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Hair Transplant: The OR

Posted Aug 24 2008 1:49pm
Introduction

MICHAEL REED: Hello. I'm Dr. Michael Reed. I'm a dermatologist who specializes in microsurgical hair restoration. I'm a faculty member at the New York University Department of Dermatology, where I specialize in microsurgery. And I teach the residents how to move hair around successfully to cure baldness.

Today we're going to be presenting a case of the latest in follicular unit hair transplantation. This technique has evolved over the past 10 years and has become highly specialized and has become the state of the art method of correcting baldness. The patient today is a healthy 42 year old man who has no medical problems, no bleeding problems, no problems with infection, and is a good candidate for this surgery. He has been slowly losing his hair, starting at the front of his head, for the past 10 years or so. And he has been treated with medical treatment, including topical minoxidil and Propecia with limited results in the frontal scalp, which is the area where the forehead ends and the hairline begins.

So the purpose of today's procedure is to show a state of the art method and to show the ideal way to do a hair transplant that's really the best for the patient. The basic rule that we follow is we do one patient at time; we have one surgeon-that will be me-with him the whole time. We have one team working, coordinated in time. And we want this one hair transplant we do to stand the test of time, to stand alone. And if he never had another one, to still be a good result that will last him a lifetime.

Preparing the Donor Area

MICHAEL REED: Now first I'd like to show the area where we're going to perform the transplant. This is the patient's frontal scalp. If we draw a line from the top of each ear across the top of the head, and we stay in front of that, that is the frontal scalp. So the frontal scalp is where the hair starts, in the so-called anterior hair zone, or hairline, and then where it stops, at this point between the ears.

This is the target area for today's hair transplant. This is the area where hair will do Mr. T the most good in terms of his day to day life and how people see him and perceive of him in terms of his hair. Remember this: that when somebody looks at another person, they first make eye contact. Then their eye unconsciously travels up the forehead until it stops at the hairline. If it does not stop at the hairline and it goes off the head into outer space, the mind perceives baldness. So what we're going to do here is create a new hairline, which is natural in the front and dense in the back, so that Mr. T will basically no longer be perceived of as bald by people who look at him in most normal circumstances.

Now I'm going to go around to the back and mark the donor site that we're going to harvest for hair to move to the frontal scalp. Okay, put your head down. This area, which roughly speaking, if we draw a line across the top of the ears in the back, and we stay below that, is the potential donor area. This is about 25 to 30% of the total scalp. And we can safely remove half of it or a little more, and move it elsewhere, without this area becoming noticeably thin.

Also, from the nape of the neck we generally try to go up about four centimeters, approximately 1.5 inches, and leave this area alone, since this is really a part of the neck and does not heal well. Staying above this narrow zone, we enter the donor site area. And that's what we're going to prepare now.

So now we have an area that is 12 centimeters in length, by 1.5 centimeters in width. And I can estimate that there are about 1,200 so-called follicular units which are anatomical clusterings containing one, two or three, and sometimes more, hair follicles per unit. All right? So we probably have about 3,000 hairs in this area that we're going to move to their new location.

All right, now we have Mr. T in the prone position and we're about to anesthetize his donor area. We're going to use a little trick called mechanoanesthesia, where we use this vibrating device-it sounds like this-and it goes on the scalp and it creates a kind of a camouflaging, or counterstimulation to pinches, or pin pricks, of the local anesthesia. Mr. T, you're going to feel a little tiny pinch here. And it'll smart for a few seconds. Breathe normally. We'll do this; we'll try not to inject this too quickly. Local anesthesia does cause discomfort when it's administered. It's relatively mild and it's diminished significantly by this vibrating device.

We're administering plain Xylocaine at this time. Plain Xylocaine is less uncomfortable than Xylocaine with adrenaline because it's less acidic. We're going to follow with a second longer-acting anesthetic called Marcaine because this procedures going to take awhile and we don't want the anesthesia to wear off before we're done, obviously. This anesthesia will last for six to eight hours.

Now I'm going to put in a little bit of preparation containing a little bit larger quantity of adrenaline just to reduce bleeding in this area. This is called Super Juice. It's one to 30,000 adrenaline. It will reduce bleeding in the area while we do this, and it will also prolong the anesthetic effect.

The last step before we remove the donor strip is to inject some physiological saline into these areas for the purpose of what's called tumescence and to make it hard.

