The Procedure Itself: The Nuts and Bolts of Hair Transplantation

An Office-Based Surgery

So far, we have discussed a wide variety of hair restoration techniques, although we have concentrated of Follicular Unit Transplantation (FUT). That will be our entire focus here. We do not perform the outmoded large graft or mini-grafting techniques, flaps, or scalp reductions; as such, we will confine our discussion to what we consider the state of the art in hair restoration surgery, which is FUT done in an office setting.

Another topic we will neglect is the administrative, legal, and financial aspects of the agreement by the patient to undergo FUT by the surgeon. It is not that these are not important, for they are, and they need to be understood by all parties and the details completed prior to the procedure’s beginning. However, they are beyond the scope of this discussion. This entire manuscript is aimed at educating the patient, or potential patient, and to demystifying the process of hair transplantation. Therefore, we are limiting our comments to those pertaining directly to the history, practice, art, and science of modern and post-modern hair restoration surgery. The more prosaic elements of the patient’s interaction with staff and physician will be left to the time and place of that interaction.

Pre-Operative

The pre-operative phase is that period leading up to the performance of the surgery. Sometimes, certain medications, like antibiotics, will be started the night before. Occasionally, in extremely anxious patients, sedation or sleeping medication will be given the previous night as well, to insure a good nights sleep. It is the rare patient that requires this extra effort. Photos may be taken from various angles to document the level of pre-operative balding. The patient may have a movie they wish to watch, or music they wish to hear, during the procedure. This can be determined in advance or after the surgery begins.

Often, a brief second consult with the surgeon takes place, during which the patient may restate his or her goals and desires, and the surgeon may respond or help the patient modify these goals into a more realistic and aesthetically appropriate plan. The physician may at this point draw in the hairline with a surgical marker, with the patient observing in a mirror, and may mark other points, such as the boundaries of the crown, if that area is being grafted, and reexamine the donor area for scarring, density, and laxity. This is a good time for final questions relating to the surgical plan, and the long-term plan, to be put forth, so that all parties are satisfied that they are moving forward with an acknowledged and satisfactory effort on the part of the patient.

At this point, after checking for the presence of drug allergies, medication for limiting swelling and inflammation may be administered. Other drugs for sedation may also be given. This will be discussed further in the section below.

Sedation

Is sedation mandatory for follicular unit transplantation? Strictly speaking, no, it is not. However, there exist many good reasons for using mild sedation for this procedure, not the least of which is the patient’s comfort during what may be a long procedure. Much of the time spent in the surgical chair can be quite boring. There are other reasons, though, as we shall see.

The only part during FUT that is remotely painful is the injection of the numbing medications, or local anesthetics (see below). This is necessary in the donor area in back and also in the recipient areas that will receive the grafts. This is one of the first things that are done during the operation, and it can sting a good bit. People demonstrate a wide range of pain tolerances, and it has nothing to do with being strong, or "manliness", or a lack of these attributes. It’s simply how our nervous systems are "wired". For some patients, the injection of local anesthetic barely gets their attention; they continue talking as though nothing was happening. For others, the shots are quite bothersome, and they may begin to sweat or feel dizzy. So often, if a little sedation is used at the beginning of the procedure, this potential for pain and anxiousness is relieved before it even occurs.

Another reason for using the type of sedation we prefer is that it can prevent or relieve the potential side effects of the local anesthetics we use (see below). Generally, we choose a class of drugs known collectively as the benzodiazepines, specifically diazepam, midazolam, and lorazepam. These are similar to the drug Valium, and are considered sedatives and anti-anxiety agents. They may be given orally, intravenously, or intramuscularly; the intravenous route works the quickest and the oral route has the longest time to onset of effect. Used appropriately, they are quite safe, and we seldom see complications associated with their use. Given by any of the methods above, these medications render the patient relaxed, maybe slightly drowsy, and usually with a noticeable sense of wellbeing. The local anesthetic injections may become unnoticeable, or just a slight annoyance. Depending on the drug used and the route by which it is given, it may last an hour, or several hours. We have found this method of sedation to be safe, effective and well accepted and tolerated by our patients.

Some physicians routinely give opioids, or narcotic type drugs (pain relievers). Although this class of drugs is quite effective as well, it does not relieve anxiety as well as the Valium class of drugs, and in some instance can cause dysphoria (a sense of non-wellbeing). Also, the narcotics have a much stronger effect on the respiratory centers in the brain, and can depress the breathing. Moreover, they can cause nausea and vomiting quite frequently, which is distressing to the patient (and the last thing you want is vomiting just after a hair transplant – you could pop a graft!). Also, itching is a common side effect of narcotic drugs, which can be a miserable situation for the operative team and for the patient during a long case that requires stillness on the part of the transplant recipient. Lastly, if these narcotics are used along with the Valium type of drugs, a synergistic action takes place: they may greatly enhance one another’s effects, which could lead to depressed breathing, over-sedation, lowered blood pressure, or other problems. For these reasons, we usually choose not to administer opioids/narcotics, and try to stick with the relatively safe, tried-and-true sedatives mentioned above (the benzodiazepines).

