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Avoiding pitfalls in planning for a hair transplantation (part 1)
Author: Robert M. Bernstein, MD, FAAD
Although many technical advances have been made in the field of surgical hair restoration in the past decade, particularly with the widespread adoption of follicular transplantation, many problems remain. Most doctors recommend around the surgery for patients who are not good candidates. Most of the reasons that patients should not proceed to surgery is that they are too young and that their pattern of hair loss is too unpredictable. Young people also have expectations that are generally very high - often demanding the density of hair and a teenager. Many people who are in early stages of hair loss should simply be treated with medication, rather than to be eager to go under the knife. And some patients simply are not mature enough to make the head of the decisions at the level of your problem is emotional.
In general, the young patient, the physician must be careful to operate, especially if the patient has a family history of Norwood Class VII hair loss, or a pattern of diffuse alopecia.
Problems also occur when the doctor can not properly assess the patient? s supply of donors, and the hair does not have enough hair to make the patient? s objectives. Careful measurement of a patient? S density scalp and other features allow the surgeon to know exactly how much hair is available for transplantation and allow you to develop a model for restoration can be achieved within these constraints.
In all these cases, spending a little more time listening to the patient? S is concerned, a more closely with the patient and recommend a treatment plan that conforms to what can be achieved, will contribute greatly to having satisfied patients. Unfortunately, scientific advances that improve the technical aspects of the hair restoration process and do little to ensure that the procedure was performed with the right or planning in the patient.
Five years
Improved surgical techniques have allowed an increase in the number of grafts that are placed in small receptor sites has almost reached its limits and limitations of the supply of donors remain the major obstacle for patients to regain a full head of hair. Although the initial enthusiasm of the follicular unit extraction, a technique in which hair can be operated directly by donors Peludo skin (or body) no linear scar, this process has added little to the increase in the patient? s available for hair transplantation. Progress will come when the donor supply can be extended if cloning. Although some progress had been made in this area (especially in animal models) the ability to clone hair is at least 5 to 10 years.
Key Issues
1. The biggest mistake you can make a doctor for treatment of a patient with hair loss is to perform a hair transplant to someone who is too young, that expectations are very high and the structure of future hair loss unpredictable.
2. Chronic exposure the sun? S life much more significant negative impact on the outcome of hair transplant peri-operative exposure to the sun.
3. A bleeding diathesis, enough large to the effects of surgery can be performed on the patient? History, but often not reported OTC (non-steroidal) and must be requested specifically.
4. Depression is perhaps the most common psychiatric disorders found in patients? S seeking hair transplantation, but also is a symptom of these people to lose their hair. The physician must distinguish between an emotional calvicie reasonable and depression requiring psychiatric counseling.
5. To perform a hair transplant, the physician must balance the patient? s present and future needs for the hair to the present and the future availability the supply of donors. It is well known that a d? calvicie model evolves over time. What is less appreciated is that the donor site in May to change.
6. The patient? S donor supply depends on a number of factors including the physical dimensions of the area permanently, laxity of the scalp, the density of donor characteristics hair and, most importantly, the degree of miniaturization of donors in the region - because it is a window on the future stability for the supply of donors.
7. Patients with very loose leather extended donors often heal with scarring.
8. You should never assume that the d? hair loss is stable. Hair loss tends to move forward in time. Even patients who show a good response to finasteride may lose more hair.
9. The position of adult men of normal hair is approximately 1.5 cm above the top of the front fold. Avoid placing new hair transplanted to the position of adolescents, rather than a case of an adult.
10. One way to avoid having a hair transplant with a look that is too thin to limit the scope of coverage on its face and scalp to mid-appropriate donor and a model of baldness can be reasonably assured - a guarantee that can only come by age. Until then, it is preferable to avoid adding to the coverage the crown.
Introduction
Hair transplantation has been available as a treatment for hair loss for more than 40 years. [1]
With a majority of cases, hair transplantation has been characterized by the use of corks, slot grafts, flaps and micro mini-grafts. Even if they are the best tools available to physicians at the time, were unable to consistently produce results.
With the introduction of the transplant unit follicular (FUT) in 1995, doctors were able to produce these results. [2] However, the mere ability to produce will not necessarily guarantee that these results are natural. The procedure has raised new challenges for the hair restoration surgeon, and only when the procedure was well planned and perfectly executed, that the patient really benefit from the power of this new technique [3].
