Does haphazard implantation of follicular units affect the long term outcome of hair growth redirection in hair restoration surgery in male baldness?

Does haphazard implantation of follicular units affect the long term outcome of hair growth redirection in hair restoration surgery  in male baldness?

Ahmed F el Sherif, MD; Nahed S Boughdadi,MD; Basim M Zaki,MD Departmant of Plastic Surgery, Ain-Shams University, Cairo, Egypt.

Abstract

The ideal goals of hair restoration surgery are to achieve dense hair, naturally matching with the recipient hair direction and minimal donor site scarring. This study was done on 15 male patients with grades II, III and IV male pattern baldness to evaluate the one-year cosmetic outcome of hair restoration surgery, regardless of their initial direction of implantation at the recipient bald area. The strip graft technique was used for harvesting the follicular units. The study showed that hair could be directed as willingly through regular combing, even though other surgeons have postulated the theory of a fixed direction at the initial insertion of the follicles during surgery, in order to maintain a more natura/look  post-surgery. In conclusion, time wasted during surgery for insertion of follicular units in certain direction at the recipient site aiming for a natural post-operative outcome, proved unworthy.

Introduction:

Hair  transplantation has  been  of  major concern to a considerable percentage of men with male pattern baldness, thus increasing the demand for hair transplantation or other methods of hair treatment.I With evolution of instrumental technology, follicular  unit  transplantation has evolved to higher standards of satisfactory results  to both patients and surgeons.2 A major concern was always the direction of transplanted hair, how natural it appeared after surgery and minimal scarring at  both   the  donor  and   recipient  sites.3

Extracting follicular units is time consuming, and in addition, this procedure also has a higher liability of wasting precious follicular units in the inexperienced hands and lack of appropriate

3D stereomicroscope. The sole advantage of harvesting follicular units over strip grafts is the minimal donor scar, and faster wound healing at the donor site.4

Scarring at the recipient site  is now minimized by the use of special introduction needles, which  render small slit  or  oval

incisions.s These instruments also help produce

a more  natural post-operative outcome of transplanted follicles, avoiding epidermal hypertrophy  at the recipient  site, and the old hair  doll  appearance of larger diameter harvested follicles in need of wider incisions at the site of bald areas.6

The concern  now is directed  to the long­ term outcome  of hair  transplantation when hairs grow to noticeable lengths, and whether their direction of growth will be in harmony with the naturally occurring hairs or not ?.7,8

For this reason, we carried  out this study to evaluate  the long- term outcome  of the hair direction after follicular implantation regardless of their initial direction of implantation at the recipient bald areas.

Patients and methods:

The study was done on 15 male patients with grades II to N male pattern baldness with their variants that became stable for at least -

12 months. Their ages ranged between 25 and

30 years. Exclusion criterion included patients with  systemic co-morbidity, malnutrition, previous scalp surgery and scalp infection. A

written consent was taken from each patient according to the regulations of the research ethics committee in Ain Shams University Faculty of Medicine. One hair transplantation session was done for nine patients, two sessions

for five patients and three sessions for one patient Table(l). The interval between the sessions was at least nine months apart and one  year  follow   up  after  each  session.

Table (1): Shows the number and percentage of patients who underwent single session,two sessions and three sessions of hair restoration surgery.

Technique of hair restoration surgery: Donor site preparation:

The safe donor area for permanent folloicle

harvesting was marked at the occipital area of the  scalp  between  two  imaginary lines, superiorly joining the highest points to the two ear helical arches and inferiorly a line located

2cm above the inferior hair line while the patient is sitting upright. The hair is cut to

2mms  in height using a sterile electric hair trimmer. The donor area was injected with 2% lidocaine in a mixture of adrenaline solution and 0.9 % normal saline solution in a ratio of

1:50. Injection  of the mixture was done at

Figuer (1): Showing spear shaped instrument for slit incisions.

During the initial phase of follicular unit transplantation, the  concept of fixed arrangement of follicular units in one direction, or even a direction in match with nearby follicles was not considered. Follicles were

depths of the scalp to render the strip site bloodless and turgid for easier strip harvesting. Recipient site preparation:

The recipient bald area was also marked to mock the original male pattern hair and aided with any old photos of the patients looks prior to their baldness. The same mixture of the donor area was injected at the recipient area.

