aesthetic surgery journal - james e. vogel, md · procedure is a follicular unit hair transplant...

25
http://aes.sagepub.com/ Aesthetic Surgery Journal http://aes.sagepub.com/content/early/2012/10/09/1090820X12468314 The online version of this article can be found at: DOI: 10.1177/1090820X12468314 published online 20 November 2012 Aesthetic Surgery Journal James E. Vogel, Francisco Jimenez, John Cole, Sharon A. Keene, James A. Harris, Alfonso Barrera and Paul T. Rose Hair Restoration Surgery : The State of the Art Published by: http://www.sagepublications.com On behalf of: American Society for Aesthetic Plastic Surgery can be found at: Aesthetic Surgery Journal Additional services and information for http://aes.sagepub.com/cgi/alerts Email Alerts: http://aes.sagepub.com/subscriptions Subscriptions: http://www.sagepub.com/journalsReprints.nav Reprints: http://www.sagepub.com/journalsPermissions.nav Permissions: What is This? - Nov 20, 2012 OnlineFirst Version of Record >> at ASAPS on December 12, 2012 aes.sagepub.com Downloaded from

Upload: others

Post on 14-Jul-2020

4 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: Aesthetic Surgery Journal - James E. Vogel, MD · procedure is a follicular unit hair transplant (FUT).27-34 ... (FUE) donor harvest. ... do not fully explain its positive action

http://aes.sagepub.com/Aesthetic Surgery Journal

http://aes.sagepub.com/content/early/2012/10/09/1090820X12468314The online version of this article can be found at:

 DOI: 10.1177/1090820X12468314

published online 20 November 2012Aesthetic Surgery JournalJames E. Vogel, Francisco Jimenez, John Cole, Sharon A. Keene, James A. Harris, Alfonso Barrera and Paul T. Rose

Hair Restoration Surgery : The State of the Art  

Published by:

http://www.sagepublications.com

On behalf of: 

  American Society for Aesthetic Plastic Surgery

can be found at:Aesthetic Surgery JournalAdditional services and information for    

  http://aes.sagepub.com/cgi/alertsEmail Alerts:

 

http://aes.sagepub.com/subscriptionsSubscriptions:  

http://www.sagepub.com/journalsReprints.navReprints:  

http://www.sagepub.com/journalsPermissions.navPermissions:  

What is This? 

- Nov 20, 2012OnlineFirst Version of Record >>

at ASAPS on December 12, 2012aes.sagepub.comDownloaded from

Page 2: Aesthetic Surgery Journal - James E. Vogel, MD · procedure is a follicular unit hair transplant (FUT).27-34 ... (FUE) donor harvest. ... do not fully explain its positive action

Special Topic

Aesthetic Surgery JournalXX(X) 1 –24© 2012 The American Society for Aesthetic Plastic Surgery, Inc.Reprints and permission: http://www .sagepub.com/journalsPermissions.navDOI: 10.1177/1090820X12468314www.aestheticsurgeryjournal.com

Alopecia, the term for generic hair loss, involves a diminu-tion of visible hair. There are numerous types of alopecia. The most common form of surgically treatable alopecia is androgenic alopecia (AGA). Throughout time, the pres-ence of scalp hair has represented attributes of health, vigor, vitality, and strength. Accordingly, loss of hair in men (MAGA, or male pattern androgenic alopecia) and especially women (FPHL, or female pattern hair loss) can have significant psychosocial effects. The overwhelming majority of procedures for hair restoration are hair trans-plants, and the advent of microvascular surgical instru-mentation as well as an improved understanding of the anatomy and physiology of hair loss has revolutionized the art of surgical hair restoration since the original description and early refinements.1-3

AnAtomy, Genetics, And PhysioloGy of hAir loss

Androgenic alopecia is characterized by progressive visible thinning of scalp hair in genetically susceptible men and in some women. The current scientific data support the thesis that AGA is a polygenic trait. Significant associations

have been reported with variant regions of the androgen receptor gene, which is located on the X chromosome. Epidemiologic surveys of AGA reveal the highest incidence in Caucasians, followed by Asians and then Africans, with the lowest incidence in Native Americans.4-8

For the purpose of hair transplantation, the scalp may be divided into the frontal, midscalp, vertex, and temporal areas (Figure 1A-C). Hair thinning and subsequent shed-ding is due to gradual miniaturization of genetically

Hair Restoration Surgery: The State of the Art

James E. Vogel, MD; Francisco Jimenez, MD; John Cole, MD; Sharon A. Keene, MD; James A. Harris, MD; Alfonso Barrera, MD; and Paul T. Rose, MD, JD

AbstractHair restoration is a highly sophisticated subspecialty that offers significant relief to patients with hair loss. An improved understanding of the aesthetics of hair loss and cosmetic hair restoration, hair anatomy and physiology, and the development of microvascular surgical instrumentation has revolutionized the approach to surgical hair restoration since the original description. Additional elements that contribute to the current state of the art in hair restoration include graft size, site creation, packing density, and medical control of hair loss. The results of hair restoration are natural in appearance and are provided with a very high level of patient satisfaction and safety. This aspect of cosmetic surgery is a very welcome addition to a traditional aesthetic practice and serves as a tremendous source for internal cross-referral. The future of hair restoration surgery is centered on minimal-incision surgery as well as cell-based therapies.

Keywordshair transplant, alopecia, follicular unit graft, hairline, CME

Accepted for publication September 28, 2012.

Dr Vogel is Associate Professor, Department of Plastic Surgery, The Johns Hopkins Hospital and School of Medicine, Baltimore, Maryland. Dr Jimenez is a hair restoration surgeon in private practice in Canary Islands, Spain. Dr Cole is a hair restoration surgeon in private practice in Alpharetta, Georgia. Dr Keene is a hair restoration surgeon in private practice in Tucson, Arizona. Dr Harris is a Plastic surgeon in private practice in Greenwich Village, Colorado. Dr Barrerra is Clinical Assistant Professor of Plastic Surgery, Baylor College of Medicine, Houston, Texas. Dr Rose is a hair restoration surgeon in private practice in Coral Gables, Florida.

Corresponding Author:Dr James E. Vogel, 4 Park Center Court, Owings Mills, MD 21117, USA. E-mail: [email protected]

continuing medical education Article

Aesthetic Surgery Journal OnlineFirst, published on November 20, 2012 as doi:10.1177/1090820X12468314

at ASAPS on December 12, 2012aes.sagepub.comDownloaded from

Page 3: Aesthetic Surgery Journal - James E. Vogel, MD · procedure is a follicular unit hair transplant (FUT).27-34 ... (FUE) donor harvest. ... do not fully explain its positive action

2 Aesthetic Surgery Journal XX(X)

marked hair follicles and represents shortening of the anagen (growth) phase of the hair follicle with an increase in the telogen/anagen ratio of the affected scalp. An understanding of the normal hair follicle life cycle is criti-cally linked to an appreciation of the physiology of hair loss.9-14

Miniaturization results in the conversion of terminal (large) hairs into smaller, barely visible, depigmented vel-lus hairs (Figure 2).15 At the cellular level, follicle minia-turization is thought to be caused by a reduction in dermal papilla volume, as a consequence of a decrease in the number of cells per papilla. Nonetheless, hair follicles are still present and cycling, even in bald scalps.16,17 Although testosterone is the major circulating androgen that causes hair loss, to be maximally effective, it must first be con-verted to dihydrotestosterone (DHT) by the enzyme 5α-reductase. The importance of DHT as an etiologic fac-tor in male pattern hair loss is shown by the absence of AGA in men with congenital deficiency of type II 5α-reductase and by varying amounts of hair regrowth in men with MAGA treated with finasteride, a selective type

II 5α-reductase inhibitor.18 Balding scalp contains exces-sive concentrations of 5α-reductase, DHT, and the DHT androgen receptor. The action of DHT is mediated by intracellular nuclear androgen receptors.19

In women, there is no consensus on whether hair loss is truly androgen dependent. Most women with FPHL do not have biochemical hyperandrogenism. In fact, some women without detectable circulating androgens may also develop FPHL, suggesting a possible role for non-andro-gen-dependent mechanisms. Based on this evidence, it seems appropriate to replace the term androgenic alopecia in women with the previously mentioned, more contem-porary and scientifically descriptive term female pattern hair loss (FPHL), to include this recognized heterogene-ity.4,6-8,19-26

On a macro level, the majority of human hair shafts emerge from the scalp as single-, 2-, and 3-hair groupings (Figure 3). The groupings are the visible superficial por-tion of a distinctive histologic structure, known as the follicular unit (FU). Present-day hair transplants almost exclusively use follicular units as the transferred element

Figure 1. Surgical anatomy of the scalp. (A) Frontal view emphasizing the level of the hairline, relationship to the temporal triangle, and the lateral canthal line. (B) Profile view to illustrate the relationship between the lateral hump and lateral aspect of the forelock. (C) Caudal view to illustrate the relationship with the lateral canthal line and lateral extent of the anterior hairline.

