a philosophy and strategy for surgical hair restoration
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A philosophy and strategy for surgical hair restoration

The last 10 years of hair restoration technology has seen the development of new techniques and their effective usage both as single and in combination. Of all the techniques and their variations evolved over a period of over 80 years, three techniques such as follicular unit grafts, scalp reduction and scalp or flap rotation have been found to be extensively used of which follicular unit grafts have gained importance owing to its near perfect effect after transplantation. With the percentage of patients opting for follicular unit grafts increasing, hair surgeons have not written off scalp reduction and flap rotation techniques but are still using them in some patients and achieving good results.

One of the foremost necessities before any hair transplant procedure is suggested is the patient’s emotional well being, his perception and desires and how effectively the hair surgeon can point out difficulties if any and clear all the patients myths about the procedures. Not only the patient’s psychological well being but also his physiological parameters are responsible for the overall success. Any patient who has realistic views about hair transplantation and one who understands what the doctor is trying to explain, in all likelihood will be very co-operative all through the procedure.

A surgeon evaluates his patients for the following parameters –
1. Reasons for balding – such as male pattern baldness, accidents, hormonal imbalance, exposure to radiation, drug abuse, deficiency in diet and supplements, heavy smoking habits.
2. Medications used to prevent balding – if the patient has already been using drugs such as finasteride and minoxidil for stopping hair loss and the time period since under medications and if the patient has been using herbal remedies such as saw palmetto.
3. Prior surgical corrections if undergone, then when, where and how.
4. Psychological parameters – patient’s willingness to co-operate during the full course of the procedure, what he expects and to what extent the surgeon can provide help.
5. Physiological parameters – density of the scalp hair, thickness, growth patterns, hair texture, color, curliness, scalp color and scalp elasticity.

Generally patients who have used wigs to cover their baldness find it difficult to digest the fact that the final result especially with respect to hair density may not look the same after the surgery. They are also concerned about the time involved in regaining lost hair and like a fast solution. Instead of recommending follicular unit grafts in these patients, scalp reduction and flap folding methods are recommended for faster results.

All patients who need to undergo hair transplant are administered drugs such as Midazolam as a sedative. The amount of this drug given intravenously prior to surgery depends on the patient’s alcohol consumption. The amount of sedative also depends on the type of hair transplantation to be performed and also during harvesting donor hair. In procedures involving Juri flap technique, especially when lots of tissue excision is necessary, the patient needs heavy sedation under the guidance of an anesthetist.

The grafting techniques mainly aim at covering as much area as possible and retain the natural hair line. The donor hair is harvested usually from the back of the head as single or two strips measuring 17 cm in length. According to Dr. Lam and colleagues, usage of minigrafts with 5-6 hairs per graft results in greater density. This is a deviation from follicular unit grafts with respect to the number of hairs per graft. The grafts are about 2mm in diameter and are placed in position in 1.75mm hand drill created slots.

When grafting techniques seem slower in yielding faster results, scalp reduction technique is used. In this technique, an inverted Y shaped slit is made on the crown. Since the shape of the slit resembles the Mercedes logo, it is also called the Mercedes incision or configuration. In one session of slitting, removing extra tissues and suturing, up to 4 cm of the hair from the sides of the ear can be closed in on the crown. When 3 such sessions are performed, up to 9 cm of bald pate can be brought closer. If the size of the bald area is more than 13 cm then scalp reduction combined with follicular unit grafts gives better result since beyond 13 cm scalp reduction technique is not effective. After each scalp reduction process, extenders are used to hold the scalp. When extenders are used, the time between each session of scalp reduction is reduced to 1 month. During the last session of closure, a technique called multiple Z - plasty is performed to reduce the perception of scarring.

When scalp reduction techniques are not favorable on a patient, then the surgeon has the choice of Juri flap method, a type of scalp rotation technique. In this technique, a strip of donor hair is harvested from the side of the head, behind the ear running along the back of the head at a distance of 4 cm above the arch of the ear. The band of hair is 2 cm in width and can cover a maximum width of 4 cm area of the forelock region. This procedure is slightly cumbersome as it involves blood loss during donor hair harvest. Also closing the wound after the harvest is difficult and can result in various after operation problems such as hemorrhages and heavy scarring. The scarring gets reduced with time and can also be reduced if no improvement is seen. But the effect can be both favorable and disastrous depending on the hair loss pattern. When hair loss is continuous the crown region may show an abrupt ending of hair which is an unpleasant sight cosmetically. In patients with very little hair loss after the initial onset, this technique seems to be sufficient for crown coverage.

After a successful procedure, a patient has to take post operative care. It is very common for the transplanted hair and some non transplanted hair to fall after 2-3 weeks of the procedure due to the initial shock and also the regular hair fall experienced by everyone. A few months later the hair growth regains and the normal hair cycle is restored. In some patients the restoration of the hair cycle may take a few more months than usual. The normal hair coverage is however achieved within a year of hair transplant.

A philosophy and strategy for surgical hair restoration references

  • Lam SM, Hempstead BR, Williams EF. A philosophy and strategy for surgical hair restoration: a 10-year experience. Dermatol Surg. 2002 Nov;28(11):1035-42; discussion 1042. PMID: 12460300
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