MEDICAL PRACTICE

Hair transplantation inmale-pattern alopeciaWalter P. Unger, m.d., f.r.c.p. [c], Toronto

In 1959, Norman Orentreich,1 a der-matologist at New York University,published a paper on the results ofautografts carried out in the investi¬gation of various types of alopeciaand other dermatological conditionsincluding vitiligo, psoriasis and wool-ly hair nevus. The findings revealedby his experiments were interesting ingeneral and remarkable in one re¬

spect: autografts from hair-bearingareas ofthe scalp were "donor domi¬nant" and continued to grow hairwhen implanted in areas ofphysiolog-ic male-pattern alopecia."Donor dominance" can be de¬

fined as the maintenance ofthe integ¬rity and characteristics of transposedgrafted skin independent ofthe recipi¬ent site. It has been recognized previ¬ously, in a number of skin conditions,but never before had it been demon¬strated in alopecia prematura.The implication of Dr. Oren-

treich's finding was not lost on themedical community or on the public.Since 1959 an estimated 30,000 pa¬tients have undergone the "hair trans¬plantation" procedure and the num¬

ber continues to increase. The same

procedure has been used successfullyfor the correction of localized scar¬

ring alopecias secondary to trauma,burns and infections.2

Rcprint requests to: Dr. Walter P. Unger, 40 Welles¬ley Street East, Suite 306, Toronto 284, Ontario.

Although many lay publicationshave reported on the procedure, fewscientific journals have done so.

Therefore, I felt it worth while torelate my personal experience in 218transplanting sessions performed on17 patients since 1967, and useful tooutline the principles, technique andmanagement of complications thatsometimes occur.

PrinciplesThe procedure is based on the now

well-recognized principle of "donordominance" in alopecia prematura,and the fact that even markedly baldmen virtually always retain a rim ofhair in the temporoparietal and oc¬

cipital regions of the scalp for theirlifetime. It is logical therefore thathair transplanted from these sites toareas of alopecia can be expected togrow for the remainder of the pa¬tient's lifetime. In actual practice thisdeduction seems to be valid, becausealthough the "hair transplantation"procedure is only approximately 12years old and its success cannot yet befully verified, to this date not a singlecase of loss of transplanted hair hasbeen reported.3"6

Although "donor dominance" inalopecia prematura has been con¬firmed in all patients undergoing theprocedure, the basic question of whysome follicles survive longer than oth¬

ers has not been satisfactorily an¬swered. It is hypothesized that eachhair follicle has its own separate life-span, and that ordinary male-patternalopecia is due to the fact that the hairfollicles in the areas where hair is lostare predestined to have a short life-span. Since moving the longer-livingfollicles to areas of alopecia does notseem to curtail their life-span, previ¬ous theories that this type of hair losswas due to changes in nerve or bloodsupply or to unknown chemical alter¬ations in the areas of hair loss wouldnow seem to be discredited.

ScreeningPatients in whom transplantation iscontemplated are screened at the ini¬tial interview for physical as well as

potential psychological problems.The rim of hair on the scalp must: (1)be wide enough to offer sufficientplugs to obtain the desired effect, (2)contain eight or more hairs per 4-mm.area, and (3) have reasonable pros¬pects of remaining sufficiently wideand dense for the patient's lifetime.The patient's ability psychological-

ly to submit to the entire transplant¬ing procedure, which requires repeat¬ed operations and extends over sever¬al months, must also be evaluated.Some physicians who carry out hairtransplantation insist that the patientbe interviewed by a psychologist or

psychiatrist as part of preoperativeevaluation. Most practitioners, my¬self included, prefer to make a per¬sonal psychological judgment.A popular misconception exists

that people seeking this procedureC.M.A. JOURNAL/JULY 24, 1971/VOL. 105 177

must be very strange or effeminate orin some way mentally unbalanced.On the contrary, they tend to beperfectly average in every way exceptfor their strong desire for permanentscalp hair. The patients come from allwalks of life. My own series includestwo dentists, two lawyers, two teach¬ers, a semi-professional athlete, a

psychiatrist, two "blue-collar" work¬ers, a farmer and various business-men. Most patients took a verystraightforward and reasonable ap¬proach to the matter. They were baldand did not want to be. There was a

proven medical means of correctingthe condition and they were availingthemselves ofit.At least half of the patients who

came for a consultation to inquireabout the procedure werejudged to beineligible by the screening proceduresoutlined above. Nearly all of themwere refused because they had eithertoo narrow a rim of remaining hair,too sparse a growth in prospectivedonor sites or too poor a prospect formaintaining a wide enough or thickenough rim.

