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H air

T ransplantation
The Art of Follicular Unit
Micrografting and Minigrafting
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H air
T ransplantation
The Art of Follicular Unit
Micrografting and Minigrafting
Second Edition

Edited by

Alfonso Barrera, MD, FACS

Clinical Assistant Professor of Plastic Surgery,
Baylor College of Medicine,
Houston, Texas

Carlos Oscar Uebel, MD, PhD

Professor and Head, Division of Plastic Surgery,
School of Medicine, Pontifical Catholic University RS,
Porto Alegre, Brazil

Quality Medical Publishing, Inc.

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Alfonso Barrera, MD, FACS James A. Harris, MD, FACS

Clinical Assistant Professor of Plastic Clinical Instructor, Department
Surgery, Baylor College of Medicine, of Otolaryngology/Head and
Houston, Texas Neck Surgery, University of
Colorado School of Medicine,
Fernando F. Barrera, BA, BM Aurora, Colorado
Medical Student, University of
Texas Health Science Center School Francisco Jiménez, MD, PhD
of Medicine, San Antonio, Texas Dermatologist and Hair Transplant
Surgeon, Department of
Jerry E. Cooley, MD Dermatology, Demotecnia Clinic,
Private Practice, Carolina Las Palmas de Gran Canaria,
Dermatology Hair Center, Charlotte, Canary Islands, Spain
North Carolina
Jorge Augusto Moojen da Silveira, MD
Márcio R. Crisóstomo, MD, MS Assistant Plastic Surgeon, Uebel
Medical Director, Hair Transplant Clinic, Porto Alegre, Brazil
Center, Fortaleza, Brazil; Diplomate
of the American Board of Hair Clerisvaldo Almeida Souza, MD
Restoration Surgery Director, Plastic Surgery Clinic, Life
Center, Salvador, Bahia, Brazil
Marcelo Gandelman, MD
Private Practice, São Paulo, Brazil Carlos Oscar Uebel, MD, PhD
Professor and Head, Division of
Anajara Gazzalle, MD Plastic Surgery, School of Medicine,
Plastic Surgery Resident, Pontifical Catholic University RS,
Division of Plastic Surgery, Porto Alegre, Brazil
Pontifical Catholic University RS,
Porto Alegre, Brazil James E. Vogel, MD, FACS
Associate Professor, Department
Joseph F. Greco, PhD of Plastic Surgery, The Johns
President, Greco Medical Group; Hopkins School of Medicine,
Director of Clinical Research, Baltimore; Private Practice, Owings
OroGen BioSciences, Inc., Mills, Maryland; Past President,
Sarasota, Florida Inter­national Society of Hair
Restoration Surgeons (ISHRS)
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Over the past half-century I have witnessed the tremendous evolution of plastic
surgery, from a budding specialty to a complex, multidisciplinary field of ever-
expanding knowledge. Today plastic surgery can be performed on any region of
the body, from the hair to the lower extremity. It has become nearly impossible
for a single surgeon to develop technical skills in so many areas; consequently, a
tendency for specialization has occurred. Hair restoration surgery is one such area.
Precise technique and instrumentation require personal aptitude and many hours
of dedicated training. Because of the advances achieved through the painstaking
efforts of surgeons who have refined the techniques of hair transplantation, today’s
patients need not expect the suboptimal results produced with punches and flaps.
Currently nothing less than a natural-looking result is deemed acceptable.

Alfonso Barrera and Carlos Uebel are internationally recognized as leaders in

hair transplantation. This new edition of Hair Transplantation: The Art of Fol-
licular Unit Micrografting and Minigrafting is a praiseworthy book that addresses
the challenges faced by both the novice and the experienced surgeon when per-
forming hair restoration. The scope of the book is exceptional: basic procedures
are covered, progressing to more advanced concepts and techniques. Up-to-date
information is provided about the frontier of stem cell research and platelet-rich
solutions, opening the exciting possibility of follicular stimulation and replication.

I am very pleased to recommend this book and to congratulate Drs. Barrera and
Uebel for sharing their vast experience with their readers.

Ivo Pitanguy, MD, FACS

Professor and Head of the Plastic Surgery Division,
Pontifical Catholic University,
Rio de Janeiro, Brazil;
Full Member of the Brazilian Society of Plastic Surgery;
Full Member of the International Society of Aesthetic Plastic Surgery,
American Society of Plastic Surgeons, and American Society for Aesthetic
Plastic Surgery
viii Forewords  

I was delighted to learn that Drs. Alfonso Barrera and Carlos Uebel have united
to publish this excellent book on hair transplantation. Both colleagues are out-
standing experts in the field, and they have gathered a group of excellent contrib-
utors who focus on specific topics regarding hair restoration. The authors review
the fundamentals of hair anatomy and physiology, the importance of preoperative
planning, and the value of having a well-coordinated, skilled team working in
concert during the harvesting and transplantation process.

In the past hair transplantation procedures were performed with local anesthesia
only; the authors present their experience combining local anesthesia with in-
travenous sedation, which means less discomfort for the patient. The correction
of male pattern and female pattern baldness is well described and illustrated. A
chapter by Dr. Souza is devoted to the specific handling of baldness in the crown
area. Dr. Crisóstomo discusses using the untouched strip technique in combining
FUE and FUT.

The text details postoperative care and the instructions to be given to patients to
obtain optimal healing. Also addressed is the progressive nature of baldness and
why it is important to educate the patient about the potential need for a future
session of hair transplantation.

Some surgeons stretch the skin significantly during hair transplantation, deform-
ing the limits of the hair-bearing tissue and thus creating alopecic areas. These
expert surgeon-authors have developed special techniques for correcting these
problems. Dr. Vogel provides a discussion on revision of unfavorable results from
previous sessions of hair transplantation. The authors also present hair trans-
plantation in reconstructive procedures to repair the beard and mustache. They
describe their experience using platelet-enriched growth factors to obtain better

Drs. Barrera and Gandelman report techniques for reconstructing the brows and
eyelashes. For transgender patients, Dr. Barrera describes the technique of femi-
nization of the frontal hairline. Another chapter describes the procedure for com-
bining a face lift and hair transplantation in one single session.
Forewords ix

Dr. James Harris describes follicular unit extraction, Dr. Jerry Cooley covers the
exciting potential of hair cloning and tissue engineering, and Dr. Greco describes
autologous tissue transfer in androgenetic alopecia and in inflammatory illnesses
resulting in loss of hair. Dr. Barrera provides a helpful report on photographically
documenting the patient’s appearance preoperatively and postoperatively. Drs.
Barrera and Uebel also describe their results, the complications associated with
hair transplantation, and incorporating hair transplantation into a plastic surgery
practice. The illustrated results confirm the success of their techniques.

I congratulate Drs. Barrera and Uebel on this outstanding publication which

expands our knowledge in this important area of plastic surgery. All plastic sur-
geons who perform hair transplantation will benefit greatly from reading Hair
Transplantation: The Art of Follicular Unit Micrografting and Minigrafting.

José Guerrerosantos, MD
Jalisco Institute of Plastic and Reconstructive Surgery;
Secretary of Public Health Services,
University of Guadalajara,
Guadalajara, Jalisco, Mexico
x Forewords

Premature hair loss is a source of concern and embarrassment for men and women
alike. Fortunately, current hair transplantation techniques offer natural and aes-
thetic hair restoration for a broad range of male and female alopecia problems,
whether typical male or female pattern baldness or sideburn, eyelash, or eyebrow
loss resulting from surgery or traumatic injury.

This new second edition by Dr. Alfonso Barrera and Dr. Carlos Uebel presents
state-of-the art knowledge and techniques in this burgeoning field by two of the
world experts on the subject. Both Drs. Barrera and Uebel have written exten-
sively about their work, and 10 years ago both published separate outstanding
texts on the topic. Now they have joined forces and have brought us the most
advanced publication ever written on this complicated subject.

In this book they discuss their individual approaches to patient evaluation, de-
termining patient expectations, and devising plans to meet those expectations.
These plans include patient education preoperatively and postoperatively as well
as the details of the operation and the postoperative course for a complete recov-
ery, with expectations met.

The book points out that not all cases of hair loss are the same; there are a variety
of causes and patterns to be considered, and each patient requires an individu-
alized approach that takes into account the individual’s hair growth pattern,
age, specific expectations, and the potential problems to be addressed. Specific
operative procedures are well described and discussed, as well as sophisticated
approaches such as follicular stimulation employing advanced concepts such as
stem cells. The authors are assisted by a small group of worldwide experts who
present alternative techniques for achieving excellent results.

The authors are to be congratulated for putting together this major work, which
is destined to be standard reading for any surgeon performing hair replacement

Thomas M. Biggs, MD, FACS

Clinical Professor,
Department of Plastic Surgery,
Baylor College of Medicine,
Houston, Texas
P reface

Since the first edition of Hair Transplantation: The Art of Follicular Unit Micro-
gafting and Minigrafting, published more than 10 years ago, many advances and
refinements have occurred in the field of hair transplantation. For that reason,
Carlos Uebel, my close friend, colleague, and mentor, and I felt it was important
to produce a new edition of this book to share these innovations with other plas-
tic surgeons who perform hair restoration. In compiling this book, we have drawn
on our three decades of experience and observations in hair transplantation. In an
effort to improve our results and make follicular unit transplantation easier and
safer, with more predictable results, over time we have modified our techniques
and our philosophy, as we explain in detail throughout this book.

Adhering to meticulous technique and proper patient selection, we are now able
to consistently and predictably:
•   Produce natural and aesthetically pleasing results in hair transplantation for
male pattern baldness, female alopecia, and restoration of facial (mustache,
beard, eyebrows, and eyelashes) and body hair
•   Achieve undetectable recipient site scarring
•   Improve the donor site scar by incising longer, narrower donor site ellipses
and closing the site with no tension, often without the need to undermine
the edges
•   Dissect the donor strip into follicular unit micrografts and minigrafts with
even greater safety and accuracy, minimizing follicular transection (occur-
ring in less than 1% to 2% of hair shafts; formerly 5% to 10%)

In this book we describe improvements in managing the patient’s postoperative

course and recovery. In the past, patients commonly developed significant facial
edema after surgery, which would peak at about the second or third postopera-
tive day, and he or she would experience pain in the donor site for the first 7 to
10 days. We have significantly minimized and in many cases completely elimi-
nated postoperative edema and pain by modifying our tumescent solution.

Improvement in graft survival by using platelet-enriched growth factors has al-

lowed enhanced results. The text discusses revision of undesirable results from
previous hair transplantation procedures and refinements on the treatment of
xii Preface

crown baldness. We also have an update on tissue engineering and cloning and
the use of injectable protein-rich plasma to speed healing and convert miniatur-
ized hair into terminal hair.

In facial hair transplantation we now use finer blades and needles to create the re-
cipient sites on the eyebrows, improving the density and direction of hair growth
in a single session. For the mustache, beard, and eyebrows, we have modified our
technique by making the recipient site incisions first and then inserting the fol-
licular unit grafts, facilitating denser packing of the grafts in a given session. The
use of a French needle for eyelash reconstruction is also presented and updated.

There is an update on follicular unit extraction for donor hair harvesting from
the scalp and body, which in selected cases has definite advantages, and a chapter
on combining the strip method and the FUE technique. I (A.B.) prefer to use a
composite scalp strip as opposed to follicular unit individual grafts, accomplishing
reasonable density in one session.

A DVD is included with the book, presenting videos on follicular unit graft dis-
section; reconstruction of the eyebrows, eyelashes, mustache, and beard; face lift
and hair transplantation in a single session; reconstruction of the lost sideburn
secondary to face lift surgery; advances in aesthetic and reconstructive hair trans-
plantation; and follicular unit megasessions.

We feel privileged to have had the help of our expert colleagues who contributed
so generously to this book. They remind us that the future of hair transplantation
will be dynamic, challenging, and fulfilling for our patients as well as ourselves.

Alfonso Barrera
Carlos Oscar Uebel

I would like to thank my six children, Alfonso, Fernando, his precious wife,
Alana, and my first grandchild, Rita; and my daughters, Laura, Ana Cristina
(Kiki), Veronica, and Marisa for their patience as we brought this project to

Thanks also to my dear colleague and close friend, Carlos Uebel, who introduced
me to hair transplantation; he is a wonderful mentor and has been an inspiration
to me for so many years in the field of hair transplantation.

Karen Berger and her QMP team are an amazing group of professionals; I would
like to thank them for their invaluable help in putting the information together
and making this project possible.

My appreciation to our distinguished colleagues, who contributed their expertise

so admirably to this book: Drs. Francisco Jiménez, Fernando F. Barrera, James
Harris, Márcio Crisóstomo, James Vogel, Marcelo Gandelman, Clerisvaldo Al-
meida Souza, Anajara Gazzalle, Jorge Moojen da Silveira, Joseph Greco, and
Jerry Cooley.

Alfonso Barrera

My gratitude to my lovely family: to Walderez, my wife, who encourages me every

day; to my children, Juliane and Hiddo, Paulo and Mariana, and to my dearest
grandsons, Matheus and Philip. Thank you forever.

Carlos Oscar Uebel

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Pa rt I   F u n dame n ta l s
Chapter 1 Anatomy and Physiology of Hair  3
Francisco Jiménez, Alfonso Barrera, Carlos Oscar Uebel
Chapter 2 Patient Evaluation and Selection  23
Alfonso Barrera, Carlos Oscar Uebel
Chapter 3 Preoperative Planning and Patient Instructions  51
Alfonso Barrera, Carlos Oscar Uebel, Fernando F. Barrera
Chapter 4 Incorporating Hair Transplantation Into Your Practice  69
Alfonso Barrera

Pa rt I I   T ech n ique
Chapter 5 Intravenous Sedation  81
Alfonso Barrera, Carlos Oscar Uebel
Chapter 6 Correction of Male Pattern Baldness  87
Alfonso Barrera, Carlos Oscar Uebel, Jorge Augusto Moojen
da Silveira
Chapter 7 Correction of Female Pattern Baldness  169
Carlos Oscar Uebel, Anajara Gazzalle
Chapter 8 Combining Face Lift and Hair Transplantation  195
Carlos Oscar Uebel, Alfonso Barrera
Chapter 9 Follicular Unit Extraction  217
James A. Harris
Chapter 10 Combining Follicular Unit Extraction and Transplantation:
Untouched Strip Technique  237
Márcio R. Crisóstomo
Chapter 11 Revision of Unfavorable Results  263
James E. Vogel
Chapter 12 Complications  275
Carlos Oscar Uebel, Anajara Gazzalle
xvi Contents

Pa rt I I I   S pecia l P r o b l ems
Chapter 13 Hair Transplantation to Enhance Reconstruction of the Face
and Scalp  297
Alfonso Barrera, Carlos Oscar Uebel
Chapter 14 Correction of Scarring Alopecia After Face Lift  317
Alfonso Barrera, Carlos Oscar Uebel
Chapter 15 Reconstruction of Eyebrows and Eyelashes  331
Marcelo Gandelman, Carlos Oscar Uebel
Chapter 16 Correction of Hair Loss in the Crown Area  347
Clerisvaldo Almeida Souza
Chapter 17 Transgender Patients: Feminization of the Frontal Hairline  363
Alfonso Barrera

P a r t I V  New D i r ecti o n s
Chapter 18 Benefits of Platelet-Enriched Growth Factors  371
Carlos Oscar Uebel, Jorge Augusto Moojen da Silveira,
Anajara Gazzalle
Chapter 19 Benefits of Autologous Cellular Therapy  391
Joseph F. Greco
Chapter 20 Cell-Based Treatments: Tissue Engineering and Cloning  409
Jerry E. Cooley

Index 417

D V D V ide o s
Follicular Unit Graft Dissection
Alfonso Barrera
Reconstruction of Eyebrows, Eyelashes, Mustache, and Beard
Alfonso Barrera
Face Lift and Hair Transplantation in a Single Session
Alfonso Barrera
Reconstruction of the Lost Sideburn Secondary to Face Lift Surgery
Alfonso Barrera
Advances in Aesthetic and Reconstructive Hair Transplantation
Alfonso Barrera
Follicular Unit Megasessions: Personal Approach
Carlos Oscar Uebel
H air
T ransplantation
The Art of Follicular Unit
Micrografting and Minigrafting
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Pa rt I

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C H A P T E R 1

A natomy
and P hysiology
of H air

Francisco Jiménez, Alfonso Barrera,

Carlos Oscar Uebel
4 Part I  ▪ Fundamentals

  hair has been a source of pride to humans and is a distinguishing
that adorns as well as protects. It is also one of our most variable character-
istics. Wide differences in color, density, texture, length, and style distinguish dif-
ferent races and ethnic groups. Hair styling and adornment have evolved through-
out the ages. Today men as well as women place a premium on hair fashion and
products to enhance their appearance. Considering the significance placed on
hair, it is easy to understand why hair loss often causes severe emotional distress
and why people seek hair restoration. A surgeon performing hair transplantation
must have a basic understanding of the anatomy and physiology of human hair.
Hair transplantation demands excellent technical skills, a nuanced technique,
and an appreciation of a natural, aesthetically pleasing result to produce an op-
timal restoration.

Types of Hair
Although all human hair has the same basic structure, it varies considerably in
size, shape, and density, depending on its location and stage of development. Hair
shafts are mainly composed of fibrous alpha-keratin proteins. Two types of hair
shafts are recognized:
1. Vellus hairs are the soft, hypopigmented, unmedullated, almost invisible
hair seen on the forehead. These hairs are less than 0.03 mm in diameter
and less than 1 cm in length. Vellus hairs spread over the body surface and
are difficult to see without appropriate magnification.
2. Terminal hairs are longer, coarser, and of variable pigment. They character-
ize the adult years and exceed 0.06 mm in diameter and 1 cm in length.
Subtypes of terminal hair are found on the scalp, eyebrows, upper lip, chin,
axillae, chest, and pubis.1

Roughly 5 million hair follicles cover the human body at birth. It is generally
accepted that new follicles cannot develop in adult skin, although the size of
the follicles can change with time, primarily under the influence of androgen
hormones. For example, in adolescent males facial vellus hairs may turn into the
terminal hairs of the beard and mustache. In contrast, terminal hairs on the scalp
may turn into thin vellus hairs in men with male pattern baldness and in women
with androgenetic alopecia.
Chapter 1  ▪ Anatomy and Physiology of Hair 5

Hair Follicle Development


indentation Hair

Mesenchymal cells

Vellus hair


Hair shaft

Sebaceous gland



Erector pili muscle

Embryogenesis of capillary unit by interaction of mesenchymal and epidermic

cells, and generation of the hair sprout with all histologic structures

Hair grows from follicles, which are stockinglike invaginations of the superficial
epithelium. In an embryo, the hair follicles originate from both ectoderm and
mesoderm in the third gestational month and continue to develop over the next
3 months. The first morphologic sign of hair follicle development is the appear-
ance in the fetal epidermis of regularly spaced thickenings of epithelial cells
known as placodes. The placodes signal the underlying mesenchyme to form a
cluster of cells called the dermal condensate, which will develop into the dermal
papilla. The proliferation and growth of placode cells into the dermis will form a
primitive hair germ. Along the length of this primitive follicular epithelium, two
bulbous protuberances are formed: the upper protuberance will give rise to the
sebaceous gland, and the lower one, also known as the bulge region, coincides with
the insertion site of the erector pili muscle. The bulge region has lately attracted
considerable attention because it is the main reservoir of cutaneous stem cells.2
6 Part I  ▪ Fundamentals

Primitive Hair Follicle



A longitudinal section of fetal skin of 21 weeks’ gestational age stained with

hematoxylin and eosin is shown. Note the two protuberances of the follicular
epithelium: the upper one develops into the sebaceous gland, and the lower one,
known as the bulge, is the insertion site of the erector pili muscle.

The cells that form the hair matrix and the melanocytes are of ectodermal origin.
The melanocytes produce the color granules in the central, hollow core of the
hair shaft that give hair its natural color. The cells from the matrix divide and
are pushed upward; they are continuously replaced by new cells forming beneath
Chapter 1  ▪ Anatomy and Physiology of Hair 7

Erector pili
Sebaceous muscle
gland Dermis


Sweat Cortex

Henle’s Inner
layer root
bulb Outer root sheath

Glassy membrane
Fibrous sheath

As the matrix cells continue to be pushed up and outward and become dehydrated
by an extrusion process, they form a tubular hair shaft of dead protein called
keratin. This hollow tube is then filled with color granules (melanin) that give
hair its natural color. As we age, the melanocytes cease functioning, resulting in
gray or white hair.3
8 Part I  ▪ Fundamentals

Hair Follicle Histology


gland Isthmus

pili muscle Bulge

Inferior portion


To accomplish natural, aesthetic results in hair transplantation, one must pay

attention to many small details, starting with the important histologic features
of hair follicles. If we longitudinally section a terminal hair follicle of the scalp,
the follicle can be divided into three portions: (1) the infundibulum, which is the
superior portion that extends from the follicular orifice to the entrance of the
sebaceous duct, (2) the isthmus, which is the midsection of the follicle bounded
superiorly by the sebaceous duct and inferiorly by the insertion of the erector
pili muscle, and (3) the inferior segment, which is the section extending from the
insertion of the erector pili muscle to the base of the follicle (follicular bulb).
The follicular bulb is composed of the matrix cells and the dermal papilla. The
infundibulum and the isthmus constitute the permanent portion of the hair fol-
licle, because they remain intact throughout the entire hair cycle. In contrast,
the inferior segment undergoes periods of regression and regeneration during the
hair cycle.

It is essential for the hair transplant surgeon to know at what depth the most
important follicular compartments for hair regeneration are located. The average
total length of a scalp terminal hair follicle (or the distance between the scalp
epidermal surface and the dermal papilla) is about 4.2 6 0.4 mm,3 although there
is some variability among individuals.
Chapter 1  ▪ Anatomy and Physiology of Hair 9

Measurements of the Human Hair Follicle of the Scalp

Total length 4.2 mm
Infundibulum 0.8 mm
Isthmus 0.9 mm
Inferior portion 2.5 mm
FU density 65-85 FUs/cm2
Hair density 260 6 30 hairs/cm2
Bulge located 1-2 mm from scalp surface*
*Bulge as defined by immunoreactivity to the bulge stem cell marker cytokeratin 15.
FU, Follicular unit.

1 mm


2 mm

Multiple follicular units of Closeup view

various sizes

Another key component of the follicle is the isthmus or midportion of the follicle.
The isthmus is where the main niche of epithelial follicular stem cells (bulge)
is located. Hair transplant surgeons should be especially careful to avoid any
surgical transection of this 1 mm long zone, which is found 1 mm below the skin
surface. A vertical section of a terminal hair immunostained with an antibody
anticytokeratin (CK15) is shown that labels bulge stem cells (brown color). Note
that CK15-positive bulge stem cells extend all along the isthmus portion of the
follicle. A microscopically dissected hair follicle is shown (right), in which an oval
indicates the CK15-positive bulge region.
10 Part I  ▪ Fundamentals

Epidermis, dermis, dermal appendages, and subcutaneous fatty tissue can be seen
on vertical histologic sections of skin taken for skin biopsies or when checking
tissue margins after excision of skin lesions.
Chapter 1  ▪ Anatomy and Physiology of Hair 11

Follicular Unit Concept

Multiple follicular units of various sizes Closeup view

Two-hair follicular unit One-hair follicular unit

However, only transverse (horizontal) sections demonstrate that hair follicles

grow in follicular units. In his landmark 1984 article, “Transverse Microscopic
Anatomy of the Human Scalp,” Headington4 described the follicular unit (FU) as
including one to four terminal hairs, one vellus hair (rarely, two), their associated
sebaceous glands, insertions of erector pili muscles, a perifollicular vascular plexus,
a perifollicular neural net, and the perifolliculum (a circumferential band of fine
adventitial collagen that defines the unit). This suggests that a unit constitutes,
at least to some degree, a physiologic entity.
12 Part I  ▪ Fundamentals

This photo of occipital donor scalp shows how the hairs exit the skin in groupings
(follicular units). Most groupings in this area are two- and three-hair follicular

The FU density—the number of follicular units per square centimeter (FU/cm2)—

is an important concept for the hair transplant surgeon when evaluating how
much donor tissue needs to be harvested. In the donor occipital scalp of most
individuals, the FU density ranges from 65 to 85 FU/cm2.5 The FU density is dif-
ferent from the hair density, which is the number of hairs per square centimeter
(hairs/cm2). As a rule of thumb, the scalp hair density is about two to three times
the FU density. Significant racial differences have been reported: Asians and
those of African ancestry tend to have a lower hair density than whites, who have
an average scalp hair density of approximately 260 6 30 hairs/cm2.
Chapter 1  ▪ Anatomy and Physiology of Hair 13

Hair Follicle Cycle

New hair

Secondary germ cells

Dermal papilla


2-6 years 2-3 weeks 2-3 months
(Active growth (Transition (Resting phase)
phase) phase)

The hair follicle has a unique capacity to reconstitute itself, and this property as
well as its easy accessibility makes this a valuable and interesting organ for biolo-
gists and stem cell researchers. Each hair follicle perpetually goes through consec-
utive cyclical periods of growth (anagen), involution (catagen), and rest (telogen).
In humans, the follicular cycle is dysynchronous, which means that neighboring
follicles can be at different stages of the cycle.

At the onset of a new growth cycle (the start of anagen), the bulge stem cells are
activated by the dermal papilla, emerging from multiple positive and negative
dermal papilla signals. On activation, the stem cells exit the bulge and proliferate
downward, creating a long linear trail of cells, the outer root sheath. Enveloping
the dermal papilla at the hair follicle base, matrix cells divide rapidly before differ-
entiating upward to generate the hair shaft and its channel (inner root sheath). In
mature hair follicles, the outer root sheath extends from the bulge to the matrix.
14 Part I  ▪ Fundamentals

Hair follicles in different areas of the body produce hairs of different lengths, with
the length proportional to the duration of the anagen cycle. For example, scalp
hair follicles stay in anagen for 2 to 8 years and produce long hairs. The average
rate of growth of scalp hair is approximately 0.35 mm/day or 1 cm/month. Eye-
brow hair follicles stay in anagen for only 2 to 3 months and produce short hairs.
On average, 90% of scalp hairs are in the anagen phase at any one time, 1% will
be in catagen, and 5% to 15% in telogen. The catagen phase of scalp hairs lasts
several weeks, and the telogen phase 2 to 3 months. During telogen, hair growth
ceases and the attachment at the base of the follicle becomes weaker until the
hair is finally shed. Assuming 100,000 scalp hairs with 10% of them in telogen,
approximately 50 to 100 telogen hairs from various regions of the scalp are shed
daily and replaced by newly growing anagen hairs.

After hair transplantation, the hair grafts enter into catagen and telogen phases.
For this reason, significant growth of the hair grafts is not seen until these phases
are over, approximately 2 to 4 months after the transplant. In addition, some of
the native hairs often go into the catagen phase and then into the telogen phase
from the trauma of the surgery (telogen effluvium).

Approximately 10% of hair follicles in a nonbalding scalp are in the telogen

phase. When the rate of hair loss exceeds the rate of growth, thinning and even-
tually baldness develop.

Follicular Stem Cells

Stem cells are characterized by their multipotency and in vivo quiescence, and
hair follicle stem cells are fundamental for the regeneration of the pilosebaceous

A hair follicle contains both epithelial and mesenchymal stem cells. The main
niche of follicular epithelial stem cells is located at the bulge region.2,6 It is im-
portant to realize that although the bulge region was originally described as the
anatomic protuberance of the hair follicle to which the erector pili muscle at-
taches, in its biologic sense as an epithelial stem cell niche, the bulge extends all
along the isthmus region (see image on p. 9).
Chapter 1  ▪ Anatomy and Physiology of Hair 15

Mesenchymal stem cells have been found in the dermal papilla and dermal
sheath. These cells have the capacity to differentiate into a range of cell types,
making hair follicles a potential source of multipotent cells with therapeutic sig-
nificance in regenerative medicine.7 There is also evidence to support the argu-
ment that epithelial bulge stem cells and dermal sheath/dermal papilla stem cells
can play a role in wound healing, repairing the epidermis and dermis after injury.8

The presence of stem cells in hair follicles has opened a window for new treatment
strategies in hair restoration. A number of research teams are working to isolate
and culture follicular stem cells to inject or transplant them in a recipient balding
scalp with the goal of forming new hair follicles, or activating and transforming
dormant vellus hair follicles into terminal ones.

Applied Anatomy: Alopecias Suitable for Hair

Restoration Surgery
Alopecia, a generic term for hair loss, results from a diminution of visible hair.
There are numerous types of alopecia; some are permanent and some are revers-
ible. In this chapter we will focus on androgenetic alopecia and the scarring
alopecias, which are the reasons for most requests for hair restoration surgery.

Androgenetic Alopecia
Androgenetic alopecia, or common baldness, is characterized by the progressive,
visible thinning of scalp hair in genetically susceptible men and in some women.
The thinning is caused by the gradual miniaturization of the hair follicles. Min-
iaturization results in the conversion of large (terminal) hairs into small, barely
visible, depigmented (vellus) hairs. At the cellular level, follicle miniaturization
is thought to be caused by a reduction in dermal papilla volume as a consequence
of a decrease in the number of cells per papilla.

The clinical pattern of male androgenetic alopecia is well described in the Nor-
wood classification system9 (see Chapter 2). Most commonly, androgenetic alope-
cia begins with bitemporal recession, followed by vertex baldness and midfrontal
hair loss, with sparing of the occipital scalp, even in the most severe cases.

The pattern of androgenetic alopecia in women is characterized by diffuse central

thinning over the midfrontal scalp, as described by Ludwig10 (see Chapter 2).
16 Part I  ▪ Fundamentals

Sinclair photographic scale of female androgenetic alopecia. (Sinclair R, Patel M, Dawson TL, et al. Hair loss
in women: medical and cosmetic approaches to increase hair fullness. Br J Dermatol 165:12-18, 2011.)

These photos show the sequence of female androgenetic alopecia over time. In
female androgenetic alopecia (also known as female pattern hair loss), the anterior-
most hairline is usually spared, and the thinning of the hair occurs in the parietal
central scalp. These patients are candidates for hair transplantation if the donor
scalp hair is thick and dense enough. Women with androgenetic alopecia usually
do not have abnormalities in circulating androgens, but they should be checked
for iron deficiency (serum iron and serum ferritin), and thyroid function tests
(TSH and free T4) should be performed to rule out other causes of diffuse hair
loss. Women with bitemporal recessions, as seen in male pattern baldness, should
also be screened for hyperandrogenism.

Androgenetic alopecia in males and females, especially when it is severe and

premature, may have significant psychosocial effects.

Pathophysiology of Androgenetic Alopecia

The current scientific data support the thesis that male pattern androgenetic alo-
pecia has a polygenic trait. Eight susceptibility loci have been described to date,
including the androgen receptor gene on the X chromosome.11,12 Interestingly,
unexpected genetic associations between early androgenetic alopecia, Parkinson’s
disease, and decreased fertility have been recently reported.12
Chapter 1  ▪ Anatomy and Physiology of Hair 17

It has been known for some time that androgens are important in the pathophysi-
ology of androgenetic alopecia. Although testosterone is the major circulating
androgen, to be maximally active in scalp hair follicles it must first be converted
to dihydrotestosterone (DHT) by the enzyme 5-alpha-reductase. The importance
of DHT as an etiologic factor in male pattern hair loss is shown by the absence of
this condition in men with a congenital deficiency of type II 5-alpha-reductase,
and by varying amounts of hair regrowth in men treated with finasteride, a selec-
tive type II 5-alpha-reductase inhibitor. In women, however, there is no consensus
as to whether female pattern androgenetic alopecia is truly androgen dependent.
Most affected women do not have biochemical hyperandrogenism, and women
without circulating androgens may also develop female pattern androgenetic alo-
pecia, suggesting a possible role for non-androgen-dependent mechanisms.

Recently it has been discovered that certain prostaglandins can also play an
important role in the pathophysiology of androgenetic alopecia. Prostaglandin
D2 reduces hair growth, and PGD2 levels are increased in the balding scalp of
androgenetic alopecia.13 In contrast, prostaglandin F2 (or its analog, bimatoprost)
stimulates hair growth.14

Scarring Alopecias
Scarring alopecia can be divided into primary and secondary types. In the primary
type, the hair itself is the principal target for destruction. In secondary scarring
alopecia, the follicle is an “innocent bystander” and is destroyed in a nonspecific
manner. A patient with scarring alopecia should be clinically and histologically
evaluated to specifically classify the condition.

Classification of Scarring Alopecias

Primary Secondary
Frontal fibrosing alopecia Burns
Lichen planopilaris Radiotherapy-induced alopecia
Chronic lupus erythematosus Traumatic injuries
Classic pseudopelade of Brocq Postrhytidectomy
Folliculitis decalvans Postfungal infection scarring
Central centrifugal cicatricial alopecia
18 Part I  ▪ Fundamentals

In primary scarring alopecias, such as lichen planopilaris, frontal fibrosing alope-

cia, or discoid lupus erythematosus, the inflammation occurs in the mid-upper part
of the follicle, involving the stem cell−rich bulge area. The resultant destruction
of the stem cells inactivates further follicular cycling and leads to a permanent
loss of the follicle.

This patient has frontal fibrosing alopecia showing the typical recession of the
frontotemporal hairline with loss of the sideburns and eyebrows. Patients with
this condition are normally not suitable candidates for hair transplantation. Fi-
brosing alopecia should not be confused with the female pattern hair loss seen in
the patient on p. 16.

These primary scarring alopecias have a tendency to be progressive and to recur

intermittently over time. Medical therapy should be initiated as soon as possible
before irreversible scarring takes place.15 Only nonactive, stable, primary scarring
alopecias should be considered for surgical treatment. Otherwise, the transplanted
grafts will be destroyed by the inflammatory process. Therefore it is advisable to
confirm that the disease has been inactive or quiescent for at least 2 years before
undertaking hair transplantation.

Secondary types of scarring alopecia include those caused by burns or traumatic

injuries or the scars associated with radiotherapy, fungal infection, and rhytidec-
tomy. These scarring alopecias are stable and nonprogressive and are particularly
suitable for hair restoration surgery.
Chapter 1  ▪ Anatomy and Physiology of Hair 19

Surgeons performing hair transplantation procedures must be equipped to re-
store sideburns, the temporal and retroauricular hairline, eyebrows, eyelashes,
mustache, beard, and areas of the scalp. A sound grounding in anatomy and
physiology is essential to produce successful outcomes. As our understanding of
anatomy and physiology of the hair has grown, it has become clear that optimal
graft survival and ultimate hair growth depend on transplanting more than just
bare hair shafts.

Slightly chubby grafts and intact follicular unit grafts thrive better, as demon-
strated by Seager in 1997.16 Dissecting FU micrografts to the bare hair shaft may
decrease the percentage of graft take. Whether it is the perifollicular vascular
plexus, the sebaceous glands, or other appendages that are necessary for survival
is unknown. Seager reported 113% hair survival and growth with follicular unit
grafts. (Presumably, hairs that were in the telogen phase were not initially counted
but ultimately grew hair.) The hairs in the telogen phase are also included when
slightly chubby micrografts and minigrafts are transplanted. Care must be taken
not to make the grafts too chubby, particularly when transplanting eyebrows or
eyelashes. In these situations, ultrafine single-hair FU grafts are needed; these
must be gently trimmed close to the hair shaft.
20 Part I  ▪ Fundamentals

Key Anatomic Concepts

• When harvesting the donor ellipse, the surgeon should make the incision
at the deep subcutaneous level and superficial to the fascia to preserve the
occipital nerves and vessels.
• Dissection should separate the plane between the subcutaneous tissue and
• The elasticity of the scalp in the donor area is usually greatest in the occipi-
tal midline and becomes less elastic laterally toward the ears and temple.
• The density of hair is usually greatest at the midline and diminishes as one
proceeds laterally.
• Recipient sites at a depth of 4 mm are recommended to match the average
length of terminal scalp hairs.
• Follicular unit grafts should be inserted in the recipient site following the
same angulation and orientation of the residual hair to mimic the natural
direction of hair growth.
• The epidermis of the graft should remain superficial to the epidermis of the
scalp to avoid ingrown hairs and epidermal inclusion cysts.
• Grafts larger than one follicular unit will produce an unnatural appearance
as a result of compression.

1. Mens J, Wyss AR. Multituberculate and other mammal hair recovered from Palaeogene
excreta. Nature 385:712-714, 1997.
2. Cotsarelis G, Sun TT, Lavker RM. Label-retaining cells reside in the bulge area of pilose-
baceous unit: implications for follicular stem cells, hair cycle, and skin carcinogenesis. Cell
61:1329-1337, 1990.
3. Jimenez F, Izeta A, Poblet E. Morphometric analysis of the human scalp hair follicle: practi-
cal implications for the hair transplant surgeon and hair regeneration studies. Dermatol Surg
37:58-64, 2011.
4. Headington JT. Transverse microscopy anatomy of the human scalp. Arch Dermatol 120:449-
456, 1984.
5. Jimenez F, Ruifernandez JM. Distribution of human hair in follicular units. Dermatol Surg
25:294-298, 1999.
6. Hsu YC, Pasolli HA, Fuchs E. Dynamics between stem cells, niche and progeny in the hair
follicle. Cell 144:92-105, 2011.
7. Driskell RR, Clavel C, Rendl M, et al. Hair follicle dermal papilla cells at a glance. J Cell Sci
124:1179-1182, 2011.
8. Jahoda CA, Reynolds AJ. Hair follicle dermal sheath cells: unsung participants in wound
healing. Lancet 358:1445-1448, 2001.
Chapter 1  ▪ Anatomy and Physiology of Hair 21

9. Norwood OT. Male pattern baldness: classification and incidence. South Med J 68:1359-1365,
10. Ludwig E. Classification of the types of androgenetic alopecia (common baldness) occurring
in the female sex. Br J Dermatol 97:247-254, 1977.
11. Ellis JA, Skebbing M, Harrap SB, et al. Polymorphism of the androgen receptor gene is as-
sociated with male pattern baldness. J Invest Dermatol 116:452-455, 2001.
12. Li R, Brockschmidt FF, Kiefer AK, et al. Six novel susceptibility loci for early-onset an-
drogenetic alopecia and their unexpected association with common diseases. PLoS Genet
8:e1002746, 2012.
13. Garza LA, Liu Y, Yang Z, et al. Prostaglandin D2 inhibits hair growth and is elevated in bald
scalp of men with androgenetic alopecia. Sci Transl Med 4:126ra34, 2012.
14. Khidir KG, Woodward DF, Farjo NP, et al. The prostamide-related glaucoma therapy, bima-
toprost, offers a novel approach for treating scalp alopecias. FASEB J 27:557-567, 2013.
15. Harries MJ, Sinclair RD, MacDonald-Hull S, et al. Management of primary cicatricial alo-
pecias: options for treatment. Br J Dermatol 159:1-22, 2008.
16. Seager DJ. Micrograft size and subsequent survival. Dermatol Surg 23:757, 1997.
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C H A P T E R 2

Patient E valuation
and S election

Alfonso Barrera, Carlos Oscar Uebel

24 Part I  ▪ Fundamentals

T o date, we have no method for creating new hair. All current techniques for
hair restoration involve redistributing the patient’s existing hair. Therefore can-
didates for hair transplantation are limited to those who have a favorable donor
site surface area and density relative to the size of the area to be transplanted.
The higher the density and larger the size of the potential donor area (occipital
and temporal areas) and the smaller the surface area to be grafted, the better the
candidate. Older individuals with more predictable balding patterns are ideal pa-
tients. Several centers worldwide are working on tissue engineering in an attempt
to clone hair follicles or to culture and multiply hair follicles in the laboratory
setting (see Chapter 20). When this proves successful, we will be able to treat
patients who have limited donor hair (follicularly challenged patients) and need
only harvest a sample of hair follicles, thereby eliminating donor site morbidity
completely. For the time being, however, transplantation depends on the avail-
ability of autologous hair.

Careful patient evaluation and good communication are essential. Patients must
have realistic expectations as to the result that can be achieved. They must un-
derstand that the procedure involves redistributing their existing hair and that
currently there is no method to create new hair. Therefore there are limits to the
hair density that can be expected. All patients, especially young ones, need to
understand that male pattern baldness is a progressive condition and that the hair
loss will continue; thus there is a high likelihood that they will need additional
hair transplantation sessions in the future. To obtain the best result possible, it
will often take two sessions and in some cases three. However, a reasonable im-
provement can often be obtained in just one megasession.

Patients under 30 years of age are often the most demanding. They must under-
stand that because of their young age, it is impossible to determine in advance the
endpoint of their hair loss. Conservatism is recommended in these cases.

When patients are afforded proper consultation and have developed realistic
expectations, we have found that 97% of our patients are satisfied after a single
hair transplantation session. The 3% of patients who were dissatisfied with hair
density after surgery have had second sessions to improve the density and were
pleased with the results.1,2,9-12
Chapter 2  ▪  Patient Evaluation and Selection 25

Hair Loss Patterns

Male pattern baldness type VI

Ludwig grade II Ludwig grade III

Male pattern baldness is by far the most frequent type, followed by androgenetic
(pattern) alopecia in females. The patients shown here represent typical hair loss
26 Part I  ▪ Fundamentals

Postsurgical alopecia may occur after oncologic resection of the scalp or eyebrows.
After facial rejuvenation or craniofacial procedures, loss of sideburns or frontal,
temporal, and retroauricular hair loss is not uncommon.

Posttraumatic alopecia includes hair loss resulting from injuries such as burns,
traumatic injuries of the scalp and eyebrows, and scalp avulsions.
Chapter 2  ▪  Patient Evaluation and Selection 27

Examples of congenital hair loss include the absence of mustache hair in cases of
bilateral cleft lip (not obvious until after puberty), triangular temporal alopecia,
and nevus sebaceus of Jadassohn.
28 Part I  ▪ Fundamentals

Classification Systems
Norwood Classification


III IIIvertex IV


From Norwood OT, Shiell R, eds. Hair Transplant, 2nd ed. Springfield, Ill: Charles C Thomas, 1984.

