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Chapter: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |11 | 12 | 13 | 14 | 15 | 16 |17 | 18
PATIENT GUIDE TO SURGICAL & MEDICAL HAIR
RESTORATION
PAGE 12 |
The Nuts and Bolts of Hair Transplantation-An Office-Based
Surgery |
| So far, we have discussed a wide variety
of hair restoration techniques, although we have concentrated of Follicular Unit
Transplantation (FUT). That will be our entire focus here. We do not perform the
outmoded large graft or mini-grafting techniques, flaps, or scalp reductions; as
such, we will confine our discussion to what we consider the state of the art in
hair restoration surgery, which is FUT done in an office setting. Another topic
we will neglect is the administrative, legal, and financial aspects of the
agreement by the patient to undergo FUT by the surgeon. It is not that these are
not important, for they are, and they need to be understood by all parties and
the details completed prior to the procedure’s beginning. However, they are
beyond the scope of this discussion. This entire manuscript is aimed at
educating the patient, or potential patient, and to demystifying the process of
hair transplantation. Therefore, we are limiting our comments to those
pertaining directly to the history, practice, art, and science of modern and
post-modern hair restoration surgery. The more prosaic elements of the patient’s
interaction with staff and physician will be left to the time and place of that
interaction. |
Pre-Operative |
| The pre-operative phase is that period
leading up to the performance of the surgery. Sometimes, certain medications,
like antibiotics, will be started the night before. Occasionally, in extremely
anxious patients, sedation or sleeping medication will be given the previous
night as well, to insure a good nights sleep. It is the rare patient that
requires this extra effort. Photos may be taken from various angles to document
the level of pre-operative balding. The patient may have a movie they wish to
watch, or music they wish to hear, during the procedure. This can be determined
in advance or after the surgery begins. Often, a brief second consult with the
surgeon takes place, during which the patient may restate his or her goals and
desires, and the surgeon may respond or help the patient modify these goals into
a more realistic and aesthetically appropriate plan. The physician may at this
point draw in the hairline with a surgical marker, with the patient observing in
a mirror, and may mark other points, such as the boundaries of the crown, if
that area is being grafted, and reexamine the donor area for scarring, density,
and laxity. This is a good time for final questions relating to the surgical
plan, and the long-term plan, to be put forth, so that all parties are satisfied
that they are moving forward with an acknowledged and satisfactory effort on the
part of the patient. At this point, after checking for the presence of drug
allergies, medication for limiting swelling and inflammation may be
administered. Other drugs for sedation may also be given. This will be discussed
further in the section below. |
Sedation |
| Is sedation mandatory for follicular unit
transplantation? Strictly speaking, no, it is not. However, there exist many
good reasons for using mild sedation for this procedure, not the least of which
is the patient’s comfort during what may be a long procedure. Much of the time
spent in the surgical chair can be quite boring. There are other reasons,
though, as we shall see. The only part during FUT that is remotely painful is
the injection of the numbing medications, or local anesthetics (see below). This
is necessary in the donor area in back and also in the recipient areas that will
receive the grafts. This is one of the first things that are done during the
operation, and it can sting a good bit. People demonstrate a wide range of pain
tolerances, and it has nothing to do with being strong, or "manliness", or a
lack of these attributes. It’s simply how our nervous systems are "wired". For
some patients, the injection of local anesthetic barely gets their attention;
they continue talking as though nothing was happening. For others, the shots are
quite bothersome, and they may begin to sweat or feel dizzy. So often, if a
little sedation is used at the beginning of the procedure, this potential for
pain and anxiousness is relieved before it even occurs. Another reason for using
the type of sedation we prefer is that it can prevent or relieve the potential
side effects of the local anesthetics we use (see below). Generally, we choose a
class of drugs known collectively as the benzodiazepines, specifically diazepam,
midazolam, and lorazepam. These are similar to the drug Valium, and are
considered sedatives and anti-anxiety agents. They may be given orally,
intravenously, or intramuscularly; the intravenous route works the quickest and
the oral route has the longest time to onset of effect. Used appropriately, they
are quite safe, and we seldom see complications associated with their use. Given
by any of the methods above, these medications render the patient relaxed, maybe
slightly drowsy, and usually with a noticeable sense of wellbeing. The local
anesthetic injections may become unnoticeable, or just a slight annoyance.
