Hair Transplantation

Updated 3/2017-- photos and all links removed as many are no longer active and it's easier than checking each one.

Just as some want to remove hair, others want to replace lost hair. The loss may be from male pattern balding or trauma or previous surgery (loss of side burns from a face lift).

HISTORY

Modern day hair transplant surgery began in 1952 when a New York Dermatologist by the name of Dr. Norman Orentreich performed the first known hair transplant in the US on a man suffering from male pattern baldness. However, the "roots" were actually cultivated in Japan in the late 1930's, but were not known to western medicine due to WWII, etc. In 1939, Dr Okuda, a Japanese dermatologist, described in detail his groundbreaking work (burn victims). He used a punch technique to extract round sections of hair bearing skin, which were then implanted into slightly smaller round holes. These holes were prepared in the scared or burned areas of the scalps of his patients.

In 1943 Dr. Tamura, another Japanese dermatologist, refined Okuda's technique by using significantly smaller grafts consisting of one to three hairs. Dr. Tamura used an elliptical incision to extract the donor tissue and then dissected each individual graft. Interestingly enough, Dr. Tamura's technique was very similar to the techniques being used today (follicular unit micro grafting).

The work of Norwood, Ayers, and Stough defined candidates for hair transplantation. Dr Walter Unger defined the ideal graft size of 4.0-4.5 mm for maximum hair growth. Additionally, particular patterns for best aesthetic results were reviewed. Uebel and others developed the approach of micrografts (1-3 follicles) or minigrafts (3-8 follicles) to improve the natural appearance of the grafts.

WHO ARE CANDIDATES

As with any surgical procedure, there must be realistic expectations. With hair loss patients, they must also (depending on their cause of hair loss) realize that there may be continued hair loss. Care should be taken in transplanting young patients in whom the full extent of alopecia at age 40, 50, or 60 years cannot be determined.

That said, the best candidates for hair restoration surgery are:

• Men who have been losing their hair due to male pattern baldness (MPB) for more than five years or who have progressed to a Norwood class 3 or above.
• Men who have been balding for many years and who's pattern has stabilized and are interested in just adding some hair to provide a more youthful appearance.
• Men and women who have lost hair due to trauma or burns
• Men and women who have lost hair due to other cosmetic procedures such as face-lifts (often the side-burns, along the incision sites).
• Women who have suffered hair loss due to mechanical or traction Alopecia (non hormonal)
• Women who have a distinct pattern of baldness, similar to that of male pattern baldness. This includes, hairline recession, vertex thinning, and a donor area that is not affected by androgenetic Alopecia.
• Women with alopecia marginalis, a condition that looks very similar to traction alopecia.

Staging alopecia into both pattern and degree of severity can be accomplished through the Norwood-Hamilton classification for men and the Ludwig Classification of female balding.

As can be appreciated from the above picture (male patterns), Hamilton I and II have very early limited alopecia requiring minimal treatment, if any. Conversely, patients with patterns VI and VII may no longer be candidates for the surgery since their alopecia is so extensive there may be inadequate donor sites. The very best candidates fall into patterns IV to V, which produce the best, most natural results.

MEDICAL THERAPY

Medical therapy is often used in conjunction with hair restoration surgery.

Minoxidil (Rogaine) is available in 2% and 5% topical solutions. Cosmetically useful hair is obtained in only about one third of cases. Minoxidil must be used indefinitely to maintain a response.

Finasteride (Propecia) is a type 2 5 alpha -reductase inhibitor available in 1 mg tablets and given once daily. It lowers the dihydrotestosterone on the scalp and the serum of treated patients. Clinical trials have shown finasteride to be effective in preventing further hair loss and increasing hair counts to the point of cosmetically appreciable results. Interestingly, hair loss on the temples is not improved. Patients must remain on the drug indefinitely since the benefit may be lost after discontinuation.

SURGICAL TRANSPLANTATION

These technical innovations give the transplant surgeon the ability to harvest and implant large numbers of mini-micrografts and cover large areas of balding scalp. In the mid-1980s, extensive mini-micrografting was very popular. Not uncommonly, patients received 700-1000 minigrafts to cover extensive areas of bald scalp. It was also common to perform transplants in younger patients with bald frontal and occipital areas who were thinning in other areas.

Dr Emanuel Marritt has examined the consequences of the procedures on patients 10 and 15 years after surgery. Those who have progressed to more extensive baldness have developed deformities in hairline and hair growth. Particular problems have occurred as the progression of hair loss has left some unnatural appearance of hair growth / balding or left exposed scars from scalp reduction procedures.

A sobering conservative view is emerging in the field of hair transplantation: the surgeon should evaluate the patient both with regard to the improvement he or she can provide in the immediate future and for long-term results. The problem remains that surgeons cannot always predict which patients will progress to grade VI and VII classification and produce these unnatural results. Care should be taken in transplanting young patients in whom the full extent of alopecia at age 40, 50, or 60 years cannot be determined.

Harvest Techniques

A number of different techniques are available for harvesting hair follicles. In androgenic alopecia, there are "protected hair follicles". These are hair follicles that are usually not lost. They tend to be found in the inferoposterior scalp and inferior parietal scalp. It is important that only protected follicles be transplanted to ensure maximal survivability. In all the techniques for harvesting, the punch, blade, and blades used are angled parallel to the hair follicles and not perpendicular to the scalp so as not to injury the follicle. 

