I.Male Pattern Baldness = Androgenic Alopecia (AGA)

     The most common form of hair loss, affecting over half of the male population.

     Related to genetic pedigree, male hormone & age.

     Still unsure why hair loss occurs in specific areas of the scalp.

  II.Hair Transplant History

     Japanese experimented with follicular transplants in the 1930’s.

     Orentreich (1959) described "donor dominance" where the ability to grow transplanted hair was found
     to be dependent on the site from which the graft was taken and not on the site to which it was
     transplanted. Based on this finding he showed that transplanted hair could be used to correct early
     AGA, and the modern era of hair transplant began.

  III.Hair Transplant – Patient Selection

     Anxiety and psychological effects of AGA can have a profound impact on the patients’
     self-image and social interaction.

     AGE –- Most patients seek advice between the ages of 20 and 40. Older patients are easier to
     work with because they are typically better adjusted to their hair loss, more mature, more realistic and
     better able to afford treatment.

     The normal progression of hair loss – generally the earlier the onset, the grater the ultimate
     extent of hair loss. Thus, patients with very early onset  will usually progress to such
     extensive baldness that they will be poor candidates for hair restoration procedures. Hair transplants
     are not recommended before the age of 25! There is no contraindication to hair transplant in the healthy
     elderly patient.

     EXTENT OF LOSS -- The present and predicted future extent of loss should be evaluated.

     Measure the bald area over the top of the scalp in a line connecting the EACs (interauricular line).
     10-12cm = Moderate, 12-14cm = Extensive and 14-16cm + Severe (not correctable).

     Exceedingly mobile scalp is an advantage.

     THE DONOR SITE  Measurement of the donor site -- see Figure 19-5.

     Color: Gray hair is most preferable. Dark hair (brown & black) readily shows imperfections
     against Caucasian skin. Remember that the transplanted hair retains the characteristics of the donor
     site, so there may be a color mismatch.

     Curl; Wavy hair provides considerably more coverage than straight hair, but exceedingly curly
     hair can be technically difficult to work with, at harvest and at transplant.

     Caliber (of the hair shaft) ; Thin caliber hair (usually blond or red) requires more hairs per
     square cm for coverage and does not provide the lift of thicker hair, so it is more difficult to style.

     Density (hairs per square cm) -- High-density donor hair is best. Density varies by donor site, with the
     midocciput usually of highest density. Sites measuring 4mm in diameter that contain less than 10 hairs
     are inadequate donors – a rotation flap may be preferable.

     Extent of safe, permanently growing terminal hair; The "safe zone" is typically found on the
     sides and posterior scalp. The "safe zone" area must be predicted, and grafts must be harvested at
     least one cm below the presumed superior border of the "safe zone." Care must also be taken to avoid
     harvesting from the extreme inferior border of the occipital region, since these hairs will ultimately be
     lost with progression of baldness. The supraauricular donor site may be easier to assess, but remember
     that the density is less here, and scalp reduction procedures and hair styling (parts) can effect the
     appearance of the area. The anterior border of the "safe zone" is bounded by a vertical line drawn from
     the EAC. Once the extent of the "safe zone" and the hair density is known, you can calculate the
     number of grafts available. Macrografts = 4mm x 4mm. Minigrafts = 2mm x 2mm (3-8 hairs).
     Micrografts = individual follicles.

     CONTRAINDICATIONS : Uncontrolled diabetes or HTN; viral illnesses (active HSV, hepatitis
     or HIV; conditions of the scalp (Psoriasis or seborrheic dermatitis); Bleeding disorders; Improper
     motivation or unrealistic expectations, psychological illness, etc.; Age under 25.

  IV.HAIR TRANSPLANT : Technique

     DESIGN OF THE FRONTAL HAIRLINE : The rule of 1/3:

     Most male patients measure 14 cm from the glabella to the mentum. Half this height (7cm), represents
     the forehead height of the normal female or juvenile male. The inferior border of the adult male hairline
     should be placed between 1 to 2 cm above this measurement, and in severe cases 3cm above. A
     retained forelock can complicate this measurement.

