Health, Follicular Transportation (part 3)

Eliminate Contrast The next element in planning the follicular transplantation is the elimination of contrast. We have already gone to great lengths to illustrate how eliminating contrast on the “micro” level is important, i.e. eliminating the contrast between the individual graft and the surrounding skin. It is equally important to eliminate contrast on the “macro” level, i.e. between one part of the scalp and the other. One of the most striking features about the balding process is that practically all of the Norwood Class A patients look aesthetically worse than their regular Norwood counterparts. In fact, most Norwood Class A patients look worse than patients in the next higher Norwood Class, in spite of the fact that those patients have more hair. Thus, a Norwood Class 4A often looks worse than a Class 5, and a Norwood Class 5A often worse than a Class 6. Clinically, we find that the Class A patients are often the most distraught over their hair loss and benefit most from the hair transplant procedure. The reason for this is simple. In the Class A patient, there is the greatest contrast between the hair bearing area and the totally bald scalp. Curly or wavy hair increases the clinical appearance of density. In the regular Norwood classes, a curly or wavy haired patient will look less bald, because any slight coverage on top will be magnified by the character of the hair. In contradistinction, curly or wavy hair will make the Class A patient look more bald, because in this patient it will accentuate the contrast. The same reasoning helps to explain why an older patient looks better as a Class 6 than a younger patient. The younger patient has had patterned androgenetic effects causing hair loss in the bald area. His donor density is essentially unchanged. The older patient, however, has had hair loss due to both patterned androgenetic balding as well as loss due to the aging process itself, the latter affecting the “permanent zone”. In addition, the older patient has a higher degree of miniaturization in the donor area, which further reduces the contrast. Furthermore, the younger patient with higher donor density will look more bald than his Norwood counterpart with lower density. In patients of all ages where the bald area is too extensive to be covered by adjacent hair, the patient?s cosmetic appearance is generally enhanced by keeping the hair short, which is just another means of decreasing the contrast between the two areas. Fortunately, the higher the density of the permanent zone, the worse the bald areas look in comparison, but the more hair there is available to transplant. In a sense, hair transplants do not add hair, they decrease contrast by moving hair around. Angulation The single most useful clue to proper angulation is to observe the patient?s existing hair. Even in very bald areas, a few vestigial hairs will often indicate the original orientation of the terminal hair. When this information is not available, the safest direction to follow, aside from the crown, is generally forward. The majority of hair anterior to the crown points forward with the angle becoming more acute anteriorly. The direction of the frontal hairline is also forward, rather than radial, and only deviates significantly from this as one approaches the temples. Horizontal placement of the frontal hair is usually appropriate, regardless of the slope of the forehead. Follicular implantation provides almost unlimited freedom in choosing the angle at which the future hair will emerge from the scalp. This is because the mechanical forces facing the larger grafts placed at acute angles do not affect the follicular implant. The delicate swirl of the crown, the abrupt directional changes of the cowlick, and the sharp angulation of the temples, can all be re-created with follicular implants. The challenge is not merely creating these angles, but observing the myriad of patterns seen in nature so that this variety can be duplicated for our patients. Distribution In almost all cases of balding, there is a rationing of donor hair due to the necessity of covering an ever expanding recipient area with a much smaller, but finite, donor supply (Table 3). We try to evenly space the individual units in a random rather than grid-like pattern and always try to increase the density in the areas of cosmetic importance. In doing so, we remember the adage “To cover a baseball field with grass, use seed rather than sod….., and if you only have a limited amount, use it in the infield.” THE FUTURE We began this article by stating that “Follicular Transplantation is the logical end point of over 30 years of evolution in hair restoration surgery”. Although working at the follicular level may be an end point with regard to size, it by no means implies that our work is complete. We feel that four exiting new areas deserve mention. The first is the use of ultra-pulsed CO2 laser systems. The major advantage that lasers are purported to have over traditional slit and punch grafting is that they can create a slit while at