Patients considered ineligible forpsychological reasons were few, andfell into two basic groups. The firstgroup consisted ofpatients who, whenthe procedure and prospects were ful¬ly explained, seemed less anxious toproceed than they had been at first. Itis my practice to make the operationand the results sound a little worsethan I actually think they will be,which allows me a margin of errorand eliminates many potential prob¬lems. In the case of these patients, afurther description of what had to bedone and what problems might occur

usually resulted in agreement be¬tween us that their motivation wasless than optimal and that to proceedwith arrangements would be unwise.The second group was composed ofindividuals who in my opinion werenot themselves really interested butwere being impelled by a wife ormother. Two teenagers, accompaniedby their mothers, requested the proce¬dure, but when they were interviewedprivately they admitted that they real¬ly did not want to go through with thetransplant but were being pushed intoit by an overly concerned mother.Similarly, at least three husbandswere being goaded by overbearingwives.

TechniqueBasically, the punch autograft tech¬nique for hair transplantation con-

FIG.l.Orentreich punch.

sists of taking full-thickness grafts inthe form of 2- to 4-mm. plugs whichare punched out of the hair-bearingtemporoparietal and occipital regionsof the scalp and inserted into holesmade by the same punch in the baldareas.The instrument used is a scalp

transplant punch (Fig. 1). The otherequipment used is listed in Table I.The hair over the donor area is

clipped short. The donor and recipi¬ent sites are anesthetized with 2%lidocaine hydrochloride solution.Ethyl chloride is sprayed on the scalpto minimize pain before each inser¬tion of the needle, and a dental-typesyringe allows rapid and easy infiltra¬tion of large areas. Usually no largerthan a 4-mm. punch is used, as plugsof large diameter often result in fi-brotic reactions and tend to lose an

inordinate number of hairs in theircentral portion. The initial nourish-ment for the graft is plasma, butwithin 48 hours grafts of 4-mm. dia¬meter or less are usually already vas¬cularized.5The operation is carried out with

the patient in a sitting position andthe plugs are bored from the donorarea by the use of slight pressure on

TABLEIEquipment required for hair

transplantationIris scissors.curved and straight.V/i"1.8-c.c. dental syringe with steriledisposable 25-gauge short needlesLidocaine hydrochloride 2% with andwithout epinephrine 1:100,000 in1.8-c.c. cartridgesEthyl chlorideAdson tissue forceps.serrated 41/4'FPetri dishesSterile physiologic salineHydrogen peroxide 3%Gauze sponges.4" x 4" 12-plyElastic bandageTelfa sterile padsBacitracin ointmentKerlix bandage 4Vi"

the punch combined with a twistingmotion. The cut is initially vertical tothe scalp surface and is then angled.Care is taken to bore down into thesubcutaneous tissue and in the direc¬tion of growth of the hair follicles sothe matrices of these follicles are in¬cluded. The plugs are removed andplaced in sterile physiologic saline in aPetri dish and the excess fat and anyattached galea aponeurotica are thentrimmed away. Any hairs whose ma¬trices have not been included in theplug are removed, since they tend toact only as inert foci for the develop¬ment of infection.

Similarly, plugs are bored out ofthe recipient site, taking care to anglethe cut so that when the donor plugsare inserted the hairs will point in theproper direction (Fig. 2). Hairs nor¬

mally point forward and usuallyslightly to one side over most of theanterior portion of the scalp. At the

FIG. 2.Four-millimetre plugs being bored out ofthe recipient site. Note the thick growth of hair fromplugs previously transplanted posteriorly. This unusu¬al patient grows 14 to 16 hairs from each 4-mm. plugtransplanted.

