Hair Tr ansplant a nd Lo c al

Anesthetics
Samuel M. Lam, MD, FACS

KEYWORDS
 Hair transplant  Local anesthesia  Platelet-rich plasma  Robotic follicular-unit extraction
 Hairline design  Hair restoration

KEY POINTS
 The surgeon should understand the natural Norwood hair-loss patterns so as to recreate natural
patterns.
 The surgeon should have thorough knowledge of dermatologic conditions that preclude surgery,
such as scarring alopecia, and also be well versed in the medical management aspects of hair
restoration, such as the use of finasteride and minoxidil.
 The surgeon should understand the principles of good hairline design and the objective of framing
the face for aesthetic purposes.
 The surgeon should be technically well versed in recreating the natural angle and direction of recip-
ient sites according to the specific region of the scalp.
 The team should be excellent at both graft preparation and graft placement, and be aware that infe-
rior performance leads to devastating outcomes.
 The surgeon should be a lifetime student, learning new techniques by attending workshops and
major conferences as well as reading and analyzing his own work.

Video of technique for donor and recipient tumescence for hair transplant accompanies this article
at www.plasticsurgery.theclinics.com

INTRODUCTION a patient naturally, will age well for him, and

have been created in such a way that provides
Hair restoration has advanced remarkably since optimal visual density for the number of grafts
the bygone era of unnatural “plug” grafting.1,2 transplanted. Besides outlining the fundamentals
Nevertheless, despite the use of follicular-unit of what every surgeon should know when perform-
grafting, bad results persist because of technical ing a hair-transplant procedure, this article also
errors, lack of judgment, and poor artistry. Many discusses some of the major advances in the
plastic and cosmetic surgeons look askance at past several years in hair restoration, including
hair transplantation because it is thought of as an regenerative medicine (the use of platelet-rich
easy procedure to master, which is absolutely plasma [PRP] and ACell [Acell Inc, Columbia,
not the case, or that it can be taxingly boring and MD]), and follicular-unit extraction (FUE) methods
tedious, which is an erroneous perception. Hair that obviate a linear scar. Hair transplantation
restoration, when mastered, can be an extremely can be undertaken with any level of anesthesia,
plasticsurgery.theclinics.com

rewarding procedure for both the patient and but because it is essentially a skin-based surgery
surgeon alike. In this author’s opinion hair trans- it can be easily performed from start to finish under
plantation is thoroughly enjoyable because artis- local anesthesia only.
tically designed patterns can be created that fit

Willow Bend Wellness Center, 6101 Chapel Hill Boulevard, Suite 101, Plano, TX 75093, USA
E-mail address: [email protected]

Clin Plastic Surg 40 (2013) 615–625

http://dx.doi.org/10.1016/j.cps.2013.08.006
0094-1298/13/$ – see front matter Ó 2013 Elsevier Inc. All rights reserved.
616 Lam

