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Quantum leap advancements in hair transplantation have occurred in the past 10 to 15 years, particularly the use of micrografts (one- to two-hair follicular unit grafts) and minigrafts (three- to four-hair follicular unit grafts) used in large numbers (>1000 grafts) in a single session (megasession). This was initially described for the treatment of male pattern baldness. Since that time I have found many other applications, particularly in facial and scalp reconstruction. Common causes for aesthetic reconstructive hair restoration in my experience include: hair loss due to facelift and forehead lift procedures, revision of unsatisfactory results from previous hair transplantation, burn alopecia, congenital reasons, postoncological resections, and idiopathic. The basic technique is described in detail, including the variations for each of the challenging anatomic areas including sideburns and temporal hairline, eyebrows, eyelashes, mustache, beard, and remaining scalp. Especial attention is given to the direction of hair growth, texture, aesthetic planning, and absence of detectable scars, so as to mimic nature. The use of micrografts and minigrafts in the aesthetic reconstruction of the face and scalp has been found to be safe and predictable and has provided a high level of patient satisfaction.
Traditionally little attention has been given to fine details in hair restoration especially in reconstructive surgery. The techniques most frequently used in the past include tissue expansion, scalp flaps, hair plugs, and scalp strips, most of which should remain as part of the armamentarium in hair restoration.
The introduction of micrografts (one- to two-hair grafts) and minigrafts (three- to four-hair grafts) has made a most significant advancement in the care of male pattern baldness and female androgenic alopecia (Fig. 1). Finally natural and aesthetically pleasing results were possible.1,2,3,4
In addition to the use of these grafts in cases of male pattern baldness, many other applications in aesthetic reconstruction have been found, particularly on the face.7 In my experience the use of micrografts and minigrafts in aesthetic reconstruction of the face and scalp in order of frequency include:
The procedure is performed under IV sedation and local anesthesia in my own surgical suite, unless the patient is a child in which case it is done under general anesthesia in the hospital. I usually use Versed (midazolam, Bedford Laboratories, Bedford, OH), usually 2 to 10 mg, and fentanyl (Abbott Laboratories, North Chicago, IL) (sublimaze), usually 50 μg for the sedation, and 0.5% marcaine with epinephrine 1:200,000 for nerve blocks and local infiltration.
When doing scalp hair transplantation, the technique used is basically as described previously by slit and immediate insertion of the grafts.1,2,3,4,5 With the patient in the supine position and mildly sedated, occipital nerve blocks and supraorbital nerve blocks are done with 0.5% Marcaine (bupivacaine, Abbott Laboratories). The donor site is harvested from the occipital area as a horizontal ellipse (Fig. 8A) after a mild tumescent infiltration, which is done with 0.5% xylocaine (AstraZeneca LP, Wilmington, DE) with epinephrine 1:200,000 for hemostasis and to intentionally produce temporary edema, which facilitates the grafts insertion.
The incisions for harvesting the donor ellipse are done with a no. 10 Bard Parker blade incising parallel to the hair shafts using 3.5× loupe magnification; subsequently the grafts are dissected by making 2-mm thick slices by me (Fig. 8B) out of the donor ellipse. Then the actual grafts are dissected from these slices by technicians making an effort to maintain the follicular units intact under 3.5 to 10× magnification (Fig. 8C).
The insertion is done without the need for dilators. For the front 5 to 10 mm of the scalp I use the 22.5 Sharpoint blade. I make the slit and immediately one of my assistants with a fine curved jeweler’s forceps inserts the grafts into the slit (Fig. 8D). Because these blades are so small and sharp, they almost invariably leave no detectable scarring. Posteriorly I use a Feather 11 blade; here also the technique is slit and immediate insertion. Slits made with the Feather 11 blades also heal beautifully but occasionally may leave slightly detectable scarring (minimal pitting), so I never use them right in front.
Hair restoration of the face (eyebrows, mustache, and sideburns) is more difficult because the grafts tend to “pop out” rather easily as one makes slits near other grafts; the neighboring grafts tend to pop out of their corresponding slits. On the face I make the slits in a preliminary fashion, inserting the grafts a few minutes later. Here I use a 22.5 Sharpoint blade. For the eyebrows I lay the blade at a very acute angle up and laterally try to follow the natural direction of eyebrow growth. For the mustache the blade enters in a caudal to cephalic direction and as flat as possible to the lip surface to promote a downward growth. The same principles apply to beard restoration, trying to mimic the natural direction of hair. On the eyelashes the technique is a bit more complicated as the eyelids are thin, delicate, more mobile, and intimately adjacent to the eye globe.
I am evaluating two techniques for eyelash restoration. One is by insertion of follicular unit micrografts to the eyelid margin exclusively by using the 22.5 Sharpoint blade; I use a chalazion clamp to stabilize the lid and protect the eye globe. It is difficult to get enough hair density in one setting. If the donor source was the scalp as is often the case the patient must be told in advance that the neolashes will grow at the normal scalp hair growth rate, so periodic, perhaps weekly, trimming will be needed. The other technique of eyelash restoration I am evaluating is creating a pocket along the ciliary border of the eyelid, elevating a skin flap superficial to the orbicularis occuli muscle for the upper lids, and placing a hair scalp strip into it; this was previously described.8
Another reasonable potential donor site is nasal vibrissae.9 I try to orient the eyelashes in as much a natural direction as possible. Eyebrow hair has more similarities to eyelashes than scalp hair as far as texture, speed, and length of growth (8 to 12 mm), so when feasible (available) this is a most favorable donor site.
