Alopecia: Methods of hair replacement

Alopecia has been haunting people for so long that its origins are lost in the fog of centuries. It is interesting to note that some primates, such as chimpanzees and individual monkeys, also suffer from age-related hair loss.

With the passage of time, a great number of imaginary cures for alopecia have accumulated: from camel feces to stump water and even less attractive substances. Records of such "medicines" were first discovered in ancient papyri, composed 5000 years ago. The Bible sympathized with those who had a bald head, but could not find a cure.

In our time, there are elegant and effective surgical methods of hair transplantation, and they, in fact, heal. These new techniques are based on the combination of small grafts of various sizes, attention to the smallest details of preparation and implantation of grafts, the definition of branches dictated by the quality of the hair, and adaptation of the procedure to each individual patient.

New techniques have truly revolutionized hair replacement surgery. Due to advances, the results in men with focal alopecia have reached an astonishing level of skill, effectiveness and recognition by patients. Today's methodology requires a high level of planning and execution.

Other forms of permanent alopecia are alopecia areata in women, scarring due to trauma or surgery, loss of hair due to irradiation, localized scleroderma and baldness associated with individual skin disorders of the scalp, are also well amenable to correction by the expanded arsenal of remedies available to surgeons dealing with replacement of hair.

Until recently, microtransplants were used only in the frontal region. However, the spread of the use of small grafts to areas outside the border of hair growth on the forehead significantly improved the quality of the results. Now there is a tendency to transplant hair in "follicular units", a term that defines hair in their natural groups consisting of one to four strands. When transplanting follicular units look quite natural.

The definition of follicular unit transplantation varies between surgeons. Limmer (personal communication) determined the transplantation of follicular units as follows:

• The transplantation of follicular units is, by definition, the redistribution of naturally existing groups of follicles (follicular units) of 1-4 hairs, rarely more, collected in the donor area by elliptical excision and careful microscopic dissection under a binocular microscope, and transplanted into needle tunnels or very small incisions in the bald recipient zone. Donor tissue is carefully cut into such follicular units with the removal of "proletchin". From the recipient zone, bald tissue is not removed to minimize the impairment of blood supply, which is necessary for engrafting the grafts. An unsaturated congestion (20-40 grafts per cm) during the first session is usually done to obtain a cosmetic result that is sufficient if there are no other transplant sessions.
• After the selection of donor strips by doctors, different methods of their separation are used. On the one hand, this is the use of a microscope to create transplants of follicular units consisting of 1-4 hairs, on the other - automatic cutting of donor tissue with the help of special devices.

In this article, we will describe in detail our technique for restoring the hair follicle with the implantation of follicular units. We call our approach the method of separate transplantation with the help of needle piercings. This widespread use of small grafts is a large, perhaps the most important, step forward in the last two decades to achieve a natural appearance after transplantation.

Another important achievement is the admission of small grafts without the initial removal of the tissue from the recipient zone. This technique, called transplanting in the slot, makes the maximum amount of hair in the transplant and the coverage achieved by any amount of donor hair.

The transplant procedure in the slot, although it can provide a complete recovery, but in fact it achieves its greatest potential when used to create a natural appearance with minimal access to donor hair. It also allows you to effectively transplant hair in patients with poor hair quality. Transplant transplantation in the slot is successful because it does not destroy the vasculature, as when grafts are transplanted into circular channels, it is extremely effective and rational in using donor hair. Some doctors combine transplantation into slits and round channels: this combination gives excellent results.

Although this is difficult to quantify, repeated observations show that the total number of hair growth and growth after transplantation in the slots is greater than after the traditional transplantation into round channels, possibly 2 times.

Even without a quantitative assessment, it seems clear that this difference in engraftment should be attributed to differences in the degree of damage to the subcutaneous vasculature. Any damage to the interconnected network of arteries, veins, lymph vessels and nerves found here is a physiological problem that tissues must overcome before the graft begins to feed. Violation associated with the removal of cylindrical fragments of tissue, increases this problem.

