various method for hair restoration

1. HAIR RESTORATION
Dr. Suiyibangbe
Plastic Surgery

2. History
• Local flaps and graft
• Little attention was paid to correction of baldness until
the work of Orentreich in 1959 on the use of punch
grafts that resulted in duplication of this work by
others and the development of the punch graft as the
standard technique in hair transplantation at that time.
• One of the earliest flaps for hair restoration was the
temporal-parietal-occipital flap described by Juri.
• Tamura had to be reinvented in the 1980s and 1990s,
leading to the refinement in micrografting and
minigrafting.

3. • Scalp excision and tissue expansion
• With the refinement of hair transplantation,
the use of flaps, excision and tissue expansion
is taken away.
• Hair transplantation involves relocation or
transfer of hairs from the occipital area to the
bald area.

4. Anatomy
• Ectodermal (hair + pilosebaceous
gland) and mesenchymal (dermal
papilla) origin
• Shaft and root
 Vellus hair (soft, hypopigmented),
on frontal area of scalp and over
the body
 Terminal hairs (thick, long,
pigmented) over the scalp,
eyebrows and pubic area
• With age, vellus hairs replace
terminal hairs
• In bald areas, hair follicles are
present but are atrohpic

5. Hair cycle

6. The normal hairline
• Young males usually do not have this recession.
• Both women and children tend to have a
continuous line between the frontal and
temporal areas without this recession .
• Design of the frontal-temporal recession is critical
to a natural result.
• Natural hairlines are not straight and regular.
• Other important factors are that the hair follicle
sits about 3–3.5 mm below the surface of the
scalp and that scalp thickness varies between 5.5
and 6.5 mm

7. PATTERNS OF BALDNESS
• Most common type of hair loss in both men and
women is referred to as androgenic alopecia.
• The mechanism of androgenic alopecia is
inherent in each individual hair follicle as it
responds to external stimuli, essentially
androgens.
• The progressive loss of hair is predetermined by
genetic characteristics associated with these
responsive scalp follicles.
• The mode of action of androgens on the target
cells occurs at the bulbar region of the follicle.

8. • In most men with hair loss, the hair follicles in the
frontal and crown regions of the scalp appear
most likely to be affected .
• Hair loss in women is frequently of a diffuse
nature.
• The pattern of hair loss, because of its
diffuseness, often results in a lack of appropriate
donor hair.
• However, there is a subgroup of women who
demonstrate hair loss similar to the male pattern.

9. Etiology
• Androgenic alopecia.
• Secondary to numerous factors, such as
surgery, metabolic disorders, chemotherapy,
stress, trauma, and autoimmune disease.
• This type of hair loss is often of an acute
nature most.

10. Norwood classification

11. Ludwig scale for women

12. Sinclair scale

13. Patient Evaluation
• It is critical in the early phases of a patient's
evaluation to design a hair pattern that will be
appropriate not only as the patient ages but
also on the basis of progressive hair loss .
• Patient must be counselled that they are going
to undergo extensive further surgery

14. Criteria for rejection of a patient
• Inadequate donor hair and too low a density,
especially in patients with class VI or VII Norwood
patterns.
• Patients who may have little available usable
donor hair because of too much scarring from
previous grafting that was healed by secondary
intention.
• The patient who has unrealistic expectations.
• There are also patients with medical problems
that can interfere with grafting, such as
hypertension.

15. Planning of the hairline
• Single hair grafts are used to
create a natural hairline.
• To locate the ideal hairline in a
bald patient.
• In the midline, the hairline starts
7-10 cm from the glabella.
• A curve sweeps around to the
lateral side of the forehead from
the center. At this point, the sides
of the hairline should be oriented
parallel to the curve when the
subject is looking straight ahead.
• The lateral hairlines are usually
9.5–11.5 cm above the lateral
canthus of the eyes.

16. • The temporal angles :
form relatively sharp right
angles or acute angles in
most men but these
angles should be more
rounded in women.
• The micrografts in the
hairline should be placed
in an irregular saw-
toothed pattern to give a
natural appearance.

17. • It is useful to draw a
specific pattern on the
scalp to demonstrate as
the patient is looking in
a mirror where the
most appropriate
hairline pattern should
be.

18. • Usually 250–300 single hair (micro)grafts will
be necessary to create a new hairline in any
individual.
• Behind the hairline, two hair FUGs are used to
provide new hair.
• Three or four hair FUGs are used just further
behind.

