Face Lift and Hair Transplantation as a Single Procedure

Frequently, when a face lift procedure is performed, several pieces of healthy scalp are discarded as waste unless a pre-hairline incision is used.

In selected cases, such as patients with hair loss, these pieces of scalp may be used to create micrografts (grafts with I to 2 hairs) and minigrafts (grafts with 3 to 4 hairs) and transplanted to the areas of need in the same session.

Over the past several years, as I have become more familiar and efficient with the use of micrografts and minigrafts, I have been combining hair transplantation with various other aesthetic procedures, such as rhinoplasty, blepharoplasty, otoplasty, CO, laser resurfacing, and face lifts.

I have found this to be very rewarding, particularly the combination of face lift and hair transplantation, because patients who need both procedures benefit immensely by having them done together. This way, the pieces of healthy scalp that normally would have gone to waste are recycled, making micrografts and minigrafts and then transplanting them immediately to the areas of need. These patients would have otherwise ended up with a somewhat depleted, more limited, or insufficient donor scalp to undergo hair transplantation at a later date.

Orentreich described “the donor dominance” concept, which is key for successful hair transplantation. He states basically that each hair follicle contains its own unique genetic makeup. When transplanted to another site, its original genetic properties are preserved regardless of the transplantation site (enabling the hair to grow at the recipient area for as long as it was going to do so at the site of origin). This is a most encouraging finding.

The occipital area is the most desirable donor site for hair transplantation (as it usually is genetically programmed to grow hair for a lifetime); it is also precisely the main area of scalp to be discarded during a face lift. When appropriate and if feasible, we must recycle it.

Scalp from the temporal areas can also be used, because it, too, is genetically favorable for transplantation.

Technique

I prefer to do this procedure under general anesthesia in the hospital or at an outpatient surgery center.

I do a subcutaneous face lift using a retrotragal, horizontal below the sideburn and sometimes a short temporal pre-hairline incision; in the retroauricular area, the incision extends posteriorly into the occipital area. In addition, an open submental lipectomy is performed when needed. The combined procedure of upward plication of the platysma laterally and midline plication of the platysma in the submental area usually takes me about 3.5 to 4 hours.

Having done several hundred cases of hair transplantation by using the micrograft and minigraft megasession technique previously described, (2-5) and having also done quite a few face lifts, I can safely determine how much occipital scalp I would excise during a face lift. Also, I know how much scalp I need or can harvest from the occipital area for a hair transplantation and still be able to close the donor site without undue tension.

With this in mind, I start the combined procedures by having the patient in the supine position and the head turned to the left. I first harvest a triangular piece of retroauricular and occipital scalp from one side and hand it to an experienced assistant who, under a 3.5X loupe using Personna Prep blades or no. 22 BardParker blades on a hard wood board, dissects it into micrografts and minigrafts as I do the face lift procedure. When I go to the second side of the face lift, I give the assistant another strip of occipital donor scalp; as the grafts are being dissected, I continue with the face lift.

When I am done with the face lift, which may or may not include an upper and lower blepharoplasty, my assistants have the micrografts and minigrafts lined up and ready for insertion Usually, we generate about 1000 micrografts and minigrafts from those strips that normally would have been discarded. If more grafts are desired, or if I need a larger piece of scalp to produce the required number of grafts, I would in a preliminary fashion harvest the donor strip of the appropriate size.

Once the grafts are lined up and ready for insertion, we are able to transplant about 1000 grafts per hour. So, combining the two procedures adds only about I hour to the surgical and anesthesia time.

The grafts are inserted into slits created with either a 65 Beaver miniblade or a Feather 11 Personna blade without the need for dilators.

Examples

A 53-year-old man underwent a face lift, upper and lower blepharoplasty, and hair transplantation consisting of a 1300 micrograft and minigraft megasession as a single procedure. This was done by using the triangular pieces of scalp from the retroauricular occipital areas that would have gone to waste otherwise. The length of the surgical procedure was 6.5 hours and was done under general anesthesia in the hospital with an overnight stay. He is shown in Figure 4 before and at 8 months postoperative; he has also dyed his hair. Further hair growth is expected.

A 48-year-old woman had great concerns about her hair thinning on the front part of her scalp. She underwent a face lift, upper and lower blepharoplasty, and hair transplantation consisting of 900 micrografts and minigrafts as a single procedure, also by recycling the triangular pieces of scalp from the retroauricular occipital area. The length of the surgical procedure was 6 hours and was done under intravenous sedation and local anesthesia in my office surgical suite. She is shown pre-operatively and I year postoperatively.

A 56-year-old man underwent a face lift and hair transplantation consisting of a 1300 micrograft and minigraft megasession as a single procedure. He had low hair density in the donor site, so I used a horizontal ellipse as seen in Figure 2, so that a larger number of grafts could be made for him. The length of the surgical procedure was 6 hours, it was done under general anesthesia in the hospital, and the patient went home the same day. He is shown before and only 7 months after the procedure; further hair growth is expected (Fig. 6).

Results

At the time of this publication, I had performed 12 such procedures with a follow-up of 6 to 18 months. All patients had hair loss and were quite pleased that we had recycled hair that would have otherwise gone to waste; furthermore, all were satisfied with the results of the combined procedures.

