanical dermabrasion with a rotating diamond fraise or
wire brush continues to offer one of the most effective means
of resurfacing a number of skin defects and blemishes. Ini-
tially described by Kurtin in 1953,15,16 the technique of der-
mabrasive surgery continues to be refined and articulated
among a host of other new resurfacing treatments including
chemical peels, ablative and non-ablative laser resurfacing,
and radiofrequency treatments. This section will address the
specific clinical situations for which dermabrasion is uniquely
indicated in the context of other resurfacing options.
Today, as well as in the initial series of patients,15 the most
common indication for dermabrasion continues to be facial
acne scars.17 Specifically, deep-shouldered acne scars that do
not disappear by simply stretching the skin can be sculpted
and recontoured by a non-thermal resurfacing dermabrasive
procedure. These punched-out scars frequently present along
with stretchable or distensible scars over the cheeks and
forehead. Dermabrasion as a ‘sculpting’ procedure can be
combined with carbon dioxide (CO2) laser as a ‘tightening’
procedure to address both types of acne scars within the same
surgical setting. Not uncommonly, patients with extensive
acne scars may also require surgical excision, punch graft-
ing,18,19 and/or subcision to treat full-thickness defects that
extend into the subcutaneous tissue.18,20 Such surgical proce-
dures should be performed 6–8 weeks or more before der-
mabrasive or laser resurfacing.21
Like acne scars, deep rhytides, especially around the mouth,
usually occur in the context of more diffuse photodamage
over the entire face. The CO2 laser and, to a lesser extent,
the erbium:yttrium aluminum garnet (Er:YAG) laser will
tighten and smooth superficial acne scars and rhytides.22 Der-
mabrasion is a helpful resurfacing adjunct for sculpting the
elevated ridges of wrinkles that persist despite two to three
passes with an ablative laser. Furthermore, dermabrasion
removes the thermal coagulum left after the heat-induced
injury of CO2 lasers, thereby promoting healing and reducing
postoperative erythema.

531
Chapter 31  Microdermabrasion and Dermabrasion
procedures, a line drawn one to two fingerbreadths below the
angle of the mandible should extend from earlobe to earlobe
in a symmetric fashion. This allows the transition zone from
the non-abraded skin on the neck to the abraded facial skin
to be hidden in the shadow of the jawline. Similarly, partial
abrasions (e.g. around the mouth, nose) should follow the
lines of facial cosmetic subunits.
Use of cryoanesthesia and spray refrigerants has been con-
troversial because of their potential to produce injury and
scarring in the skin, but they are helpful in that they provide
a firm surface upon which to work. Refrigerants containing
freon-12 (−30 to −60°C) produce excessive cold injury and
scarring.26,31,32 The refrigerant most commonly used today is
freon-114 (Frigiderm, Delasco Dermatologic Lab & Supply,
Inc, Council Bluffs, IA). A 10-second spray time will freeze
acne scars and rhytides in position so that they can be
sculpted.
Tumescent anesthesia with a 0.05–0.1% lidocaine solution
can be used to anesthetize the entire face for dermabrasion
as well as CO2 or Er:YAG laser resurfacing.33,34 Before infil-
trating the cheeks, central facial nerve blocks (mental,
infraorbital, and supraorbital nerves) can be performed (see
Chapter 3). The blocks will provide anesthesia without
hemostasis of the central face. The lateral cheeks and fore-
head can then be infiltrated with a 25-gauge spinal needle
from a single entry point just in front of the preauricular
crease. Thereafter, the central face can be tumesced if indi-
cated for hemostasis. If this is not required, supplemental
injections will still be necessary if the full face is to be treated
around the oral commissures, medial and lateral canthi,
eyelids, mid-chin, mid-upper lip/nose. This is most efficiently
carried out using a 30-gauge 1-inch needle attached to a
10-mL syringe. A volume of 250–350 mL of tumescent solu-
tion is adequate for the entire face. The infiltrate should be
placed in a superficial plane just beneath and into the dermis
so that complete blanching is produced. Complete anesthesia
allows the procedure to be much less traumatic for the
patient and the surgeon. The use of spray refrigerants on
tumescent tissue should be carried out with caution. The
vasoconstriction of the tumescent anesthesia extends the
length of time that the skin remains frozen. A 10-second
spray time should be reduced to 5 seconds.