at ASAPS on December 12, 2012aes.sagepub.comDownloaded from

Page 4: Aesthetic Surgery Journal - James E. Vogel, MD · procedure is a follicular unit hair transplant (FUT).27-34 ... (FUE) donor harvest. ... do not fully explain its positive action

Vogel et al 3

of tissue, and thus the contemporary nomenclature for this procedure is a follicular unit hair transplant (FUT).27-34

The clinically observed patterns of MAGA have been well described by Norwood,35 after whom the most com-mon classification system for this condition is named. On the other hand, hair loss patterns in women are typically characterized by maintenance of the anterior hairline and

diffuse central thinning over the midfrontal scalp, as described and originally classified by Ludwig.36,37 Exceptions to these patterns occur. Some men will exhibit a Ludwig pattern of loss, and some women will display a typical Norwood pattern.

nonsurGicAl oPtions for treAtinG hAir loss

There are currently only 2 medications approved by the US Food and Drug Administration (FDA) to promote hair growth in the scalp. These medications are finasteride and minoxidil. Other options for medications claiming to treat hair loss are extensive but also of questionable value.38-40

Finasteride (Propecia; Merck & Co, Inc, Whitehouse Station, New Jersey) is a medication that lowers DHT through blockades to the 5α-reductase type 2 pathways (Figure 2). In a prospective randomized study by the manufacturer, finasteride was shown to reduce hair loss or have positive effects related to hair growth in 90% of patients, and the drug’s safety and efficacy have also been reported by independent research.41 Propecia is FDA approved for men only. The FDA only allows the manufac-turer to make claims regarding growth in the vertex area of the scalp, but many physicians have noted that this medication has a global effect on the scalp hair.

Side effects reported with finasteride include a decrease in libido, erectile dysfunction, testicular pain, and benign

Figure 2. Progression of hair loss. In youth, testosterone is limited in concentration; however, during puberty and adulthood, testosterone is converted to dihydrotestosterone (DHT). Exposure of susceptible hair follicles to DHT results in miniaturization and ultimately hair loss. The enzyme 5α-reductase is responsible for the conversion of testosterone to DHT. Finasteride is an oral medication that blocks this pathway and prevents hair loss.

Figure 3. Magnification view of in situ follicular units (FUs). A 4-hair FU has been scored in preparation for a follicular unit extraction (FUE) donor harvest.

at ASAPS on December 12, 2012aes.sagepub.comDownloaded from

Page 5: Aesthetic Surgery Journal - James E. Vogel, MD · procedure is a follicular unit hair transplant (FUT).27-34 ... (FUE) donor harvest. ... do not fully explain its positive action

4 Aesthetic Surgery Journal XX(X)

growth in the male breast. The side effects associated with the drug generally disappear with discontinuation of finas-teride. Some controversy exists regarding its relation to breast and prostate cancer as well as the temporary nature of sexual side effects.42,43

Minoxidil (Rogaine; McNeil-PPC, Inc, Morris Plains, New Jersey) has been available since 1988 as a topical medication indicated to treat hair loss. It has been used in men and women. The mechanism of action is unclear, but it is recognized that the vasodilatory effects of minoxidil do not fully explain its positive action on hair growth. Observed benefits include increased proliferation of der-mal papillae cells, increased hair caliber, and diminished telogen phase during the hair growth cycle.

evAluAtion And PlAnninGPhotographyPhotography of the hair restoration surgery (HRS) result is the principal measure by which results are objectively documented. The use of lighting and standard positions for hair photography has been described.44 The use of a light gray or blue-colored background is recommended, so that the top borders of dark hair will not blend into the background. This background will also work for white and blond hair.

General Evaluation

Young men and women are particularly distraught by the signs of hair loss.45,46 Low self-esteem and vulnerability to a fantasized outcome place this subset of patients at par-ticular risk for quick decision making and unrealistic expec-tations. Managing these expectations and formulating a realistic surgical plan for patients with hair loss is a critical component to the long-term success of the procedure.

A fundamental concept that physicians and patients are advised to maintain during the evaluation and planning for HRS is that hair loss is progressive. The appearance of hair loss in the office during consultation is merely a snap-shot along a continuum that began years earlier and will progress until death. Communication regarding the quality of the patient donor hair is also an additional essential component in managing expectations. The qualities of the hair that should be reviewed include curl, hair shaft diam-eter, color, texture, follicular unit density, and the telogen/anogen ratio of in situ donor hair. These aspects of the donor hair should be not only reviewed but also docu-mented as a means to predict how well the transplanted hair will camouflage areas of scalp alopecia.

Lab tests for diagnosis are generally unnecessary in men with typical pattern AGA. However, a differential diagnosis for nonandrogenic causes for hair loss should be maintained for consideration during the evaluation.47-50 Finally, most men younger than 60 years will also be encouraged to consider the use of finasteride, 1 mg daily, to reduce crown hair loss.

In women, the pattern of hair loss with FPHL, espe-cially in the early stages, can be mimicked by a variety of other conditions. These include frontal fibrosing alopecia, diffuse alopecia areata, and telogen efluvium (acute and chronic).51-54 Women with bitemporal recessions, as seen with male pattern baldness, should be screened for hor-monal imbalances. Finally, women with typical FPHL in a Ludwig pattern should be checked for iron deficiency as well as thyroid function to rule out other causes of diffuse hair loss.55

Recipient Area

The first step in assessing the recipient area is to deter-mine where to place the grafts. A conservative and princi-pled surgical plan for the recipient site is an initial forelock distribution hair transplant. The forelock is the area bounded anteriorly by the frontal hairline, posteriorly by the anterior crown region, and laterally by the parietal fringe (Figure 1). This is a commonly maintained, normal distribution of hair seen in male patients with mild hair loss. A forelock pattern hair transplant is initially planned when there is anticipation of considerable future hair loss, especially in a young patient. For the same reason, this approach is also very appropriate for older patients who present with extensive baldness and limited donor supply. The rationale for this approach is that the distribution of grafts in a forelock limits the requirements from the donor supply. Creation of a forelock pattern also provides an opportunity for a large, single-session procedure to achieve the 2 fundamental goals of hair restoration surgery—namely, to recreate a normal pattern of hair loss seen in nature and to create a frame of hair for the face (Figure 4).56-58 The beauty of this conservative and safe surgical approach is that this graft distribution can be expanded posteriorly for additional crown coverage as desired.

Determining the number of grafts for the initial proce-dure and over the lifetime of the patient is the next step in recipient planning and evaluation. This assessment depends on a number of factors. These include current degree of baldness, donor hair characteristics, degree of anticipated hair loss, patient’s goal for density and ulti-mate coverage, technical expertise of the hair transplant team, and financial considerations of the patient. A good visual transplant result will be apparent with densities between 25 and 40 FU/cm2. To put this into perspective, in adult men with no “visible” hair loss, the typical den-sity in the frontal hairline ranges between 38 and 78 FU/cm2 (average 52 FU/cm2), whereas the average frontal density of prepubertal males is approximately 80 to 100 FU/cm2.59

Donor Area

It cannot be overemphasized to the patient that his or her own intrinsic donor hair characteristics will dictate the fullness of the hair transplant result. Patients with a thick

at ASAPS on December 12, 2012aes.sagepub.comDownloaded from

Page 6: Aesthetic Surgery Journal - James E. Vogel, MD · procedure is a follicular unit hair transplant (FUT).27-34 ... (FUE) donor harvest. ... do not fully explain its positive action

Vogel et al 5

Figure 4. This 38-year-old man with male pattern hair loss requested hair restoration. He underwent a 2200–follicular unit forelock transplant in 1 session and is shown intraoperatively in part A. (B, D) Preoperative views. (C, E) At 10 months postoperatively, the patient’s face is framed with hair in a natural distribution. This result could be a stand-alone outcome or additional grafts could be added for more coverage as desired.

at ASAPS on December 12, 2012aes.sagepub.comDownloaded from

Page 7: Aesthetic Surgery Journal - James E. Vogel, MD · procedure is a follicular unit hair transplant (FUT).27-34 ... (FUE) donor harvest. ... do not fully explain its positive action

6 Aesthetic Surgery Journal XX(X)

hair shaft (>80 microns) are better candidates than those with narrow hair (<60 microns). Recently, a novel device has been described to measure hair density and caliber.60

Even when transplanted densities are high (>40 FU/cm2), individuals with fine, straight hair will have a more “see-through” result compared with those with coarse, curly, and large-caliber hair transplanted at a lower den-sity. In addition, patients with low follicular density (1-2 hairs/FU) will have a more sparse result than those with higher follicular density (3-5 hairs/FU).