From 1993 to 2004 I performed over 750 aesthetic and reconstructive hair transplantations. Every single graft was inserted by me. The overwhelming majority of these cases were done for purely aesthetic reasons and most of these cases were for male pattern baldness.
The only complications were two cases of keloid scarring at the donor site (0.4%)—fortunately not on the recipient area—and two cases of poor hair growth (0.4%) after the procedure (this happened earlier on when my assistants were learning to cut grafts). If the grafts are not dissected carefully, atraumatically and maintained wet with normal saline throughout the case, nothing will grow.
Ingrown hairs and inclusion cysts can develop if the grafts are buried too deep. My first 10 cases had a lot of ingrown hairs (2%). I have been able to decrease this to near 0% by keeping the epidermis of the grafts superficial to the epidermis of the recipient scalp. The grafts at the end of the procedure should look like little bumps; as the healing occurs the epidermis of the grafts becomes a crust, and finally sheds after ~10 to 14 days, ending up smooth. It takes a minimum of 3 to 4 months before any hair growth is noticed. It then continues to improve over the next few months until the final result occurs at ~10 to 12 months.
Due to their small size, micrografts and minigrafts appear to have a lower metabolic requirement to thrive. I am pleased to see them grow in areas of fibrosis, burn, and overskin grafts and flaps, including split-thickness skin grafts. The survival and ultimate hair growth under these circumstances appears to be ~85%, compared with ~95% on nonscarred healthy tissues.
More recently I have been hearing of the use of follicular unit grafts in hair transplantation. The “follicular unit” concept was originally described by Headington in 1984.10 He studied the transverse histological anatomy of the scalp and found that hair grows in groups of one, two, three, or four hairs, with their independent sebaceous glands, sweat glands, neurovascular bundle, and piloerectile muscle, surrounded by a sheath of collagen. These are true physiological units and an effort must be made to maintain them intact. Maintaining them intact appears to increase the graft survival and ultimate hair growth.
Various techniques have been described in the past for hair restoration in reconstructive cases of the face and scalp in the past. There is definitely a place for some of them in special circumstances, particularly the use of tissue expansion and in some cases scalp flaps and free tissue transfers and even some strip grafts.
I tend to favor the use of follicular micro- and minigrafts for the following reasons: first, the safety of the procedure, usually performed under sedation and local anesthesia, with no worries about potential exposure of tissue expanders or flap ischemia or necrosis; often reasonably good results in a single session, although a second session is sometimes needed to increase hair density; undetectable scars; no need for hospital stay (ambulatory surgery, usually in our office surgical suite).
The main disadvantage I think is the fact that it is a tedious process for which a great deal of patience is required from both the surgeon as well as the assistants. But like everything else, with practice one can get quite efficient. There is of course a learning curve, especially to be able to pack the grafts close enough to each other to obtain a reasonable degree of density in just one or two sessions, but it can be done. As with all other surgical procedures, the more we do these, the more efficient we become and our results improve.
The use of follicular unit micrografts and minigrafts for reconstructive purposes of the face and scalp has also been found to be very safe predictable and provide aesthetically pleasing results. There is a high level of patient satisfaction even in a single session.
I have found the use of micrografts (one- to two-hair follicular unit grafts) and minigrafts (three- to four-hair follicular unit grafts) very useful both in aesthetic (i.e., male pattern baldness) and reconstructive cases (lost sideburns after facelift procedures, burn alopecia, etc.). Therefore, adding the basic principles of hair transplantation to the practicing plastic surgeon’s armamentarium of procedures is most beneficial.
Before performing minigraft and micrograft transplantation, it is advisable to take a course and visit someone who routinely performs these procedures.
A surgical team is key, especially when doing more than just a few grafts. Select the members of your surgical team carefully. Look for surgical assistants you already know who are skilled and have had experience working under magnification. The ideal candidate is someone who has assisted you on microvascular procedures. Good hand-eye coordination is a must. The surgical team works closely and should have personalities that mesh. They must be able to work for several hours at a stretch. Patience is prerequisite, especially in the beginning. The members of the team should remain the same to achieve the highest efficiency. I use two registered nurses and a certified surgical technician. You may wish to start them on a part-time basis until you can evaluate their performance. Before performing an actual transplant session, you and your prospective assistants should practice cutting grafts out of healthy pieces of scalp discarded after facelift or coronal forehead lifts.
Initially, limit the number of transplants you perform to no more than 500 grafts, and progress to larger number of transplants as you and your assistants become more comfortable with the procedure and can handle true megasessions (over 1000 micro- and minigrafts).
I usually perform hair transplantation in my office operating room (accredited by the American Association for Accreditation of Ambulatory Surgery Facilities, Inc.). Since in most cases this is not a procedure covered by insurance, as for other aesthetic procedures I try to help patients by providing reasonable facility costs.
You can get most surgical supplies and equipment from local medical suppliers. However, more specialized surgical instruments, surgical blades, and supplies such as background lighting, surgical microscopes, and magnifying loupes can be purchased from: