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Hair transplantati on 구구구구구구구 구구구구 1 구구 구 구 구

Hair Transplantation

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Hair Transplantation

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  • Hair transplantation 1

  • IntroductionTreatment option of hair loss are important and growing in cosmetic surgery because of many male pattern baldness and increased number of female pattern baldnessHair transplantation remains the gold standard-natural and undetectable lookWe can use hair transplantation in cleft patient or with facial lift technique etc. in oral & maxillofacial surgery

  • History of Hair transplantation1939 Okuda : first surgery in present method (standard punch graft)1959 Orentreich : donor dominance1970 Orentreich, Ayres : minigraft, micrograft1996 Rassman : emphasize the follicular unit graft Seagel : emphasize the microscopepresent technique : composite graft ex) micrograft + minigraft

  • PrincipleDonor dominance : key for successful hair transplantationeach hair follicle contains its own unique genetic makeup.When transplanted to another site, its original genetic properties are preserved regardless of the transplantation siteThe occipital area is the most desirable donor site for hair transplantation (as it usually is genetically programmed to grow hair for a lifetime)

  • Indication Correction of baldness Eyebrow reconstructionEyelashes graftBeard or whiskers graftGraft of scar area -in cleft patient : lip area -after facial lifting technique -scar of scalp

  • Classification of alopeciaAndrogenetic alopecia - Male pattern baldness - Famale pattern baldness Alopecia areataTelogen alopecia Anagen alopecia

  • Androgenetic alopecia< Male pattern alopecia >A;M, B;C, C;O,D;U, E;MO, F;CO < Female pattern alopecia >Grade I, Grade II, Grade III

  • Anatomy of Hair Infundibulum Isthmus Matrix Hair shaft -hair cuticle -hair cortex -medulla

  • Cycle of HairAnagen (3-7 yrs)Catagen (1-3 wks)Telogen (3 months)0.35-4mm / day

    (arector pili muscle;APM, bulge(B), cortex(C), dermal papilla(DP), epidermis(E), inner root sheath(IRS), matris(Md), outer root sheath(ORS), sebaceous gland(S)

  • Anatomy of ScalpOccipital m.Subaponeurotic layerGalea aponeuroticaskinSubcutaneous fatperiostiumCranial boneFrontal m.

  • Donor site

  • BoundariesInferior margin : within a margin of clearance of about 2.5 cm from the lateral and inferior fringes of the occipital hairline

    Latral limit : vertical line extended upward in the preauricular areaUpper limit : horizontal line drawn from about 5 cm from the tops of the external ears

    5cm2.5cm

  • Harvesting

    the incision lines : parallel the lines of minimum tension line (in order to avoid collagen transection scarring) parallel to the orientation of hair follicles (in order to avoid follicular transection) ex) Taprering the ends : trapezoidal pattern

  • Determining the nomber of grafts needed100 units or 200 hairs in 1X1cm area on the occipital donor area Densitometer For example, 700-1500unit graft 7-15cm2 needed for 1000 graft session 1.5X6.5cm or 1X10cm if tight occipital scalp

  • Closure of donor sitesimple one-layer closure

    significant tension existsmodification of deep plane fixation

    To minimize scarring -no more than 1.3cm width-check for donor site elasticity

  • Recipient site

  • Hair lineTransition zone : anterior portion -soft, irregular hairDefined zone : posterior portion -more defined, dense hairLateral hump

  • Recipient site angulationComparision : the angles of openings were 10[degrees], 45[degrees], and 60[degrees].10 degree : denser, natural appearanceIn most patient acutely angled (10degree-30degree)

  • Operation

  • AnesthesiaDental syringe 1% xylocaine with 1:100,000 epinephrine or more diluted solutionBlock anesthesia -supratrochlear n. supreorbital n. -zygomaticotemporal n. -auriculotemporal n. -lesser and greager occipital n. Tumescent anesthesia

  • TumescenceInfiltration of solution below the dermisGood tissue turgor (hardness)Spread out the follicules allowing minimal hair shaft transection during incisionLift the subcutaneous tissue away from the occipital arteryTransection of hair follicle when punch is usedCause of tumescence

  • Operation techniqueStandard punch graft : 20-30 hairsMinigraft : 3-4 hairsMicrograft : 1-2 hairsSlit graft : slit shape Follicular unit graftA. micrograft, B. minigraft C. standard graft