In general, patients require a donor density of at least 40 FU/cm2 to be considered for transplants. A higher den-sity donor supply is extremely advantageous. To accu-rately assess the size of the donor strip, required measurement of donor follicular unit density is performed using one of several available specialized instruments (hair densitometer, digital video camera, etc).61 Then the size of the donor strip can be determined according to the desired number of follicular units to be transplanted. The region between the occipital protuberance and 1 cm above the top of the ears is considered the “safest” physiological place from which to harvest hair. In most patients, this area is approximately 5 to 6 cm in width. The higher area above the ear and below the occipital protuberance may thin over time and should be avoided, as this hair may be susceptible to future AGA.

In women with a diffuse pattern, the quality of the donor hair is often less than ideal. Clinical judgment and the objective criteria listed above are components with which to determine suitability for the procedure.

Hair Transplant Technique

As with any surgical procedure, the techniques of the operation will vary based on personal preference and clinical circumstances. Although the fundamental approach described herein is nearly universally applicable, the specific techniques do reflect most closely the method-ology preferred by the lead author (JEV).

AnesthesiaHair transplantation can be performed under local anes-thesia alone or with supplemental sedation. The local anesthesia solution is a 40-mL mixture of 0.25% bupiv-acaine with 1:200 000 epinephrine + 20 mL 1.0% lido-caine with 1:200 000 epinephrine. This solution is used in the donor and recipient sites, and supplementation with additional bupivacaine 0.25% is performed in both regions of the scalp prior to discharge from the operating room. If conscious sedation is included with the procedure, the patient is premedicated with 1 to 2 mg PO aprazolam. In the operating room, an intravenous cocktail of ketamine 5 mg/mL, midazolam 0.5 mg/mL, and fentanyl 10 mcg/mL is titrated to achieve the desired level of sedation. All patients receiving any type of sedation are continuously monitored during the procedure with oximetry and receive supplemental nasal oxygen.

Donor Site HarvestIn contemporary practice, follicular units can be obtained either through strip excision of the donor scalp with subsequent microscopic tissue dissection26-28 or by removal using a technique called follicular unit extrac-tion (FUE).62-69

Strip excision. In preparation for the strip harvest, the selected area of donor hair is trimmed to 4- to 5-mm length and the patient is positioned in a lateral decubitus posi-tion. An ellipse of donor scalp is outlined, and following the administration of local anesthesia, tumescent saline solution is infiltrated. Tumescence in conjunction with pre-cise knife blade angulation parallel to the hair shafts reduces follicle transection. Dissection level of the donor strip should be at the superficial fat to avoid injury to the occipital neurovascular bundle. The wound is closed in 2 layers, with an absorbable suture in the deep layer and a monofilament suture of choice at the level of the skin. Sta-ples or dissolving sutures are also options.

Trichophytic closure. With the advent of shorter hairstyles, there has been an increased interest in minimizing (or maxi-mally concealing) the donor scar. The trichophytic closure has been described to promote scar camouflage by allowing hair growth through the scar.70,71 After the first layer of the donor wound is closed, the entire lower edge of the incision epithelium is excised. The final running suture is then com-pleted, with care taken to avoid deep “bites” of scalp that have the potential to damage underlying follicles (Figures 5A-F and 6A-C). This important anatomic detail is worth emphasizing to maximize the results with the trichophytic closure technique. Deepithelization as well as suture depth should not exceed 1 mm, to avoid injury to the follicle “bulge” zone. Although the bulge was originally described as the portion of the hair follicle to which the arector pili (AP) muscle attaches, this important region has lately attained significant interest because it is where follicular epithelial stem cells have been identified.9 The bulge region starts at a depth of approximately 1 mm and extends down to 1.8 mm.29-31 Recently, a double-layer trichophytic closure technique was described.72

Graft preparation. Once the donor tissue has been har-vested using the strip excision method, the tissue is immediately immersed in chilled isotonic saline or another type of preferred “holding” solution. Graft preparation is per-formed using stereomicroscopes and microsurgical instrumentation. Initially, the donor strip is subsectioned into slivers, each being 1 FU in width (approximately 1-2 mm). Considerable skill and experience are required to avoid tran-section of grafts during slivering and at the same time maintaining an efficient pace of preparation. Each sliver is then dissected into FU grafts (Figure 7). These grafts are placed back into a holding solution until they are planted. It is imperative that these grafts stay moist in order for them to avoid desiccation.

Follicular unit extraction. Follicular unit extraction is an alternative method of donor harvest. This technique is essentially a refined “micropunch grafting” version of the older punch graft technique. Using the current technique

at ASAPS on December 12, 2012aes.sagepub.comDownloaded from

Page 8: Aesthetic Surgery Journal - James E. Vogel, MD · procedure is a follicular unit hair transplant (FUT).27-34 ... (FUE) donor harvest. ... do not fully explain its positive action

Vogel et al 7

of FUE, 1 FU is removed at a time. There are several tech-niques and instruments to perform FUE. These include manual, power-assisted, and automated methods. No

matter which technique is employed, the net result is still the isolation and removal of a single FU (Figures 3 and 7). The remaining puncture is left to heal by secondary

Figure 5. Donor site harvest and trichophytic closure technique. (A) Patient is shown in decubitus position with donor hair shaved to 4 mm. (B) Excised donor strip. (C) The first of the 2-layer donor site closure is complete. (D, E) The intraoperative technique is shown and illustrated, with deepithelization of the donor wound margin. (F) The final closure is shown, with superficial bites of 1 mm. Superficial needle entry into the scalp is performed to avoid injury to the follicle “bulge” zone.

at ASAPS on December 12, 2012aes.sagepub.comDownloaded from

Page 9: Aesthetic Surgery Journal - James E. Vogel, MD · procedure is a follicular unit hair transplant (FUT).27-34 ... (FUE) donor harvest. ... do not fully explain its positive action

8 Aesthetic Surgery Journal XX(X)

intention. Some hair transplant surgeons choose to employ FUE on a selective basis for small cases (Figure 8), whereas others select this donor harvest technique for their larger sessions (Figure 9). The increased popularity of FUE has been linked to the development of power-assisted technology as well as a general trend toward minimally-invasive techniques. The indications, out-comes, and techniques for FUE as a donor harvest option are found elsewhere.62-69

Follicular unit extraction comprises approximately 22% of all hair restoration donor harvest procedures performed, as reported in a worldwide poll of hair restoration sur-geons.73 As with any emerging technology, there is debate regarding this methodology. Controversy related to this donor technique includes the idea that this method is a return to earlier methods of punch harvesting, the specific indications, the ideal harvesting tools (blunt vs sharp), and the survival and growth of the grafts themselves as compared with those obtained with strip harvesting. Depletion of donor density as well as overharvesting of

Figure 6. A healed donor harvest site is shown after strip excision and closure with the trichophytic closure technique. (A) Eight months postoperatively. (B) Diagram of healed donor scar following trichophytic closure. (C) Reexcision of the donor scar shown in part A, illustrating hair growth through the initial closure site on tangential view of the specimen.

Figure 7. Microscopic dissection of donor “sliver” and subdissected individual follicular units containing 1, 2, and 3 hairs.

at ASAPS on December 12, 2012aes.sagepub.comDownloaded from

Page 10: Aesthetic Surgery Journal - James E. Vogel, MD · procedure is a follicular unit hair transplant (FUT).27-34 ... (FUE) donor harvest. ... do not fully explain its positive action

Vogel et al 9

hair vulnerable to AGA is also a concern with extensive FUE harvesting. However, increased acceptance and popu-larity of FUE are emerging as a result of evolving patient

interest and technical refinements. In fact, a novel robotic automation of the FUE technique is in the developmental stage.74 Most hair restoration surgeons feel this donor

Figure 8. Intraoperative view of small follicular unit extraction (FUE) donor harvest site. (A) Manual FUE harvest tool in use. (B) FUE donor harvest completed. (C) Donor site 8 months after initial harvest.

Figure 9. Large-session follicular unit extraction (FUE) donor harvest site. (A) Immediate intraoperative view upon completion of approximately 2500 FUE harvest. (B) Same donor area, 1 week postoperatively.

at ASAPS on December 12, 2012aes.sagepub.comDownloaded from

Page 11: Aesthetic Surgery Journal - James E. Vogel, MD · procedure is a follicular unit hair transplant (FUT).27-34 ... (FUE) donor harvest. ... do not fully explain its positive action

10 Aesthetic Surgery Journal XX(X)

technique is “here to stay,” and future refinements and experience with FUE will solidify its indications.

Hairline Design and General Recipient AreaThe first landmark that needs to be determined is the height of the anterior hairline (AHL) (Figure 1). In most instances, the location of the most anterior, midfrontal portion of the hairline is between 7.5 and 9.5 cm above the glabella. The shape of the head, predicted future hair loss, and donor capacity are factors to consider in this creative decision. One must place the hairline in such a location that it will look natural as the patient matures and continues to lose hair.

