Pain perception of a new Ahmad-Humayun solution for local anesthesia in hair transplantation: One step ahead.

BACKGROUND: Local anesthetic is one of the major ways to obtain satisfactory anesthesia in majority of plastic surgical procedures. OBJECTIVES: To compare the effect on pain while injecting buffered vs nonbuffered local anesthetic. MATERIALS AND METHODS: The single-blind, split-scalp study was conducted in 25 patients undergoing first hair transplant surgery after informed consent and ethics committee approval using two solutions. Solution A was composed of normal saline (200 mL), 2% lidocaine (40 mL), 1 mL of epinephrine 1:1000, and triamcinolone acetate (40 mg). Solution B was composed of normal saline (200 mL), 2% lidocaine (40 mL), 1 mL of epinephrine 1:1000, triamcinolone acetate (40 mg), and 8.4% soda bicarbonate (5 mL). A 3-mL syringe with 30-G needle was used. On one side of the scalp, solution A was used and solution B on the other side. The pain response was recorded using Wong-Baker Faces Pain Scale corresponding to 0-10 scale. The data were analyzed statistically. No preoperative analgesic was used in any patient. The injections were administered by the 2nd author. RESULTS: A total of 25 patients were included in the study. The mean age of the patients was 33.4 years (range; 28 to 41 years). The average pain score was 4.96 (range, 3-7) with solution A whereas 3.28 (range, 2-6) using the solution B (P < .05). Eleven of the patients (44%) were smokers. The average pain score in smokers was 5.82 with solution A and 3.73 with solution B. The pain score in nonsmokers was 4.29 with solution A and 2.93 with solution B (P < .05).

The first comprehensive classification of hair transection: A step forward.

There has been an increase in the hair transplant surgeries especially FUE all over the world during last two decades. The more the number of grafts being harvested result in increase in transection. Unfortunately, there is no classification dealing with the hair transection. The authors have proposed the first comprehensive classification for document different levels of hair transections.

Vertical or horizontal scalp mobility: What to assess.

BACKGROUND: Scalp is comprised of five layers namely skin, connective tissue, aponeurosis, loose areolar tissue, and periosteum, each having distinct characteristics. The scalp mobility plays an important role in scalp wound closure. Thus, the estimation of scalp mobility is necessary to obtain a tension-free closure and fine scar in hair restoration surgery. AIMS: To know the difference of available number of FUs while using two different scalp mobility methods, that is, horizontal vs vertical methods. PATIENTS/METHODS: The study was conducted in a private hair restoration clinic in the patients undergoing surgery after taking informed consent from all the patients. Any patient with a previous scalp surgery was excluded. The horizontal mobility was calculated using Mayer's method, and the vertical mobility was calculated using Mohmand 7 Ahmad's method on the same areas. All the data were recorded and analyzed statistically using Mann-Whitney test. RESULTS: A total of 15 patients were included in the study. The average length of the strip was 24.7 cm (range; 20-29 cm) with hair density of 138.1 cm2 (range; 114-195.7 cm2 ). The average strip width was found to be 17.1 mm by using horizontal mobility scale and 19.6 mm by using vertical scalp mobility. The horizontal scale resulted in average strip area of 42.0 cm2 as compared to average area of 49.1 cm2 by using vertical scale. The average number of hair by horizontal scale was calculated to be 5792.8 hairs and 6762.5 hairs by using vertical mobility scale (P < .05). The average number of more hair to be available by using vertical scale was 969.7. CONCLUSION: The vertical scale resulted in more number of hair from the donor strip in the same patient.

Effect of hair restoration surgery on the scalp sensitivity.