The most commonly used classification for male pattern baldness is the one de-
scribed by Norwood3:
Type I There is minimal or no anterior hairline recession at the fron-
totemporal areas.
Type II Triangular symmetrical frontotemporal recessions extend pos-
teriorly no more than 2 cm anterior to the coronal plane drawn
between the external auditory canals.
Type III The frontotemporal recessions extend posteriorly beyond 2 cm
anterior to the coronal line drawn between the external audi-
tory canals.
Type IIIvertex Primarily a vertex hair loss but may be accompanied by a fron-
totemporal recession that does not exceed that described for
type III.
Type IV The frontotemporal recession is more severe than in type III.
There is sparse or absent hair in the vertex area, but both ar-
eas are separated by a band of moderately dense hair that goes
across the top of the head.
Type V Hair loss in both the frontotemporal and vertex areas is more
extensive and only separated by a narrower and sparser band of
hair across the top.
Type VI The band of hair that separated the frontotemporal area and
vertex is gone. The two areas are interconnected. The entire
area has extended laterally and posteriorly.
Type VII This is the most severe form of male pattern baldness. There is
only a narrow horseshoe-shaped band of sparse, fine hair.
Chapter 2  ▪  Patient Evaluation and Selection 29


IVa Va

From Norwood OT, Shiell R, eds. Hair Transplant, 2nd ed. Springfield, Ill: Charles C Thomas, 1984.

Norwood also described a less common type a variant that applies to about 3% of
cases of male pattern baldness in which the baldness starts at the anterior hair-
line without a peninsula of hair and advances in a posterior direction. The type
a anterior variance patterns are classified as follows:
Type IIa The entire anterior hairline is high on the forehead. The mid-
frontal peninsula is represented by only a few sparse hairs. The
area of denudation extends no farther than 2 cm from the mid-
frontal line.
Type IIIa The area of denudation essentially reaches the midcoronal line.
Type IVa The area of alopecia extends posterior to the midcoronal line.
Type Va This is the most advanced degree of alopecia and extends further
posteriorly. If it progresses, it may be indistinguishable from
types V and VI.

Ludwig Classification

Grade I Grade II Grade III

From Ludwig E. Ludwig’s classification of female androgenic alopecia. Br J Dermatol 97:247, 1977.

The most common classification used for female androgenetic alopecia is the
Ludwig classification.4 It consists of the following grades:
Grade I Mild hair loss
Grade II Moderate hair loss
Grade III Severe hair loss
30 Part I  ▪ Fundamentals

For women, hair thinning is usually more generalized, in most cases sparing the
front hairline, with significant thinning of the vertex, temple, and parietal ar-
eas. The only area of reasonably good hair quality and density tends to be in the
occiput. Women who develop androgenic alopecia do not necessarily have an
abnormal increase in circulating androgenetic or hormonal imbalances. Many,
in fact, have normal adult female androgen levels. It may be that the androgen
receptors in the hair follicles are hypersensitive to or have a greater binding af-
finity to dihydrotestosterone, which may or may not be genetic in origin.5

Other Common Types of Hair Loss and Alopecias

Although genetic predisposition is the cause of most forms of hair loss, other
sources of hair loss include:
• Hair loss resulting from aesthetic facial rejuvenation surgery: coronal and
endoscopic forehead lifts may cause loss of sideburns, hair loss in the tem-
poral hairline, and distortion of the retroauricular hairline
• Scalp and facial hair loss associated with burns and other traumatic injuries
• Congenital abnormalities of the face or scalp, such as vascular malforma-
tions, melanotic nevi, and bilateral cleft lip, that require surgical excision
or revision
• Postoncologic resections resulting from the excision of tumors of the skin
or scalp

Current techniques of follicular unit (FU) hair transplantation can help to en-
hance aesthetics in the reconstruction of the face and scalp. In selected cases,
autologous fat injections a few months in advance of the hair transplantation
procedure may help to prepare the recipient site, making it a better ground for
the grafts.

The Progressive Nature of Hair Loss

One of the most important characteristics of baldness is its progressive nature.
The rate of hair loss may slow after the age of 40, but it never stops completely.
This subject has already been very well covered by Marritt and Dzubow6 and by
Norwood,7 who described it as a condition of “progression and predictability.”
When hair loss is correctly evaluated, it will provide the means for establishing
a lifelong hair restoration program for the patient.

We know that baldness has three causes: heredity, hormones, and age. Heredity
provides the best means for evaluating the future course of a patient’s baldness.
We normally find that a patient’s predisposition for baldness can be traced to their
maternal genealogy: the maternal grandparents and brothers. By observing the
maternal genealogy, we are better able to understand the type and progression of
a patient’s baldness. If the father is also bald, we can more precisely estimate its
limits and devise a suitable preoperative plan.
Chapter 2  ▪  Patient Evaluation and Selection 31

Hair loss in both men and women is naturally occurring and usually has a genetic
origin. These hereditary conditions appear to be controlled by a single, dominant,
sex-linked autosomal gene. The expression of this gene depends on the level of
circulating androgens. The initial signs of thinning clearly correlate with puberty
in males, when the levels of androgens (testosterone) start to rise, gradually con-
verting terminal hair into vellus hair. Initially this results in a receding hairline,
and, depending on the genetic features inherited, may progress until only a tem-
poral and occipital fringe remains.

Testosterone secreted by the testes is the principal androgen circulating in plasma

in men, whereas in women the adrenal steroids dehydroepiandrosterone sulfate,
androstenediol sulfate, and 4-androstenedione are the most abundant proandro-
gens. A proandrogen is a 19-carbon steroid that is converted at the target tissue
into active androgen. The enzymatic reduction of testosterone and the above-
mentioned androgens in females by 5-alpha-reductase into dihydrotestosterone
is necessary for the induction of androgenetic hair loss in men and women.8

Another cause of progressive baldness is age: as patients get older, we can see, in
addition to definitive loss, a thinning of the implanted hair. Hair is lost from the
whole scalp, including the donor area, as is seen in this middle-aged patient whose
implanted hair began thinning 8 years postoperatively. A second transplantation
will increase his hair density.
32 Part I  ▪ Fundamentals

Before surgery 6 years postoperatively After second transplantation

Hair loss can also be observed in the occipital region, where there is an increase
of the crown area, and a thinning of all the hair in the posterior region. We can
better evaluate the progressive nature of baldness in the crown area.

The progressive nature of baldness is a reality for hair restoration professionals

as well as their patients seeking a solution to baldness through surgery. Once
patients appreciate this progression, they confidently return to their physicians
for multiple replacements over time.

The man on p. 33 received three hair replacement procedures over 15 years. He

is shown preoperatively and 5 years after his first hair replacement. The crusts of
the implanted hair are shown in closeup. At 7 and 12 years postoperatively his
hair had thinned, and he underwent additional hair replacement procedures. He
is shown 15 years postoperatively with good hair density, which is evident in the
closeup view of his hairline.

Surprisingly, the quality and strength of the implanted hair in some patients lasts
for an indefinite time, without subsequent thinning or diffuse baldness. This oc-
curs because of a very particular characteristic and a high histologic quality of
the donor area, which is seemingly immune to the effects of heredity, hormones,
or aging.
Chapter 2  ▪  Patient Evaluation and Selection 33
34 Part I  ▪ Fundamentals

This man had hair transplantation when he was 34 years old. He is shown pre-
operatively and 2, 9, and 22 years postoperatively, without substantial hair loss
from the transplanted region.
Chapter 2  ▪  Patient Evaluation and Selection 35

This patient received hair replacement with minigrafts and underwent a subse-
quent micrograft session years later to increase hair density. He is shown 14 years
postoperatively. The transplanted hair is still of good quality, confirming that in
some patients baldness and thinning can be inconspicuous.
36 Part I  ▪ Fundamentals

Patient Profiles
The following patient profiles represent the range of clinical challenges encoun-
tered in a hair restoration practice.

This 22-year-old man with male pattern baldness type II to III was the youngest
patient that I have operated on for male pattern baldness. Extreme caution and
a conservative approach are warranted, since the endpoint of hair loss cannot
be determined in this age group. It must be assumed that hair loss will progress
significantly. The density of this patient’s donor hair appears to be good; however,
the individual hair shafts are of moderate thickness. His family history suggests
that he will retain his temporal and occipital hair. I recommended strengthening
the front hairline but leaving it at a relatively high position to ensure sufficient
donor hair for future procedures when needed.

If a lower hairline is established in patients of this age, more grafts will be required
to cover the entire top of the head at a later date. A mature hairline pattern is
essential for long-term planning. The grafts will be concentrated only on the
front. The decision to graft the crown should be deferred until he is older, when
his hair loss pattern can be more accurately assessed and the available amount of
donor hair determined. The patient must understand that because of his young
age, future sessions will be needed as hair loss progresses. I rarely perform surgery
on patients in this age group.
Chapter 2  ▪  Patient Evaluation and Selection 37
38 Part I  ▪ Fundamentals

This 31-year-old man with male pattern baldness type V has a more mature pat-
tern of baldness than the previous patient. Although hair loss will continue to
progress, his hair loss pattern as he ages can be better determined, making a more
aggressive approach acceptable. His donor hair is extraordinarily full, thick, and
wiry. A lower front hairline can be established than in the previous case, and the
entire area of baldness can be grafted. This particular patient should have suf-
ficient donor hair for future procedures when needed.
Chapter 2  ▪  Patient Evaluation and Selection 39

This 53-year-old man with type VI male pattern baldness is an ideal candidate,
because his pattern of hair loss is well established and will probably not change
dramatically. In such cases a maximal density procedure (such as 1500 to 2500
micrografts and minigrafts) can be planned. His donor hair has good density
and thickness, and the entire area of baldness will be grafted. A hairline pattern
consistent with the patient’s mature age is the preferred approach to produce the
most natural result. Thus a slight frontotemporal recession will remain.
40 Part I  ▪ Fundamentals

This 43-year-old man has type III vertex male pattern baldness without fronto-
temporal recession. The density and thickness of his donor hair are excellent.
The front part of his scalp is covered with healthy, full hair. His pattern of bald-
ness is well established and limited to the crown. I recommended two sessions of
micrografts and minigrafts a year apart to achieve an optimal result. The crown
typically will take at least two sessions to obtain reasonable coverage. Although
the whorl can be reconstructed by orienting the grafts in a circular orientation,
it probably does not warrant the additional time and effort.
Chapter 2  ▪  Patient Evaluation and Selection 41

This 72-year-old man with type VI male pattern baldness has limited donor areas
as well as very fine hair. Interestingly, white hair produces an optical illusion of
more hair than is actually present. In my experience, people with white or gray
hair can anticipate good results because of this phenomenon. However, in pa-
tients with white, gray, or extremely light blond hair it is imperative to use the
operating microscope and background lighting to accurately dissect the micro-
grafts and minigrafts, since it is difficult to see the hair bulbs and hair shafts. This
patient’s pattern of baldness is very stable and will not progress much further. For
this patient I recommended a 1500 to 2000 graft megasession. I do not foresee
the need for additional sessions in the future.
42 Part I  ▪ Fundamentals

This 46-year-old man with type VI male pattern baldness exhibits uniform thin-
ning and no areas of complete hair loss. This patient was advised that further
thinning can be expected for the first 3 to 4 months after the procedure (telogen
effluvium). The donor hair has a high density and thickness. I recommended
transplanting approximately 1500 micrografts and minigrafts in a single megases-
sion. The surgical plan is to strengthen his mature hairline and proceed posteri-
orly. The hairline is at an appropriate level; I would not move it down.
Chapter 2  ▪  Patient Evaluation and Selection 43

This 36-year-old man with minimal hair loss (type I) has a scar at the hairline
that he wanted camouflaged. He also requested a slightly lower hairline. His hair
is so dense and healthy that it is unlikely that he will experience much further
hair loss. Hair density and thickness are excellent over the entire scalp. Trans-
plantation of approximately 600 micrografts at each of two sessions will provide
sufficient hair density. No minigrafts should be used in this patient, since they
will be too large and look unnatural at the front hairline. Although this patient’s
hair loss is minimal, matching the existing density of the remaining scalp poses
a challenge to the surgeon.
44 Part I  ▪ Fundamentals

This 37-year-old man has type IV male pattern baldness. His coarse, wavy donor
hair will provide good coverage. Because his hair loss is not severe, approximately
700 to 800 micrografts and minigrafts should be sufficient to cover both the front
scalp and crown. Again, he must be forewarned that there will be further tem-
porary thinning. The hair must be continuously parted as the grafts are inserted;
however, it is not necessary to shave the residual hair in the recipient areas. The
plan is to maintain and strengthen the current hairline.
Chapter 2  ▪  Patient Evaluation and Selection 45

This 48-year-old man with thick, curly, salt and pepper hair has type VI male
pattern baldness. In such patients a reasonable density can often be obtained in
a single session. Dissection of micrografts and minigrafts in a patient with curly
hair is more difficult, because the hair will be curly even within the dermis. In
such cases I make 5 mm thick slices off of the donor ellipse instead of the typical
2 mm slices. I then make the micrografts and minigrafts from these slices. This
helps preserve intact follicular units. Background lighting and the operating mi-
croscope may be needed in this situation because of the gray hair.
46 Part I  ▪ Fundamentals

This 43-year-old woman has Ludwig grade II to III female androgenetic alopecia.
Patients such as this tend to exhibit uniform thinning over the entire scalp, with
preservation of the front hairline. Candidates for the procedure must have an area
(which tends to be in the occipital region) with good hair quality and density.
I recommended that this patient undergo a megasession of 1000 micrografts and
minigrafts. The patient must be forewarned that she can expect further temporary
hair thinning for the first 3 to 4 months in the area grafted (telogen effluvium).
I recommend that female patients use 2% minoxidil twice a day postoperatively
to help preserve and increase the density of the existing hair as well as the grafted
Chapter 2  ▪  Patient Evaluation and Selection 47

This 39-year-old woman has scarring alopecia of the sideburns and temporal
hairline as a result of a face lift procedure. She has plenty of donor hair. The plan
is to place 1000 FU grafts. The patient must be told that it is not unusual that a
second procedure a year later may be required for optimal density.
48 Part I  ▪ Fundamentals

This 67-year-old man has male pattern baldness type VI and a limited amount of
donor hair. We must strategically plan on giving priority to restoring hair to the
frontal scalp and not so much to the crown. This will help to frame his face by
providing a frontal hairline; from there he can comb his hair back and partially
cover the crown.
Chapter 2  ▪  Patient Evaluation and Selection 49

1. Barrera A. Micrograft and minigraft megasessions: review of 100 consecutive cases. Aesthetic
Plast Surg 17:165-169, 1997.
2. Uebel CO. Micrografts and minigrafts: a new approach for baldness surgery. Ann Plast Surg
27:476-487, 1991.
3. Norwood OT. Classification of male pattern baldness. In Norwood OT, Shiell R, eds. Hair
Transplantation Surgery, ed 2. Springfield, IL: Charles C Thomas, 1984.
4. Ludwig E. Classification of the types of androgenic alopecia (common baldness) arising in
the female sex. Br J Dermatol 97:247-254, 1977.
5. Norwood OT. Female androgenic alopecia. Hair Transplant Forum Int 4:12, 1994.
6. Marritt E, Dzubow LM. Reassessment of male pattern baldness: a reevaluation of the treat-
ment. In Stough DB, Haber RS, eds. Hair Replacement—Surgical and Medical. St Louis:
Mosby−Year Book, 1996.
7. Norwood OT. Male pattern baldness: classification and incidence. South Med J 68:1359-1365,
8. Mens J, Wyss AR. Multituberculate and other mammal hair recovered from Palaeogene
excreta. Nature 385:712-714, 1997.
9. Barrera A. Clinical decision making in hair transplantation. In Nahai F, ed. Art of Aesthetic
Surgery: Principles & Techniques. St Louis: Quality Medical Publishing, 2011.
10. Barrera A. Hair transplantation. In Lin SJ, Mustoe TA, eds. Aesthetic Head and Neck Sur-
gery: An Operative Atlas. New York: McGraw-Hill Professional, 2013.
11. Barrera A. Hair transplantation. In Carniol PJ, Monheit GD, eds. Aesthetic Rejuvenation
in Clinical Practice. London: Informa Medical, 2009.
12. Vogel JE. Correcting problems in hair restoration surgery: an update. Facial Plast Surg Clin
North Am 12:263-278, 2004.
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C H A P T E R 3

P reoperative
P lanning and Patient
I nstructions


Alfonso Barrera, Carlos Oscar Uebel,

Fernando F. Barrera
52 Part I  ▪ Fundamentals

ertain basics must be addressed before one undertakes follicular unit micro-
and minigrafting for hair restoration. Adequate training of both the sur-
geon and staff is essential for success. The surgeon will also want to confirm that
the right equipment and instrumentation are available to ensure good results and
safe patient management. Once the fundamentals are mastered, attention must
be directed to careful preoperative planning, combined with effective patient
instruction. These critical issues are discussed in this chapter, which also provides
guidance on preoperative planning, the timing of treatment, preoperative and
postoperative patient instructions, and informed consent.

Preoperative Planning: Important

Timing of Treatment
We have operated on an increasing number of young patients who have come to
us for hair replacement. Whenever possible, we recommend surgery after 23 years
of age, when the patient has become conscious of the progressive nature of bald-
ness. In individuals who are younger than 23, we often see incipient baldness
and recommend the use of topical solutions, such as minoxidil 5% or Alfatradiol
(U.S.)/Avicis (Brazil) and finasteride (Propecia) orally 1 mg a day. One problem
with finasteride is that it may cause decreased libido, which occurs in up to 8%
of the patients treated in our clinic after 6 months. When this occurs, we discon-
tinue the treatment. After 2 to 3 years, when the patient returns to our clinic, he
or she will be more conscious of their progressive baldness, and we can suggest a
surgical program with follicular unit (FU) grafts.

We occasionally proceed with hair transplantation in younger patients with male

pattern baldness, as long as the patient and his or her family understand that we
will focus on the front hairline and not the crown at this early age. We also tell
them that since we do not know what the ultimate degree of the hair loss will
be, we must be very conservative, and a further session of grafting will likely be
necessary in time.

The hairline design must be very natural and preserve the temporal recessions, so
that undesirable hair will not be implanted in this region in the future.
Chapter 3  ▪  Preoperative Planning and Patient Instructions 53

In planning the future hairline of this 23-year-old patient, we maintained the

temporal recessions 2 cm back.

This young patient received one replacement procedure. Five years later, intense
progressive baldness can be seen, showing gaps between the implanted hair and
the hair-bearing scalp on the crown.
54 Part I  ▪ Fundamentals

3 years before first procedure

3 years after first procedure After 6 years in need of second procedure

Progressive baldness is seen in this young patient, 3 and 6 years after surgery. It
was then time for a second replacement. The implanted hair is still in place.

The most significant problem for young patients is the increase in capillary den-
sity, mainly in cases in which hair rarefaction is in its initial stage. In this situa-
tion, the punctiform (stick and place) technique contributes greatly—we are able
to add hair among the remaining hair, without damaging it. We do not remove
sections of the scalp or capillary roots from this area, but only introduce new roots
through small incisions, which are added to the remaining hair.
Chapter 3  ▪  Preoperative Planning and Patient Instructions 55

Before surgery

2 years after surgery 8 years after surgery

Another example of progressive baldness in a young patient seen before hair

transplantation, 2 years after surgery with good density, and 8 years later, with
only the implanted hair remaining. The patient has cut his hair short.

As baldness increases, we observe the loss of the remaining hair; this is not the
implanted hair, which preserves its strength and genetic quality from the donor
area. Patients may become worried and believe all their hair is falling out. Thus
it is very important to provide adequate orientation, preferably talking to the
patient in the presence of family members so they will be aware of this phenom-
enon and the possible need for a second replacement in the future. Some patients
undergo three or four replacement procedures during their lives, depending on the
intensity of the baldness, and what is most important, the size of the donor area.
56 Part I  ▪ Fundamentals

Topography of the Scalp

An entire scalp measures approximately 500 cm2 (50,000 mm2) and has an av-

erage of 200 hairs/cm. Because the normal nonbalding scalp has one follicular
unit/mm2 and each unit contains an average of two hairs (a density of two hairs/
mm2), there is a total of approximately 100,000 hairs. This, of course, varies from
patient to patient.1

Donor Site Selection

The best donor sites are the areas in which the hair tends to grow permanently—
primarily the occipital and temporal regions. Ideally, the donor ellipse is taken 3
to 4 cm from the upper balding fringe and from the lower hairline boundary in the
lower occipital or temporal areas. Further thinning and baldness as an individual
ages may well result in lowering of the upper fringe and elevation of the lower
occipital hairline.

Transplanting 25% of the total scalp may be safe in some cases. As much as 50%
of the hair from a given area can be moved without the donor area appearing too
thin. In theory, in cases of moderately severe male pattern baldness (types V or
VI), 12.5% of the scalp is usually safely available for hair transplantation; that is,
Chapter 3  ▪  Preoperative Planning and Patient Instructions 57

12,500 hairs, or about 6250 FU grafts with an average of two hairs each.1 This
means approximately 3000 to 4000 micrografts and minigrafts can be transplanted
in two megasessions.

Hair Quality
Depending on the quality of the hair (thickness, texture, color, and curl), sig-
nificant improvement can be achieved in areas of baldness over the front of the
scalp or the entire area of baldness. If the technique of hair transplantation as
described in this book is followed meticulously and with proper patient selection,
results that mimic natural hair can be consistently expected.

The density that can be achieved with this technique is another important con-
sideration. The appearance of fullness has to do with hair mass, which is related
to the number of hairs, the thickness of the individual hair shafts, the texture and
color of the hair, and the curliness of the hair. Furthermore, the contrast of colors
between the scalp and the hair also has a significant influence on the optical il-
lusion of fullness. Most experts today agree that the average healthy nonbalding
patient has a density of about 200 hairs/cm2 (range 130 to 280) and that only 50%
of this number is needed to give an appearance of normal density, which is about
100 hairs/cm2 (range 65 to 140). Realistically, this number can be transplanted
in two sessions of micrografting and minigrafting.2,3

When transplanting hair in a patient with light skin and black, thick or coarse
hair, the surgeon should inform him or her that the density achieved in one ses-
sion will probably not be enough to mask the contrast between the scalp and hair
(there will be “see through”). A second session will probably be needed in the
future to create the optimal appearance of hair fullness.
58 Part I  ▪ Fundamentals

Black, curly hair provides good density in a single session, as is evident in this
32-year-old man who is shown preoperatively and 18 months postoperatively after
placement of follicular units in one session.
Chapter 3  ▪  Preoperative Planning and Patient Instructions 59

Curly hair provides very natural results with good density in a single session. A
second replacement procedure is usually not required, unless the patient’s hair
loss is progressive in nature.

Number of Sessions

To obtain a surgical result that mimics nature, a large number of randomly trans-
planted small grafts (FU size grafts) is essential and provides a result unmatched
by any other method of hair restoration. Patients must be forewarned that two
sessions and occasionally three sessions may be necessary to obtain the desired
density, assuming there is sufficient donor hair. Often, however, significant im-
provement is seen after just one session and will persist for years, even without a
repeat procedure.
60 Part I  ▪ Fundamentals

Distance Between Grafts

A distance of 1 to 2 mm must be maintained between grafts during a given ses-
sion, but once the scalp has healed and the hair begins to grow, the gaps can be
grafted so that the desired density is ultimately obtained. Usually patients 45 years
and older are pleased with the results of a single megasession, but the density can
be increased later if desired. Young patients, especially those under 30 years of
age, are more demanding as far as density is concerned, and additional procedures
should be planned in advance if the patient has sufficient donor areas. A more
conservative approach should be adopted in these cases.

Ratio of Donor Hair Surface to Recipient Area

Again, candidates must have a favorable ratio of donor hair surface to recipient
area, and the density of the donor area must be adequate for the area to be grafted.
Frontotemporal recessions should be incorporated into the plan for mature hair-
lines. Emphasis is placed on the front hairline rather than on the crown, especially
if the donor site is limited.

If the ratio of donor to recipient area is favorable, we transplant the entire area
of baldness. If the ratio of donor to recipient area is not favorable, we may only
transplant the front hairline or a median forelock. If it is clear that there is insuf-
ficient donor hair, the surgeon may choose not to proceed with transplantation.
It is clearly a judgment call.

When feasible, we prefer to transplant the entire area of baldness, with special
emphasis on providing the greatest density possible at the front hairline. Patients
can style their hair in such a way that it layers farther back to give the visual ap-
pearance of density in the back.
Chapter 3  ▪  Preoperative Planning and Patient Instructions 61

Front Hairline Design and Position

Irregular irregularity Maintain mature hairline

8 cm

The design and position of the front hairline is critical for a natural result as
well. Conservatism is in order. The goal is to achieve a mature hairline. The size
and shape of the head vary from person to person, and so does the position of
the hairline. Generally, a distance of about 8 cm from a horizontal line above
the eyebrows to the hairline at the midline works well, but in some patients a
slightly longer or shorter distance is appropriate, depending on the specific facial
features and shape and size of the head; the interrelationship and proportions
of the face and skull are also important factors. From there the hairline recedes
somewhat laterally, creating a moderate frontotemporal recession that produces
a V shape. In a mature individual 45 years or older with mild hair loss (types II or
III) and plenty of donor hair, the hairline can be designed a little lower or only
minimal recessions are left in the frontotemporal areas, especially in those with
a full head of hair who only want the front hairline strengthened. On the other
hand, in younger patients with a borderline donor hair supply, an ultraconserva-
tive approach is advised. The hairline may be placed higher than 8 cm from the
eyebrows, and the available donor hair should be concentrated in the front scalp,
leaving only the crown bare.
62 Part I  ▪ Fundamentals

Some naturally occurring cases of male pattern baldness are seen in which the
median frontal forelock remains intact. Patients with severe baldness who may
have insufficient donor hair to graft the entire head may benefit from establishing
a frontal forelock to help frame their face.
Chapter 3  ▪  Preoperative Planning and Patient Instructions 63

Hair density is Area of greater

greater medially elasticity

Area of less
Hair density 0.5 cm
0.5 cm
is sparser
laterally 1 cm 1 cm

1.5 cm


The donor ellipse must be harvested from the safest site to ensure long-term hair
growth. In a patient 40 years and older, this will be half of the vertical distance
from the posterior upper healthy fringe to the lower hairline to compensate for
further recession with age.

In individuals younger than 35 years of age,

we prefer to harvest the donor ellipse at
the junction of the middle third with the
caudal third of the vertical distance from
the posterior upper healthy fringe and the
lower hairline. In these individuals the pos-
terior upper fringe tends to recede down-
ward more rapidly than the lower hairline
from the nape of the neck recedes upward.
The reverse process tends to occur after 60 20 cm
to 65 years of age; that is, recession from 1 cm

the nape of the neck upward occurs as well.

Patient Education
Good communication is critical to ensure that the patient has realistic expecta-
tions of what can be achieved during an initial hair transplantation session. It
is important to advise the patient that the final result will not be immediately
evident; he or she needs to be patient while the grafts mature and grow over the
next 5 or 6 months and takes a year for the final result. It may take several sessions
to achieve the appropriate hair density while accommodating the progressive
nature of hair loss.
64 Part I  ▪ Fundamentals

The instructions in the box below are given to the patient preoperatively.

Preoperative Instructions
1.  Do not take aspirin, ibuprofen, or antihistamine allergy medications for
10 days prior to surgery.
2. Wear comfortable old clothes, since they may become soiled during surgery.
3. Make arrangements for transportation to and from surgery.
4. On the day before and on the day of surgery, wash your hair with a mild
shampoo such as Neutrogena, Progaine, or Johnson & Johnson baby sham-
poo. Massage the entire scalp gently.
5. There is no need to get a special haircut. The hair will be prepared at the
clinic. We prefer that the hair in the donor area be 1½ inches or longer to
help conceal the transplantation donor area postoperatively.
6. You may wish to bring videos to watch during surgery.

Postoperative Remarks and Instructions

The results of most aesthetic plastic surgery procedures are evident within a few
days. This is not the case with hair transplantation. The patient needs to be in-
formed preoperatively and reminded periodically, that it will take longer to see
the results. The healing process is quick, 10 to 14 days, but the results are not
evident until approximately 5 to 6 months postoperatively, and it takes about a
year for the final result as far as hair growth and density.

Patients with some remaining hair on the transplanted area must be warned that
it is likely that they will temporarily experience further thinning (telogen efflu-
vium) as a result of the hair transplantation. This is called “shock loss”; it results
from the trauma of so many small incisions in the grafted area.

The grafted hair will usually grow nicely for the first week to 10 days, and then
half to two thirds of the hair will shed temporarily as the grafts shift into the
telogen phase (rest phase). Three to four months later the grafts will shift to the
anagen phase (the growth phase), and the hair will continue to grow for as long
as it would be expected to grow at the donor site. This is because the hair roots
are transplanted with the genetic features of the donor site, which will determine
the longevity of hair growth of those grafts.

During the early recuperative period, the bandage is left in place for 48 hours.
After which the patient removes the bandage and gently shampoos his or her
hair (mild shampoo, such as Johnson & Johnson) once a day. At about 10 days
postoperatively, the donor site sutures (3-0 Prolene or nylon) are removed. At
this point a lot of the small crusts and scabs have come off, but some may remain
Chapter 3  ▪  Preoperative Planning and Patient Instructions 65

for a few more days. After 2 to 3 weeks, once all the scabs are off, the scalp will
look just as it did before the procedure, except it will be slightly pink, as if the
patient had a mild sunburn.

Postoperative instructions and a typical consent form are provided in the follow-
ing boxes.

Postoperative Instructions
1. Rest for the first 72 hours after surgery while keeping the head elevated at
a 45-degree angle. From the first day postoperatively it is important to get
up and walk around; initially have someone assist you.
2. Swelling of the eyelids and forehead region will occur on the second or
third day; this is caused by the normal saline solution and local anesthetic
that were injected into the recipient scalp during the procedure. Swell-
ing usually resolves by the seventh postoperative day. You may apply cold
compresses to these areas.
3. The helmet-type bandage will be taken off on the second day. Afterward,
you should wash your hair daily with lukewarm or room-temperature
water (avoid hot water) using a mild shampoo such as Progaine or Neu-
trogena. Make certain that the shower head is set on low pressure, or use a
cup for washing and rinsing.
4. After the bandage is taken off, wear a hat or cap for protection, especially
when going out.
5. Start applying 5% minoxidil (sold over the counter) twice daily for the
first 6 months. This is optional. This will help speed the growth of the
newly transplanted hair and may minimize the initial further thinning in
patients who still have hair in the grafted area. If scalp irritation occurs,
stop for a few days and then begin using 2% minoxidil. If the irritation
persists, discontinue its use.
6. Avoid the following:
• Driving until eyelid swelling (if present) has resolved.
• Smoking in the first 2 weeks.
• Strenuous exercise or sports activities in the first 2 weeks.
• The sun or excessive heat exposure for at least 3 weeks.
7. The stitches of the donor area will be removed at about 10 days after sur-
8. The small crusts around the micrograft will drop off naturally 10 days after
surgery along with some of the transplanted hair. However, the hair root
has become safely incorporated into the scalp by that time and is not at
9. Hair growth starts at 3-4 months after surgery and at 6 months generally
we can see a significant improvement, but the final result will take 1 year.
10. If you have any questions or concerns, please call the office.
66 Part I  ▪ Fundamentals

Disclosure and Patient Consent

You have the right as a patient to be informed about your condition and the
recommended surgical, medical, or diagnostic procedure to be used so that you
may make the decision whether or not to undergo the procedure after knowing
the risks and hazards involved. This disclosure is not intended to scare or alarm
you; it is simply an effort to make you better informed so you may give or with-
hold your consent to the procedure.
I voluntarily request that Dr. treat my condition, which
has been explained to me as male pattern baldness.
I understand the following surgical procedure is planned and I voluntarily con-
sent and authorize minigraft and micrograft hair transplantation.
I understand that Dr. may discover conditions that
require additional or different procedures than those planned. I authorize
Dr. to perform such other procedures that are advis-
able in his professional judgment.
I understand that minigrafts and micrografts will provide definite hair growth,
but the density will not approximate that on the lower part of the back of the
head or sides of the head even after several procedures.
I also understand that the hair graft success is approximately 90% normally, but
individual variations can be expected. The results are as permanent as the hair
growth at the donor site.
I do □ do not □ (check one) give my permission for use of my photographs for
medical lectures or publications.
I understand that no warranty or guarantee has been made to me as to result or
I realize that common to any procedure is the potential for infection, blood
clots in veins and lungs, hemorrhage, allergic reactions, and even death. I also
realize that the following risks and hazards may occur in connection with this
particular procedure:
1. Unsatisfactory appearance
2. Possible numbness in the back of the head, which usually subsides
within a few weeks to a few months, but on rare occasions could be
3. Creation of additional problems such as poor healing, skin loss, nerve
damage, or painful or unattractive scarring
4. Blood collection under the skin requiring removal
5. Problems related to anesthesia

Patient name (please print) Patient signature

Witness Date and time

Chapter 3  ▪  Preoperative Planning and Patient Instructions 67

Disclosure and Patient Consent — cont’d

I understand that anesthesia involves additional risks and hazards, but I request
the use of intravenous sedatives and local anesthetics for the relief of and pro-
tection from pain during the planned procedure and any additional procedures.
I realize the anesthesia may have to be changed, possibly without explanation.
I understand that certain complications may result from the use of any local
anesthetic, including respiratory problems, drug reactions, paralysis, brain dam-
age, and even death.
I have been given the opportunity to ask questions about my condition, alterna-
tive forms of anesthesia and treatment, risks and nontreatment, the procedure to
be used, and the risks and hazards involved, and I believe that I have sufficient
information to give an informed consent.
I certify that this form has been fully explained to me, and I understand its

Patient name (please print) Patient signature

Witness Date and time

1. Bernstein RM, Rassman W. The aesthetics of follicular transplantation. Dermatol Surg 23:
785, 1997.
2. Limmer B. The density issue in hair transplantation. Dermatol Surg 23:747, 1997.
3. Marritt E. The death of the density debate. Dermatol Surg 25:654, 1999.
4. Barrera A. Clinical decision making in hair transplantation. In Nahai F, ed. Art of Aesthetic
Surgery: Principles & Techniques. St Louis: Quality Medical Publishing, 2011.
5. Barrera A. Hair transplantation. In Lin SJ, Mustoe TA, eds. Aesthetic Head and Neck Surgery:
An Operative Atlas. New York: McGraw-Hill Professional, 2013.
6. Barrera A. Hair transplantation. In Carniol PJ, Monheit GD, eds. Aesthetic Rejuvenation in
Clinical Practice. London: Informa Medical, 2009.
7. Vogel JE. Correcting problems in hair restoration surgery: an update. Facial Plast Surg Clin
North Am 12:263-278, 2004.
8. Vogel JE, Jimenez F, Cole J, Keene SA, Harris JA, Barrera A, Rose PT. Hair restoration surgery:
the state of the art. Aesthet Surg J 33:128-151, 2013.
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C H A P T E R 4

I ncorporating H air
Transplantation I nto
Your P ractice

Alfonso Barrera
70 Part I  ▪ Fundamentals

Personal Experience
Today hair transplantation represents a significant part of my practice. This was
not always the case. During my 7 years of surgical training I didn’t observe even
one case of hair transplantation. My interest in this procedure developed in the
early 1990s when I became aware of the outstanding work of Carlos Uebel. I vis-
ited him to observe his technique, to learn more about the procedure, and to have
it performed on me. That was my beginning.

When I decided that I wanted to add hair transplantation to my practice, I started

by contacting former patients who had male pattern baldness and who knew and
trusted me. I told them about this procedure, explained that I had undergone
hair transplantation myself, and that I had learned the technique. I offered to
perform hair transplantation for them with no surgeon’s fee—only the cost of
performing the procedure at my own facility. These former patients agreed, and
thus I performed my first cases. One year later, I had enough examples of results
to show to other patients. Then I started charging for the procedure.

I have found hair transplantation to be very rewarding, not only for cases of male
pattern baldness but also for female hair loss, and that the procedure can enhance
the aesthetic results achieved with reconstructive surgery of the face and scalp.
What follows are my recommendations for incorporating hair transplantation
into your practice.
Chapter 4  ▪  Incorporating Hair Transplantation Into Your Practice 71

Getting Started
Visit a Surgeon Who Regularly Performs Hair Transplantation
Before performing micrograft and minigraft transplantation, it is advisable to take
a course and train with someone who actively performs this procedure. Ideally,
you should observe several cases from beginning to end. Include your surgical
team and become familiar with preoperative and postoperative care and patient

Select Your Surgical Team

Select the members of your surgical team carefully; the team can consist of regis-
tered nurses, physician assistants, medical assistants, or certified surgical assistants.
I have a four-person surgical team consisting of one registered nurse, two medical
assistants, and me.

Look for surgical assistants you already know who are skilled and have had ex-
perience working under magnification. The ideal candidate is someone who has
assisted you on microvascular procedures. Good hand-eye coordination is a must.
The surgical team works closely and should have personalities that mesh. They
must be able to work for several hours at a stretch. Patience is prerequisite, es-
pecially in the beginning. To achieve optimal efficiency, the team should be
composed of the same members consistently. You may wish to start them on a
part-time basis until you can evaluate their performance.

Practice With Your Team Before Performing Your First Case

Before performing an actual transplant session, you and your assistants should
practice cutting grafts out of healthy pieces of scalp discarded after face lifts or
coronal forehead lifts. The graft insertion technique can then be practiced using
pig’s feet. Be patient with yourself and your team.
72 Part I  ▪ Fundamentals

Stick and place team



Stick and place technique

I use the stick and place technique. This means that I insert the surgical blade
at the desired location and angle, controlling the direction of hair growth while
the assistant inserts the graft. I feel that there is more quality control when the
surgeon is present for every single graft insertion. It takes longer, but it eliminates
the risk of piggybacking (two grafts or more in a single slit) or skipping recipient
slits, which can occur when the recipient site incisions are all done before graft
insertion. Stick and place requires more of the surgeon’s time, but I think it is
worth the investment, because it ensures a high-quality result.
Chapter 4  ▪  Incorporating Hair Transplantation Into Your Practice 73

For facial hair transplantation—mustache, beard, or eyebrows—I make the re-

cipient site incisions first, but I am also there for every graft insertion. On the
face there is often more bleeding and popping out of grafts than on the scalp, so
establishing hemostasis first helps for the graft insertion. The same applies when
excessive bleeding is encountered in scalp hair transplantation. In this situation,
I make the recipient site incisions first, and once there is a dry field, I start insert-
ing the grafts with the help of an assistant.

Choose Initial Patients Wisely: Start Small

Start with small cases of hair loss, such as sideburns or retroauricular areas of alo-
pecia secondary to face lift procedures, or male pattern baldness cases. Initially
it is advisable to limit the number of transplants you perform to no more than
500 grafts and progress to larger numbers of transplants as you and your assistants
become more comfortable with the procedure and can handle true megasessions.

Have the Appropriate Facility, Equipment, and Supplies to Ensure

Patient Safety
Clearly, as in any surgical procedure, hair transplantation needs to be performed
in a well-equipped facility. I usually perform this procedure in my office operating
room connected to the hospital rather than a freestanding facility. This seems to
make patients feel more secure. I had my facility certified by the American As-
sociation for Accreditation of Ambulatory Surgery Facilities (AAASF); it was
not difficult to obtain this certification, and meeting these standards supports that
we provide the measures essential for patient safety.

Facility certification
74 Part I  ▪ Fundamentals

Equipment and Supplies

The procedural equipment needs are pretty basic, except for the special blades,
jeweler’s forceps, and magnification equipment.

Surgical Needs
• American Association for Accreditation of Ambulatory Surgical Facilities
(AAASF) and Joint Commission on Accreditation of Healthcare Organiza-
tions (JACO) are good options
• Basic surgical equipment
• No. 10 Bard Parker blades
• No. 11 feather blades
• No. 22.5- and 15-degree Sharpoint blades, which fit perfectly on the Beaver
blade handles
− Notice the angle of the Sharpoint blades: one is 22.5 degrees and the other
is 15 degrees. The 22.5 makes a slightly larger recipient site incision than
the 15. I like the 15-degree blade for facial work and the very front of the
• 3-0 Prolene
• Mantis microscope (103)
• Magnifying loupes (3.53)
• Background lighting for graft dissection
• Chilled petri dishes for graft preservation

Aftercare Needs
• Adaptic
• Polysporin ointment
• Kerlex
• 3-inch Ace bandage

The Adaptic, Kerlex, and 3-inch Ace bandage are used for 48 hours.
Chapter 4  ▪  Incorporating Hair Transplantation Into Your Practice 75

Basic surgical set No. 10 Bard Parker blades with round handles

Sharpoint blades
Sharpoint blade Jeweler’s forceps

Sharpoint blades Sharpoint blade being used for stick and place technique
76 Part I  ▪ Fundamentals

No. 11 feather blade with round handle

3-0 Prolene suture

Mantis microscope (103)

Chapter 4  ▪  Incorporating Hair Transplantation Into Your Practice 77

Background lighting for graft dissection

78 Part I  ▪ Fundamentals

Chilled petri dishes with normal saline solution for graft preservation Application of Adaptic, Kerlex, and 3-inch Ace bandage

Key Points to Natural-Looking Scalp and

Facial Hair Transplantation
These elements are essential to a successful result:
• Small grafts
• A level hairline
• A natural design
• Sufficient hair density
• No detectable scarring

Hair transplantation is not only a matter of getting the grafted hair to grow, but
also of getting hair to grow and look natural.

Important Considerations When Getting Started

• Visit a surgeon who performs hair transplantation on a regular basis.
• Select your surgical team carefully.
• Practice in advance.
• Operate in a well-equipped and safe facility.
• Choose initial patients wisely: start with small cases.
• Be patient with yourself and with your team.
Pa rt II

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C H A P T E R 5

I ntravenous Sedation

Alfonso Barrera, Carlos Oscar Uebel

82 Part II  ▪ Technique

A s certain
with any other elective surgical procedure, it is extremely important to
that the patient has a pleasant and ideally pain-free experience
during a hair transplantation procedure, as well as minimal pain postoperatively.
Hair restoration surgery lasts 2 to 4 or even 5 hours, depending on the number
of grafts, and the surgeon and his staff need to be in a comfortable, stress-free
operating room.