19. PREOP THERAPY
• Finasteride 1mg (5 alpha reductase inhibitor)
• 85% efficacy in slowing hair loss.
• Most effective in posterior scalp region
• Topical minoxidil 2-5% increases anagen hair
percentage, enhances local vascular perfusion
• Scalp massage from 4 weeks
• Photographs / HD video
• Donor site hair trim to 2-3mm

20. • Discontinuation of herbal medications,
Acetylsalicyclic acid, anticoagulant 3 weeks
• Abstaining from alcohol and smoking.

21. Donor site

22. • The ideal donor site is the region containing hair
follicles that are not subject to the gradual
miniaturization process that causes baldness
(invisible hair)
• Hair density is greatest at the midline and
diminishes laterally above the ears and again
below the inferior border approaching the nape
of the neck.
• 50% of hair can be harvested before the donor
site becomes noticeably depleted.

23. NUMBER OF PROCEDURES
• Patients will be pleased after only one
procedure with limited hair loss but atleast
two sessions are required
• The patient with more extensive hair loss,
however, may require as many as three or four
procedures.

24. ANESTHESIA
• Field block inferior to
the donor region
• Field block anterior to
the recipient area
• Regional.
Supraorbital/Supratroch
lear nerve block

25. • Figure 59-22 Donor site outlined with hairs trimmed. Tumescent technique is
being used to distend the tissues for both anesthesia and hemostasis.

26. Preoperative preparation
• The patient is asked to shampoo his head on
the day before, and on the morning of the
surgery.
• The hair in the donor area (occipital region) is
trimmed to a length of 2–4 mm.
• The local anaesthetic solution is injected just
below the donor area.

27. HAIR RESTORATION TECHNIQUES
• There are three broad categories of surgical
restoration procedures:
1. scalp flaps (advancement flaps, rotation flaps
and free flaps)
2. surgical excision (alopecia reduction)
3. free auto grafts of hairy scalp from the well
haired to the bald area.

28. Hair Transplantation
• Micrograft : one to two hairs
• Minigraft : three to six hair .
• Single FU : one to two / three to four hair
• Multi FU : two to three unit/two to six hair
grafts

29. Strip Excision
• Carlos Uebel
1. minimizing the amount of hair follicle transection
2. extracting donor strip widths with caution in
order to minimize closing tension .
3. producing only a single scar regardless of the
number of session.
• To minimize the transection of hair follicles
1. Use magnification
2. Use tumescent solution at the dermal level
3. Skin hook technique

30. • A long section of scalp that varies
in width from 0.5 to 1.5 cm, and in
length from 10 to 25 cm.
• The multibladed knife harvests
numerous (two to six) parallel
strips of varying width (depending
on the spacer used), which may be
1.5, 2, or 2.5 mm.
• Incision should be angled so that
the blade passes parallel to the
follicles

31. • Figure 59-17 A, Proper angulation of
the knife is important to prevent
transection of the donor graft
follicles.
• B, Elevation of the donor tissue is
performed in a subcutaneous plane,
with care taken to avoid transection
of the base of the hair follicles.
• C, Initial alignment of the donor site.
D, Closure with a running suture. The
donor site is easily closed because of
laxity of tissues in the posterior scalp
and neck area.
• E, The harvested donor strip before it
is cut into transverse breadloaf
sections. These are then cut into the
individual follicular grafts.

32. Dissection of individual FU
from the "slivers."
• The grafts may be cut on wooden tongue
depressors or on a clear vinyl dissecting surface
with a backlighting system.
• Loupe magnification of 2X or 3X power is useful
in creating FUGs.
• The grafts are kept in gauze-lined, chilled, normal
saline-filled petri dishes to prevent rapid
dehydration.
• Survival of transplanted grafts decreases about
1% per hour out of body.

33. • The ideal "pear-shaped"
graft possesses little or no
surplus epidermis and
retains an appropriate
amount of protective
dermis and subcutaneous
adipose tissue around the
follicle, the intact sebaceous
glands, and the dermal
papilla in order to reduce
their sensitivity to traumatic
handling, temperature
changes, and graft
desiccation

34. • Figure 59-19
Follicular grafts that
have been cut and
sorted by the
number of hairs in
each.
• The towel is soaked
in icechilled saline
kept in a metal tray.
• The grafts are sorted
in rows of 10.

