Late Reconstruction of the Nail Bed

Updated 3/2017-- photos and all links (except to my own posts) removed as many are no longer active and it's easier than checking each one.

Recently I received the following e-mail:

"I came across your blog about fingertip injuries. When I was 4 years old I slammed a door on my pinky finger. The tip came off leaving me with what they call a hook nail. I have been trying to research any procedures that may improve the appearance of my finger. Do you have any suggestions or info on any procedures."

Secondary reconstruction is always less effective than "doing it right" at the time acute care is given to a nail bed injury. The appearance and shape of the nail improves during the first year after the injury so no attempts at reconstruction of the nail bed should be made until after the first year. You may want to refer back to my post on fingernail anatomy and fingertip injuries.

Typical nail deformities that require reconstruction include:

• Non-adherent nails -- is the most common deformity of the nail plate after injury. It occurs due to scar tissue in the sterile matrix which prevents attachment of the nail plate to the nail bed. The non-adherent nail "sits" upwardly deviated from the nail bed. The lack of nail plate adherence becomes more of a functional than a cosmetic problem when more than one third of the distal nail is non-adherent. This allows it to catch on clothing and other articles putting the nail bed at risk for further injury. Dirt and other debris gather underneath the non-adherent nail and cause further irritation. Nail adherence on more than two thirds of the nail bed rarely results in a functional impairment.
• Split nail deformities -- A longitudinal split in the nail is often the result of an underlying axial scar beginning in the germinal matrix of the nail bed. The scar divides the nail plate during formation. The nail plate grows out as 2 distinct plates.
• Irregular contours -- The linear ridging deformity of the nail following a trauma is most often associated with an underlying bone or soft tissue abnormality. The ridging usually is more of a cosmetic problem more than a functional one.
• Hook nail -- is usually the result of a fingertip amputation, with partial or complete loss of the supporting tuft of the distal phalanx (bone) and a loss of the distal nail bed and fingertip soft tissue. The regenerating nail plate follows the contour of the repaired fingertip amputation, angling in a dorsal (top) to volar (palm) direction. The hook-nail deformity is more than a cosmetic disfigurement to the patient's finger. The tip of the finger is often tender and chronically irritated, and sensibility may be impaired. The patient may also have difficulty grasping fine objects. Occasionally, the nail may catch on clothing or other utensils and become a constant source of trauma.

• Pincer nail deformity -- represents a loss of the normal convex shape of the nail plate. The lateral edges of the nail plate have a marked convexity, turning acutely volarly (towards the palm) and taking on the characteristic shape of an omega sign when viewed head on at the distal phalanx. The exact etiology of this deformity is somewhat obscure, but a loss of the lateral integrity of the distal phalanx may occur, allowing this greater curvature of the nail plate. Paronychial infections may be more frequent with this type of nail irregularity.

• Loss of the eponychium with synechiae -- Burns are the most common cause of loss of the eponychium. Other causes include friction avulsions, crush injuries, and complex lacerations. The eponychium contributes to the epidermoid keratinization of the nail, providing the characteristic sheen on a dorsal nail plate. So loss of the eponychium can result in an unsightly nail or notched deformity which can be a source of tenderness for the patient.

TREATMENT
Non-adherent Nail

• Treatment involves trimming the nail back to normal sterile matrix. The scar in the nail bed is then excised and the defect is closed primarily or with split matrix grafts. Primary closure may be obtained with minimal nail bed undermining if the defect is less than 1-2 mm. The nail plate should adhere to the graft.
• If the cause of non-adherence is due to hyperkeratosis of the nail bed, then the nail is removed. Then the hyperkeratosis is removed by scraping the sterile matrix with the edge of the scalpel blade down to the level of the normal nail bed. The nail either grows out completely or partially adheres to the nail bed. The procedure may be repeated if complete adherence is not achieved.

Split Nail Deformities

• Treatment is determined by the underlying problem.
• Longitudinal scars on the sterile matrix of the nail bed can usually be treated by excision and primary closure. Small Z-plasties (2 mm in length) can be used to alter the direction of the scar. Larger scars will require a split-thickness nail bed graft following excision. Loss of the central portion of the germinal matrix requires grafting with a full-thickness germinal matrix graft from the toe.
• Adhesions within the eponychial fold are treated by removing the nail plate and dividing the synechia transversely. Upward traction on the open portion of the nail fold should allow visualization to perform the transverse incision. Any scar tissue of the germinal matrix and dorsal roof of the eponychium must be excised. A germinal matrix graft is then applied. Simple excision of the germinal matrix scar with primary approximation is less effective.
• Reconstruction of the dorsal roof of the eponychium help restores the normal sheen to the regenerating nail. A silicone sheet (acts as a splint for the graft) should be placed in the nail fold to maintain the integrity of the eponychial fold until the grafts have "taken".

