Follicular Unit Excision Donor Area Management and Considerations of the Scalp.

Over the last several years, follicular unit excision (FUE) donor harvesting has become the predominant donor harvest method, surpassing the traditional method of linear strip excision donor harvesting. While this may offer advantages in specific clinical settings, the reality of ongoing losses with the natural evolution of male patterned hair loss places a premium on obtaining as much lifetime donor hair as possible to address this clinical reality. This lifetime demand requirement must be weighed against the possibility of a detrimental cosmetic appearance of the donor area with serial donor harvests utilizing FUE. This chapter will examine the important technical and artistic considerations critical for hair restoration surgeons to appreciate in order to maintain cosmetically high-quality donor area outcomes in patients choosing to undergo FUE harvesting for hair transplantation surgery.

Combining Follicular Unit Extraction and Scalp Micropigmentation for the Cosmetic Treatment of Alopecias.

Two relatively new modalities, follicular unit extraction (FUE) and scalp micropigmentation have changed the treatment of hair loss, to reduce the number of procedures and the total costs of the hair restoration process. These 2 modalities augment each other when treating patients with thinning hair and balding. The explosion of FUE procedures (which reflected 52.6% of the hair transplant procedures performed in 2016, up from 48.5%) and the appearance of more and more new physicians offering hair restoration technologies employing FUE have caused a 20% annual growth in this industry over the past few years. This article reviews the use of FUE and scalp micropigmentation when used in combination.

Scalp micropigmentation: a concealer for hair and scalp deformities.

BACKGROUND: Cosmetic deformities, resulting from some dermatologic diseases or deformities caused by hair restoration surgeries, have had few, if any, good, permanent solutions. Most of these patients have learned to live with their problems. OBJECTIVE: A cosmetic tattoo technique has been developed to address unsightly scalp and hair conditions. MATERIALS AND METHODS: The technique called scalp micropigmentation uses specialized techniques and conventional cosmetic tattoo instruments and pigments in a stippling pattern on the scalp. RESULTS: A variety of alopecias, refractory to treatment and hair transplant deformities, impact millions of men and women. Many of these deformities can be concealed with scalp micropigmentation, making the deformities minimally detectable. Included are the results of treatment. Patient satisfaction is very high. CONCLUSION: Scalp micropigmentation offers a good nonsurgical alternative treatment for hair and scalp deformities. This paper demonstrates scalp micropigmentation results and discusses the histology, physiology, and pathology of tattoo pigments in the skin. The regulation of the tattoo process by the United States Food and Drug Administration and state governments is summarized. Unlike medical devices, scalp micropigmentation offers a tattoo-based, non-medical "cover-up" that effectively hides unsightly conditions on the scalp and creates the illusion of thicker hair. The authors believe that scalp micropigmentation is destined to become a standardized offering for physicians specializing in cosmetic office procedures.

Phenotype of normal hairline maturation.

Hairlines change shape with age, starting at birth. A good head of hair is frequently present some time after ages 3 to 5 years. The look of childhood has its corresponding hairline, and, as the child grows and develops into adulthood, facial morphology migrate changes from a childlike look to a more mature look. This article discusses the dynamics of hairline evolution and the phenotypic variations of the front and side hairlines in men and women. A modeling system is introduced that provides a common language to define the various anatomic points of the full range of hairlines.

Scalp micropigmentation: a useful treatment for hair loss.

Scalp micropigmentation (SMP) is a highly sophisticated medical tattoo process for balding or thinning hair. SMP looks amazingly simple, but this novel technique must be customized for each patient because the skin in each patient differs with regard to how the scalp reacts as it holds on to the tattoo dye. There are many variables involved with performing SMP that makes this process more of an art form than a science. SMP is a very labor-intensive process that could require multiple sessions and up to 20 hours of procedural time to satisfy the patient. This review discusses applications and technical considerations of the SMP process.

Graft anchoring in hair transplantation.

BACKGROUND: Since it is not known precisely how long it will take for grafts to be securely anchored after hair transplantation, the advice that the medical profession has offered patients regarding postoperative care has been somewhat arbitrary. OBJECTIVE: This study attempted to provide scientific data that can be useful in refining postoperative hair transplantation protocols. METHODS: Forty-two patients participated in the study. During their postoperative period, each had several grafts pulled to determine at what point they could no longer be manually dislodged. RESULTS: For the first 2 days, pulling on a hair always resulted in a lost graft. By the sixth day, pulling on a hair no longer dislodged the graft. Pulling on an adherent scab always resulted in a lost graft through day 5. At 9 days postoperatively, grafts were no longer at risk of being dislodged. CONCLUSION: The presence of crusting extends the interval that grafts are at risk of being dislodged postoperatively. If one can prevent crust formation following hair transplantation, this would both shorten the time patients are at risk of losing their grafts and enable them to return to their normal hair care routines more quickly.