On the other hand, careful insertion of the graft into the slot minimizes trauma to the tissues and allows almost instantaneous feeding of the transplanted material. The transplant in the slot also minimizes scarring and the formation of "donuts." Transplanting grafts in the slits leaves existing natural hair viable, as it does not require the removal of tissue. One can argue that the problem with such a transplantation is the compression of surrounding tissues. However, the more natural appearance achieved with this technique outweighs any consideration that could lead to the use of a standard transplant of cylindrical grafts to create a line of hair growth on the forehead. The use of cylindrical grafts should be limited to the posterior regions (that is, those that are farther than a centimeter from the border of hair growth). In such places, especially with total alopecia, it can be very effective to insert small, for example quarter, transplants into small holes, from 1.5 to 1.75 mm, made in the skin. The transplant placement profile is the same for both methods. The number and size of transplants are also the same.

[1], [2], [3]

Patient selection

There are many factors and indicators that need to be taken into account when planning the restoration of the hair growth line and reconstructing the hair on the same scalp. The following list contains some of the most important considerations:

• Classification of alopecia.
• Classification of hair quality.
• The similarity of the color of hair and skin.
• Forecast of further loss of hair.
• Age of the patient.
• Motivation, expectations and desires of the patient.

Consultation

At the initial consultation, doctors decide who will be a good candidate for surgical hair restoration and who does not. In doing so, we evaluate five qualities: the age of the patient, the area of alopecia, the coincidence of the color of hair and skin, the tortuosity of the hair and the density of the donor zone. If the patient is an acceptable candidate, then the probable complications and advantages are discussed with him, as well as preoperative laboratory tests and medication preparation. Usually we are testing for hepatitis B, C and HIV. There is a general medical history, including information about current medicines and allergies to medicines.

[4]

Classification of alopecia

Now the classification of alopecia by the Norwood system is the most recognized. It describes the structure of male pattern baldness by seven stages and their typical variations. Stage I is the least severe, with a minimal deviation of the border of hair growth at the temples and without parietal alopecia. Stage VII is the heaviest, with a classic horseshoe-shaped aureole of extant hair. The system is similar to that developed by Hamilton, and gives similar results. A new look at alopecia suggests that these classifications can be used, mainly, as a means of identifying population groups for clinical trials, and not for determining a treatment approach.

[5], [6],

Classification of hair quality

The term quality of hair includes indicators of density, texture, crimp and color. For the division of hair quality, broad criteria were defined. Different degrees of expression of hair qualities can overlap, and each of the qualities can be divided into even smaller ones. Coarse hair and above average hair are designated "A" and are the most qualitative in terms of transplant, while thin and rare hair is designated "D" and has the worst donor quality. Two groups, "B" and "C", cover the intermediate characteristics. In general, people with hair color that is suitable for skin color, you can expect better results than those whose hair color contrasts with the skin. Curl of hair is also an advantage.

The resemblance of hair and skin color The most suitable for transplantation are blond hair, red, gray hair, and also a combination of "salt and pepper". Brunettes and shatens represent a particular problem, especially those with straight hair. Persons with straight black hair and light skin are the least suitable for transplantation. The final appearance after transplantation is largely dependent on the degree of similarity of hair and skin color. Coincidence minimizes visual contrast. The most favorable combination is dark skin combined with black, wavy hair. The most unfavorable combination of light, pale skin and dark, straight hair. In the latter case, the degree of visual contrast is enhanced by the visibility of any attempted transplantation. Between the two extreme manifestations there are many combinations, even in one person the color of hair in the region of the vertex and occiput may sometimes differ.

[7], [8], [9]

Forecast of further loss of hair

Since androgenic alopecia is genetically controlled and, therefore, is hereditary in nature, the prediction of further loss of hair can be roughly established by referring to a carefully collected family history. Information on close relatives should be collected during the initial survey and used to make a prediction, in combination with other factors such as age, present condition and pattern of alopecia. It is impossible to predict future hair loss with absolute accuracy, and patients need to be warned about this.

Age of the patient Androgenic alopecia is a constant process (that is, it usually goes to a significant part of a person's life). The age of the patient shows its place in the continuum of alopecia. Knowing whether the patient is at the beginning of the process or at the end of the process allows you to plan more accurately. The truth is that with the help of today's techniques virtually any patient can get a satisfactory improvement in appearance, but the truth is also that those who wish the impossible will be disappointed.