The ability of the follicular unit transplantation to imitate nature produces the best results that have been completely undetectable. This is the mark of Follicular Unit Hair Transplantation. [4] Equally important, however, is the preservation of hair - A correspondence between what is harvested from donors and what motivates end account, the beneficiary of the scalp. As a limited supply of donors is the main obstacle for hair transplantation, the preservation of the hair is a fundamental aspect of each technique. However, unlike the previous procedures used large grafts, the delicate follicular units are easily traumatized and very sensitive to desiccation, the follicular unit transplant, thousands of transplants, particularly difficult. [5]
To date, the vast majority of hair transplants performed in the United States the use of Follicular Unit Transplantation. Seats is limited, this review only and not on technical procedures. Also focus on the follicular unit extraction, as this technique is still evolving and how to avoid the major risks of this procedure are still being developed and a subject in itself. As the title suggests, this document focuses on the prevention of various problems encountered in WAS, rather than its treatment - an important topic that has already been thoroughly examined. [6, 7]
For those unfamiliar with the follicular unit transplantation is a brief description of the surgical textbooks of dermatology skin [8]. For more information, Several handbooks have hair transplant sections devoted to this technique. [9, 10]
Most types of problems that can occur in FUT procedures grouped into two broad categories: those related to errors in planning for the transplantation of hair and those caused by errors in surgical technique. Of the two, planning errors often lead to much more serious consequences for the patient and will be here.
Patient selection
Age
The biggest mistake you can make a doctor for treatment of a patient with hair loss is to perform a hair transplant to someone that's too young. Although there is no specific age that can be used as a cut (which varies from person to person), the understanding of the problems associated with Restoration of hair in young people can help the doctor to decide when surgery in May. Error can literally ruin a young person? s life.
When a person begins to lose hair in their teens or just over 20 years, there is a strong likelihood that he (or she) can become large bald later in life and that the donor site in May to become thin and see through time. Although miniaturization (reduced diameter hair) at the donor site is a first indication that this occurred in May and can be detected by densitometry, that these are not obvious when a person is still young.
If a person had to be very simple (a Norwood Class 6 or Class 7), it is often not sufficient to cover the hair of his crown. A scalp transplant crown or a fine of baldness is a justification for an adult, but totally inappropriate for a person in their twenties. [11] In addition, if the donor area have been thin over time, the donor can scar be visible, if it is short hair - a style that is much more common in people who are young.
Expectations
This topic is very closely related to age. Surgical hair restoration to succeed, expectations must correspond to what can actually be achieved. Expectations a young person is usually re-appearance was as a young person, ie have a wide, flat and have all of the hair density, did a few years ago.
The problem is that the transplantation of hair no more hair (and therefore can not increase the density) prevents the prosecution or the loss hair (for the model must be adapted to the person's age). But decreased from the temples and crown a fine is not acceptable to a younger, surgery should be postponed more than one person is not acceptable. As a person ages, often becomes more realistic and is happy with the hair transplantation can achieve. And, over time, if a person? s donor site is stable and limited hair loss, more ambitious targets can be achieved.
Chronic exposure sun
While it is common wisdom to avoid sunburn after a hair transplant, in fact, chronic sun exposure? S a lot of life more significant negative impact on the outcome of hair transplant peri-operative, where exposure to the sun.
Actinic damage to collagen and elastic fibers so that the buds are not included in the security and changes in the vasculature reduces the ability Receptor support tissues for transplantation of a large number of transplants. Even with very small receiver locations used in follicular unit transplantation, it is too close to the sites may jeopardize the blood supply and low growth.
Another problem is that the hair transplant to cover the areas of sun damage and cancer detection more difficult. When wines are ultimately linked Actinicus treated sections of hair transplantation will be destroyed.
The best approach for a person to damages caused by the sun first to treat the entire scalp with aggressive 5-flurouracil to eliminate precancerous lesions before transplantation is considered hair. You need at least 6-12 months after treatment to the scalp to heal completely, because the tissue is more fragile during this period. Although this treatment can return to surgery a year or more, which will translate into better graft survival and fewer problems in the future detection of skin cancer.
Terms medicines and medical
Although not necessarily an absolute indication for surgery against a series of conditions are the medical unit transplantation hair follicle procedure more difficult and must be taken into account. Provided that the medical conditions are present, it is always prudent to obtain medical authorization for the patient? s primary care physician or specialist.