lateral aspects of the central and an¬terior scalp the hairs point more andmore to whichever side of the scalpthey are on until finally they aredirected inferiorly in the temporalareas. More posteriorly, over thecrown, the hairs are angled radiallyand point away from the centre ofthecalyx. Often a few original hairs stillpersist in areas of even marked alo¬pecia, and their direction of growthprovides a natural guideline for thedirection of the donor hairs. Uni-formity in the direction of all donorplugs produces a normal-looking newgrowth of hair.The donor area can usually be cov¬

ered entirely by the hair superior to itso that ordinarily it does not showeven immediately after the proce¬dure. The plugs from the recipientarea are discarded and the donorplugs are placed in the punched-outsites where they are anchored within afew minutes by the formation of a

fibrin clot. Simple pressure applied to

178 C.M.A. JOURNAL/JULY 24, 1971/VOL. 105

FIG. 3.Case 1. Initial series of plugs. Anterior twolines are three weeks old. Posterior three lines are twoweeks old.

both the recipient and donor sites isnearly always sufficient to stop bleed¬ing and the scalp is then dressed usingbacitracin ointment and Telfa stripsfollowed by a pressure bandage. Thisdressing is left in place for 48 hoursand can then be removed by the pa¬tient. Shampooing of the scalp isallowed five to seven days after theprocedure, but care should be takennot to massage the area that has beentransplanted.The process is repeated at weekly

intervals until all the plugs have beenimplanted. At the first sitting usuallyonly 10 plugs are transplanted; thepatient thereby becomes accustomedto the procedure. At subsequent sit-tings from 20 to 75 plugs are inserted.As a rule, at least six weeks areallowed to elapse before adjacentareas are transplanted so that ade¬quate vascularization has occurred inand around the first graft before asecond is placed beside it.

It is difficult to generalize as to howmany sessions or plugs are required inthe average patient, as each individu¬al has a different concept ofhow largean area he wants covered as well as adifferent amount of hair available tocover the area of alopecia. Generallyspeaking, deep frontal hairline reces-sions require approximately 150

FIG. 4.Case 1. Patient after transplantation. Thispatient refused "filler plugs" as he was satisfied withthe results seen here.

plugs, four sessions and approximate¬ly 16 weeks to complete. Four to sixmonths later a good growth of haircan be expected and a "filler session",described below, is carried out ifnecessary. A large bald area may take500 to 600 plugs, 10 to 12 sessions andfive to six months to complete. Themost time-consuming part of thewhole procedure is the interval be¬tween sessions and not the number ofsessions or plugs required. Thus theinsertion of 150 plugs extends over 16weeks, and 600 plugs take only four toeight weeks longer.

Subsequent course

After the effect of the anesthetic hasworn off, a vague discomfort is felt;few patients complain of this andthose who do are nearly always re¬lieved by one or two tablets of acetyl¬salicylic acid with 8 mg. of codeine.

Although the procedure is not en¬

tirely painless, all ofthe 17 patients inthis series commented that they ex¬

pected it to be much more painful.Lay journals and magazines report¬ing on hair transplantation usuallyimply or state bluntly that the pa¬tients suffer a great deal of pain.People seem unwilling to believe thatthe only significant pain experiencedoccurs in the first five minutes of theprocedure when donor and recipientsites are anesthetized.A crust forms and usually remains

attached to the graft site for 10 to 21days. The patient is cautioned againsttrying to remove these crusts. Thehairs in the plugs are usually shed intwo to eight weeks and new hair isfirst seen on the surface ofthe graft 10to 14 weeks after the procedure. Onan average, six to 12 hairs grow out ofeach plug, although the rare patientmay have up to 16 hairs (Fig. 2).The donor site heals with hairless

scar formation. Following the normalcontracture of scar tissue, a line ap¬proximately 1 to 2 mm. wide is allthat remains. Careful inspection ofthe scalp reveals these lines whichotherwise lie undetected beneath hairgrowing above them. It is not unusualto be able to remove over 600 plugsfrom donor sites without apparentscarring or thinning being noticed(Fig. 5).

Four to six months after the initialset of implants has been completed,the patient returns for "filler" plugswhich are placed in areas where thereis not a thick enough growth, espe¬cially in the anterior portion. Theinsertion of 2- to 3-mm. plugs be-

FIG. 5.Case 1. This patient has had 550 plugsremoved from the temporoparietal and occipital

tween the 4-mm. plugs in the hairlineproduces a more natural appearance.The importance of these follow-upplugs cannot be overemphasized.Without them the results are oftendisappointing. Four of my patientscompleted their "filler" sessions oversix months ago and all four are satis¬fied with their results. One patientwas satisfied with what he had grownwithout fillers and preferred to savethe rest of his potential donor plugsfor a rapidly thinning crown area.Three additional patients receivedtheir "filler" plugs less than threemonths ago and are waiting for themto grow hair.The final appearance of the trans¬

planted site varies from the usual"thinning" but far from bald scalp toone which looks perfectly normal (ap¬proximately one in every 10).From a strictly cosmetic point of

view, a hairpiece or so-called "hair-weaving" nearly always produces athicker final result. This is stronglyemphasized at the patient's first visit.The most important advantage hairtransplantation has over its alterna¬tives is that it satisfies the patient'spsychological need for his own per¬manent hair. Figs. 3 to 8 show howsatisfactory post-transplantation

FIG. 6.Case 2. Before transplantation.