We typically perform hair transplantation using intravenous sedation and local

anesthesia. Our preference for intravenous sedation is midazolam (Versed [U.S.];
Dormonid [Brazil]) and fentanyl (Sublimaze). For nerve blocks and local anes-
thesia, we prefer bupivacaine (Marcaine). This combination provides patient
comfort and amnesia during the first half of the procedure, and during the second
half the patient is completely numb, and there is no longer a need for sedation,
unless the patient prefers it.

Anesthesia Stages
The patient is instructed to arrive in the early morning, having fasted since
midnight the night before. Anesthesia can be divided in three stages: sedation,
blockage of the nerves, and scalp ballooning (tumescence).

Patients are placed in the supine position. We start an intravenous line and ad-
minister 2 mg of midazolam and 25 μg of fentanyl. We observe how the patient
responds to that, and 2 to 3 minutes later, we add another 2 to 3 mg of midazolam
and another 25 μg of fentanyl, always making certain that the oxygen saturation
remains optimal: 95% to 100% throughout the procedure. Within 5 to 10 min-
utes we often administer another 5 to 15 mg of midazolam and 50 to 100 μg of
fentanyl. Male patients are more anxious than female patients, and we normally
need to sedate them a bit more.

Nerve Blockage
We then perform a supraorbital nerve block by injecting 0.5% bupivacaine with
epinephrine 1:200,000 and local infiltration (field block) just anterior to the pro-
posed hairline, with about 15 ml to further localize the area. In the donor area we
inject the caudal margin of the horizontal ellipse with another 15 ml, for a total
30 ml of bupivacaine, which can achieve 6 to 8 hours of numbness in the scalp.
Chapter 5  ▪  Intravenous Sedation 83

Zygomaticotemporal branch
of trigeminal nerve
Supraorbital nerve

Auriculotemporal Supratrochlear nerve


Temporal branch
of facial nerve

auricular branch
of facial nerve

Lesser occipital nerve Supratrochlear nerve

Greater occipital nerve

Greater auricular nerve

Supraorbital nerve

Supraorbital foramen

Supraorbital and trochlear nerve blocks

We block the supraorbital nerves and supratrochlear nerves. With the index
finger we touch the supraorbital foramen, and above this point we inject 1 ml of
this solution on both sides.
84 Part II  ▪ Technique

Ring block in front of hairline

A coronal blockage of 1 cm beyond the hairline is important, extending laterally

to the suprauricular area. We prefer multiple levels of depth of 0.5 ml apart to
infiltrate all the scalp levels, from the subgalea to the dermis. A total of 10 ml of
the anesthetic solution is needed in the front. We then turn the patient laterally
and finish the donor area with another 10 ml of solution.

We block the occipital nerve branches and all along the caudal margin of the
donor ellipse. Then we perform the tumescence infiltration.
Chapter 5  ▪  Intravenous Sedation 85

Scalp Ballooning (Tumescence)

In 1991 we published our initial study for the tumescent technique for the scalp.1
We called it scalp ballooning because of the balloon effect produced by the massive
infiltration of a saline solution into the scalp. There are three reasons to use scalp
ballooning: to achieve an ischemia to minimize bleeding, to produce a temporary
thickness to facilitate easier implantation of the follicular units, and to comple-
ment the anesthesia. The saline solution is a concentration of:
• Saline solution 0.9% → 120 ml
• Lidocaine chlorhydrate 2% (Xylocaine) → 20 ml
• Epinephrine 1:1000 → 1 ml
• 40 mg triamcinolone (Kenalog)

Injection at
two levels



We inject this solution 15 minutes before we begin the micrografting. A total

of 160 to 320 ml can be injected to achieve swelling and ischemia. All the scalp
levels are infiltrated, from the subgaleal area to the subcutaneous region, reach-
ing the dermis, where the vasoconstriction of all the capillary vessels causes the
“white marbling” phenomenon. It is important to inject the surface of the der­
mis immediately before the transplant to achieve hemostasis at the microvascu-
lar plexus level (minimizing bleeding). The tumescent process can be repeated
every 30 minutes, each time we observe that the tumescence and ischemia are
diminishing. We use about 50 to 70 ml of the same solution in the donor area to
produce swelling of the hair-bearing flap and to spread the follicular units, which
facilitates dissection of the grafts. This maneuver allows the assistant to prepare
the follicular units with a No. 10 sharp blade without damage to the hair follicles.

The patient may be placed in the lateral decubitus position to inject the donor
site (occipital); then we return the patient to the supine position and inject the
recipient area again. We are then ready to begin the stick and place technique
86 Part II  ▪ Technique

with a microsurgical blade and microforceps, and there will be no oozing or pump-
ing of blood. Usually the patient remains supine during the entire grafting proce-
dure, and we rotate the head to the left, allowing the surgeon to inject and suture
the right half of the strip. Then the patient’s head is rotated to the right and the
same procedure is carried out on the left.3-7

The tumescence (ballooning) injection to the scalp is very important, but com-
monly results in edema of the midforehead, eyebrows, and eyelids area, which
generally develops about 36 to 48 hours after it is initiated and resolves in 5 to
7 days. It is not painful, but it is an inconvenience; the patient should be advised
of this preoperatively. In 2004 Gholamali Abbasi suggested adding 40 mg of
triamcinolone (Kenalog) to the tumescence solution; this helps immensely in
minimizing postoperative edema, and it significantly reduces the postoperative
pain that often occurs in the donor area.2

The tumescent technique produces a swelling on the scalp that lasts for about
2 days and can travel to the forehead and eyelids up to 3 days. We recommend
using prednisone 20 mg twice a day for 3 days postoperatively.

When the procedure is completed, the patient is usually ready to get up and go
home without the need for an interval in the recovery room; the patient should
rest for another 4 to 6 hours at home. We recommend that the patient not drive
during the first 24 hours, and he or she should sleep in the horizontal supine posi-
tion for 48 hours so the swelling can drain to the occipital area.

1. Uebel CO. Micrografts and minigrafts: a new approach for baldness surgery. Ann Plast Surg
27:476-487, 1991.
2. Abbasi G. Hair transplantation without postoperative edema (Abbasi’s solution). Presented
at the Twelfth Annual Meeting of the ISHRS, Vancouver, Canada, Aug 2004. (Published in
Hair Transplant Int 15:149, 2005.)
3. Barrera A. Refinements in hair transplantation: micrograft and minigraft megasession. Perspect
Plast Surg 11:53-70, 1998.
4. Barrera A. The use of micrografts and minigrafts for the correction of the postrhytidectomy
lost sideburn. Plast Reconstr Surg 102:2237-2240, 1998.
5. Barrera A. Advances in aesthetic hair restoration. Aesthet Surg J 23:259-264, 2003.
6. Barrera A. The use of micrografts and minigrafts in the aesthetic reconstruction of the face
and scalp. Plast Reconstr Surg 112:883-890, 2003.
7. Barrera A. Hair restoration. In McCarthy JG, Galiano RD, Boutros S, eds. Current Therapy
in Plastic Surgery. Philadelphia: Saunders-Elsevier, 2006.
C H A P T E R 6

Correction of  M ale
Pattern Baldness

Alfonso Barrera, Carlos Oscar Uebel,

Jorge Augusto Moojen da Silveira
88 Part II  ▪ Technique

I safen ourandexperience, follicular unit micrografts and minigrafts have proved to be

effective for treating hair loss and remain my (A.B.) preferred approach
for hair restoration because of the natural results produced with minimal residual
scarring and recuperation time. This chapter describes the micrografting and
minigrafting technique that we use to treat male pattern baldness.

We (A.B. and C.U.) use basically the same technique for hair transplantation,
since I (A.B.) am a disciple of Carlos Uebel.7-10 He was the first to introduce the
technique that allowed transplantation of a large number of FU grafts (over 1000)
in a single session; therefore he is the father of modern hair transplantation. We
have minimal variations on how we perform these cases, mainly having to do
only with personal preferences regarding blade selection, dressings, and slight
variations as to patient positioning during donor site harvesting.

Follicular unit micrografting and minigrafting is labor intensive and requires an

organized and efficient surgical team. Our surgical team consists of three surgical
assistants and a surgeon. We both choose to remain in the operating room for
the duration of the procedure and insert all grafts personally. The members of the
team are carefully selected and trained and must have good hand-eye coordina-
tion. Ideally, the surgical team remains the same so that the members become
experienced in all steps of the procedure. Efficiency is essential when transplant-
ing large numbers of grafts in a single session. We normally transfer between 1000
and 3000 grafts per session (megasessions), depending on the degree of hair loss.

Assistants prepare the grafts. The minigrafts are separated without the use of
a microscope. With their training and skill, two or three assistants are able to
separate 800 to 1000 units per hour. A surgical assistant and the surgeon work
together as the surgeon inserts all of the grafts using the stick and place technique.
Chapter 6  ▪  Correction of  Male Pattern Baldness 89

Operative Sequence



O2 tank

O2 saturation,
and pulse Supplies

work area

Dissection table

Television monitor

Once the patient is comfortably sedated and a local anesthetic has been admin-
istered, we begin the procedure. The operating room setup is illustrated.
90 Part II  ▪ Technique

Preoperative Markings

Preoperative markings delineate the design and level of the proposed hairline.
There is no magic number as to the distance from the eyebrows to the ideal
hairline, because there is great variation among individuals in terms of head
dimensions and craniofacial proportions. However, as a general rule, a pleasing
aesthetic distance is about 8 cm from the midglabella to the hairline. We mark
this according to what seems appropriate and aesthetically pleasing, incorporating
irregularity at the front of the hairline to mimic nature.

Frontotemporal recessions are included in a conservative and mature frontal hair-

line. The patient then reviews the markings to make certain that he understands
the plan and is in agreement.
Chapter 6  ▪  Correction of  Male Pattern Baldness 91

The donor site is prepared by outlining the tentative donor ellipse with a surgical
marker. The hair within the planned ellipse is trimmed with scissors or with an
electric hair clipper. One-inch Micropore tape is used on the cephalic edge of the
donor site to part the hair upward and out of the way.

The donor ellipse is designed horizontally in the occipital area; it is 1 cm and no
more than 2 cm wide and as long as needed, often up to 25 to 32 cm, extending
well into the temporal areas. Making the ellipse no more than 1 or 2 cm wide
ensures closure without tension and a safer and more predictable degree of mini-
mal scarring.

The occipitotemporal areas are generally where the hair is the thickest and the
most permanent; that is why they are ideal as donor sites. The genetic information
for hair growth is at the hair follicular level, and the hair roots taken from these
areas almost invariably are programmed to grow hair for a lifetime. Therefore hair
taken from this area and transplanted to areas of baldness on the top, crown, and
front of the scalp will continue to grow hair in these transplanted locations for as
long as it was going to do so in its original donor area, a most encouraging finding.

Usually our estimates of grafts needed are close to the number of grafts used. We
prefer to have more grafts available than are actually needed rather than not
enough. Patients appreciate having an extra 100 or 200 grafts inserted at no ad-
ditional cost. However, many patients have limited donor areas available, and it
is inexcusable to discard scalp or grafts, since hair follicles are finite and irreplace-
able. It is important to always transplant any extra grafts in the areas where you
think they will be needed later, such as the temporal areas or occipital fringe;
this strategy reflects good long-term planning and accommodates future hairline
changes associated with the aging process.
92 Part II  ▪ Technique

The procedure consists of three components: (1) donor site harvesting, (2) graft
dissection, and (3) graft insertion.

Donor Site Harvesting

The many variables encountered during donor site harvesting test the surgeon’s
clinical judgment. The size of the donor ellipse will vary, depending on the num-
ber of grafts planned or the size of the area to be grafted, as well as the hair density
of the donor site and the pliability and elasticity of the donor scalp. Only the
amount of scalp needed should be harvested, yet the surgeon must ensure that
enough donor scalp is obtained for the number of grafts planned and that the
donor defect can be closed under minimal tension.

The laxity of the scalp varies from person to person. The surgeon must be alert
to the presence of scar tissue from previous procedures, since this will result in
reduced elasticity and pliability of the donor scalp. Most patients’ scalps permit
ellipses 1 to 1.5 cm wide (occasionally up to 2 cm) to be harvested with minimal
tension on closure. The surgeon must feel the donor scalp to assess its laxity,
elasticity, and pliability.

Area of greater
Hair density is elasticity
greater medially
Area of less

Hair density 0.5 cm

0.5 cm
is sparser
laterally 1 cm 1 cm

1.5 cm


A long, narrow, horizontal donor ellipse is preferable to a short, wide ellipse. Hair
density and the elasticity of the donor occipital site are usually greater near the
midline. The hair becomes sparser and the scalp less elastic more laterally, par-
ticularly over the mastoid area. The scalp above the ears is usually quite inelastic.
These factors must be taken into consideration so that the ellipse can be designed
to allow closure with minimal tension.
Chapter 6  ▪  Correction of  Male Pattern Baldness 93

Normally the hair density in the donor area is approximately 200 hairs/cm2 (range
130 to 280 hairs/cm2). The diameter of the individual hair shafts varies from 0.06
to 0.14 mm.

Assuming a density of 150 hairs/cm 2,

an ellipse 10 by 1 cm will yield approxi-
mately 1500 hairs. Naturally occurring
follicular units have one to four hairs per
unit. These units must be kept intact as
much as possible. The exact number of
grafts can only be determined after dis-
secting the donor ellipse into grafts, but
10 cm
an ellipse of this size will yield approxi- 1 cm
mately 500 to 600 grafts.

If hair density is approximately 150 hairs/

cm2, a horizontal, occipital donor ellipse
of 20 by 1 cm with 3375 hairs will be
needed to produce 1000 to 1200 micro-
grafts and minigrafts (one to four hairs
per unit). 20 cm
1 cm
94 Part II  ▪ Technique

A maximal density procedure (2000 to 2500

grafts) in patients with type VI or VII male pat-
1-1.5 cm tern baldness makes harvesting enough donor
1 cm tissue a greater challenge. In these cases we
1 cm
harvest a horizontal ellipse approximately 30 to
0.5 cm 0.5 cm
32 cm long and 1 to 1.5 cm wide at the midline
(scalp elasticity permitting), gradually tapering
the width laterally to 1 to 0.5 cm at the ends.
30-32 cm In most patients this yields approximately 2000
to 2500 FU micrografts and minigrafts and be-
tween 5000 and 6000 hairs and allows closure
with minimal if any tension. Guidelines for
dimensions of the donor site are given in the

Donor Site Dimension Guidelines

Micrograft and Hair Density (hairs/cm2)
Minigraft Follicular Units
(number of hairs) 150 (low) 200 (average) 201-250 (high)

500-600 (6 1500 hairs) 10 3 1 cm ellipse 6-7 3 1 cm ellipse  5 3 1 cm ellipse
1000-1200 (6 3000 hairs) 20 3 1 cm ellipse  15 3 1 cm ellipse 10 3 1 cm ellipse
1500-1800 (6 4500 hairs) 25 3 1 cm ellipse  20 3 1 cm ellipse 15 3 1 cm ellipse
2000-2500 (6 6000 hairs) 30 3 1.5 cm ellipse  30 3 1 cm ellipse 25 3 1 cm ellipse
note: All ellipses are 1-1.5 cm wide, tapering only at the 1-0.5 cm ends. (If there is sufficient scalp laxity the incision may
be up to 2 cm in width.)

At this point the patient is in the supine po-

sition. The head is turned to the left, and a
No. 10 or No. 15 Bard Parker blade is used
to make the incisions parallel to the hair fol-
licles. We initially harvest approximately a
third to half of the donor ellipse (right side
first) so that the assistants can begin preparing
the grafts as early as possible.
Chapter 6  ▪  Correction of  Male Pattern Baldness 95

The right half of the donor ellipse is harvested under 3.53 loupe magnification.
The plane of dissection is just deep to the hair follicles and superficial enough to
avoid injury to significant vessels and sensory nerves, often leaving a little sub-
cutaneous fatty tissue over the galea or fascia. The right half of the donor strip
is shown.

The right half of the donor ellipse is now handed to the graft dissection team.
Usually without the need to undermine, we close the right half of the donor
ellipse with a continuous running suture with 3.0 Prolene. Next the left half of
the donor strip is harvested as our assistants dissect grafts. Undermining will be
done as needed.
96 Part II  ▪ Technique

Graft Dissection

The dissection team starts by processing the donor ellipse into 1.5 to 2 mm thick
slices, parallel to the hair shafts (A.B.). They use 103 magnification under the
microscope or 3.53 loupe magnification for the graft dissection process.
Chapter 6  ▪  Correction of  Male Pattern Baldness 97

Alternatively, the donor strip can be dissected into 0.5 to 1 cm wide strips (C.U.)
with fast, precise movements, incising parallel to the hair shafts and follicular
units, thereby preserving intact about 95% of the hair follicles, all the way from
the root to the surface.

The subcutaneous fat is trimmed away, leaving a little around the follicles, which
is important for future nutrition of the hair. The assistants then dissect the slices
into FU grafts as the surgeon continues the donor site harvesting and closure.
98 Part II  ▪ Technique


Maximum number
of hairs in graft

Sebaceous gland

Subcutaneous fat

Follicular unit micrograft Follicular unit minigraft

(1 or 2 hairs) (3 or 4 hairs)

Natural grouping patterns of hair follicles are preserved. Thus two-, three-, or
four-hair follicle groupings are kept intact as a unit. Conversely, a hair shaft that
is separated from the surrounding FU is taken as a single-hair micrograft, leaving
some perifollicular tissue to serve as a safety margin. An atraumatic technique is
essential to avoid damaging the hair follicle units.
Chapter 6  ▪  Correction of  Male Pattern Baldness 99

The key points to remember in graft dissection are:

• The FUs should be maintained intact when feasible.
• In patients with dark hair, 3.53 loupe magnification is sufficient to dissect
most grafts as FUs.
• In patients with very light or white hair, we use 103 microscopes for safe
dissection of the grafts; we prefer the Mantis microscope.
• In patients with light or gray hair, surgical microscopes and background
lighting may be needed for more accurate dissection.

As the assistants dissect the grafts, the surgeon continues harvesting and closure
of the second half of the donor strip.
100 Part II  ▪ Technique

We use digital traction to estimate whether there is a need for undermining to

ensure closure without tension, since closing under undue tension can cause prob-
lems and is to be avoided. A running nonabsorbable suture is applied superficially
to the dermis so as not to damage the follicles. This patient is shown during and
immediately after incision closure with 3-0 Prolene and no undermining. The
running suture remains in place for 7 days. We apply wet gauze pads with saline
solution and soft bandages for 2 days after the grafting session.
Chapter 6  ▪  Correction of  Male Pattern Baldness 101

The harvested scalp and all grafts are kept chilled in normal saline solution until
the grafts are transplanted.

Careful dissection of the thin slices into one- or two-hair FU micrografts and
three- or four-hair FU minigrafts continues. This is done with background lighting
using a No. 10 scalpel blade and magnification. This is the most tedious part of
the procedure, yet one of the most important steps. The grafts need to be handled
gently and atraumatically. The darker and thicker the individual’s hair shafts, the
easier it is to dissect the grafts.

The ideal grafts have intact hair shafts all the way from the subcutaneous fatty
tissue to the scalp surface and contain from one to four hairs each, as they appear
in nature. The grafts are handled carefully and as atraumatically as possible using
a jeweler’s forceps to hold them by the fatty tissue under the hair bulbs or by the
tissue around them, not by the hair bulb or dermal hair papilla itself.
102 Part II  ▪ Technique

Several hundred grafts will have been dissected at this point. They are lined up
in rows on a wet green or blue surgical towel and are now ready for insertion.
The process of graft dissection and insertion continues until all of the grafts are
transplanted. It is imperative to keep the grafts wet, since desiccation damages
the hair bulbs.

Graft Insertion

At this stage of the procedure, infiltration of tumescent solution into the recipi-
ent area is critical to promote hemostasis and to produce temporary edema of
the scalp, which facilitates graft insertion with minimal bleeding and limits graft
pop out.

Our tumescent solution consists of:

• 120 ml of normal saline solution
• 20 ml of 2% plain lidocaine
• 1 ml of epinephrine 1:1000 (1 mg)
• 40 mg of triamcinolone (Kenalog)
Chapter 6  ▪  Correction of  Male Pattern Baldness 103

Stick and Place Technique




Our preferred surgical blades for graft insertion are the 65 Beaver blade (C.U.)
and the 22.5 Sharpoint blade (A.B.) for the front 2 cm of the hairline to create a
nice transition zone, intentionally creating a slight irregularity to mimic nature.
With these blades the scars are undetectable every time. The follicular unit is
put into the orifice and the introduction is completed with the help of the blade.
This is a synchronized maneuver we call stick and place.
104 Part II  ▪ Technique

In the posterior scalp and crown area, we both prefer No. 11 Personna Feather

It is important to work in various areas, periodically returning to the anterior

area and proceeding posteriorly until all of the grafts are inserted. If the main
area of baldness is the crown and not the front hairline, we start the grafting on
the crown and then work on the front, if it also needs some grafting, then we
go back and forth in the previously described fashion to obtain optimal grafting
with minimal pop outs. The grafts are inserted in a random pattern, not in lines,
to better mimic nature.

When working on the crown, it is often more practical and comfortable to have
the patient sitting upright.
Chapter 6  ▪  Correction of  Male Pattern Baldness 105

Hair bulb


(low hold)

(high hold)

The hair bulb itself should never be gripped to avoid trauma to this delicate struc-
ture. It is best to pick up the graft by the fat underneath the bulb or above the
bulb with as mild gripping pressure as possible. Pressure on the blade translates
into much greater squeezing pressure at the tip of the jeweler’s forceps.
106 Part II  ▪ Technique

Tilt facilitates
graft placement

Angle blade

Blade holds
graft as forceps
Gently push in are withdrawn
with tip of blade

After the slit for the graft is made, the blade is tilted approximately 10 to 15 de-
grees to open the entrance of the slit for insertion of the grafts. As the graft is
inserted, the blade is withdrawn and the tip is used to hold the graft in place.
Chapter 6  ▪  Correction of  Male Pattern Baldness 107

Neighboring pressure
grafts pop out
Neighboring pressure
grafts pop out
grafts pop out

Insert new
Place grafts at 5 mm distance existing grafts
Fibrin holds Insertbetween
Place grafts 5atmm
5 mm distance existing graft existing grafts
Wait 20-30 Fibrin holds graft between Repeat
Place grafts 5atmm
5 mm distance in place existing grafts after 20-30
minutes existing graft Repeat
Wait 20-30 Fibrin holds
5 mm in place minute wait
minutes existing graft after 20-30
Wait 20-30 Repeat
in place minute wait
minutes after 20-30
minute wait
turns to fibrin
turns to fibrin
Fibrinogen 2.5 mm 2.5 mm
1-2 mmturns
to fibrin
between grafts 2.5 mm 2.5 mm
1-2 mm distance
between grafts 2.5 mm 2.5 mm
1-2 mm distance
between grafts

The grafts are less likely to pop out if the surgeon initially maintains a distance
of 4 to 5 mm between the grafts and continues to graft other areas, allowing
20 minutes or so for the fibrinogen to turn into fibrin, which fastens the grafts in
place somewhat. Then the surgeon can return to graft the spaces in between, and
the distance between grafts becomes 2 to 2.5 mm. The same process is repeated
several times until the grafts are as close as possible, usually 1 to 2 mm from each
other; this is “dense packing.” This equals approximately 35 to 40 FU grafts for
every square centimeter. The sharper the blade, the less pressure is created when
making the slits, which helps decrease the likelihood that the graft will pop out.
At the beginning of the procedure about 100 grafts can be inserted with one
blade. However, toward the end of the procedure the grafts will tend to pop out
more frequently, and the blade may need to be changed after 10 to 20 slits.
108 Part II  ▪ Technique

Using a 4 3 4 gauze pad can also help prevent the grafts

from coming out as the surgical blade is withdrawn.
4 3 4 gauze pad
used to maintain
graft in slit

Epidermis of graft should be Grafts placed too deep

slightly superficial to will cause cysts and
scalp epidermis ingrown hairs

Correct Incorrect
depth depth

The grafts should not be inserted too deep. The epidermis of the graft must be
slightly superficial to the epidermis of the recipient scalp. If the graft is placed
deep, the epidermis of the scalp closes on top of the graft and invariably results
in an ingrown hair and/or cyst. Multiple small bumps should be evident after
closure, as shown above, but as they heal, these will flatten and the scalp will be
smooth. An ingrown hair becomes manifest about 3 to 4 months postoperatively
as a pustule, which matures, comes to a head, and finally drains and heals. Despite
this, the ingrown hair will usually grow, but the process is a nuisance and should
be avoided. An inclusion cyst at a deeper level may require surgical excision.
Chapter 6  ▪  Correction of  Male Pattern Baldness 109

The stick and place technique provides us with great flexibility. The surgeon
can concentrate on the artistry involved in designing the hairline, the desired
direction of hair growth can be achieved, and the appropriate graft sizes can be
placed in the various areas for the most natural result. In addition, piggyback-
ing or skipping slits is avoided, which often happens when the slits are made in
advance. The assistants concentrate on picking up the grafts of the appropriate
size and atraumatically inserting them at the next best possible site, as directed
by the surgeon. My (A.B.) preference is to insert all grafts myself.

The surgical team communicates constantly during the procedure about the ap-
propriate size for the area being grafted. In the front hairline, for example, we
use the smallest FU micrografts (one- to two-hair grafts only), totaling about 400
grafts. We use a mixture of one- to two-hair FU micrografts and three- to four-hair
FU minigrafts 1 cm beyond the front hairline. We also stay in close touch with
our graft dissection team as to the number of grafts that are ready for insertion and
the approximate number of grafts they anticipate making from the donor strip.
This helps us insert the remaining grafts strategically to provide the best coverage.

Clearly, the front hairline is the most critical area, and the grafts are packed as
densely as possible there and on the hair part as well, if the patient parts his hair.
Once these areas are covered as densely as possible, we proceed to areas of next
priority, leaving the areas of least importance such as the crown to last. If there
is abundant donor hair, 2000 to 2500 grafts should provide maximal coverage of
the entire area of baldness, including the crown.
110 Part II  ▪ Technique

Three closely Insert

placed slits three grafts

Another method for placing the grafts as close as possible is to make three con-
secutive slits about 1 mm apart and then insert the grafts. The surgeon then
proceeds to another area and a few minutes later returns to complete the inser-
tion. We prefer not to make more slits at any one time to avoid confusion and
piggybacking or skipping slits when inserting the graft later. As mentioned earlier,
if the donor hair is limited, we skip the crown and concentrate on grafting the
front two thirds of the scalp.

If donor hair is significantly limited, we transplant only the median frontal fore-
lock area. A naturally occurring medial frontal forelock is shown. In some cases
the patient’s donor hair may be so severely limited that he is not a candidate for
micrografting and minigrafting or any other hair restorative surgical technique.
Chapter 6  ▪  Correction of  Male Pattern Baldness 111

Angling the surgical blade when making the slits controls the direction of hair
growth. Thus the hair can grow straight forward, to the left, or to the right or it
can even be grafted as a whorl.

or slight
forward angle
Forward angle

or slight

or slight

Normally the hair should grow forward at an angle of about 45 to 60 degrees at

the front hairline and 75 to 80 degrees more posteriorly. At the crown the grafts
are placed 90 degrees perpendicular to the scalp, and on the posterior aspect of
the crown they are angled downward 45 to 60 degrees. At the lateral fringes the
direction of the existing hair is followed.
112 Part II  ▪ Technique

The stick and place procedure is performed with a microsurgical blade, while the
FU insertion is done with microforceps.

Surgeon’s hand

Gauze pad

Friction from gauze will

dislodge grafts

For stability the surgeon may gently rest his hand on the patient’s head with a
moist 4 3 4 gauze pad at the interface. However, any friction must be avoided to
prevent dislodging the grafts from their corresponding slits.
Chapter 6  ▪  Correction of  Male Pattern Baldness 113

Postoperative Care

After the procedure is complete, I (A.B.) place an Adaptic dressing impregnated

with Polysporin ointment on the patient’s head over the transplanted hair. The
head is then wrapped in Kerlex bandages and a 3-inch Ace bandage.

Alternatively, I (C.U.) prefer to use a simple dressing of gauze wet with a saline
solution with a soft elastic bandage.

The dressing selected is kept in place for 48 hours. Then the patient is allowed to
gently shampoo the hair daily with a mild product such as Johnson & Johnson’s
baby shampoo.
114 Part II  ▪ Technique

The patient receives orientation from the nursing staff after the surgery and is
ready to go home. We recommend that someone accompany the patient; he or
she is not allowed to drive during the first 24 hours because of the aftereffects
of sedation. Patients can also return to their professional activities the day after
surgery. We recommend the use of an analgesic such as Tylenol with codeine for
the discomfort the patient will feel in the donor area beginning 6 to 8 hours post-
operatively. We recommend prednisone 40 mg/day for 3 days to avoid swelling in
the forehead. We do not routinely prescribe antibiotics.

It is important that the patient sleep during the first 24 to 48 hours with the head
propped up to diminish swelling. Forehead edema occurs in 25% of patients and
can, after the second day, travel down to the eyelids and cheeks. Cold compresses
can help diminish the swelling. We recommend that the patient remove the Ace
bandage himself after 24 hours and take a shower wearing the remaining dress-
ings, which may be adherent to the scalp, and let lukewarm water flow over them
until they can come off without adhering to the grafts. If the patient removes an
implant together with the dressings, there will be some bleeding, which can be
stopped by pressing the local area for 3 to 5 minutes. The patient must then wash
the scalp with an antiseptic shampoo or soap, trying to remove only the dry blood
but not the crusts. This procedure can be done every day for 1 week, after which
he can resume using his regular shampoo.

All sutures are removed at 7 to 10 days. The crusts formed in the grafted areas
will fall off within 8 to 15 days. Patients are normally concerned about how long
the signs of the surgery will be detectable. To accelerate the process of the crusts
Chapter 6  ▪  Correction of  Male Pattern Baldness 115

falling out, we recommend the application of mineral oil, as is used for babies,
30 minutes before a shower and shampoo. This oil softens the crusts and within
1 week makes the removal easier.

After 1 month postoperatively we recommend the use of 5% minoxidil 30 drops

twice a day over the implanted area, massaging softly and letting it dry naturally.
This drug, used for 3 months, increases the blood supply in the scalp and also
the hair-growing process. In Brazil we also use Jaborandi, a plant used in herbal
medicine, and aloe vera, both found in the Amazon, that activate hair growth,
making it stronger and more luxuriant. They have been widely used by our pa-
tients for many years. We also recommend finasteride (Propecia, Proscan) for a
smaller group of patients, especially young ones. We have had interesting results,
although 5% of these patients reported a reduction of libido. When this occurs,
the patient is instructed to stop using the medication.

Postoperative Hair Growth Cycle

During the first 1 to 3 weeks after surgery, the transplanted hair is in the catagen
(transition) phase as it reaches 3 to 4 mm in length. This is initially encouraging
for the patient. However, from 3 weeks until approximately 9 to 12 weeks, much
of the transplanted hair will revert to a telogen (rest) phase and will gradually
shed (telogen effluvium). This makes the hair look even thinner than before the
procedure and may concern the patient. For this reason it is important for the
surgeon to inform the patient during the consultation and postoperatively of this
natural and expected stage in the process so that it does not come as a surprise.
The patient should also be given written information to describe this phase of
the recovery process.

At about 12 to 14 weeks, the transplanted hair will once again shift into an
anagen (growth) phase, and new hair will begin to grow from the remaining
matrix. By the third or fourth month, hair growth is evident. Over the next 6 to
10 months, the hair will become longer and thicker. The final result is usually
evident at 1 year postoperatively in men; it takes a few months longer in women.
Then, if the patient desires greater hair density, a second session is scheduled.

The implanted hair can be expected to retain its original genetic characteristics
from the donor area, but the patient must also be informed that baldness is pro-
gressive and that the implanted hair can become thinner and fall out over the
years, but that given adequate donor site density, he can undergo a new replace-
ment procedure to recover its previous density.
116 Part II  ▪ Technique

Problems and Complications

Fortunately, there are few complications after hair transplantation. In 25% of our
patients we may see some ingrown hairs and cysts after the third month postop-
eratively. These occur especially in oily skin and can be ruptured with a forceps
or needle and cleaned with antiseptic solution.

Key Concepts
The keys to a natural result in hair transplantation include the following:
• Small grafts
• Appropriate distance of the hairline from the eyebrows up
• Uneven frontal hair design
• Density
• Direction of hair growth
• Absence of detectable scarring
• Single hair FUs at the front 1 cm of the hairline (posterior to that, one-,
two-, three-, or four-hair FUs can be used)
Chapter 6  ▪  Correction of  Male Pattern Baldness 117

case examples
Long-Term Results and Appearance Over Time
Carlos Oscar Uebel

7 days after surgery 3 weeks after surgery

3 months after surgery 6 months after surgery

This 38-year-old man had FU hair transplantation.

He is shown 7 days postoperatively with crusts,
3 weeks postoperatively with shading, 3 months
postoperatively with beginning hair growth, and 6
and 8 months postoperatively. He exhibits a typi-
cal postoperative hair growth cycle.

8 months after surgery

118 Part II  ▪ Technique

This 38-year-old man had approximately 1200 FU grafts placed. He is shown

postoperatively at 1 month, 5 months, and 1 year.
Chapter 6  ▪  Correction of  Male Pattern Baldness 119

Alfonso Barrera

This 63-year-old man with type IIIa male pattern baldness underwent FU grafting.
He is shown preoperatively and 19 years postoperatively. His results confirm the
long-term growth of these grafts.
120 Part II  ▪ Technique

This 56-year-old man with type V to VI male pattern baldness requested hair
transplantation. Twelve years earlier, at age 44, he underwent a single session
with 2050 grafts placed. He is shown preoperatively and 12 years later, after a
second session.
Chapter 6  ▪  Correction of  Male Pattern Baldness 121

It is interesting to see the donor dominance factor; that is, that the transplanted
hair follicles from the donor area continue to grow for the period of time that
they were genetically programmed to in their original location, and have followed
this timing in their new site. This is a very encouraging finding, given the nature
of male pattern baldness, and confirms the validity of current techniques of hair
122 Part II  ▪ Technique

The Role of Hair Color

Carlos Oscar Uebel

Gray hair produces the best results because it provides less contrast between the
scalp and hair, as is evident in this 56-year-old patient, shown 3 years after a
single session.

Special care is needed when transplanting black hair, especially if it is coarse

and being implanted on a bright, oily scalp. In these cases the contrast is high,
which re­sults in an artificial appearance. A random distribution of implants is
Chapter 6  ▪  Correction of  Male Pattern Baldness 123

recommend­ed, and the temple recessions should be maintained to create a natural

appearance. Patients who have thick, dark hair are encouraged to modify their
hairstyles by combing the hair to the front or the side. This 48-year-old patient
underwent two FU replacement procedures over the course of 3 years. He is
shown 4 years postoperatively.

This 78-year-old man presented with a large area of baldness. He is shown 2 years
after a one-session FU replacement. Because he has white hair, we were able to
achieve a natural result.
124 Part II  ▪ Technique

This 65-year-old man presented with frontal baldness. He is shown 2.5 years after
undergoing one-, two-, and three-hair FU replacements performed in one session.
Subsequently he began coloring his hair.
Chapter 6  ▪  Correction of  Male Pattern Baldness 125

Brown, blond, or red hair is usually found on young patients with incipient bald-
ness. It is easier to work with than black hair. Its contrast against the scalp is
lower, and the result is aesthetically more natural. This type of hair will gray with
age, improving the surgical result. In this 45-year-old patient we performed two
replacements in 3 years and achieved good density.
126 Part II  ▪ Technique

Alfonso Barrera

This 46-year-old man with type IIa male pattern baldness had mild frontotempo-
ral recessions. He had 930 FU grafts placed in a single session to just the frontal
hairline, particularly to the frontotemporal recessions. He is shown 1 year post-
Chapter 6  ▪  Correction of  Male Pattern Baldness 127

The patient’s hairline is shown 1 year after the procedure with a natural, aestheti-
cally pleasing appearance.

The Role of Hair Density

Carlos Oscar Uebel

Hair density is an important factor in hair restoration. Hair density varies from
one patient to another; the younger the patient, the denser the hair. One of the
best techniques for improving hair density is placing additional grafts in between
the remaining hair shafts. Patients are satisfied with the results and are able to
change hairstyles and color. This patient is shown preoperatively and 2 years after
a single session.
128 Part II  ▪ Technique

Alfonso Barrera

This 53-year-old man with type VI male pattern baldness presented with low hair
density, even on the donor site area. It is important to stress to the patient in
such cases that we can accomplish a reasonable improvement to the front part of
the scalp, and help him frame the face, but not to the crown, because the crown
requires a lot of grafts to show a significant improvement. If we focus grafts to the
crown, we will not have enough for the front. So we did a strategic placement of
the grafts for this patient, all to the frontal scalp. He underwent a single session
of 2652 grafts. He is shown 1 year postoperatively.
Chapter 6  ▪  Correction of  Male Pattern Baldness 129
130 Part II  ▪ Technique

This 63-year-old man with type VI male pattern baldness and moderate donor
hair density requested hair transplantation. Because he had gray hair, the graft
dissection was done under the microscope and with background lighting. He is
shown before and after a single session of 2320 FU grafts.
Chapter 6  ▪  Correction of  Male Pattern Baldness 131
132 Part II  ▪ Technique

This 38-year-old man with type V male pattern baldness had moderate hair thick-
ness and donor site hair supply. The donor area markings are shown. He had 1829
follicular unit grafts placed in a single session. He is shown 2 years postoperatively.
Chapter 6  ▪  Correction of  Male Pattern Baldness 133
134 Part II  ▪ Technique

This 42-year-old man with type VII male pattern baldness had limited donor hair
as well as thin hair. If a patient understands the limitations of the technique and
has reasonable and conservative expectations, we may still proceed, as in this
case. He had 2090 FU grafts placed in a single session. He is shown preoperatively
and postoperatively, when he returned for a second session. The donor area is
marked and trimmed in preparation for the second session.
Chapter 6  ▪  Correction of  Male Pattern Baldness 135
136 Part II  ▪ Technique

This 52-year-old man with type VI male pattern baldness had very thin and lim-
ited donor hair. He requested hair transplantation, knowing that only a modest
improvement was possible. He had 2232 follicular units strategically placed. He
is shown 2 years postoperatively.
Chapter 6  ▪  Correction of  Male Pattern Baldness 137
138 Part II  ▪ Technique

This 49-year-old man with type V male pattern baldness had thick hair and good
donor site density. He had 2230 FU grafts placed in a single session. He is shown
2 years postoperatively.
Chapter 6  ▪  Correction of  Male Pattern Baldness 139
140 Part II  ▪ Technique
Chapter 6  ▪  Correction of  Male Pattern Baldness 141

This 57-year-old man with type IIIa variant male pattern baldness had plenty of
thick donor site hair and a limited area of hair loss in the front scalp region only.
He had 2003 FU grafts placed in a single session. He had a lower blepharoplasty
procedure at the same time. He is shown 2 years postoperatively.
142 Part II  ▪ Technique

This 54-year-old man with type Va male pattern baldness was a good candidate
for hair transplantation because he was mature and had a favorable ratio between
the area of supply and the area of demand.
Chapter 6  ▪  Correction of  Male Pattern Baldness 143

His hair was relatively thick. He had 2167 FU grafts placed in a single session.
He is shown 2 years postoperatively.
144 Part II  ▪ Technique

This 47-year-old man with type VI male pattern baldness requested hair trans-
plantation. I explained that it would be likely that a second session would be
necessary to produce an optimal result. He understood, but asked for the best
possible result in a single session. He had 2460 FU grafts placed. He is shown
before and 2 years after the procedure.
Chapter 6  ▪  Correction of  Male Pattern Baldness 145
146 Part II  ▪ Technique

This 60-year-old man with type VI male pattern baldness was a good candidate
for hair transplantation. He had 2345 FUs placed in a single session and is shown
1 year postoperatively.
Chapter 6  ▪  Correction of  Male Pattern Baldness 147
148 Part II  ▪ Technique

The Role of Age

Alfonso barrera

This 36-year-old man with type IIIa male pattern baldness requested hair trans-
plantation. He had excellent donor site hair with a very favorable supply and
demand ratio—in other words, he has a limited area of baldness and a lot of donor
hair. Still, because of his young age we explained that he will need additional
grafting as he ages. He had 1574 grafts placed in a single session and is shown
1 year postoperatively.
Chapter 6  ▪  Correction of  Male Pattern Baldness 149
150 Part II  ▪ Technique

This 37-year-old man presented with type V male pattern baldness that was pro-
gressing to type VI. He had 1585 FU grafts transplanted primarily to the front
scalp in a single session. It was explained to him that he will likely need additional
grafting in the future.
Chapter 6  ▪  Correction of  Male Pattern Baldness 151
152 Part II  ▪ Technique

Carlos oscar Uebel

This 69-year-old patient with frontal pattern baldness underwent only one session
of hair replacement. He is shown 18 months postoperatively.
Chapter 6  ▪  Correction of  Male Pattern Baldness 153

The Role of Hair Texture

Carlos Oscar Uebel

Hair texture can have an impact on the results of hair transplantation, as can
be seen with this black patient with thick, curly hair; an outstanding result was
obtained with his hair transplantation procedure. His curly hair provided substan-
tial covering of the scalp without the scalp “see through” appearance sometimes
noted in patients with thin, straight hair. The patient is shown preoperatively
and 3 years after a single session.
154 Part II  ▪ Technique

Alfonso Barrera

This 46-year-old man with type IIIa male pattern baldness desired hair trans-
Chapter 6  ▪  Correction of  Male Pattern Baldness 155

He had nice coarse hair and good donor site density, and a limited area of bald-
ness, which made him a great candidate for hair transplantation. He is shown
before and a year after a single session of 2674 grafts.
156 Part II  ▪ Technique

Preservation of the Median Forelock

Alfonso BarrerA

This 38-year-old man had type VI male pattern bald-

ness and an unusually strong residual frontal forelock.
The central forelock island seemed so thick that I felt
no need to transplant it. The patient understood that
additional grafting in the future most certainly will
be necessary to keep up with further hair loss. The
preoperative markings are shown outlining his new
hairline and the donor site.
Chapter 6  ▪  Correction of  Male Pattern Baldness 157

He is shown immediately after placement of 2288 FU grafts during one session.

and 1 year later with improved hair density (see pp. 72-73).
158 Part II  ▪ Technique
Chapter 6  ▪  Correction of  Male Pattern Baldness 159
160 Part II  ▪ Technique

Multiple Sessions
There is only so much density we can generate in one session of hair transplanta-
tion. In patients who desire optimal density, as long as they have plenty of donor
hair density and thickness, we can perform repeated sessions of hair transplan-
tation. Ideally, subsequent sessions should be scheduled no sooner than 10 to
12 months. The following cases show examples of the results that can be achieved
with more than one session.