Because the scalp is very vascular, including the procedures and the participation of a large surgical team, patients who had blood born pathogens such as HIV and hepatitis B and C, some risk to the staff, despite the precautions universal use. It is helpful if the team is aware of the clinical history of hair transplant patients, so they can proceed to a higher level of alert in case necessary.
In an HIV-positive patients, it is important to ensure that the patient? S, state immunity is sufficient, so the patient no no increased risk of infection. In the patient? S with hepatitis, it is important to assess their liver function so that the medication dose is appropriate.
Patients with diabetes mellitus in May to an increased risk of peri-operative infection. In this case, the conditions of asepsis that most hair transplants are performed can be modified by a amendment sterile technique (modified in that it is difficult to prepare the scalp). This should also be considered in patients with valvular disease and other implanted cardiac devices in which bacteria can be sown more serious consequences. Antibiotics should be administered to persons at high risk, but it is not necessary in the routine of hair restoration procedures. [12]
A bleeding, large enough for effects of surgery can be performed on the patient? History, but the drugs often pass under the radar must be specifically requested. patient? s not often? Do not think of taking aspirin and the report must be requested, as well as other non-steroidal anti-inflammatory drugs. Plavix, in particular, can significantly increase the bleeding during the procedure. Alcohol, of course, as well as increased bleeding. [13]
We need to make adjustments to a patient? s anticoagulant in conjunction with a cardiologist or doctor. In general, we must put an end to anti-platelet medication a week before the transplantation of hair, but the interval may vary depending on the drug, the size of procedures and the importance of the drug to the patient? s health. Can be taken three days after the procedure. If anticoagulation can not be stopped in May, it is reasonable for a small session.
Since epinephrine is used in most of the hair restoration procedures, whether a person has a history of heart rhythm disorders or other diseases that could be exacerbated by adrenaline, the patient's medical certificate? s doctor or cardiologist should be obtained. Epinephrine can also interact with a wide beta-blockers such as propranolol, causing a hypertensive crisis, therefore, it is preferable that the patient move a selective beta-blocker surgery. [14]
A series of manipulations can be used for the checking of bleeding and reduce the need for adrenaline. Among the most useful, is widely dispersed sites in the graft recipient site (allowing extrinsic pathway of coagulation start) and then fill with other sites, when the bleeding has stopped. [15]
If patients have a history of seizures, it is important not to abandon their medication and that the procedure doctor gets. Attention is also drawn from normal patients can have a vaso-vagal episode during the procedure, especially during the administration of local anesthesia. This can be avoided by placing the patient immediately Trendelenberg when the patient complains of nausea or start to sweat, or look pale.
A patient should be monitored with a pulse oximiter if a large quantity of sedatives and other respiratory depressants are used. The patient should be monitored closely to ensure that local anesthetics are administered in amounts of insurance and that the signs of an overdose of lidocaine are well known to all members of the surgical team. [16]
Finally, it is useful to have a pre-printed summary of all drugs and their doses are commonly used during the procedure. This can give the patient? S Medical research care.
Psychological factors
Hair loss can have a psychological evaluation of a person? S self-esteem and lead to distress emotional. When a person has underlying psychiatric problems, the consequences can be severe and, therefore, the management of hair loss more difficult. It is important to identify these problems and other psychological factors can play a role in a patient? s ability to understand both the process of hair restoration and results.
In some cases, counseling can be done in collaboration with the restoration of hair, but often must precede the treatment, especially when considering surgery. It is prudent to obtain authorization for surgery from a psychiatrist or clinical psychologist if there is a history of mental illness, or when suspected at the time of consultation.
A number of psychiatric disorders are particularly important to the success of a hair transplant. These include Trichotillomania, obsessive-compulsive disorder (OCD), body dysmorphic syndrome (SDE), and depression.
Trichotillomania is characterized by a relatively common continuing need for an exit? s hair. It is usually the hair of the scalp, but may also involve the eyelashes, facial hair or other body hair. Of It follows often vague and can be identified by the short hair in the affected area that are not long enough to understand. trichitollomania assets anywhere in the body Obviously it is compared to a hair transplant, but if a person has a history of the disease, the doctor should also be careful and make the surgery, if the therapist is convinced that the condition is unlikely to be repeated.