TREATMENT GOALS AND PLANNED from the baldest man (think of a horseshoe config-
OUTCOMES uration in the occiput) and transplanted to the front
of the scalp retains the genetic characteristics of
Before outlining what is surgically necessary, the the native donor region; that is, it will not be lost
larger scope of understanding the nature of male after being moved to the front of the head. How-
pattern baldness (MPB) is critical. Discussing ever, for young men who are losing hair one cannot
every type of hair loss lies beyond the scope of predict with absolute accuracy how much donor
this article, so the focus here is on the principal hair is actually safe to transplant and how their
type of hair loss, MPB. Many surgeons are over- hair loss will progress. At this point the surgeon
zealous to begin their career in hair restoration with experience use considered judgment to
without this prerequisite knowledge, and this can prognosticate if there will most likely be enough
be a great disservice to the patient who may donor hair to address both present hair loss and
encounter a serious problem perhaps not today additional demands for future transplants going
but in a decade, when the hair-transplant result forward. Furthermore, it is important that every
that originally looked natural now cannot be fixed budding hair-transplant surgeon also takes
as a consequence of poor or absent judgment. the time to review dermatologic conditions that
The best way to explain the nature of MPB is can mimic MPB but that may in fact represent
that hairs transition from thick “terminal” hairs nontransplantable conditions such as scarring
slowly over time into thin, wispy, “vellus” hairs alopecia, especially if the physician is not a derma-
that in turn ultimately disappear altogether to leave tologist by training.
a bald pate. Medications such as oral finasteride
and topical minoxidil, along with laser technology, PREOPERATIVE PLANNING AND
are useful if not in fact particularly important in PREPARATION
slowing down this process, and any male patient
who is in the early process of hair loss should be When planning to perform a hair-transplant proce-
counseled vigorously on the importance of medi- dure, the surgeon should keep in mind the afore-
cal management to slow down and partially re- mentioned tenets of whether the patient has the
verse hair loss, and perhaps avoid the need for proper hair density, usable donor hair, and degree
surgical intervention, at least for the present. and area of baldness, along with the age of the
Finasteride and minoxidil are synergistic in their patient. In addition, it is important to look at how
benefit and should be considered better together much hair is on the verge of being lost (ie, are mini-
than either alone; they work toward slowing aturized or vellus in nature) and may need surgical
down the conversion of terminal hairs to vellus correction to avoid a problem in the near future of
hairs and also retard the conversion of vellus hairs progression of hair loss in that area. The curlier
to absence of hairs, and finally help reconvert hairs and thicker the hair, the greater the impact the
from vellus hairs back, at least partly, to thick ter- hair-transplant result will be. Furthermore, if the
minal hairs. Their biggest drawback is that once color-to-contrast ratio of scalp to hair is minimal
patients stop taking these medications, they lose (eg, dark scalp and dark hair or light hair and light
all the hairs that were preserved during the scalp), the patient will also potentially have a much
time they were taking them. Despite this limitation, improved outcome of visual density because the
it is important to counsel every man who is expe- underlying bald scalp will be less apparent. These
riencing hair loss about how potent these medica- factors will all be evaluated by an expert physician
tions are, and also on the patient’s suitability when determining the successful outcome of a
as safe candidates for surgery, something that procedure. Every prospective surgeon should re-
demands further explanation. view the Norwood-Hamilton (N-H) scale of MPB
The reason that young men (eg, early to mid- because these patterns represent the majority of
twenties) may be unsafe as candidates for hair how men lose their hair. When designing a pattern
transplantation is that they may lose more hair for hair transplantation, it is imperative that the
over time and not have a sufficient supply of donor physician follows the rules prescribed by the N-H
hair in the occipital region to cover further hair loss scale so that the result will mimic nature.
over the longer term. It is a losing battle of in- The primary goal in most first cases of hair trans-
creasing demand for hair and an ever dwindling plantation is to “frame the face”; that is, to provide
supply of donor hair, owing to either further bald- hair along the frontal region of the scalp so that the
ing or use of the donor hair for transplantation. person has a more attractive face when hair is
Taking a step back to explain the preciousness there to frame the face. Many men who are thinning
of donor hair may be important here. Norman throughout may become focused on their crown,
Orentreich discovered in the 1950s that hair taken which is an important area for transplantation.
 Hair Transplant 617

Nevertheless, the surgeon in most cases should

steer a man toward the importance of framing the
front of his scalp first, so that there is a frontal
aesthetic benefit. This observation brings up an
important corollary point, namely that there typi-
cally is not enough hair to transplant both the front
of the scalp and the crown in a single session of
hair restoration when performing a standard linear
harvest from the back of the head. Typically a min-
imum of 1 year should pass before performing a
second donor harvest to ensure that the donor
scar is sufficiently healed and relaxed, and also
so that most of the hair-transplant result can be
observed growing in, thus to determine if a few
extra grafts would be beneficial in the previously
transplanted zone.

