Summaries and Tidbits from Mondays Presentations

TPO Flap for Frontal Alopecia

Doctor Daniel Rousso, MD, of Birmingham, Alabama, discussed temperal-frontal-parietal flap procedures.  The most popularized type of this operation is known as the 'Fleming-Meyer' flap.  Dr. Rousso emphasized that this operation offers the best results to patients who have a family history of only frontal loss, because it can take care of their frontal loss and provide superior density than normal transplants.  Dr. Rousso also provided a description of some of the variations of different flap operations.

Dr. Rousso also listed the advantages and disadvantages of flap procedures, including:

Surgical Alternatives for Hair Restoration

Martin Unger of the University of Toronto discussed alternative hair restoration procedures to the normal mini/micrografting.  There are quite a few operations that can produce enhanced results beyond that available through normal transplants when done properly.  "I think it's our job to inform them and let them make the choice," said Dr. Unger.

Prolonged Acute Tissue Expansion

One procedure developed by Dr. Unger allows scalp expansions to be done in a shorter and easier procedure.  Tissue expanders are placed in the sides of the scalp and inflated and deflated over a period of about 45 minutes.  The prolonged expansion and deflations stretch the skin and allow it to expand rapidly, unlike conventional expanders which take weeks.  The whole expansion and reduction can be done in a period of 3-4 hours as practiced by Dr. Martin Unger. "The advantage is that we're doing one operation... With tissue expansion and the Unger PATE technique we continue to find new and entertaining uses."

Still Flapping and Reducing After All These Years

Paul Rose, MD, presented information about flap operations and scalp reductions, including the pros and cons involving them.  "I increasingly hear people criticizing scalp reductions... I believe that in certain cases these operations are beneficial to patients with alopecia," said Doctor Rose.  He outlined the arguments for transplants, including reliability, low morbidity, and simplicity of the surgical procedure.  The arguments against reductions, lifts, and extenders include scars, stretchback, morbidity (pain, hemotamosis, necrosis, infection, and altered sensation).  variability of results, and  altered direction.  Stretchback is when the reduced scalp grows new skin and allows the reduced hair to 'stretch back' down, thus lowering the amount of the reduction.  "Under minimal tension, you don't get much stretchback... I think it's important we to try to close these flaps under minimal tension."

Dr. Rose's arguments for lifts include excision of large areas of bald scalp, movement of the hairbairing skin evenly, reduction in the # of transplants required, better density in the occipital area, and more immediate results.  The appropriate patient for a reduction or flap has adequate hair on the side of the scalp, low hairline adjacent to ears, a stable hairloss pattern, age (not too young), and limited donor hair.  "I think it's important that we not be dogmatic about reductions or hair transplantation.  We need to recognize that it's a very important tool in our armament... to criticize it in every case is criminal," said Dr. Rose.

The Rise and Fall of Scalp Flaps, Reductions and Lifts

Tony Mangubat of Seattle, WA is one of the leading doctors performing scalp reductions.  "I've noticed in the Seattle area over the last two years a fall in the area of scalp reductions... I was a little disappointed in it, and I was almost upset until I started looking at it in a more objective way... the answer to this question becomes very clear."  Dr.Mangubat outlined his feelings on reductions and why he thinks the number of doctors performing the procedure has decreased.   "We want fast results, we want a home run..   Managed care has caused an influx of newcomers.  The fact is I make more income off of hair transplants than scalp lifting, so from a financial point of view maybe it's not such a bad idea..."  The fall has been precipitated by an influx of newcomers due to doctors who are earning less due to managed care and HMOs.  "These are all victims of our new managed care society," said Dr. Mangubat.  Doctors coming in have been resistent to learning reductions, flaps, and lifts due to the steeper learning curve, greater risks, and marketing against reductions.  The number of doctors performing are remaining steady, but the number of doctors coming into transplants are growing, so the overall percentage are lower.

Alopecia Reductions of the Future - Make Dust or Eat Dust

Mario Marzola of Adelaide, Australia spoke in favor of scalp reductions in selected patients.  "I do feel quite missionary and quite strongly about reductions and the procedures position in a doctors arsenal," said Dr. Marzola.   The advantages of reductions, according to Dr. Marzola, include instant results, less cost per hair, "will it grow" is not a concern, better use of available hair, and they are useful in repair work (previous unaesthetic results, lifting a hairline too low, alopecia from injury/burns).  Reductions are indicated in patients without much hair in the scalp to be excised, with well defined bald-hair bearing borders, dense hair in the back and sides, loose scalp, and of course a patient who has a preference for the results this kind of operation can offer.  "Some of us are fairly fond of the procedure and will list a dozen advantages... One of the interesting and gratifying things with this procedure is that the scar gets smaller with each operation," Dr. Marzola said in summary.