     The position of the apex of the frontotemporal angle is another important consideration. Draw a vertical
     line from the lateral canthus superiorly until it intersects the lateral portion of the newly constructed
     hairline. The apex of this angle will move posteriorly as the temporal hairline recedes
     DO NOT place grafts anterior to the frontotemporal angle as this blunts the angle, lowers the lateral
     frontal hairline and creates an obvious cosmetic deformity.

     Remember that with an increase in hair loss, scalp reduction may be needed and this often raises the
     lateral arms of the established hairline and/or displaces the midpoint of the frontal hairline anteriorly
     and inferiorly. Therefore, it is best to err by placing the hairline too high!

     PREOP PREP :Shampoo with Hibiclens. Mark the hairline and donor sites. Trim donor hair to
     2mm in length. Oral, IV or IM sedation/analgesia is administered (Demerol/Vistaril/Valium, etc.) Inject
     the recipient site with 1% Lidocaine w/ 1:100,000 epi, followed by 2% lidocaine w/ 1:100,000 epi. Next
     rotate the patient and inject the donor site with 60 – 90 ml of "Coleman solution" (0.5%
     lidocaine w/ 1:1 million epi). The traditional maximal dose of 7mg/kg of Lidocaine should be adhered to.
     Recipient holes are cut first, then donor grafts are harvested (surgeon’s preference).

     GRAFT SIZE: Micrografts (single hairs) are placed anterior to other grafts to provide a
     natural frontal hairline (300-600 required). Minigrafts (3-8 hairs) are placed inferior/anterior to standard
     grafts to enhance the frontal hairline or are used for the bulk of the replacement to create a thinned but
     natural look. Standard macrografts (4mm diameter) are used where high-density hair is desired, usually
     in mid-aged patients with limited hair loss. Macrografts are placed behind the smaller mini- and
     micro-grafts to provide bulk, while the smaller grafts provide finesse. On average, the smaller the graft
     size, the lower the percentage survival rate.

     PREPARATION OF GRAFTS: Grafts are placed immediately in a Petri dish on sterile gauze
     moistened with LR solution and are placed in rows of 10. The individual grafts are then cleaned by
     removing all severed hair shafts, trimming excess skin and trimming the fat 1mm from the base of the
     follicles. They are then sorted by quality and kept moist until transplant.

     RECIPIENT SLITS VS. HOLES : Minigrafts and micrografts can be placed in either slits or
     holes. The round holes are cut with a machine-driven trephine or a hand-held punch. Sharpness of the
     blade is key. Slits are made with a #11 or #15 scalpel blade, a spear- or chisel-shaped blade or with a
     #18 needle. Advantages of slits are: speed and no removal of existing hair or skin. Disadvantages are:
     compression of the graft, causing lengthening and narrowing, which may lead to elevation,
     cobblestoning, desiccation, extrusion or poor growth of the graft. Also slits condense the hairs, creating
     a higher density of hair which may have an inferior cosmetic appearance. Remember that the direction
     of the recipient hole is critical in determining the ultimate direction of hair growth (important for styling).
     Also in the frontal row, the grafts must be slightly overlapped to hide the scars and create a more subtle
     and natural hairline.

     DESIGN OF THE DONOR SITE: Use precise measurements to prevent under- or
     over-trimming the donor site. Factors key in defining the shape of the donor site are: 1) ability to
     camouflage the donor site after harvest, 2) stability of the donor site during harvest, 3) ease of
     infiltration with saline (to decrease distortion during harvest), 4) minimize vascular damage (originating
     inferiorly from the occipital and postauricular arteries), and 5) uniform color and quality of donor hair.