PATIENT POSITIONING
Patient positioning for the procedure is important,
and will vary depending on the part of the proce-
dure being undertaken, all of which are detailed
in the respective subsections herein. Fig. 1. The lowest acceptable midline, anterior point
of a hairline marked at the 45 intersection of the
vertical forehead with the horizontal scalp. (From
PROCEDURAL APPROACH Lam SM. Hair transplant 360. vol. 1. Delhi (India):
Hairline Design Jaypee Brothers Medical Publishers; 2010.)
Hairline design is very important because it repre-
sents one of the most tell-tale signs of the artistry
and judgment of a surgeon, and will be the most concave lateral to the midpupillary line, based on
conspicuous and lasting testament to his work. A the patient’s head shape and other artistic criteria.
hairline must not only look natural for today’s Once these points are connected, the physician
patients; but with predictive capacity accumulated should walk to the side of the patient and ensure
from experience, a surgeon must also ensure that that the hairline is either flat along the Frankfort
the hairline will not become incongruous for an in- horizontal plane or slopes upward (Fig. 2). If the
dividual as he further ages. The lowest acceptable, hairline slopes downward from the lateral view,
midline point for the hairline is drawn first with a this is not a natural configuration that exists in
colored eyebrow pencil and typically represents nature. Finally, the physician should close one
the 45 intersection of the vertical plane of the eye and use a mirror to evaluate the hairline so
scalp (the forehead), and the horizontal plane of that the hairline is observed in a 2-dimensional,
the scalp (the hair-bearing scalp) (Fig. 1). It must flat aspect. Doing so provides rapid feedback as
be emphasized that this is the lowest point, but to whether the hairline is reasonably straight,
the physician may decide to be more conservative although it may look tilted even though it looks
with the design and start higher up. However, if the straight 3-dimensionally with both eyes open. The
starting point is too high the physician may fail to reason for this discrepancy is that the asymmetric
frame the face properly. The surgeon then should topography of bony scalp can throw off the shape
draw the lateral termini of the hairline where, at a of the hairline more on one side than the other.
point lateral to this terminus, the temporal hair Accordingly, it is important for the physician to
begins. The lateral terminus of the hairline is situ- marry the best 2-dimensional and 3-dimensional
ated at a vertical line drawn upward through the evaluations of a planned hairline. Once the hairline
lateral canthus of the eye. After drawing this lateral has been confirmed by the patient and the surgeon
point, the surgeon tilts the head downward to to be appropriate, the surgeon can then reinforce
ensure that both lateral points are situated sym- the initial tentative eyebrow marking with a more
metrically both in the anterior-posterior direction tenacious Sharpie permanent marker, but slightly
and laterally from the midline. The surgeon then irregularizing the line when drawing it in to ensure
should gently connect these dots using a rounded that the hairline will be more irregular (ie, natural)
arc with the option to suppress the arc more than a straight line.
618 Lam

Fig. 3. The parameters of the safe donor hair, starting

at the occipital protuberance (A) in the midline, arch-
ing upward over the mastoid protuberance (B), and
ending approximately 2 fingerbreadths above the
superior helix (C). The donor hair can be removed
above this point, depending on how sure the surgeon
Fig. 2. Side view of the hairline, which should either is that advancing recession of hair loss will not
slope upward or be relatively flat but should never encroach on the proposed harvest area. (From Lam
slope downward on the profile view. (From Lam SM. SM. Hair transplant 360. vol. 1. Delhi (India): Jaypee
Hair transplant 360. vol. 1. Delhi (India): Jaypee Brothers Medical Publishers; 2010.)
Brothers Medical Publishers; 2010.)

short guard (leaving approximately 1 to 2 mm of

Donor Planning hair left) for 2 to 3 cm around the proposed area
of harvesting, with the long hair above the incision
Once the area of baldness has been outlined, the taped upward to keep it out of the way for donor
surgeon should now plan how many hair grafts harvesting. Of note, the patient is sitting upright
will be needed to fill the proposed circumscribed for the entire period of hairline design, donor plan-
region. One can accomplish this task by first ning, and donor harvesting.
determining how many follicular units (FU) exist
per cm2 in the donor area. For example, if there
Donor Harvesting and Closure
is observed to be on average 100 FU/cm2 the
donor area and there are 100 cm2 of area to be Conscious sedation
transplanted in the recipient area with the desire See author’s video on preparation of donor and
for approximately 25 FU transplanted per cm2 in recipient tumescence. In his practice the author
the recipient area, then one will need 25 FU/cm2 prefers intravenous level-2 conscious sedation
 100 cm2 5 2500 FU. If the donor density again for performing hair-transplant procedures. Howev-
is 100 FU/cm2, one will need to harvest an area er, most clinics rely on simple oral narcotics and
of approximately 25 cm long  1 cm wide to anxiolytics to perform their procedures, with mini-
attain the requisite number of grafts to cover the mal discomfort. The first goal is to anesthetize the
proposed area for transplantation. There will donor and recipient area by performing a ring
undoubtedly be some transection of hairs during block around the head that anesthetizes the entire
harvesting, so the surgeon should factor 5% to area superior to the ring block. Before the ring
10% loss when planning the donor area. block is administered, the author prefers to start
The so-called safe donor area is roughly situ- with a supraorbital nerve block using 0.25% bupi-
ated around the occipital protuberance in the vacaine with 1:100,000 epinephrine for a total of
midline occiput and arches upward to approxi- 0.5 mL per side. The physician palpates the supra-
mately 2 fingerbreadths above the superior helix orbital notch with his nondominant thumb and then
of the ear (Fig. 3). This area is then shaved with a injects below the notch using a 30-gauge needle,
 Hair Transplant 619