Scalp Reduction - How I Do It

Dominic Brandy of Pittsburgh presented information on his operations, primarily including the scalp lift.  The scalp is stretched all the way from the bottom of the nape, which gives a much greater extension since there is no galea in the lower area of the rear of the scalp.  Most of the negative aspects of the past (numbness, altered sensation), can be avoided by not disconnecting one of the nerve bundles in the back of the scalp, so lifts today are better as far as fewer complications than in the past.  What makes lifts different than normal scalp reductions is that some of the connective muscle and tissue in the rear of the scalp is at least partially disconnected to allow greater mobility in stretching the scalp upward.  "Some of the advantages of this operation are that you really limit the amount of stretchback..." said Dr. Brandy.  An ideal candidate is over 40, has slick baldness that is narrow and well delineated, good density on the sides and back of the scalp, good density in nape hair, low periauricular hair line, a wide donor fringe, and good scalp laxity (loosity).

"Retrofits" and Revisiting Old Taboos

Walter Unger of Toronto, Canada is one of the most respected transplant doctors in practice today, both for his results as well as his willingness to be forthright and honest about his opinions on different transplant and reduction methods.   He began his speach by saying, "I want to urge you to aim high... I would urge you once you master whatever level of competence you hope to achieve... that you extend yourself a little bit farther... be very reluctant to use the words don't or never."

Doctor Unger sees many patients for repair work of existing transplants.  He sees both patients from other doctors with less than satisfactory results as well as some of his older patients who had plugs when those were what was only available and now wish to have some improvement.  Repairs make up about 30-50% of his practice.  Dr. Unger recommends moving the hairline forward if there is enough donor area with micro-mini graft.  Areas behind are still filled with standard round grafts because there is no other way to get as many hairs grafted closer together, so they provide greater density behind the hairline.  He suggests filling the remaining space with the same density and texture as existing grafts to give a uniform appearance.   Dr. Unger elaborated, "...if there is a 4mm space, why not use a 4mm punch?  Use what common sense tells you to use... sometimes only micros and minis if that is what fits best."  If grafts are very dense or course and stand out, they should be punched out and moved back to a more appropriate place.  The majority of patients need 2 or 3 sessions, but some can be done in one. 

As one ages, 2 things happen - the alopecic area enlarges and the rim hair density decreases.  So doctors have to take future hairloss and loss of density into account due simply to aging as well.  Dr. Unger recommends a mixture of grafts to get the best results in revising previous operations.  Doctors should try to anticipate permanent fringe hair density as well as size.   Temporal thickening is "graft expensive."  The younger the patient the more difficult the task; the older the patient the easier.

Criteria for using mixed grafts include patients with high hair density, a good donor hair to recipient hair ratio, relatively dense temporal hair now and future, some existing hair in the recipient area is advantagous, and good hair characteristics are also advantagous (lighter color and fine hair texture.)

Revision Hair Restoration

Dr. Jeff Epstein of Miami, Florida also made a presentation on improvements to previous transplants which he has done.  "Revision" hair restoration is indicated when there is an abrupt, dense hair line (including poor hairline position or design  or abnormal elevation of the hairline,)  insufficient density,  a pluggy appearance, poor direction of the grafts, poor position of the grafts or donor site scarring.  Dr. Epstein places the mistakes of doctors doing inferior work into two categories.  Errors of commission include poor technique, over-zealous pre-operative counseling, and scarring in the back of the scalp due to over resection.  Errors of omission include not anticipating future hairloss or inadequate pre-operative counseling.

Approaches to repair that can be done include the removal of grafts, punch reduction, replantation of grafts, more graft transplantation, scalp reduction, scar revision, and in some cases, scalp flaps.  Unique considerations for a doctor to consider before performing a revision include poor scalp laxity, compromised scalp circulation (necrosis, poor growth, or limited flap length), limited resources (little donor tissue, or limited financial resources), and previous misconceptions that the patient may have due to his prior results.

Graft removal or reduction is an option some patients are opting for.  They desire bald scalp due to poor direction or position or a pluggy appearance of their prior grafts.  Dr. Epstein has had good results in removing these plugs and using a laser to resurface and minimize any scarring.  Dr. Epstein recommends having procedures done in a staged process due to length of the procedure.

Ellipse and multibladed knife comparison for harvesting

David S. Alkek gave a presentation comparing two different tools and techniques for removal of the donor hair.  A big problem in removing donor hair is removing the hair without destroying follicles by cutting through the base of the follicle.  This loss of follicles is called transsection.  Transplant doctors are always trying to find the best way to cut the donor hair out without losing any hairs.   According to Dr. Alkek, an ideal technique for harvesting should preserve largest number of follicles, preserve the remaining donor area, leave as small a scar as possible, minimize graft preparation time, and decrease the possibility of nerve and blood vessel damage.

Advantages of strip harvesting over punch harvesting include less area for possible injury, the angle of blade can more easily follow parallel to the follicles, the wound can be closed easiers with less scarring, more efficient use of donor area, and the donor area is better preserved for future use.  Advantages of the multi-bladed knife include several longitudinal incisions at 2mm widths simultaneously, which greatly speeds preparation of mini and micrografts.  Disadvantages include the fact that a small error of the angle of the knife will damage many follicles and the angle of the follicles vary from the sides to the mid-rear scalp area.