Slits at the recipient area were done using

a special sharp spear of 1.2 mm in diameter and 5 mm length Figure(l). The slits at the recipient area were all created in no particular direction to the scalp and were then dilated using   a  special slit   dilator Figure(2).

Figure (2): Showing recipient  slits made in no particular direction.

introduced at the recipient site in no particular direction, and the wound was dressed and secured by vaseline gauze and crepe bandage. The follicles were inspected six days later. Stitches were taken out from the donor area

two weeks  post-operatively, and follow  up every two months was recommended  until 4 em of hair length could clarify the direction ofhair and its harmony gained by hair combing with the original follicles adjacent to the treated bald area. In order to reach a 4 em hair length suitable for appropriate combing, a period of at   least  seven  months is  necessary.

Evaluation of the aesthetic  outcome  was done subjectively  by patient self- evaluation with four Likert  subscales  for the degree of satisfaction (very  satisfied, satisfied, less satisfied and unsatisfied). Objective evaluation of standard pre- and late postoperative photos was assessed by hair transplantation surgeons who had not participated in the surgical procedure, based on hair density, direction and symmetry of the hairline.

Results:

Patients were followed up for a period of

12 months post-operatively, to allow hair to grow to 4 em or more in length. All patients showed natural harmony of hair direction  to nearby follicles. None of our  patients commented on the transplanted hair direction, but rather its density, and the possible need of another hair transplantation session in the near future.

The aesthetic outcome of the patients was highly  acceptable by most  of  the patients. Satisfied and very satisfied patients constituted

73.2   %  of  our  cases   Table(2). The  low percentage of very satisfied patients was based on their judgment  of hair density  alone and not hair direction.

Table (2): Showing results of the aesthetic outcome shown by Likert subscales.

The objective evaluation  of the standard photographs considered the aesthetic outcome good to very good in 80 % of cases. In general, unfavorable results of patient dissatisfaction, and fair to poor aesthetic outcome were limited to cases subjected to one hair transplantation session with insufficient hair density. None of

Table (3): Showing objective evaluation results.

our patients commented on the hair direction or the anterior hairline and its symmetry Table(3). Figures (3-6) Complications were few and limited to postoperative pain at the donor site and mild edema of the forehead and upper eyelids that resolved completely within

72 hours.

Figure  (3a):  Pre-operative Figure  (3b):  6 month  post-  Figure  (3c):  6 months  post- marking.              operative frontal view.                 operative lateral view.

Figure (3): Case 1: Showing preoperative and 6 month post-operative views with harmonious hair.

Figure  (4a):  Pre-operative. Figure  (4b):  Early  post- Figure (4c): Post-operative 6 operative.                mths.

Figure (4d): One year follow up right side.            Figure (4e): One year follow up left  side. Figure (4): Case 2: Showing preoperative,early and late postoperative harmonious hair direction.

Figure (5a): Pre-operative  Figure (Sb): 6 months post-   Figure  (5c):  I  year post-

frontal  view.                       operative.                                  operative.

Figure (S):Case J: Showing preoperative and post-operative direction and hair length.

Figure (6a): Showing luJphazard aTI'tJIIgement

of sparse luJir.

Figure    (6b):  Showing  harmonious arrangement  of  trasnsplanted hair.

Figure(6): Case 4: Showing preoperative and post-operative direction andhair length.

DiJeUHion:

The techniques ofhair transplantation were

refined over decades inan attempt to a.chieve the best aesthetic outcome.The goals of hair restoration surgery are achieving natural appearance of the transplanted hair, pro ding

as much density as possible in the least number of sessions, and minimizing donor site morbidity.3