BACKGROUND: Hair transplant procedure is a surgical procedure which affects the sensitivity of the scalp. OBJECTIVES: To compare scalp two-point discrimination (2PD) values in healthy controls and patients who had hair transplant surgery. PATIENTS/METHODS: The comparative study was conducted in 25 healthy individuals and 25 patient who underwent hair transplant surgery (either strip surgery or FUE). An area was marked o scalp about 10 cm from the nasion. A caliper with 15 g weight was used. Both the prongs were ensured to be placed perpendicular to the skin. The contact time was only 2.0 seconds. An interval of 10 seconds was given before increasing the 2PD distance. In each measurement, the distance was increased by 1 mm. All the data were recorded and analyzed statistically using ANOVA test. RESULTS: The mean age of the control group was 29.72 and 31.7 years in patients' group. The average 2PD score in controls was 12.76 and 17.80 mm in patients. The average 2PD score was found to be 17.7 in patients who had surgery less than 18 months ago as compared to the score of 17.6 in patients who had surgery more than 18 months ago (P > .05). The smokers had less sensitivity as compared to the nonsmokers (P < .05). CONCLUSION: The scalp sensitivity was found to be less than 39% in patients after hair transplant surgery.

Effect of surgeon's workload on rate of transection during follicular unit excision/extraction (FUE).

OBJECTIVES: To compare the transection rate at the start and at the end of the FUE procedure. MATERIALS AND METHODS: The study was conducted in a private setup in patients undergoing first session of FUE surgery over 2000 grafts. Six areas of 1 cm2 were marked, two in midline and two on either side. All the procedures were undertaken by the single surgeon to avoid any bias. At the start of the surgery, the extraction of hair was performed in areas A1, A2, and A3. All the excised hair and transected hair were counted. The surgery was then completed but the remaining three areas (B1, B2, and B3) were left intact. Later, FUE was done in these areas. The excised hair and transected hair were counted. All the data were analyzed statistically by paired t test. RESULTS: A total of 25 patients were included in the study. The mean age of the patients was 35.2 years. The transection rate was 5.3/cm2 in mid-zone, 4.4/cm2 on right side, and 5.7/cm2 on left side at the start and 27.7/cm2 in mid-zone, 25.6/cm2 on right side, and 24.2/cm2 on left side at the end. The transection rate increased from 5.03 to 6.0/cm2 for FUS <2500 but increased from 4.83 to 6.6/cm2 with FUs over 2500 and increased from 5.5 to 6.67/cm2 when FUs were over 3000. CONCLUSION: The surgeon's workload increases the hair transection during FUE.

Transection rate at different areas of scalp during follicular unit extraction/excision (FUE).

BACKGROUND: Although the follicular unit excision/extraction (FUE) is regarded an easy procedure to perform, however, there are various factors which affect the outcome. The hair transection is dependent of various factors and the donor site characteristics affect largely. OBJECTIVES: To know the difference in transection rate on various areas of scalp during FUE. MATERIALS AND METHODS: The study was conducted in 10 patients undergoing FUE after obtaining informed consent. In each patient, 1 row was marked with intervening 1 cm2 . The row contained five boxes of 1 cm2 . Harvesting of FUs was performed using 0.9 mm serrated punch. The procedures were performed with the patient in supine position with the surgeon sitting on head side. The harvested FUs were checked under microscope. Any transection was calculated. All the data was collected and analyzed statistically. RESULTS: The total number of FUs and hair were more in center zone as compared to the sides. Whereas, the transection rate was lowest in the mid-occipital zone as compared to the sides. Similarly, the FUs: hair ratio was more in the sides 1:1.85 as compared to 1:1.62 in central zone. The right and left sides also showed some variations. The transection was more on right side (17.7%) of the patient as compared to the left side (16.3%) CONCLUSION: The hair transection was more on sides than in the mid-occipital area.

A Survey among Plastic Surgeons Wearing a Mask in Operating Room.

BACKGROUND: Face mask is considered to be an integral part of a surgeon's dress in operating room. The following study was carried out among the plastic surgeons to know their views about the wearing the face masks in operating room (OR). METHODS: A questionnaire was developed and was sent to the 2 groups of plastic surgeons which included 8 questions. Group A consisted of 100 plastic surgeons from the subcontinent. Group B consisted of 100 plastic surgeons of USA and European origins. The questionnaires were sent by emails and the data was analyzed. The questionnaire was consisted of 8 questions. RESULTS: About 93% of the plastic surgeons in group A wore the mask and 86% in group B. About 96% of plastic surgeon in group A and 99% in group B used disposable masks and only 4% in group A and 1% in group B used re-usable/washable face masks. About 59% in group A and 63% in group B covered the nose. Botox and filler injections were the commonest procedures in which the surgeons opted to perform without face mask (74% in group A and 68% in group B), followed by liposuction (41% in group A and 34% in group B). The majority in both groups believed that face mask decreases the surgical site infection. CONCLUSION: Most of the plastic surgeons wore the face masks in the OR. Care must be taken to ensure that properly designed studies that determine if surgical masks prevent post-operative wound infection.