If the temporal point is expected to recede, a higher hairline should be considered because a low hairline with a lost temporal point suggests a hairpiece. The temple point should be even or slightly posterior to the frontal hairline. Along with the aforementioned principles, a gen-tly curving hairline should be created, with care taken to always maintain a significant frontal-temporal recession. Restoration of the temporal triangle is performed accord-ing to the personal preference of patient and surgeon.

The design should begin by ensuring the presence of a lateral hump (Figure 1). If the lateral hump is absent, this should be designed first. The lateral hump is the superior extension of the inferiorly directed hair of the temporopa-rietal fringe. The superior extent of this important land-mark is even with or just medial to a line drawn vertically from the lateral canthus. This landmark is important because it represents the lateral extent of the AHL. The intersection of the lateral AHL and the lateral hump is the apex of the frontotemporal recession and should always be convex in a male AHL design (Figure 10).75-77

The single most important component to achieving a natural appearance to the hair transplant is the creation of an outstanding AHL (Figure 11). This is accomplished through proper location and design of the hairline as well as the use of large numbers of small grafts. The shape of the frontal hairline should not be linear but should be broken up with major irregularities (triangles and gaps). The hairline should consist of a transition from the bald forehead to a zone consisting of random placement of single hair grafts from the softest hair available in donor supply.78,79 Typically, these single hairs are taken from the temporal donor fringe. Posterior to the single hair grafts are FU containing 2 and 3 hairs with stronger physical characteristics (Figure 12). Recreating a female hairline requires a design that includes a more rounded temporal infill and lower hairline than the one normally created for men (Figures 13 and 14).80

When a forelock pattern is created, the rear border should be located somewhere along the midscalp. Whether or not there is a plan to graft the vertex, the rear hairline should be constructed with an irregular border of small grafts. The lead author prefers to create a tapered posterior forelock pattern of trailing design that renders the crown less circular and mimics a natural variation on the balding process (Figure 15). A distribution of grafts recreating a natural whorl pattern can be constructed at the posterior aspect of the forelock. The crown area can be further

grafted as indicated but should always be considered as an extension of the posterior forelock to maintain a natural distribution of hair (Figure 15).

Recipient Site CreationThere are numerous instruments and methods with which to create a site in which a hair graft is placed. The funda-mental principles that should underlie any technique include matching the size of the individual recipient site with the length and width of the patient’s FU. For example, if short, single hair grafts are placed at the anterior hairline in a thin scalp, a smaller and more shallow site is created than would be required to accommodate a larger 3- to 4-hair FU placed in the thicker scalp. The most simple and cost-effective instrument for recipient site creation is a hypodermic needle. Needle sizes ranging from 23 to 18 gauge are typically used. A 19-gauge needle will produce a 1.1-mm slit that will accommodate the size of the majority of FU of average density (Figure 16). Another popular instrument for site creation is the sharp-point, 22.5-degree or the “mindi” knife. These instruments, as well as micro-scopes designed for hair restoration surgery, are available through different vendors (Ellis Instruments, Madison, New Jersey; Tiemann-Bernsco & A to Z Surgical, Hauppauge, New York). Customized recipient blades can also be cut to specific size from flat surgical prep blades using specialized cutting devices. In some circumstances, a 0.8-mm to 1.5-mm hole punch might be utilized as well.81

The angle of the recipient site should mimic the angles of the nontransplanted, existing hair growth. When hair is absent, a natural flow of hair is created. On most hair-lines, the angle of graft site creation should be approxi-mately 30 to 45 degrees anteriorly off the scalp. This results in the illusion of more coverage as well as a natu-ral angle. The hair on the left side of the hairline should be angled anteriorly and toward the midline. As the hair progresses to the right side, a switch should be made so that the hair on the opposite side is angled toward the midline. As mentioned above, a whorl is created at the midpoint of the crown vertex area through a spiraling of the angulation of recipient sites through a 360-degree rotation (Figure 15).

Most patients will require a follicular density of approx-imately 25 to 40 FU/cm2 for satisfactory coverage. However, as mentioned above, the individual hair characteristics play an important role in this regard. Although highly variable between surgeons, the typical density of site packing in a completely bald scalp is approximately 25 to 35 sites/cm2/hair transplant session. The density for opti-mal site packing as well as the use of “skinny” (closely trimmed) or “chubby” (containing more fat and sebaceous tissue) grafts is controversial. The considerations in this debate are based on limited reports of survival at different densities, surgeon’s preference, and also the skill of the transplant team.82-85

Graft PlantingAs with site creation, numerous techniques and instru-ments are available for graft placement. The different

at ASAPS on December 12, 2012aes.sagepub.comDownloaded from

Page 12: Aesthetic Surgery Journal - James E. Vogel, MD · procedure is a follicular unit hair transplant (FUT).27-34 ... (FUE) donor harvest. ... do not fully explain its positive action

Vogel et al 11

Figure 10. This 58-year-old man with male pattern alopecia who underwent a 2500-graft follicular unit hair transplant is shown during immediate preoperative planning (A, C) and immediately postoperatively (B, D, E). Note the design of the posterior forelock taper and fill of the temporal hump.

at ASAPS on December 12, 2012aes.sagepub.comDownloaded from

Page 13: Aesthetic Surgery Journal - James E. Vogel, MD · procedure is a follicular unit hair transplant (FUT).27-34 ... (FUE) donor harvest. ... do not fully explain its positive action

12 Aesthetic Surgery Journal XX(X)

forceps used for planting are essentially adaptations of those used in microvascular surgery. The fundamental principles of this aspect of the procedure include gentle grasping of the grafts, maintenance of graft hydration, placement of grafts in the identical angle of site creation, and also maintaining appropriate rotation of the natural curvature of the hair graft. As with graft preparation, con-siderable skill is required to perform this delicate task in a repetitive, atraumatic, and efficient manner. Frequently, several “planters” work simultaneously to complete the procedure in an efficient manner. An experienced assis-tant or physician can plant 200 to 300 grafts per hour. Typically, the recipient sites are designed first and the grafts are placed as a following step. However, another technique known as the “stick-and-place” method incor-porates both maneuvers in a sequential manner. The “sticker” creates the site with a blade of choice, and the “placer” inserts the graft immediately before the next slit is developed.

Conclusion of Procedure, Postoperative Care, and Emergence of ResultsHair transplants are lengthy procedures. A typical session of 1500 to 2500 grafts utilizing 4 assistants will last approxi-mately 6 to 7 hours. The procedure is conducted using a clean technique with sterilized or disposable instruments. Postoperatively, the recipient sites and donor area are typi-cally not bandaged, and perioperative antibiotics are not prescribed on a routine basis. Patient instructions include head elevation and icing of the forehead and donor area, along with analgesics. Aloe ointment administration to the grafted area and gentle shampooing in the shower should commence on postoperative day 2. Most of the recipient site eschars are gone by day 10, and donor sutures are removed on day 14. Although there are exceptions to the rule, most grafts enter a telogen phase for the first 3 months prior to entering their anagen phase. Full growth and evaluation of transplant results cannot reliably be assessed for 8 to 12 months following the procedure (Figure 17).

Figure 11. (A, C) This 63-year-old man with male pattern alopecia requested restoration of his anterior hairline. (B, D) Eight months after receiving 3200 grafts in 2 sessions.

at ASAPS on December 12, 2012aes.sagepub.comDownloaded from

Page 14: Aesthetic Surgery Journal - James E. Vogel, MD · procedure is a follicular unit hair transplant (FUT).27-34 ... (FUE) donor harvest. ... do not fully explain its positive action

Vogel et al 13

sPeciAl considerAtionsBody Hair as Donor

Body hair is useful to treat areas of hair loss when the scalp donor area supply is near or at exhaustion. The results of body hair transplants are impossible to predict with certainty because of the intrinsic physical and short life cycle characteristics of this type of hair. In general, the beard is the best source of body hair because its intrinsic life cycle and physical characteristics most closely resem-ble that of scalp hair.86-89 Follicular unit extraction as a donor technique is particularly well suited to the submen-tal area when beard hair is harvested.

Reconstructive Applications

Hair transplantation can have a significant role in correct-ing alopecia associated with scars from previous aesthetic

surgery, burns, radiation, trauma, and congenital deformi-ties.90-93 Hair transplants do grow in scar as well as radi-ated tissue; however, the survival rate is lower than in noninjured recipient beds. Formal studies on this topic have not been published (Figure 18).

In the case of hairline reconstruction for female-to-male gender reassignment, androgen supplementation and ensuing temporal recession or thinning is generally all that is necessary. In male-to-female reassignment, the hairline design includes a typical rounded temporal infill and the lower hairline described earlier for restoring FPHL (Figure 14).