the same time removing recipient tissue, like a punch. In follicular transplantation, the implant is already trimmed of excess tissue, therefore, this is of little value. In addition, the laser slit is far too large to grasp the tiny follicular implant. Most importantly, the laser seals the microscopic vasculature while removing tissue. It is the relative preservation of this critical recipient blood flow that makes follicular implantation such an appealing process and allows for the survival of extensive numbers of implants. As laser technology improves and the issues of spacing and thermal injury have been adequately addressed, the advantage of rapidly producing large numbers of uniform slits may make the laser a more valuable tool. The second is video-imaging. The video-imager9 is actually a sophisticated densitometer, and because of its very high resolution (up to 200X) and its photographic capabilities, it is a means by which implants can be assessed for physical damage, hair counts can be more accurate, and the question of graft survival and yield can be addressed in a scientific way. The third is cloning. Although still in its infancy, this technique gives rise to the possibility that the hair follicle may be cloned with minimal surrounding connective tissue to produce the ideal follicular implant. Besides having an unlimited donor supply, the surgeon could customize the size of the follicular unit to produce the perfect balance between density and naturalness in the various parts of the recipient scalp. Finally, the area of automation should have the greatest impact on hair restoration surgery in the near future. Follicular transplantation is a labor-intensive procedure making huge physical demands on the hair transplant surgeon and staff. Instrumentation currently being developed will streamline the entire process from the harvesting of the donor strip, to the insertion of the implants. With certainty, these future developments will increase the speed and lessen the manpower required in the hair transplant process. If they can also increase the quality of our results, we will have a better, more affordable treatment to offer our patients. GLOSSARY of TERMS Follicular Unit - the unit of tissue moved in the follicular transplantation process, consisting of a hair follicle, associated hair shafts and peri-folliculum. Follicular Implant - the follicular unit that has been placed in a recipient site created by a puncture wound just large enough to accommodate it. Follicular Transplantation - a method of hair restoration surgery by which follicular implants are harvested, prepared, and placed in accordance with long-term strategic planning of design to maximize the cosmetic benefit to the patient throughout his lifetime. Grafts - skin and hair moved in the hair transplantation process in which the transplanted tissue contains approximately the same ratio of follicles to skin present in the donor area. Mature Hairline - the adult hairline that has not yet shown the effects of genetic balding. At the midline of the forehead, it generally begins 2 cm above the uppermost brow wrinkle. Modified NoKor - a standard 18 gauge NoKor needle that has be modified so that the blade is 1 mm in diameter. Its specific use is for the creation of single hair recipient sites in patients with hair of average diameter and for one and two hair units in patients with fine hair. Miniaturization - the progressive diminution of hair shaft size often associated with the loss of pigment due to genetically determined effects of androgenic hormones on the hair follicle. Natural Hair Groupings - the number of hairs naturally growing together due to the anatomic fusion or association of individual hair shafts. These hairs may share anatomic structures and emerge from a single or adjacent follicular orifices. Original Hairline - the teenage or adolescent hairline which is generally flat, i.e., does not show bitemporal recession. REFERENCES 1. Headington JT: Transverse Microscopic Anatomy of the Human Scalp. Arch Dermatol 1984; 120:450. 2. Rassman WR, Pomerantz MA: The Art and Science of Minigrafting. International Journal of Aesthetic and Restorative Surgery 1993; 1:28-29. 3. Stough, DB: International Society of Hair Restoration Surgery, Third Annual Meeting 1995; Verbal Communication. 4. Haas AF, Grekin RC: Antibiotic Prophylaxis in Dermatologic Surgery. JAAD 1995; 32:155-164. 5. Salasche SJ, Bernstein G, Senkarik M. Surgical Anatomy of the Skin. Norwalk, Connecticut: Appleton and Lange, 1988 pp 176-177. 6. Rassman WR, Carson S: Micrografting in Extensive Quantities, The Ideal Hair Restoration Procedure. Dermatologic Surgery 1995; 21:306-311 7. Larson PO: Topical Hemostatic Agents for Dermatologic Surgery. J Dermatolgic Surg. Oncol. 14:6 1988. 8. Marritt E, Dzubow L: The Isolated Frontal Forelock. Dermatologic Surgery 1995;21523-538. 9. Transplant Videografting System of the Professional Hair Institute; displayed at the International Society of Hair Restoration Surgery, Third Annual Meeting 1995. 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.