Others have advocated the use of nitrous oxide (N₂O, or laughing gas). While this drug can be a quick acting, effective sedation and pain relief agent, there are problems with its use and its effects, too. First of all, it requires a more complicated system (you may have seen these at the dentist’s office) than for the oral or injectable agents. Secondly, it must always be used with oxygen, and both oxygen and nitrous oxide come in relatively bulky metal tanks. Special monitoring of the patient’s vital signs is necessary, and when the nitrous oxide is stopped, the patient must always inhale pure oxygen to avoid decreased levels of oxygen in the blood (called diffusion hypoxia). Occasionally, patients will experience dysphoria, which may present much like a panic attack; this quickly resolves with discontinuation of the gas.

Others promote the use of heavier sedation, citing the patient’s comfort, the length of the procedure, and the ease with which the surgical team may work, as their rationale. This author feels that, unless one has a strong anesthesia background, that the benzodiazepines (Valium family of drugs), and, possibly, the less potent opioid/narcotics, should remain the agents of choice for sedation in hair transplantation.

Anesthesia

Many people think of anesthesia as being "put to sleep". However, there are other ways of achieving anesthesia, which just means rendering one insensitive to pain impulses. In hair transplantation we use local anesthesia, which, as the name implies, locally deadens (temporarily) the nerves, rather than the whole central nervous system (unconsciousness). This is most desirable because, when using local anesthesia, no pain is felt, the procedure can be done in the office, we avoid the expense and hazards of the hospital operating room and general anesthesia, and the patient is awake throughout the process, and can remain an active participant in decision making.

There are two main classes of local anesthetics (LA’s): esters and amides. The esters are more prone to causing allergic reactions than the amides, and are less widely used. Even amongst the esters, however the incidence of true allergic reactions is extremely rare. Very often, people claim an allergy to "Novocaine" or all the "-caine" drugs, when they have actually experienced either a temporary reaction to too much anesthetic (mild overdose), or a reaction to the epinephrine (adrenaline) that is often added to local anesthetics to prolong their action and to decrease bleeding. We take great pains to avoid any LA or epinephrine toxicity by injecting slowly, always guarding against intravenous injection, maintaining verbal communication with the patient, and by limiting the total amount of these agents that are injected to dosages well below the known safe limits.

The most widely used LA’s in hair transplantation are of the amide class, namely, lidocaine (Xylocaine) and bupivicane (Marcaine). These have an established safety record, and we rarely see problems with them. Comparatively, they are similar in effect, with lidocaine being faster acting, and bupivicaine lasting for a longer time. They are injected into the skin and subcutaneous layers, and/or around larger nerves in the form of nerve blocks.

There are several areas where nerve blocks can be used. The first is the occipital nerve, which is in the back of the head, above the neck. When this nerve is blocked, the back of the head (donor area) and crown

are numbed; this can be of benefit after the surgery, also, as the donor area may be painful that night. The supraorbital nerve, above the eye, may also be injected; this results in hairline and frontal area numbness. Two other nerves in front and behind the ear may also be blocked to help with anesthesia in the top of the head and around the sides.

However, we do not do the surgery with just the blocks; we always inject locally, wherever incisions will be made. One of the reasons for this is that the blocks may be incomplete at times, and we want the scalp completely numb and unable to feel any pain; the other reason is to add epinephrine (adrenaline) to the area. This has a two-fold purpose: 1) to prolong and intensify the action of the LA’s and 2) to constrict the small blood vessels in the area and decrease the amount of bleeding. The importance of diminishing the amount of bleeding, especially in the recipient area, cannot be overemphasized. The less bleeding there is, the more easily and accurately the recipient incisions can be placed; likewise, with minimal bleeding, placement of the FU grafts causes less trauma to the follicles and is generally smoother and quicker.

Intra-Operative

Once the initial steps determining the hairline, the areas to be grafted, and the extent of the donor strip, have been carried out, and the areas have been marked and trimmed, then the local anesthetics are injected into the donor area, and then into the scalp in the areas to be transplanted. The numbness is essentially instantaneous; after these injections various sensations like pulling or tightness may be felt, but there is no pain sensation.

