How to avoid the pitfalls of planning a hair transplant (Part 2)
Patient Assessment
Donors supply
By performing a hair transplant, the physician must balance the patient? s present and future needs for hair with availability this and future supply of donors. It is well known that it s? pattern baldness progresses over time. What is less appreciated is that the donor area may also change.
The patient? S donor supply depends on a number of factors, including the physical dimensions of the area permanent, the laxity of the scalp, the density of donors, the characteristics of hair, and especially, the degree of miniaturization in the field of donors – Since it is a window on the future stability of the supply of donors.
The size of the donor area is determined by both its width (height) and its length. When assessing the potential breadth of the donor area, doctors usually assess the lowest point that baldness is scope namely the upper part of the area permanently. However, it is also important to pay attention to the lower margin. It is common for hair clarify significantly to the neck as a person ages, producing a hair "growing." Since this can significantly reduce the width the donor area, no evidence that this process can occur must be taken into account in planning. Loss of points in time is another process that has a significant impact on the supply of donors. Not only does it shorten the potential length of the donor band, but it suggests baldness often very important.
laxity of the scalp is another variable that affects the amount of donor hair. hair tight severely limit the amount of hair Donors can be removed in the Gaza harvest. The constraint imposed by a tight scalp is not always obvious at first session, but could hit the hair restoration on the whole line, and therefore should be carefully evaluated in the initial patients. A very loose scalp can present its own problems, such as patients with very loose scalp often heal the scars of donors has increased. [18]
The average density of a Caucasian donor is about 225 hairs/cm2. This can easily be measured using a portable instrument, with a densitometer. (2) When the density of a Caucasian is less than 180, a hair transplant should be undertaken with great caution. In this author? The opinion, when the density of donors is below maximum 150/hair mm2, a person should generally not be transplanted, as there will not be enough donor hair to make the process interesting and cosmetically the risk of a scar visible donor is too large. (3) Exceptions would be an older person with very limited expectations and races where the normal density is lower (Ie, Asians and Africans).
characteristics of hair, especially hair shaft diameter, are as important as the absolute number hairs in determining the outcome of a procedure. The amount of transplanted hair is linked to both the number of hairs Mobile (determined by the size of the donor site, scalp laxity and donor density), multiplied by the hair shaft cross section. Since each hair a person with coarse hair can have more than 5 times the volume as a person with fine hair, the estimate (or measure actual) diameter the shaft of hair is important in determining the overall supply of donors.
The miniaturization, the gradual reduction of the diameter of the tree and length of hair (the result of the action of DHT on the hair follicle) produces a thinning on the front, top and crown of the scalp and is the brand of androgenetic alopecia. But the back and sides of the scalp can miniaturize as well and when a significant portion of a patient? donor area s is miniaturized hair in this area can be rendered unusable for a hair transplant. (Figures 1 and 2)
This condition, called the loss of Diffuse hair without reason (or DUPA) is the most common type of hair loss in women and it is not uncommon among men. It goes without saying that each patient man or woman, in whom a transplant is planned, should be assessed in the miniaturization of donors using densitometry to ensure the hair of donors to be transplanted is stable.
Beneficiary Request
Never assume that the person? S hair loss is permanent. Hair loss tends to progress over time. Even patients with good response to finasteride eventually lose more hair. It is always best to consider reasonable worst-case scenario when assessing how bald the patient can become, so that donor hair can be finished properly attributed. Although the classification of Norwood is very useful in realizing the loss of hair, it doesn? t take into account the actual dimensions of the scalp. Just as the donor site, the recipient area must be effectively measured. Even within a single class Norwood, there is a big difference between a patient with a narrow forehead and another with a head very large in relation to the actual area to be covered, and thus, the number of transplants required for restoration.
Designing the hairline
Hairline position
In adolescent the hairline is just above the upper brow crease formed by the upper edge of the frontal muscle just below. The position of the normal adult hairline men is about 1.5 cm above the fold on the midline). A common mistake is to place the newly transplanted hair roots at the place adolescents, rather than a single case of an adult. While the younger patient, first experience hair loss, can exert considerable pressure the doctor put the hair in the lower position, the physician must not yield to this demand.
