hair transplantation

1. HAIR TRANSPLANTATION
DR SAMIK SHARMA

2. ANATOMY OF HAIR
• EMBRYOLOGY... Originates from both ectodermal and mesodermal.
ectoderm forms both hair and pilosebaceous follicle.
endoderm forms dermal papilla.
• Parts... Shaft and root.
shaft ... Visible portion above scalp, diameter varies from 60-100 micromt.
3layers... Cuticle, cortex and medulla- consists of keratinized cells.
keratin...fibrous protein produced by the hair follicle, end product of the
hair matrix, which exists at the base of hair follicle canal within s/c tissue
Follicle sits at an oblique angle in the scalp.
• Proper angulation is the key in hair restoration surgery.
• In androgenic alopecia, the follicle reduces in size and the number of dominant follicle increases.

4. ANATOMY OF NORMAL HAIRLINE
• Landmark is formed by the emergence of two convex lines making up
the frontal and temporal hairlines.
• Critical anatomic landmark … fronto-temporal recession.
• As baldness progresses, fronto-temporal recession increases, forming
acute angle.
• Natural hairlines are not straight and regular.

5. TYPE/CHARACTERISTICS OF HAIR
• Lanugo hair – soft, fine, usually unpigmented, no medulla, in fetus, shed at 8th
month of gestation
• Two primary types… vellus hair and terminal hair.
• Density…vary between 200-400 per square centimeter.
• Vellus hair… soft, short, lightly pigmented/hypopigmented, unmedullated, almost
invisible. Found in entire body. In scalp…frontal area of forehead.
• Terminal hair… coarse, longer and pigmented, medullated…individual destinated
to hair loss then terminal hair replaced by vellus hair…progressive evolution.
• Bald area, hair follicle present but atrophic in nature and no longer producing
significant hair.
• Cross sectional characteristic…wavy hair oval on cross section…stiff / straight hair
tends to be round.

6. Critical variable
• Critical variable is the angle at which the hair exit the scalp normally.
• Frontal area…angled forward, temporal and parietal area…angled
slightly downward and forward, vertex…spiral pattern, occipital
angled downwards towards neck.
• Violaton of this principle … unnatural appearance.
• Thickness and density per sq. cm. important variables.
• Dark hair effective in covering areas.
• Converse is true, when blonde hair gives more acceptable result when
it is transplanted versus dark hair , especially in light skinned
individuals.

7. HAIR GROWTH CYCLES

8. • After follicle transplant, usually a resting or telogen phase, and
patient should not expect any significant hair growth 3-4months…
• Occasionally some of hairs transplanted seem to continue to grow
immediately after surgical procedure, misleading,
• this early growth frequently leads to a shedding of the hair shaft before the
telogen phase, therefore the patient needs to wait several months before any
significant hair growth is seen.

9. ALOPECIA
• Incidence
• n It is estimated that 35,000,000 men and 21,000,000 women in the United States
have hair loss.
• n It is so common in men that it is actually accepted as normal.
• Of men seeking hair replacement surgery, approximately 33% have variable
amounts of
alopecia by their mid-30s.
• • 50% have variable amounts of alopecia by age 50 years.
• • 66% have variable amounts of alopecia by their mid-60s.
• n Highest incidence is in whites, followed by Asians and blacks, and the lowest is
in American Indians.

10. TYPE AND PATTERN OF BALDNESS
• MC type of hair loss
• androgenic alopecia…predetermined by genetic characteristic of hair follicle.
• Androgen reduce the hair growth rate, hair shaft diameter, and the length of
anagen phase.
• Mode of action of androgen
• bulbar region of hair follicle.
• Frontal and crown region most likely affected.
• Most likely under control of a single dominant sex-linked autosomal gene, family
history significant.
• Hair loss in women, diffuse in nature, lack of appropriate donor site, begins at
vertex and progresses anteriorly,
• secondary to surgery, metabolic disorder, chemotherapy, stress, autoimmune disorder, acute
in nature, not candidate for hair transplantation.