Depending on the drug used and the route by which it is given, it may last an
hour, or several hours. We have found this method of sedation to be safe,
effective and well accepted and tolerated by our patients. Some physicians
routinely give opioids, or narcotic type drugs (pain relievers). Although this
class of drugs is quite effective as well, it does not relieve anxiety as well
as the Valium class of drugs, and in some instance can cause dysphoria (a sense
of non-wellbeing). Also, the narcotics have a much stronger effect on the
respiratory centers in the brain, and can depress the breathing. Moreover, they
can cause nausea and vomiting quite frequently, which is distressing to the
patient (and the last thing you want is vomiting just after a hair transplant –
you could pop a graft!). Also, itching is a common side effect of narcotic
drugs, which can be a miserable situation for the operative team and for the
patient during a long case that requires stillness on the part of the transplant
recipient. Lastly, if these narcotics are used along with the Valium type of
drugs, a synergistic action takes place: they may greatly enhance one another’s
effects, which could lead to depressed breathing, over-sedation, lowered blood
pressure, or other problems. For these reasons, we usually choose not to
administer opioids/narcotics, and try to stick with the relatively safe,
tried-and-true sedatives mentioned above (the benzodiazepines). Others have
advocated the use of nitrous oxide (N2O, or laughing gas). While this drug can
be a quick acting, effective sedation and pain relief agent, there are problems
with its use and its effects, too. First of all, it requires a more complicated
system (you may have seen these at the dentist’s office) than for the oral or
injectable agents. Secondly, it must always be used with oxygen, and both oxygen
and nitrous oxide come in relatively bulky metal tanks. Special monitoring of
the patient’s vital signs is necessary, and when the nitrous oxide is stopped,
the patient must always inhale pure oxygen to avoid decreased levels of oxygen
in the blood (called diffusion hypoxia). Occasionally, patients will experience
dysphoria, which may present much like a panic attack; this quickly resolves
with discontinuation of the gas. Others promote the use of heavier sedation,
citing the patient’s comfort, the length of the procedure, and the ease with
which the surgical team may work, as their rationale. This author feels that,
unless one has a strong anesthesia background, that the benzodiazepines (Valium
family of drugs), and, possibly, the less potent opioid/narcotics, should remain
the agents of choice for sedation in hair transplantation. |
Anesthesia |
| Many people think of anesthesia as being
"put to sleep". However, there are other ways of achieving anesthesia, which
just means rendering one insensitive to pain impulses. In hair transplantation
we use local anesthesia, which, as the name implies, locally deadens
(temporarily) the nerves, rather than the whole central nervous system
(unconsciousness). This is most desirable because, when using local anesthesia,
no pain is felt, the procedure can be done in the office, we avoid the expense
and hazards of the hospital operating room and general anesthesia, and the
patient is awake throughout the process, and can remain an active participant in
decision making. There are two main classes of local anesthetics (LA’s): esters
and amides. The esters are more prone to causing allergic reactions than the
amides, and are less widely used. Even amongst the esters, however the incidence
of true allergic reactions is extremely rare. Very often, people claim an
allergy to "Novocaine" or all the "-caine" drugs, when they have actually
experienced either a temporary reaction to too much anesthetic (mild overdose),
or a reaction to the epinephrine (adrenaline) that is often added to local
anesthetics to prolong their action and to decrease bleeding. We take great
pains to avoid any LA or epinephrine toxicity by injecting slowly, always
guarding against intravenous injection, maintaining verbal communication with
the patient, and by limiting the total amount of these agents that are injected
to dosages well below the known safe limits. The most widely used LA’s in hair
transplantation are of the amide class, namely, lidocaine (Xylocaine) and
bupivicane (Marcaine). These have an established safety record, and we rarely
see problems with them. Comparatively, they are similar in effect, with
lidocaine being faster acting, and bupivicaine lasting for a longer time. They
are injected into the skin and subcutaneous layers, and/or around larger nerves
in the form of nerve blocks. There are several areas where nerve blocks can be
used. The first is the occipital nerve, which is in the back of the head, above
the neck. When this nerve is blocked, the back of the head (donor area) and
crown are numbed; this can be of benefit after the surgery, also, as the donor
area may be painful that night. The supraorbital nerve, above the eye, may also
be injected; this results in hairline and frontal area numbness. Two other
nerves in front and behind the ear may also be blocked to help with anesthesia
in the top of the head and around the sides. However, we do not do the surgery
with just the blocks; we always inject locally, wherever incisions will be made.
One of the reasons for this is that the blocks may be incomplete at times, and
we want the scalp completely numb and unable to feel any pain; the other reason
is to add epinephrine (adrenaline) to the area. This has a two-fold purpose: 1)
to prolong and intensify the action of the LA’s and 2) to constrict the small
blood vessels in the area and decrease the amount of bleeding. The importance of
diminishing the amount of bleeding, especially in the recipient area, cannot be
overemphasized. The less bleeding there is, the more easily and accurately the
recipient incisions can be placed; likewise, with minimal bleeding, placement of
the FU grafts causes less trauma to the follicles and is generally smoother and
quicker. |
Intra-Operative |
| Once the initial steps determining the
hairline, the areas to be grafted, and the extent of the donor strip, have been
carried out, and the areas have been marked and trimmed, then the local
anesthetics are injected into the donor area, and then into the scalp in the
areas to be transplanted. The numbness is essentially instantaneous; after these
injections various sensations like pulling or tightness may be felt, but there
is no pain sensation. The first incision is for the donor strip. This is done
with a single or double-bladed scalpel, and is performed with a "tumescent"
technique. What this means is that a fairly large volume of fluid is injected
into the numb donor area in order to raise the hair follicles up off the scalp;
doing this allows us to cut more easily without damage to underlying nerves and
blood vessels. In addition, when we free up the strip from its deeper tissues,
we can do so with minimal damage to the bulbs of the follicles. Since the
tumescent fluid is a saline solution with dilute amounts of local anesthetic and
of epinephrine, the technique also helps to decrease bleeding and ensure that no
pain is felt at any level of the dissection. Once this donor strip, with its
many intact hairs, is harvested, it is handed off and the important, meticulous
"slivering" begins. As you recall, slivering is the process of dividing the
strip, under the microscope, into small pieces that are one FU wide. As these
slivers are created, they are passed off in turn to other members of the
operative team, who begin the long, arduous task of dissecting out the
individual FU’s under stereo-microscopic guidance. As they are dissected out,
the FU’s are segregated, according to type, into groups of singles, doubles, and
so on. They are kept in chilled saline solution until they are ready for
planting in the scalp. Meanwhile, the surgeon sets about closing the donor site.