  • Operation techniqueMegasession : > 1000 follicular unitsMaxisession : > 5000 follicular unitsA typical session : 700-1500 follicular units or 1500-2000 follicular unitsMicrograft megasession

  • Follicular unit graftHair follicles did not just grow individually but often 2,3 or 4 hair (average 2 hairs -cochacian: 2.3 -oriental: 1.7 )

    Average density : 1/mm2 or 100/cm2

  • Follicular unit graftNatural undetectable lookDamage to hair follicle ( > minigraft, < single hair graft)Lesser hair density Less tissue insulation of follicleDifficult technique

  • Operation

  • Operation

  • Operation

  • Operation transplanter dilator

  • Post-op. careComplication : inclusion cyst (ingrowth hairs) occuting im 10% patient.Post-op 3 weeks : transplanted hair fell outPost-op 3-6 months : new hair coming outGrow 1cm/monthPost-op 9months : the effect of hair transplantatn

  • Survival rate after follicular unit transplantationFew report about survival rate and fate of micrograft In orientals (92%, in korea)In korea, survival rate : 80-90 %In Canada (6months) - one hair micrograft : 82 % - follicular unit graft : 113 %

  • Combination of face lift and hair transplantation

  • ConclusionThe donor site routinely looks excellent even after multiple procedures Debate persists over whether the smallest grafts are always preferable; however, in most cases follicular unit micrografting is better We can use hair transplantation in cleft patient or with facial lift technique etc. in oral & maxillofacial surgery

    Good morning ladies and gentleman.My name is In this time, I will present about hair transplantation.

    Treatment options for hair loss are important and growing in cosmetic surgerybecause many male pattern baldness and increased number of female pattern baldness

    Hair transplantation remains the gold standard. Today, it is a highly effective procedure offering patients what they want most, a natural and undetectable look.

    in oral & maxillofacial surgery We can use hair transplantation in cleft patient or with facial lift technique etc. to hide scar.

    In the 1939 (nineteen thirtynine) okuda surgery skin graft with hair in present method.

    in the 1950s,(nineteen fifty)Hair transplantation for male pattern baldness began when a New York City dermatologist, Dr. Norman Orentreich, used skin punches to transplant "plugs" of hair from the occipital area

    & report the concept of donor dominanceThis concept of donor dominance remains the hallmark of why hair transplantation is successful. In the 1970 (nineteen seventy), orentreich introduce concept of minigraft and micrograft

    In the 1996 (nineteen ninety six) rassman emphasize the importance of follicular unit graft In the present, generally surgeon use the composite graft For example, micrograft in the anterior hairline and minigraft in the posterior part"donor dominance" concept is key for successful hair transplantation. He states basically that each hair follicle contains its own unique genetic makeup.When transplanted to another site, its original genetic properties are preserved regardless of the transplantation site

    So, the occipital area is the most desirable donor site for hair transplantation because it usually is genetically programmed to grow hair for a lifetimeIndication of hair trasnplantation

    Correction of baldness Eyebrow graftEyelashes graftBeard or whiskers graft

    And Graft of scar area for example -lip area in cleft patient -to hide scar after facial lifting technique -scar of scalpClassification of alopecia

    Androgenetic alopecia - Male pattern baldness - Famale pattern baldness Alopecia areataTelogen alopecia Anagen alopeciaAndrogenic alopecia is divided into two group. One is male pattern alopecia, and the other is female pattern alopecia.

    In male pattern alopecia, there are several classificationsIn this slide, you can one of the classofication which is adusted to korean male

    Female pattern alopecia is different from male pattern alopeciaFemale pattern alopecia is classified, gradeI, gradeII, gradeIII according to severity.

    The cause of difference between male and female There are 2 factors.One is low testosterone and androgen. Testosterone is trasnformed to DHT(dihydroxytestosterone) by 5-a reductase. In female scalp, DHT is half level compared with in male. And the other is that female have aromatase which inhibit DHT production especially in anterior portion of scalp.Hair is divided into 3 part. Infundibulum, Isthmus, Matrixand we can see only hair shaft coming out from scalp.In animal, all hairs have synchronous cycle. So animal have molting season. But in human individual follicular unit has asynchronous, independent cycle. The cycle is anagen, catagen, telogen phase.