11. CAUSES OF HAIR LOSS
• SENILE alopecia…universal scalp hair thinning… 7th -8th decade…both
sex…but male pattern baldness is a non uniform thinning of hair.
• ANDROGENIC alopecia…1st in temporal area…then to vertex…50%
hair density may be lost before most people may notice thinning…
20% by trained clinician.
• CICATRICAL alopecia…due to trauma like chemical burn,thermal
burn,surgery, severe infection,scleroderma,radiation…permanent
follicle destruction… no medical treatment effective…hair
transplantation effective

12. • TELOGEN EFFLUVIUM
• transient increase in the number of hairs in the telogen phase
• loss more than 150hairs per day
• Reversible
• triggering events…normal gestational delivery, crash dieting, high fever, shock,
malnutrition, OCP
• DO NOT NEED TRANSPLANTATION.
• ALOPECIA AREATA…loss of hair without evidence of scarring…autoimmune
phenomenon may play role…not good candidate for transplantation.
• DRUG INDUCED alopecia…almost always reversible…thallium,excess
vitamin A, retinoids, allopurinol, oral contraceptives, propanolol,
antithyroid drugs, indomethacin.

13. Traumatic alopecia
• Secondary to ischaemia of hair bulb.
• It can be secondary to direct tissue loss… as in postburn alopecia.
• Comatose patient…prolonged pressure in a particular area of scalp.
• One of the most common causes…aesthetic surgery of face and scalp
…due to damage of the hair bulb from subcutaneous dissection in the
temporal area or excess skin traction with resulting ischaemia.
• Coronal forehead lift…hair loss in the area of a coronal scar.
• Alopecia is temporary…regrow after several months.

14. •Indications
• n Androgenic alopecia
• n Cicatricial alopecia
• n Traumatic alopecia
• n Traction alopecia
•Contrai ndications
• n Diffuse female pattern baldness
• n Non-donor-dominant alopecia
• n Alopecia areata
• n Active scarring alopecias (discoid lupus erythematosus, lichen
planopilaris, and other cicatricial alopecia)

15. CLASSIFICATION
• Numerous
• first attempt, Beck1950
• Hamilton,1951
• Norwood suggested modifications of Hamilton classification.
• Useful tools in planning hair restoration.

16. • • Type I: Minimal or no hairline recession at the frontotemporal areas
• • Type II: Symmetrical triangular frontotemporal recessions extend posteriorly, no more
than 2 cm anterior to the coronal plane drawn between the external auditory canals
• • Type III: Symmetrical triangular frontotemporal recessions extend posteriorly more than
2 cm
• • Type IIIvertex: Primarily vertex hair loss; may be accompanied by frontotemporal recession
that conforms to type III guidelines
• • Type IV: Sparse or absent vertex hair with more severe frontotemporal recession; areas
separated by a band of moderately dense hair that extends across the top of the head

17. •• Type V: Same as type IV, but more severe hair loss; band of
hair narrower and more sparse
•• Type VI: Band is absent and two areas interconnect.
•• Type VII: Most severe form; only a narrow horseshoe-shaped
band of fine, sparse hair

21. EVALUATION OF PATIENT
• Not only progressive but also unpredictable.
• Not unusual for a young patient late teen or early 20 with significant hair
loss to wish to design the hairline juvenile appearance…young patients can
be dissatisfied on hearing that their transplanted hairline should be placed
high with temporal recession.
• Demand inappropriate hairline…should be rejected for surgery.
• Initial consultation…certain parameters…decision making…family history
maternal side…if brothers, uncle with significant baldness… likely to have
significant baldness.
• Available donor hair… 200-400/sq cm…need multiple future procedure…far
less donor hair…conservative approach.

22. • Pattern of hair loss…C/I to surgery Norwood VI and VII …also of
characteristics such as colour, texture, …curly hair looks more denser than
straight hair.
• During aging process…simultaneous recession of frontal and temporal
hairline…thus maintenance of fronto-temporal angle critical…blunting or
fill in the fronto-temporal angle cause unnatural appearance and significant
problem as hairline recedes.
• Medical problem…hypertension...cause bleeding…should be corrected
before surgery.
• Some patients with significant hair loss…frontal forelock…sitting low on
forehead…appropriate to begin the process slightly posteriorly to the
centrally located tuft of existing hair.