Follicular unit transplantation: 2005.

The recognition that the follicular unit is a discrete, anatomic and physiologic entity, and that preserving it through stereomicroscopic dissection is the best way to ensure the naturalness of the restoration, has brought hair transplantation into the twenty-first century. Issues yet to be resolved include determining the maximum density and number of grafts that can be used safely in a single session, deciding whether it is preferable to premake recipient sites or immediately place grafts into sites as they are made, and defining the precise role of follicular unit extraction. The essence of providing the best care for patients rests on proper patient selection, establishing realistic expectations, and using nonsurgical management for young persons who are just starting to thin.

The art of repair in surgical hair restoration--part II: the tactics of repair.

BACKGROUND: As patient awareness of new hair transplantation techniques grows, the repair of improperly planned or poorly executed procedures becomes an increasingly important part of surgical hair restoration. OBJECTIVE: Part II of this series is written to serve as a practical guide for surgeons who perform repairs in their daily practices. It focuses on specific repair techniques. METHODS: The repairs are performed by excision with reimplantation and/or by camouflage. Follicular unit transplantation is used for the restorative aspects of the procedure. RESULTS: Using punch or linear excision techniques allows the surgeon to relocate poorly planted grafts to areas that are more appropriate. The key elements of camouflage include creating a deep zone of follicular units, angling grafts in their natural direction, and using forward and side weighting of grafts to increase the appearance of fullness. In special situations, removal of grafts without reimplantation can be accomplished using lasers or electrolysis. CONCLUSION: Meticulous surgical techniques and optimal utilization of a limited hair supply will enable the surgeon to achieve the best possible cosmetic results for patients requiring repairs.

The art of repair in surgical hair restoration part I: basic repair strategies.

BACKGROUND: An increasingly important part of many hair restoration practices is the correction of hair transplants that were performed using older, outdated methods, or the correction of hair transplants that have left disfiguring results. The skill and judgment involved in these repair procedures often exceed those needed to operate on patients who have had no prior surgery. The use of small grafts alone does not protect the patient from poor work. Errors in surgical and aesthetic judgment, performing procedures on noncandidate patients, and the failure to communicate successfully with patients about realistic expectations remain major problems. OBJECTIVE: This two-part series presents new insights into repair strategies and expands upon several techniques previously described in the hair restoration literature. The focus is on creative aesthetic solutions to solve the supply/demand limitations inherent in most repairs. This article is written to serve as a guide for surgeons who perform repairs in their daily practices. METHODS: The repairs are performed by excision with reimplantation and/or by camouflage. Follicular unit transplantation is used for the restorative aspects of the procedure. RESULTS: Using punch or linear excision techniques allows the surgeon to relocate poorly planted grafts to areas that are more appropriate. In special situations, removal of grafts without reimplantation can be accomplished using lasers or electrolysis. The key elements of camouflage include creating a deep zone of follicular units, angling grafts in their natural direction, and using forward and side weighting of grafts to increase the appearance of fullness. The available donor supply is limited by hair density, scalp laxity, and scar placement. CONCLUSION: Presented with significant cosmetic problems and severely limited donor reserves, the surgeon performing restorative hair transplantation work faces distinct challenges. Meticulous surgical techniques and optimal utilization of a limited hair supply will enable the surgeon to achieve the best possible cosmetic results for patients requiring repairs.

Follicular unit extraction: minimally invasive surgery for hair transplantation.

BACKGROUND: Follicular Unit Transplantation (FUT) is performed using large numbers of naturally occuring individual follicular units obtained by single-strip harvesting and stereo-microscopic dissection. Donor wound scarring from strip excision, although an infrequent complication, still concerns enough patients that an alternative solution is warranted. OBJECTIVE: The purpose of this paper is to introduce Follicular Unit Extraction (The FOX Procedure), in which individual follicular units are removed directly from the donor region through very small punch excisions, and to describe a test (The FOX Test) that determines which patients are candidates for this procedure. This paper explores the nuances, limitations, and practical aspects of Follicular Unit Extraction (FUE). METHODS: FUE was performed using 1-mm punches to separate follicular units from the surrounding tissue down to the level of the mid dermis. This was followed by extraction of the follicular units with forceps. The FOX test was developed to determine which patients would be good candidates for the procedure. The test was performed on 200 patients. Representative patients who were FOX-positive and FOX-negative were studied histologically. RESULTS: The FOX Test can determine which patients are suitable candidates for FUE. Approximately 25% of the patients biopsied were ideal candidates for FUE and 35% of the patients biopsied were good candidates for extraction. CONCLUSION: FUE is a minimally invasive approach to hair transplantation that obviates the need for a linear donor incision. This technique can serve as an important alternative to traditional hair transplantation in certain patients.