The first incision is for the donor strip. This is done with a single or double-bladed scalpel, and is performed with a "tumescent" technique. What this means is that a fairly large volume of fluid is injected into the numb donor area in order to raise the hair follicles up off the scalp; doing this allows us to cut more easily without damage to underlying nerves and blood vessels. In addition, when we free up the strip from its deeper tissues, we can do so with minimal damage to the bulbs of the follicles. Since the tumescent fluid is a saline solution with dilute amounts of local anesthetic and of epinephrine, the technique also helps to decrease bleeding and ensure that no pain is felt at any level of the dissection.

Once this donor strip, with its many intact hairs, is harvested, it is handed off and the important, meticulous "slivering" begins. As you recall, slivering is the process of dividing the strip, under the microscope, into small pieces that are one FU wide. As these slivers are created, they are passed off in turn to other members of the operative team, who begin the long, arduous task of dissecting out the individual FU’s under stereo-microscopic guidance. As they are dissected out, the FU’s are segregated, according to type, into groups of singles, doubles, and so on. They are kept in chilled saline solution until they are ready for planting in the scalp.

Meanwhile, the surgeon sets about closing the donor site. This may be accomplished with sutures or surgical staples. We prefer the use of sutures rather than staples; they tend to be less uncomfortable, and, because we generally use dissolvable sutures, the patient does not have to look forward to returning in 7 to 10 days for staple or suture removal! The ease or difficulty of the donor site closure is to some degree dependent on the tightness or laxity of the scalp. This is one more reason that we try to take great care with the donor area; multiple scars and poor closures not only deplete donor hair, but also contribute to tightness of the scalp, and subsequent difficulty with approximating the wound.

After the donor site is closed, then the surgeon begins the tedious and painstaking process of creating the hundreds or thousands of recipient sites. These are generated using small needles or tiny scalpels; the size of these miniscule incisions is based on several factors: the area of the scalp, the thickness and laxity of the scalp, and the size of grafts (one hair, two hair, etc) that will be placed. Great care is taken to avoid damage to existing hairs, and all this work is done under magnification (as is the harvesting of the donor strip). This may be one stage of the surgery when talking to the surgeon is discouraged; it is necessary for us to keep count of hundreds or thousands of incisions being made. In this way, the number of grafts harvested will match up with the number of sites created.

The tumescent technique that is used for the donor strip is also used to a degree in the recipient area. A saline solution, containing local anesthetic and epinephrine, is injected into the area, to "plump up" the scalp; this makes it less likely for the needles and scalpel blades to lacerate blood vessels below the layer of the hair bulbs, and thus interfere with nourishment to the new grafts. And again, it decreases the amount of bleeding from the scalp, which greatly facilitates the creation of the recipient sites, and of the graft placement; this in turn may improve survival and growth of the FU grafts.

After the sites are created, and as the ongoing work for dissecting grafts under the microscope proceeds, members of the team begin the fine work of placing the individual FU grafts. This is done, under magnification, by gently grasping the delicate connective tissue at the base of the graft with ultra-fine jeweler’s forceps, and sliding the graft into its waiting recipient site. This is more difficult even than it sounds; the level of expertise required is nothing short of amazing. Not only must the FU’s be placed at the appropriate angle, with as little trauma as possible, but it must be done quickly and smoothly; remember that we try to minimize the number of hours that the grafts are "out of body", and that we may be creating and placing thousands of grafts. This procedure is not possible with out a large, expert and highly motivated surgical team.

Of all the steps of the surgical procedure, this graft placement phase may be the most relaxing, or boring, for the patient. Many patients will "unwind" and nap during this time. Hours may go by just sitting and chatting; this is where music and movies may be a blessed relief. These are not distracting to the operative team; they are used to maintaining high levels of concentration during hair transplants.

One question that is often asked is "what do we do with ‘leftover grafts’?" Answer: there are none. In other words, we try meticulously to match the number of grafts harvested with the number of incision sites made. Often, because of the careful techniques of graft cutting employed, there are more grafts than planned for. If this is the case, they do not go into the wastebasket! The patient gets those extra follicular units "on the house!"

At the end of the procedure, a final check is made to insure that every graft is in place, that no "popping" or extrusion of FU’s has occurred, and that no bleeding is taking place. The hair is dampened and combed very carefully, again to avoid any graft displacement. We generally use no dressings; if the patient is using GraftCyte, they may leave the clinic with several of the saturated gauzes in place over the grafted areas.

Patients will receive post-operative instructions at several stages of the treatment: often before, during and after the procedure, as well as in writing. Repetition of these guidelines is important for several reasons. Patients need to follow these directives carefully in order to insure the best possible growth of grafts and avoidance of complications. Also, people often forget what they are told within the context of the procedure, due to excitement, anxiety or information overload. Therefore, we try to reinforce the information at several points during the patient’s entire surgical experience. We will discuss the post-operative course within the next section.