Flaps/Scalp Reduction/Expanders

In contemporary practice, hair-bearing scalp flaps and alopecia reductions for elective aesthetic hair restoration surgery are primarily of historic interest. A comprehensive

Figure 12. This 48-year-old man demonstrates the irregularity required for graft distribution at the anterior hairline. (A) The patient is shown intraoperatively, after a single session of 2200 grafts. Note the distribution of grafts containing 1 and 2 hairs per follicular unit at the leading edge of the hairline and larger grafts posteriorly. (B) The patient’s hairline is shown preoperatively. (C) Eight months after grafting, the irregularity and distribution of graft size clearly contribute to the natural appearance of the patient’s transplanted hairline.

at ASAPS on December 12, 2012aes.sagepub.comDownloaded from

Page 15: Aesthetic Surgery Journal - James E. Vogel, MD · procedure is a follicular unit hair transplant (FUT).27-34 ... (FUE) donor harvest. ... do not fully explain its positive action

14 Aesthetic Surgery Journal XX(X)

review of the previous use of these techniques in the treat-ment of AGA can be found in 2 studies.94,95 In some cases, these procedures have resulted in an excellent outcome for the patient. However, as a result of poorly designed surgi-cal incisions as well as naive surgical planning in the face of progressive hair loss, the long-term results of these procedures have also resulted in exposed, unattractive scars as well as misdirection of hair flow. The use of scalp expanders, reductions, and flaps for reconstruction of traumatic hair-bearing scalp defects remains well entrenched in the scalp surgeon’s armamentarium.

comPlicAtions And PAtient sAfety

Fortunately, the incidence of complications in HRS is quite low. Unfortunately, there are no published reports of sig-nificant size detailing the frequency of complications in large series. Nevertheless, the types of complications seen have been well described and can be categorized into surgi-cal and aesthetic complications. In contemporary practice,

the incidence of primary surgical problems is estimated to be less than 2% to 3% and includes bleeding, arteriovenous fistula, cysts, pustules, infection, frontal necrosis, neurosen-sory changes, and scarring.96 Primary aesthetic complica-tions include poor growth of grafts, postsurgical effluvium, and unnatural appearance. The incidence of poor growth ranges from 0% to 25%, but this number is highly subjec-tive. These complications and other patient safety concerns have been reviewed in detail elsewhere.97

Surgical Complications

Folliculitis/Cysts/PustulesA variety of cysts and pustules can present within the first few weeks or months following a transplant. They can be isolated or occur as clusters of diffuse lesions. The causes are not clear. Theories include “ingrown” hair, foreign body reactions, epithelium logged into slit sites during recipient site creation, piggybacked grafts, and the “idio-pathic” intrinsic properties of the host scalp. In the majority

Figure 13. (A, C) This 68-year-old woman with typical female pattern hair loss presented for hair restoration. (B, D) Eight months after undergoing a second treatment session, for a total of 3300 total grafts.

at ASAPS on December 12, 2012aes.sagepub.comDownloaded from

Page 16: Aesthetic Surgery Journal - James E. Vogel, MD · procedure is a follicular unit hair transplant (FUT).27-34 ... (FUE) donor harvest. ... do not fully explain its positive action

Vogel et al 15

of cases, a pathogen cannot be cultured from the lesions, but a secondary, uncultured bacterial agent cannot be excluded as having a secondary role in pathogenesis. Oral antibiotics, warm compresses, and unroofing of the cysts are the mainstays of treatment.

Neurosensory ComplicationsA certain amount of pain, especially in the strip harvested donor site, is to be expected. Occasionally, some patients will experience severe pain in the donor site, requiring prolonged periods of narcotics. Although some patients report headaches following the transplant procedure, there have been reports of a decrease in this symptom as well. Neuralgias and hypoesthesia symptoms are uncommon and almost always resolve within the first 6 to 8 months. Neuromas have been rarely reported and are treated with steroid injection or excision.

ScarringScarring in the donor area remains the primary concern, even with modern strip harvesting techniques. The advent of the trichophytic closure technique and the awareness of the critical importance of avoiding tension in donor site closure have reduced the incidence of donor scar complications. True

keloid scarring is rare in the donor site and interestingly has never been reported as occurring in the recipient area. Reduction in donor density secondary to extensive punctate scarring is a potential risk of FUE harvesting.

Aesthetic Complications

Poor GrowthIt is unrealistic to expect 100% of grafts to survive. Accurate measurement of growth requires precise hair counts using magnification, scalp tattooing, and macro-photography. Studies of this caliber are small in size and very limited. However, most would agree that growth rates less than 85% to 90% would be considered poor growth. Causes for poor growth are numerous but generally focus on follicular trauma and dehydration during the different stages of the lengthy procedure. Some limited studies on out-of-body time indicate that graft growth is not effected until 6 to 8 hours following harvest.82,83 Different holding solutions are being investigated to maximize graft integ-rity. Other factors for poor growth include host factors such as vascularity of scalp, smoking, and the presence of scar tissue.

Figure 14. A female hairline design is shown in a 32-year-old genetic male, transgender patient seeking a feminine appearance. (A) Preoperative markings are shown following healing of a previous forehead-lowering procedure by another surgeon. (B) The patient is shown intraoperatively. (C, D) Eight months after a third treatment session and a total of approximately 4700 grafts.

at ASAPS on December 12, 2012aes.sagepub.comDownloaded from

Page 17: Aesthetic Surgery Journal - James E. Vogel, MD · procedure is a follicular unit hair transplant (FUT).27-34 ... (FUE) donor harvest. ... do not fully explain its positive action

16 Aesthetic Surgery Journal XX(X)

Postsurgical EffluviumOccasionally there can be a shedding of the in situ, non-transplanted hair. This postsurgical shedding can be either

an anagen or a telogen effluvium and typically takes place 2 to 6 weeks following the transplant procedure. This situ-ation most frequently occurs in female patients with dif-fuse pattern hair loss but can be seen in men as well. In addition, effluvium can also be seen in the donor harvest sites. Fortunately, the effluvium is usually temporary. In some instances, the hair will grow back with a more narrow caliber or not at all. To reduce the likelihood of efflu-vium, the surgeon can minimize the number of recipient sites, as well as their size, and also consider the use of minoxodil (Rogaine) or finasteride (Propecia) during the perioperative period.

Unachieved Patient ExpectationsAs in any type of aesthetic surgical procedure, the expecta-tions of the patient need to be realistic. However, unique for the hair restoration patient is the importance of appre-ciating the progressive nature of nontransplanted hair loss over time, the inherent qualities of their donor hair as a source for scalp coverage, and their individual limitation in donor supply.

Poor Cosmetic Appearance of the TransplantThe expected outcome using contemporary techniques of hair transplantation is a result that is generally indistin-guishable from the appearance of native scalp hair.

Figure 15. (A) This 43-year-old man with primary alopecia in the crown region presented for hair restoration. (B) Eight months after posterior forelock grafting and creation of crown whorl pattern with approximately 2000 grafts.

Figure 16. Relationship of size between 1-, 2-, and 3-hair follicular unit grafts and the 19-gauge and 1.0-mm blades used to create recipient sites. It is important to create recipient sites with a depth and width that match the graft size.

at ASAPS on December 12, 2012aes.sagepub.comDownloaded from

Page 18: Aesthetic Surgery Journal - James E. Vogel, MD · procedure is a follicular unit hair transplant (FUT).27-34 ... (FUE) donor harvest. ... do not fully explain its positive action

Vogel et al 17

Figure 17. (A, C, E) This 28-year-old man with male pattern alopecia presented for hair restoration. (B, D, F) Eight months following a single session of hair grafting with 2500 grafts placed in a forelock distribution. Note the beneficial effect from finasteride in the nontransplanted posterior crown region. The benefit to forelock grafting is that additional grafts can be placed in the crown region if desired or the result can stand alone.

at ASAPS on December 12, 2012aes.sagepub.comDownloaded from

Page 19: Aesthetic Surgery Journal - James E. Vogel, MD · procedure is a follicular unit hair transplant (FUT).27-34 ... (FUE) donor harvest. ... do not fully explain its positive action

18 Aesthetic Surgery Journal XX(X)

Unfortunately, older techniques as well as some poorly performed recent transplants have not resulted in a natu-ral appearance. As a consequence, there are a considerable number of patients who bear the visual and psychological burden of an unnatural hair transplant. A complete review of these types of problems and their management was published elsewhere.98-105

The most frequent type of cosmetic problems following hair transplants are

1. Unsightly appearance of plugs2. Wide scars in the donor area3. A poorly designed hairline4. Errors in surgical planning and inappropriate dis-

tribution of grafts at a young age, in which the progressive nature of hair loss was not considered

All of the above cosmetic complications result in the same fundamental problem for the patient: an unnatural appearance to the scalp hair that yields a strange and unnatural appearance. Patients are plagued with these unnatural results, which become worse over time as their surrounding hair recedes and thus further exposes the original unnatural hair grafts. Understandably, these patients are angry with the original surgeon and themselves for submitting to the original transplant; they often wish they could trade the unnatural appearance for simple bald-ness. Correction of these tragic results is difficult and time-consuming, requires a special relationship of trust between the surgeon and patient, and often requires 3 or more surgi-cal procedures. The techniques and approach for correction of these challenging cases are beyond the scope of this cur-rent review. The references cited in this section provide the principles and fundamental techniques for restoring normalcy

to a patient whose life has been undesirably transformed by the initial hair transplant procedures (Figure 19).

the future of hAir trAnsPlAntAtionFUECurrently, a minority of hair transplant surgeons provide FUE for all patients. Most practices use FUE for selected indications. However, the future direction appears to be moving toward a greater interest in and application of FUE. Improved instrumentation, automation, and an ever- increasing interest in minimally-invasive techniques are driving this trend.