Alfonso Barrera

This 46-year-old man with type VI male pattern baldness had a thin central fron-
tal island of hair and reasonable hair thickness and donor site density. However,
the island of hair will likely thin over time.
Chapter 6  ▪  Correction of  Male Pattern Baldness 161

The operative plan was to focus on the front scalp, but grafting also needed to be
done to the entire top of the head. The island in the front had to be grafted as
well to prevent having an “empty island” later. He had a total of 2549 FU grafts
implanted in two sessions. He is shown 1 year after the second session.
162 Part II  ▪ Technique

This 63-year-old man with type VII male pattern baldness had very high hair
density in the occipital and temporal donor site areas. He had very thick hair
and plenty of donor hair supply, which made him a great candidate for hair trans-
plantation. He underwent a total of 8109 grafts in three sessions, which is about
20,000 hairs (since the grafts have one, two, and three hairs per graft). He is
shown preoperatively, and 1 year postoperatively after the third session.
Chapter 6  ▪  Correction of  Male Pattern Baldness 163
164 Part II  ▪ Technique

This 48-year-old man with type V male pattern baldness requested hair trans-
plantation to improve the hair density in his crown. The crown region requires
a significant number of grafts to cover well. He had good donor site hair density,
and a total of 2022 FU grafts were placed in two sessions. He is shown 1 year
Chapter 6  ▪  Correction of  Male Pattern Baldness 165

Carlos oscar Uebel

This 52-year-old patient had incipient baldness and requested increased hair
density. After 5 years and two replacement procedures, he accented his hairstyle
with some blond highlights.
166 Part II  ▪ Technique

In response to the progressive nature of his baldness, this 32-year-old man under-
went two FU replacement procedures over 12 years. He is shown postoperatively
after the second procedure with good hair density and a natural hairline.
Chapter 6  ▪  Correction of  Male Pattern Baldness 167
168 Part II  ▪ Technique

1. Vogel JE, Jimenez F, Cole J, Keene SA, Harris J, Barrera A, Rose P. Hair restoration: state of
the art. Aesthet Surg J 33:128-151, 2013.
2. Barr L, Barrera A. The use of hair grafting in scar camouflage. Facial Plast Surg Clin North
Am 19:559-568, 2011.
3. Barrera A. Clinical decision-making in hair transplantation. In Nahai F, ed. The Art of Aes-
thetic Surgery: Principles & Techniques, ed 2. St Louis: Quality Medical Publishing, 2011.
4. Barrera A. Hair transplantation. In Lin SJ, Mustoe TA, eds. Aesthetic Head and Neck: An
Operative Atlas. New York: McGraw-Hill, 2013.
5. Barrera A. Hair transplantation. In Carniol P, Monheit G, eds. Aesthetic Rejuvenation in
Clinical Practice. London: Informa Healthcare, 2009.
6. Vogel JE. Correction of problems in hair restoration surgery: an update. Facial Plast Surg Clin
North Am 12:263-278, 2004.
7. Uebel CO. Baldness surgery: the mega-punctiform technique. Plast Surg Techniques 1:95-103,
8. Uebel CO. Micrografts and minigrafts: a new approach for baldness surgery. Ann Plast Surg
27:476-487, 1991.
9. Uebel CO. The punctiform technique with 1000 micro- and minigrafts in one stage. Am J
Cosm Surg 11:293-303, 1994.
10. Uebel CO. Micrograft—a new approach for pattern baldness surgery. Transactions of the
Tenth International ISAPS Congress, Zurich, Switzerland, 1989.
C H A P T E R 7

Correction of F emale
Pattern Baldness

Carlos Oscar Uebel, Anajara Gazzalle

170 Part II  ▪ Technique

he most common cause of hair loss in women is androgenetic alopecia; this
occurs after 40 years of age, when women enter menopause, causing the
thinning and rarefaction of the hair. As in men, about 10% of women develop
baldness, but with women the emotional and psychological aspects are more in-
tense. Because women are accustomed to having good hair density from youth,
and there is a greater cultural stigma for balding women, they do not accept the
idea of becoming bald at this stage in their lives. They strongly reject hair fallout
and start to use any kind of systemic and topical treatments available to reverse
this. They may use everything from synthetic fiber hair-filling systems to the most
exotic adhesives, kerchiefs and turbans, and even capillary prostheses, in an at-
tempt to hide the balding areas. By the time a woman comes to see a surgeon for
a microtransplant, it is very likely that she has already tried all manner of possible
treatments and tricks.

The most important preoperative evaluation is a thorough history and physical

examination and, if indicated, selected laboratory tests. If a patient has scarring
alopecia, a scalp biopsy may be necessary to make a diagnosis.1-4

Female androgenic alopecia has its origin in the male hormone testosterone,
which is produced in the ovaries and suprarenal glands. Although it is produced
at lower levels than in men, when testosterone comes into contact with 5-alpha-
reductase, an enzyme contained in the matrix of the capillary bulb, it changes
to dihydrotestosterone (DHT), which will cause involution and atrophy of the
bulb. The excess testosterone produced by the stimulus of the hypophysis can
cause other effects in women, such as acne, seborrhea, menstrual disturbances,
and hirsutism—a syndrome that may appear after the age of 15. Fortunately,
5-alpha-reductase is less common in women than in men, which is why alopecia
is significantly lower in women.

In the literature, there are several classifications for baldness, as proposed by Lud-
wig,5 Hamilton,6 Olsen,7 and Basto.8 The Ludwig classification is the most widely
used and is simple and well known. We have identified four different patterns in
female baldness, depending on the localization and appearance.
Chapter 7  ▪  Correction of Female Pattern Baldness 171

Geographic Pattern

Geographic pattern baldness is the most common type of female pattern bald-
ness. It begins 1 to 2 cm from the front hairline and extends through the posterior
region and up to the crown, as shown in this 28-year-old woman. This kind of
baldness is progressive in nature, becoming more accentuated with age and even-
tually reaching the occipital and temporoparietal region.

The occipital posterior region of the neck is normally not affected by the hor-
monal action, and good hair quality is maintained in this area. It is important to
evaluate the patient and make a differential diagnosis of alopecias brought on by
medicines, stress, and drastic diets, which may lead to telogen effluvium of the
whole scalp.
172 Part II  ▪ Technique

Frontal Pattern

The frontal pattern is also a very common female baldness pattern in which the
hairline recedes and much of the patient’s forehead appears enlarged, producing
a very strong and rough aspect to the female face, as is shown in this patient. The
transplantation goal is to create a new, lower hairline to reframe the face and
soften the facial contour.

Temporal Recession

Women usually find temporal recession very upsetting, as do men, because it

creates a very masculine and aging appearance. Fortunately, the results obtained
with grafting of follicular units are quite good, producing a very natural hairline.
Chapter 7  ▪  Correction of Female Pattern Baldness 173

Diffuse Alopecia

Diffuse alopecia affects the whole scalp. There is extensive loss of hair, also in-
volving the posterior cervical region, which is the typical donor area for the har-
vesting of follicular units. This is different from the other patterns in that there is
no thinning of hair; the remaining hair is strong and thick (left). This condition
must be differentiated from cicatricial alopecia (right), in which atrophic areas are
located in a more concentrated region of the scalp, for which grafts or flaps offer
positive results. In diffuse alopecia a complete evaluation is necessary to verify
that the patient has appropriate donor area from which adequate grafts can be
harvested, and the patient must be made aware of this possible limitation.
174 Part II  ▪ Technique

The introduction of the punctiform technique using follicular units (FUs) was a
significant step in the treatment of female baldness, with the possibility of improv-
ing the density of the balding area with up to 4000 to 5000 hairs. The method is
similar to that used for men; the follicular units are harvested from the neck area,
where the best histologic quality of follicular units is found. We prefer to remove
an ellipse of the scalp, large enough to fill the recipient area we intend to treat.
The procedure is done with the patient under sedation and local anesthesia.

Female hair is thinner than male hair, and we prefer to implant more FUs with
two- and three-hair shafts than with single hairs. In the front hairline, we mix
single FUs with one- or two-hair shafts. In the recipient area, we leave the re-
maining hair intact and do not cut the hair.

In the early 1990s we cut the remaining hair short or even shaved it to make the
replacement process easier. The hair density achieved was undeniably greater, but
because many patients did not accept having their hair cut or shaved, we now pre-
fer to leave the hair in place and separate it into rows. This became our routine,
and today we wet the hair and make parallel rows with a thin comb, beginning the
replacement from the posterior region and working toward the anterior region.
Chapter 7  ▪  Correction of Female Pattern Baldness 175

It is important to perform the scalp ballooning tumescent technique 5 to 10 min-

utes before the implantation procedure is begun. A massive infiltration of sa-
line solution with epinephrine 1:120,000 is administered to achieve edema and
ischemia of the scalp. For the hair placement we use No. 11 and microsurgical

After surgery, we apply moist gauze pads and a bandage to the replanted area for
24 hours, after which the patient may remove the bandage herself and wash the
hair gently with Johnson’s baby shampoo.

We normally expect to see the final result in women at 15 months postopera-

tively. The hair grows longer and finer in the beginning and becomes thicker
after 2 years.

Complications and Secondary Hair

Transplant Procedures
After 3 to 4 months, some oil retention cysts may appear, which may be ruptured
with a disposable needle and cleaned with an antiseptic solution. This procedure
can be done in the office or at home.

We recommend the use of 5% topical minoxidil for 3 to 4 months. This medica-

tion has been shown to be effective in female pattern hair loss,2,14,15 starting in
the first month postoperatively to prevent fallout of about 20% of the remaining
hair, which is very common in the first 3 to 4 months. The patient must be made
aware of this telogen effluvium, so as not to be surprised when this occurs. Several
studies are being conducted to determine the efficacy of new therapies, including
finasteride16-18 and Avicis, which is available in South America and Europe.

Patients should be told that they must not dye their hair for 1 month after surgery;
the hair coloring products currently available on the market can be destructive
to the hair bulbs. Patients also need to be careful of using abrasive and allergenic
products on the scalp.

If the woman would like more hair density, we can schedule a second replace-
ment session after 15 months, when the final result of the first implantation will
be evident. The procedure is the same, and if the patient’s donor area is adequate,
we can harvest as many FUs as she needs.
176 Part II  ▪ Technique

Case Examples
Geographic Pattern Baldness
Carlos Oscar Uebel

This 36-year-old woman had geographic female pattern baldness that began 1 to
2 cm from her hairline. She underwent hair transplantation with FUs. She is
shown 2 years postoperatively with a very natural result.
Chapter 7  ▪  Correction of Female Pattern Baldness 177

This 68-year-old woman with geographic female pattern baldness was treated
with one hair transplantation session using FUs. She is shown 14 months post-
178 Part II  ▪ Technique

This 49-year-old woman with geographic female pattern baldness was treated with
FUs placed in one session. She is shown 2 years postoperatively.
Chapter 7  ▪  Correction of Female Pattern Baldness 179

This 69-year-old woman with progressive baldness had FU grafts transplanted.

She is shown 3 years postoperatively.
180 Part II  ▪ Technique

This 61-year-old woman with geographic hair pattern baldness had one hair re-
placement procedure in which FUs were transplanted. She is shown 18 months
Chapter 7  ▪  Correction of Female Pattern Baldness 181

Frontal Pattern Baldness

This 58-year-old woman with frontal pattern baldness had a new hairline created
with FU hair transplantation. She is shown 3 years postoperatively.
182 Part II  ▪ Technique

Temporal Recession

This 43-year-old woman had hair transplantation to fill in her temporal recesses.
She is shown 14 months postoperatively.
Chapter 7  ▪  Correction of Female Pattern Baldness 183

This 66-year-old woman presented with temporal baldness. She is shown

18 months postoperatively with newly transplanted hair that is coarse and firm.
184 Part II  ▪ Technique

Diffuse Alopecia

This 62-year-old woman presented with diffuse alopecia that affected her entire
scalp as well as the posterior occipital donor area. She is shown 16 months post-
operatively following follicular unit hair transplantation with hair harvested from
undamaged areas that were not affected by thinning.
Chapter 7  ▪  Correction of Female Pattern Baldness 185

This 58-year-old woman had diffuse cicatricial alopecia in a circumscribed area of

her scalp. She had FU hair transplantation and is shown 21⁄2 years postoperatively.
186 Part II  ▪ Technique

Androgenetic Alopecia
Alfonso barrera

This 48-year-old woman had a much less severe case of female androgenetic
alopecia (Ludwig grade I to II) compared with that of the following patient. Hair
loss was confined primarily to the front half of the top of her head. She retained
a strong frontal hairline. There was no family history of hair loss in this case. She
is shown 1 year after 900 micrografts and minigrafts were transplanted in a single

This 43-year-old woman had Ludwig grade II to III female androgenetic alopecia.
Her hair had thinned gradually, primarily on the top of her head with preservation
of the front hairline. The hair at the sides and temples had also thinned, but to a
lesser degree. The occipital area was the only site of good-quality hair and density,
which is typical in female androgenetic alopecia. Her mother had a similar type
of hair loss. The patient had no hormonal imbalances. Alopecia appears to result
from some hypersensitive androgen receptors at the hair root level. The occipital
area, as in male pattern baldness, seems to be less sensitive to androgen recep-
tors. A donor ellipse measuring 15 by 2 cm was harvested and 1000 micrografts
and minigrafts were transplanted in a single session. She is shown 1 year postop-
eratively. I always warn such patients that further thinning (telogen effluvium)
invariably occurs during the first 3 to 4 months and may be severe. This can be
reduced significantly with applications of topical 5% minoxidil.
Chapter 7  ▪  Correction of Female Pattern Baldness 187
188 Part II  ▪ Technique

Carlos Oscar Uebel

This 28-year-old woman presented with androgenetic female pattern baldness—

very rare for a person of this age. She is shown 18 months after FUs were trans-
planted in a single session. She has also highlighted her hair postoperatively.
Chapter 7  ▪  Correction of Female Pattern Baldness 189
190 Part II  ▪ Technique

This 26-year-old woman with female androgenetic alopecia is shown 2 years

postoperatively after FUs were transplanted in a single session.
Chapter 7  ▪  Correction of Female Pattern Baldness 191

This 62-year-old woman had progressive androgenetic alopecia. She is shown

2 years postoperatively with good hair density after FUs were placed in a single
192 Part II  ▪ Technique

This 35-year-old woman had female androgenetic alopecia. In addition to the

androgenetic nature of her hair loss, she also had hair thinning and baldness from
related job stress. She is shown 2 years postoperatively after hair restoration that
also extended to her temporal region.
Chapter 7  ▪  Correction of Female Pattern Baldness 193

1. Cotterill PC, Unger WP. Hair transplantation in females. J Dermatol Surg Oncol 18:477-481,
2. Sinclair R, Patel M, Dawson TL Jr, et al. Hair loss in women: medical and cosmetic approaches
to increase scalp hair fullness. Br J Dermatol 165(Suppl 3):12-18, 2011.
3. Rulon E, Safranek S, Gauer R. Clinical inquiries: what is the best diagnostic approach to alo-
pecia in women? J Fam Pract 58:378-380, 2009.
4. Blume-Peytavi U, Blumeyer A, Tosti A, et al. S1 guideline for diagnostic evaluation in an-
drogenetic alopecia in men, women and adolescents. Br J Dermatol 164:5-15, 2011.
5. Ludwig E. Classification of the types of androgenic alopecia (common baldness) occurring in
the female sex. Br J Dermatol 97:247-254, 1977.
6. Hamilton, JB. Patterned loss of hair in man; types and incidence. Ann NY Acad Sci 53:708-
728, 1951.
7. Olsen EA. Female pattern hair loss. J Am Acad Dermatol 45(3 Suppl):S70-S80, 2001.
8. Basto FT Jr. Calvície feminina: classificação proposta. Rev Bras Cir Plast 21:196-202, 2006.
9. Griffin EI. The treatment of female pattern alopecia by hair transplantation. In Stough DB,
Haber RS, eds. Hair Replacement: Surgical and Medical. St Louis: Mosby−Year Book, 1996.
10. Bouhanna P. Technique personelle de minigreffes pour le traitement de l’álopécie de la femme
ménopausée. In Mole E, ed. Actualités de Chirurgie Esthétique. Paris: Masson, 1992.
11. Uebel CO. A utilização do erbium-YAG laser na cirurgia do microtransplante capilar. In
Braden AZD, Roberts TL, eds. Laser. Rio de Janeiro: Revinter, 1999.
12. Uebel CO. Microtransplante da unidade folicular e a utilização do laser erbium-YAG na
cirugia da calvície. In Horibe EK, ed. Estética Clínica e Cirúrgica. Rio de Janeiro: Revinter,
13. Uebel, CO. Microhaartransplantation—die punktier-technik. In Lemperle G, ed. Ästhetische
Chirurgie, VII-2. Landsburg/Lech: Ecomed, 1999.
14. Hassani M, Gorouhi F, Babakoohi S, et al. Treatment of female pattern hair loss. Skinmed
10:218-227; 2012.
15. van Zuuren EJ, Fedorowicz Z, Carter B, et al. Interventions for female pattern hair loss. Coch­
rane Database Syst Rev 2012 May 16;5:CD007628.
16. Keene S, Goren A. Therapeutic hotline. Genetic variations in the androgen receptor gene
and finasteride response in women with androgenetic alopecia mediated by epigenetics. Der-
matol Ther 24:296-300, 2011.
17. Stout SM, Stumpf JL. Finasteride treatment of hair loss in women. Ann Pharmacother
44:1090-1097, 2010.
18. Oura H, Iino M, Nakazawa Y, et al. Adenosine increases anagen hair growth and thick hairs
in Japanese women with female pattern hair loss: a pilot, double-blind, randomized, placebo-
controlled trial. J Dermatol 35:763-767, 2008.
19. Gassmueller J, Hoffmann R, Webster A. Topical fulvestrant solution has no effect on male
and postmenopausal female androgenetic alopecia: results from two randomized, proof-of-
concept studies. Br J Dermatol 158:109-115, 2008.
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C H A P T E R 8

Combining Face L ift

and H air

Carlos Oscar Uebel, Alfonso Barrera

196 Part II  ▪ Technique

O ver
  the past two decades, we have been combining hair transplantation with
various other aesthetic procedures, such as rhinoplasty, blepharoplasty, otoplasty,
laser resurfacing, and face lifts.1-7 It is interesting to note that most plastic sur-
geons who do not perform hair transplantation are not familiar with the hair
transplantation technique, and most physicians who perform hair transplantation
are not plastic surgeons.

Thus, unfortunately, valuable pieces of scalp from prime donor areas are often
discarded and wasted during a face lift surgery. The retroauricular, occipital, and
temporal areas are the most desirable donor sites for hair transplantation and this
is precisely the area of scalp discarded during face lifts, as well as some temporal
scalp. Many patients have limited donor hair, so it truly is a pity not to use these
pieces of scalp and recycle them at that time. Face lifts can certainly be done
without discarding scalp by using prehairline incisions.

We have found the combination of face lift and hair transplantation to be very
rewarding, because patients who need both procedures benefit immensely by
having them done together, and no hair follicles are wasted.

To successfully combine these two procedures in a single setting requires an effi-

cient and well-coordinated team. As with any surgical procedure, an experienced
surgical team can accomplish more in a single session without compromising qual-
ity. I (A.B.) normally use three surgical assistants when combining a face lift and
hair transplantation, with or without upper and lower blepharoplasty. The scrub
nurse assists with the face lift and blepharoplasty, and two experienced surgical
assistants prepare the grafts for insertion after the face lift and eyelid procedures
are completed. Depending on their proficiency and experience, more than two
assistants may be needed to dissect the grafts in a reasonable time period.

We prefer to do this procedure with the patient under intravenous sedation and
local anesthesia, as described in Chapter 5; however, total intravenous anesthesia
(TIVA) or general anesthesia may be used, if preferred by the patient or surgeon.
Chapter 8  ▪  Combining Face Lift and Hair Transplantation 197

Design of
new hairline

Donor area


Excess skin

Normally discarded
Caudal scalp used to create
margin minigrafts and micrografts

Hair from the donor site is harvested at the beginning of the procedure so that
the assistants can dissect the grafts while the face lift is being performed. For the
transplant procedure the patient is placed in the supine position with his or her
head turned to the left for harvesting a triangular piece of retroauricular and oc-
cipital scalp from the right side first or from the first side of the face lift procedure.

The graft dissection is performed as described in Chapter 6, with 2 mm slices

dissected from the donor ellipse parallel to the hair follicles.
198 Part II  ▪ Technique

Design of
new hairline



Larger donor area


If more grafts are needed than what the retroauricular pieces of scalp provide or
if a donor strip has a low hair density, a larger, horizontal donor strip of the ap-
propriate size is harvested.
Chapter 8  ▪  Combining Face Lift and Hair Transplantation 199

Before transplanting the grafts the surgical team usually takes a 5- to 10-minute
break, then returns to the operating room. This final phase usually takes 1 to
1.5 hours and requires only one assistant. The grafts are inserted into slits cre-
ated with either a No. 22.5 Sharpoint blade or a No. 65 Beaver mini-blade at
the hairline, and farther back with a No. 11 Personna Feather blade. Dilators
are not required. Sometimes, to minimize the time that the grafts are out on the
petri dish, we perform one side of the face lift, then the hair transplantation, and
complete the procedure with the second half of the face lift.

All patients in whom we have performed this combined procedure for signs of
facial aging and hair loss have been pleased with the results. Because the crown
is more difficult to graft with the patient supine, we generally delay transplanting
this area until a later date. This can be accomplished in the office with the patient
awake and sitting upright.

Patients are able to go home comfortably the same day of the combined proce-
dure. It usually takes about 8 hours to perform a face lift with upper and lower
blepharoplasties and hair transplantation with 2000 grafts.
200 Part II  ▪ Technique

Case Examples
Alfonso Barrera

This 65-year-old man with an aging face and type VI male pattern baldness re-
quested hair transplantation, a face lift, and lower blepharoplasty. He is shown
preoperatively and 1 year after these procedures, in which 1062 grafts were placed
in a single session.
Chapter 8  ▪  Combining Face Lift and Hair Transplantation 201
202 Part II  ▪ Technique

This 65-year-old man with type VI male pattern baldness exhibited a moderate
degree of hair loss and had an aging face. He requested a face lift and thickening
of his hair in a single session. He is shown preoperatively and 2 years after the
face lift and placement of 1546 FU grafts in a single session.
Chapter 8  ▪  Combining Face Lift and Hair Transplantation 203
204 Part II  ▪ Technique

This 74-year-old woman had undergone a face lift, coronal forehead lift, and
upper and lower blepharoplasties 10 years earlier. She requested a secondary
face lift and upper and lower blepharoplasties as well as hair transplantation
in a single session. She is shown preoperatively and 1 year postoperatively. We
placed 962 FU micrografts and minigrafts to the frontal scalp and frontotemporal
Chapter 8  ▪  Combining Face Lift and Hair Transplantation 205
206 Part II  ▪ Technique

Case Examples
Carlos Oscar Uebel

This 54-year-old man presented with significant balding, blepharochalasis, and

fat bags in his lower eyelids. He underwent hair restoration, blepharoplasty, and
canthoplasty of his lower eyelids during a single session. A total of 1200 FUs were
Chapter 8  ▪  Combining Face Lift and Hair Transplantation 207

This 56-year-old man had a face lift, blepharoplasty, and hair transplantation
during a single session. The retroauricular hair-bearing flap was used as the donor
site to harvest sufficient follicular units. He is shown 3 years postoperatively.
208 Part II  ▪ Technique

This 62-year-old man had a blepharoplasty and during the same session, 1200 FUs
were transplanted. He is shown 18 months postoperatively.
Chapter 8  ▪  Combining Face Lift and Hair Transplantation 209
210 Part II  ▪ Technique

This 41-year-old man had frontal-occipital baldness and a heavy neck. A retro­
auricular hair-bearing flap was used to harvest an adequate number of FUs for hair
replacement. He also underwent a neck lift.
Chapter 8  ▪  Combining Face Lift and Hair Transplantation 211
212 Part II  ▪ Technique

This 52-year-old man had extensive baldness. We planned only a forelock to

reframe his face. A conventional face lift was performed, and the hair-bearing
flap was used as the donor site. A closeup of the forelock is shown postoperatively.
Chapter 8  ▪  Combining Face Lift and Hair Transplantation 213

This 62-year-old man had a conventional face lift and blepharoplasty, combined
with assisted liposuction. Hair replacement was performed at the same time, using
the retroauricular hair-bearing flap as the donor site.
214 Part II  ▪ Technique

This 34-year-old-man had hair restoration with rhinoplasty in a single procedure.

He is shown 2 years postoperatively.
Chapter 8  ▪  Combining Face Lift and Hair Transplantation 215

This 28-year-old man had frontal and temple recessions. He had conventional
hair restoration and rhinoplasty in a combined session. He is shown 4 years post-

1. Barrera A. Facelift and hair transplantation as a single procedure. Plast Reconstr Surg 104:1831-
1838, 1999.
2. Lessa S, Sebastiá R, Flores E. A simple canthopexy. Ver Soc Bras Cir Plást 14:59-70, 1999.
3. Flowers RS. Canthopexy as a routine blepharoplasty component. Clin Plast Surg 20:351-365,
4. Toledo LS. Syringe technique. Clin Plast Surg 23:683-692, 1996.
5. Uebel CO. The punctiform technique with the 1000-graft session. In Stough DB, Haber RS,
eds. Hair Replacement: Surgical and Medical. St Louis, Mosby−Year Book, 1996.
6. Uebel CO. A utilização do erbium-YAG laser na cirurgia do microtransplante capilar. In Ba-
din AZD, Moraes LM, Roberts TL III, eds. Rejuvenescimento Facial a Laser. Rio de Janeiro:
Revinter, 1998.
7. Uebel CO. Micrograft—a new approach for pattern baldness surgery. Transactions of the Tenth
International Congress of ISAPS, Zurich, Switzerland, 1989.
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C H A P T E R 9

Follicular Unit
E xtraction

Follicular unit micrograft Follicular unit minigraft

(1 or 2 hairs) (3 or 4 hairs)

James A. Harris
218 Part II  ▪ Technique

ollicular unit extraction (FUE) is a method of single follicular unit (FU) har-
directly from the donor area. The formulation of the basic technique has
been credited to Dr. Raymond Woods from Australia and to Drs. Rassman and
Bernstein and colleagues.1 There are two principal advantages of this technique:
the lack of a linear scar, such as those produced with strip harvests, and a quicker
recovery time, with less postoperative pain and discomfort.2

There are several methods and types of instrumentation used by surgeons to per-
form FUE. The general types are punches with either sharp or dull tips; these are
available as either manual or powered versions. The various instruments and their
related techniques, general FUE considerations, and donor area management will
be discussed in this chapter.

There is some debate as to the utility of FUE and whether it should be used as a
primary harvest method for the average patient. Both the strip and FUE methods
have some inherent advantages and disadvantages, but both are reasonable op-
tions, as long as the patient understands the limitations, relative advantages, and
potential consequences of each method.

In terms of the postoperative recovery time, strip surgery is usually associated with
2 to 3 nights of mild to moderate pain followed by 6 to 8 days of soreness. In ad-
dition, there is usually hypesthesia of the donor area and a sensation of tightness
for 2 to 3 months after the procedure. The patient usually recovers quicker from
an FUE procedure: within 48 hours there is an absence of pain or soreness, and
rarely do patients experience any hypesthesia or tightness.

There seems to be two major reasons for patients to seek an FUE procedure. The
first is the desire to avoid the removal of a strip of skin from their scalp, because
this is perceived to be more invasive or more akin to “surgery.” If a patient has
this opinion regarding the strip harvest and has decided that hair restoration is
important, it seems the only factor that may induce a change of opinion will be
the cost differential between the procedures, the FUE method being the more

The other major reason given by patients is the desire to avoid a linear scar, for
whatever reason they deem important. Patients frequently cite a preference for
wearing their hair short and thus want to avoid the possible detection of a linear
Chapter 9  ▪  Follicular Unit Extraction 219

This man had more than 2000 FUs harvested from two strip harvests. The scar
from the procedure is visible, especially with his hair cut short.

The length of hair that an individual may wear his hair after an FUE procedure
depends on several factors, including the size of the punch used, skin color, hair
color, and hair density.

The donor areas in two patients after 2800 FUE grafts (left) and 2200 FUE grafts
(right) are shown. No scarring is evident, although their hair is short.
220 Part II  ▪ Technique

It is important that patients be aware that FUE is not a scarless procedure; it will
leave punctate scars. If they decide to shave their scalp, the dotlike scars or the
absence of hair in the extraction site will be visible to some degree.

FUE donor sites are shown with the hair shaved close to the scalp. The dotlike
scars are visible 10 months after approximately 1000 grafts were extracted.

One of the factors to be considered when presenting options to the patient is the
limit of graft availability in a single surgery. In general, the limit for strip surgery
is based on the capability of the physician and his or her team, the laxity of the
patient’s scalp, and the patient’s FU density. The actual numbers vary, but 3000
to 4000 graft strip surgeries are not uncommon. For FUE surgery, the average
realistic limits are probably between 2500 and 3000 grafts per surgery, and this
will often take 2 consecutive days.

There is also a difference in the immediate postoperative appearance of the donor

area between strip and FUE harvests. The strip harvest donor site is usually well
hidden under the longer hair above the strip so that there are little or no cosmetic
concerns immediately after surgery. For FUE harvest cases, there are usually three
options. The first is a microstrip shave, which consists of 2 to 4 mm wide shaved
areas separated by 2 to 4 mm of unshaved areas so that the shaved regions will be
hidden by the longer hair. The second option is to cut the hair short on just the
FUs to be extracted, leaving the rest of the hair the same length. If the patient
desires a higher number of grafts, the entire donor area will have to be shaved,
the donor sites will be visible, and there will be scabbing for 9 to 12 days. The
details of donor area management will be discussed later.
Chapter 9  ▪  Follicular Unit Extraction 221

The absolute limit in terms of available grafts is approximately the same for strip
and FUE harvest techniques. The limit for strip surgery is usually determined by
the patient’s laxity and native FU density. The limit for FUE surgery is mostly
determined by the patient’s native hair density and how well the remaining or
nonextracted hair covers the donor area. When a certain point is reached, the
donor area can become too thin and leave a “moth-eaten” appearance. One of
the advantages of FUE is the ability to target units with more hairs to create
density in the recipient area. As a matter of fact, it is not uncommon to achieve
an average hair per graft of 2.5 to 2.8, even when the native density is closer to
2.1 hairs per graft. The downside of this higher density extraction is that lower
density units left in the donor area may be unable to provide adequate coverage
of the donor area.

There are a great number of patients who have exhausted their donor capability
with one type of harvest method, yet they are a likely candidate for the alternate
harvest method without any apparent degradation of the appearance of the donor
area. I have patients who through a combination of strip and FUE have received
well over 10,000 grafts without an untoward appearance of their donor area.

Utility of Follicular Unit Extraction

There are multiple scenarios for the use of the FUE, the details of which are be-
yond the scope of this chapter, but I will mention them briefly. The first is the use
of FUE to maximize the number of grafts obtained in a 1- or 2-day surgical session.
For example, a patient may elect to have a maximal strip surgery on the first day,
then have an FUE procedure the following day. A theoretical possibility would
be to have 3000 to 4000 grafts in a single day, followed by an FUE procedure with
another 1000 to 1200 grafts harvested; this would yield a 2-day total of 4000 to
5200 grafts. This number is usually beyond the number available with a single
procedure, and without pushing the limits of a reasonable strip width. Of course,
a patient could undergo an FUE procedure the first day, followed by a strip surgery
the second day; however, this strategy will reduce the total number of grafts if the
FUE has been performed in the potential strip region.

A second possibility for FUE is the ability to extract body hairs, with minimal
scarring, for use in either a scalp recipient area or the donor area for the repair
of linear scars. The two most common body donor sites are the submental beard
area and the chest. The units from beard grafts typically contain a single hair;
however, the caliber is greater than that of scalp hair, which may enhance the
density in the recipient area. The other possible advantage of beard hair is the
fact that the length of the anagen phase more closely matches that of scalp hairs.
In some patients the submental beard may have more than 5000 available grafts.
222 Part II  ▪ Technique

The chest is also a reasonable donor area, with the average graft having slightly
more than one hair. The hair caliber is finer than that of beard hair, but it more
closely matches that of scalp hair. Even though it is likely that the anagen phase
is shorter than for scalp hair, often the patient can get adequate length from chest
hair grafts. Some physicians, including myself, feel that the survival rate of chest
hair grafts does not match that of beard or scalp grafts.

Finally, FUE can be used to thin FUs from minigrafts or plugs placed in inappro-
priate locations, such as the frontal hairline or the central crown. The surgeon
may identify the offending units in the minigraft or plug, trim the hair and extract
the FU. The advantage of this technique is that the larger grafts are thinned out,
and there is an immediate visual feedback on the change in the “plugginess.” In
the conventional method of placing FUs in front of or in between the plugs, it
often took two or more procedures to eliminate the appearance of a double hair-
line, or a pluggy appearance. When the larger grafts can be thinned using FUE,
there is a greater chance that a more aesthetic result can be achieved in a single
surgery, although this cannot be achieved in all cases.

Follicular Unit Extraction Procedure

The major challenge in performing FUE is that although a surgeon may have a
general idea of the subcutaneous course of the follicles within the potential graft,
there is usually a difference between the emergence angle and direction of the
hairs versus the subcutaneous course of the follicles. The difference in the subcu-
taneous angle of the hair indicated in blue (right) can be compared to the angle
of the corresponding hair when it emerges at the skin surface.
Chapter 9  ▪  Follicular Unit Extraction 223

Two strategies have evolved to compensate for this variability. The first is a lim-
ited-depth dissection, which is typically used in conjunction with sharp punch
instrumentation. The second method is to use a dull punch, which may allow a
deeper dissection, with the theory that the dull leading edge allows the follicles
to slide into the punch lumen while minimizing the risk of transections. Both
techniques are intended to provide a margin of safety for the follicles so that the
unknowable factors, such as subcutaneous angles and directions, can be compen-
sated for.

The sharp and dull punch systems can be employed as manual devices, and each
has also been adapted to powered systems. Surgeons have individual preferences
on punch type and whether they will use the manual or powered version, based
on their experience and the type of FUE procedure to be performed. For example,
I use the powered dull punch system for scalp and body hair extractions but em-
ploy the manual dull punch system for thinning plugs or minigrafts.

The critical step of the sharp dissection technique, whether using a manual or
powered device, is determining the limited depth penetration of the sharp punch.
The ideal depth is that which will minimize the risk of transection to the follicles
yet achieve a depth that will separate the sebaceous gland from the surrounding
tissue and sever the erector pili muscle. Typically several test extractions are per-
formed to determine the proper depth, and then the procedure can proceed. The
proper depth can be maintained by visualizing the punch insertion, by feeling
the change in tissue transmitted through the punch, or by using a physical depth
limiter on the punch.

The dull dissection punch technique requires two slightly different routines. For
manual application, the dissection is a two-step process. 3,4 The first step is to
create a shallow (0.5 to 0.6 mm deep) scoring incision into the epidermis and
upper dermis to allow entry of the dull dissecting punch, which is then inserted
and rotated until it reaches a full depth of approximately 4 mm. The powered
dull dissection device uses a single-step dissection process whereby the punch is
inserted to the appropriate depth to fully dissect the FU from the skin.5,6
224 Part II  ▪ Technique

There is one additional device that is “automated” to some degree and uses a dull
punch dissection system called the ARTAS system (Restoration Robotics, Inc.,
San Jose, CA). This robotic device calculates follicular unit density, the angles
and directions of the emerging hair, and estimates the appropriate approach for
the dissection. The operator must monitor the progress of the system and make
changes to the dissection parameters as the need arises.

There are no published transection rates studies; however, the range should be
similar to strip surgery harvest. Reports at meetings suggest that 2% to 10% is the
appropriate range for FUE transection rates. In my opinion, the follicle transec-
tion rate does not tell the entire story about follicle damage during the harvest
procedure, but it is the most objective of any measure. It is generally accepted
that transection rates should be reported as a percentage representing number
of transected follicles divided by the total number of follicles that were targeted
for extraction.

Donor Area Management

One of the factors that patients and physicians must take into consideration when
planning an FUE procedure is the need for the hair in the donor zone to be cut to
approximately 1 to 2 mm long. When a patient’s entire donor area is shaved to
this length, an FUE procedure may yield 2200 to 3200 grafts, depending on the
follicular unit density, the extraction density, and the punch size used. This can
create an issue with the obvious visibility of the FUE sites that has to be taken
into consideration by the patient. In cases where the patient has had a single or
multiple strip procedures or is reluctant to have an exposed donor area, the likeli-
hood is that the patient will not be willing to shave.

If shaving the entire donor zone is not an option, the patient may elect to have
the microstrip prep or the stealth shave. This works best when the unshaved hair is
longer than 1 cm; however, there are limitations to this technique. By keeping
approximately half of the potential donor area excluded (not shaved), the number
of grafts may be limited to approximately 1000 to 1500 grafts per procedure. Pa-
tients who need a larger number of grafts will require multiple smaller procedures.

The other issue with the microstrip prep is that grafts are harvested from discrete
locations rather than a more diffuse harvest. During subsequent harvests, every
effort should be made to ensure that the shaved extraction areas are placed in
between the previous donor areas.
Chapter 9  ▪  Follicular Unit Extraction 225

There is some controversy about what the “safe” extraction zone for FUE should
be. As a general rule it would be approximately the same area as described by Alt,
Unger, and Cole7; however, for a variety of reasons the zone can be extended.
Because the extraction sites heal by secondary intention, the donor hair may be
obtained from the immediate suprauricular area as well as the low occiput, where
strip removals are inadvisable. These areas are also a good source of finer hair for
re-creation of the frontal hairline.

More controversial is the potential donor hair adjacent to hair at risk for being
lost by androgenetic alopecia. These areas would be the superior occipital, pari-
etal, and temporal fringe regions. Prudence must be used when dealing with these
areas, but by using proper magnification, FUs with predominantly terminal hairs
may be preferentially extracted. This strategy is safer in older patients with greater
hair loss to begin with, but in whom the more stable terminal hairs are readily
visible for targeting. In younger patients in the earlier stages of hair loss it will
be more difficult, if not impossible, to target units that are less likely to be lost.

A reason to consider FUE in the superior aspects of the temporal, parietal, and
occipital scalp is that if a margin (1.5 to 2 cm, for example) is not harvested, these
areas will likely have a visible difference in hair density and mass greater than
the FUE donor areas below. This can lead to styling issues and require eventual
harvest from these areas to make the appearance more even.

FUE surgery can be accomplished with a variety of sizes of punches, but there
is controversy as to whether the size can make a significant difference in the
appearance of scarring. As in many aspects of these procedures, there may be a
trade-off, such as the scar size versus the number of hairs per graft or the scar size
versus the transection rate.

In an anecdotal study presented in 20118 that investigated the differences in

the appearance and size using punches of 0.8, 0.9, and 1.0 mm, it was apparent
that the variability in healing renders the debate open for discussion. In the four
patients examined, two showed clear circular scars but with indistinct margins,
making measurement of the scar diameters impossible. In the other two cases the
healing by secondary intention did not result in distinct scars at all.
226 Part II  ▪ Technique

0.8 mm 0.9 mm 1.0 mm

Comparison of scarring in four patients (20 FUE sites per photo) using three punch sizes
Chapter 9  ▪  Follicular Unit Extraction 227

Macrophotographs of scars from 20 FUE sites using punches (left to right) of 0.8,
0.9, and 1.0 mm indicate more visible scarring with the larger punches. Therefore
in general I prefer to choose the smallest punch size that will minimize scarring,
result in the lowest transection rate possible, and allow dissection of the follicles
within a unit with minimal fractionation of the intact unit. I usually survey the
donor area and see if the follicles within the units are bundled or in a “picket
fence” configuration. I find that a 0.9 mm will usually accommodate the FUs in
most patients, but if the follicles are spread out then I use a 1.0 mm punch. I find
that the use of the 0.8 mm punch will drop the average hairs per graft from about
2.5 to 2.6 down to about 2 hairs per graft and will result in an increase of the fol-
licle transection rate.

Follicular Unit Extraction Surgery

After it has been decided where the adequate donor zone will be located and the
type of shave the patient will have based on his or her preference, the surgeon
administers the local anesthetic. The block is similar to one that would be used
for strip surgery, with one difference. Because FUE will often be conducted in the
lower aspect of the occiput, the surgeon will have to block the greater occipital
nerves, which exit at the region of the external occipital protuberance, as well as
the inferior aspect of the extraction zone, where the main sensory nerves are the
lesser and third occipital nerves.

I prefer to place the patient prone for extraction in the occiput and in the lateral
decubitus position for extraction in the temporal and parietal areas. This maxi-
mizes patient comfort and provides the best access for the surgeon. Of course,
the selection of position is up to the individual surgeon, but I want to be in a
position that is opposite the direction of hair emergence so that hand and arm
motions during the dissection process are toward the surgeon. I feel this provides
better visualization, less fatigue, and improved hand and arm stability during the
228 Part II  ▪ Technique

Novice physicians commonly ignore the requirement of adequate magnification

while performing FUE. It is one thing to use magnification to identify a unit and
entirely another matter to use the magnification to precisely center the dissecting
punch over the emerging hairs. After having taught a number of physicians to
perform FUE, I find the number one difficulty in performing FUE is the inability
to place the punch accurately over the target unit. If this initial step cannot be
performed, it is unlikely that the remainder of the dissection will be successful.
I recommend the use of high-quality expanded-field surgical loupes with a mini-
mum of 4.53 magnification.