Obsessive-compulsive disorder (OCD) is a condition characterized by recurrent thoughts (obsessions) and behaviors (compulsions), which sought to neutralize the anxiety or stress caused by the obsessions. In the consultation, the patient usually requires a litany TOC questions and, often, the question before hearing the answer to the question above. OCD patients is extremely difficult to meet even in a good transplant hair may be concentrated in a small imperfection forget the apparent total success.
Body dysmorphic disorder (BDD) is a mental disorder that involves a distorted image of one of the? Body. The person is very self-critical physical, although there is no real failure in May. It should be obvious that patients with BDD will not be satisfied with a hair transplant or other forms of cosmetic procedures and the condition is best treated by a psychiatrist rather than a surgeon. Another cautious note is that patients with BDD have a suicide rate much higher than the rest of the population, even more than patients with depression. [17]
Depression is perhaps the most common psychiatric disorders found in patients? S seeking hair transplantation, but also is a symptom common to those experienced hair loss. The physician must distinguish between an emotional reaction and reasonable calvicie depression requiring psychiatric counseling. It is important to realize that the hair transplant would be ineffective in curing depression, and unmet medical needs can lead to an increase of the condition.
References
1. Orentreich N: autografts in alopecia and other skin diseases. Annals of the New York Academy of Sciences 83:463-479, 1959.
2. Bernstein RM, Rassman WR, Szaniawski W, Halperin A: Follicular Transplantation. Int J Aesthetic Restorative Surgery 1995; 3: 119-32.
3. Bernstein RM, Rassman WR: Follicular Transplantation: Patient Evaluation and Planning surgery. Dermatol Surg 1997; 23: 771-84.
4. Bernstein RM, Rassman WR: The Aesthetics of Follicular Transplantation. Dermatol Surg 1997; 23: 785-99.
5. Gandelman M, et al: Light and electronic microscopic analysis of damage control to the follicular unit grafts. Dermatol Surg 2000; 26 (1): 31. \
6. Bernstein RM, Rassman WR, Rashid N, Shiell R: The art of surgical repair of Hair Restoration - Part I: basic repair strategies. Dermatol Surg 2002; 28 (9): 783-94.
7. Bernstein RM, Rassman WR, Rashid N, Shiell R: The art of surgical repair of Hair Restoration - Part II: The tactics of repair. Dermatol Surg 2002; 28 (10): 873-93.
8. Bernstein RM, follicular unit hair transplantation. In: Robinson JK, Hanke CW, Siegel DM, Sengelmann RD, editors: Surgery the skin, Mosby Elsevier, London, United Kingdom. 2005.
9. Unger WP, R. Hair Transplantation Shapiro. New York: Marcel Dekker, Inc. 2004.
10. Bernstein RM, Rassman WR. Unit Follicular Transplantation. In: Haber RS, Stough DB, editors: The transplantation of human hair, in Chapter 12. Elsevier Saunders, 2006: 91-97.
11. Norwood OT. Male baldness: classification and incidence. Tan Med J 1975, 68:1359-1365.
12. Haas AF, Grekin RC: Antibiotic Prophylaxis in Dermatologic Surgery. J Am Acad Dermatol 1995; 32: 155-76.
13. Otley CC. Perioperative assessment and management of dermatologic surgery. J Am Acad Dermatol 2006; 54: 119-27.
14. Gandelman M, R Bellio, Barretto M: Beta-blockers and vasoconstrictors with local anesthetics: a dangerous combination. Int J Aesthetic Restorative Surgery 1995 3 (2): 143-45.
15. Bernstein RM, Rassman WR: Limiting epinephrine in large sessions of hair transplantation. Forum International Hair Transplant 2000, 10 (2): 39-42.
16. Skidmore RA, Patterson JD, Tomsick, RS: Local anesthetics. Dermatol Surg 1996; 22:511-522.
17. Phillips KA, Menard W: body dysmorphic disorder, suicidal tendencies: a prospective study. Am J Psychiatry 2006; 163:1280-82.
18. Bernstein RM, Rassman WR. The scalp laxity paradox. Forum International Hair Transplant 2002, 12 (1): 9-10.
About author:
Dr. Bernstein is Clinical Professor of Dermatology at the College of Physicians and Surgeons of the University of Columbia in New York. It is recognized world wide for pioneering Follicular Unit Hair Transplantation. Dr. Bernstein hair restoration center in Manhattan is dedicated to treatment of hair loss using your current techniques of hair transplantation.
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