Harvesting the Donor Site

MICHAEL REED: What I'm going to do is make my incision and I'm going to go along parallel to the hair shafts in the area. As I go along, I'm going to actually look at what's being cut here, change the angle of my blade as needed. Come around to the edge. I'm going to bring into field the infrared coagulator. This is an unfocused laser. There's just a little tiny bleeder, one area here, that I'm going to stop.

MICHAEL REED: Now I'm going to use some surgical scissors. I'm dissecting now beneath the hair follicles and area on the so-called galea, which is a white membrane that covers the entire scalp. I'm going to be going in and out of the field with the infrared coagulator as we see these little vessels. Okay. All right.

Okay, so I'm going to lay this out and we can see what we've got and inspect it. Here you see the totally intact donor site. The yellow part of the bottom represents fat. The little dark spots represent the living hair follicles on the edge. You can see the white part, which is the skin on the surface. And these little tiny, tiny hair shafts, which we left a little length on for the purposes of directionality later on. We're going to clean this up and then we'll show you momentarily what comes next with this donor tissue. But this is the initial section removed.

Before we do that, of course, we have to finish what we started in the back: clean this up and close it.

Closing the Donor Area

It is very important to close without tension on the wound edges. If there's too much tension when we close, then we might get a nice scar, but the hair around it can be killed by lack of oxygen. That's called ischemic alopecia, meaning loss of hair follicles due to inability to get oxygen from the blood vessels. So I'm going to make a little tiny incision, start an incision along here, my blade pointed down a little bit.

The purpose of undermining in the galea is so that when we close, because we're going to close with some buried sutures, the galea can pull together. And it pulls the scalp together without putting any tension on the wound edges where the hair follicles are. So when we cut under the galea, we can move the galea, and the skin above it just follows it. But when we close, we're not going to have tension.

Now I'm going to check and see how much tension is on the wound to see if we can close. See, it's nice and loose now. So now we can start to put in the buried sutures. And you're going to see I'm going to lift up the edge; I'm going to put this needle through some galea and bring it up below the level of the hair follicles. Now I'm going to line this up-will you clean that-so that we have even wound edges; lift the bottom part up; put the needle in at the same location; go through the galea.

Now see, I can put as much tension as I want on these buried sutures without affecting the overlying remaining hair follicles. We want to save the donor site if we need it for future work. Even though we try to do each transplant like it's our only chance and do the best job we can, there are many patients who want more transplants because some of them continue to lose hair or have large areas and need more than one transplant to make them happy. So we have to take great pains not to damage this precious and limited donor tissue.

The assistant on my left will make sure that there's no hair trapped in the sutures; will make sure also that we get the two edges together very nicely without one overlapping. That's called wound apposition. The assistant on my right here, Lavone, will make sure that we're getting proper alignment, so that we don't end up with irregular tissue at one edge, which results in what's called a dog ear. Lavone, where's the only place you want to see dog ears?

LAVONE: On dogs.

MICHAEL REED: On a dog, right. Okay. Okay, not on the back of our patient's head. Okay? All right. Now, we've completed, I believe, the buried interrupted tubovicral suture job. If you look along here, if you look at this you can see that it's still not totally closed but it's not wide open like it was before. And the second phase of suturing will be with a 3O nylon suture. We'll cut that. Trim a little.

Okay, now we have complete closure. Let's inspect what we've done. Rhonda will count the number of sutures and record them. How many is that?

RHONDA: Thirteen.

MICHAEL REED: Thirteen. Lucky thirteen? Are you sure it's thirteen?

RHONDA: One, two, three, four, five, six, seven, eight, nine, 10, 11, 12, 13.

MICHAEL REED: Okay. It's a lucky number for Mr. T. 13. T is for 13. Okay. So I'm just looking at the edges here. We've got good apposition; good alignment; complete closure. And we're going to clean this now. We're going to sit Mr. T up; put a temporary pressure dressing on. And for the rest of the procedure he'll be sitting up, watching television, having snacks, being entertained by our staff.

Dissecting the Scalp Tissue

MICHAEL REED: The next part of the procedure is to begin the microdissection of this living scalp tissue containing these several thousand hair follicles. I'm using a 10 power dissecting microscope, where I can see very close up the individual follicular units, which as I said, are anatomical-naturally-occurring, anatomical clusterings of individual hair follicles. And each scalp is a little bit different, but the typical Caucasian scalp, such as Mr. T, has an average of three, or maybe a little over three, hairs per follicular unit. If we have less than two hairs per unit, it's a rather thin area and can be difficult to transplant. But it still can be done.

