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2 Surgical Hairline Augmentation
Hair transplantation surgery is a more invasive method of restoring the
hairline. This procedure involves harvesting donor hair follicles from a
distant area (usually the occipital scalp) and transplanting the donor
follicles near the hairline. If the scalp is not an option, or if patients wish to
avoid vertical scarring, distal body hair can be transplanted near the
hairline. These surgeries require an experienced aesthetic surgeon, and the
entire process can take several hours [1, 2].
Hairline-lowering surgery is an additional surgical option for patients
who wish to reduce the appearance of a larger forehead resulting from
receding hairline or underlying genetics. In suitable patients, the resulting
aesthetic improvement is similar to that achieved by implanting over 7000
hair follicles [3].
2.1 Hair Transplantation Surgery
Surgical hair transplantation incurs additional risk to patients when
compared to nonsurgical hairline rejuvenation. As such, it is increasingly
important to perform a thorough patient assessment. The past medical
history should be obtained in detail, and any current inflammation/scarring
of the scalp should be further investigated with a scalp tissue biopsy, as
discussed with nonsurgical rejuvenation. These conditions should be
resolved before surgery is considered [132].
Additional consideration of hair loss patterns and estimated future
losses should be made, to allow for natural-appearing results in the long
term [4]. Patients should be counseled prior to surgery to discuss the
realistic changes that can be made. Optimal aesthetic appearance is often
reliant on the number of follicles that can be harvested, and individuals with
larger/denser available donor areas tend to have better outcomes.
Individuals with finer hair shafts (<60 micrometers in diameter) or
transparent hair note less perceived improvement to the hairline when
compared to those with thicker hair (>80 micrometers) or wavy/course hair.
Surgery is generally the second line therapy, after patients have attempted
nonsurgical/minimally invasive treatments (discussed in the previous
section) [5].
Currently, there are two widely accepted methods for harvesting the
donor hair follicles, named for their respective harvest techniques: follicular
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unit extraction (FUE) and follicular unit transplantation (FUT) or strip
harvest. While each technique can usually be applied to all patients, there
are some indications based on the patient’s aesthetic goals and available
location of hair follicles [6].
2.1.1 Follicular Unit Extraction
Follicular unit extraction uses a punch tool to remove individual follicles of
hair, and can utilize distant follicles (beard, body hair, etc.). Removal of
occipital scalp skin is not required, eliminating the risk of visible linear
scarring and suture closure. The punch incisions can result in damage to the
extracted follicles, although this risk is lower with experienced surgeons.
FUE is ideal for individuals whose future hair loss pattern cannot be
predicted, especially younger individuals who would require additional
surgery and/or have existing scarring from prior rejuvenation. If the
cutaneous scalp tissues are too tight and cannot be easily manipulated, FUE
is indicated. Any resultant scarring comes in the form of small pinpoint
hypopigmentation and can be easily concealed in most patients, regardless
of hair length [6, 7].
Surgeons begin by trimming the hair at the donor area, as well as any
adjacent hair if necessary. Some providers prefer to keep the hair long,
allowing for a more natural appearance immediately after transplantation.
This requires the use of an asymmetric or slotted punch device and is not as
efficient as other methods, indicating a need for improved punch devices [8,
9].
With manual removal of shaved follicles, surgeons carefully center the
metal punch device around the exit point of the hair and continue
advancement into the scalp (about 3mm). If the punch is placed too deeply,
the hair follicles can be damaged or splayed apart, leading to follicle
transection (slicing through the FU). Successful extraction requires careful
technique, and experienced providers have a better understanding of the
skin layers and required pressure application. Images of punch devices are
shown in Figs. 1 and 2 [10–12].
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Fig. 1 The above image shows a surgeon performing traditional manual removal using a handheld
punch device [3]
Fig. 2 Various attachments for the ARTAS robotic extraction device with different punch diameters
are shown in the figure, which are chosen depending on the indicated harvest method [13]
Sharp punch devices allow for less force to puncture the skin and
require greater control of the surgeon to avoid transection of the follicles.
Hybrid or blunt-tipped punch tools require less depth control and can be
placed deeper than 3 mm while avoiding transection; however, the
increased pressure may push the follicles deeper into the tissues and prevent
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successful harvest. The latter requires assistance from motorized devices,
which rotate, oscillate, or vibrate the punch and improve ease of removal
[14]. Removal of buried follicles should be attempted using fine-tipped
forceps when possible, to avoid the risk of cyst development [9].