Cell-Based TherapyIn the foreseeable future, hair restoration surgery will be intermingled with some type of cell-based therapy. The concept of the hair follicle as a mini-organ is recognized by cell biologists pursuing hair replication research. Biotech and basic research labs are currently investigating pathways for hair induction, hair development, and hair follicle regeneration. The results of this research will undoubtedly make their appearance into clinical trials and, theoretically, daily practice. It should be recalled that androgenic alopecia is, at least in principle, a reversible condition. Although the terminal hairs have become min-iaturized beyond recognition by the naked eye, the same hair follicles (with fully intact stem cell machinery) con-tinue to be present in the balding scalp. The ultimate solu-tion to finding a cure for androgenic alopecia would be a product that is able to switch on the differentiation mechanism from vellus to terminal hair. The ability to

Figure 18. (A) This 28-year-old man presented for beard reconstruction after a burn injury and secondary chin reconstruction. (B) Twelve months after placement of approximately 1000 grafts in 2 sessions. Reprinted with permission from Barrera A. The use of micrografts and minigrafts in the aesthetic reconstruction of the face and scalp. Plast Reconstr Surg. 2003;112(3):883-890.

at ASAPS on December 12, 2012aes.sagepub.comDownloaded from

Page 20: Aesthetic Surgery Journal - James E. Vogel, MD · procedure is a follicular unit hair transplant (FUT).27-34 ... (FUE) donor harvest. ... do not fully explain its positive action

Vogel et al 19

Figure 19. (A) The patient’s preoperative markings are shown prior to the first procedure. The dots indicate the location where plugs are to be removed and recycled into new follicular unit grafts for immediate grafting. The irregular anterior hairline was also marked for creation of a new leading edge hairline. Dome marking in the area of the lateral hump above the ears indicates planned distribution of grafts to fill in bald “alleys” of scalp. (B, D, F) This 38-year-old man had previously undergone a hair transplant at age 20 but was cosmetically dissatisfied with the appearance of his scalp. The patient had experienced progressive hair loss with resulting exposure of previously transplanted 4-mm “plug” grafts. In addition, progressive hair loss above his ears resulted in “alleys” of baldness. He desired correction of this unnatural appearance. (C, E, G) Eight months after the third procedure; all procedures consisted of primary hair grafting from the occipital donor site, plug reduction, and recycling of 4-mm plug grafts. In total, the patient underwent removal and recycling of approximately 252 four-mm previously grafted transplant “plugs” and 2000 follicular unit grafts over a 2-year period. The patient was also maintained on finasteride oral medication.

at ASAPS on December 12, 2012aes.sagepub.comDownloaded from

Page 21: Aesthetic Surgery Journal - James E. Vogel, MD · procedure is a follicular unit hair transplant (FUT).27-34 ... (FUE) donor harvest. ... do not fully explain its positive action

20 Aesthetic Surgery Journal XX(X)

Figure 19. (continued) (A) The patient’s preoperative markings are shown prior to the first procedure. The dots indicate the location where plugs are to be removed and recycled into new follicular unit grafts for immediate grafting. The irregular anterior hairline was also marked for creation of a new leading edge hairline. Dome marking in the area of the lateral hump above the ears indicates planned distribution of grafts to fill in bald “alleys” of scalp. (B, D, F) This 38-year-old man had previously undergone a hair transplant at age 20 but was cosmetically dissatisfied with the appearance of his scalp. The patient had experienced progressive hair loss with resulting exposure of previously transplanted 4-mm “plug” grafts. In addition, progressive hair loss above his ears resulted in “alleys” of baldness. He desired correction of this unnatural appearance. (C, E, G) Eight months after the third procedure; all procedures consisted of primary hair grafting from the occipital donor site, plug reduction, and recycling of 4-mm plug grafts. In total, the patient underwent removal and recycling of approximately 252 four-mm previously grafted transplant “plugs” and 2000 follicular unit grafts over a 2-year period. The patient was also maintained on finasteride oral medication.

at ASAPS on December 12, 2012aes.sagepub.comDownloaded from

Page 22: Aesthetic Surgery Journal - James E. Vogel, MD · procedure is a follicular unit hair transplant (FUT).27-34 ... (FUE) donor harvest. ... do not fully explain its positive action

Vogel et al 21

enhance hair graft growth and survival through the use of platelet-derived growth factors is an additional area for research and development.106

Cloning

Initial enthusiasm for replication of a single hair into thou-sands of hairs suitable for transplantation has been tem-pered by the difficulties of culturing and replicating hair in vivo. Even when this biological task has been minimally accomplished, the effective number of viable hairs created as well as the subsequent delivery techniques into tissue has been disappointing thus far.

Incorporating HRS Into Plastic Surgery Practice

A traditional aesthetic surgery practice that includes hair restoration surgery enjoys excellent internal marketing opportunities and patient crossover between the 2 prac-tices. For this and other reasons, HRS often piques the interest of plastic surgeons. However, lack of exposure to HRS in plastic surgery residency training renders this field difficult to fully incorporate into practice. The fact is that HRS is a “subspecialty” in itself and does not exclusively reside within the domain of any one of the specialties endorsed by the American Board of Medical Specialties (ABMS). The International Society of Hair Restoration Surgery is the largest organization dedicated to education and training in HRS. Six- and 12-month fellowships in HRS as well as annual educational meetings and local surgical workshops are offered through this organization. Although not recognized by the ABMS, the American Board of Hair Restoration Surgery does offer an excellent educational cur-riculum leading to certification. This later curriculum is a particularly good educational track for a board-certified plastic surgeon to expand his or her knowledge base in this field. However, establishing a practice setup, training hair transplant technicians and front office staff, and develop-ing a marketing program in this subspecialty require a disciplined and multifaceted, long-range business plan.

conclusions

Hair restoration surgery has developed into a highly sophis-ticated subspecialty that offers significant relief to patients with hair loss. This aspect of cosmetic surgery is a very welcome addition to a traditional aesthetic practice and serves as a tremendous source for patient satisfaction and internal cross-referral. The results of contemporary hair restoration are natural, enduring, and are performed with a very high level of patient safety. This degree of refinement has been established through an improved understanding of hair biology and physiology as well as the incorporation of standard microsurgical techniques. The combination of graft size, site creation, packing density, and selected donor

hair are the key elements the hair restoration surgeon uti-lizes to artistically craft the transplant. The future of HRS and the treatments for alopecia are centered on minimal- incision surgery as well as cell-based therapies.

disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

funding

The authors received no financial support for the research, authorship, and/or publication of this article.

references

1. Okuda H. The study of clinical experiments of hair transplan-tation. [in Japanese]. Jpn J Dermatol Urol. 1939;46:1-11.

2. Orentreich N. Autografts in alopecias and other selected conditions. Ann N Y Acad Sci. 1959;83:463.

3. Uebel CO. Micrografts and minigrafts: a new approach for baldness surgery. Ann Plast Surg. 1991;27(5):476-487.

4. Ellis J, Stebbing M, Harrup S. Polymorphism of the androgen receptor gene is associated with male pattern baldness. J Invest Dermatol. 2001;116:452-455.

5. Blume-Peytavi U, Blumeyer A, Tosti A, et al. Guidelines for diagnostic evaluation in androgenetic alopecia in men, women and adolescents. Br J Dermatol. 2011;164(1):5-15.

6. Hillmer A, Hanneken S, Ritzmann S, et al. Genetic varia-tion in the human androgen receptor gene is the major determinant of common early onset androgenetic alope-cia. Am J Hum Genet. 2005;77:140-148.

7. Levy-Nissenbaum E, Bar-Natan M, Pras E. Confirmation of the association between male pattern baldness and the andro-gen receptor gene. Eur J Dermatol. 2005;15(5):339-340.

8. Sinclair R, Greenland KJ, van Egmond S, Hoedemaker C, Chapman A, Zajac JD. Men with Kennedy disease had a reduced risk of androgenetic alopecia. Br J Dermatol. 2007;157:290-294.