     CAUSES OF POOR DONOR GRAFTS:  Distortion of the graft related to dull trephines or
     blades, slow trephine speed (shearing), inadequate saline infiltration (soft skin), advancing the trephine
     or blade too rapidly, and less than ideal patient positioning. See Figure 19-35.

     STRIP DONOR HARVESTING : an alternative to the use of round "punch" grafts. Here
     square or rectangular grafts are harvested from a rectangular donor strip. This is accomplished by using
     a multi-blade knife which will cut a strip of multiple rows. Advantages are speed and ease of cutting the
     donor strip into individual grafts. Disadvantages are loss of precision with loss of follicles (up to 60%).

     DESIGN OF GRAFT PLACEMENT: Standard macrografts are placed in one of three
     geometric deigns (see Figure 19-39) in three or more sessions. Scalp recipient holes are made 0.5 to
     0.75 mm smaller than the donor graft. Minigrafts are placed in a random fashion over the recipient site,
     and into holes just slightly smaller than the diameter of the graft. The holes are placed one graft width or
     less apart from each other in the frontal hairline, requiring multiple transplant sessions. Micrografts are
     placed in front of the minigrafts to provide a transitional zone, mimicking a natural hairline. The holes
     and slits must be angled in the direction of the desired hairstyle. All grafts are placed so that the skin
     level matches the recipient site; this prevents cobblestoning and graft failure. Care must be taken not to
     crush or twist the graft!

     Megasessions are where 1000 or more grafts are transplanted in a single sitting (reports of 2500 grafts
     in 10 hours). Advantages are that fewer session are required and improvement is noted sooner.
     Disadvantages are the time required during which time the patient and staff may become tired and
     uncomfortable/unhappy, the risk of lidocaine toxicity from repeated injections, the risk of graft failure or
     even tissue necrosis from dense and prolonged packing, and possible higher patient cost.

     POSTOPERATIVE CARE: Antibiotic ointment or cream is applied. A pressure dressing (not
     too tight!) of Telfa, gauze, Kling and Coban is applied for 12 to 18 hours to immobilize the grafts. The
     dressing is removed in the office on POD #1, and the recipient and donor sites are cleaned with a mild
     shampoo. The hair is then dried and styled. The patient may return to work, but should avoid bending,
     straining or lifting x 1 week. Shampooing is allowed.

     COMPLICATIONS: Local anesthesia in the scalp skin superior to the donor site is usually
     temporary, resolving in weeks to months. Significant post-op bleeding is rare, and is associated with
     ASA, NSAIDS, Niacin use and anxiety/HTN. Infection is also rare and usually readily controlled with
     oral antibiotics.

     Edema may become severe and is avoided by use of pre-operative steroids and head elevation.

     Scarring occurs most often at the donor site . This can be minimized by avoiding using a donor height
     less than 1.5 cm and by minimizing tension at the closure. Correction of defects can be accomplished by
     serial scar excision or by grafting at the donor scar.

     Vascular abnormalities (A-V fistulae and aneurysm) are exceedingly rare. They present as a painful
     pulsating mass at the donor site and are treated with intralesional Kenalog injections, local ligation or
     excision.

     Seborrheic dermatitis occurs in susceptible patients and is treated with topical shampoos. Systemic
     antibiotics and topical steroids are used in cases of secondary infection.

     Inadequate growth is most often related to techinque, such as: 1) poor angulation of donor punch with
     transection of follicles, 2) excessive drying of grafts before implantation, 3) trauma to the grafts, 4)
     compression of the grafts, 5) inadequate time interval between sessions (recommended 3-4 months).