This may be accomplished with sutures or surgical staples. We prefer the use of
sutures rather than staples; they tend to be less uncomfortable, and, because we
generally use dissolvable sutures, the patient does not have to look forward to
returning in 7 to 10 days for staple or suture removal! The ease or difficulty
of the donor site closure is to some degree dependent on the tightness or laxity
of the scalp. This is one more reason that we try to take great care with the
donor area; multiple scars and poor closures not only deplete donor hair, but
also contribute to tightness of the scalp, and subsequent difficulty with
approximating the wound. After the donor site is closed, then the surgeon begins
the tedious and painstaking process of creating the hundreds or thousands of
recipient sites. These are generated using small needles or tiny scalpels; the
size of these miniscule incisions is based on several factors: the area of the
scalp, the thickness and laxity of the scalp, and the size of grafts (one hair,
two hair, etc) that will be placed. Great care is taken to avoid damage to
existing hairs, and all this work is done under magnification (as is the
harvesting of the donor strip). This may be one stage of the surgery when
talking to the surgeon is discouraged; it is necessary for us to keep count of
hundreds or thousands of incisions being made. In this way, the number of grafts
harvested will match up with the number of sites created. The tumescent
technique that is used for the donor strip is also used to a degree in the
recipient area. A saline solution, containing local anesthetic and epinephrine,
is injected into the area, to "plump up" the scalp; this makes it less likely
for the needles and scalpel blades to lacerate blood vessels below the layer of
the hair bulbs, and thus interfere with nourishment to the new grafts. And
again, it decreases the amount of bleeding from the scalp, which greatly
facilitates the creation of the recipient sites, and of the graft placement;
this in turn may improve survival and growth of the FU grafts. After the sites
are created, and as the ongoing work for dissecting grafts under the microscope
proceeds, members of the team begin the fine work of placing the individual FU
grafts. This is done, under magnification, by gently grasping the delicate
connective tissue at the base of the graft with ultra-fine jeweler’s forceps,
and sliding the graft into its waiting recipient site. This is more difficult
even than it sounds; the level of expertise required is nothing short of
amazing. Not only must the FU’s be placed at the appropriate angle, with as
little trauma as possible, but it must be done quickly and smoothly; remember
that we try to minimize the number of hours that the grafts are "out of body",
and that we may be creating and placing thousands of grafts. This procedure is
not possible with out a large, expert and highly motivated surgical team. Of all
the steps of the surgical procedure, this graft placement phase may be the most
relaxing, or boring, for the patient. Many patients will "unwind" and nap during
this time. Hours may go by just sitting and chatting; this is where music and
movies may be a blessed relief. These are not distracting to the operative team;
they are used to maintaining high levels of concentration during hair
transplants. One question that is often asked is "what do we do with ‘leftover
grafts’?" Answer: there are none. In other words, we try meticulously to match
the number of grafts harvested with the number of incision sites made. Often,
because of the careful techniques of graft cutting employed, there are more
grafts than planned for. If this is the case, they do not go into the
wastebasket! The patient gets those extra follicular units "on the house!" At
the end of the procedure, a final check is made to insure that every graft is in
place, that no "popping" or extrusion of FU’s has occurred, and that no bleeding
is taking place. The hair is dampened and combed very carefully, again to avoid
any graft displacement. We generally use no dressings; if the patient is using
GraftCyte, they may leave the clinic with several of the saturated gauzes in
place over the grafted areas. Patients will receive post-operative instructions
at several stages of the treatment: often before, during and after the
procedure, as well as in writing. Repetition of these guidelines is important
for several reasons. Patients need to follow these directives carefully in order
to insure the best possible growth of grafts and avoidance of complications.
Also, people often forget what they are told within the context of the
procedure, due to excitement, anxiety or information overload. Therefore, we try
to reinforce the information at several points during the patient’s entire
surgical experience. We will discuss the post-operative course within the next
section. |
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| Next- Post-Operative Course |
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