So the first thing I'm going to do here is microdissect this large portion into smaller portions. And this is going to be a kind of zig zag movement of my blade here because these units are not exactly lined up. And so I'm actually watching what I'm doing very closely here, taking great pains not to break up the follicular units or to transect them.

What I'm doing here is I'm looking at the number of follicular units, and I'm cutting small slivers of tissue which have anywhere from two large or three small follicular units per-in the width of each small section I cut. And then these small sections, or so-called slivers, will be microdissected further into smaller follicular units for actual placement into the scalp.

Here are these slivers. They are approximately two millimeters, 1.5 to 2.5 millimeters in width. And 1.5 centimeters in length. And what will happen next is they'll be given to the microdissection team, to the cutters we call them, and to the sorters. And they'll be begin to prepare them. And what I'll do next is work on the patient's head. And I'll go back and forth, and we'll make sure that we have grafts that are exactly the right size and shape to fit perfectly into the openings on the scalp. And I'm going to show you how that happens next.

Preparing the Scalp

Mr. T is a professional man. He doesn't want to look like something from the age of the Neanderthals. So we don't want to give him a hairline that goes too low. Also if we make the hairline that goes really too low, we're going to use up a lot of hair of that donor tissue that we might want to save for the future behind this hairline.

All right, let me anesthetize this area now. Mr. T will feel some little pinches here, a little smart, so we'll try to do it fairly quickly. Just breathe normally. Apologies for the discomfort. Real slow. Just real slow. Any time the surgery is done in this anterior portion of the scalp, meaning in the frontal scalp, if you can imagine the Continental Divide, which is sort of on the top of the head, the fluid-the water or the fluid that is released from the trauma is going to go in the way of gravity, which is down the forehead. So during the post-op period, we have patients for the first three days wear an Ace bandage to reduce the probability of that and severity of that. And they wear it for three or four days continually except when they wash their hair or clean their scalp.

Most of the patients have, as a primary concern, not the procedure and not the final result, but the immediate post-op period. The cosmetic downtime as it were. The cosmetic downtime is always much less than the patient anticipates. But patients are self conscious. That's part of the reason why they do this procedure. And some of them who are very self conscious may elect to take a little time off than work. But more than a week is really not necessary. And people can go back to work and resume normal activities and normal functions, although not intense exercise, as early as three days. By two weeks, patients are civilians again. The sutures that we put in the back, those running sutures on the surface, can come out between seven and 14 days. In a first time patient, seven days is okay, but usually we leave them in for 10 days.

This is like a choreographed dance repertoire, where I'm going to do a little surgical dance with my team down the hall that are cutting to make sure that the grafts fit perfectly into the graft recipient sites. If a graft recipient site is too large for the graft, and the graft falls into it, it may heal with a little unpleasant looking pit, or it may not survive because it doesn't get good oxygen supply. If a graft is too large for the graft recipient site, and it's a struggle to get it in, then the shearing forces of trying to get it in may decapitate the hair follicles in the graft and then, again, there's poor graft survival. So that's why we go back and forth and do a few fittings, make a few openings, to see what exact size grafts are ideal.

The next thing I'm going to do is make a couple of small incisions into the scalp. This is called the Star Punch. It's a tri-beveled punch with three cutting surfaces. It looks like the Mercedes sign for the Mercedes car, without the circle around it. And when we cut an opening in the scalp, we have one of the apexes of this little blade facing forward to give the graft the proper direction. It will open up into a temporary triangle, which will close down on the graft and hold it a little bit like a tricuspid valve type of effect.

An incision is made with the flat end of the tri-bevel punch facing me, and the pointing end facing forward, to give a small triangle shaped opening. This will not stay for a long time, but it will stay like this for an hour or so until we get the grafts in. This particular tri-bevel punch is two millimeters in diameter, which means that the short arm of each is one millimeter in length. This will hold quite a variation in the size of grafts, as you'll see.

The other size that I'm going to make along the frontal zone is 1.5 millimeters in diameter. All right, and this will be for the single follicular unit grafts containing smaller number of hairs along this anterior hair zone. If a person has really dark, straight, coarse hair, we will use even a smaller Star Punch, which is one millimeters, to put in single hair grafts. So I've made two openings here.