  V.LASER HAIR TRANSPLATATION

     Originated in 1992, utilizing the Ultrapulse CO2 laser for production of the recipient-site slits.
     Advantages are less bleeding, pain and postoperative edema, and cosmetically superior results. The
     main potential drawback is adjacent thermal damage with impairment of revascularization and resultant
     poor growth. The amount of thermal damage depends upon the watt setting, millijoule setting, spot size
     and speed at which the spot is moved along the line – all factors can now be chosen and
     automatically fixed. The Ultrapulse CO2 laser emits high-energy pulses or bursts whose duration is less
     than the thermal relaxation time of skin (1/693 second). In contrast, the Silktouch CO2 laser emits a
     continuous beam of light which is moved at a computer-regulated high speed designed to limit tissue
     exposure time to less than one millisecond. Other disadvantages are the initial cost of the
     instrumentation and its maintenance, a learning curve, postoperative crusting and delayed hair growth (2
     – 6 weeks)

  VI.SCALP REDUCTION

     A technique used to reduce the size of a bald area to maximize the benefits of hair transplantation. It
     allows the maximal use of a limited number of grafts by reducing the need for transplanting, especially in
     the crown. It also raises the rim hair border superiorly, bringing this natural hair-bearing tissue into a
     more prominent position. Potential disadvantages are decreased donor density (due to stretching), poor
     scars and abnormal direction of hairgrowth.

     Traditional vertex scalp reduction is indicated for the patient with extensive baldness in whom it is
     anticipated that the donor area is insufficient to restore the predicted hair loss. Various patterns of scalp
     reduction are advocated

     Hair transplantations and scalp reductions are performed in separate staged procedures (at least 6
     weeks apart) to ensure revascularization and to optimize graft success. Serial transplants and reductions
     can be performed as needed.

     Complications of scalp reduction include infection, minor skin necrosis, wound dehiscence, hematoma, or
     facial edema. Variation in the appearance of the scar is the most common sequela, with some patients
     developing a depressed or widened scar.

 VII.SCALP FLAPS

     Scalp flaps have been used since the early 20th century. The impractical design of some flaps (Juri flaps
     taken horizontally from the crown) and unfortunate results and injudicious use of other flaps (flaps taken
     vertically from the crown) have caused many to think negatively about scalp flaps. Now, the appropriate
     use and indications for scalp flaps are better defined. Sometimes scalp flaps should be first-line
     treatment (10% of cases), while in other cases flaps should be combined with scalp reductions and hair
     transplants.

     INDICATIONS: One must consider 1) the degree of baldness, 2) the diameter, shape and color
     of hair, 3) the laxity, thickness and blood supply of the scalp, and 4) a balance between the
     patient’s age, expectations, prognosis and probable outcome of the procedure(s) offered.

     DESIGN OF THE FLAP: See Figure 22-9. Advantages of vertical flaps are that the anterior
     frontal hairline will be of good quality with a natural outline and normal growth of the emergent hair. The
     cosmetic result is near-immediate, with the remaining bald patches able to be hidden or eventually
     covered by later hair transplants.

     COMPLICATIONS: The flap should be closely monitored and any hematoma evacuated.
     Necrosis of the flap tip occurs in less than 3% of cases. Thin, poorly vascularized skin, poor circulation
     and smoking contribute to necrosis. Pre- and post-operative minoxidil treatment improves flap viability.
     Tip necrosis can be corrected by transplanting minigrafts. Anterior hairline scar complications can be
     prevented by removing the epidermis and "burying" the flap, using fine intraepidermal superficial
     sutures, avoiding tension on the wound and avoiding sun exposure x 3 months. In 2% of cases a
     noticeable scar results at the anterior hairline and can be hidden with micrografts. More frequently (less
     than 10%) an unsatisfactory donor scar results from excess wound tension. This can be corrected by
     creating release incisions in the epicranial aponeurisis at the time of closure or by later minigraft
     transplantation. "Dog-earing" occurs frequently but typically disappears spontaneously in 2 – 4
     weeks. Excision is necessary in less than 1% of cases.

VIII.CONCLUSION

          There are many new techniques in hair restoration surgery. Minigrafts and micrografts are
          indicated in more than 80% of male pattern baldness correction. However, the vertical scalp flap
          is recommended in over 10% of cases. Often an approach that combines several techniques is
          most efficacious.