A Technique for Hair Grafting Between Existing Follicles in Patients with Early Pattern Baldness

A patient with early male pattern baldness.	Same patient after one session utilizing the magnification technique described in this article.

BACKGROUND: When using follicular hair transplantation on patients with early male or female pattern baldness, there can be significant trauma to preexisting hair follicles. This becomes especially important as more men and women use finasteride and minoxidil to stop or slow hair loss.

OBJECTIVE: Develop a system that averts damage to preexisting hair follicles in patients with early male or female pattern baldness.

METHODS: A Lutex® headlight - 2.5x loupe magnification system is used to make 1 - 1.5mm spear incisions in between the hair follicles in patients with early male or female pattern balding. Magnification is also utilized during the graft cutting and placement phases of the procedure.

RESULTS: This headlight-loupe magnification system has dramatically decreased the amount of permanent hair loss and anagen effluvium on 144 patients with early male and female pattern baldness. With less permanent hair loss there is greater density observed with each progressive session.

CONCLUSION: Hair surgeons now have a method to consistently and significantly minimize the amount of damage to preexisting hair follicles in patients in the early stages of male and female pattern baldness. This becomes even more important as more patients use finasteride or minoxidil to stop or slow the thinning process.

Hair transplantation was first introduced in the medical literature in 1939 by Okuda. But it wasn't until Orentreich wrote his renowned paper on donor dominance that hair transplantation became a common procedure known to the medical community and lay public.

As most cosmetic surgeons know, this technique involved the boring out of recipient skin with a trephine that was usually .5mm smaller than the size of the punch hair-graft taken from the donor site. For example, a 4.5mm donor graft would be placed into a 4mm recipient hole, or a 4mm graft into a 3.5mm hole. Unfortunately, these recipient holes would remove a great deal of the patient's preexisting hair - especially in those with early male or female pattern baldness.

In 1984, the whole concept of hair transplantation changed dramatically when Dr. Wayne Bradshaw spoke at the 1984 International Congress of Hair Replacement Surgery at the Plaza Hotel in New York City. At this meeting, Bradshaw introduced the idea of making small incisions with a #15 blade into the recipient area, then filling those incisions with what he called minigrafts. These grafts were made by cutting 4.5mm punch grafts into four sections, which created grafts that contained approximately 6-8 hairs. Some called these quarter grafts.

In a patient with early male or female baldness, this slit mini-grafting procedure involved making incisions into the recipient scalp which unfortunately destroyed some of the patient's own hair. Other surgeons adopted the minigraft idea of Bradshaw, but utilized holes instead of incisions. In these cases, an even greater degree of permanent hair loss occurred because the pre-existing hair in the recipient site was physically removed by the boring process, which was similar to Orentreich's original technique. In both scenarios, one would essentially be taking two steps forward then one step backward.

As time has progressed, the idea of follicular unit transplantation has taken hold, which involves transplanting units of 1,2,3 or 4 hairs as they occur in their original hair bundle formation. This technique involves making very tiny incisions in the recipient site, then placing these follicular units into the incisions. Although this technique is more refined than placing larger mini-grafts into bigger incisions or holes, there can still be a fair amount of trauma to preexisting hair follicles in individuals with early male or female pattern baldness.

This hair destruction has lately become even more important in the light of the fact that more and more patients are using finasteride or minoxidil to stop the thinning process. It is therefore paramount that existing hairs be preserved.

In this paper, the author introduces a method that utilizes the follicular unit technique while at the same time significantly minimizing damage to preexisting hair follicles in patients with early male or female pattern thinning.

In an attempt to eliminate the problem of damaging existing hair follicles in patients with early male and female pattern thinning, the author developed a headlight magnifying system. The use of this system during the hair restoration surgery process has been found to significantly reduce the problem of permanently destroying preexisting hair.

A Lutex®-Xenon type headlight is the light source that the author routinely uses for all of his hair restoration procedures; but any headlight will suffice for the development of this system. A pair of specially designed loupes (2.5x power) are taped over the headlight. The loupes utilized are very inexpensive and can be purchased from Ellis Instruments for approximately $50 US. The interesting aspect of these loupes is that they can be elevated upward and downward, on and off the field, quickly and easily.

It is important to note that headlight-loupe combinations can be purchased from some surgical supply companies. These units, however, have loupes that are virtually impossible to quickly change from the "on" to "off" position, which is a feature that is critically needed in hair restoration surgery. These pre-constructed units are also quite expensive.