Advantages of removing donor area as an elipse include the ease of checking the position of the blade relative to follicles and a lower possibility of damage to fewer follicles.  The disadvantages of this technique include the fact that a large block of tissue is difficult for technician to section causing more likelihood of damaging follicles by the technician.

Dr. Alkek's suggestion is to combine the best features of both techniques by using vertical slits in the donor area with the multiblade, then single blade cuts to remove the donor area with the ellipse.

Marc Avram and David Perrot presented two separate presentations on the use of lasers in hair transplantation.  Here is a combined summary of the two presentations.  Both doctors agree that in general lasers currently get their best results with grafts of 1-3 hairs.  These results are comparable to normal transplants.  Larger grafts of 4+ hairs tend to have lower end results and yield, although Dr. Perrot believes that the new laser by Coherent is able to do comparable larger grafts due to it being able to cut slits rather than only holes.  The FDA has officially approved two laser devices for hair transplantation as of December 1997 by two companies called Sharplan and Coherent.  Both are CO2 lasers.  Dr. Perrot believes the Sharplan is a good laser for single to three hair grafts, but not as good for larger grafts.  The Sharplan performs only round graft holes and not slits.  It is less expensive and Dr. Perrot believes it can deliver better results in the front.   The Coherent laser does both slits and round holes and may offer the best density in the fewest sessions.  Each seems to have their own advantages and you may want to be aware which (if only one) your doctor uses.

Erbium lasers are a newer type of laser that cause less peripheral damage and may yield better results.  The disadvantages are that since there is less damage, bleeding is more similar to standard manual graft punches or slits.  There is also more of a plume.  Furthermore, fewer handpieces and scanners are available due to the newness of this type of laser, which makes it more difficult for doctors to get the best results.  This laser holds promise for the future but is probably not a mainstream option yet.

Clinical Evaluation of GraftCyte Moist Dressings in Hair Transplant Surgery

Dr. Matt Leavitt presented preliminary information on a study they are conduction on ProCyte's moist dressings for hair transplantation.  These dressings are supposed to prevent the fallout of hairs shortly after transplant surgery (known as "telogen effluvium") and speed up the regrowth of the new grafts.   Their objective was to "...evaluate the enhancement of hair bearing scalp graft viability following application of either GraftCyte Moist Dressings, based on growth cycle status of transplanted hair follicles and gross observation of basic healing quality (erythema and edema)."

The copper tripeptide in GraftCyte is responsible for the stimulation of synthesis of extracellular matrix, angiogenesis, and protection from damaging oxygen species (antioxidative and antiinflammatory actions.)  Technically, the active copper tripeptide in GraftCyte is Glycyl-L-Histidyl-L-Lysine Copper (6HK-CU 2:1, Procyte code PC 1020.)  Patients are supposed to perform 16 applications, 4 times per day for 4 days, treatments performed at the office and 2 at home.   Photographs were taken with a videomicroscope and mirror image digital photography daily.

The study lasted for 13 weeks and was investigator blinded and placebo controlled using men class IV or greater on their first procedure. 200 grafts were done with 60 minigrafts and 40 micrografts for a total of 100 on each side.  One side was treated with placebo and one with the GraftCyte, so each patient was his own control.   The results show that meticulous wound care regardless of use of GraftCyte gives better, faster healing.  Faster healing results in less telogen effluvium which in turn gives the patient faster growth and a more noticable, quicker result.  If nothing else, the dressings greatly reduced or eliminated redness after surgery and enhanced healing, which made the procedure much more comfortable for patients and gave them a quicker chance to get back to their normal life.  The full results will be published shortly.

Hair Replacement

Dr. Carlos Puig gave a presentation regarding hair replacements to help doctors identify local specialists of quality to refer patients to in cases where patients are not suitable for transplants.  According to Dr. Puig, each hair system has three components:  the fiber, the base, and the attachment.  The base was originally a textile piece but has moved first to a mono-filament netting and now to fine lace edges and gas permeable lenses.  Hairs are made of either a synethic fiber or processed human hair, which are stripped, have the cuticle removed, repigmented to the desired color, and permed to the desired shape.  The hairs are attached to the base generally at the factory and better hair replacements are custom fitted to each are custom fitted to each individual's head.  The length of time they are worn depends on the type of attachment.  Units attached with clips or tape can be removed daily.   Adhesives can be used for semi-extended wear attachments to keep units in place for 3-5 days.  Finally, FDA approved medical adhesives can be used for extended wear units to keep hair units in place for 3-5 weeks, the length depending on the individual.   The latest techniques include a base of a gas permeable membrane that is transluscent, attached by medical adhesives that are also gas permeable.  This allows units to be worn without removal for weeks without suffocating the scalp.

Another development in non-surgical hair replacement is the new standard for Certified Hair Replacement Specialists.  Starting just recently, hair replacement professionals can now be certified.  To do so, they must be a member in good standing of the American Hairloss Council, which requires them to agree to a code of ethical behavior.  In addition, they must take an AHLC accredited course, 50 hours of specialty training, and 20 hours of continuing education every two years.