withdrawing first to ensure that it is not intra- mark the 1-cm width using a Sharpie permanent
arterial. Injecting the patient with this anesthetic marker to ensure that too narrow or too wide a
first truly makes the anterior half of the ring block strip would not be inadvertently removed, which
significantly less uncomfortable and also tends to would lead to inadequate grafts or too much clos-
allow the anesthesia of the anterior half of the ing tension, respectively. A No. 10 Personna blade
scalp to be more uniformly long lasting, to the is used as the harvesting instrument of choice,
completion of the procedure in most cases, whether a single-blade or double-blade approach
whereas not doing so many lead to more irregular is used.
longevity of the anterior ring block. Donor harvesting should progress very slowly,
ensuring that the blades are not transecting the
Ring block hair shafts, adjusting the blades upward or down-
After the supraorbital block is administered, the ward when transection is evident. In addition, as
ring block can now be performed. During the in- mentioned previously, care should be taken to
jection of the circumferential ring block of anes- avoid cutting beyond the base of the hair follicles
thesia, if the patient is not receiving intravenous where the nerve and blood supply could be
sedation a vibration anesthesia device (Blaine compromised. The neophyte surgeon must be
Labs, Santa Fe Springs, CA) can be used to aware that it is imperative to stay far above the
further mitigate the pain. Ten milliliters of 1% lido- galea and not to ever go through it, as this will
caine with 1:100,000 epinephrine is infiltrated into destroy the nerve and blood supply and also
the subcutaneous plane along the inferior border exponentially increase closing tension. A pair of
of the planned donor area, and an additional Metzenbaum scissors is used to remove the
10 mL of 1% lidocaine with 1:100,000 epinephrine donor strip, which is in turn placed immediately
is infiltrated to complete the anterior half of the into a chilled saline bath in preparation for
ring block, ensuring that the block circumscribes graft dissection (see later discussion). To reduce
the area below the planned hairline and area for closing tension exacerbated by the recently
transplantation. The anesthetic is slowly infil- applied tumescent fluid, the surgeon should use
trated, which can truly minimize the pain, and a towel clamps placed across the wound to aid
buffered solution is avoided because it has been with dispersion of the remaining fluid before
shown to possibly increase the postoperative donor closure commences. Once the donor strip
edema along the forehead. Current opinion states has been removed, the surgeon can then close
that the speed of anesthesia delivery has more the donor incision with a running, nonlocking 3-0
bearing on the level of perceived discomfort nylon suture with the needle passing approxi-
than does rendering the anesthetic more alkaline mately through the mid-follicular depth. After the
in nature. donor incision is closed, 10 mL of 0.25% bupiva-
Once the ring-block anesthetic has been admin- caine with 1:200,000 epinephrine mixed with
istered, it is imperative that the donor area be 0.1 mL of triamcinolone 40 mg/mL is infiltrated
adequately tumesced with fluid (consisting of along the posterior half of the ring block to
250 mL 0.9% sodium chloride, 1.25 mL epineph- reinforce it, and 10 mL of 0.25% bupivacaine
rine 1:1000, and 12.5 mL plain lidocaine 2%) to with 1:200,000 epinephrine without triamcinolone
minimize transection of underlying neurovascular is infiltrated along the anterior half of the ring
structures and of the individual hairs planned for block. The plane of infiltration is in the sub-
harvesting. Approximately 100 to 250 mL tumes- cutaneous plane. The patient is then placed into
cent fluid is rapidly injected into the subcutaneous a supine position in preparation for recipient-site
plane until the tissue feels rigid and appears flat creation.
and blanched. At this time, the physician may
begin to undertake the donor harvest. The injector
Recipient-Site Creation
developed by Cole Instruments (Atlanta, GA)
allows for rapid infusion of tumescent anesthesia; Recipient-site creation is one of the highest ex-
it involves a 3-mL syringe outfitted to a spring- pressions of a surgeon’s artistic ability, making
loaded trigger that siphons from a 250-mL intrave- hair-transplant work satisfying and enjoyable. It
nous bag hanging superior to it. The author prefers is important that the recipient sites be created in
to use a multiblade instrument that houses 2 such a way that the angle (the anterior-posterior
blades, to ensure that the donor width will be direction of a recipient site) and the direction (the
uniformly 1 cm. However, a multiblade device radial pointing either forward or laterally to one
increases the risk of transection in inexperienced side of the recipient site) are done to mimic how
hands, and the surgeon may elect to use a hair naturally grows on the head (Fig. 4) and for
single-blade device. If he does so, he should maximal visual density. It lies beyond the scope
620 Lam