Under normal circumstances, such as aging Patient density decreases and the natural hairline back a little. However, a trait is immutable transplanted. Therefore, when the transplant patient continuous thin or bald (which will be invariable) fixed low hairline front will start to find his place, because it is natural for a person with a decrease the overall volume of hair to have a little down hairline, rather than one who is still in the position of adolescents.
Hairline Beauty
A similar logic applies when choosing the shape of the hairline. Poised male from adolescence to adulthood, his broad, straight hair is moving towards a more tapered with a recession at the temples. A persistent low, broad hairline is appreciated by those who maintain also their density in adolescents. This situation is not present in those who suffer from androgenetic alopeica, therefore, a hairline transplanted apartment will not "age well" over time and are not natural for the patient? s decreases the overall density and more than the crown begins to thin.
If a person is older, has maintained a high density of donors, and has a low risk of extensive loss of hair, greater hairline is possible. However, this is not the case for the person who begins to bald at a young age, since it has a significant risk of baldness area and, more importantly, the extent of its future hair loss can not be known at the time of surgery surgery is planned.
Distribution graft
The nuances of the distribution of the graft and the multitude of problems resulting from the distribution grafts are evil beyond the scope of this writing, but there are two main themes related but that the hair transplant surgeon must be aware of deciding where to place the grafts. The first is to define a target area of coverage that takes into account the patient? The future pattern baldness, Thus, the total supply of donor hair. The second is to transmit the weight of the grafts, rather than distributing them evenly on top of leather scalp.
Extent of coverage
The problem of deciding how bald a hair transplant should cover can be illustrated as follows. For example, take a patient whose total number of follicles unit grafts available for harvest is around 5500. The front part of the scalp has area of approximately 50 cm2. The top or mid-scalp has an area of about 150 cm2 and the top or crown of about 175 cm2. However, the size of the crown Bald can vary considerably depending on the extent of hair loss, reaching more than 200cm2 in a patient Norwood Class VII.
If the front and top of the leather scalp were transplanted using all the hair donor patients transplanted density is only 5,500 or 27.5 grafts/200cm2 grafts/cm2 (less of 1 / 3 of the density of the patient? s hair original). If the crown were covered and it would be 5500 or 12.5 grafts/400cm2 grafts/cm2 (only 15% of the density patient? Hair S original). Using various manipulations, such as the creation of different densities in different parts of the scalp, a skilled surgeon may be 1 / 3 of the overall density appearance as a significant amount of hair. However, working with only 15% of the initial density, can make work of creating a natural look much more difficult or impossible.
The way to avoid having a hair transplant with a look that is too thin or see-through, is to limit the scope of coverage to the front and mid-scalp until supply sufficient donor and baldness Limited model can be reasonably assured – the confidence that can only come after the age of the patient. Until then, it is preferable to avoid adding the crown cover.
Another problem with transplantation of the crown is too early as the crown grows hair will be needed to follow the expansion of the area of baldness to the outside, just to keep the first hair transplant that looks natural. This may require considerable amounts of hair that will not be available to cover the front and mid-scalp if it was bald too well. On the other hand, if the hair transplant has been limited to the transition point vertex or VTP (see figure above) restoration would look natural, without further surgery, no matter how the loss of hair in the crown increased. The reason is that the front and top scalp represents a complete unit makeup, drifting as the natural border post – it is natural for the hair to cover this region of the scalp, but not beyond.
Density gradients
Another way for surgeons to prevent a thin, see look out, is to prevent the distribution of grafts uniformly transplantation region. It goes without saying that only 1 hair grafts should be used the root hair, with large grafts behind them, but there are other ways to produce gradations of density to mimic the way hair grows in nature. Specifically, the higher density should be in the front of the scalp (brown) and particularly in the field frontal nerve (shown in dark brown).