Debate amonghair transplanlation surgeons has been focused on adjusting the direction of the slit incisions made at the recipient site, the

direction of introducing follicular units, or both. Unger, 2004, stressed that slits should

be made at the recipient bald area to mimic directions and angles seen in natural hair.s Bernstein, 2005, recommended creation of lateral slits at the recipient sites, also called coronal or horizontal slits.He mentioned that lateral slits have the advantage of orienting the hair within the follicular unit to match the way it grows innature.9 Beebner, 2005,considered that mispla.cing follicular units at the time of introduction to be of greater importance.to Sparse hair near the recipient bald area usually shows  haphazard direction  and arrangement. Literature was lacking as to whether this ammgement is due to weak hair

unable  to maintain  a certain  direction, hair vulnerability to external  factors as wind, or finally whether patients lose intimate care of the  sparse  area  they   usually call  "totally bald".11

In our  study,  this  important fact  of the haphazard  arrangement of the sparse hair at the frontal area was noted in all 15 patients. The enhanced post-operative results were based on improvement of hair direction and density and thus the ability to comb denser homogenous hair, as compared to pre-operative haphazardly arranged sparse hair.

We preferred the use of a spear  shaped instrument  (1.2mm in diameter and 5 mm in length).  As reported by many authors, a slit incision of less than 1.5 mm in diameter at the recipient bald area leaves no visible scars.t2

The spear created limited depth incisions, minimized injury to the deeper scalp vessels and ensured non-visible post-operative scars. These scars are responsible for pitting or surface irregularities seen with other instruments used in hair restoration procedures.n

Because transplanted follicles have to pass through all phases of hair growth (catagen, telogen and anagen) phases, enough hair length for proper assessment of hair direction could not be judged before at least a "seven" month period from the operation. This is explained by the fact that after follicular transplantation, the catagen phase sets in, and the follicles are between shedding and new growth. This phase lasts for about two weeks. Catagen  phase is then preceded by the telogen phase, where the old hair is dead but in place,  until the new roots of the growing hairs are strong enough to remove them. This phase lasts for nearly two to four months. Two and half to four and a half months  later, the final anagen  phase commences, where hairs start to grow. This phase lasts for two to seven years. Hair growth is about 1cm every 28 days.s

This study proves that neither fixing the direction of slit incisions created at the recipient area, nor adjusting the direction of follicular units  themselves, to have  any  unfavorable effect on the pattern of hair growth and its direction in relation to the original hair after reaching considerable lengths of more than 4 em. Hair could be directed as willingly through

regular combing, even though other surgeons have postulated the theory of a fixed direction at the initial insertion  of the follicles  during surgery, in order to maintain  a more natural look afterwards.I4

Conclusion:

Direction of  both  slit  incisions at  the recipient site and transplanted hair has no effect on the remote  final direction of hair . Time wasted during surgery for insertion of follicular units in certain direction at the recipient site, proved unworthy.

References:

1- Girman C J: Effects of self-perceived  hair loss  in  a  community sample of  men. Dermatology   1998;  197: 223-229.

2- Tykocinski A: A one-year study of using exclusively "follicular grouping grafts" in specific areas to increase hair density and volume during FUT.  Hair  Transplant Forum Inti 2003;  13(4):  366: 369-700.

3- Rassman WR, Carson S: Micrografting in extensive quantities: The  ideal hair restoration procedure. Dermatol Surg 1995;

21:306-311.

4- Bernstein RM, Rassman  WR, Rashid N, Shiell RC: The art of repair in surgical hair restoration - part II : The tactics of repair. Dermatol Surg 2002; 28 (10): 873-893.

5- Perez-Meza  D, Mayer M:  Comparison  of different instruments to make sites in the recipient area: Needles vs.  blades. International Society of Hair Restoration Surgery 2005;  Sidney,  Australia.

6- Rassman WR, Pomerantz, MA: The art and science of minigrafting. IntJAesthet Rest Surg 1993; 1: 27-36.

7- Stenn K, Paus R: Hair cycle and hair biology.

Physiological Reviews  January 2001.

8- Unger  WP: Recipient area hair direction and angle in hair transplanting. Dermatol Surg 2004; 30(6): 829-836.

9- Bernstein RM, Rassman  WR: Follicular unit transplantation. Dermatol Clin 2005;

23(3): 393-414.

10-Beehner ML: One year follow-up study of FU  growth  at four  different densities: International Society of Hair Restoration Surgery 2005;  Sidney,  Australia.