Linear Ridging Deformity

• As with the other deformities, the nail plate must be removed and the sterile matrix visualized. An incision is made over the ridge in a longitudinal fashion. The sterile nail bed is elevated from side to side (radially and ulnarly) to expose the underlying tissue. Scar tissue, foreign bodies, or bony exostosis must be removed. The nail bed is redraped and sutured with 7-0 chromic sutures. Any excessive scarring of the sterile matrix should be excised and replaced with a split-thickness nail bed graft. The nail plate or silicone sheeting is then placed over the repair and under the eponychial fold.

Hook Nail Deformity

• Can be somewhat difficult because of the loss of bony and soft tissue support. Secondary reconstruction is centered on recreating the initial defect, then restoring the bony and/or soft tissue support.
• Soft tissue support on the volar (palm-side) aspect of the finger can be accomplished with V-Y Atasoy/Kleinert flaps, lateral Kutler flaps, a cross-finger flap, or a thenar crease flap.
• Split nail bed grafts (distal edge) are applied directly to the volar flaps, and the proximal edge is sutured to the native nail bed.
• Restoring the bony support is less predictable. Distraction osteogenesis, bone grafting, and step cutting in the distal phalanx are likely to lead to a high rate of resorption.
• Microvascular composite flaps of nail bed, bone, and soft tissue from the toe have been described with excellent results. A high level of microsurgical expertise is essential and the patient must be willing to sacrifice a toe for this procedure. This may be hard to justify as the local flaps mentioned above are easily and more reliably performed.
• Revision amputation is an alternative to reconstructing a problematic hook-nail deformity.

Pincer Nail Deformity

• Is corrected by using dermal grafts to "build up" the sides of the nail bed. This is done by first removing the nail plate. Then an incision is made in an oblique fashion in the pulp of the distal fingertip just distal to the end of the lateral nail folds. The nail bed is elevated off the distal phalanx by passing a Freer periosteal elevator into the wound gently pushing proximally. This will create a tunnel that is 2-3 mm wide and extends the full distance of the nail bed, including the germinal matrix. Care must be taken not to damage or buttonhole the overlying nail bed.
• Nylon sutures (5-0) are then placed through the dorsal skin into the tunnel created between the distal phalanx and the lateral bed. The suture is carried out of the wound to capture the proximal end of a dermal graft. The suture is passed back through the tunnel and out the dorsal skin, exiting near the entrance of the previous suture. The dermal graft is advanced through the tunnel by pulling on the sutures. The suture is tied, securing the dermal graft in the tunnel. The excess length of the dermal graft is excised, and the wound is closed with a single nylon suture. Both sides (medial and lateral) of the nail plate are done in the same way.
• A silastic sheet (the old nail won't work here--wrong shape) is introduced into the eponychial fold. The sheeting is removed in approximately 10 days. The procedure has had excellent results in restoring the nature contours of the nail plate.

Loss of the eponychium with synechiae

• Entirely removing the nail plate is often necessary to see the remaining edges of the proximal nail fold. As with the other deformities, any scar tissue of the nail bed, matrix, etc must be removed.
• Composite grafts can be obtained from the large or second toe. These composite grafts include the dorsal roof of the eponychial fold as well as the dorsal skin.
• The composite graft is sutured in place with a 7-0 chromic and 6-0 nylon sutures, and the nail plate is replaced. The surgical site is then covered with sterile gauze and dressed as described previously.
• The survival of the grafts can be precarious. The postoperative immobilization must be meticulous.
• Occasionally enough skin is available on the dorsum (top) of the finger to rotate or transpose as local flaps to the eponychium. A split sterile matrix graft can then be sutured to the undersurface of the flap to restore the dorsal roof bed. The donor site of the flap is closed primarily or covered with a split-thickness skin graft.

COMPLICATIONS / OUTCOMES
The results of the initial repair are far better than reconstructive attempts.
Infections to the nail bed following repair are uncommon.

Split-thickness sterile matrix grafts are required for areas of nail bed loss. The excellent results obtained from split grafting the nail bed defects have made this procedure common practice for most hand surgeons. The donor site heals without difficulty with most authors reporting no residual deformities secondary to graft harvesting. Orientation of the split graft on the recipient bed does not affect adherence or nail plate morphology. Though most will have good results, some patients may have some nail plate irregularity with linear ridging or distal nonadherence (usually at the site of the initial avulsion and not at the site of donor harvesting).

Germinal matrix defects must be treated with a full-thickness germinal matrix graft. The type of material (silicone sheet, nail plate, sterile petroleum jelly-impregnated gauze) placed in the eponychial fold does not appear to influence the final outcome and appearance of the regenerating nail plate.