Discussion

To be able to do these two procedures in a single setting, one most be efficient and have a well-coordinated surgical team.

As with any other surgical procedure, the more we do the same procedure, the more we can avoid unnecessary motions; this allows us to save time without compromising the quality of our work and enables us to safely accomplish more in a single procedure.

For certain procedures, a surgical team approach is a must. Such is the case in hair transplantation, particularly when using the micrograft and minigraft megasession technique. I normally have three surgical assistants when doing such a procedure.

When combining face lift and upper and lower eyelids with hair transplantation, or face lift alone and hair transplantation, I normally have a scrub nurse assisting me with the face-lift and eyelids and an experienced surgical assistant cutting grafts. There is plenty of time to cut the grafts, because they are inserted after the face-lift and eyelid procedures are completed.

The assistant who is cutting the grafts then lines them up in rows in preparation for insertion. Usually it takes me about 4 to 5 hours to be done with the face lift and eyelids, which is how long it takes my assistant to have 1000 to 1500 grafts ready for insertion.

It may be necessary to have two or more assistants cutting grafts (depending on their experience, proficiency, and speed, which clearly varies).

Once we are done with the facial work and prepare the grafts, we (the surgical team) take a 5- to 10-minute lunch break. After which, feeling much better, an assistant and I return to the operating room, where in I to 1.5 hours we usually transplant all of those grafts.

The only area that is difficult to graft under these circumstances is the crown, as the patient is supine. If the crown needs grafting, I usually do that at a later date, when I can have the patient in a sitting upright position (in the office with the patient awake).

I have done these combined procedures (face lift and hair transplantation) under intravenous sedation and local anesthesia in my office surgical suite, with the patient going home the same day. This, however, makes for too long a day for the patient, necessitating a more prolonged period of sedation than when the procedures are done alone.

For patient comfort and my convenience, as mentioned earlier, I prefer to do these cases under general anesthesia, usually with an overnight stay in the hospital.

When I am doing the hair transplantation as a separate procedure (without the face lift), we usually do 1500 to 2500 micrografts and minigrafts. It is easy on the patient to be sedated for the initial part of the procedure with Versed (midazolam) and sublimaze while nerve blocks are done (occipital and supraorbital) with Marcaine (bupivacaine). The patient is then allowed to be fully awake as he or she is totally pain free (because of the nerve blocks). More than half of the procedure is done in about 3 hours. Often, we all take a break during which the patient has a chance to eat, stretch, and go to the restroom. We have not had any patient become nauseous or vomit, and most of them take a good lunch.

In contrast, patients undergoing the face lift and hair transplantation combined as a single procedure usually do not have the luxury of this nice break. This makes them very tired and sometimes anxious. For that reason, I prefer that these patients be under general anesthesia.

In patients concerned about their aging face and hair loss, provided that they are good candidates for both procedures, I have found that combining face lift and hair transplantation as a single procedure can be done safely and provides a very high level of patient satisfaction.

Summary

Frequently, when a face lift procedure is performed, several pieces of healthy scalp are discarded as waste unless a pre-hairline incision is used.

In selected cases, such as patients with hair loss, these pieces of scalp may be used to create micrografts (grafts with I to 2 hairs) and minigrafts (grafts with 3 to 4 hairs) and transplanted to the areas of need in the same session.

I have found particularly rewarding the combination of face lift and hair transplantation, because patients who need both procedures benefit immensely by doing them together. This way, the pieces of healthy scalp that normally would have gone to waste are recycled.

In a preliminary fashion, a strip of retroauricular and occipital scalp that normally would be discarded is harvested from one side and handed to my assistants. Under magnification, they dissect it into micrografts and minigrafts as I do the face lift on that side. When I go to the second side of the face lift, I give them the other strip of scalp; again, as they dissect it into grafts, I continue with the face lift.

Usually, we generate about 1000 micrografts and minigrafts from those strips that would have normally been discarded. If I want more grafts, I would (in a preliminary fashion) harvest the donor strip of the size required.

As the face lift with or without eyelids is completed, we usually have the grafts ready for insertion. Today, we are able to transplant approximately 1000 grafts in about I hour. Therefore, combining the two procedures adds only about an hour to our surgical and anesthesia time.

References

1. Orentreich, N. Autografts; in alopecias and other selected dermatological conditions. Ann. N. Y Acad. Sci. 83: 463, 1959.

2. Uebel, C. 0. Micrografts and minigrafts: A new approach to baldness surgery. Ann. Plast. Surg. 27: 476, 1991.

3. Barrera, A. Micrograft and minigraft megasession hair transplantation: Results after a single session. Plast. Reconstr. Surg. 100: 1524, 1997.

4. Barrera,A. Micrograft and minigraft megasession: Review of 100 consecutive cases. Aesthetic Surg. J. 17: 165, 1997.

5. Barrera,A. Refinements in hair transplantation: Micrograft and minigraft megasession. Perspect. Plast. Surg. 11: 53, 1998.

Alfonso Barrera, M.D.
West Houston Plastic Surgery Clinic, P.A.
915 Gessner Rd., Suite 825
Houston, Texas 77024

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