9. Paus R, Cotsarelis G. The biology of hair follicles. N Engl J Med. 1999;341:491-497.

10. Ansell DM, Kloepper JE, Thomason HA, Paus R, Hard-man MJ. Exploring the “hair growth–wound healing connection”: anagen phase promotes wound healing re-epithelialization. J Invest Dermatol. 2011;131:518-528.

11. Driskell RR, Clavel C, Rendl M, Watt FM. Hair follicle der-mal papilla cells at a glance. J Cell Sci. 2011;124:1179-1182.

12. Woo WM, Oro AE. Snapshot: hair follicle stem cells. Cell. 2011;146:334.

13. Fujiwara H, Ferreira M, Donati G, et al. The basement membrane of hair follicle stem cells is a muscle cell niche. Cell. 2011;144:577-589.

14. Hsu YC, Pasolli HA, Fuchs E. Dynamics between stem cells, niche and progeny in the hair follicle. Cell. 2011;144:92-105.

15. Jahoda CAB, Reynolds AJ. Hair follicle dermal sheath cells: unsung participants in wound healing. Lancet. 2001;358:1445-1448.

at ASAPS on December 12, 2012aes.sagepub.comDownloaded from

Page 23: Aesthetic Surgery Journal - James E. Vogel, MD · procedure is a follicular unit hair transplant (FUT).27-34 ... (FUE) donor harvest. ... do not fully explain its positive action

22 Aesthetic Surgery Journal XX(X)

16. Tobin DJ, Gunin A, Magerl M, et al. Plasticity and cytokinetic dynamics of the hair follicle mesenchyme: implications for hair growth control. J Invest Dermatol. 2003;120:895-904.

17. Garza LA, Yang CC, Zhao T, et al. Bald scalp in men with androgenetic alopecia retains hair follicle stem cells but lacks CD 200-rich and CD34-positive hair follicle progeni-tor cells. J Clin Invest. 2011;121:613-622.

18. Mella JM, Perret MC, Manzotti M, Catalano HN, Guyatt G. Efficacy and safety of finasteride therapy for andro-genetic alopecia: a systematic review. Arch Dermatol. 2010;146:1141-1150.

19. Sawaya ME, Price VH. Different levels of 5-alpha-reduc-tase type I and II, aromatese, and androgen receptor in hair follicles of women and men with androgenetic alo-pecia. J Invest Dermatol. 1997;109:296-300.

20. Labrie F, Luu-The V, Labrie C, Belanger A, Simard J, Lin SX, Pelletier G. Endocrine and intracrine sources of androgens in women: inhibition of breast cancer and other roles of androgens and their precursor dehydroepi-androsterone. Endocr Rev. 2003;24(2):152-182.

21. Price V, Roberts J, Hordinsky M, et al. Lack of efficacy of finasteride in postmenopausal women with androgenetic alopecia. J Am Acad Dermatol. 2000;43:768-776.

22. Dinh Q, Sinclair R. Female pattern hair loss: current treat-ment concepts. Clin Interv Aging. 2007;2(2):189-199.

23. Keene S, Goren A. Genetic variations in the androgen receptor gene and finasteride response in women with androgenetic alopecia mediated by epigenetics. Derm Ther. 2011;24:296-300.

24. Cousen P, Messenger A. Female pattern hair loss in com-plete androgen insensitivity syndrome. Br J Dermatol. 2010;162:1135-1137.

25. Orme S, Cullen DR, Messenger AG. Diffuse female hair loss: are androgens necessary? Br J Dermatol. 1999;141:521-523.

26. Birch MP, Lashen H, Agarwal S, Messenger AG. Female pattern hair loss, sebum excretion and the end-organ response to androgens. Br J Dermatol. 2006;154:85-89.

27. Limmer BL. Elliptical donor stereoscopically assisted micrografting as an approach to further refinement in hair transplantation. Dermatol Surg. 1994;20:789-793.

28. Bernstein RM, Rassman WR, Szaniawski W, Halperin A. Follicular transplantation. Int J Aesthetic Rest Surg. 1995;3:119-132.

29. Bernstein RM, Rassman WR. Follicular transplantation: patient evaluation and surgical planning. Dermatol Surg. 1997;23:771-784.

30. Jimenez F, Ruifernandez JM. Distribution of human hair in follicular units. Dermatol Surg. 1999;25:294-298.

31. Jimenez F, Poblet E. Gross and microscopic anatomy of the follicular unit. In: Haber RS, Stough DB, eds. Hair Trans-plantation. Philadelphia, PA: Elsevier Saunders; 2006:35-42.

32. Jimenez F, Izeta A, Poblet E. Morphometric analysis of the human scalp hair follicle: practical implications for the hair transplant surgeon and hair regeneration studies. Dermatol Surg. 2011;37:58-64.

33. Headington JT. Transverse microscopy anatomy of the human scalp. Arch Dermatol. 1984;120:449-456.

34. Sperling LC. Hair density in African Americans. Arch Der-matol. 1999;135:656-658.

35. Norwood OT. Male pattern baldness: classification and incidence. Southern Med J. 1975;68:1359-1365.

36. Ludwig E. Classification of the types of androgenetic alo-pecia (common baldness) occurring in the females sex. Br J Dermatol. 1977;97:247-254.

37. Vogel JE. Hair transplantation in women: a practical new classification system and review of technique. Aesthetic Surg J. 2002;22(3):247-259.

38. Bergfeld WF, Andersen FA. Natural products for hair care and treatment. In: Blume-Peytavi U, Tosti A, Whiting D, Trueb R, eds. Hair Growth and Disorders. Berlin: Springer Verlag; 2008:515-523.

39. Messenger A. Male Androgenetic alopecia. Blume- Peytavi U, Tosti A, Whiting D, Trueb R, eds. Hair Growth and Disorders. Berlin: Springer Verlag; 2008:160-168.

40. Rogers N, Avram M. Pharmacotherapy. In: Unger W, Sha-piro R, Unger M, Unger R, eds. Hair Transplantation. 5th ed. London: Informa Healthcare; 2010:91-101.

41. Sato A, Takeda A. Evaluation of efficacy and safety of finasteride 1 mg in 3177 Japanese men with androgenetic alopecia. J Dermatol. 2012;39(1):27-32.

42. Redman HW, Tangen CM, Goodman PJ, Lucia MS, Cottman CA, Jr, Thompson IM. Finasteride does not increase the risk of high-grade prostate cancer: a bias-adjusted mod-eling approach. Cancer Prev Res. 2008;1:174-181.

43. Hamilton R, Freedland S. 5 alfa reductase inhibitors and prostate cancer prevention: where do we turn now? BMC Med. 2011;9:105.

44. Vogel JE, Vogel JE. Clinical hair photography. In: Unger W, Shapiro R, Unger M, Unger R, eds. Hair Transplan-tation. 5th ed. London: Informa Healthcare; 2010: 216-221.

45. Hadshiew IM, Foitzik K, Arck PC, Paus R. Burden of hair loss: stress and the underestimated psychosocial impact of telogen effluvium and androgenetic alopecia. J Invest Dermatol. 2004;123:455-457.

46. Cash TF. The psychosocial consequences of androgenetic alopecia: a review of the research literature. Br J Derma-tol. 1999;141:398-405.

47. Harries MJ, Trueb RM, Tosti A, et al. How not to get scar(r)ed: pointers to the correct diagnosis in patients with suspected primary cicatricial alopecia. Br J Derma-tol. 2009;160:482-501.

48. Kossard S, Lee MS, Wilkinson B. Postmenopausal frontal fibrosing alopecia: a frontal variant of lichen planopilaris. J Am Acad Dermatol. 1997;36:59-66.

49. Hillmann K, Blume-Peytavi U. Diagnosis of hair disor-ders. Semin Cutan Med Surg. 2009;28:33-38.

50. Olse EA. Disorders of Hair Growth: Diagnosis and Treat-ment. New York: McGraw-Hill; 2003.

51. Chartier MB, Hoss DM, Grant-Kels JM. Approach to the adult female patient with diffuse nonscarring alopecia. J Am Acad Dermatol. 2002;47:809-818.

52. Kossard S. Postmenopausal frontal fibrosing alopecia: scarring alopecia in a pattern distribution. Arch Derma-tol. 1994;130:770-774.

53. Rebora A, Guarrera M, Baldari M, Vecchio F. Distin-guishing androgenetica alopecia from chronic telogen effluvium when associated in the same patient. Arch Der-matol. 2005;141:1243-1245.

at ASAPS on December 12, 2012aes.sagepub.comDownloaded from

Page 24: Aesthetic Surgery Journal - James E. Vogel, MD · procedure is a follicular unit hair transplant (FUT).27-34 ... (FUE) donor harvest. ... do not fully explain its positive action

Vogel et al 23

54. Lew BL, Shin MK, Sim WY. Acute diffuse and total alo-pecia: a new subtype of alopecia areata with a favorable prognosis. J Am Acad Dermatol. 2009;60:85-93.