It can not be said enough:
Careful initial repair has a better outcome than secondary reconstructive surgery.
REFERENCES
Nail Pathology; Michael Neumeister MD and Dimitrios Danikas MD; eMedicine Article, October 27, 2004
The Perionychium; Zook EG, Brown RE; In: Green DP, ed. Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone; 1999.
Nailfold Reconstruction for Correction of Burn Fingernail Deformity; Plastic & Reconstructive Surgery, 117(7):2303-2308, June 2006; Donelan, Matthias B. M.D.; Garcia, Jesus A. M.D., Ph.D.
Nail Transfer: Evolution of the Reconstructive Procedure; Plastic & Reconstructive Surgery. 100(4) Supplement 1:907-913, September 1997; Endo, Takashi M.D.; Nakayama, Yoshio M.D.; Soeda, Shougo M.D.
Nail Lengthening and Fingertip Amputations; Plastic & Reconstructive Surgery. 112(5):1287-1294, October 2003; Adani, Roberto M.D.; Marcoccio, Ignazio M.D.; Tarallo, Luigi M.D.
Nail Regeneration by Elongation of the Partially Destroyed Nail Bed; Plastic & Reconstructive Surgery. 111(1):167-172, January 2003; Lemperle, Gottfried M.D., Ph.D.; Schwarz, Martin M.D.; Lemperle, Stefan M. M.D.
Nail Surgery; Neh Onumah MD and Richard Scher MD; eMedicine Article, September 18, 2006

Call for Submissions--SurgeXperiences 115

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

Chris over at Made a Difference will be hosting SurgeXperiences 115 on February 17. Submissions should be made by February 15th. He has asked:

"Please send me your impressions of the effect of war on surgery, of surgery on war, and any observations, musings, or comparisons from inside or outside the theater of war. Please submit your entries here, or if it is easier, you can email them to me here."

The current SurgeXperiences is up here at Notes of an Anesthesioboist.

Here is the catalog of past surgXperiences editions.   If you wish to host a future edition, please contact Jeffrey who runs the show here.

Basket Quilt

This is a basket quilt I made in 2000. I don't recall where I got the pattern. The quilt is 41 inches square. The baskets were fused on and then blanket stitched with embroidery thread.

The quilting was done by machine.
It's easier to see the stitching detail on this basket.

Each flower petal begins with a circle. The circle is folded into quarters and gathered along the edge. Each flower takes five petals. The center is a "yo-yo" and a button.

This techniques give 3-D to the flowers, as they are only attached with the button center.

"Because I Am Able"

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

Susan over at DonorCycle will be participating in the 11th Annual Hustle Up the Hancock event to help raise money for lung disease research and education. It takes place on February 24, 2008 and involves climbing 90+ stories along with her friend Steve. Steve is a double lung recipient. You can read his story here.

I like the reason Susan gives: "You may think that it's crazy to climb the John Hancock Center but I am doing so because I am able. I can breathe freely, and there are many people who are not as lucky as I."

She would like to have some help reaching her fundraising goal. If you would like to make a donation go here to her personal page.

Thank you!

Neighbor in Need Fund

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

One of our local radio stations, KATV, began this fund initially to help our "neighbors" to the south of Arkansas affected by Hurricane Katrina. It was then used to aid the Dumas community when it was flattened by a tornado a year ago. Wednesday, KATV announced it is re-activating the Neighbor in Need relief fund because help is needed again after Tuesday's killer twisters. No matter if it's $1, $5, $10, or more -- it will all add up. KATV kick-started the fund with a $5,000 donation. The money will help the Red Cross meet the needs of those living in Arkansas' affected areas. Our local Red Cross has been hit hard this year due to several apartment fires which has depleted their reserves. For more information on how you can contribute, click here.

If you live in one of the other states affected, Tennessee, Alabama, or Kentucky, then consider giving to your states Red Cross. There is also a need for blood donations. Consider being a part of your church's group to aid in clean up.

To see video of the storm damage done in Clinton, Arkansas as seen from KATV's chopper go here.

Eyebrow Reconstruction

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

The eyebrow plays an important role in facial harmony and eye protection. Eyebrows can be injured by burn, trauma, tumor, tattooing and alopecia. Eyebrow position, contour, and movement are important features of facial expression. There are some really nice tips on "shaping your eyebrow" here. Many of those tips can be used in reconstructing an eyebrow. I particularly like these:

• The best shape for eyebrows is a straight line from the beginning of the eyebrow to the arch, and then a soft curve from the arch out to the end of the eyebrow.
• Go with the natural line of your eyebrow. All bone structure is different, and so are your eyebrows. Not sure where your eyebrows should be? Run your finger along your eyebrow bone. That's exactly where the line of your eyebrow should be. If you try to arch your eyebrows too high above the bone, it will look too fake. Stay with the arch that works best with your bone structure. It's the one that you naturally have already.
• Make sure the beginning and end of the eyebrow is on the same line. If one side is too high up or too far down, it can throw off the shape of the eye.
• The goal of perfect eyebrows?
  To bring attention to your beautiful eyes, not your eyebrows.