26. METHODS OF MEASURING HAIR
CHARACTERISTICS-INVASIVE, SEMI-INVASIVE, NON-INVASIVE

29. Surgical treatment of alopecia
• Composite hair-bearing scalp grafts (hair transplant) – FUE/ Strip graft
(FUG)
• Scalp flaps –
1. Rotation flaps
2. Transposition flaps (temporo-parieto-occipital/Juri flaps, large scalp flaps,
temporal vertical flaps)
3. Bipedicle flaps
4. Multiple flaps
5. Microvascular free flaps
• Scalp reduction – serial excision of alopecia, excision of alopecia with scalp
expanders

33. PREOPERATIVE PERIOD
• Discontinuation of herbal medicine such s vit E , fish oil 3wk prior to
surgery, may increases bleeding tendency.
• Ten days prior to surgery, ASA or drugs containing ASA should be
discontinued.
• Twice daily application topical minoxidil 2%-5% recipient area
beginning 1wk prior to surgery.
• Photograph must be obtained.

34. SURGICAL PREPARATION AND ANASTHESIA
• Preoperative sedation…oral benzodiazepine(diazepam 10-20mg or
lorazepam 2mg)
• Surgical design is drawn and donor hair area are trimmed to 2-3mm in
length.
• Donor region prepped with povidone-iodine prior to i.v administration of
an anti-anxiolytic (midazolam 2mg,diazepam 5mg) coupled with analgesic
fentanyl(50microgram).
• Local anasthesia…donor site…field block…inferior to donor region using 1%
lidocaine HCl with epinephrine(1:100000) followed by longer acting 0.25%-
0.5% bupivacaine HCl with epinephrine (1:100000) …effectively
anasthetizes the greater and lesser occipital nerves.
• Supraorbital and supratrochlear nerves are alternative method of
anasthesia for recipient site.

35. Harvesting techniques
• Strip excision most common method…producing single scar
regardless of number of sessions performed.
• Tumescent solution at dermal level…increases the inter-FU distance
and align the follicle shaft more perpendicular…minimal follicle
transection.
• Pre-op evaluation of scalp laxity…excessively wide strip lead excess
tension at the time of closure.
• Depth of incision should be ideally superficial to galea.
• Approximation to assist in determining the amount of donor tissue to
harvest is 100 grafts per 2 sq.cm. Thus 500 grafts require 10sq.cm.

39. CLOSURE

40. GRAFT PREPARATION
• Some follicular unit exist as single hair…others are groups of two, three or
four hairs.
• Magnification required…backlighting system to transilluminate the graft.
• Attempt not to split the hairs…great care in the handling is paramount
• Ultimately, 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.
• Kept in cool and moist all the time…desiccation is the most detrimental.
• Commercially available holding solution…1)i.v fluid…RL 2)culture
media…M199, DMEM 3)hypothermic tissue holding solution…
Hypothermosol.

41. Creating the hairline
• Normal hairline not at all a line…irregular arrangement of sparse,thin
hair in front of progreesively more dense hair.
• By using single-hair grafts in front of intermediate-sized grafts and
then slightly larger graft behind that a normal-appearing transient
zone, or hairline can be established…typically placed 1-2mm apart.
• Interdigitation of subsequent new grafts with already grown
transplant provides a reliable density that could not be achieved by
placing the same number of graft per unit area in a single session.

42. • Debate…whether slits or holes.
• Benefits of holes…removal of bald scalp, more control of transplanted
hair direction, ease of graft placement and less compression.
• Slits…allow closer packing…creates less raw surface therefore less
scarring, quicker to create, more easily interdigitated with insitu hair.
• Slits are placed at a 45deg angle, facing forward.
• Hold the grafts by subpapillary fat and to avoid crush injury to follicle.
• Popping out of neighboring graft…reduced by planting graft into every
other slit…allowing time for fibrin connection.

43. FUE
• An alternative method that involves removal of individual FU’s.
• Benefit…no linear scarring…more rapid and comfortable recovery.
• Utilized for beard and body hair follicle extraction as well as removal of
improperly placed grafts during corrective procedure of previous hair
transplant.
• Hair trimmed 2-3mm length…random distribution area…avoid
overharvesting from a particular area…use of a sharp 1mm “cookie cutter”
like punch…
• Avoiding graft transection or “decapitation”…to minimize follicle
transection , non-sharp motorized punches developed to perform “blunt”
dissection.

45. • Alternatively two step process…initial sharp scoring incision at a 0.3-0.5mm
depth around the follicle followed by insertion of blunt dissecting cylinder
that reaches the full depth of the follicle 4-5mm…enables full separation of
the intact follicle from the native tissue…mannual extraction using forceps.
• 1mm punch...avg 2.5hairs/graft.
• Transection ranges from 2%-8.5%...1mm punch.
• Cosideration…1)overall density of donor area reduced. 2)reducing the most
likely permanent follicle available for transplantation…as every third or
fourth FU removed.
• Donor site heals by secondary intension.

46. Graft…FUE vs EXCISED FROM STRIP

47. POSTOPERATIVE PERIOD
• Postoperative bandage for one night…maintaining appropriate moisture balance for wound
healing and prevent microbial infection
• Postoperative pain…minimal…increased tension in donor area.
• Postop 3-5days…tissue odema forehead and temporal area…periorbital tissue…ice their forehead
and temple region.
• Soaking…crust dissolution…prevent further crust formation.
• Initial 48hrs…no shampooing.
• Showering of recipient area is reserved until after 5-7days postop.
• Ointments, gels donor area.
• Topical minoxidil application(3.5%)…for 5-12wks.
• Suture left place donor area…10-14days.
• Donor area complications…localized wound dehiscence, hyperesthesia, a-v fistula
• Substantial cosmetic improvement 9-12 months post-op.

48. PERIOPERATIVE ADJUNCTIVE THERAPY
• Finasteride 1mg(5 alpha reductase inhibitor)…FDA approved…
relatively low adverse profile…hair growth most noticeable at vertex.
• Encourage young patients to complete a trial of oral finasteride…most
effective posterior scalp…ideal adjunctive therapy who opts HRS in
frontal and mid scalp areas.
• Autologus PRP administration emerging adjunctive therapy but
require further investigation…increase overall hair count and hair
diameter.

49. EYEBROW-HAIR TRANSPLANTATION
• First hair transplantation teclmiques to be described
• eyebrow is divided into the head (medial one-fifth), the tail (lateral
one-third), and the body (connecting the head and tail). The medial
most aspect of the eyebrow(head) should have FU directed
somewhat vertically while the direction gradually becomes more
horizontal while proceeding laterally as the head transitions into the
body… Angles should be as acute as possible.
• Requisite 400 to 450 FU is an area of the scalp.

50. TRANSPLANTING IN HAIR BEARING AREAS
• Mid twenties or younger, not completely alopecic…request surgical
intervention for their hair loss.
• Difficulty … uncertainty of future pattern of MPB and huge
expectation…desire a low, thick hairline.
• Careful evaluation of their projected donor to recipient ratio…medical
adjuncts.
• Avoiding transections of preexisting hairs …risk of temporary
effluvium should be minimized by creating the smallest recipient site
incisions.

51. ADJUNCT TREATMENT FOR FACELIFTING
• Face lift…permanent sign…discolouration temporal or postauricular
hairline…even well-placed incisions may widen or become hypochromic.
• Exposed temporal or pre-auricular scar effectively concealed by re-creating
a “sideburn” with fine caliber hair grafts.
• Preserving the already compromised underlying vascular perfusion is
paramount…aided by both avoidance of epinephrine and transplanting at a
graft density not high enough to overwhelm the limited vascular supply.
• Dermal recoil and laxity limited…critical to optimize recipient site size to
allow a “snug” fit of graft to ensure minimal graft handling by prevention of
repeated “popping” or slipping out of grafts above the surrounding
epidermis.

52. FUTURE OF HAIR TRANSPLANTATION
SURGERY
• Advent of robotics…allows for automated harvesting of FU…
PERFORMING both retrieval and implantation. Drawbacks…potential
decreased graft viability secondary to denuded grafts and noticeable
punctate scarring in the donor region.
• Stem cell therapy…mesenchymal cells located at both bulb region
and the bulge region…thus isolating hair follicle stem cells and
propagating them in vitro to generate new hair follicle…autogenous
implantation of these replicated hair follicles into balding scalp
generate new hair follicles……..BUT COSISTENT GROWTH OF
SIGNIFICANT AMOUNTS OF HAIR FROM SUCH HAS NOT BEEN
ACCOMPLISHED IN HUMANS.

53. THANK YOU…