Follicular Transportation (part 1)
INTRODUCTION
Follicular Transplantation is the logical endpoint of more than 30 years of evolution in hair restoration surgery beginning with traditional larger plugs
culminating in the movement of one, two and three hair units, which reflect how Hair grows in nature. The key to follicular transplantation is to identify
the patient? s natural hair groupings, dissect the follicular units of the skin surroundings, and placing these units in the area of the receiver in a density and
appropriate distribution for a mature person. The critical elements of follicular transplantation are an accurate estimate of the supply of donor hair
meticulous dissection of follicular units, careful design of the receiving area to maximize the impact cosmetic hair transplantation, the use of large
number of implants in fewer rather than more sessions, a long-term master plan to account for the progression of male pattern alopecia, and realistic
expectations by the patient.
FOLLICULAR UNITS
The concept of follicular transplantation is based on the observation that, in general, hair does not grow in isolation but, with the exception of the hairline
emerge from the scalp in groups called units follicular. Histologically, these units are composed of 1-4 and 1-2 terminal villous hairs that form a
distinct group bounded by a circle of collagen band of the adventitia, the perifolliculum1. Two or three hairs within this group is often integrated in a
common channel and protrude through a single follicular orifice (Figure 1a). The merger of the axes is usually done in the infrastructure of the infundibulum
hair follicle. The variations can be seen on the axes to share some anatomical structures with their neighbors get through the individual pores, but next. The
no anatomical fusion importance of unity, but the fact that the distance between the follicular groups exceeds the width of the follicular unit
it (Figure 1b). If these follicular units are ignored in the dissection, then more skin will be transplanted hair and skin more than being
moved as needed. If these groups are recognized, the implant can be "follicular" and anatomical proximity of the hairs within each unit can be used for
Surgeon? s advantage.
The advantages of using follicular implants in contrast to the grafts traditional include:
- Size of the surgical wound at the recipient site is minimized
- The skin surface deformity is eliminated
- Distortion due to fibrosis associated with healing is reduced
- Natural scalp contour is preserved
- The diffusion of oxygen to implants is maximized
- Interruption of blood supply is minimized
- The recovery time after surgery is reduced
- Units can be placed hair close together
- The vast numbers of implants can be moved per session
- Hair can be distributed in a natural pattern
- Greater flexibility receptor site design
NATURAL HAIR GROUPS
The observation of more than 1,200 patients using the densitometer2 shows that the donor area the great majority of one? s terminal hair grows in "natural
hair clusters "of two, three, four, and rarely five or more hairs. These groups Natural hair is the clinical signification of the follicular unit, and have a
density of approximately 10 units per 10mm2 field, supporting the view that Headington1 absolute number of follicular units per unit area in man
appears to be relatively constant and is about one per mm2. The density of donors (the axes of Hair by mm2), however, is highly variable and can go anywhere
1-4 hairs per mm2. The number of hair shafts in each follicular unit varies for each individual and related to the patient? S donor average
density. Thus, in a patient with a high density (Figure 2a), would be a greater proportion of groups 3 and 4 setae follicular unit, but
Number of follicular units per mm2 still would be around one. In a person with low density (Figure 2b), the dominant groups Hair can be one and
two. The presence of many hairs occurring separately, thus the exception rather than the rule. To put it another way, a person with high density
no hair closer clusters, but has hair groupings with normal spacing between them. Each group, however, contains a higher than average
number of hairs. Similarly, in a patient with low density, the distance is no more, only the hair groupings are smaller. As the patient ages, hairs randomly
begin to miniaturize in each group so that each group will contain a combination of complete terminal hair, terminal part of miniaturized hairs, and hairs
hairs (which are clinically insignificant). Finally, the miniaturized hairs are lost and natural hair groupings are reduced in number. In all adults
patients the donor site contains terminal and miniature hair, indicating that this area is not really permanent, but thin gradually over time. It
not until the density total hair in the donor area falls below 1.5mm2 some follicular units completely disappear, and follicle density is seen
to decrease.
In a person susceptible to androgenetic alopecia, the balding area thins out in a manner analogous to the donor, or miniaturized hairs gradually
replace terminal hair, and hair groupings initially decrease in size as in number. The main difference is that in the area of baldness,
hair miniaturized hair can fill any group as the baldness progresses and can be as thin as to be indistinguishable from vellus hairs, whereas
the donor site usually remain three rather distinct populations of hairs, terminal, miniature, and fluffy. In some patients experiencing early
stages of what will end up in baldness extensive (ie, Norwood Class 6), where there is still something very light sparse coverage, the density of receptors in
these areas is surprisingly normal (ie close to the patient? s donor density). However, all the hairs in each follicular unit are extensively miniaturized.