The pictures here illustrate how important brows are to how our face looks. The first is pre-transplantation and the second post. To me it is a dramatic difference.

Eyebrow Anatomy and Physiology
The density of eyebrow hair generally remains stable with age. Men often have an increased number of eyebrow hairs than women. The eyebrow is frequently altered in appearance by plucking.

There are four very distinct characteristics of eyebrow hair:

• The direction of eyebrow hair changes dramatically in different parts of the brow. In the region of the eyebrow nearest the nose, the hair points upward, almost vertical in orientation. The hair across the top of the eyebrow points outward and downward. The hair in the lower part of the brow grows outward and upward.
• The hairs of the eyebrow emerge from the follicle at a very acute angle so that the hair grows flat to the skin’s surface. This is in contrast to scalp hair where the angle between the hair and scalp can be 45 degrees.
• The hairs grow as individual strands, rather than in the 1- to 4-hair follicular unit grouping that are characteristic of scalp hair.
• The growth cycle of eyebrow hair is very short. This means that eyebrow hair will grow (in anagen) only for about 4 months before it enters the resting (telogen) phase and falls out. In contrast, scalp hair has a growth phase that can last 3 to 7 years, enabling the scalp hair to grow much longer.

Methods for Eyebrow Reconstruction include:

• Hair Transplant Grafting -- It is important to follow the natural hair direction very closely. This entails very subtle angle changes to recreate the fan-like splay of hair at the medial end of the brow and the converging hair direction as one moves laterally along the brow. You want the hair will lie as flat as possible on the surface of the skin as it grows so the recipient sites have to be created at very acute angles to the skin surface. Only individual hair follicles should be used. If the patient’s hair is waved or curly, it is important to rotate the hair so that curve of the hair shaft follows the natural curve of the eyebrow.  The hair transplanted to eyebrows will continue to grow and must therefore be periodically cut. This leaves a cut-end that is not as delicate as the fine-tipped end of an untouched hair. In the process of healing, all wounds contract. This may slightly change the hair's flat orientation and result in eyebrow hair that is slightly more elevated than one would like. Over time, the transplanted scalp hair will slowly begin to approximate the growth pattern and characteristics of the existing eyebrow hair, but may never totally match it. The appearance of eyebrow hair transplants will mature over the course of a year. During this interval, the eyebrow can be tweezed and shaped as needed.
• Superficial temporal artery island flap with anterior or posterior branch -- There are two draw backs for use of this flap--1) the frontal area is a common site of hair loss in men and this can affect the reconstructed brow and 2) the hair will grow downward when placed in the brow position
• Island flap from lateral parietal area -- This area of scalp is not usually affected by alopecia. This flap used the superficial temporal artery. The hair will grow in the correct direction, sort of (see above on the complex changes of direction of eyebrow hairs). Care must be taken so that when the flap goes through the cutaneous tunnel of the temporal area, there is no torsion or tension.

Complications

The complications will depend on what procedure is done. For each there is always the risk of infection, bleeding, and scar (donor site and brow site). For the flap techniques, there is the risk of loss (partial or complete) of the flap to necrosis. To each, there is the possibility of a poor result.

And though most of us don't wish to have Groucho Marx eyebrows, you must admit the way he "wiggles" them can make you laugh. Check him out in this scene from "Monkey Business"

REFERENCES
Comparison of Four Surgical Methods for Eyebrow Reconstruction; Indian Journal of Plastic Surgery, Vol 40, #2, pp 147-152, 2007; Omranifard Mahmood, Koushki A Mehrabi
EYEBROW TRANSPLANTS -- From Scalp to Brow; Plastic Surgery Products 2006; 34-8; William R. Rassman, M.D. and Robert M. Bernstein, M.D.
Eyebrow Reconstruction; Plastic & Reconstructive Surgery, 107(5):1225-1228, April 15, 2001; Juri, Jose M.D.
Reconstruction of ear, eyebrow, and sideburn in the burned patient; Plast. Reconstr. Surg. 55: 312, 1975; Brent B
Reconstruction of the Localized Eyebrow Defect; Plastic & Reconstructive Surgery. American Society of Maxillofacial Surgeons 50th Anniversary. 100(3):685-689, September 1997; Cedars, Michael G. M.D.
Aesthetic Analysis of the Eyebrows; Plastic & Reconstructive Surgery. 99(7):1808-1816, June 1997; Gunter, Jack P. M.D.; Antrobus, Steve D. M.D.
Eyebrows--Oculoplastic Gallary
The Model Eyebrow by Elle von Frendenberg; The Beauty Newsletter(blog), November 8, 2006
Anatomy of ‘A Beautiful Face & Smile’; J Anat. Soc. India 52(1) 74-80 (2003); Patnaik, V.V.G; Singla Rajan, K; Bala Sanju.