Recent advancements in robotics have allowed for the development of
robotic systems, which make follicular extraction much easier. These
systems include ARTAS (shown in Fig. 3) and Venus Concept, among
others, and are currently commercially available for purchase [15, 16].
Additional information regarding the robotic advancements in follicular
extraction will be further discussed throughout later chapters.
Fig. 3 The ARTAS robotic hair follicle extracting system [13]
Depending on the severity of hair loss, multiple sessions of surgical
hairline rejuvenation may be necessary. It can take up to 2h to harvest 1000
follicles (and potentially longer for inexperienced providers), and some
patients require transplantation of at least 2000 follicles for sufficient
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aesthetic improvement. Even when placed in solution, the follicular grafts
cannot survive for more than 6h outside the body [14].
2.1.2 Follicular Unit Transplantation
Follicular unit transplantation, otherwise known as strip harvesting,
involves resection of a 10–15 mm strip from the occipital scalp. This strip
will be sectioned and prepared for follicular unit removal, which requires a
specialized team to create follicular grafts of assorted sizes. Some consider
this procedure to be more invasive, and it can result in a linear scar on the
posterior scalp which is not as easy to cover with shorter hair. Individuals
who do not have adequate growth of hair follicles or minimal skin laxity in
the occipital scalp are not ideal candidates [7].
Surgeons base their decision of strip size on the calculated follicular
density, and the area excised is limited by the degree of laxity in the scalp.
The Mayer-Paul formula is commonly used to assess the degree of scalp
elasticity, requiring an additional physical examination maneuver. The
thumbs are placed 50 mm apart, and the scalp is compressed inwards and
remeasured at the maximal manipulation point. The percent of scalp
elasticity is equal to: [50mm-compressed scalp distance(mm)]/50 * 100.
Indications for maximal strip size are specified through this formula,
depending on the calculated laxity. Figure 4 demonstrates the relative
markings used for strip harvesting [17, 18].
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Fig. 4 The left image depicts an incision pattern for FUT strip harvesting, using an angled approach
on the sides of the strip for reduced scar visibility after excision [19]
Saline injections around the donor area can help to reduce follicle
transection, as well as careful scalpel technique around the edges of the
excised strip. The incision should be limited to the depth of subcutaneous
fat, allowing for the complete removal of FUs while avoiding damage to the
underlying nerves and vasculature [6].
The resultant wound is relatively small and does not usually require any
undermining (reduction of tissues near the wound edges) before closure.
Trichophytic incisions can help to reduce the appearance of a linear scar,
which require alteration of the thickness and pattern around the wound
edges [6]. Absorbable sutures are placed in the dermis to ensure stability of
repair, and nonabsorbable sutures are used to close the upper layer of the
epidermis, which can be removed around 10–12days postoperatively [26]
(Fig. 5).
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Fig. 5 The image illustrates the initial markings (a), appearance after strip excision (b), and closure
of the resulting wound (c) [19]
Once the graft is harvested, it can be preserved in physiological saline
or Lactated Ringer solution for 6hours, which helps to keep the tissues
hydrated. At this point, the follicular units must be separated from the
excised scalp skin under a microscope. The team may prepare minigrafts
(3–4 hairs) or micrografts (1–2 hairs) depending on the surgeon’s
recommendation [5].
FUE and FUT are both performed under local anesthesia (1% lidocaine
or 0.25% bupivacaine with epinephrine 1:200,000), injected at subsequent
intervals to prevent excessive plasma concentrations of
lidocaine/bupivicaine. A bilateral supraorbital nerve block can help to
minimize pain, although it is not performed by all providers. If patients
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begin to feel discomfort during longer procedures, additional injections of
local anesthetic may be given. Providers should be aware of the maximal
doses for each local anesthetic solution. The maximum dose of 1%
lidocaine solution is 7mg/kg, and the maximum dose of 0.25% bupivacaine
solution is 3mg/kg. Patients experiencing local anesthetic toxicity may
describe taste disturbances, perioral anesthesia/paresthesia, and dizziness.
Bupivicaine toxicity incurs additional cardiovascular risks to patients,
including precipitation of fibrillation or ventricular tachycardia [20, 21].
2.1.3 Implantation Techniques
The design of the new hairline should be considered prior to the procedure,
with the goal of creating a well-blended and naturally irregular appearance.
Female patients tend to have a lower, flatter hairline before hair loss, while
men have a higher midfrontal point. Good coverage is generally provided
with 25–45 FU grafts/cm2, depending on the existing hair thickness and the
patient’s desired appearance [22].
