Dr Jayanta Kumar SahaConsultant Cosmetic & Plastic Surgeon

Surgical management of Hair Loss

ANATOMY OF HAIR

Hair consist of a shaft and a rootShaft is the visible portion above the scalp surface: Root or bulb is the follicle-sits at an oblique angle to the scalpShaft has 3 layers: cuticle, cortex and medulla

MICROSCOPIC ANATOMY OF HAIR

Hair matrix present at the base of the hair follicle canal within subcutaneous tissueWithin the matrix are rapidly dividing cellsAbove this layer lies zone of keratinization which makes the hair shaftThe 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

HAIR GROWTH CYCLES

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

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

Anterior hairline

Fronto temporal recession

Irregular margin

Vellus to terminal hair gradually

TYPES AND PATTENS OF BALDNESS

MALE TYPE:ANDROGENIC ALOPECIAMost common type of hair loss in both male and femalePredetermined by genetic characteristicsIn regions of scalp susceptible to androgenic alopecia androgens reduce the growth rate, hair shaft diameter and length of the anagen phaseTarget cells found in bulbar region of follicleDihydrotestesterone(DHT) act on target cellsMostly affects the frontal and crown region of scalp

TYPES AND PATTENS OF BALDNESS

IN FEMALEMostly diffuse typeIn a subgroup of women hair loss pattern similar to menStart at the vertex and progress anteriorly as they approach 30s and 40sUsually family history positiveMost of them maintain a low anterior hairline unlike the men who show progressive frontal hair loss.

OTHER CAUSES OF ALOPECIA

Post ChemotherapySurgeryMetabolic disordersAutoimmune diseasesTraumatic:

Temporary Permanent

Post burnAesthetic surgery of face

Hair transplantationComatose patient lying in one posture

NORWOOD CLASSIFICATION OF BALDNESS

FEMALE TYPE BALDNESS

LUDWIG SCALE

SAVIN SCALE

Evaluation of patient

Invasive – scalp biopsy

Semi invasive – trichogram

Non invasive – hair pull testtrichoscanfolliscope

ROLE AND EFFECTIVENESS OFMEDICATIONS

MINOXIDIL:LOCAL APPLICATIONWorks 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 IIThere is uptake of testesterone by hair follicles which is converted to DHT by 5 α- reductaseDHT acts on androgenic receptor

1.Hair grafts2.Scalp flaps3.Expanded hair bearing flaps4.Scalp reduction

SURGICAL PROCEDURES

HAIR TRANSPLANTATION- TERMS USED

Micrograft=one to two hairsMinigraft= three to six hairsSingle Follicular Unit (FU)=one to four hairMulti Follicular Unit (FU)=two to three unit/two to six hair grafts.

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%

INSTRUMENTS FOR GRAFT/FOLLICULAR UNIT PREPARATION

Petri dishes with saline 0.9% Scalpel handle (blades available: no. 10) Delicate tissue forcepsExtremely delicate dissecting forceps Forceps for micro- and minigrafting (implantation) Wood for preparation

HAIR TRANSPLANTATION

Instruments for Micropunch TechniqueMicropunch 0.8 mm diameter Micropunch 1.0 mm diameter Handpiece for micropunch

HAIR TRANSPLANTATION

Instruments for Microslit TechniqueSharpoint (15°/22.5°/30°/45°

pointed tip) Handle

Techniques of hair graft harvest

Follicular unit transplant (FUT)

Follicular unit extraction (FUE)

HAIR TRANSPLANTATION-DONOR AREA

Preparation of the Patient, Hairline DesignDonor AreaThe 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 densitmeterWith this figure, the number of follicular units to be transplanted can be calculated from the total area of the donor strip.

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.

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.

CLOSURE

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

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 transectionsThe segments are divided further into strips; the follicular units are now arranged in a row on a piece of gauze.

FOLLICULAR UNIT PREPARATION

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 .

RECIPIENT AREA, HOLES AND SLITS

TRANSPLANT OF THE GRAFT

Transplantation of follicular units with a sharp angled microtweezersPerform 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 itThe FU to be snugly fit

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

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.

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

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

SCALP FLAPS

Earliest flap used: Temporal parietal-occipital flap described by JuriScalp flaps give immediate results with dense frontal hairlineProblem:

Dense frontal hairline shows an unnatural appearance because of its abruptnessTends to round out a normal temporal recessionRequires micro and mini hair transplants in front of the flap to cover the scar Dog ear

SCALP FLAPS

Scalp flaps mainly used for frontal baldness

Limitation of scalp flap:Relative inelasticity of scalp tissueWidth is limited if the area has to be closed primarily

Limitation can be overcome by tissue expansion and scalp flaps

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.

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)

Complications

Low anterior hairline

Poorly designed hairline

Large hair plugs – corn row appearance

Hematoma/infection

Inclusion cyts

Corn row appearance

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