You're Invited!

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

Tomorrow night Sid Schwab, MD will be interviewed by Dr Anonymous on The Doctor Anonymous Show. Dr. Schwab is one of my favorite medical bloggers. He is author of Surgeonsblog and also the book, Cutting Remarks. Both are good reads. If you haven't already, I hope you will check them out.

Dr. Anonymous has offered this invitation:

"Join us on Thursday, February 7th, 2008 at 9 pm Eastern Time where we will be talking about his blog, his book, and a lot more. You can also join us in the live chat room or even call into the show to ask Dr. Schwab a question. Now, it's been a couple of weeks since I've had my show. Hopefully, I remember how to do the show. We'll see what happens this time. Tune in tomorrow for details!"

Consider yourself invited to the party. Please, come and join us.

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

Permanent Hair Removal

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

Recently I posted on using hair for charity--raising money or making wigs. There are many of us who chose to remove unwanted body hair for cosmetic, social, cultural, or medical reasons. This includes both men and women. Even the indications that are considered "Medical indications" are influenced by the social and cultural norms. The hair on a chest like Tom Selleck's should be left alone (just my opinion), hairy backs are another thing.

The medical indications include:

• Hirsutism, which is excess terminal hair in the distribution of hair growth influenced by androgens (ie, face, chest, back, abdomen)
• Hypertrichosis, which is congenital or drug-induced increase in hair growth in areas that are not androgen dependent.
• Pseudofolliculitis
• Hair growth from a grafted donor site
• Sex-change operations performed in men.

IMPORTANT TERMINOLGY

Temporary hair reduction is defined as a delay in hair growth, which usually lasts 1-3 months, consistent with the induction of telogen.

Permanent hair reduction refers to a significant reduction in the number of terminal hairs after a given treatment. This reduction must remain stable for a period of time longer than the complete growth cycle of hair follicles at the given body site. It has recently been suggested to add another 6 months to this posttreatment observation time (ie, the time necessary for a damaged follicle to recover from the laser injury and reenter a normal growth cycle). Note that "permanent" does not mean no regrowth of hair.

Complete hair loss refers to a lack of regrowing hairs (ie, a significant reduction in the number of regrowing hairs to zero). Complete hair loss may be either temporary or permanent.

METHODS of HAIR REMOVAL

There are many methods available for temporary or permanent hair removal. Each has its own relative efficacy and adverse effects. Different methods for the removal of body hair include the following:

• Temporary hair removal - Shaving, epilation, depilation, bleaching

• Temporary hair reduction - Eflornithine hydrochloride (VANIQA cream 13.9%), laser-assisted hair removal
• Permanent hair removal - Electrolysis, Laser-assisted Hair Removal (LHR), Intense Pulsed Light Hair Removal (IPL)

Electrolysis

Electrolysis (or electrology) involves the insertion of a small, fine needle into the hair follicle, applying a pulse of electric current that damages and eventually destroys the hair follicle. Multiple treatment sessions are required to achieve a clinically significant result. The 2 types of electrolysis are galvanic electrolysis (direct current electrolysis) and thermolysis (alternating current electrolysis).

Proper electrolysis requires accurate needle insertion technique and appropriate intensities and duration of current. In addition, only anagen-phase hairs should be treated because telogen-phase hairs are believed to be more resistant to damage. Anagen-phase hairs can be distinguished easily from telogen-phase hairs by shaving the area to be treated and, in a few days, treating only those hairs visible on the skin surface (anagen-phase hairs).

Potential adverse effects of electrolysis include:

• Scarring (ie, keloid formation)
• Postinflammatory hyperpigmentation
• Hypopigmentation
• Pain--can be diminished with the use of topical anesthetic creams (Emla, ELA-Max, Topicaine) applied 1 hour prior to the procedure.
• Local bacterial and viral infections

The adverse effects (and success) of electrolysis are dependent on technician experience and the duration and intensity of the current. Electrolysis is not safe for patients with pacemakers and should not be used on these patients.

Hair removal with light (laser, IPL)

Since 1996, when hair removal laser technology first became available for general use, numerous advances have occurred in laser hair removal. This has resulted in the many different types of lasers now available for treatment of excessive hair. Laser hair removal is based on the theory of selective photothermolysis, or selective destruction of the follicular unit, resulting in significant hair reduction in treated areas.