35. Recipient area
• Incisional instruments : needles, miniblades,
and micropunches.
• For one to two hair grafts, the most commonly
used instruments are probably an 18-gauge
hypodermic needle for coarse hairs and a 19-
gauge hypodermic needle for finer hairs.

36. Graft insertion
• It is important to employ an atraumatic
technique for graft placement.
• The grafts are placed into the recipient slits /
holes using fine angled forceps.
• To avoid damage, the FUGs are grasped by the
2 mm of subcutaneous tissue left below the
hair bulbs to position them into the recipient
sites and not by the follicle

37. • Figure 59-18 The Uebel
technique of graft
insertion.
• The No. 11 blade is
used to make a small
incision and then
partially withdrawn as
the assistant places the
graft at the beginning
of the orifice.
• The surgeon then
inserts the graft into
the hole that has been
made.

38. • Steady pressure is applied to ensure that the
grafts are flush with the surrounding skin.
• Burying the grafts beneath the level of the skin
avoided
1. because it can give a pitted appearance
2. lead to the formation of epidermal cysts
• If the grafts are too elevated from the surface:
cobblestone appearance

39. Postoperative care
• Traditional dressing is a bilayered protective and
absorptive affair with the first layer made from
several nonstick Telfa pads covered with a thin
layer of an antibiotic.
• Some swelling is obvious after a hair
transplantation surgery and the patient should be
informed of this prior to the procedure.
• Headband worn immediately after the operation
is useful in preventing the swelling from coming
down on to the face and creating a puffy
appearance.

40. • The patient is instructed to wash his hair with a
mild shampoo on the 2 or 3 postoperative day.
• While combing the hair in the transplanted area
for three weeks, the tooth of the comb should
not strike against the transplanted grafts.
• Wearing clothes like T shirts or pullovers which
have to be taken off over the head should also be
avoided for three weeks.
• Hair oils or other stronger shampoos as well as
helmets are also to be avoided for the same
period.

41. Postoperative Adjunctive Therapy
• Topical minoxidil application (2-5 %) :
1. not only for its vasodilatory effects that may enhance
wound healing but also because data suggest that
minoxidil decreases postoperative effluvium .
2. Continued minoxidil use is encouraged for to 5 - 12
weeks postoperatively.
• To slow or prevent further hair loss : 1 mg of
finasteride to slow or prevent further hair loss and thus
prevent or delay the need to “chase baldness” with
multiple procedures.

42. Postoperation Follow-up Visits
• 1 day after the operation : for dressing change
• 14 days : Sutures are removed.
• 8 weeks : wound-healing check.
• 16 weeks early regrowth check.
• 6 to 12 months : final visit for photography

43. Outcome
• In healthy individuals with unscarred recipient
sites, it is reasonable to expect 90% to 95% of
the grafts to grow successfully.

44. COMPLICATIONS
• Periorbital edema
• Scalp hypoesthesia
• Temporary hair thinning
• Folliculitis
• Wound dehiscence
• Visible, hypertrophic scarring
• Keloid

45. Scalp flap
• Figure 59-10 A, Design of the triple
advancement transposition flap,
which consists of bilateral, vertical
and temporal posteriorly based
transposition flaps in conjunction
with expanded temporal-parietal-
occipital advancement flaps as well
as the addition of a third expanded
occipital flap for vertex coverage.
(Courtesy of Dr. Robin Anderson.) B,
Patient at completion of expansion
before the flap procedure. C, Patient
after removal of the expanders and
the result with the triple
advancement transposition flaps. D,
Close-up of the anterior hairline with
the proper anterior angulation as
well as maintenance of the temporal
recession.

46. • Figure 59-11 A, A patient who had plug
grafts inserted anteriorly at a young age and
then proceeded to go bald behind this area.
• B, The initial procedure consisted of excision
of the scarred low anterior hairline, including
most of the previous plug grafts. Sutures
were inserted into the outer table of the
skull for permanent elevation of the hairline.
• C, Closure of the defect after fixation with
Mitek sutures placed between the frontal
bone and the elevated periosteum of the
forehead flap
• D, Early postoperative result showing
significant improvement with elevation of
the hairline and design of acute frontal-
temporal angles, which can now be followed
by appropriate grafting.

47. FUTURE OF HAIR RESTORATION
• There are three potential areas of future
development in hair restoration.
• These are cloning, automatic devices for
cutting and implanting hair, and synthetic
materials for implantation.
• There are, however, reports in Europe of new
types of artificial hair fibers that describe
biocompatibility, but these have presently not
been validated.

48. THANK YOU