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CHAPTER 8 0 Hair Transplantation Neil Sadick, MD KEY POINTS FOR SUCCESS ● Choose the appropriate surgical candidate, i.e., appropriate donor site density. CHOOSING THE RIGHT CANDIDATE ● Age ● Degree of baldness ● Hair shaft diameter ● Hair color ● Perform the procedure utilizing “follicular unit” grafting in order to present natural hair grouping. ● Contrast characteristics of skin and hair ● Dissection of the donor strip should be performed under stereoscopic control. ● Donor hair density ● Patient expectations ● Perform hair transplantation with an integrated team including a surgeon, a cosmetic coordinator, and welltrained technicians. PHYSICAL EXAMINATION ● Key factors ● Look at other family members—the patient’s own hair loss pattern may mimic in pattern as well as in chronological course, the pattern and rapidity of other family members. INDICATIONS FOR HAIR TRANSPLANTATION ● Androgenetic alopecia—male or female. ● ● Usually hair transplantation is not performed until the patient is at least 25 years of age. Personal history—if hair loss began at a young age it most likely will be progressive. ● Evaluate the degree of hair loss to measure the degrees of miniaturization on both the donor and the recipient areas. This can be performed with a hairmagnifying device called a densitometer (Fig. 8.1). Assessing the degree of miniaturization from various areas of the scalp (normally no more than 20%) will allow predictor insight as to the progression or hair loss in various anatomic areas as well as the stability of the donor area, which translates into long-term viability of the transplanted hair. ● Senescent alopecia—women. ● Scarring alopecia (inactive disease for at least 6 months duration), i.e., discoid lupus, lichen planopilaris, burns, etc. ● Congenital defects, i.e., alopecia triangularis. CONTRAINDICATIONS FOR HAIR TRANSPLANTATION ● Severe coagulopathy ● Platelet inhibitors—blood thinners (Coumadin, NSAIDS, and aspirin), which the patient is unable to discontinue ● Herbal preparations ● Active HIV or hepatitis B (relative) ● Poor donor area ● Unrealistic expectations ● Active inflammatory scarring alopecia PREOPERATIVE GOALS ● Creation of a natural hairline ● The most natural hairlines are those that are not exact but have a natural feathered appearance. It should be high enough when planned to give a natural tethered appearance of a mature individual so that it can be functional for the patient’s entire lifetime. The general rule is to place the hairline 3–4 fingerbreadths above the glabellar notch. Discuss the location with the patient preoperatively. Copyright © 2008 by The McGraw-Hill Companies, Inc. Click here for terms of use. 74 | Concise Manual of Cosmetic Dermatologic Surgery FIGURE 8.1 Portable hair densitometer may be used to calibrate donor hair density. Large caliber hair shafts greater than 70 microns yield most optimal results ● Area to be transplanted ● ● Number of sessions ● ● The area to be transplanted should be discussed with the patient—front, vertex, and crown sites are specified. If a limited number of grafts are available, the transplant surgeon may choose not to treat the crown area. Using follicular unit technology, most patients can achieve natural coverage in one or two treatment sessions. The standard has been to transplant 30 follicular units/cm2. The recipient area is usually about 80 cm2. ● Implantation device for follicular unit based micro- and minigrafts. ● Stereoscopic microscopic dissecting device. MEDICATION ● All medications that increase bleeding time should be stopped two weeks prior to the surgery. ● NSAIDS Optimizing donor site ● Maximal number of grafts. ● A small linear donor site is the optimal goal in this region. In order to maximize the number of grafts as well as to improve cosmesis, it is often helpful to excise the previous donor site scar as part of the donor area if a second procedure becomes necessary. INSTRUMENTATION (Fig. 8.2) Instrumentation utilized for hair transplantation is listed in Table 8.1. ● Appropriate blade device for excision of the donor area. FIGURE 8.2 Instrumentation tray for performing hair transplantation Chapter 8: Hair Transplantation TABLE 8.1 ■ ● Instrumentation Used in Hair Transplantation 2 Addson forceps with teeth ● 1 #3 knife handler ● | 75 PROCEDURE TECHNIQUES ● Harvesting hair from the donor area. ● Taken from the occipital scalp where donor terminal hair grows for an individual’s lifetime. 