Fig. 13.27 Autoclavable container to store jeweller’s forceps that has rubber walls to protect the forceps’ tips from being damaged

Fine tipped Jeweller’s forceps are required for planting to avoid crushing or damaging the grafts. The tips are very fragile and can be easily blunted or nicked in the cleaning process. It is advisable to place a plastic guard over the tip during sterilization. A holding device (Fig. 13.27) can be purchased that holds the forceps safe and secure between rubber cushions during sterilization.

13.17 Re-creating a Natural Hairline

At the beginning of surgery the frontal hairline, which has been agreed upon by both the physician and patient at the time of initial consultation, is drawn on with a black grease pencil employing the proper principles of

Random scatter hairs

Fig. 13.28 The anterior hairline zone is feathered and made irregular with the use of small groupings of three to five hairs and single, randomly placed hairs (Reprinted with permission from Berg and Cotterill [24]. Copyright Elsevier Limited 2009)

planning an anterior hairline, (see surgical planning). A photo should be taken at this time if it was not already done at the time of the initial consultation. The aim in creating the recipient sites is to create a zone of naturally increasing density with the irregularities that one sees in a natural hairline. Hairlines that are too abrupt, too sharp, too dense, or too symmetrical can draw the eye to it and appear unnatural. The author will use for the hairline either 19–20 gauge needles, or

.8–1.2 mm chisel tipped blades to accommodate single FUs. An initial defined zone of evenly spaced singlehaired FUs sites is made just posterior to the drawn hairline. Anterior to this zone, micro-irregularities employing three to four single-haired FUs are utilized in clusters as well as scattering random (Fig. 13.28), single-haired FUs, placed erratically in front and between groupings. In this way the hairline is softened and abrupt straight lines are avoided (Fig. 13.29). What is created is a gradually increasing density in a hairline

zone, approximately 5–10 mm in width. With experience, the surgeon will understand that different hair types and colors will dictate a zone that should be wider or narrower. For example, a patient with black, coarse wiry hair and pale skin may require a wider transitional zone to avoided abruptness, while a patient with fine, salt and pepper hair and pale skin will achieve a feathered result with a narrower zone. At a distance one can also appreciate widow’s peaks and lateral peaks that can be re-created by using a small number of FUs concentrated in areas at the hairline.

Once the hairline zone has been created then increased density can be achieved posteriorly. For the beginner or surgeon that performs transplants infrequently it can be difficult to know how densely one should attempt to place the grafts. It is suggested that the surgeon practice by drawing a 1 cm2 box and assess the degree of difficulty of placing grafts at 20, 30, 45, and 75 FU/cm2. Densities greater than 35 FU/cm2 are considered dense packing. However, as densities increase the concern of graft viability also increases. With high numbers of densely packed grafts there is also the need for higher numbers of skinnier grafts, with consequently the need for more skilled technicians to assist with the procedure. It should be kept in mind that excellent results can be achieved with densities of 30–35 FU/cm2 using oneto three-haired FUs and fourto six-haired MFUs. A 1.5–3.0 mm spear tip blade is an example of the type and size of blade required to make a site that will accommodate the larger MFUs. A suggested scenario would be to create a frontal hairline zone with 600 oneto threehaired FUs followed posteriorly by 600 fourto sixhaired MFUs. This will yield approximately 4,200 hairs. An oval shaped area at the midline frontal region, just behind the hairline zone, is often densely transplanted to give the illusion of density. This can be achieved with single FUs placed at 30–35 FUs/cm2 or with MFUs placed slightly farther apart. It should also be remembered that to transplant a bald frontal zone it is wise to instruct the patient they may require two sessions and possibly a third finishing session. While some surgeons will attempt to complete a bald frontal area in one pass using high numbers (3,000–4,500+) of densely planted all oneto three-haired skinny FUs, as well as spacing all the grafts in a CAG orientation, this technique is not recommended for the casual hair transplant surgeon. It would be more prudent, with an equally great result, to split the transplant into two

procedures, 1 year apart, of approximately 1,500 FUs each, using a combination of FUs for the hairline zone and a combination of FUs and MFUs for the rest of the anterior frontal scalp.

Pearls: For the novice or casual hair surgeon

1.Limit transplant to front one-third of scalp.

2.If area is bald, split the procedure into two sessions of 1,200–1,500 grafts per session spread 1 year apart.

3.Use a combination of FUs and MFUs.

4.Place grafts using SAG orientation.

5.Use 19 gauge needles or similar sized blades.

6.Place sites at densities of 25–35 FUs/cm2.

7.Remove donor grafts using strip excision technique.

Pearls: For the novice surgeon for choosing their first patients.

1.Use family or friends.

2.Select a male that is over 50 years of age, with moderate thinning confined to the frontal scalp, such that there is preexisting recipient hair to aid in camouflage.

3.Have excellent hair characteristics: Salt-and-pepper or gray hair color with pale scalp to minimize color contrasts. Fine, wavy or curly hair to yield a feathered hairline with added fullness behind hairline zone.

4.Good to high density in the permanent hair-bearing donor zone.

5.Appropriate expectations as to what to expect from one session.