This highlights the fact that not only the absolute number of hairs but their diameter and character that contribute to the clinical appearance of
fullness. In the area of baldness, it is only after the hair loss becomes extensive and the follicular units are composed of only one or two miniaturized hairs
each, that the actual follicular units begin to disappear from the bald area.
The importance of understanding the concept of hair groupings and their age-related changes is to look hair transplant natural hair
placed in the receptor site should approximate what would have been present naturally had the individual does nothing. Because hair natural
groups in the donor area correspond to the original hair groupings in the recipient area before they were affected by androgenic hormones, which reveal
proper that this area should be restored. For example, in the transplantation of a 45 years old Norwood Class 6 with an average density of 2.2 donors
hairs/mm2, could try to restore the front and top of the scalp, leaving significant bitemporal recession and the crown exposed. The distribution of natural resources
hair groups in this case could be 20% 1? s, 45% 2? S, 30% 3? S, and 5% 4? St. Therefore, attempting to place predominately 5 or 6 hair groups in this area
would be destined to look unnatural. Similarly, all one? S and 2? s in this situation would be too thin. In all situations, of course, the frontal hairline
units would consist of hair. In the vast majority of restoration procedures, it would be appropriate to attempt to adapt these groupings, as
occur in nature, to produce an aesthetically balanced appearance.
Wound Healing
There are four benefits associated with wound healing receiving area when follicular implants are used exclusively. This is to minimize the recipient site
size of the surgical wound, removing the skin surface deformity, decreasing the skin fibroplasia associated with healing and prevent the alteration pigment.
By limiting the implant to the elements of the skin follicle, the recipient wound site may be slightly higher than the same way as follicular unit
The unit sits comfortably in it. Since follicular units are so compact, one and two small pieces of hair have essentially the same space and can be placed
on site size, and two, three and four units of hair are the same size and can be placed on site size. Where contracts Slit extended
around the follicular unit inserted, the perfect fit minimizes the space of a clot to form and reduces the distance to return to epithialization. In this
situation, the fibrin "glue" will be most effective in obtaining the implant, exudate and crust formation is reduced, and the time will cure
shortened. We instruct all patients to shampoo the day after surgery, allowing the flow of water on low pressure transplanted area. This irrigation
allow most patients to be free of scabs within 24 hours, requires no bandages in the receiving area. We have found that removing
crusting in one day, the surrounding erythema fades more quickly. Within several days, the majority of patients Mild erythema and hair stubble
the only clue to his hair restoration procedure.
The hair on the back and sides of the scalp grows at an angle approximately 30 degrees. When larger grafts (which are essentially cylinders of skin and
hair) are harvested, the epithelium creates an acute angle at its top edge and an obtuse angle at the bottom. When the grafts are inserted into
the recipient site, which should be placed at an angle that matches the angle of the original hair ranging from about 30-60 degrees. Because
this angle, the mechanical forces acting on the graft immediately after placement and throughout the healing, interrupt edge to edge alignment of the prosthesis
with the surrounding skin causing either the solution or the elevation of the graft, or both. As each graft is distorted ever so slightly, the combined effect of
these grafts produced many surface irregularity (stoning songs wheel) Traditional hair transplantation. This irregularity of the surface becomes more clinically
evident with increasing graft sizes and sites strokes are made instead of slits. This phenomenon is mostly avoided when implants are
devoid of unnecessary skin.
cleft grafting prevents paved but often produces a dimpling or puckering of the place of the appearance of hair growth by skin down
together with the graft. Although technically follicular units are placed in "cuts" to reduce the perifollicular epithelium in the implantation follicular
the site is so necessary small (1 mm) and follicular unit so compact that this deformity does not occur.
Fibrosis resulting from wound healing biggest causes of an additional problem. And angulation
causes surface irregularities, it also produces a distortion of the dermis that may not be evident clinically. The importance of this is that
grafts placed parallel do not always end up having a parallel of hair on the surface of the skin where dermal reorganization is complete. This distortion prevents
the placement of the grafts near future due to the risk of damaging the existing (even if the original angle would be exactly reproduced). This distortion of
the hair shaft caused by fibrosis is easy to see each time the hair is harvested and dissected with a tissue donor site previously removed.
Indeed, one of the difficulties in repairing unsightly plugs, obviously, by the simple method of reducing density plugs with electrolysis is
the distortion of fibrosis prevents the introduction of needle electrolysis. Cutaneous Changes procedures and successive
difficulty in reproducing angulation are among the most compelling reasons for packing a high density area, given the first time instead of repeatedly violating a
transplanted area with several sessions.
