|
Implant
site preparation
To prepare you, the hair transplant patient, for receiving the
graft implants, you will be asked to sit in a surgical chair or
in a semi supine position on a surgery table. There are arguments
about which position is more comfortable and which leads to fewer
complications with the procedure. So far no clear winner has emerged.
The advantage of the semi supine position is that it reduces the
chances of fainting or dizziness during the procedure. This can
happen before the anesthesia is injected into the implant area,
but rarely happens once the anesthesia takes effect. On the other
hand, a sitting position reduces the amount of bleeding when the
grafts are being implanted. The vertex (front and top of the scalp)
has a high density of blood vessels in it. When the skin is cut
on the scalp it can bleed quite a lot. A sitting position helps
drain blood away from the scalp and in so doing reduces the amount
of blood that bleeds from the implant wounds. Some surgeons may
arrange for you to lie down for the initial anesthetic injection
and then have you sit in a chair for the implant procedure to get
the best of both approaches.
The
hair line
The area of skin for implantation is sterilized by swabbing with
an antimicrobial solution. Anesthetic is injected locally in the
area of skin ready for implantation. Once the anesthetic has taken
effect, the implantation procedure can begin. For those with classic
androgenetic alopecia in a male pattern and recession of the frontal
hair line, the hair line is the first problem to be addressed.
The surgeon, rather than any assistants, should be the one to make
the incisions for the graft implants that will form the hair line.
In general the surgeon will also be the one that fills the hair
line incisions with grafts, although sometimes a nurse will do
it. The hair line is the most important part of any hair restoration
procedure. This will determine whether the result looks natural
or artificial. For the hair line to look as natural as possible,
the surgeon must make the line reasonably bilaterally symmetrical
although perfect bilateral symmetry of the implanted hair line
is unlikely. The hair line needs to adjusted on each side depending
on the shape of the face - particularly if your face is not very
symmetrical! When the hair follicles are actually implanted, only
the small one, and occasionally two, hair follicle unit grafts
are implanted into the hair line. They may not be in an exact line
as, if you look at a natural hair line, there are always a few
odd follicles out of line. A very slight “wiggle” in
the hair line makes it look just that much more natural.
Making
the incisions and inserting the hair follicles
Different hair transplant doctors have different personal preferences
for how they make the incisions into the skin ready to receive
the hair follicle grafts. Some use needles of 16-18 gauge – which
is pretty small. Others use small scalpels and make little slits
in the skin into which the implants can be squeezed. A few hair
transplant surgeons still use punch biopsies, although punch biopsies
are only made as small as 2mm which is, for the most part, too
large for the modern practice of follicular unit implantation.
There are also some special implantation devices available that
some surgeons use. Regardless, the objective is to make nice clean,
small wounds ready to receive the hair follicle implants. The hair
follicle units are then pushed into the small wounds using watchmaker’s
forceps. Because the follicular units are so small and there are
often many of them to implant, there are usually two nurses working
on either side of the head to speed up the implantation process.
Time is important, the longer the hair follicle grafts are lying
in cold saline the longer they are away from nutrients in the blood
that they need to grow. This is probably why it takes so long for
transplanted hair follicles to grow after a procedure. The hair
follicles have been starved and that usually sends them into a
state of suspended animation (telogen). Once the grafts are healed
in and they start receiving food via the blood again, so the hair
follicles can repair themselves, rearrange themselves and start
growing hair.
Pattern
of implantation
 |
|
A
close up of the root of a whole human hair follicle. In
the bulb at the end in the center you can see part of the
dermal papilla surrounded by the proliferating matrix cells
that form the hair fiber (like a cup and ball). The dark
brown stuff is melanin pigment being incorporated into
the hair fiber.
|
The pattern of incisions and hair follicle implantation is very
important for ensuring a natural looking result. Hair follicles
grow at an angle over the scalp and the angle changes depending
on what area of the scalp you look at. For most people, though
not everyone, the hair on the top of the scalp grows in a clockwise
whorl pattern with the center of the whorl at the vertex. For this
reason, if there is a parting it is usually on the left hand side
of the scalp. It is much harder to part hair on the right and have
the hair lay flat. Because of this whorl pattern, the surgeon will
similarly arrange the implanted hair to match this natural hair
growth whorl. The hairs will be implanted into the skin at an angle
consistent with any remaining hair and pointing in a direction
that follows the whorl pattern. The parting is also an important
consideration for the surgeon. He/she may implant hair follicle
units at a slightly higher density around the natural parting than
on the opposite side of the scalp. This will help give the parting
a normal looking hair follicle density.
Whilst the ideal is to give you a normal hair density in a natural
growth pattern over the entire bald area, the limitations on how
many donor hair follicles you have and the size of the recipient
area to cover will modify the nature of the implantation. If there
aren’t enough hair follicles to transplant, then the surgeon
may implant more towards the front of the head than the back so
that the hair can be grown longer and combed back to cover the
thinner areas behind. The surgeon must also modify the implantation
when there is more than one surgical procedure in the complete
hair restoration. If subsequent transplant sessions are expected,
then the implanted follicles may be more spread out than would
be expected with just one implantation procedure. The surgeon is
leaving room for hair follicles to be implanted in the next session
in between the grafts implanted in the current session. This means
the total hair restoration is built up over multiple session, and
until the final session is done, it is not possible to determine
just how natural (or not) the transplant looks.
Eventually all the grafts should be implanted and the basic procedure
is complete.
|