C.M.A. JOURNAL/JULY 24, 1971/VOL. 105 179

FIG. 7.Case 2. Front view after transplantation.

"early thinning" is, and were chosento demonstrate the average resultsseen after this treatment.The more loose the screening

procedure, especially with regard tothe denseness of hair growth in thepotential donor sites, the poorer theresults obtained. The criteria for ac-

cepting a patient for hair transplant-ing should be rather strict, allowingthe physician to offer good results as areasonable goal.

ComplicationsInfectionIt is remarkable how seldom infectionoccurs. In one series its incidence wasreported as 1 per 5000 sessions.5 Theprocedure is impossible to carry outin a practical form under strictly ster¬ile conditions. Shaving the scalp isnaturally objectionable to the patient,so that proper preparation is impossi¬ble. The best one can accomplish is a"clean" procedure in which the in¬struments and materials used aresterile and the scalp is cleansed by a

shampoo containing hexachloro-

FIG. 8.Case 2. Side view after transplantation.

phene on the morning of the opera¬tion.

Fortunately minor bacterial insultoffered to the skin is rapidly con¬

trolled, as demonstrated by the lowincidence of infection encountered.Infection occurred twice in one ofmypatients who routinely covered theimplanted sites with a hairpiece 48hours after the procedure, whichprovided the warmth and moistureconducive to infection. Surprisingly,many patients who wear hairpiecescan wear them after 48 hours withoutany problems of clinical infection,although they should be informed ofthe hazard.Two incidents ofinfection occurred

within 48 hours of the procedure inanother patient who was an athlete inthe habit of having a heavy physicalworkout which produced much localperspiration and general exhaustion,but eight of his 10 sessions were notthus complicated.

Infection is quickly controlled withoral potassium penicillin G, 500,000units three times a day, or ery¬thromycin 250 mg. four times a dayand topical bacitracin ointment. De¬spite effective treatment of infection,however, the area involved seldomgrows an acceptable number of hairs.Such sites can be retransplanted twoto three months later when an ade¬quate number of hairs is producedeven in these areas.

In an effort to minimize infection,we now give tetracycline or ery¬thromycin 250 mg. orally four timesdaily prophylactically for seven daysafter the procedure. In almost a yearno infection has occurred in over 100sessions.A minimum of sutures is used, as

all suture material is contaminated bythe non-sterile surface through whichit must pass. Some physicians suturethe donor sites in an attempt to pro¬duce a very thin scar line. In view ofthe minimal scarring that occurs evenwhen no suture is used, the increaseddanger of infection from suturing isbelieved to constitute an unaccepta-ble risk.

HemorrhageThe scalp, whether hair-bearing or

bald, has an abundant blood supply,but the incidence of hemorrhage issurprisingly small. Occasionallybrisk bleeding occurs, but firm steadypressure usually controls it complete¬ly. Less often, bleeding occurs afterthe patient leaves the office. All pa¬tients are instructed to apply pressure

with clean gauze for approximately15 minutes if this should happen, andthis is almost always successful instopping the hemorrhage. Occasion¬ally it is necessary to suture either thedonor or the recipient sites; such su¬tures are removed five days later.Thirteen of my patients required no

suturing. One patient required su¬tures on two occasions. In three pa¬tients, who tended to bleed freely,some suturing was necessary at virtu¬ally all the sessions and was carriedout liberally in order to avoid thepossibility of bleeding after they leftthe office.

SyncopeOccasionally, very nervous patientsfaint or feel faint during the proce¬dure, but this can be managed bysimple measures such as lowering thehead between the knees or laying thepatient prone.

