hair transplant surgeon in kolkata | dr. jayanta kumar saha
TRANSCRIPT
Dr Jayanta Kumar SahaConsultant Cosmetic & Plastic Surgeon
Surgical management of Hair Loss
ANATOMY OF HAIR
Hair consist of a shaft and a rootShaft is the visible portion above the scalp surface: Root or bulb is the follicle-sits at an oblique angle to the scalpShaft has 3 layers: cuticle, cortex and medulla
MICROSCOPIC ANATOMY OF HAIR
Hair matrix present at the base of the hair follicle canal within subcutaneous tissueWithin the matrix are rapidly dividing cellsAbove this layer lies zone of keratinization which makes the hair shaftThe layering of these newly keratinized cells at the base of the shaft causes the process of hair growth as the shaft moves up through the surface
HAIR GROWTH CYCLES
IMPORTANCE OF GROWTH CYCLES
Relevant in discussing hair transplantation with patients
After the follicle has been transplanted, one usually sees a resting/telogen phase and the patient should not expect any significant hair growth for 3 to 4 months
Characteristics of hair
Vellus / terminal
Thickness - racial
Cross section- round/ oval
Density : 200 – 400/sq cm
Angle – different in frontal/parietal/occiput
Color – varies from race to race
Anterior hairline
Fronto temporal recession
Irregular margin
Vellus to terminal hair gradually
TYPES AND PATTENS OF BALDNESS
MALE TYPE:ANDROGENIC ALOPECIAMost common type of hair loss in both male and femalePredetermined by genetic characteristicsIn regions of scalp susceptible to androgenic alopecia androgens reduce the growth rate, hair shaft diameter and length of the anagen phaseTarget cells found in bulbar region of follicleDihydrotestesterone(DHT) act on target cellsMostly affects the frontal and crown region of scalp
TYPES AND PATTENS OF BALDNESS
IN FEMALEMostly diffuse typeIn a subgroup of women hair loss pattern similar to menStart at the vertex and progress anteriorly as they approach 30s and 40sUsually family history positiveMost of them maintain a low anterior hairline unlike the men who show progressive frontal hair loss.
OTHER CAUSES OF ALOPECIA
Post ChemotherapySurgeryMetabolic disordersAutoimmune diseasesTraumatic:
Temporary Permanent
Post burnAesthetic surgery of face
Hair transplantationComatose patient lying in one posture
NORWOOD CLASSIFICATION OF BALDNESS
FEMALE TYPE BALDNESS
LUDWIG SCALE
SAVIN SCALE
Evaluation of patient
Invasive – scalp biopsy
Semi invasive – trichogram
Non invasive – hair pull testtrichoscanfolliscope
ROLE AND EFFECTIVENESS OFMEDICATIONS
MINOXIDIL:LOCAL APPLICATIONWorks primarily by increasing blood flow
Promotes hair regrowth or hair stabilization in those follicles which are affected by androgenic alopecia
FINASTERIDE ORALLY:Dose 1 mg/day
Selective inhibitor of α-reductase type IIThere is uptake of testesterone by hair follicles which is converted to DHT by 5 α- reductaseDHT acts on androgenic receptor
1.Hair grafts2.Scalp flaps3.Expanded hair bearing flaps4.Scalp reduction
SURGICAL PROCEDURES
HAIR TRANSPLANTATION- TERMS USED
Micrograft=one to two hairsMinigraft= three to six hairsSingle Follicular Unit (FU)=one to four hairMulti Follicular Unit (FU)=two to three unit/two to six hair grafts.
HAIR TRANSPLANTATION- Instruments
Scissors, small Mosquito forceps, small Needle holder, small Dissecting forceps Delicate tissue forceps Tissue forceps, small Metal matrix for trichodensitometry (Neidel)Scalpel handle (blades available: sizes 10, 11, 15) Metal comb Syringe, Luer LOK 20 cc, for tumescence with saline 0.9%
INSTRUMENTS FOR GRAFT/FOLLICULAR UNIT PREPARATION
Petri dishes with saline 0.9% Scalpel handle (blades available: no. 10) Delicate tissue forcepsExtremely delicate dissecting forceps Forceps for micro- and minigrafting (implantation) Wood for preparation
HAIR TRANSPLANTATION
Instruments for Micropunch TechniqueMicropunch 0.8 mm diameter Micropunch 1.0 mm diameter Handpiece for micropunch
HAIR TRANSPLANTATION
Instruments for Microslit TechniqueSharpoint (15°/22.5°/30°/45°
pointed tip) Handle
Techniques of hair graft harvest
Follicular unit transplant (FUT)
Follicular unit extraction (FUE)
HAIR TRANSPLANTATION-DONOR AREA
Preparation of the Patient, Hairline DesignDonor AreaThe donor area should not be more than 2 cm above an imaginary line connecting the tips of the patient’s ears behind the head. To be careful not to harvest an overly large skin strip so that you will not have to discard hair follicles later.To measure follicle group density, i.e., follicular units per square centimeter by Russman densitmeterWith this figure, the number of follicular units to be transplanted can be calculated from the total area of the donor strip.