• Punch Harvesting -- This technique was used most commonly for harvesting donor follicles until the late 1980s or early 1990s. With the punch harvesting technique, a small hand engine is used (which spins approximately 10,000-15,000 revolutions per minute) with a 2- to 6-mm punch. Defects created from harvesting may be left to heal by secondary intention or may be closed using sutures or skin staples. Healing by secondary intention has been abandoned, largely because of results that are cosmetically inferior.
• Excision -- The donor site is excised as an elongated fusiform ellipse of full-thickness scalp using a scalpel blade size 10 or 15, taking care not to damage hair follicles at the edge of the donor tissue. The resultant defect is closed using suture or skin staples, and the scar is minimal. Then, donor tissue is dissected carefully into the desired number of grafts, which can vary in size.
• Strip harvesting -- A scalpel containing 2 or more size 15 blades mounted in parallel is used to cut strips of donor tissue. This facilitates the division of donor scalp into minigrafts and micrografts. Several multibladed scalpel handles currently are available that can accommodate as many as 6 or more No. 15 blades, which most commonly are spaced 1.5-2.5 mm apart. This technique may carry a higher risk of follicle transection than excision.

Grafts obtained by punch grafting can be transplanted directly or cut into smaller grafts using a size 15 blade or razor blade. These round grafts can be cut into halves or quarters, or they can be dissected down to single hair grafts. Grafts harvested by excision or strip harvesting can be cut to single grafts, minigrafts (3-8 hairs per graft), or micrografts (1-2 hairs per graft) by using a size 15 blade or razor blade. This is done using magnifying loupes or a dissecting microscope to aid the dissection of grafts.

Recipient Site Preparation

Several techniques are used for preparing recipient sites (where grafts are to be placed). They include:

• Single hair and slit grafting (micrografting) is most often used to recreate the frontal hairline.
• Dilation (modified slit grafting) -- Micrografting (grafts containing 1-2 hair follicles) or minigrafting can be performed using dilation. Micrografting most often is used to recreate the frontal hairline. This method has not become popular as it is typically slower than slit grafting and may result in compression of the grafts, especially when more than one hair follicle is grafted.
• Punch grafting -- a defect is created at the recipient site using a 1-4 mm diameter punch into which the graft may be inserted. The larger the size of the graft, the more likely it is to have what is termed a "doll's hair" or "cornrow" appearance.
• Laser-assisted grafting -- Carbon dioxide laser has been used to create recipient sites. Significant delay in the growth of the transplanted hairs usually occurs after laser-assisted transplantation.

After creating recipient sites, dilators may be used to enlarge the opening, by pushing adjacent scalp aside, and/or to provide hemostasis. Many surgeons believe that this aids in the insertion of grafts and reduces the trauma to the grafts during insertion. Most surgeons use jeweler's forceps or similar small non–toothed forceps to insert grafts. This is done by grasping the fat immediately beneath the hair follicle rather than the hair/hair follicle. Some surgeons use a needle to insert and tease grafts gently into place.

POST-PROCEDURE CARE

Medications

• Antibiotic use -- Significant controversy remains regarding the use of prophylactic antibiotics in hair transplant surgery. The most appropriate time to administer prophylactic oral antibiotics (as single dose) is 1 hour preoperatively. Some surgeons use oral antibiotics for 3-5 days postoperatively to reduce risk of infection. For most patients, first-generation cephalosporin is used, unless a history of cephalosporin allergy exists and then azithromycin or ciprofloxacin may be substituted. Some surgeons also use topical antibiotics during the postoperative period to reduce risk of wound infection, although no benefit has been established yet.
• Corticosteroids -- Many surgeons administer oral or intramuscular corticosteroids to reduce postoperative swelling, although few data are available supporting this practice.
• Pain medications -- Some patients require oral narcotics for the first few days after hair transplantation. Usually, Tylenol with codeine, Percocet, or Lortab 5 is sufficient to alleviate most postoperative discomfort.

Postoperative dressings

Many surgeons advocate use of surgical dressings to minimize risk of graft loss. This would include applying (1) topical antibiotic, (2) Telfa nonstick gauze, (3) gauze, (4) Kerlix gauze, and (5) Coban wrap to create a turban-like dressing. Most often, this dressing is removed after 24 hours; no dressing is required thereafter. The current trend of some surgeons is to use no postoperative dressing and require patients to wear a baseball cap. Most allow the patient to shower and shampoo their hair the day after hair restoration surgery.

COMPLICATIONS

As with any surgical procedure, there are risks. Fortunately they are infrequent. Postoperative edema is expected, so is not a complication. It may be severe. The risks of hair transplant surgery include:

• Bleeding
• Infection
• Scarring at donor site
• Scarring at recipient sites
• Dyspigmentation at recipient sites
• Cobblestone appearance at recipient sites
• Failure of graft
• Cyst formation
• Poor results -- too large plugs used, doll's hair or corn-row appearance, poorly planned hairline, etc.

Hair Transplant Surgery Process: Photo Journal -- shows photos taken along the process, very nicely done.

Revised April 6, 2008
REFERENCES
Hair Replacement Surgery, Hair Transplantation; Jorge l de la Torre MD, Gary D Monheith MD, John D Kayal MD; eMedicine Article, June 6, 2006
Surgical Hair Restoration -- American Hair Loss Association
Hair Replacement Surgery, Hair Transplantation in Women; Mark E Krugman MD and others; eMedicine Article, August 20, 2005
Hair Graft Transplantation for Baldness; Jeffrey S Epstein MD and others; eMedicine Article, October 17, 2005
Bernstein Medical Center for Hair Restoration Web-site (very nice with lots of information) and Blog