Fig. 4. (A–C) How hair grows differently in the various regions of the scalp, which will dictate how recipient sites
are created to ensure natural results. (From Lam SM. Hair transplant 360. vol. 1. Delhi (India): Jaypee Brothers
Medical Publishers; 2010.)

of this article to detail how hair grows on every re- physician tests placing the dissected grafts into
gion of the scalp, so the focus here is on the male 2 to 3 test sites for each size of needle to ensure
hairline and the central area of density behind it that the depth and width of each site will fit the
known as the central forelock. There are many dissected graft. Once confirmed, the surgeon
ways to create recipient sites, including needles can create all of the recipient sites feeling certain
and micro punches; also, if a needle is used there that the grafts should fit his sites. Recipient tumes-
is variation as to whether the direction of the slit cent fluid (100 mL of 0.9% sodium chloride, 0.5 mL
runs in the anterior-posterior direction (known as epinephrine 1:1000, 5.0 mL 2% plain lidocaine,
a sagittal or parallel site) or side-to-side (known and 1.0 mL triamcinolone 40 mg/mL) is injected
as a coronal or perpendicular site). For the sake subcutaneously in a sequential fashion into the
of simplicity, only parallel (sagittal) sites made by subcutaneous plane in each area where the sur-
needles are discussed here. In general, standard geon is making recipient sites, to minimize trauma
needles bent twice to match the length of a to the underlying neurovascular supply. Typically a
dissected graft (Fig. 5) are made, with 20-gauge total of 50 to 100 mL of recipient tumescent fluid is
(which generally accommodates 1-hair grafts), infiltrated in total into the recipient area over a
19-gauge (for 2-hair grafts), and 18-gauge (for 3- period of from 1 to 2 hours that is required to
and 4-hair grafts) needles. It is important that the make recipient sites, typically in boluses of 5 to
15 mL at a time.
The first order of business is to create a natural
and sufficiently dense hairline. It is important that
all hairline and midscalp recipient sites have a di-
rection that faces forward and does not splay
radially outward. In addition, all of the recipient
sites must have a very low angle (ie, low anteri-
orly). The surgeon can ensure that he keeps a
low angle by having the patient in a fully supine
position, which will help his hand to naturally
fall into a very low anterior angle for site creation.
The low angle is important because the hairs will
shingle over the scalp like an awning, and
thereby create a more favorable shadow over
the naked scalp. Also, the low-angled grafts will
Fig. 5. Three bent needles used to make recipient appear more natural because one cannot see
sites. The 18-gauge generally accommodates 3-hair their point of insertion into the scalp as well, an
grafts; the 19-gauge, 2-hair grafts; and the 20-gauge, area that can look unnatural because of imper-
1-hair grafts. fect graft placement (see later discussion). The
 Hair Transplant 621