The surgeon will use his or her technique and instrumentation of choice to ex-
tract the desired number of FUs. In general, one would typically avoid extracting
adjacent FUs, since this may lead to the appearance of small, linear scars. What
this strategy results in, depending on the patient’s FU density, is the extraction
of approximately a sixth to a quarter of the FUs in a given area. The number of
grafts harvested per square centimeter may be in the range of 20 to 30 grafts in
the occiput. In the temporal area, because of the lower FU density, the extraction
density will decrease accordingly. This would be the technique for harvesting a
number of grafts close to a “maximal” number of grafts in a single session. At this
extraction density I have not seen a single case of donor site effluvium.

If a patient requires a limited number of grafts (500 to 1500) and it is anticipated

that another surgery will not be required in the near future, I prefer to spread the
extraction out over a large area of the donor zone. It is in this way that the patient
will have the option of wearing his hair short without making the donor zone
visible because of lower hair density. As an example, if a surgeon were to extract
1000 FUs from the occiput and the patient decided to cut his hair short, there
is a strong likelihood that there will be a visible difference in hair density in the
extraction zone compared with the untouched donor area.
Chapter 9  ▪  Follicular Unit Extraction 229

Cautionary Notes

Strip grafts

Dull punch FUE ARTAS System FUE

The grafts produced by FUE, except for the majority of ARTAS robot grafts, are
devoid of fat which means that the grafts are more fragile and prone to handling
and desiccation effects leading to decreased graft survival rates. Special care by
the technicians during the handling is imperative. The minimization of time
spent out of the holding solution is important during the counting, sorting, and
implantation phases of the surgery. The technicians in my office will decrease the
numbers of grafts held on their fingers during implantation to approximately 50%
of the number they normally hold.
230 Part II  ▪ Technique

Mechanical trauma during the graft harvest and implantation portions of the
surgery must be avoided. It is not uncommon that forceps will be required to
remove the graft because of subcutaneous tethering, so it is important to avoid
crushing the graft or applying excessive pressure around the bulge region of the
follicles. It is helpful to use two forceps at two levels to diffuse the pressure and to
use forceps with serrations to provide friction to remove the grafts.

The implantation process is also fraught with difficulties, since FUE grafts can
have splaying of the individual follicles as well as follicles of different lengths.
These situations require additional manipulation, so care must be taken to avoid
excessive manipulation and the time out of the holding solution. I tend to make
the recipient sites slightly larger than I would for strip grafts to ease the insertion

In addition to these difficulties, one must also avoid improper implantation tech-
niques. There is a tendency for some technicians to grasp the graft proximal to
the bulb during insertion, which may bend the follicles and cause graft demise as
well as create a “hook” curvature that may cause hair fragment retention and a
foreign body reaction, with the inflammation possibly affecting surrounding graft
survival. It is my impression that implanter devices will help FUE graft insertion
and improve graft survival.

Concluding Thoughts
FUE is a method of harvesting hair for transplantation using a tool or procedure
to obtain grafts directly from the donor area; this technique gives patients another
option for treatment. It is not the ideal method for all patients, but for some it
better meets their particular needs. The FUE technique currently constitutes
22% of all hair restoration surgeries,9 and this percentage will surely increase and
create market pressure for physicians to either learn how to perform FUE or to
acquire the technology. As the technologies improve and the details of proper
handling and implantation techniques become standardized, the clinical results
of FUE will only improve.
Chapter 9  ▪  Follicular Unit Extraction 231

Case Examples

This 36-year-old man had a 16-year history of hair loss and had never used medi-
cal therapies to treat his hair loss. He has a family history of alopecia, and on
physical examination his scalp skin was normal. He had a Norwood class V/VI
pattern of hair loss. He underwent hair restoration surgery using the FUE graft
harvest technique using a 0.9 mm dull punch and the SAFE System to obtain
2491 grafts. The grafts were used to reconstruct the hairline, forelock, and mid-
scalp regions. The postoperative photos at 10 months reveal a natural appearance
and the restoration of good density in the transplanted regions. The donor site
appears to have some areas of focal thinning, but the appearance of this area is
natural, and the patient can wear his hair short.
232 Part II  ▪ Technique

This 51-year-old patient started losing his hair when he was in his twenties. He
has never used medical therapies for his hair loss and had a family history of hair
loss. His scalp examination yielded normal findings and that he had a Norwood
class VI pattern of hair loss. He underwent hair restoration surgery using the
ARTAS System for robotic FUE graft harvest, and 2561 grafts were obtained and
used to reconstruct the hairline, forelock, and midscalp. The postoperative photos
at 10 months reveal a natural appearance with good density in the transplanted
areas. The donor area appears normal, with no apparent thinning. The patient
is very happy with the result.

This 58-year-old man had a history of hair loss starting in his midtwenties, and
he stated that he has never used medical therapies for hair loss. He had a family
history of hair loss and had had several hair transplant procedures with an un-
known number of grafts over 20 years before his visit. He had been told that he
had poor donor capacity and poor scalp laxity. On physical examination he had
Chapter 9  ▪  Follicular Unit Extraction 233

sparse hair with evidence of an old “plug” transplant. He had a very tight scalp
and scattered open donor harvest technique scars over the entire donor area. He
had a Norwood class VI/VII pattern of hair loss. He underwent hair restoration
surgery using the FUE graft harvest technique using a 0.9 mm dull punch and the
SAFE System to obtain 1569 scalp FUE grafts and 460 beard hair donor grafts.
The scalp grafts were used to reconstruct the hairline and the anterior forelock,
while the beard grafts were used to reconstruct the posterior forelock and anterior
midscalp. The postoperative photos at 10 months reveal a natural appearance and
enhanced fullness of the forelock. The scalp donor area appears to have no change
in density, and the submental donor region has minimal evidence of the harvest.
234 Part II  ▪ Technique

This 41-year-old man noted hair loss starting in his twenties and never used medi-
cal treatments for his hair loss. He had had hair restoration surgery 15 years before
this visit, with the grafts placed in the thinning frontal region, particularly in the
frontotemporal region. Since his hair loss progressed and he lost native hair in
the area, it exposed the grafts leaving an unnatural appearance that he disliked.
His scalp examination showed exposed micrografts in the frontal region; he had
a Norwood class V/VI pattern of hair loss. The patient wanted to “turn the clock
back” to look like he had never had any surgery; the surgical plan was to remove
the transplanted hair. Approximately 300 previously placed micrografts were
removed using the FUE graft harvest technique using a 0.9 mm dull punch and
the SAFE System.
Chapter 9  ▪  Follicular Unit Extraction 235

The postoperative photos at 10 months reveal a natural appearance, with restora-

tion of a nontransplanted appearance and minimal residual scarring.
236 Part II  ▪ Technique

1. Rassman WR, Bernstein RM, McClellan R, et al. Follicular unit extraction: minimally invasive
surgery for hair transplantation. Dermatol Surg 28:720-728, 2002.
2. Harris J. Conventional FUE. In Unger W, Shapiro R, Unger R, Unger M, eds. Hair Transplan-
tation, ed 5. London: Informa Healthcare, 2011.
3. Harris JA. Follicular unit extraction: the SAFE System. Hair Transplant Forum Int 14:157-164,
4. Harris JA. New methodology and instrumentation for follicular unit extraction (FUE): lower
follicle transection rates and expanded patient candidacy. Dermatol Surg 32:56-62, 2006.
5. Harris JA. Powered blunt dissection with the SAFE System for FUE (Part I). Hair Transplant
Forum Int 20:188-189, 2010.
6. Harris JA. Powered blunt dissection with the SAFE System for FUE (Part II). Hair Transplant
Forum Int 21:16-17, 2011.
7. Devroye J. An overview of the donor area: basic principles. In Unger W, Shapiro R, Unger R,
Unger M, eds. Hair Transplantation, ed 5. London: Informa Healthcare, 2011.
8. Harris JA. Analysis of the measured area of FUE extraction zones and FUE sites utilizing dis-
secting punches of different sizes. Presented at the Nineteenth Annual Scientific Meeting of
the International Society of Hair Restoration Surgery, Anchorage, Alaska, Sept 2011.
9. International Society of Hair Restoration Surgery: 2011 Practice Census Results, July 2011.
C H A P T E R 10

Combining Follicular
Unit E xtraction and
Untouched Strip

FUE area – first surgery

Strip – first surgery

Untouched strip
for the second surgery

FUE area – first surgery

Márcio R. Crisóstomo
238 Part II  ▪ Technique

T here are two main ways of harvesting hair using the head as donor area: the
strip technique, or follicular unit transplantation (FUT), and follicular unit ex-
traction (FUE).1-3 Their indications, advantages, and disadvantages are discussed
in other chapters. The surgeon can usually harvest more hair with FUT than with
FUE, but that amount is limited by the elasticity of the scalp. On the other hand,
FUE is not limited by elasticity, but by local density.

In advanced degrees of baldness, such as Norwood male pattern baldness types

IV, V, Va, VI, and VII (see Chapter 2), the patient usually needs more than one
surgical session to achieve density, and normally the patient must wait months
to have the second procedure done.4,5 Since many patients with larger bald areas
want more hair, even with megasessions, the question is how to achieve more hair
in one session. The answer can be combining both harvesting techniques, FUT
and FUE, to increase the amount of hair in one surgical procedure.6-15

For larger bald areas, my routine is to excise a strip for a megasession and to
harvest FUE during the same procedure to maximize the number of grafts while
preserving an area for a possible future strip procedure.6-12

Follicular Unit Extraction and the

Donor Area


100 - 91.8 90.8 88.5

90 -
Hair restoration procedures (%)

80 -
70 - 67.5

60 - Strip
50 - FUE
40 - 32.3
30 - 22
20 - 10.8
7.02 7.4
10 -
2004 2006 2008 2010 2012

From International Society of Hair Restoration Surgery Practice Census, 2005-2013.

Compared with strip surgery, FUE has become more common in the last few years,
and there has been a trend toward greater understanding and acceptance of the
procedure by surgeons and patients.
Chapter 10  ▪  Combining Follicular Unit Extraction and Transplantation: Untouched Strip Technique 239

FUE scars

Normal scalp FUE area with fibrosis

As we perform more FUE procedures, we are gathering further knowledge about

the technique.16 Scars from FUE performed with appropriate technique are al-
most invisible, but they are present, as is seen on densitometry. Scarring leads
to some damage to the donor area, such as less density and local fibrosis, where
fibers are almost exclusively parallel to the epidermis of homogeneous thickness
and papillary fibrosis. Such alterations can make a second harvesting procedure
more difficult, yielding less hair.16
240 Part II  ▪ Technique

The Untouched Strip Concept

FUE area – first surgery

Strip – first surgery

Untouched strip
for the second surgery

FUE area – first surgery

The untouched strip technique aims to excise the maximum amount of hair in
a strip and to complement it with FUE above and below the suture, while pre-
serving an area just below the suture without touching it to retain its anatomic
features for a possible future procedure. This preserved area, called the untouched
strip, is the most important detail in this surgery, and therefore it lends its name to
this combined technique. Following the Hippocratic principle that can be para-
phrased as “Do good, or do no harm,” the patient’s donor potential is improved,
but without damaging the donor area.
Chapter 10  ▪  Combining Follicular Unit Extraction and Transplantation: Untouched Strip Technique 241


Advanced baldness grades

(Norwood Classification)

Main indication

Optional Exceptional cases

From Norwood OT, Shiell R, eds. Hair Transplant, ed 2. Springfield, IL: Charles C Thomas, 1984.

The untouched strip technique is recommended in cases of more advanced bald-

ness, especially Norwood male pattern baldness types V, Va, and VI. Selected
patients with Norwood type VII who understand the limitations of the procedure
in their cases can be included, and some patients with Norwood type IV can also
be treated using this technique. These patients usually need more than one sur-
gery, and the option to have more hair in the first surgery is important for most
of them. Other indications include patients with poor donor areas: low density,
thin hair, and limited elasticity.
242 Part II  ▪ Technique

This man with Norwood male pattern baldness type VI is a typical patient for
whom the combined procedure is indicated. He has a low density donor area,
thin hair, and for him an improvement in the number of transplanted hairs is
very important. In secondary surgery, my approach of combining FUE and FUT
is different, as explained later in this chapter.

We usually perform this procedure in men, because in a woman it will not be

acceptable to have her shave her head, and usually women do not require such
a large-scale procedure. However, in exceptional selected cases, this procedure
can be done in a woman also.

This woman underwent a combined procedure (FUE plus a strip transplant). A

defined area of her head was shaved so she could hide the shaved area during the
postoperative period. 
Chapter 10  ▪  Combining Follicular Unit Extraction and Transplantation: Untouched Strip Technique 243

It is important to perform the untouched strip technique in patients with a defini-

tive baldness grade, especially in the crown area, to avoid harvesting FUE outside
the safe donor area (SDA), where the hair will probably not fall out during the
patient’s lifetime.17 It is very difficult to determine the SDA in younger patients,
so we prefer to recommend this technique in patients over 40 years of age, and
the limits of the FUE harvest area should be determined with car.

Planning and Demarcation

It is important to determine the SDA before shaving the hair (left) so the surgeon
can visualize the fringe and the possible areas in which baldness will advance,
especially in the crown area and lateral borders. Before shaving, it is important
to draw the anterior hairline as well as the temporal points (if indicated) so the
surgeon and patient can see the aesthetic relationship between planning and the
existing hair as a reference (right). Because this chapter is fundamentally about
an approach to the donor area, I will not describe anterior hairline drawing and
FU implantation. This can be done according to the surgeon’s preferences. After
demarcation, the head is completely shaved. For some patients this could be a
problem, because in contrast to FUE, in the untouched strip technique the suture
and the scar will be exposed for 2 or 3 weeks or more. However, because this is
being done to harvest the maximal amount of hair, most patients do not object.
If the patient does object when informed about the shaving preoperatively, this
technique may not be the best option for him. Shaving the entire head makes
the excision and suturing of the strip easier and may allow a larger excision.
Also, implantation is facilitated when the hair has been shaved, and this is very
important in a long surgery. If the patient has long hair in the donor area (4 to
5 cm long), we can offer an option to shave only selected areas to perform FUE,
and the hair preserved in the untouched strip and around the SDA will cover the
shaved area when combed.
244 Part II  ▪ Technique

SDA Predicted strip

Untouched strip FUE regions

After the hair is shaved, the surgeon confirms the SDA and performs the demar-
cation of the strip, the untouched strip, and the FUE area. This demarcation is
mainly for didactic purposes, because the width of the strip is determined during
the procedure by local elasticity to achieve the largest area possible.
Chapter 10  ▪  Combining Follicular Unit Extraction and Transplantation: Untouched Strip Technique 245

The surgery is performed with the use of a local anesthetic: a solution of lidocaine
0.02% with bupivacaine 0.05% plus saline and epinephrine 1:200,000. We per-
form the surgery in a hospital with intravenous sedation and in the presence of
an anesthesiologist. This is an important factor in surgeon and patient comfort
when performing a surgery as long as this one (8 hours on average).

Strip Removal and Follicular Unit Implants

First the surgeon excises the strip. It is necessary to test local elasticity during
removal to achieve maximum width, but allowing closure without tension. Tech-
nicians initiate FU preparation.

Closure is done with two layers: internal with absorbable sutures (Monocryl 4-0 or
3-0) and a superficial running suture of Mononylon 5-0. The use of trichophytic
closure in our cases is done when there is no tension, and we have observed that
this results in better scar quality.18,19 The strip can be removed completely, or first
a half and later the other half, to avoid prolonged cold ischemia. It depends on
the case and on the team’s speed.20
246 Part II  ▪ Technique

The implantation of FUs from the strip is done.

I use a combination of premade incisions in the
anterior hairline and the stick and place tech-
nique. Since the surgeon knows he or she is going
to have more hair to work, high density can be
done from the beginning to the end of the im-

Demarcation of the Untouched Strip and FUE Harvesting

After the implantation of all FUs from the strip, the surgeon infiltrates more anes-
thetic, if needed, and marks 1.0 to 1.5 cm below the strip suture—the untouched
strip area that will be preserved.7,8 In this area FUE harvesting should not be done
to avoid damage to the donor area. This strip’s anatomic features are preserved
for use in a possible future surgery.7,8
Chapter 10  ▪  Combining Follicular Unit Extraction and Transplantation: Untouched Strip Technique 247

FUE harvesting is done in all SDAs above the suture and below the demarcation
of the untouched strip. We use a sharp motorized punch (0.8 to 1.0 mm), but this
harvesting can be done with the surgeon’s FUE method of choice. Magnification
of 2.53 to 4.53 must be used during FUE harvesting. From this patient we were
able to harvest 2409 FUs from the strip and 702 FUs from FUE for a total of 3111
FUs (FUE improvement of 29.1%). FUE was done in all SDAs, improving the
patient’s donor potential in one surgery, and the untouched strip was preserved
for a future procedure.

FUs obtained by FUE are used to complement the implantation. We usually im-
prove density in the anterior zone and go farther in the back, but this extra hair
can be used where the surgeon deems it appropriate for the best result.
248 Part II  ▪ Technique

The final aspect of the implant with improvement of density in the anterior zone
and a more posterior implant (marked in blue) and treatment of temporal region
(when indicated).21,22
Chapter 10  ▪  Combining Follicular Unit Extraction and Transplantation: Untouched Strip Technique 249

Postoperative Management and Complications

1 day after surgery

10 days after surgery 3 weeks after surgery

Postoperative care is the same as for strip surgery and FUE. The difference is that
the patient will have a visible suture and scar in the first month, and he should
be advised of this before the surgery. In the first postoperative day the hair is
washed at the clinic. Within 4 to 5 days the FUE area is completely healed; in
10 to 15 days the sutures are removed. The hair partially covers the incision, and
the FUE area can be hardly seen. Within 1 to 2 months, the donor area looks
completely normal.
250 Part II  ▪ Technique

1 day postoperatively 2 months postoperatively

3 months postoperatively 5 months postoperatively

The donor area is usually covered within a month. Since in this combined tech-
nique more hair is harvested from the donor area, sometimes there is a delay in
hair regrowth, especially in temporal areas, as seen in this patient. This was a
complication that appeared in our early cases, probably as a result of some tension
in the strip closure associated with the trauma of FUE or from overharvesting in
FUE. In all cases there was complete regrowth by the fourth month. The patient
returns 1 year postoperatively, when the need or desire for a second procedure is
Chapter 10  ▪  Combining Follicular Unit Extraction and Transplantation: Untouched Strip Technique 251

Combining FUE and FUT in Secondary Surgery

After evaluation of the final result, usually within 1 year, the patient can decide
whether he wants a second hair transplant. If the first procedure was performed
using the untouched strip technique, the patient will probably have a good num-
ber of grafts implanted and certainly a preserved area just below the suture. The
secondary surgery can be done without shaving the hair as a normal strip surgery
using the preserved, untouched area. The previous scar can be excised in the strip
or not, and this is discussed with the patient. I prefer to leave the scar to achieve
more hair, and the scar can be refined in the future if necessary. If density in the
donor area is still good, even with FUE done in the first surgery, and the patient
wants a larger procedure the second time, a combination of FUE and FUT can be
performed again. In such cases, however, since the patient already has a result, we
perform FUE in the entire safe donor area without leaving the untouched strip. 13

This 45-year-old man returned 1 year after having 3111 FUs hair transplanted
using the untouched strip technique. He was satisfied with the frontal result and
requested that the large area on the crown of his head be covered.
252 Part II  ▪ Technique

There was good hair density in the donor area after the FUE. The donor area
was shaved, showing the previous strip, the FUE scar, and the area preserved
below the suture. The SDA and strip to be excised are marked (the width will
be determined during surgery, depending on local elasticity), leaving the previ-
ous scar. A total of 3007 FUs were implanted in the crown area in a combined
FUE and FUT surgery: 2304 strip FUs and 703 by FUE (an increase of 30.5%).
The implants were placed in the crown area and with increasing density in the
anterior hairline. He is shown before the first and second procedures and 2 days
after the second procedure, with FUE harvested in the entire donor area without
leaving an untouched strip.
Chapter 10  ▪  Combining Follicular Unit Extraction and Transplantation: Untouched Strip Technique 253

Concluding Thoughts
In this technique, FUE is used as a complementary procedure to improve the
number of grafts achieved in strip surgery. The improved number of FUs with
FUE varies with the surgeon’s experience and the patient’s donor area. I prefer to
perform the strip first and FUE later. A larger team is required for the strip proce-
dure, and for team logistics it is better to perform the FUT first. The number of
FUs with the strip technique is higher, and the surgeon can plan the surgery bet-
ter and the amount of FUE needed after strip implantation. Another preference
is for the untouched strip below the strip suture, because we want a higher scar,
and we think it is more difficult to harvest FUE in the lower part because of the
acute angle and caliber of the hairs in this region. If the surgeon prefers a lower
incision, the untouched strip can be preserved above the suture. The principle is
the same: to keep an untouched area to be used in a future procedure.

It is important to avoid tension in the suture of the strip. However, since we are
dealing with large bald areas and frequently unfavorable donor areas, there may
be some tension. After performing FUE, the surrounding tissue is released. This
effect was measured by Tsilosani15 showing a decrease in tension after FUE. We
have observed excellent scar quality with this technique, probably because of this
effect, among other factors, such as avoiding tension, using trichophytic closure,
and employing delicate technique and materials.5,18,19

The untouched strip technique is a long procedure, lasting an average of 8 hours.

We prefer to perform it in 1 day. Since we use continuous intravenous sedation,
the patient stays comfortable during this long procedure. It can also be done in
2 consecutive days, with no damage: one day for the FUT and another for the
FUE. It depends on the team’s size, experience, the number of grafts expected,
and speed in harvesting FUE.

In the untouched strip technique, FUE represents an average increase of 25% to

30% and in some cases more than 40% extra FUs. We observed a total increase
of 50-60% in the final number of FUs due also to the excision of a larger strip,
254 Part II  ▪ Technique

allowed by the decrease in tension with the combination of FUE.15 Many more
FUs could be achieved in a single FUE procedure, but in this combined technique
the strip area has a width of 1.0 to 2.2 cm and the untouched strip has a width of
1.0 to 1.5 cm, which means 2.0 to 3.7 cm less width for harvesting FUE. Thus the
number of FUs achieved by FUE in this technique is not as high as in exclusive
FUE procedures, but it makes significant difference and allows for a more ambi-
tious surgical plan. With more hair the surgeon can go farther in the back, with
density improvement and/or treatment of temporal points in the first session.

This 54-year-old man with type VI male pattern baldness had a total of 4706 FUs
implanted in one session: 3836 by strip technique plus FUE 810 by FUE (an im-
provement of 21.1%). The vertex was covered with good density; the untouched
strip technique allowed enough hair that we were also able to treat his temporal
points. He is shown preoperatively and with scalp markings.
Chapter 10  ▪  Combining Follicular Unit Extraction and Transplantation: Untouched Strip Technique 255

Here he is shown immediately postoperatively and 7 months postoperatively.

Keeping the untouched strip is not mandatory, but we believe it is important to

keep this area with minimal intervention, without harvesting FUE and without
undermining it. Thus the anatomic features tend to be minimally changed, pro-
viding the option of a second harvest with slivering in an area without fibrosis
and satisfactory FU production, since the density is normal.

Combined FUE and strip surgery is an advanced hair restoration procedure; it

requires a large surgical team with experience in both harvesting techniques.
Nevertheless, in advanced baldness cases it is important for the specialist to have
the option to provide more hair in a single surgery. It may increase indications
in large baldness cases with an unfavorable relationship between the donor and
recipient areas. Some patients who might have poor to average results with one
surgery and who would have to wait for a second procedure for better coverage
may obtain a better result in the first procedure.
256 Part II  ▪ Technique

Case Examples

This 42-year-old man with type VA male

pattern baldness had a total of 4074 FUs
implanted using the untouched strip tech-
nique. He is shown preoperatively and
7 months postoperatively. The donor site
is shown 1 day postoperatively.
Chapter 10  ▪  Combining Follicular Unit Extraction and Transplantation: Untouched Strip Technique 257

This 59-year-old man with type V male pattern baldness presented with thin hair
and low hair density in the donor area. A total of 3719 FUs were implanted, with
2619 by strip technique and 1100 by FUE, using the untouched strip technique
(an improvement of 42%). The untouched strip was preserved for a second FUT.
He is shown preoperatively and 9 months postoperatively. A second procedure
will be necessary to fill in the vertex region, which justifies keeping the untouched
strip to have ideal conditions for the second surgery. The donor site is shown im-
mediately after harvesting.
258 Part II  ▪ Technique

This 35-year-old man with type VI male pattern baldness had a total of 5086 FUs
implanted in one session using the untouched strip technique, 3836 FUs by the
strip technique and 1250 by FUE (a 32.6% improvement). He is shown preop-
eratively and 15 months postoperatively.
Chapter 10  ▪  Combining Follicular Unit Extraction and Transplantation: Untouched Strip Technique 259

The donor area is shown 1 day postoperatively, with the untouched strip preserved
for a second FUT procedure.
260 Part II  ▪ Technique

1. Barrera A. Técnica. In Barrera A, ed. Transplante de Cabellos. El Arte del Micro y Mini
Injerto. Madrid: Amolca, 2002.
2. Rassman WR, Bernstein RM, McClellan R, et al. Follicular unit extraction: minimally inva-
sive surgery for hair transplantation. Dermatol Surg 28:720-728, 2002.
3. Uebel CO. Micrografts and minigrafts: a new approach for baldness surgery. Ann Plast Surg
27:476-487, 1991.
4. Norwood OT. Male pattern baldness: classification and incidence. South Med J 68:1359-1365,
5. Unger WP, Cole J. Donor harvesting. In Unger WP, Shapiro R, eds. Hair Transplantation,
ed 4. New York: Marcel Dekker, 2004.
6. Crisóstomo, M. Untouched strip: técnica para aumentar a área doadora potencial em um
transplante capilar. Presented at the Seventeenth Encontro da Associação dos Ex-Alunos
do Professor Pitanguy, Rio de Janeiro, Oct 2011.
7. Crisóstomo MR, Crisóstomo MGR, Tomaz DCC, Crisóstomo MCC. Untouched strip: a
technique to increase the number of follicular units in hair transplants while preserving an
untouched area for future surgery. Surg Cosmet Dermatol 3:361-364, 2011.
8. Crisóstomo M. Untouched strip: FUE combined with strip surgery to improve the FU number
harvested in one session, preserving an untouched area for a possible future transplant. Hair
Transplant Forum Int 22:12-14, 2012.
9. Crisóstomo M. Untouched strip: technique combining FUE and FUT to improve the number
of follicular units harvested in a safe way. Presented at the Fourteenth International Congress
of the Italian Society of Hair Restoration, Rome, May 2012.
10. Crisóstomo M. Untouched strip: a new technique to improve the amount of hair transplanted
in a hair restoration surgery. Video presentation at the Twenty-first Congress of the Interna-
tional Society of Aesthetic Plastic Surgery, Geneva, Sept 2012.
11. Crisóstomo M. Combining follicular unit extraction and strips. Presented at the International
Hair Surgery Master Course, Paris, Oct 2012.
12. Crisóstomo M. The untouched strip technique: a procedure combining FUE and strip surgery
to improve the number of FUs harvested while preserving an area for a future transplant.
Video presentation at the Advanced Surgical Video session at the Twentieth Annual Sci-
entific Meeting of the International Society of Hair Restoration Surgery, Nassau, Bahamas,
Oct 2012.
13. Crisóstomo M, Crisóstomo MGR, Tomaz DCC, Lopes AAO, Crisóstomo MCC. Combina-
tion of strip surgery and follicular unit extraction to improve the number of follicular units
harvested in primary and secondary hair transplantation. Poster presented at the Twentieth
Annual Scientific Meeting of the International Society of Hair Restoration Surgery, Nassau,
Bahamas, Oct 2012.
14. True R. Combining FUE and strip harvesting in the same procedure. Presented at the Seven-
teenth Annual Scientific Meeting of the International Society of Hair Restoration Surgery,
Amsterdam, July 2009.
15. Tsilosani A. Expanding graft numbers combining strip and FUE in the same session: effect
on linear wound closure forces. Hair Transplant Forum Int 20:121-123, 2010.
16. Bernstein RM, Rassman WR, Anderson KW. FUE megasessions—evolution of a technique.
Hair Transplant Forum Int 14:97-99, 2004.
17. Unger W. Letter to the editor. Re: Combining Strip and FUE. Hair Transplant Forum Int
20:170, 2010.
18. Crisóstomo M. Trichophytic closures and donor area minimal scars. Oral presentation at the
International Hair Surgery Master Course, Paris, Oct 2012.
Chapter 10  ▪  Combining Follicular Unit Extraction and Transplantation: Untouched Strip Technique 261

19. Marzola M. Trichophytic closure of the donor area. Hair Transplant Forum Int 15:113-116,
20. Crisóstomo MR, Guimarães SB, de Vasconcelos PR, et al. Oxidative stress in follicular units
during hair transplantation surgery. Aesthetic Plast Surg 35:19-23, 2011.
21. Crisóstomo M. Hair transplantation in temporal points. Presented at the Fourteenth European
Congress of Hair Restoration Surgery, Munich, June 2011.
22. Mayer M, Perez-Meza D. Transplantation of temporal points. In Unger WP, Shapiro R, eds.
Hair Transplantation, ed 4. New York: Marcel Decker, 2004.
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C H A P T E R 11

R evision of
Unfavorable R esults

James E. Vogel
264 Part II  ▪ Technique

W hen contemporary techniques of hair restoration surgery are used, a natural

appearing result is the expected outcome. Unfortunately, older techniques of
hair transplantation usually did not produce this level of excellence. As a con-
sequence, there is a considerable number of patients who have a cosmetically
unsatisfactory hair transplant result.

In addition, there are other patients who have similar unnatural hair transplant
results from more recently performed procedures in which poor technique was
used. This chapter reviews the two most common aesthetic problems associated
with hair transplants: the unsightly appearance of plugs, and a poorly designed
hairline. Often these cosmetic problems coexist and are often associated with
failure to plan for inevitable progressive hair loss.1-8

Unsightly Appearance of Plugs

The essential problem with the unnatural appearing hair graft is the size of the
graft, which renders it “pluggy” in appearance. Thus the most direct approach
to this problem is to reduce the size of the graft. The concept of grafting alone
anterior to the pluggy hairline to achieve improvement does not work and fails
to address the basic dense plug problem. The current technique is to employ a
punch that is approximately 0.5 to 0.75 mm smaller than the estimated size of the
unsightly plug. As an example, if 4 mm plugs are being reduced, a 3.5 to 3.25 mm
punch would typically be chosen for plug reduction and subsequent recycling.
The reason for this is to remove a substantial amount of the plug hairs and leave
behind a few hairs that will look soft and natural.

The actual technique of plug removal is very straightforward. The hair in the
plugs to be reduced is trimmed to approximately 3 mm length, and the punch
removal is performed eccentrically to leave a crescent or sliver of the remaining
original plug, retaining 3 or 4 hairs.
Chapter 11  ▪  Revision of Unfavorable Results 265

The punch excision should be deep enough to include 1 to 2 mm of subpapillary

fat. These removed plugs are then recycled into FU grafts. The yield of salvaged
FU grafts is approximately 50% to 70%.

An aggressive approach toward removing unsightly plugs will result in a thinner

hair appearance but will also yield the best improvement in a cosmetic appearance
in the shortest amount of time. A partial or timid approach to plug removal will
be reflected in the result. Follicular unit extraction (FUE) is another technique
for reducing large plugs, but it is less efficient and is likely to result in a lower
yield of recycled hairs.
266 Part II  ▪ Technique

The hair recycled from the removed plugs, as well as additional hair concomi-
tantly harvested from the occipital region, is densely transplanted anteriorly,
posteriorly, and what is most important, to areas adjacent to the plug reduction
sites. In most cases, the plug reduction sites are not sutured closed. Suturing the
sites reduces the local blood flow and increases scalp tension, thereby reducing
the success of graft growth in the vicinity of the plug reduction sites. This surgical
detail is vital, because the area next to the reduced plug is the most important
location for maximizing new hair growth, thus camouflaging scalp scars and re-
maining plugs.

If grafting is not performed in areas of plug reduction, suturing of the site with
an absorbable (chromic) suture is always performed to make wound care easier
for the patient. The final appearance of the healed scar following plug reduction
is essentially indistinguishable, whether the site was sutured or left to heal by
secondary intention.

Aggressive plug reduction and recycling of the first two or three rows of plugs is
usually all that is necessary to soften and naturalize the hairline and camouflage
the more posteriorly positioned plugs. The typical 3 and 4 mm plugs do add den-
sity, so salvage of these large grafts does have some coverage value. In many cases,
the posterior row of plugs is also reduced in the crown, and additional grafting
is needed in the vertex to create a natural “posterior hairline” as well. In other
cases, reduction in pluggy appearance of the crown is the main goal because the
patient requests this, or the supplemental donor supply is lacking.

Although each patient’s distribution of plugs is unique, the final surgical plan is
always to create a zone of natural-appearing hair at the leading edges, anteriorly
as well as posteriorly, taking advantage of the centrally located plugs of higher
hair density. In some instances, the patient may prefer to soften all plugs previ-
ously grafted.

Although a single session will provide significant improvement, two and some-
times three sessions of plug reduction are usually needed to adequately convert
the unnatural hair transplant into a result that does not draw curious attention.
In general, a second session is performed eight months following the first proce-
dure. Occasionally a faster track approach can be employed, and additional plug
reduction and grafting is performed within the first 2 months following the initial
corrective procedure.
Chapter 11  ▪  Revision of Unfavorable Results 267

Poorly Designed Hairline

A mature man’s hairline is usually not less than 8.0 to 8.5 cm from the midgla-
bellar area, is symmetrical, and exhibits bilateral temporal recession. The most
common problems associated with hairline design are blunted temporal angles
or hairlines placed too low on the forehead. Correction usually involves surgical
excision, redesign, and elevation or reorientation of the hairline. In most cases,
the hairline can be redesigned in a single surgical session, and hair grafts can be
concomitantly incorporated into the surgical plan as part of a comprehensive
approach to correction.

Invariably, a pluggy hairline appearance coexists, and the linear excision of plugs
also serves as an excellent method to eliminate the offending large plug appear-
ance. A simple linear excision of the hairline itself is performed to accomplish
this goal. Care should be taken to avoid too wide an excision. The frontal scalp is
typically more difficult to advance than one might assume based on preoperative
assessment and a tight closure at the anterior hairline will lead to a wide scar. A
second and possible third session of plug reduction and grafting is often necessary
to obtain the optimal result.

Concluding Thoughts
This chapter represents my current refinements of earlier published articles on the
same topic. The challenge for the hair restoration surgeon is to provide a level of
expertise and honesty to these unfortunate patients to restore their appearance
and self-confidence. Obtaining the trust of the patient is essential. When the
surgeon is faced with correcting these types of problems, creativity, long-range
surgical planning, and a variety of techniques are employed.

The exact techniques used in an individual patient will be as varied as the pre-
senting problem itself. Fortunately, most patients with unsightly hair transplants
can expect cosmetically significant improvements, if correction of these problem
cases is planned carefully and carried out appropriately.
268 Part II  ▪ Technique

Case Examples
James E. Vogel

This 35-year-old man had 4 mm plug transplants at an early age. He had progres-
sive hair loss since then, and the plugs became exposed and were unsightly. He
wore a hairpiece to conceal the unnatural appearance.
Chapter 11  ▪  Revision of Unfavorable Results 269

He underwent a series of two plug reduction sessions with recycling of the plug
hairs as well as a total of 2500 FU grafts. The sessions were 8 months apart. The
final result is seen 8 months after the last procedure.
270 Part II  ▪ Technique

This 54-year-old man had undergone a hair transplant elsewhere. Not only were
the grafts large and pluggy in appearance, but also the hairline was asymmetrical
and constructed in a strange shape. He had a shortage of donor hair, since most of
the available hair had been used previously. The anterior hairline was a problem,
but also the solution to donor hair shortage. He underwent a direct excision of
the anterior hairline and immediate recycling of those hairs into FUs and graft-
ing in a more natural distribution. In addition he underwent plug reduction and
recycling (PR and R) to his 4 mm plug grafts in the midscalp. No separate donor
harvest was performed in the occipital donor area.
Chapter 11  ▪  Revision of Unfavorable Results 271

His results are seen 8 months after a single corrective procedure of 2000 grafts,
plug reduction, and linear strip excision of the anterior hairline.
272 Part II  ▪ Technique

Alfonso Barrera

This 33-year-old man had hair plugs to the frontotemporal recessions. The grafts
were too low and too large. I did an excision of the plugs to recreate the fronto-
temporal recessions, and added FU grafts to soften and camouflage the scarring.
He is shown before and 1 year later.
Chapter 11  ▪  Revision of Unfavorable Results 273
274 Part II  ▪ Technique

1. Vogel JE. Correction of cosmetic problems secondary to hair transplantation. In Unger W,
Shapiro R, Unger R, Unger M, eds. Hair Transplantation, ed 5. London: Informa Healthcare,
2. Vogel JE. Hair restoration complications: an approach to the unnatural appearing hair trans-
plant. Facial Plast Surg 24:453-461, 2008.
3. Vogel JE. Correcting problems in hair restoration surgery: an update. Facial Plast Surg Clin
North Am 12:263-278, 2004.
4. Vogel JE. Correction of the cornrow hair transplant and other common problems in surgical
hair restoration. Plast Reconstr Surg 105:1528-1536; discussion 1537-1541, 2000.
5. Brandy D. Corrective hair restoration techniques for the aesthetic problems of temporoparietal
flaps. Dermatol Surg 29:230-234; discussion 234, 2003.
6. Bernstein RM. The art of repair in surgical hair restoration—part II: the tactics of repair.
Dermatol Surg 28:873-893, 2002.
7. Epstein J. Revision surgical hair restoration: repair of undesirable results. Plast Reconstr Surg
104:222-232; discussion 233-236, 1999.
8. Lucas MW. Partial retransplantation. A new approach in hair transplantation. J Dermatol Surg
Oncol 20:511-514, 1994.
C H A P T E R 12


Carlos Oscar Uebel, Anajara Gazzalle

276 Part II  ▪ Technique

C omplications and undesirable results in hair transplantation are few compared

with other kinds of surgery, such as facial procedures and body contouring, if
sensible parameters and surgical routines are followed. Because it is a superficial
surgery, the side effects are minimal. Infections and necrosis are rare, because the
scalp is well perfused and has excellent arterial and venous support. However, the
scalp neither expands nor allows tension in sutures and closure. Problems that
do occur are primarily in the donor area, both in flap surgeries and micrograft
transplant procedures. We usually divide the complications into three groups, as
indicated in the box.

Complications Following Hair Transplantation

General Complications Recipient Site Complications
• Hiccups • Actinic keratosis and sun ery-
• Herpes zoster thema
• Seborrheic dermatitis • Capillary prostheses
• Hyperesthesia and Hypoesthesia • Synthetic hair
Donor Site Complications • Swelling
• Bleeding • Milia
• Wound dehiscence • Cysts and granulomas
• Telogen effluvium • Poor hair growth
• Scar widening and hypertrophic • Straight hairline
scarring • Pluggy hair and corn rows
• Punch scars • Undesirable punch grafts
• Undesirable hair follicular grafts

General Complications
Hiccups can occur during hair transplantation surgery. The patient is supine,
usually sedated, and his breath movements are reduced because of abdominal
breathing. The hiccups may appear when the patient talks excessively during
the surgery or when he becomes euphoric, because of midriff muscle stimulation.
Chapter 12  ▪ Complications 277

This manifestation disturbs the continuity of the surgery and can last from 30 to
60 minutes. We suggest silencing the patient, and sedating him within safe limits
with midazolam. Chlorpromazine can also be used.

Herpes Zoster
Herpes zoster, or shingles, is a very rare postoperative manifestation, but when it
occurs, it is normally painful to the patient and may begin on the fourth or fifth
postoperative day. The patient presents with a skin lesion with hard, red vesicles
and an intense inflammatory reaction involving the sensitive nerve branch trajec-
tories. The patient may report that his scalp is extremely painful, with a burning
sensation. Paracetamol with codeine does not have any effect, and a subcutaneous
antiinflammatory drug must be used. The wounds are hyperemic with irregular
borders and multiple blisters, and hard vesicles appear on patients who carry her-
pes virus simplex (HVS), whose immunologic resistance has been altered by the
surgical trauma. Treatment consists of the administration of acyclovir (Zovirax)
200 mg oral, four times a day for 5 days. The wound will resolve with no further

This man with herpes virus simplex is shown before treatment and 2 weeks after
acyclovir treatment showing regression of the process.
278 Part II  ▪ Technique

Seborrheic Dermatitis
Patients with oily scalps are more likely to develop a great quantity of crusts and
seborrheic scales postoperatively. This leads to significant pruritus and oily scaling
(dandruff), with erythema and exudate. Seborrheic dermatitis is aggravated by
physical and emotional stress, and is more likely to occur in patients with those
tendencies. We recommend the use of shampoo containing selenium sulfide or
coal tar. To remove the scales, mineral or vegetable oil can be applied to the scalp
for 30 minutes before a shower, then the hair can be washed with an antiseptic
shampoo. In serious cases we use keratolytics such as 2% salicylic acid and lotion
with cortisone.