4 Kelly clamps curved ● Trimming of area with a PANASONIC trimmer. ● 1 Needle holder ● ● 1 Curved 5⬙ sharp scissor ● 1 Suture scissor Tumescent donor site formula, “ring block”: approximately 15 cc of 0.5% lidocaine with 1:200,000 epinephrine utilizing a 3-cc syringe. ● 1 Multiblade knife handle ● ● 2 Addson forceps smooth Followed by instillation of 20–30-cc saline solution to create a tissue turgor so as to minimize the risk of follicular dissection. ● 2 Curved jeweler’s forceps ● ● 1 metal comb ● 1 Elli’s #4 multiblade knife handle Excision of the donor site may be through a long single elliptical (20 cm ⫻ 7 mm) strip with average donor density (over 1.5 mm) or ● 2 Handle for 91 and 61 blades ● 1 Dissecting microscope ● Klein tumescent anesthesia inserter ● Prone-Prop-Pillow #15 Personna surgical blade ● through a multiblade knife to create multiple thinner strips. This will yield over 1000 follicular units. ● Factors affecting the amount of donor area excised Donor tissue laxity Donor tissue density Previous scars ● ASA ● Warfarin ● Clopidogrel bisulfate (Plavix) ● Herbal preparations Bristol-Myers Squibb ● Allergies: antibiotics, lidocaine, and epinephrine ● Donor strip is usually excised in a supine position. ● An angle to 110–120° will minimize graft dissection (Fig. 8.3). ● With a #10 BP blade, the depth of strip dissection is usually 1–2 mm. The ends of the strip are tapered at the ends with a #11 BP blade. ● Hemostasis is obtained with electrocautery or more rarely with ligation of sutures. PREOPERATIVE BLOOD WORK-UP ● CBC, chemistry profile, PT, PTT (INR), platelet count, HIV, and hepatitis profile. PREOPERATIVE ANESTHESIA ● Preanesthesia ● Ativan 1 mg p.o. ● Percocet (7.5-mg Hydrocodone) 500-mg Acetaminophen ● Other preanesthetic agents such as nitrous oxide have been employed in this setting. ● Local ring blocks in the donor and recipient areas have been employed with lidocaine 1% with epinephrine 1:100,000. FIGURE 8.3 Double-bladed knife allows uniform width of donor site dissection and standardization of depth of dissection 76 ● ● | Concise Manual of Cosmetic Dermatologic Surgery Donor area is closed using a buried interlocking suture of 4–0 Vicryl followed by a surface running 4–0 Monocrylic suture. Sutures are removed in 10–14 days leaving a small linear 1- to 2-mm scar. PREPARING THE GRAFTS ● After examination of the donor strip, it is placed in a Petri dish containing chilled isotonic saline. ● A team of trained technicians and the physician supervise dissecting the strip into slivers of tissue approximately 2 mm in width and subsequently these slivers are dissected into single, double, or triple haired follicular unit grafts (Fig. 8.4). ● A magnifying microscope is used for this purpose. PEARLS AND PITFALLS IN DONOR DISSECTION ● Appropriate planning in size of donor site. ● ● Prone pillow to assure the patient comfort and relative immobility. A #10 Personna razor blade in conjunction with a fine jeweler’s forceps is used. ● Use a transilluminating light source. ● Tumescent anesthesia to produce adequate tissue turgor. ● Follicular units should be kept in chilled saline in order to retain moisture prior to implantation. ● Double-bladed knife to ensure uniformity of width and depth of the donor ellipse. ● Buried interlocking suturing to decrease wound-healing tension. ● Re-excision of previous donor scars to ensure a single scar after multiple hair transplantation sessions. ● Examine donor site as the strip is being dissected to be sure that a significant transection of follicles is not occurring. ● Keep the dissection angle at 110–120° in order to minimize transection. ● At repeat procedures, the donor scar can be reexcised, thus improving cosmetic appearance. A B PEARLS AND PITFALLS OF GRAFT PREPARATION ● Use a dissecting microscope with backlighting. ● Avoid transection of hair follicles when cutting strips. ● Keep cut grafts in a moist cool environment. ● Remove excess fat and fibrous tissue from the area surrounding the grafts. PLANTING THE RECIPIENT AREA ● Keys: ● Try to recapitulate the prebalding hair pattern. C FIGURE 8.4 Technique for graft dissection involves (A) slivering of tissue into 2 mm sections, (B) followed by dissecting into follicular units, and then (C) followed by separation into single, double, and triple hair grafts