Just before the recipient sites are made the patient is placed in a semi-supine position. The recipient area is tested for adequate anesthesia and further tumescence is placed by some physicians to aid in graft site creation and to minimize bleeding. The length of the donor graft should be sized so the appropriate length of blade or needle is adjusted accordingly. If one is using SAG then it is essential to follow the direction and be parallel to any preexisting hair in the area in order to minimize the chance of transection of hairs in the immediate area. Any preexisting terminal hairs in the area can be used as a guide for direction. Hair direction at the mid-frontal scalp while growing in a posterior to anterior direction can change markedly as one creates sites from one side of the scalp to the other. As one travels from the midline to the frontotemporal corner, for example, the angle of incisions created should gradually change from a forward direction to laterally and down. The angle that hair exits the scalp at the

frontal midline is from 30° to 45° while closer to the temples the exit angel is more acute. The physician must pay close attention to changes in direction and angle of scalp hair as it exits from the scalp. Once all the sites have been made the grafts are planted. Some practices advocate “stick and place,” whereby the physician or technician will make a recipient site followed by a second technician immediately placing the graft in the site created (Fig. 13.30). This technique is used in some practices where high numbers of very small sites are made. If all the sites were left to the end to be planted, they may be difficult to find. The author

Fig. 13.30 Planting grafts using the “stick and place” method. The physician or assistant makes the site and the graft is then immediately inserted

prefers to make all the sites initially and have two to three technicians plant, once the sites are made. However, stick and place can be useful at the end of the session if there are still some final sites to be made between previously planted grafts.

13.18 Planting Recipient Grafts

Planting of the grafts can be done at the same time the recipient incisions are made, (stick and place), or once all the sites are completed. Whatever method the surgeon chooses, hair restoration is definitely a team effort. Compared to any other type of cosmetic surgery, the hair restoration nurse/technician plays an essential part in both the dissection of the donor strip and in the planting of the recipient grafts and as such has a great influence on the successful outcome of the procedure. However, with excellent, well-trained staff there is no need for the physician to plant all the grafts. The time involved would be excessive with no better outcome. However, some essential principles need to be kept in mind. The grafts should be kept moist and cool in chilled saline until such time as they are ready to be planted. Three to five grafts at a time are placed on the glove of the technician’s nondominant finger and then planted following the exact angle and predetermined depth of the incision (Fig. 13.31). The graft should not be allowed to subside into the recipient site or pitting could occur upon healing. The graft is left

slightly elevated above the dermis. If the graft was allowed to sink and another graft was placed on top (piggybacking), an inclusion cyst could form. During the planting process the area is sprayed with a dilute hydrogen peroxide mixture to enhance visibility of the work area and to aid in cleaning off blood clots and any stray hairs or hair spicules that could congregate under planted grafts.

13.19 The Vertex Region

Proper planning principles are crucial when attempting to treat a crown. The very young patient or patient who may become very bald is often best served by not transplanting the crown. However, when treatment is appropriate, the crown presents its own set of design challenges. When transplanting a crown the center of the whorl needs to be identified as that site where the hairs exit the scalp radiating out in a 360° direction. To accurately reconstitute the whorl, the physician needs to find the center of the whorl, or create one if the patient is bald in that region, and make the recipient sites radiating out from that site (Fig. 13.32). In some instances, there are the remains of a whorl to follow; in other circumstances where there is total hair loss the physician must choose an arbitrary whorl.

Fig. 13.32 Hair direction when reconstituting the whorl formation in the bald vertex

With the use of twoto three-haired FUs, one session of grafting can give a pleasing light coverage.

13.20 Postoperative Care

It is suggested that following surgery the patient be accompanied home if any intraoperative sedation was used. All patients are called the night following surgery by the physician as well as being seen in the office the morning following surgery to have the hair washed, grafts inspected, and postoperative directions confirmed (Table 13.4).

Postoperative dressings are rarely used anymore do to the small size of grafts and limited postoperative bleeding. Patients are given gauze to be used to apply pressure to any small bleeding areas as well as pads to use against pillowcases to soak up any blood. The patient is advised to take 5–7 days off work or sports, to minimize the chance of knocking out a graft or bleeding. Patients are given baseball caps when they leave the day of surgery to help keep the scalp clean and to avoid accidental injury. There may be some degree of forehead swelling, which is common when the anterior scalp is transplanted. It is suggested that the patient sleep at a 45° angle for the first three nights and to use the supplied chemical ice pack, with sleeve to prevent burning the skin, for the first 2–3 days on the forehead region. Many physicians advocate the use of postoperative oral steroids, or intralesional steroids to minimize the chance of facial edema. Antibiotics are also employed, usually just for the day of surgery, since infections are rare.

There should be no discomfort during the procedure if adequate anesthesia is used. Postoperatively, there can be some discomfort usually in the donor area due to do the pulling of the sutures. There is remarkably little discomfort in the recipient region. Patients are typically given prescriptions for acetaminophen with codeine and acetaminophen with oxycodone, as well as diphenhydramine as an antinauseant. There should be no prescription medication required after the night of surgery. At most, a patient may require acetaminophen or ibuprofen for 2–3 days after surgery.

The day following surgery, the patient’s scalp and hair is washed at the office so that the patient can be instructed in general hair care and to help remove any superficial blood clots that may have appeared