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TREATMENT

Medical therapy: Both topical minoxidil (Rogaine 2%, 5%) and finasteride (Propecia 1 mg) are useful adjunctive treatments when combined with surgical restoration in men. Such therapy helps prevent or retard further loss and may induce new hair growth in some individuals. The best candidates for potential benefit are patients with large numbers of miniaturized hair present. Topical minoxidil and antiandrogens may benefit selected females. Spironolactone is the antiandrogen used most commonly.

Preoperative details:

Planning and design

The midpoint of the frontal hairline is designed to fall approximately 8-9 cm above a horizontal line drawn through the center of the patient’s eyebrows. Then, the hairline is gently curved laterally and superiorly toward the temporal lateral fringe. This curvilinear portion of the hairline may rise gently above, but should not be designed below, the horizontal plane. Depending on the existent lateral fringe, the hairline may be connected to this temporal fringe.

When creating an isolated frontal forelock, it is best to design a central area of density and surround it by a feathering of grafts along the perimeter. This provides a more natural appearance even as hair loss progresses. When designing for crown restoration, the potential for progression of alopecia surrounding the grafted zone must be weighed carefully. While an isolated frontal forelock is an acceptable restoration and a naturally occurring process in many patients, a central crown restoration surrounded by an alopecic halo of bald scalp is not, and it represents an unacceptable consequence of inadequate planning. Transplants should mimic the natural pattern and growth direction of normal scalp hair.

Donor area

The density of the hair in the donor site is important to determine during planning to acquire the desired number of grafts. The donor area first must be clipped, and the number of follicular units per cm² counted. This can be achieved by using a densitometer (magnified field of 10 mm²) or by counting 4 positions along the donor site with a 10-power dermatoscope and a 5-mm² window. Because each follicular unit represents a graft, the number of cm² of donor surface area required to achieve the desired numbers of grafts is a simple mathematic calculation. In Caucasians, the average scalp has between 90-100 follicular units per cm² with a range of 50-140. Care must be taken to use donor hair from the zone not predisposed to future loss.

Intraoperative details:

Donor area

The number of cm² in the donor surface area required to produce the desired numbers of grafts is marked. The width of the donor excision may range from 0.7-1.5 cm depending on surgical design. Removal is performed using a single-blade knife and closure accomplished with single or double layer suture or staple technique.

Graft dissection

Once the donor tissue has been removed, it is kept in chilled saline over frozen packs to maintain a cool temperature while the tissue is dissected. To maintain graft viability, it is important to keep the grafts from becoming dehydrated or heated. The grafts are dissected under a binocular microscope using a minimum magnification of 10 X. Sterilized tongue blades placed over an autoclavable glass cutting plate create a cutting surface for the tissue. Assistants use jeweler's forceps to apply traction while cutting with a standard double-edged razor blade or knife. Donor tissue first is reduced to thin wafers or slivers containing only a few follicular units. Then, these slivers are cut into follicular units and trimmed of excess bald tissue.

The use of a binocular microscope provides minimal transection of follicles during the dissection process and dense packing in the recipient area, since minimal amounts of donor tissue are regrafted along with the follicular units.

The ability to create greater density within the recipient zone as a result of the small size of the grafts is the key to follicular unit hair transplantation. The dissection process is undeniably the most labor-intensive portion of the process and requires 2-3 graft-dissection assistants for every 1 implanting assistant.

Graft implantation

During the implantation stage, the follicular unit grafts are placed into the anesthetized recipient zone using small punch holes (0.75-1 mm), small slit incisions (1-2 mm in length), or needle tunnels made by 18- to 20-gauge needles. If using the punch or slit methods, the recipient sites may be made prior to beginning the implantation process.

The needle tunnel technique, also referred to as the stick-and-place method, requires that each graft be placed immediately after the needle has been removed, since the needle tunnel remains open only for a few seconds. An 18-gauge needle is preferred for implanting 3-4 hair grafts, while 19- to 20-gauge needles are used for implanting 1-2 hair grafts. The stick-and-place method provides greater density of follicular units within the recipient zone and causes the least trauma to the vascular system in that area. Thus, this is the method of choice for some physicians. Because of the smaller size of these grafts, it is important to handle them with extreme care and to keep them hydrated at all times. A goal of 20-30 follicular unit grafts per cm² is reasonable and readily achieved by skilled assistants.

Postoperative details: Once the implantation process has been completed, the recipient surface is cleaned using chilled saline spray. The use of a postoperative dressing is optional. A moist surface speeds up the healing process. Repetitive wetting of the surface with saline or special solutions, such as copper peptide (GraftCyte), or ointments can maintain a moist surface. Allowing the graft surfaces simply to dry and heal without dressings is the method of care used most commonly.

COMPLICATIONS

Complications are rare and seldom threatening. Postoperative bleeding and infections are unusually rare. Donor suture lines occasionally may spread and are more prone to do so if closure is performed under tension.

During the regrowth phase that occurs between 30-90 days postoperatively, pustules may form in the grafted zone, which are believed to represent a pseudofolliculitis phenomenon of regrowth. A rare furunculoid lesion or epidermal inclusion cyst may occur at the site of a buried graft.

Outcome and Prognosis

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