LOCAL ANAESTHESIA
Intradermal infiltration anesthesia using 0.5% lignocaine with adrenaline.Injection of a 0.9 % saline solution is employed to achieve tumescence of the donor area.Caution: subgaleal injection is contraindicated to prevent injury to major nerves and blood vessels during
the subsequent skin incision.
DONOR STRIP HARVESTING
To remove a trapezoidal donor strip .Avoid transection of the hair follicles by making an incision at an angle of about 45° and cutting exactly parallel to the direction of hair growth.To detach the strip below the hair roots in the fatty layer.Place the harvested strip into a sterile cooled 0.9 % saline solution immediately.No mobilization.No opening of the galea.
CLOSURE
Hemostasis should be carried out on the galea only and not near the hair follicle.Closure by continuous suture
FOLLICULAR UNIT PREPARATION
The donor strip is placed on a non-slip sterile wooden board and sliced into small segments.To work with magnifying spectacles or a binocular microscope.To avoid transectionsThe segments are divided further into strips; the follicular units are now arranged in a row on a piece of gauze.
FOLLICULAR UNIT PREPARATION
RECIPIENT AREA, HOLES AND SLITS
To work in the direction of hair growth. Following the hairline design, punch out 0.8 mm holes for transplants containing 1–2 hairs.After punching between 5 and 10 holes, make a test transplant to determine whether the transplants can be inserted without any problems. Never transplant hair only along the marked line, as this results in an unsightly “pearl necklace effect”.A feathered hairline is the effect to be achieved: “irregular regularity” is the key word .
RECIPIENT AREA, HOLES AND SLITS
TRANSPLANT OF THE GRAFT
Transplantation of follicular units with a sharp angled microtweezersPerform non-traumatic implantation with no crushing of hair roots. The follicular units are placed on moist gauze strips ; they are picked up individually and then transplanted.End of the transplant should be flush with the skin surface or .5-1mm above itThe FU to be snugly fit
POST-OPERATIVE CARE
The traditional dressing is a bilayered protective and absorptive dressing with the first layer made from several nonstick Telfa pads covered with a thin layer of an antibiotic such as mupirocin cream or ointment. Micropore tape attaches this underdressing to the patient’s forehead. A turban style overdressing wrapped over several layers of 4×4-inch gauze pads is constructed and finished off with elastic retainer netting (Surgilast no. gl-705).Some patients greatly prefer a more minimal dressing, or no dressing at all. But there is a risk of bleeding and graft dislodgement
Infection prophylaxis is given for 3 days after the operation. From the 3rd day the patient can wash his or her hair with a mild chamomile shampoo.The hair can then be washed daily. After a maximum of 2 weeks all crusts should have disintegrated with washing; crusts delay wound healing. Rough manipulation should be avoided, particularly in the 1st postoperative week, as there is a risk of postoperative bleeding.The patient can be professionally and socially active again 1 week after the operation.
FUT vs FUE
Observation FUT FUE
Pain Minor None
% of time doctor operating 10-30% 80-90%
Stitches Yes No
Extensive bleeding May occur No
Wearing short hair Not possible Possible
Natural results Yes Yes
Nerve damage, numbness Possible No
Healing time- donor area 2-3 weeks 7 days
FUT vs FUE cont…
Observation FUT FUE
Healing time – recipient area
About 2 weeks Same
Graft transection rate 1-2% 5-10%
Recovery time 2-3 weeks 1-2 weeks
Return to work The day after same
Scarring at donor area Present Microscopic
Reaction to sutures Rarely seen Never a problem
Shaving of head Not needed Needed
Large areas possible difficult
Cost cheaper expensive
Fatigue Not tiring tiring
SCALP FLAPS
Earliest flap used: Temporal parietal-occipital flap described by JuriScalp flaps give immediate results with dense frontal hairlineProblem:
Dense frontal hairline shows an unnatural appearance because of its abruptnessTends to round out a normal temporal recessionRequires micro and mini hair transplants in front of the flap to cover the scar Dog ear
SCALP FLAPS
Scalp flaps mainly used for frontal baldness
Limitation of scalp flap:Relative inelasticity of scalp tissueWidth is limited if the area has to be closed primarily
Limitation can be overcome by tissue expansion and scalp flaps
EXPANDED HAIR BEARING FLAPS
Bilateral vertical and temporal posteriorly based transposition flaps in conjunction with expanded temporal-parietal-occipital advancement flaps and a third expanded occipital flap for vertex coverage.
SCALP REDUCTION
Used in patients with extensive hair loss with limited donor site
Problem: Stretch back (Reappearance of non hair bearing skin due to re-stretching of the skin due to tension)
Complications
Low anterior hairline
Poorly designed hairline
Large hair plugs – corn row appearance
Hematoma/infection
Inclusion cyts
Corn row appearance
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