Reconstructive Hair Transplantation of the Face and Scalp

ABSTRACT

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.

KEYWORDS

Reconstructive - hair transplantation - micrografting - minigrafting

REFERENCES

APPENDIX

Getting Started in Hair Transplantation

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:

• A-Z, Santa Clara, CA (phone: [phone] or 1-408-243-3006; fax: [phone] and 1-800-243-3008; e-mail: [e-mail])

• Ellis Instruments, Inc., Madison, NJ (phone: [phone]; fax: [phone]; website: www.ellisinstruments.com; e-mail: [e-mail])

• Robbins Instruments, Chatham, NJ (phone: [phone]; fax: [phone]; website: www.robbinsinstruments.com; e-mail: [e-mail])

• Following is a list of supplies and equipment that I normally use in my practice for a typical micrograft and minigraft megasession:

• a comfortable powered surgical table such as a Midmark, Ritter, or DMI with a narrow removable headrest

• three comfortable sitting stools with armrests such as a Stryker or dental chair

• a cool and intense light source

• surgical marking pen

• hair clipper (electric)

• 1000-mL IV bag containing lactated Ringer’s solution, normal saline solution, or 5% dextrose with 1/2normal saline solution; IV tubing, and a no. 20 Jelco catheter

• Midazolam, 10 mg

• Sublimaze, 50 to 100 ug

• One 50-mL bottle of 0.5% bupivacaine with 1:200,000 epinephrine

• cephalosporin, 1 g, or alternative antibiotic such as Cipro, 400 mg, for patients allergic to cephalosporin

• oxygen tank and nasal cannula

• oxygen saturation, blood pressure, and electrocardiogram monitors

• one Basic Pack Converters disposable set (drapes) plus a pack of four blue cloth surgical field towels, one or two packs of dry laps, ∼100 4 × 4-inch gauze pads

• Hibicleans solution for skin preparation

• one bottle of normal saline solution

• 8 to 10 pairs of sterile gloves

• one spray bottle containing 2/3 normal saline solution and 1/3 hydrogen peroxide

• one metallic comb with the teeth spaced ∼2 mm apart

• six round standard surgical blade handles for no. 10 and no. 11 blades

• two Personna prep blade handles

• six to eight Personal prep blades

• approximately 30 no. 11 Personna Feather blades

• approximately 30 no. 10 Bard Parker blades

• two or three no. 22.5 Sharp point blades

• Valley Laboratory electrocautery pen, blade tip, and grounding pad

• four sets of fine surgical jeweler’s forceps or Accurate Surgical and Scientific Instruments (ASSI) nonlocking needle holders to insert the grafts into their recipient slits

• basic surgical soft tissue set with standard or preferably round surgical blade handle, Mayo scissors, small hemostats, towel clips, Brown Addsons, two double hooks, a bowl of normal saline solution, a 200-mL cup for the tumescent solution

• two 3-0 Prolene sutures, to close the donor site

• one or two autoclaved hardwood boards, to dissect the donor strip into 2-mm thick slices

• two or three background lighting sources (slide viewers)and two sterile disposable transparent sheets (purchased from Robbins or Ellis)

• two Petri dishes with underlying Petri dish holders

• 3.5× loupe magnification for each member of the team plus one or two surgical microscopes (Mantis)

• one Adaptic, two Kerlix, and one 3-inch Ace bandages

• 1 Uebel C O. Micro and minigrafts: a new approach to baldness surgery.  Ann Plast Surg. 1991;  27 476-487
• 2 Barrera A. Micrograft and minigraft megasession hair transplantation: Review of 100 consecutive.  Aesth Surg J. 1997;  17 165-169
• 3 Barrera A. Micrograft and minigraft megasession hair transplantation results after a single session.  Plast Reconstr Surg. 1997;  100 1524-1530
• 4 Barrera A. Refinements in hair transplantation: micro and minigraft megasession.  Perspectives in Plastic Surgery. 1998;  11 53-70
• 5 Barrera A. The use of micrografts and minigrafts for the correction of the post-rhytidectomy lost sideburn.  Plast Reconstr Surg. 1998;  102 2237-2240
• 6 Barrera A. The use of micrografts and minigrafts for the treatment of burn alopecia.  Plast Reconstr Surg. 1999;  103 581-584
• 7 Barrera A. The use of micrografts and minigrafts in the aesthetic reconstruction of the face and scalp.  Plast Reconstr Surg. 2003;  112 883-890
• 8 Hernandez Zendejas G, Guerrerosantos J. Eyelash reconstruction and aesthetic augmentation with strip composite sideburn graft.  Plast Reconstr Surg. 1998;  101 1978-1980
• 9 Hata Y, Matsuka K. Eyelash reconstruction by means of strip grafting with vibrissae.  Br J Plast Surg. 1992;  45 163-164
• 10 Headington J T. Transverse microscopic anatomy of the human scalp. A basis for a morphometric approach to disorders of the hair follicle.  Arch Dermatol. 1984;  120 449-456