Hair restoration

Introduction

This chapter represents a 28-year journey of hair transplantation practice, initially treating primarily cases of male pattern baldness and then expanding to other applications, such as enhancing aesthetics in the reconstruction of the face and scalp and treating complications of facial aesthetic surgery. Specific examples include addressing scarring alopecia after facial rejuvenation surgery (the loss of the temporal hairline and sideburn), alopecia due to trauma, burns, radiation therapy, and even congenital defects such as a male patient with bilateral cleft lip. In all these examples, the aesthetic outcomes can be significantly improved through hair transplantation techniques.

The senior author was influenced by of the work of Carlos O. Uebel from Brazil, the first to do follicular unit grafting (1–2-hair follicular unit grafts) in large numbers of 1000 or more grafts per session. His technique enabled natural-looking results. Dr. Uebel harvested a horizontal ellipse of scalp from which he dissected the follicular units. This is what we know today as follicular unit transplantation (FUT).

The senior author spent time with Dr. Uebel, attending live demonstrations in the early 1990s and visiting with him at his clinic in Brazil to learn more about the technique. (He even underwent the procedure himself, performed by Dr. Uebel.) He went on to incorporate the techniques in his private clinic in Houston, Texas, and within a few years it became the most frequent procedure in his practice.

Patient selection

To date, we have no method to create new hair follicles. All current techniques for hair restoration only involve a redistribution of the patient’s own existing active hair follicles from one area to another. Therefore, for the patient to be a candidate for hair transplantation there needs to be a good supply and demand ratio ( Algorithm 24.1 ). Ideally, we want a donor area (occipital and temporal areas) with a high density of healthy growing hair so we have enough hair follicles to distribute over the affected area of baldness. Unfortunately male pattern baldness is a progressive condition. The rate of hair loss may slow down after the age of 40 years, but it never stops completely. Therefore the preoperative plan must ensure natural-looking results in both the short and long term. Good communication with patients is essential to establish realistic expectations. Additionally, there is a limit to the density that can be achieved on the grafted area in one session. It is important that the patient understands this reality, and it is not uncommon to do more than one session to further increase the density. In older patients, more grafts may often be needed.

Algorithm 24.1

Hair transplantation: the supply and demand factor.

Most experts today agree that the average healthy full head of hair has a density of about 200 hairs/cm ² (range 130–280). From experience, we have learned that about 50% of this number is needed to give an aesthetically pleasing appearance. Therefore, about 100 hairs/cm ² (in the range 65–140 hairs/cm ² ) provides a reasonably good appearance. To accomplish this will take at least two procedures. The senior author recommends waiting a year between procedures (a minimum of 10 months). This time course for treatment must be explained to patients, as it helps to give them realistic expectations.

Finally, the senior author’s preferred donor hair harvesting technique is FUT, harvesting a horizontal ellipse from the donor area and doing a very careful aesthetic closure. This almost always results in a minimally detectable scar (even when looking for it). However, if the patient plans to shave the donor area or wear the hair very short, they must be alerted that the donor scar may be slightly detectable, especially after multiple procedures. Fortunately, most patients in the author’s practice are happy to wear their hair at least ¾ inch or an inch long, on the donor areas (the senior author himself included). This way the donor scar is quite undetectable. If the patient does plan on wearing very short hair, then the follicular unit extraction (FUE) harvesting technique may be considered. However, FUE harvesting must also be done very carefully to avoid visible scarring; the scarring with this method will be patchy, rather than linear. Regardless of the harvesting method, overly aggressive harvesting from any given area can create visible scarring.

With either FUE or FUT patients are advised not to wear their hair excessively short.

For general patient screening parameters, we search for and address any medical issues that could provide a safety risk for elective aesthetic surgery.