55. Kantor J, Kessler LJ, Brooks DG, Cotsarelis G. Decreased serum ferritin is associated with alopecia in women. J Invest Dermatol. 2003;121:985-988.

56. Beehner M. Update on forelock approach of hair trans-plantation. Hair Transplant Forum Int. 2007;17:11-13.

57. Beehner M. Isolated frontal forelock. In: Unger W, Shap-iro R, Unger M, Unger R, eds. Hair Transplantation. 5th ed. London: Informa Healthcare; 2010:178-182.

58. Beehner M. A frontal forelock/central density framework for hair transplantation. Dermatol Surg. 1997;23:807-815.

59. Keene S. Natural hairline density in men: findings of a pilot survey. Hair Transplant Forum Int. 2009;19(2):47-48.

60. Cohen B. The cross-section trichometer: a new device for measuring hair quantity, hair loss, and hair growth. Der-matol Surg. 2008;34:900-910.

61. Devroye J. An overview of the donor area: basic prin-ciples. In: Unger W, Shapiro R, Unger M, Unger R, eds. Hair Transplantation. 5th ed. London: Informa Health-care; 2011:247-262.

62. Rassman WR, Bernstein RM, McClellan R, Jones R, Wor-ton E, Eyttendaele H. Follicular unit extraction: minimally invasive surgery in hair transplantation. Dermatol Surg. 2002;28:720-728.

63. Gökrem S, Baser NT, Aslan G. Follicular unit extraction in hair transplantation: personal experience. Ann Plast Surg. 2008;60:127-133.

64. Harris JA. Follicular unit extraction (FUE). In: Unger W, Shapiro R, Unger M, Unger R, eds. Hair Transplantation. 5th ed. London: Informa Healthcare; 2010:23-34.

65. Harris J. Conventional FUE. In: Unger W, Shapiro R, Unger M, Unger R, eds. Hair Transplantation. 5th ed. London: Informa Healthcare; 2010:291-296.

66. Harris JA. Powered blunt dissection with the SAFE system for FUE: part I. Hair Transplant Forum Int. 2010;20:188-189.

67. Harris JA. Powered blunt dissection with the SAFE system for FUE: part II. Hair Transplant Forum Int. 2011;21:16-17.

68. Dua A, Dua K. Follicular unit extraction transplant. J Cutan Aesthetic Surg. 2010;3(2):76-81.

69. Ekrem C, Aksoy M, Koc E, Aksoy B. Evaluation of three instruments used in the FUE. Hair Transplant Forum Int. 2009;19:14-15.

70. Juri J. Use of parieto-occipital flaps in the surgical treatment of baldness. Plast Reconstr Surg. 1975;55(4):456-460.

71. Marzola M. Trichophytic closure of the donor area. Hair Transplant Forum Int. 2005;15:113-116.

72. Yamamoto K. Double trichophytic closure with wavy two layered closure for optimal hair transplantation scar. Der-matol Surg. 2012;38:664-669.

73. International Society of Hair Restoration Surgery. 2011 Practice Census Results. Geneva, IL: International Society of Hair Restoration Surgery; July 2011.

74. Harris J. Robotic assisted follicular unit extraction for hair restoration: case reports. Cosmet Dermatol. 2012;25(6):284-287.

75. Unger WP. Definition of four major surgical zones of the balding scalp. In: Unger W, Shapiro R, Unger M, Unger

R, eds. Hair Transplantation. 5th ed. London: Informa Healthcare; 2010:109-114.

76. McAndrews P. Anatomical landmarks. In: Unger W, Sha-piro R, Unger M, Unger R, eds. Hair Transplantation. 5th ed. London: Informa Healthcare; 2010:153.

77. Shapiro R. Principles and techniques used to create a natural hairline in surgical hair restoration. Facial Plast Surg Clin North Am. 2004;12:201-217.

78. Basto F, Lemos P. Linha pilosa anterior irregular e sinu-osa na microenxertia capilar. Rev Soc Bras Cir Plast. 1996;11(2):20-22.

79. Uebel CO. Refining hair restoration technique. Aesthetic Surg J. 2002;22(2):181-183.

80. Nusbaum BP, Fuentefría S. Naturally occurring female hairline patterns. Dermatol Surg. 2009;35:907-913.

81. Yamamoto K. Micropunch (0.8 mm or less in diameter) hair transplantation. Dermatol Surg. 2011;37(9):1321-1326.

82. Beehner M. 96-Hour study of FU graft “out-of-body” sur-vival comparing saline to hypothermosol/ATP solution. Hair Transplant Forum Int. 2011;21(2):33, 37.

83. Seager D. Micrograft size and subsequent survival. Der-matol Surg. 1997;23(9):757-761.

84. Beehner M. A comparison of hair growth between fol-licular units trimmed “skinny” vs “chubby.” Hair Transpl Forum Int. 1999;9:16.

85. Beehner M. Comparison of survival of FU grafts trimmed chubby, medium, and skeletonized. Hair Transpl Forum Int. 2010;20(1):1, 6.

86. Cole JP. Studies. In: Unger W, Shapiro R, Unger M, Unger R, eds. Hair Transplantation. 5th ed. London: Informa Healthcare; 2010:304-305.

87. Lee SH, Kim DW, Jae BJ, et al. The changes in hair growth pattern after autologous hair transplantation. Dermatol Surg. 1999;25:605-609.

88. Hwang S, Kim HY, Lee WJ, Kim DW. Recipient-site influ-ence in hair transplantation: a confirmative study. Der-matol Surg. 2009;35:1011-1014.

89. Cole JP. Body hair yield following Acell administration. Hair Transplant Forum Int. 2011;21(5):172.

90. Barrera A. The use of micrografts and minigrafts for the correction of the postrhytidectomy lost sideburn. Plast Reconstr Surg. 1998;102(6):2237-2240.

91. Barrera A. Correcting the retroauricular hairline defor-mity after face lift. Aesthetic Surg J. 2004;24(2):176-178.

92. Barrera A. The use of micrografts and minigrafts in the aesthetic reconstruction of the face and scalp. Plast Reconstr Surg. 2003;112(3):883-890.

93. Barrera A. Micrograft and minigraft megasession hair transplantation: review of 100 consecutive cases. Aes-thetic Surg J. 1997;17(3):165-169.

94. Marzola M. Alopecia reduction. In: Unger W, Shapiro R, Unger M, Unger R, eds. Hair Transplantation. 5th ed. London: Informa Healthcare; 2010:483-504.

95. Frechet P. Scalp extension. J Dermatol Surg Oncol. 1993;19:616-622.

96. Parsley W, Waldman M. Postoperative phase. In: Unger W, Shapiro R, Unger M, Unger R, eds. Hair Transplan-tation. 5th ed. London: Informa Healthcare; 2010: 416-427.

at ASAPS on December 12, 2012aes.sagepub.comDownloaded from

Page 25: Aesthetic Surgery Journal - James E. Vogel, MD · procedure is a follicular unit hair transplant (FUT).27-34 ... (FUE) donor harvest. ... do not fully explain its positive action

24 Aesthetic Surgery Journal XX(X)

97. Tsilosani A. One hundred follicular units transplanted into 1cm can achieve a survival rate of greater than 90%. Hair Transplant Forum Int. 2009;19(1):6-7.

98. Vogel JE. Correction of cosmetic problems secondary to hair transplantation. In: Unger W, Shapiro R, Unger M, Unger R, eds. Hair Transplantation. 5th ed. London: Informa Healthcare; 2010:473-482.

99. Vogel JE. Correction of the cornrow hair transplant and other common problems in surgical hair restoration. Plast Reconstr Surg. 2000;105:4.

100. Vogel JE. Correcting problems in hair restoration sur-gery: an update. Facial Plast Surg Clin North Am. 2004;12:263-278.

101. Vogel JE. Hair restoration complications: an approach to the unnatural appearing hair transplant. Facial Plast Surg. 2008;24:453-461.

102. Lucas MWG. Partial retransplantation: a new approach in hair transplantation. J Dermatol Surg Oncol. 1994;20:511.

103. Epstein J. Revision surgical hair restoration: repair of undesirable results. Plast Reconstr Surg. 1999;104:1.

104. Bernstein RM. The art of repair in surgical hair res-toration—part II: the tactics of repair. Dermatol Surg. 2002;28:10.

105. Brandy D. Corrective hair restoration techniques for the aesthetic problems of temperoparietal flaps. Dermatol Surg. 2003;29:3.

106. Uebel CO, da Silva JB, Cantarelli D, Martins P. The role of platelet plasma growth factors in male pattern baldness surgery. Plast Reconstr Surg. 2006;118(6): 1458-1466; discussion 1467.

at ASAPS on December 12, 2012aes.sagepub.comDownloaded from