Single hair grafts are used to create a natural hairline. The planning of the hairline is one of the most important steps in hair transplantation. The hairline is the most visible landmark and the quality of work of a surgeon is often judged by the quality of the hairline. As suggested by Michaelangelo, to locate the ideal hairline in a bald patient, it is necessary to divide the face into three equal segments.
A curve sweeps around to the lateral side of the forehead from the center. At this point, the sides of the hairline should be oriented parallel to the curve when the subject is looking straight ahead. The lateral hairlines are usually 9. The temporal angles should form relatively sharp right angles or acute angles in most men, but these angles should be more rounded in women. The hairline shape also varies according to the variation of the shape of the face—round, oval or triangular.
The patient's desires and constraints are also other factors that can affect the shape of the hairline. Usually — single hair micro grafts will be necessary to create a new hairline in any individual. The micrografts in the hairline should be placed in an irregular saw-toothed pattern of macro- and microirregularity[ 4 ] to give a natural appearance.
Behind the hairline, two-hair FUGs are used to provide new hair. Three or four hair FUGs are used just further behind. The less ideal the hair and skin characteristics, the more important it is to use smaller grafts. To give good density in alopecic recipient areas, some surgeons use punch grafts that are 1, 1. The punch grafts have the advantage of removing a circular area of bald tissue where the grafts will be placed.
These punch grafts should not be used in areas where hairs are already present as they would punch out existing hair and the surgery will be counterproductive. Punch grafts can however, be useful in areas of total baldness. The patient is asked to shampoo his head with Betadine surgical scrub on the day before, and on the morning of the surgery. Local anaesthesia is used for the entire procedure. The hair in the donor area occipital region is trimmed to a length of 2—4 mm and the local anaesthetic solution is injected just below the donor area.
The donor area is then tumesced by injecting normal saline into the entire zone.
After 10—20 minutes for complete haemostatic effect to minimize bleeding, the donor area should be turgid at the completion of infiltration, because this provides excellent anaesthesia and results in minimum bleeding. The donor strip can be harvested with a single-bladed knife or a multiple-bladed knife containing three to seven blades.
The multibladed knife harvests numerous two to six parallel strips of varying width depending on the spacer used , which may be 1. These blind incisions with a multibladed knife increase the chance of follicular damage; therefore, it is better to use a single or a double-bladed knife. It is very important that while harvesting the donor area, the blades remain parallel to the direction of the hair so that the hair roots are not damaged.
The hair in the lower part of the occipital area and the temporal area are finer, and these should be used to create a new hairline. After the strip has been harvested, the gap can be closed either with staples or sutures. Some surgeons, including the author, prefer deep sutures in the galea or the subcutaneous tissue to reduce the width of the scar. The skin can be opposed by a running suture of or monofilament nylon, or any absorbable suture.
Care is taken to take the bites close to the skin margin to avoid more damage to the tissues.
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Also, it is important to take the bites only up to the dermis so that the deeper hair roots are not damaged, and thus can be utilised in subsequent surgery. Follicular Unit Extraction[ 5 ] is a technique that involves the removal of the intact follicular unit directly from the donor area using a 1 mm punch. The yield by this harvesting technique can decrease due to transection and avulsion injury to the follicular unit. Harvesting donor hairs which are white or light coloured is more difficult. Extra care has to be taken to preserve the hair follicles.
Hair transplantation using the percutaneous technique
To enhance visibility, these patients are instructed to dye the hair a few days before the procedure. Methylene blue can be injected in a very low concentration just before surgery into the donor area to help in identifying the grey hairs during dissection. Extra care is also required in patients undergoing a second procedure because scars from previous surgery, distort the direction of the hair in the donor area.
The harvested donor strips are immediately immersed in chilled normal saline. This is achieved by keeping the tray containing the grafts, immersed in saline on ice.
Proper hydration of the donor grafts with cold saline is very important throughout the surgery as it influences the survival rate of the grafts. If a single large strip has been harvested, it can be divided into smaller pieces or slivers[ 6 ] before the cutting of individual grafts. The subcutaneous fatty tissue below the hair roots or bulbs is stripped leaving up to 2 mm of fat below the hair bulb. FUGs are made having one to four hairs. Grafts are immersed in saline in a Petridish, or kept on a moist stockinet in kidney trays, in bunches of Good illumination is essential during the cutting of the grafts.
