Detailed planning for hair transplants gets superior results

Hair restoration procedure Planning the hair transplant donor site

Planning the Hair Transplant Donor Site

The actual hair transplant information in terms of percentage of hair that can be harvested from the donor site without causing any visible scarring during its closing, or causing very little hair being left at the donor site for future hair restoration surgery, is very crucial for a hair transplant surgeon. And depending upon the Hair transplant information calculated as demand/supply ratio, an expert hair restoration surgeon exploits the donor hair for the greatest benefit of the patient according to the following procedures:

· Size of donor area and tissue to be collected

· Preparing the occipital scalp for donor skin removal

· Method of donor tissue collection

Size of donor area and tissue to be collected

This page refers to the procedure generally used for patients with androgenetic alopecia. The procedure will vary somewhat depending on the personal preference of the surgeon, and will vary even more if you have a form of alopecia other than androgenetic alopecia that is being surgically restored.

Planning the donor site is just as important is planning the hair implant recipient site in hair restoration. The donor area has to be preserved as much as possible, you don’t want an irregular shaped occipital scalp hair growth or a large scar from the removal of the donor hair follicles. The primary issue for the hair transplant surgeon in planning the donor site is how big it is and how much skin should be taken to provide enough hair follicles for the transplant session. Not all donor sites are the same size in hair transplant patients. Some men and women have quite large areas of occipital scalp where the hair follicles remain unaffected by androgenetic alopecia. In other patients, the androgenetic alopecia has spread far back on the scalp and the occipital scalp hair growth area is relatively small. In addition, there are some people in whom their androgenetic alopecia is so extensive that the hair follicles on the occipital scalp are also affected to some extent and the hairs are finer and thinner than would be expected. If the donor area is too small or the area is affected by androgenetic alopecia then the individual may not be a suitable candidate for hair restoration.

Some experience is required on the part of the hair transplant surgeon to correctly define the area of donor hair on the occipital area that is unaffected by androgenetic alopecia. It is important to get it right as transplanting hair follicles that are androgen responsive will lead to transplanted hair follicles miniaturizing in response to the androgen hormones. Also, the surgeon must leave enough hair behind after removing the donor hair follicles to ensure a natural look to the occipital hair line. It is generally believed that the “safe” area of potential donor hair follicles resistant to androgenetic alopecia is in the area from the lower hairline at the back of the neck, up to an imaginary line running around the back of the head about 2cm above the openings of the ears. This defines the maximum extent of the potential donor area for all but a few individuals. However, when actually removing the donor skin, the surgeon must leave margins above and below the removed hair follicles. The surgeon also has to take into account the possibility that the patient may need more hair restoration procedures in the future. Bearing these limitations in mind the surgeon will identify an area of skin to remove.

Preparing the occipital scalp for donor skin removal

At the start of the procedure, you, as a patient, will be dressed in a surgical gown, or at least you will be asked to cover your upper body and around your neck in a disposable apron. You will be positioned face down on an operating table with your head on a prone pillow – it has a hole in the middle for your face to go into so you can breathe! The area of skin at the back of your head will be sterilized with one or more solutions swabbed over the skin and hair. The long hair that you have hopefully been growing to use later to cover over the sutures, will be combed out of the way and held in place with hair clips. The area of skin from which the donor hair follicles will be cut, will be shaved with clippers or cut with scissors so that the long hair doesn’t get in the way of cutting the skin and later when the skin is microdissected to obtain the hair follicles. The hair is not completely removed down to the skin surface, about 2mm of hair is left above the skin surface so that the surgeon can see where the hair follicles are when he cuts the donor skin. The skin is swabbed again to get rid of the loose, cut hair and to repeat the sterilization. Usually the solution is iodine (Betadine) or chlorhexidine (especially if you are allergic to iodine).

To prepare the skin ready for cutting, your skin will be injected with a saline solution and then a local anaesthetic or alternatively you may receive both saline and anaesthetic as a mixed solution. The intention of the saline is to increase tumescence in the skin that is, to make the skin relatively hard. This makes it easier to cut with a scalpel and ensures nice clean edges to the cut skin which makes healing of the wound quicker. It also spreads the hair follicles apart so they are easier to see and to cut between with the scalpel blade. The local injections can be painful, although the pain should be brief until the local anaesthetic takes effect. To overcome the brief pain during injection of the saline and local anaesthetic, some surgeons offer the option of a partial systemic anaesthetic like nitrous oxide. You usually administer this to yourself, by breathing it through a mask you apply to your mouth as and when you feel you need it, during the injection of saline and local anaesthetic. You should remain awake throughout the procedure. The breathable anaesthetic is only used until the local injected anaesthetic takes hold.

Method of donor tissue collection

The next step is for the surgeon to actually cut the donor skin area. Most hair transplant surgeons currently (as of 2004) use a multi bladed knife to remove a strip of skin from the occipital scalp. The distance between the blades and the length of cut determines the size of the skin area that is removed. The multi bladed knife can be resized to change the distance between the blades. The surgeon will determine how much skin is needed and position the blades of the knife appropriately. The scalpel blades are inserted into the skin at one side of the head at an angle such that the blades are parallel to the hair follicles in the skin. The surgeon can predict how angled the hair follicles are in the skin by observing the angle of hair growth coming from the hair follicles. The cut is relatively quick in the hands of an experienced surgeon. It can take less than 30 seconds. However, it can take longer if you are one of the few individuals in whom the angle of the hair follicles changes across the scalp. Then the surgeon has to go more slowly and carefully to ensure he/she does not cut into the hair follicles.

The surgeon will then cut across the skin to make the strip of donor hair follicles. If you have already had one or more procedures done, the surgeon will cut the strip of skin just next to where the previous strip of skin was cut. The surgeon will cut the new strip of donor skin such that it also just cuts out the scar left from the previous operation. In this way, the surgeon can ensure that, regardless of how many implant procedures you have, you only ever have one scar on the occipital scalp. Just how much skin is removed depends on the size of the recipient area that needs to be implanted and the density of your hair follicles. Roughly speaking, the density of hairs in the donor region of the scalp typically ranges from 70 to 120 follicular units per square centimeter, with a median of 80. Therefore, in the typical patient, a 20-cm2 donor strip (20 cm in length by 1 cm in width) would be required for a 1600-graft procedure.

The strips are then cut away from the scalp. Usually, the surgeon or nurse will pull gently on one end of the donor strip with forceps and as the skin is lifted up above the remaining scalp skin, a pair of surgical scissors will be used to cut underneath the hair follicles to release the skin strip from the scalp. This is then put into a saline solution in a plastic dish in an ice bucket. This is taken away for further processing to make the grafts ready for implanting. What is left is a usually a narrow elliptical hole in the occipital scalp skin. If there is bleeding from some of the larger blood vessels, they may be cauterized. The wound is then sutured (sewn) together, often with a single running stitch. Some hair transplant surgeons use biodegradeable sutures that eventually fall out. Most however, use normal sutures that need to be taken out by a doctor at a later date. It will take a while until the grafts have been dissected ready for implantation. During this time you will probably be free to sit up and read or watch a video.

The donor skin is then processed to isolate the follicular units for transplantation.