Another victim of the use of larger grafts is the melanocyte. Repigmentation after the loss or alteration of the epidermis occurs by two mechanisms;
migration of melanocytes from adjacent normal epidermis and migrating the follicular appendages. The presence of focal hypopigmentation at the base of
larger grafts is due to the arrest of migration of melanocytes in the area and attests to the fact that the grafts have produced scar tissue that has been damaged
both epithelial elements. Hypopigmentation at the base of the grafts often serves to plugginess accentuate any apparent, highlighting the resultant
physical deformity with additional contrast ... that color. Thankfully, hypopigmentation is less common with very small grafts and has not been
observed in follicular transplantation.
And volumetric CONTOUR CHANGES
One of the problems, rarely discussed but very important cosmetic grafts is the extra volume of tissue introduced into the recipient site. This extra
tissue produces a rise in the fullness and scalp transplant and a clinically apparent ridge separating it from the surrounding bald scalp. (This
condition in which the area is relatively high soft must be differentiated from "hyperfibrotic changes" in the recipient area described by Stough3,
which is a process of proliferation and produces an area is indurated.) The reason for this is that baldness is not merely the absence of hair. It
atrophic process is a marked decrease or absent of all pilosebaecous units and their associated vasculature and supporting connective tissue. These
appendages contribute substantial volume in the normal scalp. The solution more used to solve the problem of adding additional tissue to
recipient area is cut off some of the receiving area of distance, ie, punch out. Unfortunately, the donor scalp intact is no perfect match when transplanted
in the area of white headset, since it is much richer in every one of these elements. Therefore, to remove the skin at the recipient site is a futile attempt
offsetting the increase in the volume of larger grafts, because the donor graft is much thicker than the atrophic recipient skin it replaces. The
best solution is to transplant the intact skin, first, but only to add the item follicular was lost.
Blood supply and oxygenation
In a scalp "virgin" the blood supply to the recipient area is unimpeded. Each graft placed in the receptor site induces local fibrosis that interferes with
normal blood flow, and each hit, cut down large or ultra laser site, has the possibility of transects or close blood vessels viable. Subsequent
procedures, hair located between existing grafts implanted into the scar (even though they may be microscopic) and receive the associated flow decreased
thereof. Transplantation in follicular the recipient site is created with a needle "and" knife that produces a minimal amount of trauma. A blood vessel
could be transferred immediately be resealable, much like a ship is cured after venipuncture. When the single hair graft is placed in the
site, the insert itself is gentle and causes no additional trauma the ship. If it were true that a decrease in blood flow would support uniform
Graft take it, then the asymmetry, gaps, or areas of density variable would result from this technique and are magnified in areas located very close "thick
packing "of grafts. However, this does not notes, despite the fact that follicular dense packaging techniques are used mainly in the frontal
hairline where any problem is more evident.
Since oxygen reaches the follicle by simple diffusion, oxygenation is a function of tissue mass. The higher the transplant unit, the greater the risk that
the center of the graft is affected by oxygen deprivation. By contrast, the barrier to oxygen transport is minimal with physiological
implant follicles. In this regard, the implant should have improved follicular survival and the phenomenon of "doughnuting" seen more grafts can be
avoided. In addition, from the follicular unit sits comfortably in the receiving area, one is a minimal amount of clot that prevents the spread of the dermis
the blood supply to the edge of the graft.
TRANSPLANTATION IN QUANTITY LOTS
Once the question of implant size is resolved, the corollary issue is the need transplanting large quantities of these implants in a single or
very limited number of sessions, taking into account its medical feasibility. A simplistic answer is that when graft size decreases, the number of grafts must be increased to
yield the same amount of hair, which of course is true. However, there are a number more compelling reasons to perform transplants in large sessions.
Apart from anatomical, physiological and technical issues, for the time, it is important to emphasize the social and practical reasons to strive for great
sessions. Most patients seeking Hair restoration surgery feel that their balding interferes with your life whether social, professional or
both.
Until restoration surgery capillary reaches a point where there is acceptable cosmetic improvement, patients will focus more on their hair loss than
before. Multiple, small interventions spaced over an extended period of time causes the patient focused on the problem he wanted to correct. During
this period worsens self-consciousness and the disappointment begins when he realizes that the limited procedures fall short of their hopes. Even
emotionally secure individual interruptions in the daily life of the scheduling of multiple surgeries, the limitations resulting from the activity, and
concern for their discovery may cause undue stress. In addition, post-operative numbness and paresthesias in the back of the scalp are a constant reminder
operation.
Multiple, partial procedures produce short-term cosmetic problems. Planning for the ranks of the grafts to be filled at a later time to look normal or
later be camouflaged by rows of grafts is certainly appreciated by the patient seeking cosmetic enhancement. Flaps of scalp multistage
reductions and the expansion of the tissue that requires certainly fit into this category. often the cosmetic appearance of the work is only acceptable
because the patient? s own hair camouflages it. Patients undergoing multiple procedures in a visible area as aesthetically as the scalp may be so discouraged
confidence in the whole process. In fact, many stop until the baldness progresses and becomes her own hair without success in camouflaging the
surgery. Then re-enter the partially treated patient population over a doctor to another looking for someone to complete the process. There
is a distinction between a person important in the early stages of baldness, undergoing a hair transplant, which has been well informed that future procedures
Be required as balds further and a patient who begins hair restoration without knowing that during a surgical procedure extended its appearance can be completely
unacceptable to him and can never reach your goal.