EdemaIn some patients, painless pitting ede¬ma not associated with erythema or

tenderness develops on the forehead24 to 48 hours after insertion of thegrafts. This tends to be commoner inpatients who have had extensivetransplantation carried out over a

short period of time and is probablyrelated to undue interruption of ve¬

nous and/or lymphatic drainage ofthe scalp. It resolves without com¬

plications and without treatment,usually within 72 hours, and may or

may not recur after subsequent ses¬

sions. It has been reported to us after21 of the 218 sessions in this series.When more than 50 plugs are intro¬duced during a single session, thiscomplication occurs in virtually everycase. Patients tend to want as manyplugs done as quickly as possible andthey readily accept this side effect as

the price of fewer sessions and fasterresults.

ElevatedgraftsEach plug ordinarily heals level withthe surrounding skin. Those that are

slightly elevated, or less often de¬pressed, tend to level out within 12months. Infrequently, some grafts re¬

main elevated above the surroundingsurface. If many of the grafts are

elevated, a "cobble-stone" effect isproduced. These plugs can usually belevelled off by the use of light elec-trodesiccation without impairing theviability of the hairs growing fromthem.

180 C.M.A. JOURNAL/JULY 24, 1971/VOL. 105

This undesirable result can beavoided by (a) making certain that therecipient holes are deep enough toaccept the entire donor plug so that itdoes not project and (b) taking careduring the boring initially to cutthrough the epidermis vertical to theskin surface and then to angle the cutas described earlier. The fit of donorplug to recipient site is thereby ren-dered more accurate and no excessepidermis results.

Sparse growthSome plugs produce an insufficientnumber of hairs. Generally, any pluggrowing less than four hairs should bereplaced. Usually any plug growingless than five hairs is partially re-placed by a 3-mm. plug which over-laps the deficient one.

Loss ofsensationTemporary loss of sensation nearlyalways occurs in the donor and recipi-ent areas, and is the result of thesevering of nerves by the punch as itbores out donor and recipient sites.Patients usually notice this, but rarelycomplain about it. Sensation returnsover a period of six to 12 months afterthe procedure is completed.Illustrative case historiesCase 1A 26-year-old single man, employed inadvertising and sales for a metal workscompany, was concerned about his rapidloss of scalp hair over a period of approxi-mately five years (Fig. 3).

Examination of the scalp revealed alarge area of partial alopecia in the typicalphysiological hair loss pattern. Hair wasvirtually absent anteriorly but satisfact-ory posteriorly.The anterior portion of the area of

alopecia received 550 plugs in 15 sessionsover a nine-month period. Figs. 4 and 5were taken 3½ months after the last trans-planting session. This patient was ex-tremely pleased with the result and feltthat he could do without filler plugs,preferring to save them for his crown,which was rapidly thinning. I would havepreferred to use 10 to 20 plugs to thickenout what I considered to be an inadequategrowth of hair on the left side anteriorlynear the midline, but the patient refused.No complications occurred during the

course of his transplanting sessions.Case 2A 33-year-old married blue-collar workerwas constantly getting into fights withfellow workers about the way he wore hishair to cover a rather large area of alo-pecia (Fig. 6). This patient had spent over$750 at a "hair studio" before beingreferred.

Examination of the scalp revealed awide rim of moderately thickly growinghair surrounding the denuded areas. Healso had severe seborrheic dermatitis.After the latter condition had been con-trolled by regular shampooing, 525 plugswere inserted in the area of alopecia in 17sessions over a 14-month period. Twofiller sessions were carried out six monthslater, adding 48 plugs to the total (Figs. 7and 8). No complications occurred duringthe course of his sessions.The course of treatment was longer

than usual because he was reluctant tomiss work on a regular basis, and pre-ferred not to go to work wearing a dres-sing. His entire personality has changedsince his alopecia was corrected. Wherepreviously he was tense and introspective,he now is more easy-going and person-able.

References1. ORENTREICH N:Ann NYAcadSci83: 463, 19592. STOUGH DB: Plast ReconstrSurg 42:450, 19683. Idem: GP 35: 123, 19674. AYRES S:Arch Derm (Chicago) 90:492, 19645. ORENTREICH N: Hair transplants, in Current

Dermatologic Management, edited by Maddin5, St. Louis, Mosby, 1970, p 13

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34. SCHINDLER AE, RATANASOPA V, LEE TY,et al: Estriol and Rh isoimmunization: anew approach to the management of se-verely affected pregnancies. Obstet Gyne-cot 29: 625-631, 1967

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