Analysis of the changes in scalp hair angles: In vivo and in vitro comparison before and after tumescence.

OBJECTIVES: To estimate the hair shaft exit angles and also to check the effect of tumescence on the hair angles. MATERIALS AND METHODS: Ten patients undergoing first session of strip hair restoration were included. The strip was marked at the level of external occipital protuberance and superior nuchal line. Three hairs were marked, one near upper end, one near lower end, and one in the middle. About 10 mL of 0.5% xylocaine with adrenaline was used with the needle in the subdermal level. The hair angles were measured. After the strip harvest, small slivers were prepared and photographed. The hair shaft exit angles of the three hairs were calculated using the computer software. The Kruskal-Wallis test and multiple comparisons (Bonferroni's correction) were used to analyze the data statistically. RESULTS: The mean age of the patients was 23.4 years. The average preinjection (in vivo) hair angle was 52.82° with 52.96° in upper hairs (43.2° -61.2° ), 51.77° in middle hairs (43.4° -61.3° ), and 53.72° in lower hairs (38.4° -61.3° ). The average postinjection (in vivo) hair angle was 65.34° with 65.05° in upper hairs (55.1° -86.4° ), 65.63° in the middle hairs (56.4° -71.2° ), and 65.35° in the lower hairs (51.3° -75.2° ). Similarly, the postexcision (in vitro) hair angles was 71.91° with 70.83° in upper hairs (range, 56.8° -95.7° ), 72.19o in middle hairs (64.3° -78.5° ), and 72.71° in the lower hairs (63.9° -81.4° ). CONCLUSION: The proper assessment of hair angles is very important and can be altered by the injection technique.

Occipital Hairline: A forgotten area.

Hair restoration surgery is one of the fascinating fields of modern day cosmetic surgery. A good hair transplant is characterized by a naturalness in terms of strategic distribution of hair. A very important point which is very rarely taken care is the "posterior or occipital" hairline. It is formed by the posterior 1 cm of hair which are placed on the vertex or crown and constitute the part which is normally hidden by the long hair. Many surgeons while creating the slits in the recipient area forget this equally important point. And make the slits in the lines. As the care is taken while creating the slits in the anterior hairline, the same enthusiasm is required throughout the procedure especially the posterior part of the recipient area. The slits in the posterior hairline should also be created in a wavy, irregularly irregular fashion. The posterior hairline forms an important part of a hair restoration surgery. It contributes remarkably toward the overall naturalness of the results. A carefully executed posterior hairline reduces the chances of detection by the general public.

The constant threat of terrorism: stress levels and coping strategies amongst university students of Karachi.

OBJECTIVES: To assess the levels of stress in the face of terrorism and the adopted coping strategies, amongst the student population of universities in Karachi. METHODS: A descriptive, cross sectional study was conducted on undergraduate students from four universities of Karachi. Self-administered questionnaires were filled out by 291 students. Pearson Chi-Square test was used to assess associations between stress levels and different variables at a level of significance of 0.05%. RESULTS: A total of 65.8% of the students had mild stress levels, 91.5% of university students were exposed to terrorism through television, while only 26.5% students reported personal exposure to terrorism. 67.4% students were forbidden by their parents to go out (p = 0.002). Most of those who had self exposure to an attack were the ones whose parents forbade them from going out (p = 0.00). Most commonly used coping strategy was increased faith in religion. Irritability was the most common stress symptom. CONCLUSION: A majority of students studying in universities of Karachi had mild stress levels due to the constant threat of terrorism whereas a minority had severe stress levels. Possible reasons for resilience and only mild stress levels could be the history of Karachi's internal conflicts and its prolonged duration of being exposed to terrorism. These students who are positive for stress need to be targeted for counseling either through the media or through their universities. More extensive research is needed in this area.