This patient with postoperative seborrheic dermatitis is shown before treatment

and 2 weeks after treatment with topical cortisone and keratolytic shampoo,
which was sufficient to completely heal the scalp surface and protect the follicular

Donor Site Complications

When the hair-bearing donor ellipse is harvested from the occipital posterior
region, the surgeon may cut some branches of the occipital artery on the extreme
edges of the ellipse, similar to what may occur when the wound borders are
Chapter 12  ▪ Complications 279

undermined to facilitate closure. These small vessels can bleed postoperatively

if sufficient coagulation is not achieved; this occurs primarily on excitable and
hypertense patients. For this reason we recommend relative rest for 24 hours and
advise the patient to avoid abrupt flexion and rotation of the head. If a hematoma
appears, this must be immediately drained and the bleeding vessels coagulated.
We usually do not leave drains in place.

Wound Dehiscence
Wound dehiscence on the scalp is very rare, but it could occur after sutures are re-
moved, when the patient makes abrupt movements of the head, or when sleeping
puts excessive stress on the new donor site scar. If this occurs, the wound borders
must be refreshed and resutured.

Hyperesthesia and Hypoesthesia

Hyperesthesia or hypoesthesia occurs when sensitive nerve branches are tran-
sected in the posterior area. Hyperesthesia is very rare and may suggest the pres-
ence of a neuroma, which is painful to the touch or compression. Local massage
helps to reduce edema and pain, but the wound scar should be opened and the
neuroma surgically repaired.

Hypoesthesia is a more frequent manifestation and can last from 3 to 12 months

postoperatively. This temporary loss of sensibility occurs more in the superior
region, above the horizontal scar. We recommend local massage until the area is

Telogen Effluvium
Telogen effluvium occurs as a result from ischemia resulting in excessive tension
(tightness) at the donor site closure. Some patients may present with thinning
of the hair 2 weeks postoperatively. The hair gets thinner until an alopecic area
develops that may worry the patient as well as the surgeon. It occurs more fre-
quently in the occipital posterior area above the scar, but it can spread into the
lateral regions.

We know that it is temporary, and we recommend that patient perform local

massage only. By 3 months postoperatively, fine hair begins to grow, covering the
whole alopecic area with no sequelae. Telogen effluvium must be differentiated
from alopecia areata, which has an unknown cause and a very long recovery
280 Part II  ▪ Technique

The hair of this man with telogen effluvium was thinning 2 weeks postoperatively
above the horizontal scar of the hair-bearing ellipse. The effluvium was caused by
tissue stretching and local circulatory disturbance. He was advised to massage the
site, and after 2 months the area had begun to be covered with dense, fine hair.

This 54-year-old woman presented with a lesion typical of alopecia areata. This
condition has an undefined cause and a very long, difficult recovery period. She
is shown 6 months later and has completely recovered with no further treatment.
Chapter 12  ▪ Complications 281

Scar Widening and Hypertrophic Scarring

Scar widening and hypertrophic scarring are the most frequent manifestations we
find when the wound is not correctly treated. Trying to close the incision with
tension without undermining the border leads to scar widening in the donor area,
or, more rarely, hypertrophic scarring.

We know some patients are predisposed to scar widening. Stough1 addressed this
subject, calling it “mushy dermis.” A good preoperative evaluation of the patient’s
scalp and its elasticity is essential. Patients with significant scalp oiliness generally
have more difficulty with wound healing.

The treatment consists of resecting the scar, extensively undermining the borders,
and closure in two levels. In extreme cases tissue expanders can be placed for
45 days to expand the adjacent pilous areas, so the defect can be covered without
tension. With the rare hypertrophic scars we first inject Triamcinolone three to
five times at 1-week intervals to flatten the scar. This usually provides good results,
and resection and resuturing are seldom necessary.

This man’s donor scar widened from excessive tension of the tissue during closure.
He had undergone five harvesting procedures.
282 Part II  ▪ Technique

Punch Scars

Some surgeons prefer to harvest punches from the posterior region, producing
small scars like “islands.” This method of harvesting was popular in the 1960s and
1970s, but it was found that it damages the donor area and produces scars that
make secondary harvesting of a hair-bearing ellipse difficult. When the scarred
area is small, nearby regions can be chosen for the harvest of new FUs, but in
some cases these regions are already implicated, making the harvesting of capil-
lary roots difficult.

Recipient Site Complications

Complications of the recipient site include problems associated with actinic kera-
tosis, sun erythema, and the use of synthetic hair as well as the most common
postoperative complications to this region, which include swelling, milia, cysts
and granulomas, poor hair growth, straight hairline, pluggy hair and corn rows,
undesirable punch grafts, and undesirable hair follicular grafts.

Actinic Keratosis and Sun Erythema

It is essential to carefully and thoroughly evaluate the bald area to be treated
during the patient’s first preoperative visit. Local conditions will determine the
success or failure of the hair yield, and the presurgical assessment also allows the
surgeon to devise a local and systemic treatment program for the patient. Sun
erythema, seborrheic dermatitis, and actinic keratosis must be adequately treated,
and we do not recommend hair replacement until these dermatologic lesions are
completely healed.
Chapter 12  ▪ Complications 283

This man had actinic keratosis and sun erythema preoperatively that had gone
untreated. He is shown postoperatively with a lower hair yield.

Capillary Prostheses

In the 1970s a method of prosthetic fixation of artificial hair (such as Perm-

Attach and plugs and knots) was not uncommon. This method caused fibrosis,
an intense cicatricial process, inflammatory reaction, and traction alopecias that
damaged FU growth. Patients who underwent these measures in the past must be
made aware of the potential complications regarding the decrease in hair density
from trauma or the residual scars associated with these methods.
284 Part II  ▪ Technique

Synthetic Hair
The use of artificial hair has also caused significant problems in the past, such
as an inflammatory process, rejection, and the formation of granulomas, and it
is necessary to remove those alloplastic materials, letting the scalp rest for 3 to
4 months, before a hair transplantation program is begun. Plastic surgery socie­
ties have condemned the use of synthetic hair, because it produces irreversible
sequelae to the patient’s hair-bearing scalp.

This man developed a serious inflamma-

tory response and rejection of synthetic
hair 10 months after implantation, with
serious sequelae to his scalp. Treatment
consisted of removal of all the artificial
hair and granulomas, the application of an-
tiseptic lotion, and letting his scalp heal for
3 to 4 months before he underwent a new
replacement program with autologous hair.

This 22-year-old man developed an intense

inflammatory reaction after undergoing hair
transplantation with synthetic hair. The
artificial hair was removed, and he had re-
sidual erythema for 2 months. He is shown
6 months postoperatively after placement of
autologous FU grafts.
Chapter 12  ▪ Complications 285


Swelling is a frequent manifestation of hair transplantation surgery. Ten percent

of our patients develop forehead and eyelid edema, which usually appears be-
tween the second and fourth postoperative day. The swelling occurs as a result
of scalp ballooning from the tumescent saline solution infiltration, which may
sometimes migrate to the forehead and eyelids. The tumescent technique is used
in the area to be implanted, which induces vasoconstriction, minimizing bleed-
ing during the replacement procedure. We inject 120 to 200 ml of saline solution
with epinephrine 1:120,000, enough to create ischemia and the “white marble”
signal. Although we advise the patient to lie down at a 30-degree angle to rest and
sleep, it only occurs after the second postoperative day, when the swelling begins
to go down. Some physicians such as Paul Straub2 recommend that patients lie
horizontally; they state that the swelling will thus occur at the back of the head,
not the forehead. Oral or injected cortisone may result in a rapid decrease of the
edema. Boric acid 10% in water or chamomile cold compresses have brought relief
of the edema sensation. The swelling usually remains for 1 to 2 days and resolves
without further problems.

Milia is a rare complication; it may occur after the second postoperative week
with the formation of pustules and vesicles over the entire implanted area. It
may have an infectious origin, can be caused by excessive oily secretions of the
sebaceous glands, or may be attributed to poor hygiene. It is treated by rupturing
the pustules with a fine forceps, expressing their contents by soft digital compres-
sion, and applying antiseptic solution. The patient is advised to wash the scalp
286 Part II  ▪ Technique

daily with antiseptic soap, keeping the area aerated and not exposed to heat or
sun in order to save the follicular units. We also recommend keeping the scalp
open; that is, not suffocating it with a cap or hat. The recovery of the hair bulbs
is surprising, and after 10 months, high-quality hair shafts will be evident.

This man had milia after a hair transplantation procedure. The pustules and
vesicles were ruptured and antiseptic solution was applied to save the follicular
units. He is shown 14 months after treatment demonstrating extraordinary recu-
peration of hair growth.

This 52-year-old man developed a secondary infection with multiple pustules.

The pustules were ruptured and the scalp was washed with antiseptic soap. He is
shown 4 months postoperatively.
Chapter 12  ▪ Complications 287

Cysts and Granulomas

Cysts and granulomas usually appear after the third postoperative month, when
hair begins to grow and exteriorize through the scalp. The sebaceous glands of
the follicular units produce an excessive quantity of ecrinic material. When the
orifices are sealed or cicatrized, hair begins an inflammatory process, producing
cysts that must be ruptured and eliminated with surgical forceps and the region
cleaned with antiseptic soap or solution, a treatment process that is similar to
that for cysts of the epidermis. These cysts are inconvenient for the patient, but
may not frighten him, since the implanted FU roots remain intact. Only in cases
of complete graft extrusion will there be a loss of hair growth.

Granulomas are larger nodules that appear in the sixth or seventh month post-
operatively. The inflammatory reaction is caused by incorrect placement of the
capillary graft inside the orifice, which may be transverse or upside down. Treat-
ment consists of a punctiform incision and extrusion of the necrotic material.
288 Part II  ▪ Technique

Isolated and large granulomas that appear after the fifth or sixth month postop-
eratively indicate the formation of a hairball. This results from a hair shaft that
could not exteriorize because the orifice was sealed or because it was implanted
upside down or horizontally, and the hair forms a circular ball growing in the ori-
fice. The scalp may not exhibit an inflammatory reaction, and the hairball may
be indicated only by a prominence on the scalp’s surface. The cyst is ruptured
with a forceps and the helicoidal hair is exteriorized. Many obstructed or incor-
rectly implanted hair shafts can be saved by this process, so it is very important
that the patient examine the scalp periodically for such bumps and present for
remediation of the hairball.

Poor Hair Growth

Poor hair growth, although a rare manifestation, is an undesirable result that both
the patient and surgeon want to avoid. The main cause is a donor area with poor
hair quality and low density.3,4 Perhaps the surgeon, in attempting to solve the
patient’s baldness, has made the mistake of transplanting fine, weak hair. The
surgeon must conduct a thorough preoperative evaluation of the donor site and
inform the patient straightforwardly about the limitations of the transplantation
procedure if the donor site is lacking. Minoxidil 5% topical may increase growth
in these circumstances, but it should not be considered a therapeutic rescue ap-
proach. We should not confuse “poor hair growth” with “less hair implanted.” In
this case, widely spaced implantation produces a result that is less dense, leading
to a false impression of weak hair. The distance we recommend is 1 to 2 mm be-
tween each follicular unit. If we desire more density, we schedule a second session
8 months after the first procedure.
Chapter 12  ▪ Complications 289

This 42-year-old man is shown preoperatively and 12 months postoperatively

with poor hair growth. He has less hair density and hair thinning.

This young man had good hair density and underwent a hair replacement pro-
cedure during which too few hairs were implanted, and the FUs that were trans-
planted were spaced too far apart.
290 Part II  ▪ Technique

Straight Hairline

Straight hairline Degraded hairline

Zigzag hairline Asymmetrical hairline

When we began to perform the punctiform hair transplantation technique in

1986, it was common to place the anterior hair grafts in quite a straight line,
which resulted in an artificial-looking hairline. We maintained the temporal
recessions, but the grafts looked much like palisades or fence posts.

The result was unnatural, and even when the implantation was performed shaft-
to-shaft, the patient could be readily recognized as a hair transplant patient. To
avoid this undesirable result, we began to perform the irregular hairline with 1-2
hair follicular units by the end of the 1980s, providing more natural and elegant
results.5,6 In the 1990s, after Basto and Lemos7 published their article on creat-
ing a natural hairline, we began to break up the hairline in a zigzag fashion. The
long-term results were very interesting. Today we implant hairs in an irregular
pattern to produce a discontinuous hairline that is asymmetrical with a very
natural contour.
Chapter 12  ▪ Complications 291

Pluggy Hair and Corn Rows

Pluggy hair and corn rows are an internal cicatricial

manifestation, which occurs mainly in patients with
thick, oily hair.8,9 Nodular elevations form that can
be seen and felt, similar to corn rows, because the im-
planted grafts were bigger (four or five hairs) and were
implanted too close in a row. The FUs with excess
of fibroconjunctive tissue implanted in the anterior
region produce an intense cicatricial and fibrotic re-
action, which becomes more visible when the units
are implanted in a straight line. To hide this undesir-
able aspect and to prevent this artificial appearance,
it is necessary to prepare FUs with one or two hair
shafts with minimal conjunctive tissue, placing them
irregularly along the front of the hairline.

This man presented with a “corn row,” an intense cicatricial reaction that had
formed palpable nodules on the surface at the hairline. The patient is shown fol-
lowing a procedure in which single hairs with minimal connective tissue were
implanted in an irregular fashion to conceal the corn row appearance.
292 Part II  ▪ Technique

Undesirable Punch Grafts

The Orentreich technique,10 which was used in the 1950s and 1960s, was revo-
lutionary and brought a great contribution to baldness surgery. Today, however,
with the use of follicular unit hair transplantation, the results from this earlier
technique are recognized as far from ideal, producing undesirable results for pa-
tients, who are still looking for hair restoration centers to correct and eliminate
the hair transplanted in that fashion. The solution is not easy, not only because
of the punches that formed islands, but also because of cicatricial fibrosis of the
scalp. We began to use micrografts to mitigate the rough aspect and improve the
density in these patients, always trying to break the hairline. (See Chapter 11
for more details.)

This 34-year-old man had isolated and dispersed punch graft surgery, with an un-
natural result. He is shown after a second hair replacement procedure with FU
grafts. Good hair density with a very natural hairline was achieved.
Chapter 12  ▪ Complications 293

Undesirable Hair Follicular Grafts

Implanted hair can be undesirable in certain regions, such as the anterior tempo-
ral region. Mainly on men, where the temporal recession is progressive over the
years, the skin and hair are finer. We do not recommend hair replacement in this
region, since it will become visible and isolated from the facial contour as the
hairline recedes. To eliminate undesirable hairs, we have used five or six sessions
of intense pulsed light (Epilight, ESC, Yorkham, Israel) at 1-month intervals,
obtaining a significant reduction and thinning of the hair.

This man had unwanted hair grafts in his

temporal region. The desired hairline was
marked, and he was treated with intense
pulsed light. After the third application, the
hair grafts thinned and diminished signifi-
cantly. It is important to remember that this
hair is very resistant, and five or six treatment
sessions may be necessary to eliminate the
unwanted hair.
294 Part II  ▪ Technique

1. Stough DB. Mushy dermis. Hair Transplant Forum Int 8:23, 1998.
2. Straub P. Why elevate the head? Hair Transplant Forum Int 8:13, 1998.
3. Stough DB III, Randall JK, Schauder CS. Complications in hair replacement surgery. Facial
Plast Surg Clin North Am 2:219-231, 1984.
4. Straub P. The cause of poor growth. Hair Transplant Forum Int 3:17-18, 1993.
5. Uebel CO. Micrografts and minigrafts: a new approach for baldness surgery. Ann Plast Surg
27:476-487, 1991.
6. Uebel CO. Micrograft—a new approach for pattern baldness surgery. Transactions of the
Tenth International Congress of the International Society of Aesthetic Plastic Surgery,
Zurich, Sept 1989.
7. Basto FT, Lemos P. Irregular and sinuous anterior hairline in the capillary micrograft. Rev
Soc Bras Cir Plast Estet Reconstr 11:15-22, 1996.
8. Brown MD, Johnson TM, Swanson NA. Extensive keloid formation following hair trans-
plantation. J Dermatol Surg Oncol 16:867-869, 1990.
9. Pinkus H. “Sebaceous cysts” are trichilemmal cysts. Arch Dermatol 99:544-555, 1969.
10. Orentreich N. Autografts in alopecias and other selected dermatological conditions. Ann
NY Acad Sci 83:463-479, 1959.
Pa rt III

Special Problems
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C H A P T E R 13

H air Transplantation
to E nhance
R econstruction of the
Face and Scalp

Alfonso Barrera, Carlos Oscar Uebel

298 Part III  ▪  Special Problems

W e have been able to provide significant improvements in the reconstruction

of the face and scalp using current plastic surgical techniques, such as simple
skin grafts, local and regional flaps, free tissue transfers, tissue expansion, laser
treatments, autologous fat grafting, even full face transplantation. Follicular unit
hair transplantation adds a new dimension for camouflaging scars and enhancing
aesthetics when reconstructing the face and scalp. In our practice we often see
patients who seek to correct iatrogenic, burn, and other scarring alopecias result-
ing from tumor resections, trauma, and congenital deformities.1

Although current FU hair transplantation techniques can easily be used to cor-

rect these deformities, the graft take in scarred areas is approximately 70% to
80%, compared with a graft take of approximately 95% in unscarred areas. This
difference results from the fact that in areas of scarring alopecia of the scalp or
face, fibrosis and decreased vascularity are often present, with thin tissues that
are often tight. In selected cases, the recipient site is prepared with autologous fat
injections a few months before hair transplantation, which helps to prepare the
recipient site by making it a better ground for the grafts and may increase the yield
of hair growth. The role of transferred stem cells in this process is the subject of
current investigations. In individuals who have undergone radiation therapy in
the area of scarring alopecia or those with tissues that are very thin and closely
attached to underlying bone, I prefer to inject autologous fat and 3 to 6 months
later perform hair transplantation. This enhances the graft take by providing a
better recipient site for the grafts. In these situations, it is best not to pack the
grafts too densely—no more than 30 to 35 per square centimeter to ensure that
there is no interference with graft take.

Candidates for hair transplantation to correct scarring alopecias must have a rea-
sonably good amount of donor hair so that the supply and demand ratio is favor-
able. In patients with a limited donor supply, certain areas have to be selectively
chosen to be grafted to provide the patient with a strategic redistribution to the
most important areas.

The patient must have realistic expectations and understand the limited density
that we can accomplish with hair transplantation in such situations. I always
explain that it is very likely that two or three sessions of hair transplantation will
be required to achieve reasonable hair density, and these procedures are done
at least a year apart. Eyelashes placed with the strip graft technique discussed
in Chapter 15 may well produce the desired result in one session, but this is the
exception, not the rule.
Chapter 13  ▪  Hair Transplantation to Enhance Reconstruction of the Face and Scalp 299

Camouflaging Scalp Scars

Hair transplantation offers an excellent solution for camouflaging scars on the
scalp. The technique is basically the same as that described in earlier chapters.
Almost all cases are performed with the patient under intravenous sedation (mid-
azolam and fentanyl) and local anesthesia (as described in Chapter 5). General
anesthesia is used only for small children. The procedure can be performed on
an outpatient basis.

Case Examples
Carlos Oscar Uebel

This 24-year-old man had an accident resulting in quadriplegia, and while in the
hospital developed a pressure sore (decubitus ulcer) on the crown of his head,
which subsequently resulted in scarring alopecia. He is shown here before and
1 year after two sessions of FU transplantation in which about 1000 grafts were
placed. Another option would have been tissue expansion, but there are clearly
inconveniences associated with that technique, with possible residual scarring
300 Part III  ▪  Special Problems

This 19-year-old woman had scarring of the forehead and scarring alopecia of
the right frontal hairline. She underwent a single session of scar revision of her
right forehead with approximately 400 FU grafts. She is shown before and during
surgery and 8 years postoperatively.
Chapter 13  ▪  Hair Transplantation to Enhance Reconstruction of the Face and Scalp 301

This 42-year-old man had had a melanoma excised, and a full-thickness skin
graft was done. He was treated with a single session of 1300 FU grafts. In such a
case, after slight tumescent infiltration, the grafts should be inserted at an angle
of about 45 degrees or less to ensure enough depth for the graft to fit. Today we
would prepare the site in advance with autologous fat grafting, with numerous
microtunnels, and 6 months later we would perform the FU grafting. Fat grafting
helps to plow the land for a more favorable recipient site; it also thickens the
tissues and makes the overall area healthier.
302 Part III  ▪  Special Problems

Case Examples
Alfonso barrera

This 20-year-old woman had scarring alopecia as a result of trauma in a motor

vehicle accident. She underwent one session of FU grafting with about 600 grafts.
She is shown before and 1 year after surgery.
Chapter 13  ▪  Hair Transplantation to Enhance Reconstruction of the Face and Scalp 303

This patient had scarring alopecia from a temporoparietal-occipital (TPO) flap.

He is shown before and 1 year after two sessions of FU grafting in which about
1600 grafts were placed.
304 Part III  ▪  Special Problems

Before replantation

Radial forearm flap donor site

This patient is shown after excision of a scalp malignancy and a cranioplasty with
a methylmethacrylate plate and radial forearm flap. Autologous fat injections
were done to improve the quality of the area to be grafted, then 1200 grafts were
placed on the radial forearm flap.
Chapter 13  ▪  Hair Transplantation to Enhance Reconstruction of the Face and Scalp 305

10 days after surgery

6 months after surgery

She is shown 10 days and 6 months after a single session of grafts. At least one
additional session will be needed to further improve her hair density.

Restoration of the Eyebrows, Eyelashes, Mustache,

and Beard
Fortunately, micrografts and minigrafts grow anywhere on the face and thus are
useful for restoring the eyebrows, mustache, and beard. However, since the con-
sistency of the skin is softer and more elastic on the face than on the scalp, the
surgeon will encounter more problems with bleeding and with grafts popping
out when transplanting facial areas, especially when using the stick and place
306 Part III  ▪  Special Problems

Therefore we prefer to make most of the recipient slits first (with a 22.5-degree
Sharpoint blade) before inserting the grafts. This allows the fibrinogen to turn
into fibrin, which helps to minimize bleeding and decreases the tendency for the
grafts to pop out.

Most cases are performed with the patient under intravenous sedation with
midazolam and fentanyl and a local anesthetic (bupivacaine or lidocaine with
epinephrine). Topical eye drops are instilled when hair is transplanted to these
facial regions, the direction in which the graft is inserted may be more critical
for controlling the direction of hair growth. When working on the eyebrows or
mustache, for example, the direction of the natural hair growth of the respective
sites must be followed. The hair transplanted to the face will have the character-
istics of scalp hair and will thus need to be trimmed frequently.

For eyelash reconstruction I prefer to use a scalp strip rather than individual
FU grafts. Individual single-hair grafting to reconstruct the eyelashes has been
presented by Marcelo Gandelman,2,3 who has great experience using a French
needle and feeding the graft into the lid on the skin side and exiting at the tarsal
plate (see Chapter 15).

Chalazion clamp

A strip of scalp can be harvested from a retroauricular or occipital site, taking

about two rows of hair and the length needed. I use a chalazion clamp to protect
the eyeball and to stabilize the eyelid during eyelash reconstruction.

Then a Sharpoint blade is used to incise at the tarsal plate free edge, opening the
ciliary edge of the lid, far enough to be able to accommodate the scalp strip. The
surgeon confirms the best direction of the hair on the strip. The graft is inserted
into the eyelid pocket and secured in place using a few 6-0 or 7-0 polypropylene
Chapter 13  ▪  Hair Transplantation to Enhance Reconstruction of the Face and Scalp 307

Obicularis oculi

Orbital septum
Müller’s muscle
Tarsal plate
glands Suture kept
Skin superficial

Glands of Zeis
Graft no wider
Ciliary muscle than 2 mm
of Riolin

Glands of Moll Gray line

The donor area is closed with a running 4-0 nylon suture. Sutures should be kept
as superficial as possible to avoid damage to the transplanted hair follicles. Wet
gauze is applied over the eye before the patient leaves the operating room. This
helps to absorb any blood exuding from the surgical wound and prevents the
formation of crusting that might preclude easy removal of sutures. The patient
is instructed to rest for 4 days in a semisitting position to avoid epithelial tunnel
formation. The use of operating loupes and fine-tipped forceps is advisable to
remove these sutures. The patient should be advised that regular trimming and
curling of the transplanted eyelash hair will most likely be necessary.
308 Part III  ▪  Special Problems

Insertion of micrografts

Immediately after surgery Adaptic and Steri-Strip dressings

On the eyebrows a 15-degree Sharpoint blade or a 22-gauge needle can be used to

make the initial slits in the recipient area. Here it is crucial to incline the blade
or needle as much as possible, 5 to 10 degrees, because hair tends to grow signifi-
cantly more perpendicular to the surface than one might imagine. We are trying
to mimic nature cephalically and laterally in the medial area and laterally as we
proceed to the middle and lateral thirds of the eyebrows. I usually do 150 to 200
FU grafts per eyebrow. As the grafts are inserted, the surgeon confirms that the
direction of the hair shaft of each graft is the most desirable, or turns it around,
making certain the curl, if any, tends in the direction the hair should grow.

When transplanting hair to mustaches and beards, the direction of the slits fol-
lows the natural direction of the hair growth, which is usually in a caudal direc-

For dressings one or two layers of Adaptic are used, plus trimmed squares from a
4 3 4 gauze pad, and 1⁄2-inch Steri-Strips or hypoallergenic paper tape.
Chapter 13  ▪  Hair Transplantation to Enhance Reconstruction of the Face and Scalp 309

Before surgery 1 year after surgery

Preoperative markings

Recipient slits Immediately after surgery

This 21-year-old man had a third-degree burn to his face in the mustache area.
Preoperative planning is shown. Recipient slits were made with a 22.5 Sharpoint
blade in a preliminary fashion before the grafts were inserted. He is shown 1 year
after a single session of FU grafting.
310 Part III  ▪  Special Problems

Before surgery 1 year after surgery

Preoperative markings

Immediately after procedure Donor site closure

This 11-year-old boy had a melanotic lesion removed from his left eyebrow. He
was referred for eyebrow reconstruction. He is shown before, during, and 1 year
after a single session of FU eyebrow reconstruction.
Chapter 13  ▪  Hair Transplantation to Enhance Reconstruction of the Face and Scalp 311

This girl was born with a hemangioma of the right upper eyelid. It grew to the
point that it interfered with her vision and was removed at age 2. At age 15 she
was distressed by the absence of her eyelashes and requested a reconstruction. We
discussed doing single FU grafts. In this case I used strip grafting. The patient is
shown before and 1 year postoperatively after a single procedure.
312 Part III  ▪  Special Problems

This 23-year-old man with a Tessier 1 cleft had reconstructive surgery by Paul
Tessier, with additional nasal reconstruction (radial forearm flap to nasal base
and upper lip) by Robert Walton and Gary Burget. He referred the patient to
Henry Kawamoto for scalp advancement and to Sydney Coleman for fat injec-
tions before he was referred to me for reconstructive hair transplantation to the
mustache and beard areas. He is shown 1 year after two sessions of FU grafting.
Chapter 13  ▪  Hair Transplantation to Enhance Reconstruction of the Face and Scalp 313

This 26-year-old man had scarring alopecia of the right eyebrow as a result of
a motor vehicle accident. He had a single-session 60 FU graft reconstruction
of the eyebrow. He is shown before and 1 year after the procedure. Notice the
direction of the hair growth. It must be explained to patients that they will have
to trim the eyebrow hair periodically, because it will grow like the scalp hair it
originated from.

This 43-year-old man had surgery and radiation therapy for sarcoma of the right
maxilla. He is shown 1 year after autologous fat grafting and FU hair transplanta-
314 Part III  ▪  Special Problems

Melanoma of eyebrow 4 years after surgery 6 years postoperatively

Excision of lesion Wound closure

Immediately after surgery

This 13-year-old girl had a melanotic lesion of the left eyebrow area. She was
referred to me for excision and reconstruction. I performed the excision and im-
mediate FU grafting, then an additional session of grafting. The patient is shown
before and during surgery and at 4 and 6 years postoperatively.
Chapter 13  ▪  Hair Transplantation to Enhance Reconstruction of the Face and Scalp 315

Treatment of Burn Alopecia

The fibrotic scar tissue that normally forms after burn injuries has a precarious
blood supply and is not an optimal site for any type of graft. Single- and double-
hair grafts (micrografts) and grafts with three to four hairs (small minigrafts) have
fewer metabolic requirements because of their small size, which probably permits
them to survive in this hostile environment.

We believe that it is important to allow sufficient time for the scalp to heal,
soften, and fully recover from the insult of surgery or trauma before proceeding
with hair transplantation, especially in the case of burn alopecia.

The procedure is usually performed with the patient under a mild intravenous
sedative and local anesthetic. The technique is as described for the treatment of
male pattern baldness.

Case Example
Alfonso Barrera

This 40-year-old man had third-degree burns to the face and scalp that resulted in
scarring and alopecia. He is shown before and after a single session in which 175
FU grafts were placed; notice the nice aesthetic enhancement. A second session
could be done to further increase the hair density.

Concluding Thoughts
It is much more difficult to work on some of these cases because of the severe de-
gree of scarring and fibrosis. Obviously, the graft take is less when compared with
nonscarred areas, in the graft take may be up to 95%. Of course, the grafts must
be dissected accurately and handled atraumatically. On scarred areas the take is
a bit variable—generally about 60%—and we try not to densely pack the grafts,
316 Part III  ▪  Special Problems

which can reduce the graft take. Usually I transplant about 20 to 25 FUs/cm2 per
session. It is essential that patients have realistic expectations and understand
that it will require several sessions for the optimal result. Hair grafts come with
some fat cells and likely some stem cells, and I have noticed that the grafted areas
become healthier, softer, and thicker after hair transplantation. In a patient with
sufficient donor hair supply, FU hair transplantation can safely and predictably
enhance aesthetics in the reconstruction of the face and scalp.

1. Barrera A. The use of micrografts and minigrafts in the aesthetic reconstruction of the face
and scalp. Plast Reconstr Surg 112:883-890, 2003.
2. Gandelman MA. Technique for reconstruction of eyebrows and eyelashes. Semin Plast Surg
19:153-158, 2005.
3. Gandelman M. Eyelash and eyebrow reconstruction. Oper Tech Oculoplastic Orbital Reconstr
Surg 4:94-99, 2001.
C H A P T E R 14

of Scarring A lopecia
A fter Face L ift

Alfonso Barrera, Carlos Oscar Uebel

318 Part III  ▪  Special Problems

F vancement
ace lift incisions can result in a variable degree of cephalic and posterior ad-
of the temporal hairline and sideburns. When we treat frontoglabellar
wrinkles with a traditional coronal incision and are not careful with skin traction,
we can create elongated foreheads and alopecia of the retroauricular hairline.

Alopecia can also occur after endoscopic forehead lifts. In these instances the
patient looks unnatural and disharmonic, with a surprised, operated look—an
unsightly telltale sign of a poorly performed face lift.

These stigmata can be corrected by the use of modern micrograft hair transplanta-
tion techniques, specifically follicular unit hair grafting. I (A.B.) initially reported
my technique to correct this condition in 1998.1 This punctiform or stick and
place technique can effectively remove the stigmata, the evidence the patient had
a face lift and/or a forehead lift procedure, and complements the final aesthetic
outcome, resulting in a high degree of patient satisfaction.

Planning and Technique

Because we are unable to create new hair and can only redistribute hair from one
area to another, the patient must have enough donor hair to work with to be a
candidate for a procedure to restore alopecic areas. The donor hair is commonly
harvested from the occipital area. Most patients have sufficient donor hair to
restore the sideburns as well as the temporal areas and retroauricular hairline,
because these are not large regions. The surgeon should always make certain that
the supply and demand ratio from donor site to recipient site is favorable.

The patient must have realistic expectations about the results of hair restoration.
It is not uncommon that a second replacement procedure will be required after
about 12 months if additional hair density is desired.

Before the operation it is also important to plan the patient’s new hairline by
drawing the form we wish to obtain and discussing this with the patient so that
he or she has the opportunity to express agreement with the design.
Chapter 14  ▪  Correction of Scarring Alopecia After Face Lift 319

The procedure is performed on an outpatient basis. The patient is placed in the

supine position; intravenous sedation and local anesthesia are administered as
described in Chapter 5. The surgical technique and graft dissection is essentially
the same as described for male pattern baldness (see Chapter 6). The only sig-
nificant difference here is the need to incline the surgical blade in the direction
in which we need the hair to grow.

We harvest the donor strip from the occipital area. The patient’s head is turned
to the left, and using a No. 10 scalpel blade, the right half of the donor ellipse is
harvested, incising parallel to the hair shafts, then turn the head to the right and
harvest the left half. If it is a small case, 300 to 400 grafts are harvested. The do-
nor ellipse is 1 cm wide and whatever length is needed, usually 3 to 4 cm; if more
grafts are required, a longer ellipse can be harvested. The donor site is closed in
a layered fashion with a 3-0 Prolene continuous running suture.

The key to optimal results in treating alopecia after face lifts and forehead lifts is
to place the hair so that it looks natural. To accomplish this, very small single-
and double-hair grafts are used; they are placed so that they will grow in a con-
sistent and natural direction, downward on the sideburns, perhaps in a slightly
posterior direction. The follicular units should be implanted in a discontinuous
line. Because the skin in this region is very thin and does not have the same
characteristics as the scalp, a microsurgical blade with a fine point is used, and the
depth should be no more than 3 mm. For dressings one or two layers of Adaptic
or Kerlex are placed, and a 3-inch Ace bandage is used for the scalp.

Problems and Complications

The FU micrograft and minigraft technique, as described in earlier chapters,
is safe, predictable, and very effective for correcting scarring alopecia that has
resulted from facial rejuvenation surgery. Infection is extremely rare. Hematoma
does not occur, because no undermining is done. Ingrown hairs often occur, espe-
cially during the first 3 postoperative months. We learned that simply leaving the
epidermis of the grafts slightly superficial to the epidermis of the recipient scalp
prevents this problem. When ingrown hairs do occur, they are not a significant
problem, because they will mature, come to a head, and drain, or the surgeon can
pop them as a small pustule and drain them.
320 Part III  ▪  Special Problems

Case Examples
Correcting Sideburn and Temporal Alopecia


When hair is transplanted to the sideburns, an acute downward angulation is

critical when the grafts are inserted to mimic the natural direction of hair growth.
The hair shaft is angled approximately 35 to 40 degrees or follows the angulation
of the remaining hair, if any is present. When restoring sideburns we typically
place between 300 and 1500 grafts per session, depending on the degree of alo-
pecia and the size of the area to be covered.

This labor-intensive procedure requires an organized and efficient surgical team.

The surgical team consists of three surgical assistants and the surgeon. We remain
in the operating room for the duration of the procedure, and I insert all grafts
myself. Efficiency and coordinated timing are essential when transplanting a large
number of grafts in a single session.
Chapter 14  ▪  Correction of Scarring Alopecia After Face Lift 321

Alfonso Barrera

This patient had alopecia of the sideburns and

temporal area after a face lift. The patient is
shown 1 year after two sessions of FU grafting
with a total of approximately 2000 grafts. Note
the preoperative irregular hairline markings
used to achieve a natural look.
322 Part III  ▪  Special Problems

This 39-year-old woman had scarring alopecia after a face lift. The preoperative
markings are shown and immediate postoperative appearance after 550 FU grafts
were placed per side. She is shown before, during, and 1 year after a single session.
Chapter 14  ▪  Correction of Scarring Alopecia After Face Lift 323
324 Part III  ▪  Special Problems

Correcting an Elongated Forehead

This patient had an elongated forehead after a face lift. She is shown before,
during, and 1 week and 1 year postoperatively; 1100 follicular unit grafts were
placed. Note the preoperative irregular hairline markings as well as her immediate
postoperative appearance.
Chapter 14  ▪  Correction of Scarring Alopecia After Face Lift 325

Case Examples
Carlos Oscar Uebel

This 72-year-old woman had secondary alopecia after a glabellar rhytidectomy. A

new hairline was designed in consultation with the patient and was brought down
2 cm. The new hair started to grow after 4 months. She is shown 2 years post-
operatively with good hair density. Subsequently she has dyed her hair blonde.
326 Part III  ▪  Special Problems

This 46-year-old woman had secondary frontal and temporal alopecia after a
rhytidectomy. Facial contouring and sideburns were restored with FUs placed in
a discontinuous line following the original growth of the hair.
Chapter 14  ▪  Correction of Scarring Alopecia After Face Lift 327

Before surgery 18 months after surgery

Before surgery Immediately after surgery 4 months after surgery 18 months after surgery

This 34-year-old woman had an endobrow lift performed through an endoscopic

approach. After this procedure she experienced telogen effluvium as a result of
stretching from the brow lift. Follicular unit micrografts were placed in a single-
stage procedure to correct the alopecia. She is shown preoperatively and imme-
diately postoperatively, as well as 4 months and 18 months postoperatively with
colored hair.
328 Part III  ▪  Special Problems

This 70-year-old woman had telogen effluvium following an endobrow lift. She is
shown preoperatively and 18 months postoperatively after FU hair transplanta-
Chapter 14  ▪  Correction of Scarring Alopecia After Face Lift 329

Correcting Retroauricular Alopecia

Alfonso Barrera

From Barrera A. Correcting the retroauricular hairline deformity after face lift. Aesth Surg J 24:176-178, 2004.

This patient had retroauricular alopecia as a result of a face lift. 2 She is shown
before and after FU graft reconstruction.

1. Barrera A. The use of micrografts and minigrafts for the correction of the postrhytidectomy
lost sideburn. Plast Reconstr Surg 102:2237-2240, 1998.
2. Barrera A. Correcting the retroauricular hairline deformity after face lift. Aesthet Surg J
24:176-178, 2004.
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C H A P T E R 15

R econstruction
of E yebrows
and E yelashes

Marcelo Gandelman, Carlos Oscar Uebel

332 Part III  ▪  Special Problems

T he
  principle behind hair transplantation in any area of the body is the same:
transplanted hairs continue to grow as a result of the phenomenon called donor
dominance.1 Donor dominant hair grafts maintain the properties of the donor site
after transplantation to a new site. From its inception, surgical hair transplanta-
tion has been used to treat absent or thinning scalp hair. Over time its use has
expanded to include most of the hair-bearing areas of the human body. The first of
these was the eyebrows. With the advent of eyebrow and eyelash reconstruction
surgery, hair restoration surgeons are able to help patients recover their confidence
and self-esteem by improving their appearance. Such procedures can be efficiently
and successfully performed in any clinic equipped with suitable instrumentation.

This chapter will focus on the eyebrow and eyelash reconstruction techniques
using follicular unit transplantation (FUT). Undesirable conditions can be al-
tered to restore a natural appearance through a technique that provides a more
natural appearance than scalp hair strips, is easier to perform than temporal artery
island flaps, and allows more subtle results than those achieved with punch hair

In 1914 Krusius1a rebuilt eyelashes by harvesting scalp grafts with small punches
and transplanting these grafted hairs to the ciliary border. In 1917 Knapp2 devel-
oped the technique of transplanting a free graft ribbon taken from the eyebrow
along the edge of the eyelid. In 1930 Sasagawa3 published a method of hair
shaft insertion. In 1953 Fujita4 reconstructed eyebrows through the punctiform
hair graft technique using an injection needle. Jung Ki Paek, a former Hansen’s
disease patient and paramedic in a Hansen’s disease isolation camp, developed
a hair implanter for the restoration of eyebrows in 1969. Since then, he has per-
formed more than 3000 cases of eyebrow surgery on Hansen’s disease patients.5,6
In 1980 Marritt7 transplanted roots chosen from the periphery of 4 mm punches,
transplanting them to the edge of the eyelid with a needle. Other techniques for
reconstructing eyebrows have been described, including:
• Free composite or hair-bearing pedicled strip grafts from the scalp or the
contralateral eyebrow
• Temporal artery hair-bearing island flap
• Punch hair transplantation

Micrografts were first applied in eyebrow reconstruction more than 20 years be-
fore their use in the scalp became a standard procedure. Micrografting allowed
surgeons to transplant single-hair (and occasionally double-hair) grafts obtained
through follicular unit dissection harvested from the scalp.
Chapter 15  ▪  Reconstruction of Eyebrows and Eyelashes 333

Eyebrows and Eyelashes:

Anatomic and Aesthetic Importance
It is said that the eyes are the windows of the soul, because they allow examina-
tion of a person’s state of mind through expression. People with ordinary pattern
baldness are nonetheless considered normal and healthy human beings, and they
may choose to remain bald. However, the absence of eyebrows gives an obviously
unnatural look to the face, attracting curious stares and causing discomfort for
most people. The absence or loss of eyebrows and eyelashes (madarosis) can be
associated with a number of factors (see the box), and the resulting absence of
hair in these areas is a humiliating characteristic that can affect a person’s self-
image and his or her professional, social, and romantic relationships.

Causes of Eyebrow and Eyelash Loss

• Avulsion and burns
• Tumor excision or irradiation
• Trichotillomania
• Complications from tattooing eyebrows and eyelids
• Dermatologic diseases
• Alopecia after infection and cicatrization of piercing channels
• Incisions in the supraorbital area in direct brow lift procedures
• Endocrinopathies such as thyroidopathy
• Congenital aplasia
• Repeated electrolysis for eyebrow shaping
• Repeated plucking or excessive laser hair removal

Eye-to-eye contact is an integral part of social interaction. The eyebrows play

a crucial part in the facial expressions attributed to the eyes, such as surprise
and rage. They also play a more subtle part in the facial expression of other
emotional states that we may recognize and react to on a subconscious level.
Eyelashes are also responsible for beauty and sensuality, serving as “nature’s fan”
in the art of flirting in many cultures. Additionally, the absence of eyebrows or
eyelashes increases the vulnerability of a person’s eyes, since eyebrows shield the
eyes from forehead perspiration, minor trauma, and, along with squinting, help
filter sunlight. Eyelashes are extremely sensitive to dust and debris. Foreign bodies
touching the lashes evoke eyelid-closing reflexes, preventing or limiting trauma
to the eyeball. So reconstructing the eyebrows and eyelashes not only enhances
a patient’s appearance and his or her self-esteem but also restores protection for
the eyes.
334 Part III  ▪  Special Problems

Initial Consultation
The objective of medical consultation is to inform the patient and assess his or her
eligibility for surgery. Surgeons must bear in mind that in most cases, the patient
does not view this procedure as “real” surgery, and fails to inform the physician
of his or her complete medical history.

