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1. Surgical management of Hair
Loss
Dr Jayanta Kumar Saha
Consultant Cosmetic & Plastic Surgeon

2. ANATOMY OF HAIR
Hair consist of a shaft and a
root
Shaft is the visible portion
above the scalp surface:
Root or bulb is the follicle-sits
at an oblique angle to the
scalp
Shaft has 3 layers: cuticle,
cortex and medulla

3. MICROSCOPIC ANATOMY OF HAIR
Hair matrix present at the
base of the hair follicle canal
within subcutaneous tissue
Within the matrix are
rapidly dividing cells
Above this layer lies zone of
keratinization which makes
the hair shaft
The layering of these newly
keratinized cells at the base
of the shaft causes the
process of hair growth as the
shaft moves up through the
surface

4. HAIR GROWTH CYCLES

5. IMPORTANCE OF GROWTH CYCLES
Relevant in discussing hair transplantation with
patients
After the follicle has been transplanted, one usually
sees a resting/telogen phase and the patient should not
expect any significant hair growth for 3 to 4 months

6. Characteristics of hair
Vellus / terminal
Thickness - racial
Cross section- round/ oval
Density : 200 – 400/sq cm
Angle – different in frontal/parietal/occiput
Color – varies from race to race

7. Anterior hairline
Fronto temporal
recession
Irregular margin
Vellus to terminal
hair gradually

8. TYPES AND PATTENS OF BALDNESS
MALE TYPE:ANDROGENIC ALOPECIA
Most common type of hair loss in both male and
female
Predetermined by genetic characteristics
In regions of scalp susceptible to androgenic alopecia
androgens reduce the growth rate, hair shaft diameter
and length of the anagen phase
Target cells found in bulbar region of follicle
Dihydrotestesterone(DHT) act on target cells
Mostly affects the frontal and crown region of scalp

9. TYPES AND PATTENS OF BALDNESS
IN FEMALE
Mostly diffuse type
In a subgroup of women hair loss pattern similar to
men
Start at the vertex and progress anteriorly as they
approach 30s and 40s
Usually family history positive
Most of them maintain a low anterior hairline unlike
the men who show progressive frontal hair loss.

10. OTHER CAUSES OF ALOPECIA
Post Chemotherapy
Surgery
Metabolic disorders
Autoimmune diseases
Traumatic:
Temporary Permanent
Post burn
Aesthetic surgery of face
Hair transplantation
Comatose patient lying in one posture

11. NORWOOD CLASSIFICATION OF BALDNESS

12. FEMALE TYPE BALDNESS
LUDWIG SCALE
SAVIN SCALE

13. Evaluation of patient
Invasive – scalp biopsy
Semi invasive – trichogram
Non invasive – hair pull test
trichoscan
folliscope

14. ROLE AND EFFECTIVENESS OFMEDICATIONS
MINOXIDIL:LOCAL
APPLICATION
Works primarily by
increasing blood flow
Promotes hair regrowth
or hair stabilization in
those follicles which are
affected by androgenic
alopecia
FINASTERIDE
ORALLY:Dose 1 mg/day
Selective inhibitor of α-
reductase type II
There is uptake of
testesterone by hair
follicles which is converted
to DHT by 5 α- reductase
DHT acts on androgenic
receptor

15. SURGICAL PROCEDURES
1.Hair grafts
2.Scalp flaps
3.Expanded hair bearing flaps
4.Scalp reduction

16. HAIR TRANSPLANTATION- TERMS USED
Micrograft=one to two
hairs
Minigraft= three to six
hairs
Single Follicular Unit
(FU)=one to four hair
Multi Follicular Unit
(FU)=two to three
unit/two to six hair grafts.

17. HAIR TRANSPLANTATION- Instruments
Scissors, small
Mosquito forceps, small
Needle holder, small
Dissecting forceps
Delicate tissue forceps
Tissue forceps, small
Metal matrix for
trichodensitometry (Neidel)
Scalpel handle (blades available:
sizes 10, 11, 15)
Metal comb
Syringe, Luer LOK 20 cc, for
tumescence with saline 0.9%

18. INSTRUMENTS FOR GRAFT/FOLLICULAR UNIT
PREPARATION
Petri dishes with saline
0.9%
Scalpel handle (blades
available: no. 10)
Delicate tissue forceps
Extremely delicate
dissecting forceps Forceps
for micro- and
minigrafting
(implantation)
Wood for preparation

19. HAIR TRANSPLANTATION
Instruments for
Micropunch Technique
Micropunch 0.8 mm
diameter
Micropunch 1.0 mm
diameter
Handpiece for
micropunch

20. HAIR TRANSPLANTATION
Instruments for
Microslit Technique
Sharpoint
(15°/22.5°/30°/45°
pointed tip)
Handle

21. Techniques of hair graft harvest
Follicular unit transplant (FUT)
Follicular unit extraction (FUE)

22. HAIR TRANSPLANTATION-DONOR AREA
Preparation of the Patient, Hairline Design
Donor Area
The donor area should not be more than 2 cm above an
imaginary line connecting the tips of the patient’s ears behind
the head.
To be careful not to harvest an overly large skin strip so that
you will not have to discard hair follicles later.
To measure follicle group density, i.e., follicular units per
square centimeter by Russman densitmeter
With this figure, the number of follicular units to be
transplanted can be calculated from the total area of the
donor strip.