Taking into account the age of the patient also makes it possible to assess the corresponding position and contour of the hair line. Patients aged 20 years and under are usually not satisfied with the transplantation, as it is very difficult to predict what type and course the future alopecia will take. Exceptions occur when the patient understands that the prevalence of future loss of hair is unknown and therefore accurate prediction of its course is impossible and still leaves much to be desired.

[10]

Motivation

When discussing the patient's expectations, the surgeon should find out the degree of motivation of the patient and the idea of the expected improvement. The patient should be well informed, highly motivated and receive true information about the expected results of the proposed procedure. It is necessary to draw and discuss with the patient a hair growth line that complements the face structures and reflects the surgeon's chosen approach. It is important that each patient has a full understanding of the alleged cosmetic effect before the operation begins. Some believe that it is desirable not to fully imagine the potential benefits of transplantation.

Hairline placement

Determining the placement of the hairline, so that it creates a balance and compensates for the unevenness of the face, the surgeon should treat the face as a divided, imaginary horizontal plane into three segments of approximately the same vertical length. The anthropometric boundaries of these segments look like this: (1) from the chin to the columella; (2) from columella to nadperene; and (3) from the nadir up to the existing or supposed border of hair growth on the forehead. The position in which the upper boundary of the upper segment should be located serves as a general guideline for determining the appropriate height of the hairline placement.

However, this measurement should be used with caution, as this often leads to a too low placement of the hair line. In practice, the line of hair growth is usually located 7.5-9.5 cm above the middle of the nadtransfer. This is a common reference point, and it should not be taken for an absolutely rigid parameter.

The line of hair should be placed and designed so that it corresponds to the age, rather than perpetuating a young, unselfish appearance which, in many cases, becomes unnatural and even unattractive. It is often necessary to place the edge of the future line of hair slightly behind the rest of the original hair line. This conservative approach will optimize the use of donor hair and provide a more adequate coverage. A low, wide line of hair often leads to inadequate donor hair, giving uneven coverage of donor hair and a poor cosmetic effect.

The entire transplanted, reconstituted hair line should look natural, but not every hair line aesthetically corrects and improves the appearance. Since the contours of the line will be more or less constant, their general appearance should be acceptable for the patient throughout life. It is best to establish a natural, but age-appropriate line. A low hairline that is characteristic of youth can look quite natural at a certain age, but will eventually become unacceptable. The frontal-temporal angle, which is the area with which male-type hair loss begins, is most important when creating the final species.

Over the past 30 years, most transplantologists have created a strictly symmetrical hair line.

A common tendency among surgeons was to uniformly arrange transplants along the most forward part of the hair line. The result of such a symmetrical approach may look artificial. The hair lines, in their natural state, are not symmetrical, having sharp edges, like a well-trimmed lawn. They have an uneven appearance, with hair scattered up to 1 cm anterior to the perceived border of hair growth.

Hairdresser preferences, characteristic state of fashion at this particular moment, should not dictate the shape of the hair line being created, as they are transitory and will necessarily change. Sometimes it is possible to determine the year of the previous transplantation according to the configuration of the hair line. Widow Cape is now rarely done, and its presence probably means that transplantation was done in the 60s of the last century.

Transplant in the slot

Between 1989 and 1998, we made a transition zone from single grafts, which were placed intentionally in a not too uneven manner. These single hairs were used to create a transitional zone to transplants that are more densely located in the scalp. The results were cosmetically attractive, but still did not correspond to the degree of unevenness of the natural hair line. The observation of our patients led us to the conclusion that the hairline should be more uneven, so that its artificiality was least noticeable. Now we call this a zigzag pattern. The shape of the hair line is marked on the patient before the marking of the recipient zones. After creating a common contour, we use markers to apply a wavy or zigzag line. At the same time, the originally planned hairline is used for general positioning, and then it is transformed into a wavy, uneven shape. Recipient zones are located along this undulating line as on the true edge. The density of transplantation in this zone can vary. This uneven pattern is called "sawtooth", "snail trace" or "zigzag". Behind him, to create a greater density, follicular units of a larger size, up to four hairs, are transplanted.

