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Avoid mistakes in planning for a hair transplant (part 1)

Although many technical advances have been made in the field of restoration surgical hair in the last decade, particularly with the widespread adoption of follicular transplantation, many problems remain. Most revolve around doctors recommend surgery for patients who are not good candidates. The most common reasons that patients should not proceed with surgery is too young and that their pattern of hair loss is too unpredictable. Youth also have expectations that are typically too high – often require the density and hairline of a teenager. Many people who are in the early stages of hair loss, simply must be treated with medication, rather than be running to go under the knife. And some patients are not just mature enough to make decisions at the level of head when your problem is so emotional.

In general, the younger the patient, the more cautious the practitioner should be to operate, especially if the patient has a family history of Norwood Class VII loss of hair, or a diffuse pattern of alopecia.

Problems also arise when the physician can not adequately assess the patient? s supply of donor hair, and then Hairless sufficient to meet the patient? s goals. Careful measurement of a patient? S density and other characteristics of the scalp to allow the surgeon to know exactly how much hair is available for transplantation and allow him / her to design a template for the restoration can be accomplished within those limitations.

In all these situations, spending a little time to listen to the patient? S concerns, examine the patient more carefully and carried out a treatment plan that is consistent with what actually can be done, goes a long way for satisfied patients. Unfortunately, the scientific aspects only improve technical hair restoration process and will do little to ensure that the procedure is done with the planning of the right or in the right patient.

View five years

Improved surgical techniques have enabled a growing number of grafts that are placed in increasingly receptor sites children had nearly reached its limits and limitations of the supply of donors remain the main obstacle to patients getting a head full of hair. Despite the initial enthusiasm of the great FUE, a technique in hair can be harvested directly from the donor scalp (or even the body) without a linear scar, this procedure has added relatively little to increase the patient? s total supply of hair available for transplantation. The main thrust come when the supply of donors can be expanded if cloning. Despite some recent progress has been made in this area (particularly in animal models) the ability to clone human hair is at least 5 to 10 years away.

Key Issues

1. The biggest mistake a doctor can make the treatment a patient with hair loss is to perform a hair transplant to a person who is too young, since expectations are generally very high and the model of future loss Hair unpredictable.
2. Chronic exposure to the sun more than one? S lifetime has a much more significant negative impact on the outcome of hair transplant that sun exposure peri-operatively.
3. A bleeding diathesis, severe enough for the impact of surgery, may be general, Incorporated the patient? S history, however, the counter medications often go unreported (as non-steroidal) and must be specifically requested.
4. Depression is probably the most common psychiatric disorder in patients? S-looking hair transplant, but is also a common symptom of people suffer from hair loss. The physician must differentiate between a bald reasonable emotional response and depression requiring psychiatric help.
5. In making a transplant hair, the physician must balance the patient? s present and future needs for hair with current and future availability of supply of donors. It is well known that one? s pattern baldness progresses over time. What is less appreciated is that the donor may also change.
6. The patient? S donor supply depends a number of factors including the physical dimensions of the permanent zone, the laxity of the scalp, the density of donor hair characteristics, and Most importantly, the degree of miniaturization in the donor area – as this is a window on the future stability of the supply of donors.
7. Patients with very loose scalps often heal with scarring of donors increased.
8. Never assume that a person? S hair loss is stable. Hair loss tends to progress over time. Even patients who show good response to finasteride eventually lose more hair.
9. The position of the line normal adults male hair is about 1.5 cm above the fold of the high forehead. Avoid placing the newly transplanted hair line in the position of adolescents in an appropriate place for an adult.
10. One way to avoid a hair transplant with a look that is too thin to limit the scope of coverage in the face and scalp until the middle of an adequate supply of donors and a balding pattern can be reasonably assured limited – a guarantee that can only come after the patient age. Until then, it's best to avoid adding coverage to the crown.

Introduction

Hair transplantation has been available as a treatment for hair loss for over 40 years. [1]

Through a majority of the time, hair transplantation is characterized by the use of earplugs, slit grafts, flaps and micro mini-grafts. Although these were the best tools available to physicians at the time, were unable to consistently produce natural results.