reason that the grafts cannot splay open radially grafts and to frame the 2-hair grafts. In addition,
on the scalp is that this method will lead to an un- occasionally floating “sentinel” 1-hair grafts are
combable result and also reduce visual density placed to further blur the linearity of the hairline
where it counts, which is in the central forelock (see Fig. 6C). Finally, the author builds the wall
and anterior hairline. If anything, the recipient of central density behind the hairline zone with
sites can slightly converge medially to improve recipient sites made with an 18-gauge needle
visual density in the midline of the scalp, where to accommodate 3-hair and the less frequently
the central forelock is situated. Furthermore, the encountered 4-hair grafts (see Fig. 6D). Discus-
recipient sites should be tightly interlocked and sion of how to build temporal hairline, temporal
not arranged in a parallel fashion; that is, each points, crown, female hairlines, and so forth lie
successive row of recipient sites should be stag- beyond this introductory article, and the reader
gered from the one in front of it. By doing so, the is encouraged not to perform any of these
grafts will create more visual density and also be advanced recipient-site techniques until the
able to be more tightly arranged. The author basic hairline and midscalp density design has
begins by creating the irregularly irregular hairline been sufficiently mastered.
using a 19-gauge needle along the anterior
hairline that will accommodate 2-hair grafts and
Graft Preparation (Slivering and Graft
continue backward for 2 to 3 cm to complete
Dissection)
the main hairline zone (Fig. 6A, B), before
creating 1 to 2 rows of recipient sites using Typically the surgeon is not responsible for graft
the 20-gauge needle to accommodate 1-hair preparation, but as the team leader he should

Fig. 6. (A) Close-up view shows a hairline drawn in preparation for creation of the recipient sites. (B) The first step
in recipient-site creation, whereby a 19-gauge needle is used to create sites for the hairline zone to accommodate
2-hair grafts. (C) Next, 1 to 2 rows of 20-gauge sites are made to accommodate 1-hair grafts in addition to free-
floating “sentinel” single hairs that stand in front and separate from the hairline to further blur the linearity of
the hairline appearance. (D) Finally, an 18-gauge needle is used to make the rows behind the hairline to accom-
modate 3- and 4-hair grafts, to further support the visual density of the anterior hairline.
622 Lam

understand the dynamics of what constitutes

good graft preparation to ensure that his results
are of excellent quality. Without a properly trained
and dedicated team, no matter how beautiful the
surgeon’s work is, the ultimate result will fall far
short of the desired aesthetic mark.
Graft preparation involves 2 steps:

1. Slivering
2. Graft dissection
The linear strip of the harvested donor tissue
must be first sliced across the short axis of the
donor strip in an act known as slivering. Slivering
involves cutting a single row of follicular units
Fig. 7. Schematic in the electronic medical record to
with the aid of microscopic magnification and illu- document the number, orientation, and sizes of recip-
mination. It is analogous to cutting a slice of bread ient sites for future reference, and also to be used as a
from a loaf. Once the sliver is created, the grafts guide to help the assistant team place grafts more
can be dissected into individual 1-, 2-, 3-, and effectively and accurately into the premade recipient
4-hair grafts in a process known as graft dissec- sites.
tion. Minimal manipulation and transection of the
grafts along with maintaining uniform size (based
on the cuff of fat that surrounds each follicular will sink inward and potentially cause pitting,
unit) are hallmarks of elegant dissection work. In which are observed as small depressions in the
addition, graft preparation would ideally be under- skin at the insertion site. If they sit more than
taken in a timely fashion to minimize ex vivo graft 2 mm above the surrounding skin they can cause
time, but quality should trump quantity and speed a cobblestoned appearance, or the graft may
in the early phases of team development. Keeping desiccate and die. To minimize graft trauma, the
hair-transplant sessions to very low numbers, in graft should be tucked into the site in 2 strokes:
the 100s of grafts rather than thousands, may be Stroke 1: to push the graft halfway inward
a good start for any new surgeon and team. One Stroke 2: to push the graft all the way in
can even split the sessions into multiple days to
limit ex vivo time and team fatigue when the staff By doing this, the graft has less chance of
and physician are in the nascent training phase. folding over or popping out.
Another potentially devastating mistake is to
Graft Placement “piggy-back” one graft over another, which can
cause buried grafts underneath and engender
After the recipient sites are completed and the cysts. Clearly there are many points of concern
grafts have been properly dissected (keeping in performing excellent graft preparation and graft
them hydrated throughout in a chilled saline placement, and this section has only brushed the
bath), the grafts must be placed into the recipient surface of technical competency required to
sites based on their respective size. A drawing ensure consistently superior results and avoid sur-
may be made on the electronic medical record gical misadventures. There is no substitute for
indicating the distribution of recipient-site sizes proper training and experience to facilitate excel-
so that staff has a better understanding of how lent outcomes.
to place the grafts into the proper-sized sites
(Fig. 7). Just as with optimal graft preparation,
Advances in Hair Transplantation
grafts must be minimally manipulated during inser-
tion and also must be well hydrated. Besides putt- There is no doubt that the most significant devel-
ing grafts into the right-sized site, the grafts must opment in the last decade with regard to hair
be angled correctly so that the natural curl of the restoration is the advent of regenerative medicine
hair faces forward and down. The curl refers to to support graft growth. The author has been using
the fact that each graft curls as it exits the PRP and ACell since October 2011, and has
epidermis. Also, the grafts must be placed at the witnessed a remarkable improvement in hair-
right depth, typically about 1 to 2 mm above the transplant results, not in terms of shortening the
surrounding native tissue, because they will sink recovery period but in terms of more uniform graft
with resolution of edema. It is important that the growth, higher percentage of grafts growing, finer
grafts do not sit flush to the skin because they appearing grafts, and faster onset to graft growth
 Hair Transplant 623