Separate technique of needle punctures and placement of transplants

Fence of the donor strip

On the day of surgery, the patient is delivered to the operating room, where a series of pre-operative photographs is made, the donor area is marked, shaved and infiltrated by a local anesthetic. A scalpel with two blades is used to collect a portion of donor tissue of elliptical shape. Then the donor place is closed by brackets. Immediately after receiving the donor strip, it is transferred to a group of three or four technicians who share it under a stereomicroscope with a backlight. Separation is carried out by cutting the donor tissue into thin strips, into one follicular unit with a thickness, followed by the release of the follicular unit from each strip.

[11], [12], [13]

Establishment of a recipient zone

After taking the donor strip, the patient moves from the horizontal position to the sitting position. Anesthesia of the recipient zone is performed by blockade of the supraorbital and supra-lateral nerves. Then, immediately anterior to the recipient zone, we inject lidocaine with adrenaline, and then bupivacaine with adrenaline. Adrenaline at a concentration of 1: 100,000 is infiltrated intradermally into the entire recipient zone. After that, a needle with a caliber of 18 G makes perceptive cuts for follicular units of smaller size and a needle of caliber 19 G for transplants with one hair creating a frontal border of the hair. The needles are inserted at an angle of 30-40 ° to the skin surface, so that the transplanted grafts are slightly inclined forward to the patient's nose. This gives the patient more options for hair styling. After the creation of all the recipient zones, our technician introduces follicular unit transplants. This technique is called a separate technique of needle punctures and placement of grafts because the creation of recipient zones with needles is separated in time from the introduction of transplants. This is an important difference from the simultaneous creation of needles by the needles and transplant transplantation. Both methods have their supporters and opponents.

[14], [15], [16], [17]

Introduction of transplants

After the creation of the recipient zones, the technician with jewelery tweezers introduces one transplant simultaneously. Usually, to speed up the process, two technicians work simultaneously with one patient. Immediately after the operation, the donor and recipient areas are closed by Polysporin, Tefla and acrylic gauze. Strong squeezing bandage lasts until 24 hours. On the first day after the operation, it is allowed to wash the head with shampoo gently, with a warning not to remove any scales and films that have formed in the recipient zone. Within 5 days, patients take prednisolone. Return to work can be a day after the removal of the bandage (on the 2 nd day after the operation).

Discussion

The separate technique of needle punctures and the placement of grafts allows an average of 1000 transplants to be transplanted in less than 5 hours. With minimal bleeding and good quality of donor tissue, surgery can take significantly less time. The advantage of this technique is the complete control by the doctor behind the formation of the hair line, as well as the position and direction of each transplant. Using stereomicroscopic dissection limits the intersection of follicles, which can impair the quality of hair transplanted. In addition, after completing the marking of the recipient areas, the physician is released for other work. The disadvantage of this technique is the need to learn how to work with a stereomicroscope to separate the donor tissue and create transplants.

Although there are supporters of the technique of standard, large cylindrical grafts, we use it, since we consider the cosmetic effect of the completed procedure not appropriate to the natural one. The transplantation of follicular units creates a result that is closest to the natural state.

[18], [19], [20], [21], [22]

Excision of scalp

The task of this chapter is not a detailed description of the technique of operations for excising the scalp. However, a simple description of the most important features of the procedure can outline the perspective.

Reduction of the scalp skin is usually planned individually to match a specific area of alopecia. Various forms are used (for example, a straight line, a paramedial one, in the form of a three-beam star, as well as two- or three-phantom). In practical applications, the ellipsoidal, Y, T, and S-shaped forms and the shape of the crescent are predominant. Modifications and permutations of the listed forms are also applied.

A straight ellipse is the simplest type of reduction. Although technically this is the simplest configuration, if possible, it is better to replace it with a paramedial one. The latter is cosmetically less noticeable and has other advantages when creating a hairstyle.