With respect to medical feasibility, follicular transplantation is qualitatively and quantitatively different from the traditional graft, thus
simple extrapolation of the oldest techniques will not allow one to predict the outcome of the most recent. Limitations physiological
transplanting large numbers of traditional grafts, such as impairment of blood flow and interference with oxygenation as discussed above, clearly not
apply when dealing with the movement of small follicular implants. Experience has shown that up to 3600 or more follicular units can be moved safely in a
session of the major constraint is the supply of donors rather than the physiology of the recipient site.
The issues surgical favoring large sessions are significant. Virgin scalp of normal collagen and normal blood flow. If possible, transplanting should be
total number of grafts needed in the first session to take advantage of this environment. sequential implementation in an area previously treated always
hampered by the angle of the existing grafts, the distortion due to fibrosis and impaired vascularization. Although follicular implantation can minimize these
factors certainly can not be reduced to zero. In addition, space, orientation, and distribution of implants may be scheduled at unrestricted
fashion without these parameters are controlled by their relationship to existing grafts.
In virgin scalp, the dermis retains its normal compliance, therefore, implants can be placed closer with less tendency to "explode" next door
units. During the postoperative period, the implants are less likely to raise or set as the collagen and elastic fibers to capture healthy transplanted units
firmly and add to the glue-like properties of the clot in obtaining of implants.
Hair transplantation often produces varying degrees of telogen effluvium in the recipient area. This hair loss can be substantial in patients Young is
rapidly balding and whose recipient area is characterized by a high degree of miniaturization. Often this lost hair does not return. Unless significant
amount of hair is transplanted in these individuals, the gain of the surgery may not even be enough to offset the loss due to telogen
effluvium.
Large sessions also offer an advantage over multiple small sessions at the donor site. Each time grafts are harvested from the donor, is a loss of
potential donor hair due to destruction of hair adjacent to the edges of the wound fibrosis associated with the closure of primary intention. In addition,
hair follicles adjacent to the healed suture line are often distorted and more difficult to harvest in the subsequent processes causing an increase in the number of
hair that is cut. Minimize the number of times the donor area is accessed obviously minimize the distortion and wastage due to the closure.
REFERENCES
1. Headington JT: Microscopic cross-sectional anatomy of the scalp. Arch Dermatol 1984, 120:450.
2. Rassman WR, Pomerantz EM: The Art and Science of Minigrafting. International Journal of Esthetic and Restorative Surgery 1993, 1:28-29.
3. Stough, DB: International Society Hair Restoration Surgery, Third Annual Meeting 1995, verbal communication.
4. Haas AF, Grekin RC: Antibiotic Prophylaxis in Surgery Dermatology. JAAD 1995; 32:155-164.
5. Salasche SJ, G Bernstein, M. Senkarik Surgical anatomy of the skin. Norwalk, Connecticut: Appleton and Lange, 1988 pp 176-177.
6. Rassman WR, Carson S: micrografts in large quantities, hair restoration procedure ideal. Dermatologic Surgery 1995, 21:306-311
7. Larson PO: Topical Hemostatic Agents for Dermatologic Surgery. Dermatolgic J Surg. Oncol. 14:06 1988.
8. Marritt E, L Dzubow: The tuft isolated front. Dermatologic Surgery 1 995; 21523-538.
9. Transplant Videografting Professional Hair System Institute; are shown in International Society Hair Restoration Surgery, Third Annual
1995 meeting.
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.
i cannot shut down my knife!?
I have a Smith & Wesson extreme ops knife and I can not close it. : (Help please. If you can be very detailed I'm a little slow for this kind of thing.
It is a line lock knife, so let me try to explain how. Hold the knife in his hand, by the handle, in contrast to the edge. Look into the slot where the blade folds. Look specifically for a piece of metal that leans on that slot. This piece of metal must touch the base of the blade near where the pivots. This is the line lock, and has to be pushed back in the way that you can fold the blade back into the handle. There is usually a little cut on the side of the knob along the slot to make it easier to push the liner roadblock. NOT trying to close the road while clarifying LINER LOCK! You're going to cut! You may have to firmly push the line lock to get moving. Once you are off the road, hold it and close blade with care. Each time you open the knife, liner lock is spring in the slot in the handle, and avoid breaking the blade closed when you're fingers cutting something. Best of luck to you.