With the introduction of Follicular Unit Transplantation (FUT) in 1995, doctors finally were able to produce these natural results. [2] However, the mere ability to produce will not necessarily ensure that these natural results actually achieved. The procedure presents FUT new challenges for the hair restoration surgeon and only when the procedure was well planned and perfectly executed, that the patient really benefit from power this new technique. [3]

The ability of follicular unit grafts to mimic nature soon produced results that were completely undetectable. This is the hallmark of the Unit of follicular hair transplant. [4] Equally important, however, is the preservation of hair – the one to one correspondence between what is crop the donor and what ultimately grows in the recipient scalp. Since a limited supply of donors is the main obstacle in hair transplantation, the hair preservation is a fundamental aspect of each technique. However, unlike old procedures that used large grafts, units are easily traumatized follicular delicate and very susceptible to desiccation, as the follicular unit transplantation procedures, with the participation of thousands of grafts, particularly challenging. [5]

As of this writing, the vast majority of hair transplants performed in the U.S. use techniques follicular transplant unit. Due to limited space, this review will focus on technique, and thus not only in the procedures. Nor will focus on the follicular units extraction, since this technique is still evolving, and ways to avoid the major pitfalls of this procedure are still being developed and a subject in itself. As the title suggests, this paper will focus on the prevention of various problems encountered in the FUT, rather than its treatment – an equally important issue, but that has already been covered in an extensive overhaul. [6, 7]

For those unfamiliar with the conditions of service, there is a concise review the item at the text dermatology skin surgery [8]. For more detailed information, textbooks, hair transplantation has several sections devoted to this technique. [9, 10]

The most common types of problems that occur in FUT procedures can be grouped into two broad categories: those related to errors in planning hair transplantation and those caused by errors in surgical technique. Of the two, mistakes in planning can often lead to consequences much more severe for the patient and will be the subject of this document.

Patient Selection

Age

The single biggest mistake a doctor can do in treating a patient with hair loss is to perform a hair transplant to a person who is too young. Although there is no specific age that can serve as a cutoff point (as this varies from person to person) the understanding of the problems associated with the completion of the restoration of hair in the young people can help the doctor to decide when surgery may be appropriate. mistake can literally ruin a young person? s life.

When someone is starting to lose hair in their teens or 20 years, there is a significant possibility that he (or she) may become bald later widely in life and that the donor may become thin and see-through time. Although miniaturization (diameter reduction of the hair shaft) at the donor site is a sign Early this can occur, and may be collected by densitometry, these changes may not be evident when a person is still young.

If a person to become very bald (become a Norwood Class 6 or Class 7), then do not usually have enough hair to cover his crown. A transplanted scalp with a thin crown or baldness is an acceptable model for an adult, but totally inappropriate for a person in his twenties. [11] In addition, if the donor area were to thin over time, the scar donor may be visible if you had short hair – a style that is much more common in younger people.

Expectations

This topic is very closely age-related. For non-surgical hair restoration to succeed, the expectations must match what is actually achievable. The expectations of a person young often return to the appearance it had as a teenager, that is to have an extensive background and hairline so that all the density they had only a few years earlier.

The problem is that a hair transplant does not create more hair (and therefore can? Increase the overall density of t) and prevents loss further hair (so the pattern should be appropriate to the person as they age). But retreated from the temples and crown thin look is not acceptable for a person young, the best surgery should be postponed in a person who is not acceptable. As a person ages, often becomes more realistic and is happy with what a hair transplant, can do. And, over time, if a person? s donor site appears to be stable and limited hair loss, more ambitious goals can be achieved.
Chronic Exposure sun

Although common wisdom is to avoid sunburn after a hair transplant, in fact, significant chronic exposure the sun for more than one? S life has much more negative impact in the outcome of transplantation of hair then sun exposure peri-operatively.

Actinic damage alters collagen and elastic fibers so that the grafts are not taken safely and impaired vascularization decreases the ability tissue transplant recipient to support a large number of grafts. Despite the very small recipient sites used in follicular unit transplantation, which makes close sites can result in a compromised blood supply and cause poor growth.

Another issue is that a hair transplant will be discussed aspects of sun damage and make more difficult the detection of cancer. When the growths are treated actinic Related finally, the sections involved hair transplant will be destroyed.