To reduce pain with implantation, providers inject the recipient area
with local anesthetic about 2 cm below the new hairline. The recipient sites
can be prepared before any grafts are inserted, or they may be prepared
individually as each graft is transplanted. A small opening is made about 4
mm deep using a 22–23-guage hypodermic needle or 0.6 mm blade (single
hair micrografts) or 0.8–1 mm blade (2–4 hair minigrafts) [22].
Forceps can be used to manually place the hairs into each opening,
although the use of robotic implanter devices has become increasingly
popular. These devices contain a hollow needle into which grafts will be
loaded, which can be positioned at each opening, and the attached piston
will eject the graft. Manual placement with forceps requires additional
caution, as any damage to the follicular bulb will prevent growth of new
hair. Implanters can save time in the long run but require additional staff to
load the device [22, 23].
Regardless of gender, certain techniques are beneficial to ensuring
natural results when placing the grafted FUs. The angle and direction of the
existing hair should be matched with the new transplanted follicles. To
allow for natural blending, smaller micrografts are placed at the most
anterior hairline and surrounded posteriorly with 2–4 hair minigrafts. If
there is diffuse hair loss, which tends to occur mainly in women, there may
not be enough available grafted FUs to completely recover the original
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appearance. Thus, providers should focus on the midfrontal and midcentral
scalp, as these areas are most cosmetically sensitive [24, 25].
Generally, bandages or covering of the surgical site is not necessary.
Depending on the surgeon, the patient is instructed to leave an emollientcoated Telfa pad on the recipient site for the first postoperative day. Normal
saline sprayed on the scalp helps to keep the area clean for 2–3days
postoperatively, and routine shampooing of the scalp can be performed after
one day. Antibiotic ointments are well utilized to prevent infection of suture
lines or donor sites for 3–4days after surgery, and frontal edema can be
reduced with 3days of oral prednisone [4, 26].
Patients should expect to see superficial scabbing at the sites of
transplantation, which tends to fall off around day 10. Some of the
transplanted hair shafts will shed about one month after the procedure,
although this is not uncommon and does not impact future growth at these
sites. Generally, the new hair will not begin to grow until at least 2 or
3months after surgery. Full growth occurs in most patients after one year,
although some will see these results after only 6months. Additional surgery
is performed (if necessary) at least 9–12months after the initial follicular
transplants are placed [20] (Fig. 6).
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Fig. 6 The left figure shows the preoperative appearance of a 36-year-old male patient (left) and
results from transplantation of 4800 follicles at 8months post transplant (right) [27]
2.1.4 Complications and Outcomes
As previously discussed, FUT can result in a visible linear scar on the
occipital scalp. Harvesting individual hair follicles in FUE with blunt
dissection punch tools may induce follicular burial, leading to the
development of cysts. Other inherent risks include lasting paresthesia (longterm loss of sensation) and itching, as well as inflammation around the
transplanted hair. If the tension on the sutured strip wound is too great, the
linear scar can become infected, undergo necrosis, or widen in size,
although this is considerably rare. Another inherent side effect more
prevalent in women is telogen effluvium (temporary hair loss) resultant
from the shock of transplant [25].
Inexperienced providers may overharvest when using FUE, resulting in
larger areas of scarring or excessively thin hair at the donor sites. If the hair
is not inserted in the natural direction of growth at the recipient site, or if
too much is transplanted, the new hairline will appear too low or
unnaturally thick. The same result will occur if future hair loss is not
considered prior to planning [28, 29].
Maximal growth of transplanted FUs is supported by careful handling
of the follicles and maintenance of a hydrated environment (using normal
saline or Lactated Ringer’s solution) when outside the body. Minimizing the
time each follicle spends outside of the scalp is a key factor in growth
promotion and graft survival. One in 100 patients will experience poor
growth in the transplanted follicles, which could be self-limiting (variable
scalp blood flow or intrinsic hair growth rates) or a result of poor transplant
technique [30–32].
2.2 Hairline Lowering Surgery (Scalp Advancement)
Hairline lowering surgery is well utilized to improve the appearance of
pattern hair loss while simultaneously reducing deep wrinkles and forehead
size. Surgeons make an incision at the existing hairline and remove excess
forehead skin, allowing for forward advancement of the scalp. After the
tissues have been secured in place, the site of wound closure will become
the new “hairline.” Immediate aesthetic improvement and shorter
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