• Selective photothermolysis --This principle predicts that selective thermal damage of a pigmented target structure will result when sufficient fluence at a wavelength, preferentially absorbed by the target, is delivered during a time equal to or less than the thermal relaxation time of the target. [When enough heat damage is done to the target --hair in this case]
• Melanin is the natural chromophore (light-absorbing molecule)for targeting hair follicles. It's absorption spectrum is 250-1200 nm, which spans the entire ultraviolet, visible, and infrared light ranges.
• When melanin absorbs energy in the form of heat from a pulse of laser light, there is "selective" heating which causes thermal injury to the melanin-containing cell (in this case, the hair follicle) and its surroundings. Ideally, the laser energy is absorbed selectively by the melanocytic hair bulb and matrix, thus destroying the hair follicle and its capacity to regrow, while protecting the surrounding tissue where the melanin concentration is minimal.
• Melanin in the epidermis presents a competing site for absorption. In persons with darker skin, the higher levels of melanin in heavily pigmented skin (tanned, Asian, Blacks, etc) compete as a chromophore for the laser light. This light is converted to heat and can cause skin blistering or changes in skin pigmentation.
• Selective cooling of the epidermis has been shown to minimize epidermal injury. Cooling can be achieved by various means, including ice, a cooled gel layer, a cooled glass chamber or sapphire window, a pulsed cryogen spray, or cooled airflow.
• Laser treatment usually produces complete but temporary hair loss for 1-3 months, followed by partial but permanent hair loss. Multiple treatments may be necessary.

Before the widespread use of longer wavelengths and pulse durations and more effective cooling devices, laser-assisted hair removal was best used to treat individuals with light skin and dark hair. More recently, however, long-pulsed lasers have been used to safely and effectively treat patients with darker skin types.

Laser light sources currently used in hair removal treatments include:
Long-pulsed ruby

• The long-pulsed ruby laser was the first widely used laser for hair removal. Its light energy has the most selective absorption by melanin and the shortest depth of penetration (wavelength of 694 nm).
• Use of this laser for hair removal is indicated in individuals with light skin and dark hair.
• Its efficacy has been demonstrated in numerous studies, ranging from 20-60% hair reduction after one treatment and up to 50-78% reduction after multiple treatments.
• The ruby laser penetrates the skin by only 1-2 millimeters and can cause significant absorption by epidermal melanin of thermal energy. The use of this laser on patients with darker skin types is not recommended.

Long-pulsed alexandrite

• The 755-nm alexandrite laser has now been widely used for laser hair removal. It is recognized as being efficacious and generally safe.
• This laser is still typically used for patients with lighter skin types, but its longer wavelength allows for deeper penetration into the skin, and it can be used for patients with darker skin.
• Studies have reported hair reduction from 4-56% after only a single treatment and from 33-95% hair reduction after multiple treatments, depending upon number of treatments and body location.
• The adverse effects of this laser, when used on patients with darker skin types, can include blistering, crusting, and alterations of pigment, even when skin cooling devices are used. In patients classified as having the darkest skin, residual hypo- or hyperpigmentation is the rule with the alexandrite laser.

Long-pulsed diode

• The 810-nm long-pulsed diode laser has been demonstrated to have hair removal capacity comparable to those of the ruby or alexandrite lasers. After a single treatment, hair reductions of 32-34% have been reported, and up to 84% hair reduction has been reported after multiple treatments.
• The diode laser can be used in darker skin types because of its longer wavelength and adjustable pulse duration. It should be used with an efficient skin-cooling device.
• Still, temporary adverse effects have been reported with the use of the diode laser in the form of postinflammatory hyperpigmentation when used on individuals with dark skin.

Long-pulsed Nd:YAG

• The Nd:YAG laser is the safest type used to treat unwanted hair on patients with dark skin and is most suitable for patients in this group. At 1064 nm, this laser penetrates the skin deeper than other lasers (to a level of 4-6 mm) with less absorption at the skin.
• It is also less effectively absorbed by melanin. This leads to lower instances of adverse effects and better tolerance in patients with dark skin, but also lower efficacy for hair removal.
• Permanent hair loss has been reported, however, with reported hair reductions of 27-53%, depending on the number of treatments administered and the body location.
• The FDA has approved the long-pulsed diode and the long-pulsed Nd:YAG lasers for use in hair removal in patients with darker skin classifications. All FDA-approved laser systems used for hair removal must have efficient and effective epidermal cooling devices incorporated as part of the system.

Intense pulsed light systems

• Intense pulsed light (IPL) systems utilize a xenon bulb as a light source, which produces polychromatic light with wavelengths from 550-1200 nm. This is in contrast to laser light sources, which produce monochromatic light of a specific wavelength. Light emitted by the bulb passes through a filter that excludes shorter wavelengths that may severely damage skin.
• The ability to "tune" the wavelength of light emitted by these systems gives IPL systems the advantage of versatility. Using different filters, a pulsed light system could mimic any number of laser systems, allowing the operator to treat many different conditions amenable to light therapy, including, of course, the removal of unwanted hair.
• Studies have shown intense pulsed light to be an effective method of hair removal. In a study of 210 patients who underwent hair removal by IPL, a mean hair reduction of 80% was reported after 3-5 treatments.
• Minimal adverse effects, including transient erythema and localized edema, were reported.