Chapter 8: Hair Transplantation FIGURE 8.5 Proposed recipient hairline is usually mapped 3–4 fingerbreadths above the mid glabellar notch with lateral tapering at the temporal fringes | 77 ● A maximum of 40 grafts/cm2 should be implanted in order to avoid excess packing and vasoocclusive crushing of grafts. ● Anteriorly, plant with a sharp angle of 20°. ● Posteriorly, plant with greater angle of 20–45°. ● A 19-gauge needle may be used to make all single hair insertion sites. ● Alternatively a 91-gauge Beaver blade may be used to create slits for double and triple haired follicular units (keep distance of 1–2 mm between slits in order to prevent crushing). ● Jewelry forceps are best to assure meticulous graft placement. ● Hairs in the grafts must be aligned at the appropriate angle and direction to create a snug fit into the recipient sites (Fig. 8.6). PEARLS AND PITFALLS OF RECIPIENT PLACEMENT ● ● ● ● Keep hair placement in its naturally growing direction. ● In the frontal scalp, try to maximize natural facial framing. Meticulous technique of insertion markedly improves graft survival. ● Plant with a back to front pattern to avoid displacement of grafts, compression, and popping. ● Create a mature frontal hairline with temporal blunting. ● Recreate a whorled pattern in the occipital region to recreate the natural pattern of hair growth. ● Use a feathered pattern in the anterior hairline to create a natural graded zone of hair density. The hairline should be created 3–4 fingerbreadths above the intraglabellar notch creating curved bellshaped hairline tapering at the lateral temporal fringes (Fig. 8.5). Recipient anesthesia is accomplished using a ring block with 2% lidocaine. Forces displacing graft when needle is inserted behind the graft Compression forces Displacement force Resistance forces FIGURE 8.6 Implantation of follicular unit grafts into slits is accomplished using a jeweler’s forceps 78 ● | Concise Manual of Cosmetic Dermatologic Surgery A backward forward direction of graft insertion will help minimize graft pop out. TREATMENT PLANS ● ● Majority of patients with Norwood Class V–VI alopecia require three treatment sessions of approximately 3000 total follicular unit grafts. Partial alopecia may be addressed with 1 or 2 sessions. ● ● ● ● ● ● ● ● ● ● ● Pearls and Pitfalls ● Provide adequate postoperative instructions (Table 8.2), ● Four to seven days are average for crusts to dissipate. ● In most cases no postoperative bandage is necessary. ● Shampooing may be begun gently within 24 hours. ● Facial edema and forehead swelling, particularly in the periorbital area, may begin 24–48 hours after the procedure and last for 5–7 days. Time required: 6–10 hours. This may be treated with ice packs, upright positioning (45°), sleeping on two pillows, or alternatively, a short course of prednisone 20–40 mg/day for 3–5 days Author’s personal approach ● 600–900 grafts: to cover the anterior scalp. ● 500–800 grafts: to cover the midvertex scalp. ● 400–500 grafts: to cover the occiput. TABLE 8-2 ● ● Time required for this treatment: 5–6 hours. Alternatively, larger sessions (mega sessions) of 1000–1500 grafts may be transplanted over the entire scalp in a single session. ● POSTOPERATIVE COURSE ■ ● Full exercise may be resumed in 1 week. Post-op Hair Transplant Instructions Please follow instructions carefully. If you have any questions or concerns during your recovery please call the office. You will receive products from us to be used during your recovery. These consist of treatment shampoo, post-Biotin spray, and postsurgical gel. Keep taking the Propecia as prescribed before, and also keep using the Rogaine. You may take a light shower the day after the procedure. Do not get the area of the hair transplant under the spray. You can PAT the shampoo we give you on the area of the transplant, and rinse by a very gentle spray or by patting water over the area. DO NOT RUB AREA. This you have to do for 5 days until the grafts attach. After 5 days, you need to start washing the area more aggressively. After 7 days you should be washing your hair normally. All the scabs should be off the graft area in 10–14 days. After the light shower, you may pat hydrogen peroxide over the area to cleanse area. Then you may apply the post-Biotin spray and postsurgical gel, very gently. Be very careful when brushing or combing to avoid the transplant area for the first 5–7 