23. LOCAL ANAESTHESIA
Intradermal infiltration anesthesia
using 0.5% lignocaine with
adrenaline.
Injection of a 0.9 % saline solution is
employed to achieve tumescence of
the donor area.
Caution: subgaleal injection is
contraindicated to prevent injury to
major nerves and blood vessels during
the subsequent skin incision.

24. DONOR STRIP HARVESTING
To remove a trapezoidal donor
strip .
Avoid transection of the hair
follicles by making an incision at
an angle of about 45° and cutting
exactly parallel to the direction of
hair growth.
To detach the strip below the
hair roots in the fatty layer.
Place the harvested strip into a
sterile cooled 0.9 % saline
solution immediately.
No mobilization.No opening of
the galea.

25. CLOSURE
Hemostasis should be
carried out on the galea
only and not near the hair
follicle.
Closure by continuous
suture

26. FOLLICULAR UNIT PREPARATION
The donor strip is placed on a non-slip sterile wooden
board and sliced into small segments.
To work with magnifying spectacles or a binocular
microscope.
To avoid transections
The segments are divided further into strips; the
follicular units are now arranged in a row on a piece of
gauze.

27. FOLLICULAR UNIT PREPARATION

28. RECIPIENT AREA, HOLES AND SLITS
To work in the direction of hair growth.
Following the hairline design, punch out 0.8 mm
holes for transplants containing 1–2 hairs.
After punching between 5 and 10 holes, make a test
transplant to determine whether the transplants can
be inserted without any problems.
Never transplant hair only along the marked line, as
this results in an unsightly “pearl necklace effect”.
A feathered hairline is the effect to be achieved:
“irregular regularity” is the key word .

29. RECIPIENT AREA, HOLES AND SLITS

30. TRANSPLANT OF THE GRAFT
Transplantation of follicular units
with a sharp angled microtweezers
Perform non-traumatic
implantation with no crushing of
hair roots.
The follicular units are placed on
moist gauze strips ; they are
picked up individually and then
transplanted.
End of the transplant should be
flush with the skin surface or .5-
1mm above it
The FU to be snugly fit

31. POST-OPERATIVE CARE
The traditional dressing is a bilayered protective and
absorptive dressing with the first layer made from several
nonstick Telfa pads covered with a thin layer of an antibiotic
such as mupirocin cream or ointment.
Micropore tape attaches this underdressing to the patient’s
forehead.
A turban style overdressing wrapped over several layers of
4×4-inch gauze pads is constructed and finished off with
elastic retainer netting (Surgilast no. gl-705).
Some patients greatly prefer a more minimal dressing, or no
dressing at all. But there is a risk of bleeding and graft
dislodgement

32. Infection prophylaxis is given for 3 days after the operation.
From the 3rd day the patient can wash his or her hair with a
mild chamomile shampoo.
The hair can then be washed daily.
After a maximum of 2 weeks all crusts should have
disintegrated with washing; crusts delay wound healing.
Rough manipulation should be avoided, particularly in the
1st postoperative week, as there is a risk of postoperative
bleeding.
The patient can be professionally and socially active again 1
week after the operation.

33. FUT vs FUE
Observation FUT FUE
Pain Minor None
% of time doctor operating 10-30% 80-90%
Stitches Yes No
Extensive bleeding May occur No
Wearing short hair Not possible Possible
Natural results Yes Yes
Nerve damage, numbness Possible No
Healing time- donor area 2-3 weeks 7 days

34. FUT vs FUE cont…
Observation FUT FUE
Healing time – recipient
area
About 2 weeks Same
Graft transection rate 1-2% 5-10%
Recovery time 2-3 weeks 1-2 weeks
Return to work The day after same
Scarring at donor area Present Microscopic
Reaction to sutures Rarely seen Never a problem
Shaving of head Not needed Needed
Large areas possible difficult
Cost cheaper expensive
Fatigue Not tiring tiring

35. SCALP FLAPS
Earliest flap used: Temporal parietal-occipital flap
described by Juri
Scalp flaps give immediate results with dense frontal
hairline
Problem:
Dense frontal hairline shows an unnatural appearance
because of its abruptness
Tends to round out a normal temporal recession
Requires micro and mini hair transplants in front of the flap
to cover the scar
Dog ear

36. SCALP FLAPS
Scalp flaps mainly used
for frontal baldness
Limitation of scalp flap:
Relative inelasticity of
scalp tissue
Width is limited if the
area has to be closed
primarily
Limitation can be
overcome by tissue
expansion and scalp flaps

37. EXPANDED
HAIR
BEARING
FLAPS
Bilateral vertical
and temporal
posteriorly based
transposition flaps
in conjunction
with expanded
temporal-parietal-occipital
advancement flaps
and a third
expanded occipital
flap for vertex
coverage.

38. SCALP REDUCTION
Used in patients with extensive hair loss with limited
donor site
Problem: Stretch back (Reappearance of non hair
bearing skin due to re-stretching of the skin due to
tension)

39. Complications
Low anterior hairline
Poorly designed hairline
Large hair plugs – corn row appearance
Hematoma/infection
Inclusion cyts

40. Corn row appearance

41. THANK YOU!