The medical history and a thorough medical examination should focus on dis-
covering the factors that have contributed to eyebrow and/or eyelash loss. It is
important to determine whether the cause of the alopecia still exists. Patients
with trichotillomania or other psychological disorders should have their case
reviewed by a psychologist or psychiatrist as a condition for scheduling surgery.

The candidate for eyelash or eyebrow replacement surgery must be completely

recovered or in long-term (5 years) stable remission from any dermatologic dis-
eases such as lupus or alopecia areata. Any patient with a history of a dermatologic
disease must be examined by a dermatologist before surgery. Psoriasis does not
preclude this type of procedure.

Hypertrophic scars and keloids are uncommon in the recipient area, but they
do occur in the donor area, especially in younger patients. Individuals prone to
exuberant scarring or with a history of keloid formation should be closely watched
and possibly treated prophylactically in the postoperative period. The use of topi-
cal corticosteroids and other medical preparations may decrease scar growth and
development (such as Contractubex and Madecassol). The use of silicone plates
or silicone gel may also be of benefit.

Although this type of surgery is not necessarily contraindicated in patients with

hypertension and diabetes, such medical conditions should be under clinical
control. Fashion and bizarre diets that exclude proteins may have a significant
impact on the surgical outcome. As a general rule, we recommend that any pa-
tient 65 years of age or older obtain a brief written clearance for “a minor surgical
procedure under local anesthesia with epinephrine” from an internist or general

During this initial consultation, patients should also be informed that the hair
transplanted from their scalp to their eyebrows and/or eyelashes will retain the
same hair growth patterns from the head and will continue to grow. Patients will
need to trim the transplanted hair monthly and sometimes adapt it with fixatives
Chapter 15  ▪  Reconstruction of Eyebrows and Eyelashes 335

such as skin glues. Patients should be made aware that even with hair harvested
from the low cervical region, where hair shafts are the thinnest, the harvested
micrografts are single-hair units that will still be coarser than original eyebrow
hair. Patients must be aware of this limitation so that these grafts will not become
undesirable hair.

Case Example
Carlos Oscar Uebel

This 62-year-old woman underwent eyebrow restoration with single hairs trans-
planted to her eyebrows. The hair was harvested from the thinner occipital area.
The transplanted hair must be trimmed regularly to maintain growth in the donor
336 Part III  ▪  Special Problems

Alternative Reconstruction Options

Eyebrow and eyelash tattooing often enhances the results of the surgical interven-
tion: the tattoo produces background shading, thus augmenting the implanted
hair and further defining the reconstructed design without affecting graft inte-
gration. Patients should be referred to an aesthetic center experienced with this
type of tattooing.

Nylon Implants
Marcelo Gandelman

Reaction to nylon implants

The implantation of nylon threads in baldness correction and eyebrow recon-

struction procedures is permitted outside the United States. Patients with nylon
eyebrow implants who request surgical transplants usually present with chronic
infection and permanent scarring in the area. All remaining nylon threads must
be removed, and the infectious process must be allowed time to fully recover
before transplantation surgery can be scheduled.

Preoperative Planning
When deciding on the placement of eyelash grafts, we take photographs of the
patient and draw on the photographs the areas where we and the patient agree to
insert the grafts. We recommend grafting double the amount of wanted eyelashes,
because eyelash grafts have a 50% breakdown, which could be attributed to the
fact that they are manipulated more.
Chapter 15  ▪  Reconstruction of Eyebrows and Eyelashes 337

Natural design

When designing the patient’s eyebrows, we have the patient sit in front of a
mirror as we explain and draw the most natural design. With the patient’s help,
we mark off the area where the follicles will be grafted. We recommend using
anatomic patterns for designing the eyebrow shape to achieve a natural look,
avoiding glamorous or trendy designs.


Eyebrow diagram

When it is necessary to create an eyebrow from scratch, the eyebrow’s medial

border begins on the vertical line drawn from the lateral point of the ala to the
inner canthus. The eyebrow’s external border ends at an oblique line drawn from
the lateral point of the ala to the lateral canthus.8
338 Part III  ▪  Special Problems

Women’s eyebrows are higher in relation to the orbital rim and have a more ac-
centuated arch in a C shape. Men’s brows are lower, less arched, and straighter,
with a T shape.

Patients are photographed preoperatively, and the pictures are taken to the oper-
ating room, where they serve as a model during the surgical procedure. It is appro-
priate to have the patient initial his or her preoperative photos for legal reasons.

Selection of the Donor Area

In our first eyebrow replacement surgeries, we attempted to transplant the most
delicate hair of the nape of the neck or from the temporal area behind and above
the ear, in the belief that transplanting thicker hair roots would result in unusu-
ally thick eyebrows. Over time, however, we haven’t noticed any difference in
harvesting from such areas or from the midoccipital region. Some surgeons have
found that hair roots transplanted to eyebrows, legs, and arms grow with a smaller
diameter than previously at the donor area, thus suggesting the occurrence of
recipient dominance.
Chapter 15  ▪  Reconstruction of Eyebrows and Eyelashes 339




Hair of an Asian patient Hair of a patient of European descent

William Parsley12 has been studying the diameter of scalp and eyebrow hair using
an optical micrometer and has demonstrated that scalp hair in Asian patients
is actually thicker than their eyebrow hair; however, in patients of European
descent, Parsley has noted that eyebrow hairs are larger in diameter than the
scalp hair.

We have also noted that transplanted eyebrows adjust to their new location,
merging with the original eyebrows in an apparent metaplasia, thus producing a
more harmonious and favorable outcome.

Preoperative Instructions
Bleeding causes graft popping during surgery and may lead to the formation of
hematomas and consequent infection. Therefore, 1 week before the surgery we
request that the patient:
• Stop taking aspirin, vitamin E, and NSAIDs (taking acetaminophen [Ty-
lenol] for mild pain is acceptable)9,10
• Stop any alcohol intake
• Take 2 g of vitamin C daily
• Use antiseptic soap for washing the face and hair
• Eat a light meal, to avoid fainting because of fasting
• Avoid the use of diazepam (Valium) or alprazolam (Xanax) within 12 hours
of the procedure

Since these surgical procedures are performed in aseptic environments, we do not

prescribe antibiotics.

note: A word of caution about aseptic technique: many papers warn against cor-
neal damage resulting from contact with antiseptics such as chlorhexidine. The
eye should be vigorously and immediately irrigated with saline solution or water
when the antiseptic accidentally comes into contact with the cornea.
340 Part III  ▪  Special Problems

Surgical Technique
Microscopes and magnifying glasses are mandatory for reconstructive eyebrow and
eyelash surgery. These procedures are performed with the use of a local anesthetic.

We always administer an oral tranquilizer 30 minutes before surgery to lower the

patient’s preoperative anxiety. Marc Pomerantz11 recommends the use of oral or
sublingual midazolam (Versed): 5 mg. Patients sleep through the donor harvest-
ing part of the procedure, but they recover sufficiently to drive themselves home.
Its best feature is that the patient has no memory of the discomfort of anesthe-
tization. Patients are aware and arousable. They react to the discomfort of the
anesthesia, but do not recall it.

Midazolam can be given by mouth, intravenously, or by intramuscular injection.

Intramuscular injection is ideal for an office setting. It is rapid in onset, very con-
trollable in dosage, and safe. The usual dose is 10 mg IM, but this can be decreased
to 8 or 9 mg for smaller persons and many women.

PO2 levels must be monitored—in a slight overdose, the patient will forget to
breathe, and PO2 levels will fall below 85%. If this happens, the patient must be
reminded to take deep breaths for several minutes, and the excess will burn off.

The concurrent use of diazepam (Valium) or alprazolam (Xanax) should be

avoided; as mentioned earlier, patients are told specifically to not take either
of those drugs within 12 hours of a planned procedure. Although this may seem
counterintuitive, since both drugs have effects similar to those of midazolam, both
of these drugs interfere with the effects of midazolam.

Donor and receptor areas are anesthetized with dental anesthetic (lidocaine 2%
with epinephrine 1:100,000) injected with a dental syringe.

Donor Site Harvesting
Eyebrow grafts are harvested using the Limmer technique13: an ellipse of approxi-
mately 1 by 4 cm is removed from the midoccipital area, and FUs are separated
using microscopes. FUs with more than three roots are discarded.

Graft Insertion
An Arnold microsurgical blade or 20- to 22-gauge needles are used to make inci-
sions as close together as possible parallel to the skin’s surface. An average of 150
hairs is required to reconstruct each eyebrow.14 No dressing is necessary, but the
use of protective eyeglasses for 2 days is recommended.
Chapter 15  ▪  Reconstruction of Eyebrows and Eyelashes 341

Donor Site Harvesting

We keep the hair in the donor occipital area as long as possible. We remove a
scalp ellipse.15 Then, under microscopic control, using a microsurgical blade, the
follicles are dissected from below upward to the underside of the epidermis. The
follicle, with its long thread of hair attached, is delicately pulled using a jeweler’s
forceps. The hair slides through the epidermis. We have a suture thread with a
hair root at one end. In effect, we have done a reverse FUE harvesting. All tissues
must be kept moist during the entire process.16

Graft Insertion
After applying a drop of artificial tear fluid gel to the cornea, an eye shield used
for laser blepharoplasty is positioned over the eyes.

The distal hair away from the follicle end

is inserted into a French needle as if it were
a regular suture, and the needle is inserted
into the eyelid skin and brought out at the
tarsus border at the site where the eyelashes
emerge. The root slides into place through
the hole created by the needle.
342 Part III  ▪  Special Problems

Alternatively, the hair thread graft can

be inserted into the lid using a bent
21-gauge needle.

The thread is cut to the length of an eyelash. It is not necessary to use any
dressing.17 We avoid grafting eyelashes in the inferior eyelid because it is rarely
required, and there is more likelihood that trichiasis will develop, with the hair
growing back toward the eye and scraping the cornea or conjunctiva.

Postoperative Care
To avoid dislodging the grafts by scratching, patients are required to wear goggles
while sleeping during the first night postoperatively. Ice packs are also recom-
mended to prevent edema. A light layer of ophthalmic ointment or gel is recom-
mended until the scabs fall off. Pain is managed with mild analgesics.

Postoperative Hair Growth

Eyebrow grafts have been found to have a survival rate of 90% to 100%.18 Eyelash
grafts, on the other hand, probably because they are manipulated more, have a
50% breakdown. Therefore we recommend grafting double the amount of wanted

Transplanted hairs frequently continue

to grow immediately after surgery. This
patient demonstrates an inflammatory
reaction 8 months after eyelash recon-
Chapter 15  ▪  Reconstruction of Eyebrows and Eyelashes 343

Patients should trim their brows and lashes approximately every 2 weeks, since
they continue to grow steadily as if they were strands of hair. Contrary to being
viewed as a nuisance by patients, they actually describe the ritual of clipping their
eyebrows as satisfying. After 3 or 4 months the eyelash hair will grow and must be
trimmed. The new lashes should be bent with an eyelash curler, and eventually
cold waving (a form of permanent wave using rods) is recommended.

We discuss with patients seeking eyelash reconstruction that for an individual

with real eyelash defects, such care does not become a burdensome task. However,
for a person who has normal eyelashes and wants to enhance his or her looks,
trimming the hairs at intervals and curling the lashes every day and eventually
waving becomes boring, and the patient may regret having sought the surgery.

Case Examples
Marcelo Gandelman

This 16-year-old girl was in a car accident and sustained injury to her left eyelid.
Reconstructive surgery of her left eyelid was performed immediately after the

A year after her accident, hair transplantation was performed on her left eyebrow
and left eyelashes. She is shown 1 year after reconstruction.
344 Part III  ▪  Special Problems

Repeated overplucking damaged the eyebrow hair follicles of this 57-year-old

woman. She is shown preoperatively and 1 year after eyebrow reconstruction.

This 26-year-old man presented with eyebrow aplasia. He is shown preoperatively

and 18 months after eyebrow reconstruction.
Chapter 15  ▪  Reconstruction of Eyebrows and Eyelashes 345

Case Example
Carlos Oscar Uebel

This 24-year-old woman presented with a very common brow deformity. She is
shown preoperatively and 16 months after one FU replacement.

We want to thank Marc Pomerantz, MD, for his review of this manuscript. His
comments have played an important role in improving our work.
346 Part III  ▪  Special Problems

1. Orentreich N. Autografts in alopecias and other selected dermatological conditions. Ann
NY Acad Sci 83:463-479, 1959.
1a. Krusius F. Ueber die Einplflanzung Lebender Haare zur Wimpernbildung. Dtsch Med Wock-
enschr 19:958, 1914.
2. Knapp P. Plastischer Ersatz von Wimpern. Klin Mbl Augenheilk 59:447, 1917.
3. Sasagawa M. Hair transplantation. Jpn J Dermatol 30:493, 1930.
4. Fujita K. Reconstruction of eyebrows. La Lepro 22:364, 1953.
5. Sung YA. We salute you, Mr. Paek. Hair Transplant Forum Int 10:92, 2000.
6. Ng B. How to place 1500 grafts per hour using Choi implanters [quoting Dae-young Kim].
Hair Transplant Forum Int 20:92, 2010.
7. Marritt E. Single-hair transplantation for hairline refinement: a practical solution. J Dermatol
Surg Oncol 10:962, 1984.
8. Gunter JP, Antrobus SD. Aesthetic analysis of the eyebrows. Plast Reconstr Surg 99:1808,
9. Gandelman M. Eyebrow and eyelash transplantation. In Unger W, ed. Hair Transplantation,
ed 3. New York: Marcel Dekker 1995.
10. Gandelman M. Eyelash reconstruction. Hair Transplant Forum Int 6:18, 1996.
11. Pomerantz M. Personal communication, 2011.
12. Parsley W. Personal communication, 2000.
13. Limmer BL. Elliptical donor stereoscopically assisted micrografting as an approach to further
refinement in hair transplantation. J Dermatol Surg Oncol 20:789, 1994.
14. Gandelman M. Eyebrow transplantation. In Norwood O. Hair Transplant Video Forum, vol
VII, 1993.
15. Uebel CO. Improvement of the frontal hairline with the angular flap and micrografts. Transac-
tions of the International Advanced Hair Replacement Symposium of the American Acad-
emy of Facial Plastic and Reconstructive Surgery (AAFPRS), Birmingham, AL, 1982.
16. Gandelman M, Abrahamsohn P. Light and electron microscopic analysis of controlled injury
to follicular unit grafts. Dermatol Surg 26:25, 2000.
17. Barrera A. Slit and insert technique. In Barrera A, ed. Hair Transplantation. St Louis: Quality
Medical Publishing, 2002.
18. Gandelman M, Epstein JS. Hair transplantation to the eyebrow, eyelashes, and other parts
of the body. Facial Plast Surgery Clin North Am 12:253, 2004.
C H A P T E R 16

Correction of
H air Loss in the
Crown A rea

Clerisvaldo Almeida Souza

348 Part III  ▪  Special Problems

T he crown of the head is the region between the occipital and parietal bones
and generally has a round or oval shape.

The anterior part of the crown, or vertex, is the highest point of the cranial vault.
Depending on genetic traits, this may be the only area with baldness, or the hair
loss may extend to the anterior region of the scalp.

Many patients seek help from their surgeon to restore this area, which is usually
not an aesthetic priority, because it may deplete the donor area without obtain-
ing adequate coverage, depending on the patient’s Norwood VI and VII clas-
sification. The correct indication for transplantation of the crown depends on
the quantity and quality of hair between the donor and recipient areas. In cases
of advanced alopecia, there will not be sufficient follicular reserves to transplant
the crown.
Chapter 16  ▪  Correction of Hair Loss in the Crown Area 349

The hair transplant surgeon must be cautious in patient selection, with consid-
eration of how advanced balding of the crown is and the patient’s age (minimum
30 years), and have conservative expectations as to what density can be accom-
plished. The surgeon must think long-term when transplanting this area, because
male pattern baldness advances continuously. All of this must be discussed thor-
oughly with the candidate in the first consultation.

Three basic techniques have been proposed to treat crown baldness:

• Scalp reduction (decreasing the area that needs hair transplantation)
• Tissue expansion of the donor area and advancing the scalp cephalically
(these techniques often result in unsightly scars)
• Follicular unit hair transplantation

In this chapter we will discuss only follicular unit hair transplantation to treat
balding of the vertex, because this method is, for most patients, the preferred
technique for obtaining optimal results.

A young, less-experienced surgeon must be especially cautious when treating

the crown region. This area is notoriously challenging, because it is difficult to
achieve optimal density here, and extensive replantation may cause depletion of
the donor site, resulting in patient disappointment at a later stage.

Preoperative Planning
The following points must be clearly presented to the patient. On the vertex,
“see through” (visible thinning) becomes evident after only 10% of hair density
is lost, whereas on the anterior scalp, thinning does not become evident until the
patient has lost more than 50% of the area’s hair. This results from the natural
characteristics of these areas, especially in the crown, which has a unique contour
and direction of hair growth. This makes thinning more evident on the crown
than in the front of the scalp.

The initial discussion with the candidate must focus on the fact that male pat-
tern baldness is continuous, so a young patient with a circumscribed bald area of
the crown must be aware that eventually this will evolve into a more extensive
area. If the crown is treated early but without proper long-range planning, the
patient may wind up with an island of hair at the vertex that has a halo of bald-
ness around it, a distressing and difficult problem to correct.
350 Part III  ▪  Special Problems

Furthermore, in the crown the hair normally grows in a perpendicular direction

(up and down), which is more revealing than on the anterior scalp, where the hair
grows from side to side, like shutters, and provides more coverage. For patients
who have light skin and dark hair, there is a significant contrast that highlights
the thinning areas. This can be dismaying for the patient, especially when he is
under bright lights and/or when flash photography is used.

The surgeon reviews with the patient the various techniques that have histori-
cally been used, along with the advantages and disadvantages of each procedure,
and describes the expected outcome for each approach to the crown.

Physiologic and Aesthetic Considerations

Obtaining a family history of hair loss is essential; this can be very revealing and
is necessary for appropriate planning. Young men with early crown baldness must
be treated with extreme caution. Clinical studies have established that finasteride
and minoxidil can be helpful in younger patients to add preventive care to the
patient’s long-term hair restoration plan.

Dermatoscopy shows that the hair on the crown grows in different directions,
such as anteriorly to the right (left), or posteriorly in a whorl (right), in the zone
of hair divergence. Each patient has a unique whorl spiral pattern (sometimes
called a “cowlick”). The whorl may be on the right or the left, in the center, or
there may be more than one. When transplanting FUs in the crown, the patient’s
individual whorl spiral pattern should be repeated for a natural result.
Chapter 16  ▪  Correction of Hair Loss in the Crown Area 351

As baldness develops, hair thins and the whorl becomes miniaturized. It is impor-
tant to respect these features when transplanting FUs and mimic the direction
of the original hairs. In 2003, Ziering and Krenitsky1 proposed a classification of
five types of whorls.

To obtain a good result in all surgeries, care begins at the time of the initial con-
sultation. The patient must be emotionally stable and have realistic expectations
to avoid disappointment.

The degree of importance of the vertex area to the patient must be carefully
evaluated as well as his psychological stability. It is essential to consider the cov-
erage that may be needed in the future in the frontal area of the scalp, especially
in patients younger than 40.

The surgeon must feel confident that the pattern of hair loss is stable before
grafting the crown area. The type of hair is also an important consideration; for
example, in patients with fine, straight hair, hair transplantation will not create
as much aesthetic improvement as in patients with coarser hair, especially under
bright lights, and there is very little chance of achieving the desired density in
the crown.
352 Part III  ▪  Special Problems

Surgical Technique
Depending on the patient’s donor site hair density, we consider three different
surgical strategies to obtain a good result with specific areas. The patient is po-
sitioned so that both the patient and the surgeon are comfortable during the

For patients with moderately good donor site density, the strategy is to apply grafts
at the whorl area. Hair is transplanted to the entire vertex with high density in
specific zones. The graft insertion is started on the center of the whorl, and greater
hair density is implanted in this area (right).

For patients with limited donor site density,

the strategy is to apply grafts in greater density
to the upper or cephaladmost area of the ver-
tex, allowing the growing hair to help cover
the scalp inferiorly or caudally. Graft insertion
is started in this upper region.
Chapter 16  ▪  Correction of Hair Loss in the Crown Area 353

For patients who have excellent donor site density, we apply grafts uniformly to
the entire area.

This man presented with excellent donor site density. Long hair was transplanted
to his crown in a uniform fashion. He is shown before surgery, immediately after
and 2 years after surgery.
354 Part III  ▪  Special Problems

It is very important to evaluate both the dimensions of the area to be grafted and
the amount and density of the donor area. By placing a transparent sheet of plastic
over the balding vertex area, one can outline and demarcate the surface in square
centimeters, which allows precise measurement of the area to be treated. With the
help of a densitometer we evaluate the donor site (occipital, intermediate, and
temporal regions), estimate the quantity of FUs needed to cover the crown, and
calculate the number of follicles and the number of hairs per follicular unit that
are available for transplantation. The density in the donor site varies, depending
on the patient’s sex and type of alopecia.
Chapter 16  ▪  Correction of Hair Loss in the Crown Area 355

Normally we place about 80 follicular sites per square centimeter in the vertex.
These follicles commonly have two or three hairs each, as shown here on densi-
tometry, and as the baldness progresses, they undergo miniaturization.

In advanced alopecia, these follicular sites are empty and have villous hairs. Hav-
ing made this observation, we need to use these sites (villous hair follicles) as the
recipient sites for two- or three-hair FU grafts. We then evaluate the elasticity of
the occipital region to see whether the size of the strip available is feasible, based
on the area of need (the crown).
356 Part III  ▪  Special Problems

Then our trained assistants use stereomagnification to dissect the two- or three-
hair FU grafts.

We can add pigment to assist with visual-

izing the follicular sites. When comparing
a pigmented scalp with a nonpigmented
scalp, it is remarkable how the follicular
sites are defined.
Chapter 16  ▪  Correction of Hair Loss in the Crown Area 357

The grafts are inserted into follicular sites with needles, which cause less trauma
on the recipient sites. The grafts are placed following the direction, orientation,
angulation, and depth of the native hairs on the crown, if they still exist, or oth-
erwise mimicking nature as best as possible. The goal is to restore the original
whorl or whorls and to cause minimal scarring and fibrosis.
358 Part III  ▪  Special Problems

For a patient with two whorls, greater graft density is needed, especially if he
wants to wear short hair. These patients must be willing to accept an end result
with lower density and must have sufficiently high donor site density. In the area
of the whorl, ideally we need 50 to 70 FUs per square centimeter, again following
the direction of the whorl from left, right, and center in the whorl, avoiding any
residual healthy hairs, and placing 25 to 35 FUs per square centimeter in areas
below this.

In general, patients with thick hair can be treated in a single session, and patients
with finer, thinner hair will require two sessions, assuming they have sufficient
donor hair density. We strive for a natural result even if only one session is done.
In large areas of alopecia, combing the hair back helps to get the hair to overlap
(layer on itself) and provides better coverage.

Concluding Thoughts
For a young patient with reduced hair density on the crown, we recommend the
use of a clinical adjuvant treatment (topical and/or oral) until the frontal scalp
is satisfactorily transplanted and restored. In a middle-aged or older patient with
an established pattern involving only the crown, we carefully select each case,
analyzing the donor area and projecting a long-range treatment plan so that we
may proceed without creating sequelae that will be difficult to correct. On a young
patient, the surgeon must be cautious and focus the grafting first on the front
scalp, then the midscalp, and employ medical treatment for the crown especially,
since the effectiveness of these preparations is best there.

Proper planning is indispensable. Scalp reduction, tissue expansion and scalp

advancement, and flap rotation should be reserved for special select cases. Today
FU hair transplantation with minimally traumatic insertion, which causes less
scarring and fibrosis, using a technique that mimicks the direction, depth, density,
and natural pattern of the hair, with closer proximity of graft placements, provides
the optimal result.
Chapter 16  ▪  Correction of Hair Loss in the Crown Area 359

Case Examples

This man presented for restoration of hair to his crown. He had thick hair. Hair
was transplanted to his crown in a single session. He is shown preoperatively and
postoperatively with a natural result.
360 Part III  ▪  Special Problems

This man had a large area of alopecia and had FUs transplanted to his crown.
A single session was required to complete the transplantation on the front, and
two sessions were required to transplant the vertex area. The hair transplantation
density of the crown should not sacrifice the hair transplantation of the anterior
area, which is aesthetically more important. He is shown preoperatively and
postoperatively with his hair combed back, which gives an added appearance of
density on the vertex.
Chapter 16  ▪  Correction of Hair Loss in the Crown Area 361

This African-American man presented for hair transplantation to his crown.

Curly hair, thick in diameter, results in a better effect in restoration of the crown.
Depending on the type of hair, it is possible to complete the transplantation with
high density in two sessions in both the frontal and occipital areas. He is shown
preoperatively and postoperatively.
362 Part III  ▪  Special Problems

Preoperative After first session to frontal area After second session restoring vertex whorl

This man had hair transplanted to his crown in two sessions. He is shown pre-
operatively, postoperatively after one session focusing on the frontal area, and
after the second session, which restored the natural whorl pattern in the vertex.

1. Ziering C, Krenitsky G. The Ziering whorl classification of scalp. Dermatol Surg 29:817, 2003.
2. Nordstrom REA. Transplante de cabelo: técnicas personales. In Coiffman E, ed. Cirurgia
Plástica, Reconstructiva y Estética, ed 2. Barcelona: Ediciones Científicas y Técnicas, 1994.
3. Panfilov DE. Aesthetic Surgery of the Facial Mosaic. New York: Springer, 2007.
4. Romo T, Millman AL. Aesthetic Facial Plastic Surgery: A Multidisciplinary Approach. New
York: Thieme, 2000.
5. Seager D. Dense hair transplantation from sparse donor area—introducing the “follicular
family unit.” Hair Transplant Forum Int 8:21-22, 1998.
6. Shapiro R. Placing grafts: an overview of basic principles and current controversies. In Unger
WP, Shapiro R, eds. Hair Transplantation, ed 4. New York: Marcel Dekker, 2004.
7. Stough D. The consultation. In Haber RS, Stough DB, eds. Hair Transplantation: Procedures
in Cosmetic Dermatology. Philadelphia: Elsevier Saunders, 2006.
8. Stough DB, Haber RS. Hair Replacement: Surgical and Medical. St Louis: Elsevier Mosby,
9. Uebel CO. Hair Restoration Micrografts & Flaps. São Paulo: OESP Gráfica S/A, 2001.
10. Unger MG. Alopecia reduction. In Unger WP, Shapiro R, eds. Hair Transplantation, ed 4.
New York: Marcel Dekker, 2004.
11. Unger WP, Shapiro R, Unger R, Unger M. Hair Transplantation, ed 5. New York: Informa
Healthcare, 2011.
C H A P T E R 17

Transgender Patients:
F eminization of the
F rontal H airline

Alfonso Barrera
364 Part III  ▪  Special Problems

 their natural
ale to female transgender patients often want to modify the masculinity of
hairline, a problem that may be exacerbated by the progression of
male pattern baldness. Follicular unit hair transplantation with a feminine hair-
line design allows a more complete aesthetic reconstruction for these patients.

Based on current principles and techniques in hair transplantation, and assuming

the patient has a sufficient amount of donor hair (occipital and temporal area
density related to the size of the area to be grafted), we can predictably restore
missing hair and create a feminine hairline. The technique is basically the same
as for routine male hair transplantation; the difference is providing a feminine
design for the front hairline.

There are several important details to consider for an aesthetically pleasing and
natural hairline in male and female patients. These include:
• Hairline shape, level, and design
• Irregularity and some degree of asymmetry of the hairline contour
• Direction of the hair growth
• Absence of detectable scarring

For a male transgender patient who wishes to have a feminine hairline, we must
try to create this by minimizing the frontotemporal recessions; a slight widow’s
peak is generally aesthetically pleasing as well.

In my opinion, no magic number exists as to the ideal distance from the eyebrows
up to the anterior hairline, since head size and craniofacial proportions vary
from patient to patient. An artistic approach must be used in each individual to
determine the appropriate hairline level, ranging from 5 to 8 cm above the brow.

The ideal female hairline should be roughly a third of the facial length, with mini-
mal to no frontotemporal recession and a minimal temporal peak. Similarly, on
a male patient the hairline should be about a third of the facial length, although
slightly longer is fine. However, a mild to moderate degree of frontotemporal
recession must be included, and ideally a mild to moderate temporal peak.

The goal is to provide a “no-line” hairline; that is, no regimented lines or rows,
with irregularity of the front hairline, providing a natural transition. The surgeon
must consistently follow the natural direction of hair growth (controlled by the
blade inclination as we make the slits). Visible scarring must be avoided. This can
be accomplished by making the recipient slits with very small blades or needles.
I prefer to use the 22.5- and 15-degree Sharpoint blades—the 15-degree blade
for the very front boundary of the hairline and working posterior to that with the
22.5-degree blade.

Postoperatively, patient care is exactly the same as for a patient treated for male
pattern baldness.
Chapter 17  ▪  Transgender Patients: Feminization of the Frontal Hairline 365

Basically the same technique of hair transplantation described in Chapter 6 is
used to feminize the frontal hairline; the only difference is the design of the

This 46-year-old transgender patient sought

feminization of the hairline. The proposed
hairline design is shown. The patient is shown
at the end of surgery, after 2333 grafts were
placed in the front and on the right and left
366 Part III  ▪  Special Problems

The patient is shown preoperatively and 1 year after a second session with a total
of 3900 grafts to the right and left sides.

From Vogel JE, Jiménez F, Cole J, et al. Hair restoration: state of the art. Aesth Surg J 33:128-151, 2013.

Note the feminizing changes to the frontotemporal recessions and temporal peak.
Chapter 17  ▪  Transgender Patients: Feminization of the Frontal Hairline 367

Concluding Thoughts
As with any other aesthetic surgical procedure, for feminizing the hairline we
must select our patients carefully and make certain that they have realistic ex-
pectations. We will never be able to restore the hair density the patient had at
a younger age. We cannot make new hair; we can only redistribute the patient’s
existing hair in a more strategic way to achieve a more feminine appearance.

Feminizing the hairline requires single-hair and some two-hair grafts at the an-
terior 1 cm of the hairline, following the direction of hair growth. The surgeon
attempts to create a no-line hairline with an irregular design, placed at the right
level, minimizing the frontotemporal recessions on males. This will greatly im-
prove the naturalness of the results. As discussed in Chapter 16, long-range plan-
ning is essential to ensure that sufficient donor sites remain for any follow-up
restoration procedures in the future.

The most difficult part is achieving sufficient density. With experience we are
able to pack grafts closer to each other, resulting in improved density in a single
session. A second session can certainly further improve the result. In selected
cases a third session may be required to further enhance the density.

FU hair transplantation in patients with sufficient donor hair can predictably

produce results that are natural and aesthetically pleasing both on males and fe-
males. It is an effective way of feminizing the hairline in the transgender patient.

1. Uebel CO. Micrografts and minigrafts: a new approach to baldness surgery. Ann Plast Surg
27:476, 1991.
2. Barrera A. Micrograft and minigraft megasession hair transplantation: review of 100 consecu-
tive cases. Aesthet Surg J 17:165, 1997.
3. Barrera A. Micrograft and minigraft megasession hair transplantation results after a single
session. Plast Reconstr Surg 100:1524, 1997.
4. Barrera A. Refinements in hair transplantation: micro and minigraft megasession. Perspect
Plast Surg 11:53, 1998.
5. Barrera A. Hair grafting tips and techniques. Perspect Plast Surg 15:147, 2001.
6. Barrera A. The use of micrografts and minigrafts in the aesthetic reconstruction of the face
and scalp. Plast Reconstr Surg 112:883, 2003.
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Pa rt IV

New Directions
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C H A P T E R 18

of P latelet-E nriched
Growth Factors

Platelet gel with

growth factors VEGF

Carlos Oscar Uebel,

Jorge Augusto Moojen da Silveira, Anajara Gazzalle
372 Part IV  ▪  New Directions

  correction of baldness with micrografts and minigrafts performed in
was first described in 1989 and 1991, and today it is a widely used
technique for treating both male and female pattern baldness. The procedure
transplants great quantities of follicular units harvested from the posterior oc-
cipital area of the scalp and places them in bald regions. These transplanted units
carry a good genetic histologic structure, providing the future hair with the same
quality of growth, durability, and characteristics as the donor area. Implanted
hair growth has an individual cycle. During the first 2 weeks of implantation,
the catagen phase occurs, marked by an inflammatory process in which redness
in the scalp and shedding of the hair shaft is common. The hair then enters the
telogen phase, which lasts between 3 and 4 months. This is followed by the la-
tency period, which precedes the third phase, anagen. In this phase, the future
hair begins to grow. During the resting period, substantial FU loss can occur be-
cause of apoptosis. Between 15% and 30% of the implanted grafts will either be
eliminated or absorbed by the scalp. Therefore only 70% to 85% of the implanted
hair will sprout.1

Autologous platelet-rich plasma (PRP) has been used in several experimental

and clinical studies because of its benefits in stimulating angiogenesis and cell
proliferation and improving healing. PRP has also attracted attention in plastic
surgery and dermatology because of its potential use during facial plastic surgery
for its aesthetic skin-rejuvenating effects, and in hair transplantation.2-10

The growth factors contained in platelets of blood plasma are basically three:
platelet-derived growth factor (PDGF), transforming growth factor (TGF), and
vascular endothelial growth factor (VEGF). These are protein molecules that,
in contact with their respective receptors, act in tissue angiogenesis, stimulating
the healing and growth of new organic structures.8,9 Li et al9 investigated the ef-
fects of PRP on human hair follicle growth in vitro and in vivo and explored the
possible mechanisms involved. Their report suggested that:
1. PRP induces the proliferation of dermal papilla (DP) cells.
2. PRP increases Bcl-2 protein levels, expression of which during the hair
cycle suggests that DP cells may normally be protected from apoptosis.
3. PRP increases cell growth and prolongs the survival of hair follicles by
activating ERK and Akt signaling, respectively.
4. PRP may prolong the anagen phase of the hair cycle and stimulate hair
growth through the marked increase in the expression of FGF-7 in DP
Chapter 18  ▪  Benefits of Platelet-Enriched Growth Factors 373

The final result reported by the authors is that PRP increased hair growth and
hair follicle survival of mice because of its promotion of cell proliferation and its
antiapoptotic properties.

Growth factors act in the bulge area, where stem cells are found, and they interact
with cells of the matrix, thus activating the proliferative phase of the hair. Stem
cells are more primitive and of ectodermal origin. They give origin to epidermal
cells and sebaceous glands. Germinative cells of the matrix, which are found at
the dermal papilla, are of mesenchymal origin. Both cells needs each other, and
when they get together through the action of various growth factors (PDGF,
TGF-b, and VEGF), they give rise to the future FU, which consists of the hair
shaft, sebaceous glands, erector pili muscle, and the perifolliculum. Headington11
described this histologic unit in 1984. It is the complete and developed follicular
structure in the anagen hair cycle phase, which lasts from 3 to 6 years in the hu-
man scalp.

The action of growth factors on the germinative hair cycle has already been stud-
ied in both its embryologic and adult phases; however, it has not yet been studied
in hair micrograft implantation surgery.8

Considering this important hair loss fact, we developed a clinical trial using
platelet-rich plasma growth factors obtained from the patient’s own plasma. This
experimental research was submitted to and approved by the Ethics Committee
of the Pontifícia Universidade Católica do Rio Grande do Sul in Brazil, Division
of Plastic Surgery (see p. 375).

Platelet Growth Factors and Hair Stem Cells

The first articles on growth factors derived from plasma were published in the
1970s and 1980s, describing their application for tissue repair and hemostasis
during the healing process of ulcers and undermined wound surfaces. More re-
cent works in orthopedics and odontology demonstrated the role of such factors
in bone graft recomposition and in the osteosynthesis of teeth. Man et al12 in
2001 and Bhanot and Alex13 in 2002 reported new applications of platelet-rich
plasma in the wound sites of cosmetic procedures. The action of growth factors on
the germinative hair cycle has already been studied in both its embryologic and
adult phases; however, it has not yet been studied in hair micrograft implantation
surgery. No clinical trial or experimental protocol had previously been performed
to verify the efficacy of those factors in the growth and density of implanted FUs.
374 Part IV  ▪  New Directions



Subcutaneous tissue

Galea aponeurotica


3 weeks EARLY
3-4 months
Platelet gel with
growth factors VEGF


Bulge with Sebaceous

stem cells gland

Matricial cell


Follicular units are shown being implanted, as well as the associated platelet
plasma growth factors in the dystrophic shading phase and the new proliferative
phase, with an intense vascular endoneogenesis supporting the new hair devel-
opment to the anagen phase. There is an intense growth factor migration into
the stem cells in the bulge area. These growth factors interact in the bulge area
with cells of the matrix, thus activating the proliferative phase of the hair. The
hair follicle cycle reflects the meeting of matricial cells from the papilla and the
stem cells in the bulge area, starting the growing phase of the new hair follicle.
Chapter 18  ▪  Benefits of Platelet-Enriched Growth Factors 375

Experimental Model
Twenty male patients aged 22 to 54 years with male pattern baldness in the fron-
tal, parietal, or occipital area were selected for this surgical and clinical trial. Two
symmetrical 2.5 cm2 bald areas were delineated. On the right side of the patient’s
head, FUs imbibed with platelet plasma growth factors were implanted; on the
left side, standard FUs were implanted as a control. In all patients, both areas were
implanted with an equal number of micrografts. All patients were duly informed
about the clinical trial and signed informed consent documents.

This patient is shown preoperatively with two identical areas of 2.5 cm delin-
eated in the bald area. On the right side of the patient’s head, FUs imbibed with
platelet plasma growth factors were implanted. On the left side, standard FUs
were implanted as a control. He is shown 7 months after implantation, with
improved hair growth on the right side.
376 Part IV  ▪  New Directions

Surgical Technique
Harvesting of Follicular Units

In all cases, a hair-bearing ellipse flap was taken from the occipital area of the
scalp above the neck, where the best histologic and genetic quality of hair is pres-
ent. The flap size varied according to the amount of FUs needed. For medium-type
baldness, an ellipse was obtained, usually 15 cm long by 2 cm wide, from which
1200 FUs could be obtained. The units were implanted by the “stick and place”
punctiform technique.

The donor area was closed without tension, using an intradermal or continuous
suture, to enable a secondary harvesting of grafts 3 to 4 years later if needed. Two
groups of 180 FUs were harvested and prepared: one group was imbibed with
platelet plasma growth factors and the other was kept wet with saline solution
on an acrylic surface.
Chapter 18  ▪  Benefits of Platelet-Enriched Growth Factors 377

Obtaining the Platelet Plasma Growth Factors

Before surgery, 80 ml of blood was withdrawn from the patient in eight vacuum
flasks, with each one containing 1 ml of anticoagulant, 3.2% trisodium citrate
(Vacuette; Greiner Bio-One, Kremsmuenster, Austria). The eight flasks were cen-
trifuged at 1000 rpm for 10 minutes. This slow speed is important so that platelets
are not displaced to the bottom of the flasks. The plasma was then dispensed
into four new flasks for a second centrifugation at 5000 rpm for 10 minutes. The
floating platelet-poor plasma was discharged, leaving only 2 ml of concentrate
in the bottom of the flask. The platelet-rich plasma had four to six times more
platelets than normal plasma and therefore contained a high concentration of
growth factors.

This concentrate was then added to the FUs before implantation. The FUs were
kept in the platelet growth factor solution for 15 minutes to allow the growth
factors to attach to the stem cells located in the bulge area of each FU.
378 Part IV  ▪  New Directions

After 15 minutes of imbibition, 10 drops of 10% calcium chloride was added to

the mixture to convert fibrinogen into fibrin, thereby producing the plasmatic
gel that would seal the growth factors around the micrografts. The FUs were then
ready to be implanted.
Chapter 18  ▪  Benefits of Platelet-Enriched Growth Factors 379

Implanting the Follicular Units

The entire bald area on the scalp was massively infiltrated with saline solution
containing epinephrine 1:120,000. This tumescent technique, or scalp balloon-
ing, with the vasoconstriction obtained with the epinephrine injection, helps to
limit bleeding and facilitates implantation of the micrografts.

The units were implanted by the stick and place punctiform technique. In the
outlined area to the right, the units imbibed in platelet-rich plasma growth factors
were implanted; to the left, the standard FUs considered controls were placed.
The same number of grafts was implanted on both sides, thus allowing greater
control for the clinical trial.

For this procedure, Beaver microblades, lance tip angled 15-degree blades, and
jeweler-type microforceps were used. After the two demarcated areas were im-
planted, the remaining bald area was implanted using standard FUs. Moist gauze
was applied to the implanted area and secured by an elastic bandage that was
kept in place for 24 hours. After that time, the patient removed the bandage and
washed the entire implanted area with an antiseptic, neutral shampoo.
380 Part IV  ▪  New Directions

Endpoint Evaluation
All patients were evaluated monthly for 7 months, and the yield of FUs was
counted in the outlined areas. An accurate inspection, counting the number of
FUs within the two areas, was performed by staining four india ink spots. The
surgeon performed the final count at the end of 7 months with a magnifying glass;
the hairs were recounted by two assistants for confirmation.

This 38-year-old man had 150 FUs implanted. At 7 months postoperatively, 114
were counted on the right and 95 on the left, an improvement of 20% for the
platelet plasma growth factor−imbibed side.
Chapter 18  ▪  Benefits of Platelet-Enriched Growth Factors 381

Statistical Analysis
The data were summarized using mean standard deviation. The paired t test was
used to compare the platelet-rich plasma growth factor protocol and the control
group, because data showed a gaussian distribution. Analyses were performed us-
ing SPSS version 12.0 (SPSS, Chicago). The significance level was set at 0.05.
The data are shown in the table.