days. This is to prevent the comb from catching on the grafts/scabs. You will have scabs on the area of the transplant. Do not pick at them. They will fall off when you start washing your hair more aggressively. All scabs should be off your head by day 14. You may pat hydrogen peroxide on the area twice a day to help cleanse the area and to decrease the scabbing. Also, during the first month there will be particles that fall from the graft area. This is normal. It does not mean that the grafts are falling out. You may resume normal daily activity after the procedure. Do not do vigorous physical activity for one week after the procedure. You will be put on an antibiotic the day you come in to get the hair transplant. You may also need an oral steroid to help with inflammation a week after the treatment. After the procedure is finished you may feel tight in the area of the donor site. You may take acetaminophen for any discomfort. Refrain from aspirin and ibuprofen. You should not expect to see hair growth until 6–8 months after the treatment is complete. This can take up to 18 months to see full growth. You may need additional treatments after the first hair transplantation. Chapter 8: Hair Transplantation ● The author places all males on Finasteride 1 mg/day routinely prior and 5% Minoxidil solution twice a day in order to decrease posttransplantation telogen effluvium and shorten the growth course of transplanted hair. ● ● Usually resolves in 6–12 months; most common in donor occiput area. Telogen effluvium ● ● | 79 More common in females and in area where transplants are performed into existing areas of residual hair. Arteriovenous fistula formation PEARLS AND PITFALLS ● May last for 6–12 months ● Provide adequate postoperative instructions (Table 8.2). ● Should be explained during the initial consultation ● ● Cooper peptide dressings such as Graftcyte may be used to promote wound healing and angiogenesis. Topical Minoxidil solution 5% applied b.i.d. may minimize this sequelae ● Short courses of prednisone 20–40 mg/day to decrease postoperative swelling. ● Wait for 6–12 months between transplant sessions in order to assess results and to allow hair to begin to grow. COMPLICATIONS Complications following hair transplantation are relatively rare and may include the following: ● Nausea and vomiting caused by medications ● Postoperative bleeding (less than 5%) ● Infection (less than 5%) ● Swelling (5%) ● Temporary headache ● Temporary numbness of the scalp ● Scarring around the grafts (less than 1%) ● Poor growth of grafts ● X-factor—vasoconstriction, poor host growth factor, and poor operative technique have all been hypothesized but none proven. ● Syncope ● Folliculitis ● Keloid formation ● May be secondary to genetic healing tendencies or increased wound tension secondary to taking too large of a donor strip. ● Neuroma ● Paresthesias CONCLUSIONS Hair transplantation surgery has evolved with increased patient satisfaction related to improved cosmetic techniques. Like all other cosmetic surgical procedures, best results are achieved with careful surgical planning, fastidious technique, and carefully outlined postoperative surgical care. SUGGESTED READING 1. Tan E, Shapiro J. Hair transplantation update. Cos Dermatol 2002;13:39–41. 2. Stough DB, Whitworth L, Seage DJ. Hair restoration, In: Techniques in Dermatologic Surgery, Chapter 27, 2003, Mosby, St. Louis, pp. 217–232. 3. Bernstein RM, Rossna WR, Szanlanos KIW, Halpern AJ. Follicular transplantation. Int J Aesthet Restor Surg 1995;3:119–132. 4. Schiell RC. Modern hair restoration surgery. Clin Dermatol 2001;19:179–187. 5. Auram MZ. Hair transplantation for men and women. Cos Dermatol 2002;15:23–27. 6. Bernstein RM. Rossman WR. The aesthetics of follicular transplantation. Dermatol Surg 1997;23: 785–789. 7. Eisenberg EL. Avoiding problems in hair transplantation. Cos Dermatol 2003;16:19–23. 