    In anagen phase, hair is growing. Usually 2-6(two-six) years. About 84(eighty four)% hairs of scalp.

    In catagen phase, growing of hair stop and atrophied. Usually 3weeks. About 14(fourteen)%.

    In telogen phase, hair is fell out. And secondary follicule is growing. anangen phase is started.Anterior area, there is frontal muscle.Posterior area, there is occipital muscle.

    In scalp, from superior layer, Skin, subcutaneous fat, galea aponeurotica, subaponeurotic layer, periostium, cranial bone.Follicular unit exist in subcutaneous fat.The donor sites are limited, and great care is taken to preserve hair follicles for future sessions. The basic technique is to take either one large strip or multiple strips and then suture the wound

    The Boundaries of the donor area are ill defined, but some general parameters apply. It is believed that only hair from within a margin of clearance of about 2.5 cm from the lateral and inferior fringes of the occipital hairline should be harvested. This excludes the neck region, which historically yields hair that grows poorly. Posterior neck incisions are also notably prone to the development of stretched visible scars. Hair taken close to the fringes tends to distort hair patterns and result in visible scars.

    The lateral limit of harvesting should ideally extend no further forward than a vertical line extended upward in the immediate preauricular area.

    The upper limit of the prospective donor area is difficult to define. Classically described as a horizontal line drawn from about 5 cm from the tops of the external ears, its lateral limits abut on the vertical preauricular line, thereby circumscribing or defining the donor area the incision lines should parallel the lines of minimum tension (in order to avoid collagen transection scarring) and also parallel to the orientation of hair follicles (in order to avoid follicular transection)

    surgically tapering the ends of the ellipse resulted in transection of an appreciable number of follicles designing of a trapezoidal pattern which obviated this problem a 1cm square on the occipital donor area will yield 100 units or 200 hairs

    Some surgeons will use a densitometer to ensure that the hair density in the donor region

    For example, when 700 to 1500 (seven hundred to one thousand fiee hundred) units per setting are grafted. 7-15cm2 needed

    Donor wound closure, if not attended by significant tension, allows for a simple one-layer closure.

    Where significant tension exists, a modification of deep plane fixation is recommended as an alternative to extensive undermining and traction closure

    Figure A) First suture is placed as high as possible in the dermis of the upper flap and fixed as low as possible to the deep fascia in the lower wound.f igure B) The next suture is placed from the deep dermis of the lower flap and fixed to the deep fascia in the base of the upper wound..

    And to minimize scarring at the donor site.They recommend taking no more than 1.3 cm width of donor tissue. always check for donor site elasticity.

    We must consider several factors in recipient site.The hairline conceptualized as consisting of two zones: the anterior portion ("transition zone") and the posterior portion ("defined zone") The transition zone should be soft and irregular, and the defined zone should be more defined and dense. And lateral temporal appearance should be considered. Lateral humpAll of these zones are important to the overall appearance of the hairline.

    we realize that there will be more hair loss. Conservatively, we try to use higher, narrower hairlines and opt for lighter coverage in the crown vertex

    They compared results in a patient in whom the angles of openings were 10(ten)[degrees], 45(fourty five)[degrees], and 60(sixty)[degrees]. Not surprisingly, they found grafts inserted at 10[degrees] appeared denser because of the shingling effect of hair lying over hair, In addition, these acutely angled grafts had a more natural appearancegraft recipient sites should be acutely angled (from 10[degrees]-to 30[degrees]) in most patients. Very comfortable local anesthesia can be achieved with dental syringes

    First, block anesthesia can be done according to area, -supratrochlear n. supreorbital n. -zygomaticotemporal n. -auriculotemporal n. -lesser and greager occipital n

    And then, inject tumescent anesthetic materialTumescence is theoretically a simple modality in which saline or other isotonic solution is rapidly infused into the tissues to produce the tissue turgor necessary to facilitate excision of optimal donor strips.Figure show transection oof hair follicel when punch is used. So it is caused of tumrscence. And spread out the follicles so allowing minimal hair shaft trasnsection during incision.Lift the subcutaneous tissue away from the occipital artery. tumescent solution is infiltrated just below the dermis in the occiput This provides for good tissue turgor and spreads out the follicles, allowing minimal hair shaft transection during incisions. It also lifts the subcutaneous tissue away from the occipital arteries Older methods of hair transplantation used a standard punch graft placed into a standard pattern. This generally resulted in dense frontal hairline with a variable "doll's hair" appearance. the result is quite unnatural.