The best approach in a person with sun damage is important to address first the entire scalp aggressively with 5-flurouracil to remove all pre-cancerous lesions before hair transplantation is contemplated. You must wait at least 6-12 months after treatment to the scalp to heal completely, because the tissue is more friable in this period. Although this treatment can set back surgery a year or more, the result is the survival better graft and fewer problems with future detection of skin cancer.

Medical conditions and medications

Although not necessarily a contraindication absolute for surgery, a number of medical conditions that the process of follicular unit hair transplantation more problematic and should be taken into account. Whenever major medical conditions are present, it is always wise to get medical clearance from the patient? s primary care physician or appropriate specialist.

Because the scalp is very vascular and FUT procedures involving a large surgical team, patients known to have been born of blood pathogens, such as HIV and Hepatitis B and C represent more risk to staff, despite the use universal precautions. It is useful if the team is aware of the medical records of hair transplant patients so they can proceed with greater warning when necessary.

In a patient with HIV positive, it is important to ensure that the patient? S immunological status is adequate, so the patient does not have an increased risk of infection. Patients? S with hepatitis, it is important to evaluate liver function so that the dose of medication is appropriate.

Patients with diabetes mellitus may be at greater risk have a perioperative infection. In this case, the normal conditions of asepsis that are performed most hair transplants might change under a technical sterile a change (instead of that it is difficult to prepare for the scalp). This should also be considered in patients with valvular heart disease, implanted devices and others in which the bacterial seeding may have more serious consequences. antibiotic coverage should also be administered in high – risk, although not necessary in routine procedures in hair restoration. [12]

A bleeding diathesis, severe enough to the impact of surgery, may be general, as recorded in the patient? S history, however, the drugs often pass under the radar and was specifically requested. patient? s often don? I think taking aspirin to report and this should be asked and other nonsteroidal antiinflammatory drugs. Plavix, in particular, can significantly increase bleeding during the procedure. Alcohol, after increases of bleeding as well. [13]

One must adapt to a patient? s medication anti-coagulant in conjunction with your cardiologist or family doctor. As a general rule, allow anti-platelet drugs a week before the hair transplant, but the interval may vary depending on the specific drug, the size of the procedure and the importance of medication to the patient? s health. They can resume three days after the procedure. If anticoagulants can not be stopped, it may be reasonable to proceed with a smaller session.

Since epinephrine is procedures used in hair restoration, if a person has a history of arrhythmias or other cardiac disease that could be exacerbated by adrenaline, medical certification of the patient? s primary care physician or cardiologist should be obtained. adrenalin may also interact with antibiotics of wide blockade beta as propranolol, causing a hypertensive crisis, therefore, it is best to have the patient switch to a selective beta-blocker surgery. [14]

A series of manipulations that can be used during the procedure to control bleeding and decrease the need for adrenaline. Among the most useful, is the dispersion receptor sites in general terms about the area to be transplanted (allowing the extrinsic pathway of coagulation to begin with) and then fill in the areas with additional sites when bleeding has decreased. [15]

If patients have a history of seizures, it is important not to discontinue their medication for medical clearance procedure and obtained. We must also remember that otherwise normal patients may have a vaso-vagal episode during the procedure, particularly during the administration of local anesthesia. This can be avoided immediately placing the patient in Trendelenburg as soon as the patient complains of nausea or starts to sweat or paleness.

A patient should be monitored with a pulse oximiter if used a large amount of sedatives or other respiratory depressants. The patient should be closely monitored to ensure that local anesthetics are administered in safe amounts and that the warning signs of an overdose of lidocaine are well known to all surgical team members. [16]

Finally, it is useful to have a pre-printed summary of all medications and dosages commonly used during the procedure. This can give the patient? S GP when it comes to medical certification.

Psychological factors

Hair loss can take a psychological toll on a person? S self-esteem and cause considerable emotional distress. When a person has underlying psychiatric problems, the impact may be more serious and therefore, management of hair loss considerably more difficult. It is important to identify these problems and other psychological factors can play a role in a patient? s ability to clearly understand both the hair restoration process and outcome.

In some cases, counseling can be conducted in conjunction with hair restoration, but often must precede treatment, especially when surgery is contemplated. It is prudent for 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 especially important for the success of a hair transplant. These include trichotillomania, obsessive-compulsive disorder (OCD) syndrome Body Dysmorphic (BDS) and depression.

