Methods

Indications and Contraindications

To be a candidate for this procedure, a patient had to have a favorable ratio of donor hair supply (from the occipital and posterior temporal areas) with respect to the surface area requiring hair restoration. Ideally, he or she was a mature adult, 40 years or older, because at this age the patient’s hair-loss pattern is well established. However, we have also treated younger patients conservatively, as long as they understood that they would continue to lose hair and more than likely would require more additional transplantation procedures. Although the transplanted hair generally is quite durable, the primary or native hair of the patterned area of hair loss will tend to continue shedding.

During the initial consultations, candidates were told that 1 session would give them significant improvement but that a second session is often required to achieve optimal results with regard to hair density. Factors such as thickness (hair mass), color, and texture also affect the final result, especially with respect to the appearance of hair density (fullness).

Individuals with a very limited donor area and large areas of baldness were not candidates for this procedure.

Patients

Between March 1994 and March 2002, 453 consecutive patients, comprising 399 men and 54 women, underwent hair transplantation, performed in accordance with the technique described below. Patients ranged in age from 21 to 72 years (mean 42). Follow-up ranged from 6 months to 8 years.

Technique

The final aesthetic result depends on hairline shape and level, irregularity and some degree of asymmetry in contour, direction of hair growth, and absence of detectable scarring. Because patients have different head sizes and craniofacial proportions, no set formula exists with which to determine the ideal distance between the eyebrows and the anterior hairline. An aesthetic approach must take such differences into account in determining the appropriate hairline level, which ranges between 7 and 10 cm.

The patient was placed in the supine position, under intravenous sedation with midazolam and fentanyl, and occipital and supraorbital nerve blocks with 0.5% bupivacaine with epinephrine 1:200,000. A horizontal ellipse of scalp was harvested from the occipital area; this sometimes included part of the posterior temporal scalp (Fig. 2). The dimensions of the ellipse varied, depending on the number of grafts planned and the density of the donor site. When 2000 or more grafts were planned, the ellipse generally measured 23 to 26 x 2 cm in width at the midline, tapered to 1.5 cm as it approached about 3 to 5 cm laterally, and beyond that, tapered to 1 cm as it proceded laterally. Scalp tightness was greater laterally than at the midline, and it was important to keep this in mind during closure to avoid undue tension.