Before treatment (3000 grafts)
The grafts may be cut on wooden tongue depressors or on a clear vinyl dissecting surface with a backlighting system. It is important that no piece of wood sticks to the grafts after they have been cut, because these foreign bodies can later form troublesome epidermal cysts. Graft preparation with a dissecting stereo microscope makes the dissection a little slower, but it is much more accurate.
Anaesthesia for the recipient area includes a supratrochlear and supraorbital nerve block, followed by a ring block in the frontal area beyond the zone of hair transplantation. The recipient area itself should be tumesced well with normal saline. It is the author's preference to avoid using adrenaline in the recipient area because it increases telogen effluvium in the immediate postoperative period, and it also may diminish the uptake of the grafts.
Adrenaline must definitely be avoided in the recipient area in women[ 7 ] because severe effluvium has been reported after its use. To minimize bleeding and pain, the recipient area should be turgid before slits or holes are made. While making slits or holes in the recipient area, it is very important to follow the direction of the existing hair in that region. The hairline should have a ragged, saw-toothed natural look. Holes are made with a No. About — micrografts are necessary to create a normal hairline.
The Nokor needles and Minde knife are disposable instruments and not easily procurable in India. The scalpel blades make holes that are too large and often deep, because of which the inserted grafts float and lose direction. Scalpel blades can also cause significant damage to the existing hair in the recipient area. In females, a large number of hair strands get cut by the scalpel blade during the procedure.
A hair transplant can give you permanent, natural-looking results
It creates a gap just about the size of the graft to be inserted, and ensures that the graft maintains the direction of orientation. The slit may be used in attempts to increase density in areas where there are existing hairs. In patients undergoing secondary or tertiary procedures, an increased amount of bleeding has been noticed in the recipient area. Increased bleeding is also seen in patients who have been using minoxidil lotion in the preoperative period.
Good tumescence and a waiting period of 10—15 minutes before making gaps can reduce this disturbing ooze. It is also noticed that the gaps in recipient areas are tougher to make in secondary procedures, because of fibrosis from earlier procedures. It is important to employ an atraumatic technique for graft placement. To avoid damage, the FUGs are grasped by the 2 mm of subcutaneous tissue left below the hair bulbs to position them into the recipient sites and not by the follicle end.
A steady pressure is applied to ensure that the grafts are flush with the surrounding skin. Burying the grafts beneath the level of the skin must be avoided because it can give a pitted appearance and also lead to the formation of epidermal cysts. A cobblestone appearance is seen if the grafts are too elevated from the surface. Two, or even three, persons can insert grafts at the same time to make the procedure faster and efficient. Grafting sessions can last up to five or six hours, in which — FUGs may be transplanted.
The patient is discharged the same day, usually without any bandage. Some surgeons still prefer to bandage but it must be done very carefully to avoid shearing.
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The bandage must also be removed very meticulously because grafts can stick to the undersurface and get removed inadvertently. Some swelling is obvious after a hair transplantation surgery and the patient should be informed of this prior to the procedure. Oral steroids for 3—5 days can minimize the oedema. Some surgeons use Injection Triamcinolone 40 mg in the tumescent solution and claim that this reduces the swelling. A head-band worn immediately after the operation is useful in preventing the swelling from coming down on to the face and creating a puffy appearance.
The patient is instructed to wash his hair with a mild shampoo on the 2 nd or 3 rd postoperative day. While combing the hair in the transplanted area for three weeks, the tooth of the comb should not strike against the transplanted grafts. Wearing clothes like T-shirts or pullovers which have to be taken off over the head should also be avoided for three weeks. Hair oils or other stronger shampoos as well as helmets are also to be avoided for the same period.
This is continued for a period of two to six months. This has been shown to promote earlier growth of the transplanted hair. The epidermis and dermis along with the shaft of the transplanted hair outside the skin fall off as scabs in the two to three weeks after the surgery, but the follicles remain and go into a resting phase.
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