Trichotillomania is a relatively common condition, characterized by a persistent desire to get one? s hair. The most common is the hair of the scalp, but can also include eyelashes, facial hair or other body hair. Often leads to baldness and can be identified by short hairs on the affected area are not long enough to understand. trichitollomania assets anywhere in the body is a clear contraindication to a hair transplant, but if a person has a history of this condition, the doctor should also be cautious and consider surgery only if the therapist trusts that the condition is unlikely to be repeated.

Obsessive-compulsive disorder (OCD) is a condition characterized by recurrent, intrusive thoughts (obsessions) and related provisions behaviors (compulsions) to try to neutralize the anxiety or stress caused by the obsessions. In the consultation, patients with OCD calls often to a litany of questions and often asks the following question before hearing the answer to the former. OCD patients are very difficult to satisfy and even a transplant very successful hair can focus on an apparent minor imperfection external to the good overall result.

Body Dysmorphic Disorder (BDD) is a mental disorder which involves a distorted picture of one? S body. You are very critical of his physical body, although there can be no real defect. It should be obvious that patients 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 caveat is that patients with BDD have a suicide rate much higher than the general population, even greater than patients with depression. [17]

Depression is probably the most common psychiatric disorder in patients? S for hair transplantation, but also a common symptom of those suffering the loss hair. The physician must differentiate between a bald reasonable emotional response and depression requiring psychiatric counseling. It is important to realize that a transplant hair, be ineffective to cure a medical depression and unfulfilled expectations can lead to a worsening of the condition.
References

1. Orentreich N: Autografts in alopecia and other selected dermatological conditions. Annals of the Academy of Sciences New York 83:463-479, 1959.
2. Bernstein RM, Rassman WR, Szaniawski W, Halperin A: Follicular Transplantation. Intl J Aesthetic Restorative Surgery 1995; 3: 119-32.
3. Bernstein RM, Rassman WR: Follicular Transplantation: Evaluation of patients and surgical planning. 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 electron microscopic analysis of controlled injury to follicular unit grafts. Dermatol Surg 2000, 26 (1): 31.
6. Bernstein RM, Rassman WR, Rashid N, Shiell R: The art of repair in surgical hair restoration – Part I: Strategies for repair base. Dermatol Surg 2002; 28 (9): 783-94.
7. Bernstein RM, Rassman WR, Rashid N, Shiell R: The art of repair in surgical hair restoration — Part II: The tactics of repair. Dermatol Surg 2002; 28 (10): 873-93.
8. Bernstein RM, Unit Hair Transplantation Follicular. In: Robinson JK, Hanke CW, Siegel DM, Sengelmann RD, editors: Surgery of the Skin, Elsevier Mosby, London, UK. 2005.
9. Unger WP, Shapiro R. Hair Transplantation. New York: Marcel Dekker, Inc. 2004.
10. Bernstein RM, Rassman WR. Conditions of Service. In: Haber RS, Stough DB, editors: Hair Transplantation, Chapter 12. Elsevier Saunders, 2006: 91-97.
11. Norwood OT. The male pattern baldness: classification and incidence. Tan Med J 1975, 68:1359-1365.
12. Haas AF, Grekin RC: Antibiotic prophylaxis in surgery dermatology. J Am Acad Dermatol 1995; 32: 155-76.
13. Otley CC. Perioperative assessment and management in dermatologic surgery. J Am Acad Dermatol 2006; 54: 119-27.
14. Gandelman M, BELLI R, Barreto M: Beta-blockers and local anesthetics with epinephrine: a dangerous association. Intl J Aesthetic Restorative Surgery of 1995, 3 (2): 143-45.
15. Bernstein RM, Rassman WR: Limiting epinephrine in large hair transplant sessions. Hair Transplant Forum International 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: Suicide in Body dysmorphic disorder: A prospective study. Am J Psychiatry, 2006, 163:1280-82.
18. Bernstein RM, Rassman WR. The paradox of the laxity of the scalp. Transplant Hair International Forum 2002, 12 (1): 9-10.

About the Author

Dr. Bernstein is Clinical Professor of Dermatology at the College of Physicians and Surgeons of Columbia University in New York. He is recognized world wide for pioneering Follicular Unit Hair Transplantation. Dr. Bernstein’s hair restoration center in Manhattan is devoted to the treatment of hair loss using his state-of-the-art hair transplant techniques.

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