The operation of excision of the scalp is performed under local anesthesia (ring blockade). The middle line and the expected external boundaries of the area planned for excision are marked. The first sections are drawn along the outer boundaries of the designated area. The Shaw scalpel (hot blade) helps to keep the operating field dry and shortens the operation time, since this tool has a double action - excising and coagulating.

The incision is made approximately 7-10 cm from each side of the incision. After its completion it is necessary to determine the size of the excised tissue. In general, this can be done by shifting the edges of the cut with one hand to the other and cutting off excess or overlapping fabric.

It is also necessary to take into account the degree of tension arising in the seam of the aponeurotic helmet. An aggressive approach to reduction implies the excision of a relatively large volume of the scalp, which will increase the tension in the seam. The conservative approach dictates a smaller volume of tissue excision, minimizing stress in the seam. Both approaches have advantages and disadvantages.

To stretch dense hairy areas, tissue expanders can be used during the operation. When trying to reduce in patients with thin, tight skin on the head, we recommend caution, since they are suitable for this less than people who have thick, supple skin.

After completion of excision of the head tissue, the aponeurotic helmet is first sutured, usually with PDS 2/0 threads. After the aponeurosis is sewn, the skin is stapled.

The configuration of the areas removed during excision of the scalp is often modified in order not to leave a cosmetically obvious scar. You can flex or adapt different segments of the specimen to be cut so that it is easier to hide the scar. In the back of the surface being cut, Z-plastics should be used to hide this sensitive area even further.

After excision, for a full recovery and closure of the scar, hair transplantation is almost always performed.

[23], [24], [25], [26], [27]

Dark Hair Loss

For correction of parietal baldness, excision of the skin is preferable to transplantation. And in this case, patients with a thick, elastic scalp are better suited for surgery than patients with a thin, tight scalp. Later, small transplants are transplanted into the scar area, for masking. The use of transplants greater than 2 mm in the region of the crown can lead to the formation of bundles. In this area, only quarter transplants can be inserted. Also, one should not try to place grafts too closely together along the edge of the rumen, as this can lead to the zipper effect and, as a result, disrupt the natural appearance.

The exclusion from the rule of the preferred treatment for parietal hair loss by excision of the skin is done for patients with extremely thin or extremely tight scalp, as well as for those who are afraid of the reduction surgery, believing that it will be too painful. However, most patients are surprised to note that this operation is comparable to the transplantation session, and a significant percentage of patients prefer the operation of cutting the scalp to a transplant session.

In most cases, more than one excision procedure is required. Limiting factors are the thickness and elasticity of the scalp. All patients need to be told that the scar should be closed by a subsequent hair transplant.

[28], [29], [30], [31]

Medicamentous support of operations for excising scalp

Before the operation:

• Valium, orally, 20 mg per hour before surgery.
• Nitrous oxide during the administration of a local anesthetic.
• Lidocaine 0.5% (total 20 ml) for ring blockade, then - bupivacaine (Markain) 0.25% (total 20 ml) for ring blockade.

After operation:

• Repeated ring blockade with bupivacaine 4 hours after the operation.
• Perkoket 1 g 4-6 h as an analgesic.
• Prednisone 40 mg daily for 5 days.

Female alopecia

Although attention to male pattern baldness continues to prevail in the non-professional press and medical literature, dermatologists often encounter female alopecia. Most often it manifests itself in the form of a diffuse vertical frontal dilution of the hair. In women with a family history of alopecia, either diffuse rarefaction or loss of hair can be developed in the male type. In this genetically predisposed group, different degrees of alopecia can be observed even when the androgen level is normal.

Recently it has become possible to treat women with diffuse alopecia if they have a sufficient density of hair in the occipital region. The use of small grafts in female pattern baldness has become a convenient and effective method of increasing the density of the hair cover in women, especially in the parietal and frontal parietal areas. Between the existing hair is introduced a certain number of quarter-transplants, and the final result looks like an increase in the density of the cover. The technique of transplantation in the slot, not injuring the tissue of the receiving bed, maximally protects the existing hair.

In women with male pattern baldness, the problems and approaches to treatment and transplantation are the same or similar to those in men with baldness.

[32], [33], [34], [35]

Bad results

What many incompetent people consider a bad result is often incomplete transplantation or caused by improper care. Statistics based on 25 years of experience show that 85% of patients after hair transplant were happy and would like to repeat the procedure. Out of 15% of those who did not want to continue treatment and were completely unhappy, approximately 90% did not complete the treatment as prescribed. Thus, the overwhelming majority of dissatisfied patients are those who did not want to make the necessary efforts. With the introduction of new techniques, the number of satisfied patients increases and the scope of the corrected disorders expands.

In the field of hair transplantation there was a revolution. Older approaches that used large round grafts without attention to hair quality are now archaic. As a result of technological advances, it is now possible to treat a wider range of forms of baldness of different etiologies. The application of today's techniques and attention to detail make it possible to approximate hair restoration to the goal of perfect transplantation: a natural hair line and a general appearance that has barely noticeable signs of surgical intervention.

[36], [37],

Complications of procedures of transplantation

[38], [39]

Fainting

Fainting can occur after the administration of several milliliters of anesthetic. It can also occur at later stages of the procedure. Anesthesia in the horizontal position usually prevents the onset of this condition.

[40]

Bleeding

The occipital region is the most frequent zone of arterial bleeding. This bleeding is best stopped with stitching. Adequate haemostasis often requires crushing. To do this, elastic bandages are applied that are superimposed on the donor zone and create a constant moderate pressure for 15-20 minutes after the collection of grafts and closure of the wound. After the end of the session, the squeezing bandage is put in place and holds for the next 8-12 hours. If the bleeding develops after the patient leaves the doctor's office, the patient is recommended to apply constant pressure first with his hand, and then with a clean bandage or a neck scarf. If bleeding does not stop, ligation is indicated. If bleeding occurs in the recipient areas where implants are introduced, removal of the transplanted tissue and suture of the source of bleeding may be required. After healing, there is usually a small scar, which later can be excised and, if necessary, replaced with a small graft.

[41]

Edema

Postoperative edema of the scalp and forehead skin often occurs, especially if the transplantation was extensive. Edema can be reduced by oral administration of prednisolone. Edema usually goes through the healing process.

[42], [43], [44]

Infection

Infection develops in less than 1% of cases, but, nevertheless, it should be guarded and treated.

Scarring

Scarring after transplantation of small grafts with hair rarely reaches such sizes to serve as a reason for serious consideration. Negroid people can sometimes form keloids. If the patient's anamnesis indicates the possibility of developing a keloid, after the first session, you need to take a break for 3 months. This will give enough time for keloid formation, and it will be possible to decide whether to continue treatment.

Poor hair growth

Ischemia, poor hair survival or even the loss of grafts can be the result of too tight fitting. In some patients with thin hair, the growth of transplanted grafts can be minimal, regardless of the transplantation method used.

Different

Patients with a limited number of transplants and rarefied normal hair may, to their chagrin, experience a temporary loss of hair, but such patients should be informed that the hair will necessarily grow. In the occipital region, arteriovenous fistulas can sometimes be formed, which are easily isolated and ligated.

[45]

Care

Satisfaction of the need for aesthetic hair transplantation is not limited to the design of the frontal border of the hair and other areas, but extends to providing the patient with proper care tips. As soon as patients entrust themselves to a hair transplant specialist, it is necessary to pay attention to the current needs for laying and care. The correct advice and advice on care is needed to maximize the effectiveness of transplantation and patient satisfaction.

In the market there are many reliable care products that enrich the structure and give a visible thickening of the hair. To achieve the full effect, you need a hairdresser. Patients with thin, straight hair should be treated permanently. Although many men are reluctant to attend a stylist, this reluctance is inappropriate and must be overcome. A doctor may need a recommendation or even an insist on curling hair, especially in patients with grade C or D.

Some patients can additionally benefit from the veiling of the scalp with Couvre coating or the use of camouflaging scalp cream. These products refract light in areas with rare hair and make them less noticeable. For each person should set the appropriate length of hair. To do this, it is advisable to use the help of an expert stylist.

Advice and direction of the patient to specialists in this field are the responsibility of the surgeon involved in hair reconstruction, since the final appearance of the patient is a critical factor in the overall success of the treatment.