Skin Prep and Safety

• Patients should be instructed to avoid sunlight and active tanning prior to treatment.
• Patients may shave or use depilatory creams up to the day prior to treatment. Tweezing should not be done, as the hair follicle/shaft is needed for the treatment to work.
• Topical anesthetic creams may be applied to the treatment area to reduce discomfort during the procedure. Cold compresses are also effective in reducing discomfort, erythema, and edema at the treatment area.
• The skin surface must be thoroughly cleansed of all makeup, anesthetic creams, and other applicants immediately prior to laser treatment. This may be done with water, followed by alcohol swabs, and should be allowed to dry completely.
• Laser systems are dangerous hazards to the eye. The highest concentration of melanin in the body is contained in the retina, which is highly susceptible to damage by laser light. Every person in the room during laser treatment should wear protective eyewear that is certified for the wavelength of the laser in use. Because the patient usually lies supine, he or she may require full occlusive eye protection to prevent laser light from entering underneath a sunglasses or goggle type of protective eyewear.
• A higher occurrence of adverse effects and adverse reactions has been noted at the neck region in women; higher fluences in this area should be used with caution.
• For treatment of the chin, perioral region, or upper lip, tooth enamel should be protected from excessive laser light exposure. Inappropriate exposure to certain laser light may induce hard tissue disintegration in the tooth and irreversible damage to dental pulp.
• During laser treatment, each laser spot should overlap by no more than one third of the spot size. Further overlapping of continuous pulses causes accumulation of thermal injury and potentially causes epidermal damage. No overlapping of spots could result in missed areas in the treatment area.

Post-procedure Care:

• Cold compress or ice pack may be used to decrease pain and reduce swelling.
• Patients may also be given a topical corticosteroid cream to decrease local erythema.
• If minor skin damage has occurred, a topical antibiotic ointment may be applied until the skin has sufficiently healed.
• For more serious skin damage, an oral antibiotic may be prescribed for prophylaxis if deemed necessary by the health care provider.
• Makeup may be applied to treated areas the day following the procedure if no epidermal damage has occurred.
• Patients should be told that hair casts will shed from treated areas over the following week and that this should not be confused with new hair growth.

Future treatments should be planned when they are likely to be most effective. Timing depends upon the body surface area to be treated.

• Hair on the trunk and extremities grows more slowly than on the face and head, and future treatments to the trunk and extremity should be planned after 2-4 months.
• In women, facial hair is lighter in color and finer in texture than on other parts of the body. These hair properties make the face a resistant area to treatment. Therefore, greater numbers of treatments are often required, and at shorter intervals. Treatments of the face should be timed at intervals of approximately 4-6 weeks.

Complications:

Immediate effects after a single treatment of laser-assisted hair removal include perifollicular erythema and edema. These are expected after treatment and should not be considered adverse effects. They are minimized by cold application and resolve in a few hours.

The risk of developing adverse effects or complications after laser-assisted hair removal varies widely and depends upon many factors including the type of laser used, skin color, etc.

• Blistering -- is a result of injury to the epidermis, possibly due to high fluences or increased overlapping of laser pulses. It is the most common complication and can occurs with all lasers/IPL.
• Scab formation is another common adverse effect of laser treatment. Blistering and minimal epidermal crusting have been reported in up to 15% of patients treated with both ruby and alexandrite lasers. These occurrences are more common in patients with tanned skin and darker skin types.
• Hyperpigmentation is a darkening of the skin and can occur after laser treatment. This phenomenon is usually reversible and is due to a stimulation of melanin production in skin melanocytes. This reaction is similar to a suntan.
• Hypopigmentation, or lightening of the skin, can occur after laser treatments. This is caused by damage to the epidermal melanocytes after their melanin absorbs laser light energy, causing destruction of these cells. This type of damage may be permanent and occurs more commonly in patients with darker skin.

REFERENCES
Nonlaser Hair Removal Techniques; Alicia Barba MD, Leslie S Baumann MD, and Esperanza C Welsh; eMedicine Article, December 15, 2004
Electrolysis - DermNet NZ
Laser-Assisted Hair Removal; Christine Dierickx MD; eMedicine Article, April 12, 2006
Laser Hair Removal; Joseph A Molnar MD, Christian N Kirman MD, and Samer Alaiti MD; eMedicine Article, February 21, 2007
On the Physics of Laser-induced Selective Photothermolysis of Hair Follicles: Influence of Wavelength, Pulse Duration, and Epidermal Cooling; Journal of Biomedical Optics, Vol 9, No 2, pp 353-361; Lars O Svaasand, J Stuart Nelson

SurgeXperiences 114 is Up!