8. Bernstein RM, Rossman WR. Follicular transplantation: Patient evaluation and surgical planning. Dermatol Surg 1997;23:711–784. This page intentionally left blank CHAPTER 9 Evaluation and Treatment of Varicose and Telangiectatic Leg Veins Neil Sadick, MD KEY POINTS FOR SUCCESS ● Correct diagnosis of proximal point of reflux. ● Mastering duplex ultrasound testing. ● Decision of which modality (endovascular radiofrequency or laser technology, ambulatory phlebectomy, sclerotherapy, or external laser) is most effective for the treatment of a vessel of given diameter. ● Fastidious technique. ● Choosing the appropriate minimal sclerosant concentration (MSC) for a given diameter vessel. ● Choosing the right grade and duration of compression. HISTORY ● ● ● ● INDICATIONS ● Functional saphenofemoral/saphenopopliteal incompetence (pain, ulcers, stasis dermatitis, lipodermatosclerosis) ● Truncal varicosities (symptomatic or cosmetic) ● Cosmetic spider veins or reticular veins (lower extremities) ● Periorbital veins ● Hand veins CONTRAINDICATIONS ● ● Pregnancy ● Hypercoagulable states (protein S or C deficiency, antiphospholipid antibody syndrome) ● Recurrent thrombophlebitis or deep venous thrombosis History of venous disease, recurrent thrombophlebitis or pulmonary emboli. Medical history ● Same as family history plus history of bruising, bleeding. ● Ask if veins are symptomatic, i.e. pain, edema, tiredness. Surgery ● Any history of bleeding after surgery. ● Any history of previous ligation or stripping procedures. ● Allergies/medicine sensitivity: history of allergies to a given sclerosing agent, i.e., glycerine, sodium sotradecol sulfate, or polidocanol should be elicited. ● Medications that prolong bleeding time or interfere with platelet function, e.g., Warfarin, clopidogrel bisulfate (Plavix, Bristol-Myers), aspirin, nonsteroidals, are contraindicated. ● Hormones: high-dose estrogen therapy may increase the risk of thrombotic phenomena or telangiectatic matting after any vein procedure. PHYSICAL EXAMINATION ● Lower extremity vessels may be classified according to size, degree of oxygenated hemoglobin, and connection to the greater or lesser saphenous vein (Table 9.1) ● Look for signs of chronic venous insufficiency, i.e., stasis dermatitis, ulcers, hyperpigmentation, lipodermatosclerosis. Absolute ● Family history INDICATIONS FOR VASCULAR TESTING (TABLE 9.2) Relative ● On anticoagulation therapy, ASA, NSAIDS, Plavix, herbal preparations ● Symptomatic veins ● Bulging varicosities: usually greater than 4 mm Copyright © 2008 by The McGraw-Hill Companies, Inc. Click here for terms of use. 82 | Concise Manual of Cosmetic Dermatologic Surgery TABLE 9.1 ■ Type Vessel Class Diameter Color I II III IV Telangiectasis “spider veins” Venulectasia Reticular veins Nonsaphenous varicose veins (usually related to incompetent perforators) Saphenous varicose veins 0.1–0.5 mm 0.5–2.0 mm 2–4 mm 3–8 mm Red Violaceous, cyanotic Cyanotic to blue Blue to blue-green 4–8 mm Blue to blue-green V ● Vessel Classification Duplex examination (Fig. 9. 1) Preoperative set-up (Table 9.3) ● Procedure ● Duplex evaluation of varicose veins depends upon the use of a 7.5-mHz gray scale, high-resolution Bmode scanner, and a 5-mHz Doppler probe. ● A 5 Fr catheter is placed over a 0.035-inch diameter J guide wire with intravascular placement documented by Duplex. Biosound Esoate, 8000 Castleway Drive, Indianapolis, IN 46250; model: Mylab 25. ● 400–750-nm bore tip filter is then introduced through the catheter. Terason, 77 Terrace Hall Avenue, Burlington, MA 01803; model: Terason 2000. ● Vein is subsequently reduced in diameter by administration of perivenous tumescent anesthesia (lidocaine .05% with or without epinephrine). ● 12–14 W of energy is delivered in a continuous mode with a pullback rate of 10–20 cm/minute. Suggested manufacturers: CLINICAL APPROACH TO TREATMENT OF LOWER EXTREMITY VEINS ● Procedures: Greater/lesser saphenous veins ● Options: Endovascular technologies (performed under Duplex guidance) ● ● Laser (815, 830, 870, 1320 nm) ● Radiofrequency (VNUS procedure) ● Foam sclerotherapy ● Postoperative care ● Patients are subsequently placed in a compression bandage overnight. ● Subsequently then wear Class II 20–30 mm Hg compression for 2 weeks following the procedure. Endovascular laser ● EVLT (815-nm laser; Diomed, Andover, MA) (Fig. 9.2) RADIOFREQUENCY CLOSURE ● TABLE 9.2 ■ Procedure (Table 9.4) ● The available catheter sizes 8 Fr/5 Fr allow treatment of vessels 2–12 mm in diameter ● Catheter insertion is carried out over a guide wire followed by similar perivenous tumescent anesthesia. ● A thermal sensor allows delivery of temperatures of 80–90ºC (average 85º) heating the targeted greater GSV Indications for Vascular Testing ● Symptoms (pain, fatigue) ● Clinical signs of venous insufficiency, stasis dermatitis, ulcers, lipodermatosclerosis ● Bridging varicosities ● Veins ⬎4 mm in diameter