Diazepam (5–10  mg orally) is given 30 minutes before
surgery along with meperidine hydrochloride (50–75  mg
intramuscularly) and hydroxyzine hydrochloride (25  mg
intramuscularly) to reduce the discomfort of placing the
nerve blocks and infiltrating the tumescent anesthesia. Preop-
erative patient anxiety and intraoperative patient discomfort
can be further reduced by flurazepam (15–30  mg orally),
zolpidem tartrate (5–10  mg orally) or zaleplon (5–10  mg
orally) taken the night before surgery as well as when the
patient is sleeping in a full-face dressing after surgery. If
patients experience claustrophobia with a full-face dressing,
diazepam (5–10 mg sublingually) can be helpful, especially
when used prophylactically in those with a history of anxiety.
 TECHNICAL ASPECTS
Microdermabrasion
Microdermabrasion has quickly become one of the most
popular cosmetic procedures performed. The American
Academy of Cosmetic Surgery estimates it is the second most
medical history; and review of the advantages and disadvan-
tages of a variety of available resurfacing options. In our
experience, cosmetic patients undergoing dermabrasive
surgery should expect 30–50% improvement in the appear-
ance of deep acne scars and adynamic rhytides. Realistic
expectations can be aided by reviewing before and after pho-
tographs of the results achieved by others.
In examining the patient’s skin, careful attention should be
given to the Fitzpatrick skin type, the sebaceous quality of
the skin, and the presence of hypertrophic scarring, vascular
malformations, or pigmentary alterations. Distensible acne
scars and dynamic rhytides that disappear by stretching are
best treated with tissue tightening procedures such as ablative
and even non-ablative laser resurfacing treatments. On the
other hand, sharp shoulder scars of chicken pox or acne and
deep non-distensible rhytides require sculpting and recon-
touring by mechanical dermabrasion. Some surgeons will opt
to use the Er:YAG laser for sculpting. Many patients will have
a combination of defects that require more than one method
of resurfacing for optimal results. For full-thickness defects,
surgical excision punch grafting and/or dermal grafts should
be performed at least 6–8 weeks before resurfacing. Other
surgical procedures requiring extensive undermining, such as
face lifts, can be carried out at the same time as resurfacing
if the resurfacing treatment is superficial, especially over the
undermined areas. Many surgeons prefer to wait 6 months
after resurfacing to perform face lifts and vice versa.
Patients with a history of impetigo require a nasal swab to
screen for Staphylococcus aureus colonization. These patients
should receive prophylactic antibiotics (cefalexin 1–2 g daily
for 10–14 days); otherwise patients undergoing dermabrasion
do not need prophylactic antibiotics. All patients undergoing
ablative resurfacing including dermabrasion require prophy-
lactic antiviral medication until fully epithelialized (i.e. val-
aciclovir 1 g daily for 7–14 days or famciclovir 500 mg daily
for 7–14 days). In our experience, most herpetic infections
occur 7–9 days after resurfacing surgery, and as such we
recommend that the antiviral prophylaxis should be contin-
ued for 14 days.
Delayed re-epithelialization and hypertrophic scarring have
been reported in patients undergoing dermabrasion during
or shortly after isotretinoin therapy. Therefore dermabrasion
should be postponed 6–12 months after a course of isotretin-
oin. The isotretinoin molecule is thought to have an adverse
effect on the wound healing role of epidermal cells and
fibroblasts in abraded skin.27–30 Alternately, topical tretinoin
cream when applied daily for 2–3 weeks before dermabrasion
has been shown to reduce the time required for re-epitheli-
alization.
A test spot dermabrasion is recommended in patients with
a history of keloids or koebnerizing conditions such as psoria-
sis, lichen planus, vitiligo, or pyoderma gangrenosum. An
atopic diathesis or immunosuppression may cause delayed
wound healing or an increased risk of postoperative infection.
Baseline laboratory work should include a complete blood
count, chemistry profile, hepatitis panel, and screening for
HIV. Patients with viral hepatitis and HIV infections also
have an increased risk for delayed wound healing and post-
operative infection. Because of the aerosolized viral particles
produced by dermabrasion, all healthcare personnel should
observe universal precautions in performing dermabrasion.
The areas to be abraded should be outlined preoperatively
with gentian violet while the patient is sitting. For full-face