And the next job is to do a fitting. So what I'm going to do is go into the room with the cutters, and from Rhonda, who is the supervisor and the chief cutter, I'm going to take an assortment of grafts, come back and see how they fit into these openings. Because the elasticity of the scalp varies a great from person to person and if the scalp is very elastic, then I might be able to use a bit of a larger graft. Whereas, if it's very inelastic, I might have to use a smaller graft.

Testing the Micrografts

MICHAEL REED: I'm in the cutting room now. And what I'm going to do at this time is I'm going to take an assortment of micrografts of follicular grafts of different sizes and different shapes, with different numbers of hairs. And I'm going to take them back to the patient's head and I'm going to see how they fit into the assortment of different openings that I made so that we get a proper fit of each graft and each opening, the so-called perfect or snug fit. I'm going to take a selection of them now in my hand, go back, and then I'll come back and I'll present them back to the team to tell them what they need to do so that we can get this exactly right.

All right. Here I have an assortment of single and multi follicular unit grafts. Here is a single follicular unit graft containing two hairs and maybe a third hair that's smaller and in a resting phase, called "telogen." Here's a three hair follicular unit graft. Here is a multi follicular unit graft which is probably a three follicular unit graft. This is about the largest graft that is used nowadays and would never be used along the frontal line, but is used behind it to give density.

So I'm going to look these over and I'm going to take actually the largest one here first. And I'm going to dilate this little opening and I'm going to see just how this is going to fit. Observe-I'm using these jeweler's forceps. I'm going to just slide this in very carefully. And I'm just going to roll over. Now you can see this fits in here very nicely. It's snug. We call this a perfect, snug fit. The edges of the graft come up against the sides of the recipient site. It's not falling in; it's not popping out.

So this is going to be a standard that the-this graft, which I will take back and show to the cutters, will serve as a standard for them to keep in their trays so that they cut other grafts that resemble this. Now there's a certain variation in the size that's still acceptable. So let me get all the smaller graft and put that in here. Now you can see the smaller graft right now is a little loose in there. And I wouldn't use it in that opening. However, as time goes on, in about an hour, an opening of this size will shrink and close up and this slightly smaller graft will fit very nicely in it by the end of the procedure. So this is why we're checking his scalp like this. And we can still get a graft like this in later if we want to.

For right now, I'm going to see if this graft will fit in the frontal area. And it fits in very nicely there. this is actually a single follicular unit graft with three hairs. You know, a fair amount of tissue on it, but not too much. Enough tissue so that I can handle it without damaging the hair follicles.

And I'm going to take the smallest one here and just check it out and see how it goes. And at the present time, the smallest one is a little, little small for that 1.5. But that means that what I can do is do some 1.0's and this will fit perfectly into a 1.0, as you'll see subsequently.

So now what I'm going to do is I'm going to make these moist because they're starting to dry out. And I'm going to take them back to the cutting room and I'll have a little discussion with the cutters explaining how to cut these. All right, people, I've got the sizing here and the fittings for you. I'm going to show you, Rhonda, and then you'll show the other ladies here. These are going to be-the very smallest ones, the single follicular unit grafts are going to go in the frontal zone. These are going to go into one millimeter Star Punches. The next size here are going to fit into the 1.5's. Some of them are single follicular unit and some of them are 2.0 follicular unit grafts. We're going to blend them into the smaller ones in the frontal zone. And then the final largest size, which contain two or, at most, three follicular units, are going to go into the 2.0 millimeter Star Punches. So these will serve as your standards. And you make sure that the tissue you're cutting, whenever possible, will conform to one of these three sizes. I'll go back and forth and see how many you're getting of each, and make sure that the number and size of openings I make conforms with what the scalp dictates we do.

FEMALE: Okay.

MICHAEL REED: So keep up the good work. I'll see you in a little bit.

We're back on the head of the patient now after leaving the cutting room and giving the assistants the instructions for what size grafts are needed for this particular scalp. I have already prepared the frontal row of one millimeter Star Punches. And now I'm going to continue as follows, making small incisions. I'm making sure that the front of the device, one of the apexes of the little triangle that I'm creating, is facing forward so that the hairs have a good kind of directionality.

Lasers have been used up here. However, the initial lasers, which are carbon dioxide lasers, unfortunately caused a certain amount of charring inside the recipient site. And that layer of charcoal broiled skin cut off the blood supply. And in studies that have been done comparing these cold steel instruments to the carbon dioxide lasers, the cold steel always wins because it does the least damage to the skin.

