Patient Selection

In brief, provided the general health is good, almost anyone is a candidate for micro- and minigrafts as long as there is good hair density in the donor area (occipital area).

If the affected (bald) area is not too large, and the donor area has good hair density as in most cases of male pattern baldness types II through V, and many VI, I will usually treat the entire bald area, and always with a conservative and mature hairline level, 6 to 9 cm cephalad to the upper border of the eyebrows.

If the affected (bald) area is disproportionately large relative to the donor area (type VII baldness), one may consider transplanting only the front part of the scalp or create an isolated frontal forelock, and leave the vertex and crown bare, the main objective in this case being to frame the face. Traditionally, we have been taught that individuals with dark straight hair and light skin are poor candidates for hair transplantation, the high color contrast making grafts very obvious. Cases of blonde, light brown, gray, and red hair tend to be more forgiving, and have been considered ideal candidates, as there is less color contrast. This applies primarily to conventional round plugs and large grafts.

Using exclusively micrografts at the front 1/4 to 1/3 of an inch of the hairline provides a natural appearance regardless of skin or hair color. Curly hair tends to provide better coverage, giving the optical illusion of more hair than is actually present. However, it is more difficult to dissect the micro- and minigrafts on these individuals, because the curling also is present intradermally, and more effort and time are required for my assistants to work through such cases.

Patients whose hair is only a little wavy are not a problem at all, and their hair is as easy to dissect as straight hair. Dissection of micro- and minigrafts is difficult in patients with light colored hair (blonde and especially white hair), as it is harder to see the hair shafts and bulbs, thus requiring more time, magnification, and excellent lighting. In this cases we have found background light very helpful, as cutting on an X-ray or transparency (slide) view box with a sterile translucent surface.

Women tend to have a more diffuse hair loss pattern, which makes them generally not such good candidates for hair restoration surgery, with any technique. In reconstructive cases such as trauma, oncologic resections, and burns alopecia, the use of scalp flaps and tissue expansion would usually be better choices.

Technique
Surgical Team

We have a four-person surgical team. Two of them specialize in carefully dissecting the grafts with 3.5 loupe magnification, and the other two (a surgical RN and myself) insert the grafts. So far, I have inserted every graft on all of my patients. Today we are able to cut and insert up to 600 grafts per hour, "up to" because as with any procedure the speed is a function of various factors. Generally our OR time to do 1000 grafts is about 31/2 hours; to do 1500 about 41/2 hours; and to do 2000 to 2500, about 6 to 7 hours. We estimate that at least 90% to 95% of each graft ends up growing healthy hair.

Sedation and Local Anesthesia

With the patient in the supine position, intravenous sedation is administered, with midazolam (Versed) and fentanyl citrate (Sublimaze). Prophylactically, we administer a gram of Ancef (cefazolin sodium) i.v. push, or if allergic, an alternative antibiotic is given such as Cipro (ciprofloxacin), 400 mg. For local anesthesia we use bupivacaine (Marcainc) 0.5% with epinephrine 1: 200,000 (approximately 40 cm3) to block the supraorbital, supratrochlear, and occipital nerves. Subsequently, tumescence is induced in both the donor and recipient areas with 0.5% Xylocaine (lidocaine) with 1:200,000 epinephrine (usually we use a total of about 150 cm3). (See Figs.1B, C.)


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