(typically as early as 4 months when noticeable hair and mask the area where graft take of revision
growth was observed, rather than prior to this FUE grafts may be poor. As mentioned earlier,
era at around 6 months). The author believes that recipient-site creation must follow the angle and
both PRP and ACell are required to achieve such direction outlined in Fig. 4. If a surgeon does not
results. Without ACell, the grafts do not appear understand how hairs naturally grow on a scalp,
as fine as when enlisting both products. A method he will be unable to create natural results. If the un-
is used to integrate the products whereby the PRP natural sites sparsely cover the head and reside
drawn at the outset of the case (it is important to above a desired and proposed new hairline, the
draw it before any physical trauma to the patient) surgeon can correct these errors by overpowering
is mixed with 100 mg of fine-powdered ACell. the grafts with better grafting. When the grafts, or
The majority of the mixture is injected immediately worse yet, plugs, are too strong or too low, they
after the ring block into the subcutaneous tissue of will most likely need to be punch excised and re-
the recipient bed. The remainder is placed into the cycled in smaller and better ways. Again micropig-
donor incision after closure, and the rest bathed mentation may be enlisted as needed to salvage
around the grafts before graft placement. the problem. Unfortunately, because hair takes
Another advance over the past decade has been between 6 months and a year to grow, bad results
the use of FUE, whereby no linear scar is present. performed months previously will not be evident
The author has found the ARTAS robotic FUE sys- for some time. This delay further impedes a sur-
tem (Restoration Robotics, Mountain View, CA) to geon’s ability to review his work on a timely basis,
be a reliable device with which to perform FUE. and may lead to multiple poor surgical cases
There are many competing companies offering a before the error or change of technique can be
version of this technique. To debate and discuss rectified.
the pros and cons of FUE lie beyond the scope Graft preparation and graft placement offer a
of this article. At present, about two-thirds of the wide spectrum of opportunity for additional failure.
author’s cases still use linear harvesting, with Excessive graft manipulation can lead to kinky hair
one-third being FUE based. growth. If grafts are poorly trimmed, they may not
fit the sites, may desiccate and die, may be trans-
POTENTIAL COMPLICATIONS AND ected and lost, and so forth. There is a host of
MANAGEMENT problems that can arise from poor graft handling,
which may lead to many errors that reinforce the
Complications can occur at every stage of a hair- tenet that a team is of commensurate importance
transplant procedure, and caution should be exer- to the surgeon leading the team (Figs. 8–10).
cised throughout every phase. Starting with good Quality must be ensured at every phase by every
judgment about who is a proper candidate as out- team member to achieve superiorly consistent
lined in the preoperative section, the physician outcomes.
should know on whom to operate and on whom
not to operate. Sometimes complications do not POSTPROCEDURE CARE
arise until further down the road when the patient
runs out of donor hair and is left with an unnatural At the end of the case, the patient’s head is blow
result. As mentioned earlier, the art of estimating dried at a cool setting to seal in the grafts. The
how much usable donor hair is available must be author prefers not to use any emollients or occlu-
acquired over time so that patients are not left as sive dressings, but some surgeons do advocate
“hair cripples.” Proper hairline design that fits a pa- these supplemental measures. If temple hair is
tient’s age, ethnicity, gender, facial shape, and de- transplanted, the patient is asked not to wear a
gree of hair loss, and that will age well for that baseball cap for 24 hours, as these hairs are very
person over time, are important considerations. If susceptible to being displaced with the abrasion
a hairline is too low it is difficult to repair, but if it of donning or doffing a hat. Otherwise wearing a
is too high it may lack the aesthetic raison d’être hat is absolutely acceptable. Showering should
of a hairline: to frame the face properly. not be resumed for 24 hours from the time of
During the surgical procedure, improper donor concluding the operative case. Thereafter, the pa-
harvesting may lead to a high transection rate, tient is encouraged to shower twice daily with
nerve damage, and widened scarring. These con- nonirritating baby shampoo at a very low shower
ditions are hard to repair, and widened scarring pressure. The patient is also warned that the
typically is not as easily amenable to excision but back incision can feel tight, numb, uncomfortable,
often needs targeted FUE grafting into it for partial pruritic, or some combination of these sensations,
success. Recently, the trend has been to micro- especially until sutures are removed on the 10th
pigment the scar with punctate tattoos, to simulate postoperative day. The patient is warned that
624 Lam