All right, we're going to take a break from the incisions on the top of the head. We're going to clean up Mr. T, achieve hemostasis. And then the next portion will be the placement portion.

Inserting the Micrografts

MICHAEL REED: Okay, we're going to do these, most of these that I have in this particular tray, most of these grafts are small two follicular unit grafts with two and three hairs in them. And I'm going to put these right here behind this frontal line on the second row. So the smaller grafts go in here.

We keep the patients with male pattern baldness on Propecia. We try to get them all on it if they're willing to take it. Assuming that they tolerate it and a vast majority do, we have them continue it throughout the procedure. One of the things that happens here in the top of the head is that the native hairs, which are kind of restless to begin with, will be shocked by the procedure. And even though we don't remove any of them intentionally, and we take great pains to avoid harming them, they have to regrow along with the transplanted hairs.

If there's a large amount of male hormone in the scalp, namely dihydrotestosterone, then some were-a fair number of those native hairs just may not grow back. So that's why we have them on Propecia, to help the native hairs grow back. Theoretically the Propecia won't do anything one way or the other for the transplanted hairs because they're genetically blessed and will grow back no matter what as long as they survive the trip.

I also have a preference for using topical Minoxidil prior to surgery. Turn this way. That's good. This is not been proven in any studies, but we like to use Minoxidil up to the time of the surgery. We stop it a few days before; start it again after the scalp has healed. And we believe that perhaps, or we hope that perhaps it will help the transplanted hairs and the native hairs to grow better and to achieve their regrowth potential sooner. It does, some people believe it increases blood flow to the hair roots. Others believe that it keeps the hairs in their growing phase once they start to grow.

So a combination of topical Minoxidil and Propecia is, in my opinion, desirable, adjunctive-meaning supplemental medical treatment around the time of the transplant. In the long run, we like to keep people on these medicines because we don't want them to get any balder. I don't like chasing baldness and I'd like to be able to transplant a person in one or two transplants, if they need it, and then be done with it maybe for a lifetime if these medicines work for a lifetime. So the best approach now, I think, is an eclectic approach combining medical and surgical treatment.

After these grafts have been placed, and after they heal, they will actually continue to grow for a week, maybe even two weeks. After that, they generally tend to rest, or go into what's called the telogen phase. And they stay in that phase for a period of time that varies somewhat, but generally is two to three months. It's like being asleep.

Then they wake up, the early-risers wake up around eight weeks, which is two months. The late sleepers can wake up as late as six months, but most of them are awake and growing by four months. They produce a hair shaft, which increase in length by about a half an inch a month. So in the typical male patient, we can get a post-op photo showing the significant improvement in the hair density between six and seven months, sometimes five months.

Closing Remarks

MICHAEL REED: Well the procedure is completed and it went very well. There were no problems; everything went according to our plan. And we expect the patient to get a most excellent result in just one hair transplant. This transplant should really stand the test of time. He may want to do more in the future to get more coverage. He may want to do more in the front to get a more natural look. Bu the goal of this procedure was to show the people watching how we can achieve an optimal hair transplant, meaning a best: not a minimum one and not a maximum one, but the best, which is called an optimum transplant.

Tonight he'll go home in a head dressing to keep from bleeding; a pressure dressing to keep him protected so he doesn't disrupt any of the grafts we put in. Tomorrow he'll come back here. We'll remove the dressing and we'll put him in this unit, which is called the Scalp Debridement Unit. He'll lie back here; his face will come out. And there are oscillating water jets which will go through various computer generated cycles of cleaning and debriding his scalp. It'll get him all cleaned up; it'll prevent any infection; and it'll make his post-op period much more pleasant because patients oftentimes are afraid to wash their hair. And they'll go through a very unpleasant post-op period if they don't do it. So we do it for them here. It makes it a lot nicer for him. Okay?

After that, we'll put a much smaller post-op dressing on, just over the front of his scalp, with an Ace bandage on for a couple of days to prevent swelling of his forehead and his eyes. He'll take a painkiller if he needs it because it can be sore in the back, although it's not sore in the top of the head. He'll also take some cortisone by mouth to reduce the potential swelling that can happen after a surgical procedure of the forehead and around the eyes, which happens in a small percentage of people but goes away quickly. He'll take an antibiotic to prevent infection. He'll have his sutures removed in 10 days. By two weeks, he'll be back to full activity and in six months, he'll have a new restored head of hair in that frontal region where we worked. We look forward to a great result. And we hope that you enjoyed the program.

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