The greatest density on the front of the cheek area scalp can be created in two ways: by placing recipient sites closer to that place and using more follicular units in the area (ie 3 – and 4 units of hair – rather than 1s and 2s). Such techniques can be used in combination with greater density achieved but, as discussed in the next section, if it is done excess, can compromise growth.
Summary
Follicular Unit Transplantation is a powerful technique for hair restoration which allows the surgeon to create models of natural hair and produce results that mimic nature. The success of the procedure depends largely on the selection of patients to accurately assess the patient? S donor supply, and distribution of grafts in a manner that suits a person who will continue to age and eventually thin over time. With thoughtful planning, serious mistakes can be avoided and our patients to be able to get the full benefit of this remarkable procedure.
References
1. Orentreich N: Autografts in alopecia and other selected dermatological conditions. Annals of the Academy of Sciences New York 83:463-479, 1959.
2. Bernstein RM, Rassman WR, W Szaniawski, Halperin transplantation: follicular. Intl J Aesthetic Restorative Surgery 1995; 3: 119-32.
3. Bernstein RM, Rassman WR: Follicular Transplantation: patient assessment and surgical planning. Dermatol Surg 1997; 23: 771-84.
4. Bernstein RM, Rassman WR: The aesthetics of transplantation follicular. Dermatol Surg 1997; 23: 785-99.
5. analysis Gandelman M, et al: light and electron microscopy of follicular grafts controlled injury unit. Dermatol Surg 2000; 26 (1): 31.
6. Bernstein RM, Rassman WR, Rashid N, Shiell R: The art of repair in surgical hair restoration – Part I: basic repair strategies. Dermatol Surg 2002; 28 (9): 783-94.
7. Bernstein RM, Rassman WR, Rashid N, Shiell R: The art of repair to surgical hair restoration – Part II: The tactics of repair. Dermatol Surg 2002; 28 (10): 873-93.
8. RM Bernstein, follicular unit hair transplantation. In: Robinson JK, Hanke CW, Siegel DM, Sengelmann RD, editors: Surgery of the skin, Elsevier Mosby, London United Kingdom. 2005.
9. WP Unger, transplantation Hair R. Shapiro. New York: Marcel Dekker, Inc. 2004.
10. Bernstein RM, Rassman, WR. Follicular unit transplantation. In: Haber RS, Stough DB, editors Chief: Hair Transplantation, Chapter 12. Elsevier Saunders, 2006: 91-97.
11. Norwood OT. Male pattern baldness: classification and incidence. So. Med. J 1975; 68:1359-1365.
12. Haas AF, Grekin RC: antibiotic prophylaxis in dermatologic surgery. J Am Acad Dermatol 1995; 32: 155-76.
13. Otley CC. evaluation and perioperative management in dermatologic surgery. J Am Acad Dermatol 2006; 54: 119-27.
14. Gandelman M, R Bellio, Barretto M: Beta-blockers and anesthetics with local vasoconstrictors: A dangerous combination. Intl J Aesthetic Restorative Surgery 1995 3 (2): 143-45.
15. Bernstein RM, Rassman WR: Limitations of adrenaline in large hair transplant sessions. Hair Transplant Forum International 2000 10 (2): 39-42.
16. Skidmore RA, Patterson JD, Tomsick, RS: Local anesthetics. Dermatol Surg 1996; 22:511-522.
17. Phillips KA, Menard W: suicidal Body Dysmorphic Disorder: a prospective study. Am J Psychiatry 2006; 163:1280-82.
18. Bernstein RM, Rassman WR. The paradox of scalp laxity. Hair Transplant Forum International 2002, 12 (1): 9-10.
About the Author
Dr. Bernstein is Clinical Professor of Dermatology at the College of Physicians and Surgeons of Columbia University in New York. He is recognized world wide for pioneering Follicular Unit Hair Transplantation. Dr. Bernstein’s hair restoration center in Manhattan is devoted to the treatment of hair loss using his state-of-the-art hair transplant techniques.
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