Fig. 8. (Left) Male patient after an unnatural hair transplant. The hairline is too straight, the grafts are too large
for the hairline, and the grafts do not fit the sites and are too large, being compressed into a doll’s-head appear-
ance. (Right) The same patient after correction of the transplant. There is a more natural-appearing hairline
shape, with proper graft sizes for the various points of the hairline and behind the hairline zone.

Fig. 9. (Left) Male patient after an unnatural hair transplant. The hairline is too straight, the hair grafts appear
too kinky because of excessive manipulation during graft placement, and the hair has sparse density. (Right) The
same patient after correction of his hairline. The hair is far more natural and denser.

Fig. 10. (Left) Male patient after an unnatural hair transplant. The hairline is too straight, the grafts are too large
for the hairline, and they sit too perpendicularly (high angle) to the scalp. (Right) The same patient after correc-
tion of his hairline. The hair is far more natural and denser.
 Hair Transplant 625

exuberant edema can be evident along the brow in a brief article. However, the pertinent overview
and midface for the first 2 to 5 days, sometimes of facts and philosophy can be underscored so
lasting up to a week, and that he should not be that a prospective surgeon who is looking to
concerned. The patient may be encouraged to enter the field can understand the requisite
use hand manipulation to sweep the edema knowledge required by himself and his team,
around the orbital rim down into the face to expe- so that patients may enjoy the great reward
dite the resolution of the unsightly edema. Scabs that hair restoration offers when done properly,
that remain after a week should be vigorously and so that the surgeon and his team can also
scrubbed to be removed after that time (a process reap the same reward in providing the solution
that can be facilitated by using a topical emollient to their patient.
hair conditioner to soften them for a few minutes)
or they may interfere with graft growth. The patient VIDEOS ONLINE
should avoid submersing his head in water of any
kind (as most water is a source of infection) for a Supplementary data in the form of video related to
minimum of 6 weeks. The patient can resume ex- this article can be found online at http://dx.doi.org/
ercise early on, with care taken not to overtly trau- 10.1016/j.cps.2013.08.006.
matize the grafts and especially not to injure the
newly sealed donor region. REFERENCES

SUMMARY 1. Lam SM. Hair transplant 360, vol. 1. Delhi (India): Jay-
pee Brothers Medical Publishers; 2010.
The comprehensive art and science of hair trans- 2. Karamanovski E. Hair transplant 360, vol. 2. Delhi
plantation cannot be effectively communicated (India): Jaypee Brothers Medical Publishers; 2010.