Updated 03/2017--links removed as many are no longer active.

SurgeXperiences 114 is up over at Notes of an Anesthesioboist.  I hope you will go over and check it out.  Very nice edition!
The next edition (#115) will be February 17, hosted by Chris from Made a Difference!  Glad you are back safely from Iraq, Chris!

Twisted Ribbon Quilt

I made this quilt in 2004. The white is a cotton flannel. The black is a cotton velvet left over after making a dress for one of the nieces. The print is a cotton-linen found in the bargain bin at the fabric store. The limited amounts of the black and print determined the size and helped dictate the border. I found the block design in Jinny Beyer's book, The Quilter's Album of Blocks and Borders (copyright 1980). A friend found the book at an "antique" store for $4. It is a wonderful book. 

The quilt is 45 inches X 56 inches and usually lays over the back of my husband's lazy-boy chair. Rusty insisted on getting in the picture.

A close-up. Sorry the quilting doesn't show better. The centers are quilted with roses. The ribbons are out-lined quilted.

Hair for Charity

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

Fellow medical blogger, Shadowfax, over at Movin' Meat is going to shave his head for charity. You can read his posts--"I'm a Beautiful Man" and "I get letters" that highlight his reasons.

St. Baldrick's is a fundraising foundation dedicated to raising funds for pediatric cancer research. Currently, only $1 of every $100 spent on cancer research goes to funding all of pediatric cancer research. Since the organization's inception in 2000, they have raised over $34 million for research funding. 83 cents of every dollar goes to funding, a very high percentage for a charitable foundation. Their fundraising centers around shaving the head of a volunteer, to promote solidarity with all these great kids who lose their locks to chemo. How it works: a volunteer will sponsor a child, and gets friends and family to contribute money to his fundraising efforts. There is then a public shaving to celebrate!

Well, I'm not sure that I (being female and not Britney Spears or Sinead O’Connor) will ever willing shave my head, but I have donated my hair twice for Locks of Love. They are a public non-profit organization that provides hairpieces to children under age 18 suffering from long-term medical hair loss from any diagnosis. Most of the children helped by Locks of Love have lost their hair due to a medical condition called alopecia areata, which has no known cause or cure. The first time I donated, the length they asked for was 15 inches. It is now only 10 inches. Here are their guidelines if you wish to donate.

• 10 inches measured tip to tip is the minimum length needed for a hairpiece. This includes hair that is colored or permed.
• Hair must be in a ponytail or braid before it is cut.
• Hair must be clean and completely dry before it is mailed in.
• Place the ponytail or braid inside of a plastic bag, and then inside of a padded envelope.
• Fill out the hair donation form, or write your name and address on a separate sheet of paper and include inside the envelope.
• All hair donations must be mailed to Locks of Love at: 2925 10th Avenue N, Suite 102
  Lake Worth, FL 33461-3099

Please Note:

• Shorter hair will be separated from the ponytails and sold to offset the manufacturing costs. Although the shorter hair cannot be used in the hairpieces, it still greatly helps to reduce costs.
• Gray hair will be accepted and sold to offset the manufacturing costs.
• Hair that has been bleached (usually this refers to highlighted hair) is not usable. If unsure, ask your stylist.
• Hair that is swept off of the floor is not usable.
• Hair that is shaved off and not in a ponytail or braid is not usable.
• We cannot accept dreadlocks. Our manufacturer is not able to use them in our children’s hairpieces. We also cannot accept wigs, falls, hair extensions or synthetic hair.

Then there is the Wigs for Kids program. Their guidelines for hair donation are similar to the above ones for Locks of Love. The history of this organization goes back over 25 yrs:

" founder Jeffrey Paul cannot believe his incredible journey. He was a successful hairdresser with a thriving business. He traveled all over the world to work with powerful presidents and gorgeous models. But one day, his 15-year-old niece walked into his salon, crying. She tearfully begged him to stop her hair from falling out. My immediate thoughts were not serious.

But when I saw the look in her father’s eyes, I knew it was something more.” It turned out that she had just been diagnosed with leukemia. “Uncle Jeff, you know I’ve been trying to get on the gymnastics team all my life,” she cried. “My hair is going to be falling out when it’s time to try out.”

Although chemotherapy would help save her life, it would also leave her with no hair. “I promised her that she would have hair,” Paul says. “And when you make a promise to a kid, you keep it.” Read more here.

I hope you will consider making a monetary donation for Shadowfax/ St Baldwick's and maybe donating some of hair to one of the groups that make wigs. Hair, like blood, is a renewable resource. A bad haircut is only temporary.