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Beyond Hair Plugs

Posted Aug 24 2008 1:49pm
DAVID R. MARKS, MD: Hi, and welcome to our webcast. I'm Dr. David Marks. Here's a depressing thought. 50% of us men, that's 50%, will suffer hair loss by the time we're 50 years old. The good news is, there are many surgical treatments available. Which one is the right one for you? We have two guests joining us today to help us decide. The first is Dr. Michael Reed. He's Assistant Professor of Clinical Dermatology at NYU Medical Center and he directs their hair transplant program. Welcome.

MICHAEL L. REED, MD: Hi.

DAVID R. MARKS, MD: Next to him is Dr. Robert Cattani. He's one of the founders of the American Board of Hair Restoration Surgery and he practices in New York. Welcome.

ROBERT V. CATTANI, MD: Thank you very much, David.

DAVID R. MARKS, MD: Dr. Cattani, it used to be that when you saw a man on the street who had a hair transplant you knew it. Nowadays you can't really tell. Why the difference?

ROBERT V. CATTANI, MD: I think that's a good starting point for the audience there. Hair restoration began in 1958 and I think for the first 35 years we were almost offering apologies for some of the work we were doing because we were transplanting very large grafts. We all know the names. Cornrow, dolls hair, take offense, my god they're awful. That was the only thing we had. Then because of medicine and the wonderful progress we're able to make, we decide that maybe less is more. We started to take down the size of the grafts. From ten and 12 hairs down to five, four, three and two and sometimes one hair.

We learned that men seek two things in hair restoration. One, they want maximal naturalness, and two, they want minimal detectability. Lastly, maximal naturalness doesn't have to mean maximal hairiness. It's OK not to have a full head of hair.

DAVID R. MARKS, MD: You had some picture to demonstrate the differences, correct?

MICHAEL L. REED, MD: Yes, I think this is the image that a lot of people have in their mind of going back to the 70s and 60s. You see people who had incomplete or poor work and this is the so-called old giant plug graft, the dolls hair look. That's been totally replaced by much smaller grafts. This is just one session or these tiny grafts have been put in. The knowledge that is the basis for this new work is shown here. A kind of breakthrough in understanding the anatomy of how mother nature creates density, is to understand something called the follicular unit which is a natural, anatomical clustering of hair follicles. They go in little clusterings where you can have anywhere from one up to five or six hair follicles all together surrounded by a little fibrous tissue compartment. We've taken this concept of the follicular unit and now we have what's called follicular unit grafting where we can take grafts which have one follicular unit, with one, two or three hairs, to construct a natural frontal hair line just like mother nature. Behind it we can use the same type of grafts or a little bit larger grafts to create the density, so that when hair grows in you see hair and no longer see scalp. So we can get results that are natural in the front and dense in the back, and we can do it in as little as one session in a lot of patients.

DAVID R. MARKS, MD: One session?

ROBERT V. CATTANI, MD: As little as one session, yes. Although if a person looks real close at themselves in the mirror and not just in casual circumstances, to rebuild a frontal zone may take two and even three in some individuals depending on the hair color and texture and the skin color.

DAVID R. MARKS, MD: OK. We're going to go to some video here. Take a look at this scalp. Talk to me about the pattern of hair loss right there.

ROBERT V. CATTANI, MD: Here you see typical male hair loss, and we're pointing there to the frontal scalp. You can see the forehead lines of this young man. His hair's thinned out and it's receded, and he's probably, in that frontal area, lost 80-90% of the hairs compared to what he started off with. He's also a little thin on the top but he still has pretty adequate coverage up there. So he really needs work done on the front.

DAVID R. MARKS, MD: Of course, you have to have donor hair. How do you decide where to get the hair from?

ROBERT V. CATTANI, MD: Basically we have two types of hair on our head. I don't want to be overly technical here. But the hair that we have around the sides and the back is called terminal hair. It grows five to seven inches a year, each and every year of our life and for the rest of our lives. Basically. This is simplification. It is concentrated. Each shaft of the hair is thick. This is the donor hair. So when we harvest this donor hair and we transplant it, if you will, to the new balding site, that hair acts like it's never left the donor spot. So therefore it is permanent, it will prevail for a lifetime and will have concentration and density, certainly higher than what the balding area has right now. Never to the extent that the donor hair was. In other words, we can't make it as thick as where from whence it came.

DAVID R. MARKS, MD: We have picture of harvesting that they're running right now. So this is really in the back of the head.

ROBERT V. CATTANI, MD: That's correct.

DAVID R. MARKS, MD: What do you do? You clear out a strip of hair?

ROBERT V. CATTANI, MD: Yes. Let me just say this. First of all this is done in a doctor's office or surgical suite. It is not painful. It is monitored. We give the patients novocaine-type substances. Then by the use of a surgical blade we will remove a certain segment of the scalp.

DAVID R. MARKS, MD: Is that what's outlined there, the strip that will be removed?

ROBERT V. CATTANI, MD: Yes, it is. From this harvesting we'll be able to create several hundreds of grafts. Thousands of hairs sometimes. I think it's safe to say, and I want Dr. Reed to give comment on this. I like to move approximately 2,000 hairs per procedure. Dr. Reed would like to comment on that I'm sure.

MICHAEL L. REED, MD: Yes, I think the new definition of what's called a megasession, which is the largest session that can be safely be done to make a lot of progress in just one procedure, is to move somewhere between 2,000-3,000 hairs, which, in the follicular unit world is anywhere from maybe 1,000-1,200 follicular units, which are these clusterings containing two or three hairs per unit. We take out the strip of tissue and under a dissecting microscope, it's first microdissected into little tiny slivers which are a few millimeters thick and then it's subsequently dissected into smaller grafts containing anywhere from one, or maybe two or maybe three follicular units at the most. So anywhere from one to maybe eight hairs per graft. Then those grafts are put very closely together in surgically produced sites in the new home, in the recipient site, in a pattern that resembles that found in mother nature.

DAVID R. MARKS, MD: We're going to look at that in a minute. But it looks like a very large strip that's taken out. How is the healing? Is there any scaring?

MICHAEL L. REED, MD: Any time that there's surgery there can be a scar. However, I get a kick out of telling people when they come in, "Did we get the hair from you are somebody in the family because I can't find the scar" because the techniques for closing the back are so sophisticated now. Basically, once we take the tissue out we underline and loosen the scalp up, we close it without tension, we put in some buried sutures into a membrane under the scalp called the galea.

DAVID R. MARKS, MD: I think we actually have some pictures.

MICHAEL L. REED, MD: We bring that together. Then we close, without tension on the surface. There's no tension and the sutures come out at 10-14 days and most people heal with a pencil line scar. I think in this photograph you can see the immediately postoperatively the shaved area with the running suture across it. The service ones will be removed, the buried ones will dissolve themselves. When it's all done most of the patients get a pencil line scar.

DAVID R. MARKS, MD: The hair grows over it.

MICHAEL L. REED, MD: The hair at both ends comes together so that even though there 's less hair there than there was before because it is a finite number of hairs, these hairs don't replicate. There are a fixed number of hairs brining the two edges together leaving a little tiny pencil line scar results in a very nice look that's undetectable.

ROBERT V. CATTANI, MD: I think what Dr. Reed has just expounded on is of major import here because in patient education, what they have to know is in days of old we actually got a drill and drilled into the back of the scalp and took out these plugs. There's not a person out there in the audience who doesn't know what a plug is and that's not a good thing. We took out these plugs. Not only did it limit the amount we could harvest, but it left these deficits in the scalp. One of the major contributions that has been made in hair restoration in the modern age is, we went from that to this very long strip that we suture together and this is a major concern. Every patient asks me, "Doc, are they going to be able to tell?" I tell them, "No, it is quite undetectable from that donor area," and we're able to harvest more in there.

DAVID R. MARKS, MD: Of course, one of the reasons for the undetectable nature of transplants now is that you're dividing the harvest site into follicular units. We have some pictures of that, but just tell me how that's done.

MICHAEL L. REED, MD: There's different ways of doing it. You can see here close up. What's happening here is this is actually a segment of the living scalp that has been removed, the whole piece. This is now being cut under a dissecting microscope into small slivers. Each of those slivers, and you see a whole bunch of the them there in a petri dish, those slivers are then subsequently, using magnifying lenses and backlighting on the dissecting microscope, are dissected into the final tiny grafts which contain anywhere from one to maybe three follicular unit grafts.

DAVID R. MARKS, MD: How do you know how thin to cut these?

MICHAEL L. REED, MD: We allow the scalp to determine what it needs because some people have larger follicular units, denser follicular units. So we will cut according to what the scalp requires. Also some people have more elasticity in the top of the head, some people have less. So we go back and forth and we do a sizing, I call it, where we do different kinds of openings and then we get several different sizes of grafts and shapes of grafts and we fit them and see what fits best. Then we take those standards back to the techniques who then follow the instructions and we make a certain number of each depending on how much air you're going to cover. That works out perfectly.

DAVID R. MARKS, MD: Let's take a look at that also. We have that video.

MICHAEL L. REED, MD: Here you can see the tiny grafts on the back of a surgical glove. These are what we take, and we get different size ones and we make a few openings in the tope of the head using different types of instruments. Sometimes we use something called a slot punch, which takes a little tissue out in a very bald and inelastic scalp. Then in a younger scalp with the elasticity, we usually make little openings. I like to use something called a tri-bevel punch, which opens a little temporary triangular shaped area. I can get those very close together and still get a good supply, and these little triangle shaped openings stay open for a while. Then they close down. Almost like it was called a tricuspid valve effect and evenly hold without pressure the grafts. When they heal it doesn't look like they were moved there. It looks like they started out there. That's how perfect the fit is and how natural the result is.

DAVID R. MARKS, MD: Let's see the punches. I think we have some shots of the punches here.

MICHAEL L. REED, MD: Heres a blown up shot. These are the latest cold steel instruments that I think give the best results in my hands. On this side you see something called the slot punch which is a half a millimeter wide, two millimeters in length and it creates an opening that's a small oval shaped opening. It really fits grafts much nicer than the old circular punches which tended to compress the grafts and give a micro ... hair look.

These are magnified, but this is only one millimeter in diameter and this is 1.5 millimeter in diameter. These are tri-beveled. They have three cutting edges. If you look at them directly on, they look like the Mercedes car sign without the circle around it. When you make those two little incisions they're very short arms and they open up into a little triangle that stays there for period of time. It's very forgiving. You can take a one haired draft, a three haired graft usually comfortably. So it's quite a remarkable advance in technology.

DAVID R. MARKS, MD: Let's take a look at them in action here, Dr. Cattani. Hair doesn't necessarily come up perpendicular from the scalp.

ROBERT V. CATTANI, MD: Nor should it. I think the golden rule to follow here is -- I think the message that the audience will see here, that this is a procedure of tedium and precision and one that you really have to be an experienced surgeon to perform. It is not longer just getting in and taking plugs and putting them in. This is a very precise thing. You heard Dr. Reed say microscopes and so forth. So that is the message that I think should be carried across.

MICHAEL L. REED, MD: You're absolutely right and there is a qualitative component to this in the sense that we look at each graft. Not just the size of the graft, not just the number of hairs in the graft, but their actual texture, and those are the ones that go toward the front. Less hairs, smaller graft, finer texture in the very frontal line. Larger grafts, coarser texture, larger folliculins toward the back. So it's not just a matter of dicing this into little bits of sushi and then stuffing as fast as possible. That would give a lousy transplant even with these techniques. This is the most labor intensive cosmetic procedure in the history of the world and every attempt to improve the ergonomics tends to compromise the result. At the clinic where I teach the residents, even though these are the best residents in the whole world, I believe, the first time that they get their hands on this tissue, the left hand doesn't know what the right hand is doing. It's almost comedic and if I wasn't there it might be tragic.

DAVID R. MARKS, MD: What about healing? Are there bumps when you run your hand over the scalp?

ROBERT V. CATTANI, MD: There can be what is known as cobblestoning, when these small grafts raise above. Mostly with the passage of time, they'll level out. Beyond that, David, let me make a few comments. Most of my patients, not most of my patients, all of my patients have one request. Can you do it all at one time, doc? The answer is usually no. At least in my hands. There's only a certain amount of grafting you can do per session. Secondly, I try to impart to them that a hairline is anything but a line if you think about that. It is nota line. It's a gradual transition zone from the baldness of the frontal skin to the fullness of the more posterior scalp and that's so important. So we like to get it irregular. As irregularly irregular as possible and that's naturalness. Lastly, and probably the most important thing, if my patients, who are in the 25, 30, 35 year old range, considering the fact that what we do lasts forever, we try to give them hairlines -- a 25 year old -- we'll give him the hairline of a 50 year old. So it will look natural throughout his life. That's a very hard message to impart to a young man, but a very necessary one.

DAVID R. MARKS, MD: Let's move on to scalp reduction. What is it? What exactly are you doing in scalp reduction?

ROBERT V. CATTANI, MD: I think I've been performing scalp reductions since 1978. In 1977, almost out of desperation -- but you think about it, if you have a man who is slick bald, let us say grade six, Jackie Leonard baldness if people knew who he was -- the more hair you have lost the less you have to put back. So we have to even out that ratio and one of the ways we've done this is by eliminating the bald skin by literally cutting it out. When I first started telling this to patients I almost made sure that my consultation room door was locked because there's kind of a tendency to run out when they heard this. But what is involved is the following. Let us pretend that this is the area of baldness. If we don't have enough donor area of hair to cover the entire area and the patient wants us to cover as much as possible, then somehow we have to reduce the paucity of the donor area and the expanse of the bald skin. So what we do it literally cut out the bald skin. This was done in several patterns. One, this pattern here. Lower down here is a midline incision where we cut out the bald skin and bring it together. Now we can remove approximately two inches of skin from the balding area in one session. Another pattern is a more elliptical pattern along the hair line. The third is in the crown or vertex area where we literally cut out the skin. However, this leaves scars and you have to transplant too. So what we do now is what is known as a buzz triangle scalp reduction. I will try to demonstrate. We'll make an incision along her like this, across the scalp. We'll extend it this way, as such like this, and this way as such like that. If you can visualize this you're now two tons of tissue. We will lift this up, lift that up, and literally pull the scalp together as such, and this will bring this to here, this to here. So from an area that is this bald, we will go to an area that is that bald and now we only have to micrograft in here. The principle of scalp reduction.

DAVID R. MARKS, MD: So you would follow that up with a transplant.

ROBERT V. CATTANI, MD: Always. Always. I think that is a modality that some surgeons still use to great effect. Others choose not to perform scalp reduction. I will say this. If I can micrograft and micrograft alone, that would be the procedure of choice. If we're limited as to the amount of donor site that we have, then I will then step up into scalp reduction.

DAVID R. MARKS, MD: Dr. Reed, tell me what a flap is. What is that procedure?

MICHAEL L. REED, MD: That's a third way in correcting baldness in which an incision is made in the hair-bearing scalp with it's blood supply loosened up. The bald scalp is cut out, and the flap is rotated one way or the other way over and sewn down into the previously bald area causing an immediate cure to baldness in that particular spot.

This is a procedure that is for a distinct minority of a minority of balding people. As we get more aggressive with these procedures, as we go from micrografting where there is almost a 99% chance of a good result, then you start to get into morbidity and problems with infection and necrosis and scarring that start to rise to the level where a person is taking a pretty big chance of having something go wrong. By pretty big chance, I mean that 1 chance in 10 to me is a big chance. One chance in twenty is a big chance. If it's that big for a cosmetic procedure, I don't want to do it because I wouldn't do it to me.

For people who really want a tremendous amount of density, who just want the densest hair they can, you'll get the densest hair with a flap. There is no doubt about it.

DAVID R. MARKS, MD: You have a diagram here. Can you show me?

ROBERT V. CATTANI, MD: To continue what Dr. Reed has said, I think the analog here is "Well, I don't want micrographing. I don't want the grass seed, I want sod." Well, if you want the sod and you want the thickness, there are a lot of things that have to be in place. First of all, this is a staged, surgical procedures. It's still done in the office, but it should be performed in the hands of a highly experienced surgeon who performs this frequently. What happens here is what is known as a twice-delayed flap. The incisions made along here. This is the outline of the incision. I don't mean to confuse, but the first incision is made here and here, and then sutured. This is left alone. Then the patient comes back two weeks later and the incision is carried through here and through here, and then sutured again. Two more weeks go by, they come back and take this tongue of tissue like this and they put it up front. You're transferring the entire surface of the scalp with its density to the frontal area, then you'll come back and do the same procedure on the other side. Voila, there you have it.

If there is ever a diagram that is easier said than done, it is this. As Dr. Reed alluded to, there is an 8% failure rate on these flaps. There can be as high as 8% failure rate in these hands. Let me tell you something. 8 out of 100 means absolutely nothing unless you're one of the 8. Then it means absolutely everything.

Let us say, let us put scalp surgery on the back burner. Let's put flaps on the back burner. Let's say the main thrust of our work should be in micrographing. I'm going to say this, and I hope Dr. Reed will second this. I'm very proud of the work that we're able to do right now. And I mean, very proud of it. It carries a great deal of patient satisfaction. Do you agree with that Dr. Reed?

MICHAEL L. REED, MD: I am amazed that we are almost at 100% patient satisfaction. That's really remarkable for any kind of cosmetic procedure. But day after day, patient after patient, they come in and everyone is happy with the results. That makes us happy because we're in this business to make people happy, to make them look good and feel good. We want to restore their self image, their self esteem. The results are natural and dense, and the technique is there. It's arrived. It's not going to get better in it's present form until something like gene therapy or micro-cloning comes in the next generation of hair treatments to replace it.

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