    Micrograft means grafts with 1 or 2 hairs, minigrafts are those with 3 or 4 hairs

    Today, usually between 1500 and 2000 grafts per session are performed in about 4 to 6 hours (with up to 2495 grafts)

    most hair transplants are performed with follicular unit micrografting, either exclusively or the vast majority of grafts Because These grafts easily create a natural undetectable look but achieving density is a bit more challenging.

    megasession is a procedure in which more than 1000 micrografts and minigrafts are inserted in a single session. Maxisession is a prodedure in which nore than 5000 grafts in single session.

    physicians are predominantly using micrografts (follicular units) megasession but are still utilizing some minigraftsfollicular units. It was determined that hair follicles did not just grow individually, but often in bundles of two, three, or occasionally four hairs.

    If the bundles were left intact instead of divided into individual single hairs, they looked perfectly natural.

    Follicular unit micrografting is the most popular technique in hair transplantation today

    In figure, follicular units can be seen exiting the epidermis in close proximity but can be widely spaced within the subcutaneous fat Advantage of follicular unit graft is natural undetectable look. And lower damage of hair follicle than single hair graft.Disadvantage is damage to hair follicles compared with larger minigrafts, which creates the potential for more damage during preparation, storage, and placement.lesser hair density, less tissue insulation of follicles and difficult technique.

    The hair above the donor area is taped up away from the donor area. The donor strip is typically marked out just above the external occipital protuberance, either centered in the midline or off to one side ending at the midline Triangles are marked at the ends of the rectangular donor strip The donor strip hairs are then trimmed to 4 mm3. Tumescent solution is infiltrated just below the dermis 4. The guarded scalpel is used to make the strip incisions 5. The donor strip is excised in the subcutaneous plane just below the hair follicles. 6. Towel clamps are used to approximate the wound edges. 7. Staples or monofilament suture are used to douse the donor site in layers. Undermining is not generally necessary.

    The recipient site of those grafts are formed by using wide needles, surgical blades, or trephines, or laser. The generally accepted theoretical advantage of a laser is improved hemostasis; however, with follicular unit micrografting, there is so little bleeding that cold steel blades are still used by the vast majority of surgeonsThese recipient sites have less volume than the grafts to be placed so ti is difficult to place grafts.. The dilators that are used for overcoming the above-mentioned difficulties widen recipient sites, providing easier placement of grafts.

    Tea-shaped dilator is thicker than the holes also and it provides easier placement of grafts Because it widens the inner sides of the hole and provides good hemostasis, grafts can be placed more easily and follicles are less damaged. And then we can trasplant hair grafts. Using by trasplanter.The only complication found in this group was self-resolving inclusion cysts(ingrown hairs) occurring in 9 of 90 patients (10 percent).

    Post-op 3 weeks, transplanted hair fell outPost-op 3-6months, new hair is coming out and growing 1cm per monthPost-op 9months, we can see the effect of hair transplantation.few reports about the survival rate and fate of micrografts in Orientals.

    About 50% of the transplanted hairs fell out in 1 month, but at 6 months the survival rate of follicular unit transplantation showed a good result (92%) in korea. Generally in korea survival rate is 80-90%.it is also precisely the main area of scalp to be discarded during a face lift. When appropriate and if feasible, we must recycle it.

    This is the basic outline of incisions for my face lift procedures. Note that the triangular pieces of retroauricular; occipital hair-bearing scalp pieces are saved and processed into micrografts and minigrafts. Subsequently, these grafts are transplanted into the areas of need

    When a larger piece of scalp is needed to generate the desired number of grafts a larger piece of scalp may be harvested as outlined here. The donor site routinely looks excellent even after multiple procedures Debate persists over whether the smallest grafts are always preferable; however, in most cases follicular unit micrografting is better. There are two approved medications, but they are much more effective in maintaining hair than growing new hair.

    We can use hair transplantation in cleft patient or with facial lift technique etc. in oral & maxillofacial surgery

    Thank you for your attention.