Statistical Analysis of Clinical Trial Using Platelet-Rich Growth Factor

Yield of FUs per 2.5 cm2 Platelets
Baldness FUs per
Age (yr) Region 2.5 cm2 Control Experimental Normal Plasma Rich Plasma

35 F 138 117 135 224.000 460.000

45 F 170 129 134 185.000 417.000
49 F 155 92 107 234.000 614.000
39 F 164 92 119 268.000 658.000
31 F 128 72 94 227.000 640.000
50 F 170 121 139 187.000 390.000
29 F 160 102 117 183.000 380.000
36 F 150 95 114 180.000 420.000
32 F 145 99 108 217.000 390.000
48 F 153 94 143 144.000 536.000
36 O 110 86 99 224.000 460.000
32 F 137 92 95 184.000 391.000
48 F, P, O 150 108 121 195.000 600.000
54 F, P, O 137 123 135 150.000 420.000
23 F 121 97 101 311.000 343.000
22 F 125 101 116 270.000 1.202.000
42 O 135 103 107 165.000 656.000
29 F 137 108 127 248.000 1.076.000
38 F 130 108 119 140.000 321.000
39 F, P 125 105 110 200.000 191.000
38 6 9 — 142 6 17 102 6 14 117 6 15 206.800 6 44.942 528.250 6 243.586
Data are summarized as mean 6 standard deviation.
F, Frontal; O, occipital; P, parietal.
382 Part IV  ▪  New Directions

Experimental Results


Follicular units per cm2



Implanted FUs
5 Yield experimental FUs
Yield Control FUs
0 4 8 12 16 20

Group Yield FUs/cm2 Effect/cm2 95% CI p (student t)

Implanted 22.7 ­— — —
Experimental 18.7 6 2.4 2.4 1.6 to 3.1 ,0.001
Control 16.4 6 2.2 — — —

There was a statistically significant difference observed in the yield of FUs when
the two groups were compared (p ,0.001). The experimental group with the
platelet-rich plasma growth factor showed a density of 18.7 FUs per cm2, whereas
the control group showed 16.4 FUs per cm2. The difference of 2.4 FUs per cm2
(95% confidence interval; 1.6 to 3.1 FUs per cm2 ) represented a 15.1% increase
in the yield of FU density between the two groups.

This means that if there is a 100 cm2 (10 by 10 cm) bald area to be implanted,
one can obtain 240 FUs more, or approximately 480 hair shafts, assuming two
shafts per FU. It is important to note that some patients had only a 3% increase
using the platelet-rich plasma growth factor protocol, whereas others had a 52%
increase in FU density.

The use of digital imaging is an important comparative tool for assessing density.
For one patient, a digital camera (5.0 megapixel, 24-bit color) was used at a fixed
distance from the scalp. Photographs in this study were recorded in raw format.
Image-Pro Plus 4.5 image analysis software (Media Cybernetics, Rockville, MD)
was used to perform morphometric analysis and to derive objective measures of
the hair color density from the marked areas on the right and left sides. A color
threshold level was selected interactively by an experienced observer and applied
on both images from each patient. The scale used was 40 pixels/cm. The area
covered by hair was divided by the total area measured on every image.
Chapter 18  ▪  Benefits of Platelet-Enriched Growth Factors 383

This 32-year-old man is shown preoperatively with the areas of transplantation

marked. He had 125 FUs implanted on each side. Seven months postoperatively,
117 FUs were counted on the right side and 93 FUs were counted on the left. This
demonstrates 28% more density on the right side. By counting the FUs with a
magnifying glass, an increase of 26% more hair was noted in the area implanted
with platelet-rich plasma growth factors. Software image analysis demonstrated
a similar density of 28% on the right side. This indicates that both systems are
practically the same and that the digital program could perhaps be improved in
future studies.
384 Part IV  ▪  New Directions

Case Examples
Carlos Oscar Uebel

This 78-year-old woman had female pattern baldness and was treated with FU
grafts and platelet growth factors. She is shown 14 months postoperatively.
Chapter 18  ▪  Benefits of Platelet-Enriched Growth Factors 385

This 68-year-old man with very thin hair was treated with platelet-rich growth
factors. Postoperatively he exhibits a fuller head of hair.
386 Part IV  ▪  New Directions

This 36-year-old man had poor hair growth after one hair replacement procedure.
He is shown 1 year after a second micrografting procedure with platelet-rich
growth factors. There is approximately a 55% increase in hair follicles.
Chapter 18  ▪  Benefits of Platelet-Enriched Growth Factors 387

This 75-year-old man had low density and a very thin donor area. He was treated
with PRP and is shown 18 months postoperatively.
388 Part IV  ▪  New Directions

This 76-year-old woman had very thin hair. She was treated with platelet-rich
growth factor FU grafts and is shown 1 year postoperatively.

Concluding Thoughts
In our clinical trial of 20 patients with male pattern baldness, there was 15.1%
more hair yield in FUs and density in the areas treated by platelet-rich plasma
growth factors. This new development for hair transplant surgery demonstrates
that the use of autologous platelet growth factors can improve capillary density
with low cost and low morbidity, using a simple technique—a significant improve-
ment over conventional techniques. Especially for patients with less density and
very thin hair in the donor area, this technique should be a great contribution.
Although these results are significant, further research, such as a double-blind
test, should be performed to evaluate the final results with outside assistance in
asymmetrical areas. This offers a new perspective in hair transplantation and is an
important contribution to implantation surgery with follicular unit megasessions.

1. Uebel CO. Micrograft and minigraft megasessions in hair transplantation: current techniques
and future directions. In Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques,
ed 2. St Louis: Quality Medical Publishing, 2011.
2. Vendramin FS, Franco D, Franco TR. Método de obtenção do gel de plasma rico em plaquetas
autólogo. Rev Bras Cir Plást 24:212-218, 2009.
3. Graziani F, Ivanovski S, Cei S, et al. The in vitro effect of different PRP concentrations on
osteoblasts and fibroblasts. Clin Oral Implants Res 17:212-219, 2006.
4. Vendramin FS, Franco D, Franco TR. Utilização do plasma rico em plaquetas autólogo nas
cirurgias de enxertos cutâneos em feridas crônicas. Rev Bras Cir Plást 25:589-594, 2010.
Chapter 18  ▪  Benefits of Platelet-Enriched Growth Factors 389

5. Vendramin FS, Franco D, Schamall RF, et al. Utilização do plasma rico em plaquetas (PRP)
autólogo em enxertos cutâneos em coelhos. Rev Bras Cir Plást 25:4-10, 2010.
6. Almeida AR, Menezes JA, Araújo GK, et al. Utilização de plasma rico em plaquetas, plasma
pobre em plaquetas e enxerto de gordura em ritidoplastias: análise de casos clínicos. Rev Bras
Cir Plást 23:82-88, 2008.
7. Takikawa M, Nakamura S, Nakamura S, et al. Enhanced effect of platelet-rich plasma con-
taining a new carrier on hair growth. Dermatol Surg 37:1721-1729, 2011.
8. Uebel CO, da Silva JB, Cantarelli D, et al. The role of platelet plasma growth factors in male
pattern baldness surgery. Plast Reconstr Surg 118:1458-1466; discussion 1467, 2006.
9. Li ZJ, Choi HI, Choi DK, et al. Autologous platelet-rich plasma: a potential therapeutic tool
for promoting hair growth. Dermatol Surg 38(7 Pt 1):1040-1046, 2012.
10. Sohn KC, Shi G, Jang S, et al. Pitx2, a beta-catenin-regulated transcription factor, regulates
the differentiation of outer root sheath cells cultured in vitro. J Dermatol Sci 54:6-11, 2009.
11. Headington JT. Transverse microscopic anatomy of the human scalp. A basis for a morpho-
metric approach to disorders of the hair follicle. Arch Dermatol 120:449-456, 1948.
12. Man D, Plosker H, Winland-Brown JE. The use of autologous platelet-rich plasma (platelet
gel) and autologous platelet-poor plasma (fibrin glue) in cosmetic surgery. Plast Reconstr Surg
107:229-297; discussion 238-239, 2001.
13. Bhanot S, Alex JC. Current applications of platelet gels in plastic surgery. Facial Plast Surg
18:27-33, 2002.
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C H A P T E R 19

Benefits of Autologous
C ellular Therapy

Joseph F. Greco
392 Part IV  ▪  New Directions

When a follicle has become miniaturized beyond recognition by the

naked eye, it still has the potential of retransformation and of generat-
ing large shafts.
—Ralf Paus1

T he initial use of autologous cellular therapy was in cardiac surgery by Ferrari et

al in 1987 as an autologous transfusion component after an open heart operation
to avoid homologous blood product transfusion.2 Since then the use of platelet
concentrates (PCs) and platelet-rich plasma (PRP) has expanded into various
specialties, including, but not limited to, orthopedic, cardiac, maxillofacial, cos-
metic, spine, podiatric, ophthalmologic, and general wound healing.

The first use of a PC in hair restoration surgery demonstrated an increased yield

when it was used as a graft storage medium. When bathed in activated PC, the
growth factors attach to the follicular stem cells in the bulge of the dissected
follicular unit, increasing the yield of newly transplanted follicles.3 Greco and
Brandt4 suggested expanding the use of PRP in hair restoration surgery to en-
hance donor site wound healing, decrease the incidence of infection, reduce do-
nor site scarring, increase donor scar tensile strength, and enhance recipient site
healing. After using PRP in all phases of a hair transplant procedure and injecting
PRP into the scalp of patients before hair transplantation, I noticed more mature
hair growth sooner than in patients who had not had PRP therapy. Although this
observation was anecdotal, a study was proposed to determine whether autologous
PRP components had any effect on nontransplanted miniaturized hair.5

Since 2004, growth factors have been used in various forms of autologous cellular
therapy (ACT) to treat patients with androgenic alopecia, alopecia areata, and
discoid lupus that was unresponsive to traditional therapy. What would the effect
be of traumatizing the scalp and then directly infusing concentrated amounts of
growth factors? Is it possible to “turn on” the epidermal stem cells in the bulge
region with growth factors? Can miniaturization be reversed in androgenetic
alopecia? Is it possible to turn on dormant follicular stem cells caused by inflam-
matory cytokines such as alopecia areata? What would be the overall effect of
the growth factors that had a negative effect on hair such as transforming growth
factor-beta (TGF-b) or epidermal growth factor (EGF) as well as the proinflam-
matory cytokines that cause hair loss when PRP or PC was used?
Chapter 19  ▪  Benefits of Autologous Cellular Therapy 393

Contraindications to the use of PRP are detailed in the following box.

Absolute Contraindications
• Platelet dysfunction syndrome
• Critical thrombocytopenia
• Hemodynamic instability
• Septicemia
• Local infection at the site of the procedure
Relative Contraindications
• Consistent use of NSAIDs within 48 hours of the procedure
• Corticosteroid injection at the treatment site within 1 month
• Systemic use of corticosteroids within 2 weeks of the procedure
• Tobacco use
• Recent fever or illness
• Cancer, especially hematopoietic or bone cancer
• Hemoglobin count ,10 g/dl
• Platelet count ,105/μl

The Importance of Platelets in Tissue

Platelets are cytoplasmic fragments that arise from the megakaryocytes located in
the bone marrow. They do not contain a nucleus and have a short lifespan of 7
to 14 days. Situated on each platelet membrane are holding reservoirs known as
dense granules and alpha granules. Inside of these granules are proteins or cytokines,
more commonly called growth factors. When a platelet is exposed to an activating
agent such as thrombin or collagen, it goes through a metamorphosis in which
it changes its shape from an oval to one that has multiple pseudopodia, or false
feet. During this phase it also releases the growth factors that are contained in its
dense and alpha granules.

When growth factors are released, they send out a chemotactic signal to specific
target cells that have receptors on their membranes. Once these transmembrane
receptors are bound to the growth factor, they will direct cell migration to the
site of injury, and mitogenesis or cell replication will occur. Depending on the type
of cell, various tissues, bone, and blood vessels will form to repair or regenerate
the area of injury.
394 Part IV  ▪  New Directions

Grease burn 24 days after two

before treatment treatments (CRP)

The healing and regeneration of wounds with growth factors is evident in this
man who sustained second degree grease burns on both hands. He had vascular
insufficiency in the forefinger of his right hand, and he had two topical treatments
with pure growth factors in plasma or cytokine-rich plasma (CRP). He is shown
before treatment and 24 days after two treatments.
Chapter 19  ▪  Benefits of Autologous Cellular Therapy 395

Not All PRP Is the Same: Platelet-Rich Plasma and Platelet

Over the years, manufacturers who developed platelet concentration systems
cited studies about why their systems and platelet levels were superior. This has
caused a great deal of confusion regarding autologous cellular therapy. Although
there are a vast number of studies regarding the use of cellular therapy in medical
applications, there are no true double-blind studies comparing all the systems on
the market.

There is a need to standardize the nomenclature, because not all cellular therapy
is the same; there is an art and science to the preparation of PRP and PC. For the
purposes of this discussion, I suggest that PRP is any platelet concentration of
at least 1,000,000 platelets/μl, as proposed by Marx.6 This suggests that the goal
of a PRP is to concentrate platelets three to five times over the baseline platelet
counts. Anything less than 1,000,000 platelets/μl would be considered platelet
concentrate (PC).

The Art and Science of Platelet-Rich Plasma

There are numerous methods of preparing platelet-rich plasma that include or
eliminate various cellular components.
• Platelet-rich plasma (PRP)
• Concentrated (PRPc)
• Platelet-poor plasma (PPP) with PRP
• Concentrated (PPPc) mixed with PRP
• Leukocyte-enriched PRP (LPRP)
• Leukocyte-reduced PRP
• Pure cytokines (growth factors) without platelets, leukocytes, or erythro-
cytes (CRP)
• Autologous lyophilized (freeze-dried) PRP
• Allogeneic lyophilized (freeze-dried) PRP
• Autologous and allogeneic lyophilized CRP
396 Part IV  ▪  New Directions

Erythrocytes (4%)


Platelets (92%)

The Harvest SmartPReP System (Harvest Technologies, Plymouth, MA) is an

example of a PRP system that requires double centrifugation and takes 14 minutes
to prepare. From 20 to 120 ml of blood volume, the system achieves a four to six
times baseline platelet concentration that includes leukocytes and requires bovine
thrombin/calcium chloride for platelet activation.
Chapter 19  ▪  Benefits of Autologous Cellular Therapy 397

The Components of PRP

Although growth factors and cytokines are most commonly associated with PRP,
there are other cellular components contained in platelet-rich plasma:
• Insulin growth factor (IGF)
• Vascular endothelial growth factor (VEGF)
• Platelet-derived growth factor-alpha and -beta (PDGF-ab)
• Transforming growth factor-alpha and -beta (TGF-ab)
• Platelet-derived angiogenesis factor (PDAF)
• Epidermal growth factor (EGF)
• Interleukin-8 (IL-8)
• Tumor necrosis factor-alpha (TNF-a)
• Connective tissue growth factor (CTGF)
• Granulocyte-macrophage colony−stimulating factor (GM-CSF)
• Keratinocyte growth factor (KGF)
• High concentration of leukocytes (neutrophils, eosinophils) for microbial
• High concentration of wound macrophages and other phagocytic cells for
biologic debridement
• Histamines, serotonin, adenosine diphosphate (ADP), thromboxane A2,
and other vasoactive and chemotactic agents
• High platelet concentration and native fibrinogen concentration for im-
proved hemostasis

Although some PRP systems achieve platelet counts eightfold over baseline and
other PC systems only achieve one time higher than the average human platelet
count, controversy exists as to what the optimal levels of platelet count should
be to be effective for repair and regeneration of tissue and bone. Concentrations
below 3.8 times 105 platelets/μl have a suboptimal effect, and concentrations
above 1.8 times 106 platelets/μl may have a paradoxically inhibitory effect.7

Some ACT preparations that include leukocytes are advantageous for wounds, but
the inclusion of leukocytes in the preparation is also controversial. The biologi-
cally deleterious effects resulting from neutrophils containing matrix metallopro-
teinases 8 and 93 have been well described. Moreover, neutrophils may increase
tissue damage by releasing excessive amounts of reactive oxygen species in the
inflammatory phase of muscle injury.8
398 Part IV  ▪  New Directions

Platelet-rich plasma with Cytokine-rich

RBCs, WBCs, and platelets plasma

Newer ACT processing methods allow the mechanical release of growth factors
from platelets in whole blood, without centrifugation or the use of thrombin,
then all cellular material is filtered out, such as leukocytes, erythrocytes, and
platelet membranes, rendering an analytical grade protein-rich plasma (PRP) or
cytokine-rich plasma (CRP).9

While centrifuges harvest approximately 70% of platelets in a given amount of

blood that contain platelets, leukocytes, erythrocytes and plasma, the resulting
cellular cocktail varies from system to system. In CRP, on the other hand, all
the donor whole blood is subject to an equal amount of time, temperature, and
pressure, so theoretically, 100% of the growth factors and cytokines are released,
yielding all the patient’s regenerative material. This is advantageous in that cel-
lular debris can then be filtered out, leaving analytical grade cytokine-rich plasma.
What may be of more importance than the levels of growth factors and cytokines
is the fact that there is now a balance of released regenerative material that is
specific for that person to initiate a more natural communication of growth factor
stem cell interaction.
Chapter 19  ▪  Benefits of Autologous Cellular Therapy 399

Growth Factors, Cytokines, Stem Cells,

and Hair
The human body regulates the complex symbiotic relationship of growth factor
and stem cell interaction. Think of the body as the maestro leading the orchestra
into a beautiful musical piece. First, he directs the horns to play. Then he asks the
strings to join in, all the while regulating the flow, depth, and tempo. Growth fac-
tors are present in the follicular bulge area, where stem cells are found, and they
interact with cells of the matrix, thus activating the proliferative phase of the hair.

Stem cells are more primitive and of ectodermal origin, and they generate the
epidermal cells and the sebaceous glands. Cells of the dermal papilla found at the
capillary base are of mesenchymal origin. Because both cells need each other, they
interact through the action of various growth factors thus producing the future
follicular unit.

Some growth factors have a negative effect on hair, such as transforming growth
factor-beta (TGF-b), epidermal growth factor (EGF), and fibroblastic growth fac-
tor (FGF) as well as the proinflammatory cytokines such as IL-a. Other growth
factors like platelet-derived growth factor (PDGF), basic fibroblast growth fac-
tor (bFGF), insulin growth factor-1 (IGF-1), vascular endothelial growth factor
(VEGF), and keratinocyte growth factor (KGF) positively affect hair growth.
After using ACT in over 1000 hair restoration surgical and nonsurgical proce-
dures since 2007, the overall effect of all growth factors has been positive and no
adverse side effects were reported.10

Platelet derived growth factor (PDGF) is the evolutionary sentinel growth fac-
tor that initiates all wound healing and its main functions are to stimulate cell
replication (mitogenesis) of healing capable stem cells and also stimulates cell
replication of endothelial cells. This will cause budding of new capillaries into the
wound (angiogenesis), a fundamental part of all wound healing. Takakura et al 11
demonstrated that PDGF signals are involved in both epidermis-follicle interac-
tion and the dermal mesenchyme interaction required for hair canal formation and
the growth of dermal mesenchyme.

Promising research at Yale by Festa et al12 identified that “a precursor to hair

growth is the growth of a layer of fat in the scalp.” They then identified the stem
cell responsible for that fat growth and when the hairs die, a layer of fat in the
scalp shrinks. When a new hair begins to grow, that same layer of fat expands in
a process called adipogenesis.
400 Part IV  ▪  New Directions

They also discovered that the precursor fat cells also produce platelet-derived
growth factor (PDGF), which aids in hair growth 100 times faster than normal
cells do. Up to 86% of hair follicle growth was restored in mice with the injec-
tion of PDGF. Scientists must now prove that the cellular signaling in mice is the
same as in humans for the research to be relevant to the human population, but
it appears PDGF is an important signal growth factor for hair generation.

PRP also contains several other growth factors, including VEGF. Studies dem-
onstrate that VEGF is vital to hair biology, and hair size is partially dependent
on VEGF-induced angiogenesis. In 2001 Yano et al13 identified VEGF as a major
mediator of hair follicle growth and cycling, providing the first direct evidence
that the improved follicle vascularization promotes hair growth and increases
follicle and hair size.

0.0440 0.0437 ■ Treated

■ Control
Hair shaft diameter (cm)

0.0410 0.0409

0.0400 0.0397



Before treatment 4 mo 8 mo

Greco and Brandt5,14 reported an increase in hair shaft density after scalp stimula-
tion and infusing PRP into the scalp of patients. The results revealed an increase of
9.7% in average hair shaft diameter at 4 months and 6.1% at 8 months in the
treatment group. The control group demonstrated a 2.8% average decrease in hair
shaft diameter at 4 months and a 3.5% decrease at 8 months.
Chapter 19  ▪  Benefits of Autologous Cellular Therapy 401

Case Example
Androgenetic Alopecia

8 months after one treatment

This 26-year-old man has androgenetic alopecia. He was included in the study
and had one treatment of stimulation and PRP/protein matrix before the treat-
ment seen on the left. His result is shown at 8 months. The patient noticed a
thinning of his hair at 12 months and was treated a second time at 14 months. Six
months after the second treatment, the patient reported an increase in aesthetic
density, which lasted until the twelfth month, when he returned for a third ses-
sion. There was a bell-shaped curve effect with the ACT treatment that lasted
12 months, with peak effect at 4 to 6 months.

The Extracellular Matrix and the

Importance of Plasma Proteins
Fibronectin and Vitronectin
Both of these are proteins called cell adhesion molecules. As part of cellular
proliferation and migration particularly seen in bone and cartilage healing, cells
move to new positions to lay down their products, such as bone or cartilage.
Related to bone, this is called osteoconduction. These cells move via a process of
endocytosis in which they pinch in a portion of their cell membrane into vesicles
at their tail end. These vessels are transported through the cytoplasm to their
front end, where they are reincorporated into the cell membrane surface on the
front end, and therefore the cell moves in a creeping fashion. This movement
must take place on a framework. If the framework has reversible binding sites on
it or structures into which a cell membrane may invaginate, so much the better.
402 Part IV  ▪  New Directions

Fibronectin and vitronectin also seem to be able to provide a foothold or grip for
cells as they move. Whether this is through reversible binding to the cell mem-
brane or its surface texture is unknown at this point.

Like fibronectin and vitronectin, fibrin is derived from plasma and contributes
to cell mobility in the wound. The role of fibrin, which is a crosslinked protein
derived from the fibrinogen in plasma, is not only to serve as a scaffold or surface
for cell migration, but also to entrap platelets. As a crosslinked protein where
the crosslinking occurs as part of the clotting process, it entraps platelets as well
as red blood cells. This ensures a random distribution of platelets throughout the
wound and therefore the growth factors they contain.

The extracellular matrix (ECM) is the largest component of the dermal skin
layer, and the synthesis of ECM is a key feature of wound healing, especially when
there has been a significant loss of tissue that precludes closure by primary inten-
tion. The ECM is composed of a variety of polysaccharides, water, and collagen
proteins that give the skin remarkable properties.

The Proliferative Phase

During the repair phase, the wound matrix is remodeled and replaced with scar
tissue consisting of new collagen fibers, proteoglycans, and elastin fibers, which
partially restore the structure and function of the tissue. This is accomplished by
the migration, proliferation, and differentiation of epithelial cells, dermal fibro-
blasts, and vascular endothelial cells from adjacent uninjured tissue and stem cells
that originate in the bone marrow and circulate to the wound site.

After the fibroblasts have migrated into the provisional wound matrix, they pro-
liferate and begin to synthesize new collagen, elastin, proteoglycans, and other
components that compose granulation tissue. PDGF and TGF-b are two of the
important growth factors that regulate the expression of ECM genes and proteases in
Chapter 19  ▪  Benefits of Autologous Cellular Therapy 403

Natural Protein Matrix


Hemoconcentrated plasma proteins

The “next generation” of autologous cellular therapy is the addition of an extra-

cellular matrix to pure growth factors. Independent studies by Clark14 concluded
the “GF-ECM complexes may well be the most effective method to stimulate
cell proliferation, as well as tissue healing or regeneration.” I first reported the
importance of using a patented natural concentrated ECM made from the plasma
proteins and mixing this with the autologous growth factors: OroGen Plus.15

Electron microscope image of natural protein matrix

The hemoconcentrated plasma proteins serve as a scaffold or surface for cell

migration and trap growth factors in the following manner. First, hemoconcen-
tration of the plasma proteins causes a threefold increase in the plasma proteins
(fibronectin, vitronectin), supporting the formation of the ECM in a natural
bioscaffold. Second, some of the vital growth factors for hair, such as IGF, bind
to the plasma proteins, so by increasing the concentration of fibrinogen and by
entrapping the growth factors in the ECM, this natural complex allows cells
to attach and migrate. Third, since it takes the body longer to break down the
404 Part IV  ▪  New Directions

plasma protein scaffold, the entrapped growth factors remain in the treatment
area longer, promoting angiogenesis and mitogenesis. Fourth, because hair is made
of protein, increasing the concentration of plasma proteins in the scalp, combined
with the growth factors, promotes a synergistic effect on hair growth.

The Future of Growth Factor Technology

The future of growth factor technology may be in a lyophilized form made from
allogeneic platelets. Growth factors can be released from platelets; the platelet
membranes can be filtered out resulting in an acellular protein-rich solution of growth
factors and plasma that are lyophilized, eliminating the concern for an antigenic
reaction. In 2011 Gary Hitzig16 reported on the use of an acellular matrix made
of bovine bladder in combination with arterial/PRP for retarding hair miniatur-
ization. He stated that Matri-stem (ACell, Inc., Columbia, MD), a xenogenic
matrix, provided a bioscaffold for cellular attachment and migration that yielded
an enhanced effect compared with PRP.

The advantages of the allogeneic form are as follows:

• It is an off-the-shelf product.
• In blood-banked platelets there is a known quantity of platelets, so it can
be dose specific whereas autologous platelets vary from day to day.
• There is no blood draw.
• It takes seconds to reconstitute with saline solution.
• It can be used with any ECM or with stem cells.
• There is no learning curve, and anyone licensed and trained in injections
can administer it.
• Analytical quality.

However, since platelets are a blood product, any processing like freeze-drying
must undergo strict FDA review as a drug.

In the final analysis, there are traditional medical treatments for hair loss, perma-
nent surgical techniques, and now biologic treatments. The future of regenerative
hair growth should include a combination of all three technologies until we reach
the Holy Grail of hair multiplication.

Case Examples
Autologous Cellular Therapy and Alopecia Areata
A research grant sponsored by the International Society of Hair Restoration in
2010 to study the effects of autologous platelet-rich plasma on alopecia areata
revealed that in 60% of 18 patients treated, the therapy reversed the effect of
inflammatory cytokines and stimulated hair growth.17 Interestingly, the effects of
all the growth factors stimulated the dormant follicular stem cells to turn on and
grow hair in areas when inflammatory cytokines turned off the follicles.
Chapter 19  ▪  Benefits of Autologous Cellular Therapy 405

Treated area

Untreated area

This woman had diffuse alopecia areata on the top of her head and in the postoc-
cipital region. Treatment was done only in the occipital area of hair loss; the top
was not treated. The treated area responded with hair growth, and the nontreated
area expanded the areas of hair loss.

Because alopecia areata may spontaneously resolve and hair will grow back, a case
study was proposed and conducted by Rinaldi.18
406 Part IV  ▪  New Directions

Autologous Cellular Therapy and Discoid Lupus

Before treatment

6 months after treatment 12 months after treatment

This 62-year-old woman had confirmed discoid lupus for 10 years and presented
to her dermatologist with multiple coin-size areas of hair loss. She was treated for
2 years with monthly corticosteroid injections, at which point injections were
discontinued when a linear scar was noticed in the patient’s forehead. The pa-
tient was then treated with CRP, during which 60 ml of whole blood was drawn.
Growth factors were mechanically released and centrifuged for 10 minutes at
4000 rpm to filter out cellular material, and 35 ml of CRP was then concentrated
to 10 ml using a HP Junior Hemoconcentrator (Mintech). Six months after
infusion of the CRP, the patient returned and hair growth was observed in some
of the areas of hair loss, and her overall hair character and aesthetic density had
increased. A second procedure using the same protocol was done at 6 months, and
the patient returned at 12 months for the initial treatment. She is shown before
treatment and 6 and 12 months after treatment, with a pleasing result.
Chapter 19  ▪  Benefits of Autologous Cellular Therapy 407

Although ACT will not grow hair in a lupus scar where there are no follicles, in
this case, using the patient’s hair around each of the discoid areas, the secondary
germ cells in the follicles surrounding the scars were recruited by the growth fac-
tors to grow hair into the scar circumferentially.

1. Paus R. Do we need hair follicle stem cells and hair follicle neogenesis to cure common hair
loss disorders? Hair Transplant Forum Int 18:81, 2008.
2. Ferrari M, Zia S, Valbonesi M, et al. A new technique for hemodilution, preparation of au-
tologous platelet-rich plasma and intraoperative blood salvage in cardiac surgery. Int J Artif
Organs 10:47-50, 1987.
3. Uebel CO. Platelet-rich plasma and graft survival. Presented at the Annual Scientific Meet-
ing of the American Society of Plastic Surgeons, Philadelphia, Oct 2004.
4. Greco J, Brandt R. Our experience using autologous platelet rich plasma in all phases of hair
transplant surgery. Hair Transplant Forum Int 17:131-132, 2007.
5. Greco J, Brandt R. The effects of autologous platelet rich plasma and various growth factors
on non-transplanted miniaturized hair. Hair Transplant Forum Int 19:49-50, 2009.
6. Marx RE. Platelet-rich plasma: evidence to support its use. J Oral Maxillofac Surg 62:489-496,
7. Weibrich G, Hansen T, Kleis W, et al. Effect of platelet concentration in platelet-rich plasma
on peri-implant bone regeneration. Bone 34:665-671, 2004.
8. Tidball JG. Inflammatory cell response to acute muscle injury. Med Sci Sports Exerc 27:1022-
1032, 1995.
9. Greco J. Using CRP in the treatment of alopecia areata. Presented at the Seventh EMAA
European Congress, First International Hair Surgery Masters Course, Paris, Oct 2011.
10. Greco J. Our four-year experience using autologous cellular therapy in various hair diseases.
Presented at the Nineteenth Annual Meeting of the International Society of Hair Restora-
tion Surgery, Anchorage, Sept 2011.
11. Takakura N, Yoshida H, Kunisada T, et al. Involvement of platelet derived growth factor
receptor-alpha in hair canal formation. J Invest Dermatol 107:770-777, 1996.
12. Festa E, Fretz J, Berry R, et al. Adipocyte lineage cells contribute to the skin stem cell niche
to drive hair cycling. Cell 146:761-771, 2011. 
13. Yano K, Brown L, Detmar M. Control of hair growth and follicle size by VEGF-mediated
angiogenesis. J Clin Invest 107:409-417, 2001.
14. Clark RA. Synergistic signaling from extracellular matrix growth factor complexes. J Invest
Derm 128:1354-1355, 2008.
15. Greco J. Our initial experience utilizing autologous growth factors in PRP for male and
female pattern hair loss. Presented at the International Society of Hair Restoration Surgery
Workshop, IDI Rome, May 2008.
16. Hitzig G. Early results and expectations (without surgery) in the use of injectable ACell
(Matri-stem) suspended in arterial blood serum/PRP (platelet rich plasma) and possibly re-
grow miniaturizing scalp hairs. Hair Transplant Forum Int 21:73-75, 2011.
17. Greco J. ISHRS Research grant report utilizing autologous growth factors in the treatment of
alopecia areata. Presented at the Seventeenth Annual Meeting of the International Society
of Hair Restoration Surgery, Amsterdam, July 2010.
18. Trink A, Sorbellini E, Bezzola P, Rodella L, Rezzani R, Ramot Y, Rinaldi F. A randomized,
double-blind, placebo and active-controlled, half-head study to evaluate the effects of platelet
rich plasma on alopecia areata. Br J Dermatol, 2013 Apr 22. [Epub ahead of print]
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C H A P T E R 20

C ell-Based Treatments:
Tissue E ngineering
and C loning

Jerry E. Cooley
410 Part IV  ▪  New Directions

  hope of cultured follicular cell implantation, or hair cloning, has held a
place in the imagination of hair restoration surgeons and the public alike
for many years. Several decades of basic animal research established the seeming
inevitability that cell therapy would be a successful treatment for alopecia by this
point in time, with the attendant hope for unlimited hair restoration. Yet the
current situation suggests that cell-based treatments are no closer to successful
realization than when the author last reviewed this topic 10 years ago.1 In this
chapter I will cover published research over the past decade. The basic rationale
and conceptual framework for using cell therapy to treat hair loss has been dis-
cussed in prior reviews2,3 and will not be covered here.

Although clinical trials are underway using cultured follicular cells, no published
results in humans are available at the time of this writing. Furthermore, because
of the inherent commercial potential of research findings, it can be assumed that
much more is known than is publicly available. Although knowledge of the cel-
lular and molecular mechanisms underpinning hair growth has progressed sub-
stantially over the past 10 years, it appears that this has not yet translated into a
clinically useful method for treating hair loss in humans.

The basis for cell therapy began in the fundamental research of normal mamma-
lian hair growth. It had been established that hair growth occurred because of the
dynamic interaction between epidermal and mesenchymal cell populations within
the hair bulb. Using the rat whisker as a model, Oliver showed that the spherical
aggregate of mesenchymal cells in the bulb known as the dermal papilla could
induce new follicles when removed from the whisker and subsequently implanted
into skin which normally lacks follicles.4 Carrying this research further, Jahoda,
Horne, and Oliver 5 showed that rat whisker dermal papilla that had been cultured
in vitro could induce new hair growth when implanted into incisions in the rat
ear. This research, published in the mid-1980s, initiated the race to develop cell
based treatments for hair loss. In the ensuing years, several commercial ventures
were launched based on the work of these investigators.

Over the past 10 years, we have seen a major commercial venture fail which was
based on using implanted cultured autologous dermal papilla (DP) in humans.
Although some increased hair growth was claimed, it was largely agreed that
simply implanting cultured DP in humans did not result in clinically meaningful
hair induction. A second commercial venture combining cultured DP and ke-
ratinocytes is also being put through human clinical trials at the current time.6
Although the results have not been published, early reports are that no follicular
neogenesis has been observed, although some thickening of native hair may re-
sult, which may be clinically beneficial. What has become increasingly clear is
that methods that routinely induce new hair follicles in mice and rats are largely
unsuccessful in humans.
Chapter 20  ▪  Cell-Based Treatments: Tissue Engineering and Cloning 411

A third venture is based not on using cultured dermal papilla, but the adjacent
mesenchymal dermal sheath “cup” cells (DSC).7 This is based on the research of
McElwee et al,8 who showed that implantation of cultured DSC cells from mouse
whiskers could be injected into the ear, resulting in “colonization” of the dermal
papilla of ear hair follicles with whisker cells programmed to produce thicker hair.
Early reports from clinical trials using cultured DSC in humans suggest that this
process is safe and may produce some hair thickening.

It is important to note that no published reports exist of reproducible de novo hair

follicle induction in humans; that is, the formation of entirely new hair follicles
in alopecic skin. What the current commercial ventures do appear to show is that
implantation of cultured follicular cells may result in clinically apparent thicken-
ing of native hair follicles. Whether these implanted cells incorporate into the
structure of the native follicle and survive cycling or whether they merely secrete
stimulatory agents that transiently promote thicker hair is an important distinc-
tion. If it is the former, then such a treatment may represent a true breakthrough
in alopecia treatment, with long-lasting or permanent effects. If it is the latter,
then the expense of cell-based treatment may not justify the temporary benefits.
Furthermore, the increasing popularity of injecting platelet-rich plasma (PRP)
for hair loss9,10 as well as an injectable treatment under development containing
growth factors secreted by cultured neonatal fibroblasts11 may produce similar
gains at a fraction of the expense, without the burdensome regulatory require-
ments of cell therapy.

Animal Research and Study Models

These commercial ventures have their origin in basic research conducted on
rats or mice. The seminal studies by Jahoda, Horne, and Oliver were based on
manipulating dissected rat vibrissae (whiskers), which later proved cumbersome
and limiting as research methods became more advanced. Over the years, more
refined models have been developed that have allowed researchers to study the
intricate inner workings of follicular neogenesis.

For many years, the silicon chamber model pioneered by Lichti and Yuspa12 was
the dominant model used by researchers in this area. Dermal and epidermal cells,
either fresh or cultured, could be combined in full-thickness wounds on the backs
of immunodeficient mice and covered with a bell shaped silicon chamber that
confines and protects the cells; after one week, the chamber is removed and new
hair growth is apparent within three weeks.

Qiao et al13 created a “flap graft” model that dispensed with the need for the
chamber, allowing implantation of trichogenic dermal and epidermal cells below
a flap of host skin. This model still required the implantation, and subsequent
removal, of a silicone sheet. Stenn and colleagues14 developed a patch assay that
consisted of injecting dermal and epidermal cells subcutaneously into immuno-
412 Part IV  ▪  New Directions

deficient mice. The resulting hairball consists of hair bulbs located centrally, with
hair growth occurring radially outward.

Almost all in vitro models have relied on mouse, usually embryonic, as the source
of cells. It has been noted by researchers that successful hair follicle induction us-
ing mouse or rat cannot necessarily be translated into success using human cells.
Although Stenn’s group15 did report success with their patch assay using adult
human dermal cells, it is important to note that the epidermal cells were from a
human fetus and the host was an immunodeficient mouse.

One report stands alone in using only adult human cells and tissue. Krugluger
et al16 described a human skin organ model in which injections of human DP
and epithelial cells resulted in follicle induction and growth of vellus-type hair.
However, no follow-up studies from this group, or using this technique, have been
reported in the years since its original publication.

Cell-Culturing Conditions
Early experiments clearly showed that culturing conditions determined the suc-
cess of DP-induced follicle morphogenesis. Cultured dermal papillae gradually lose
their inductive ability as they are passaged and expanded in culture. Yoshizato
and colleagues17 showed that the presence of keratinocytes or keratinocyte-
conditioned media could keep cultured DP inductive through many passages. It
was later found that the factors present in conditioned media were soluble Wnt
proteins excreted by keratinocytes,18 whose primary function appears to be keep-
ing beta-catenin in the DP active, which is essential for maintaining inductive

In addition to the presence of soluble Wnt factors to keep beta-catenin in cul-

tured DP active, it has been found that three-dimensional culture conditions favor
subsequent follicle induction over standard two-dimensional techniques.20 Sev-
eral reports have shown that cultured DP cells are more inductive when coaxed
to aggregate into spheres rather than as the standard monolayers present in two-
dimensional culture.21-23

Cell Implantation Technique

When the first reports of successful follicle induction in animals using cultured
cells was reported in the mid-1980s, it was assumed that not only would success
in humans follow shortly, but that the envisioned treatment would consist of
injections of dissociated cells directly into the scalp, where they would induce
the formation of new follicles. Over the past 10 years, it has become increasingly
clear that injection of dissociated dermal cells, with or without epidermal cells,
is largely unsuccessful in inducing new follicle formation in humans.
Chapter 20  ▪  Cell-Based Treatments: Tissue Engineering and Cloning 413

Many reports using animal models have appeared focusing on modifying and
augmenting the method of culture and implantation. The rationale is that by
optimizing the culture and delivery of cells, follicle induction will be successful in
humans. One report described the comparative success of different implantation
techniques on hair regeneration when using cultured DP alone (no epidermal
cells). Cultured rat DP placed directly beneath the host epidermis using the
“hemivascular sandwich” technique showed superior hair induction.24 These re-
searchers claimed that this technique allowed use of dissociated DP cells alone,
and that success was the result of contact between DP cells and host epidermal
cells as well as better oxygenation of the implanted cells.

Moving Toward a New Paradigm

Current research appears to be leading toward a treatment paradigm in which
dermal and epidermal cells are combined for a period of time before implantation.
In a method reported by Qiao et al,25 mouse dermal and epidermal cells were
cocultured before implantation, resulting in the formation of primitive “proto-
hairs” that could be subsequently transplanted, resulting in the growth of mature,
cycling hair. It bears repeating that this involved animal cells, not human cells.

Along these lines, Lindner et al26 described the creation of “neopapilla” using
cultured human DP and components of extracellular matrix, followed by cocul-
ture with human keratinocytes and melanocytes. This resulted in the formation
of in vitro follicles with vellus-like hair shaft growth.

Similarly, Tsuji and colleagues27 reported that cultured DP and epidermal cells
could be combined in a collagen gel to create a “bioengineered follicle germ”
that could then be transplanted along with a fine suture that serves as a guide for
follicle directionality and connection to the outside epidermis, thus preventing
cyst formation. When transplanted into the hairless skin of mice, Toyoshima et
al28 reported that these bioengineered “hair germ” grafts took root and produced
hair, and analysis of these hair follicles showed all correct layers of normal fol-
licles and accessory structures including connection with surrounding host tissue
(erector pili muscles and nerve fibers). Normal hair cycling occurred, confirming
the presence of the necessary stem cell populations within the new hair follicles.

Furthermore, these researchers reported similar success using adult human follicle
stem cells (DP and bulge-region derived epithelial cells), which may represent
an important breakthrough. In a variation of their method, they implanted the
bioengineered hair germ into the subrenal capsule of mice, providing a protected,
vascularized space for induction to occur. After two weeks, mature hair follicles
were seen in clusters and could be harvested for subsequent transplantation as
one and two hair follicular units.29 They suggested that these bioengineered hair
grafts could be used in a manner similar to follicular unit transplantation (FUT).
One might envision a treatment in which the patient’s follicles are shipped to
414 Part IV  ▪  New Directions

the laboratory, where the cells are dissected out and grown first in organ culture,
then matured in surrogate mice, before being harvested and shipped back to the
surgeon, where they could be implanted by the FUT technique.

Concluding Thoughts
Follicular cell implantation for hair loss remains an exciting possibility, but true
hair multiplication is a long way off from practical reality in the clinic. Cell-based
treatments may be available first as “hair thickening” treatments, where periodic
scalp injections produce modest clinical gains, similar to those from finasteride
and minoxidil. True hair follicle neogenesis in humans has proven far more com-
plex than that which has been routinely carried out in rats and mice, but intricate
models are now being developed that keep alive the dream of unlimited hair.

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Chapter 20  ▪  Cell-Based Treatments: Tissue Engineering and Cloning 415

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