The consent form is reviewed with the patient and the appropriate questions answered. The patient is then administered 20 mg of diazepam and two oxycodone tablets. The appropriate markings are then made at the hairline and donor sites with a Pilot® marker. The recipient site is divided and scribed into 2 cm x 2 cm squares.

Lidocaine 1% with 1:100,000 epinephrine is injected around the scribed fusiform at the donor site. After the donor strip is removed, the incision is closed with 2-0 PDS II deep and 4-0 chromic superficially. The assistants at this point start dissecting the hair-grafts into follicular units utilizing #10 Bard Parker blades enhanced with 2.5x magnification. When encountering a patient with gray, blond or red hair, a dissecting microscope is sometimes used.

The recipient area is now addressed. Lidocaine 2% with 1:100,000 epinephrine and plain Marcaine .25% is injected anterior to the proposed hairline. A 1-1.5mm spear blade is loaded into a handle that controls the academic preoccupation, unfortunately, has ignored the importance of two critical steps in the hair restoration process - the precision of the recipient incisions and the finesse of graft placement. The author has found that magnifying these two important steps significantly improves overall results.

It has been the observation of the author that when using the described headlight-loupe system on 144 patients at the time of this writing, one sees a very significant drop in the amount of telogen-anagen effluvium and a far less degree of permanent destruction of hair follicles. Additionally, there appears to be an improvement in overall hair density after a given session probably due to the fact that preexisting hair is being damaged less during the hair restoration procedure. Another reason that depth of the incisions to approximately 6mm. The author now applies the Lutex® headlight with connected 2.5x magnification to his head.

Incisions are begun at the posterior-most portion of the recipient area. Each previously scribed 2 cm x 2cm square is approached as an individual unit, moving from posterior to anterior. The goal of this approach is to start at the posterior end of a 2cm x 2cm square and make 1-1.5mm incisions BETWEEN the existing hair follicles located inside that square. This can easily be carried through with the aforementioned headlight magnification system. The primary reason for starting posterior and moving anterior is to prevent blood from flowing downward into the field. The reasoning behind the utilization of 2cm X 2cm blocks is to keep intense focus on one small space at a time.

This box-by-box method is continued to the hairline at which time an irregularly irregular hairline is drawn. At this point, one and two-haired follicular units are placed in an erratic fashion behind this irregular line. Separations between incisions are approximately 2mm, which look like 5mm separations under the 2.5x magnification.

At this point in the procedure, the nursing staff begins placing the follicular units into the recipient incisions. This, also, is done with the enhancement of 2.5x magnification.

Over the latter part of the 1990s, the thrust of discussion in hair restoration surgery has centered around the use of magnification for the dissection of follicular units from a donor fusiform. This preexisting hair is not damaged as much is due to the fact that the hair direction is much more readily visualized using high magnification; therefore, improper angulation is much less apt to occur. Unger has written "the direction and angle of hair growth, and therefore those of the punch or scalpel blade n the recipient hair must correspond exactly, or, for example, not only is the hair within a recipient site plug removed, but the surrounding hair follicles are also damaged." It is therefore critical to be as precise as possible when making hair graft incisions and this technique offers the best chance of carrying this goal through.

The author also thinks that magnifying the graft placement aspect of the surgery improves the density and overall results. Magnification with 2.5x loupes instinctively causes the assistant to handle the graft much more delicately. When vision is better and small movements become large movements, refinement of technique will result. This refinement of technique will then equate to less injury to grafts and better overall survival.

At one point in the development of this technique, the author contemplated carrying through a study using the naked eye on one side of the head and utilizing the Lutex headlight system described in this article on the outside. But after seeing the consistent and dramatic decrease in temporary and permanent hair loss on over 50 patients at that point, the author felt that he could not subject a patient, in good consciousness, to a far less accurate technique on one side of the head. For the reader, that has not used this technique and may be skeptical, a study of this technique is welcomed.

SUMMARY

The author describes a method to hair-graft in between existing hair follicles in patients with early male and female pattern baldness. The crux of this method is the use of a 2.5x loupe-headlight system for incision making in between existing hair follicles and 2.5x magnification for graft dissecting and placement. This method refines every facet of the hair restoration process - improving yield of hair growth and has dramatically decreased the damage to existing hair on 144 patients at the time of this writing. This improvement is especially important in light of the fact that more and more patients are using finasteride and minoxidil to stop further hair loss. It is thus more paramount than ever to save as many of the preexisting hairs as possible.