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.
