INTRODUCTION
A good patient selection is of utmost importance in order to get a good result. An important thing to keep in mind is that androgenetic alopecia is an ongoing process with no specific boundaries. The age of the patient, the donor area, expectations of the patient are all important things to consider.
Before hair transplantation (HT), thorough examination of the scalp should be done to evaluate any type of lesions.
Any kind of scalp pathology should be dealt with first. Scalp folliculitis should be dealt with antibiotics, seborrhea with an antidandruff shampoo and mild steroid if necessary.
The number of grafts to be offered in any patient is always an approximate calculation based on the patient's age, family history of hair loss and the present extent of hair loss and the donor quality. A young patient or a candidate with grade III or grade IV baldness should initially be prescribed the medical treatment and reassessed after a year to assess the response and need of surgery.
CONSULTATION
It is important for an HT surgeon to understand the patient's needs and demands and to make it very clear to the patient about the expected results. A simple question like “what do you expect?” makes many things clear. The HT surgeon must be able to make him understand that hair loss is an ongoing process and more than one session will eventually be needed. The patient must understand that facial framing is far more important than the density of hair and also that the transplanted hairline is permanent. Disadvantages of keeping a low hairline must be clearly explained especially in a young patient. Satisfying a young patient may lead to problems in their older age.
HISTORY
A history regarding any bleeding problems, hypertension, diabetes mellitus, any medications, drug allergies, vitamin supplementation or heart surgery should be taken. Medicines like aspirin should be stopped 2 weeks prior to surgery, clopidogrel should be stopped 5 days prior and heparin and warfarin 24 hours prior. Alcohol intake should be stopped 3–4 days before surgery.
COUNSELING
A counselor plays the role of a mediator between the physician and the patient. He should be available to answer any type of silly questions pertaining to surgery by 3the patient. He should be able to win the patient's confidence and make him comfortable. He should be able to provide factual information rather than just persuading the patient. An honest and clear opinion must be given to the patient. The counselor should educate the patient about the nature of the medical aspects of hair loss problems and the various etiological factors involved. He should explain about the concept of visual density which will be achieved after HT. The salient points about step-by-step procedure of HT should be explained in detail. The patient should also be counseled regarding the use of the Food and Drug Administration (FDA) approved topical minoxidil and oral finasteride (in males and postmenopausal women) both pre- and post-HT surgery and the progressive nature of hair loss. The care of hair, post-transplant should also be explained in detail. It is always better to under promise and over deliver.
PATIENT SELECTION
According to the authors, surgery should be postponed in young patients under the age of 25 years due to their unreasonable expectations and demands. Also they are likely to have further hair loss in their coming years and would need further sessions of hair restoration. If at all a young patient demands for hair restoration surgery, care should be taken to set a higher hairline and avoiding grafting in the vertex area. However, in cases where patient achieved Norwood grade VI we can go ahead with full coverage with a higher hairline by mixing scalp and beard hair. It is advisable to not do temple reconstruction in such cases.
Candidates with thin and fine hair should be chosen with care as poor outcome with less density is common in such patients. Even if the growth of transplanted hair in these patients is good, they will not appreciate significant difference in their pre- and post-transplant look. Those with large caliber hair shaft (>80 µm) obtain a denser coverage than those with silky hair. Patients with a good density of donor area [>80 follicular units (FUs)/cm2] are excellent candidates. Those with less than 40 FUs/cm2 are considered poor candidates.
Most patients with advanced Norwood type VI and type VII are poor candidates for surgery unless they have a donor area of at least 6,500 grafts to donate. However, coverage in such candidates is now possible with the use of beard grafts. If the donor area is sparse, it is a sensible option to just make a frontal forelock connecting the temporal zones rather than trying to give a full coverage. The vertex transplantation is the most problematic area as it consumes considerable donor grafts. In later years, the patient often becomes dissatisfied due to progressive peripheral loss of nontransplanted hair. In patients with scarring alopecia, the graft uptake and survival will be affected and should be counseled regarding the same before taking up for the surgery.4
CALCULATING THE NUMBER OF GRAFTS
A surgeon must always estimate the number of grafts required to give a satisfying result to the patient. There is no hard and fast rule of estimating the number of grafts that can be obtained from a particular donor area. However, a cosmetically acceptable extraction ratio should not exceed one of every four follicles (25% extraction). To estimate the total number of follicles that can be extracted, we have to divide the total number of FUs by 4 for obtaining a 25% yield.1 In practice, we extract much more than what guidelines say but do not see any impact on donor aesthetics even with slightly more aggressive extraction.
PREPARING THE DONOR AREA
Another challenge for a hair surgeon is to identify the safe donor area (SDA) (Fig. 1.1).
The safe donor area differs in each patient and is usually concentrated around the occipital protuberance arching upward laterally in a crescentic manner up to around 2 cm above the superior helix of the ear.2 Thus, it covers parts of temporal, parietal and occipital areas. Precaution must be taken to avoid extraction of follicles from beyond the SDA (Figs. 1.2A and B).
The margins of the SDA should be drawn and the entire area divided into six to eight zones. These zones will help the surgeon to extract approximately equal number of grafts from each zone, thus ensuring equal distribution over the extracted areas (Fig. 1.3).
However, one should remember that extraction numbers in two grids of same surface area may vary as there may be huge variation in density and graft quality in occipital region and temporal region. This may be because of presence of miniaturization in the donor region, retrograde thinning which has not become apparent yet (Fig. 1.4).
Concentrating the extraction of grafts in a particular area will later give a cosmetically unacceptable look, thus it is important to extract uniformly from wider zone of safe donor area even if the surgery is of smaller session size of 500–1,500 grafts.
Once the SDA is identified, it is trimmed closely to a length of 1–1.5 mm. Window stripping can also be done in cases where the hair length is longer (Figs. 1.5A and B).
INFORMED CONSENT
An informed consent should always be taken from the patients prior to surgery. While taking the consent the physician should know about the nature of patient's condition, the prognosis, the risks, adverse effects, complications and associated benefits of the procedure.6
Figure 1.3: Making of grids in safe donor region to ensure that extraction from these grids can be calculated.Courtesy: Dr Piero Tesauro.
Figures 1.5A and B: (A) Window stripping with hair raised; (B) The same patient postoperatively of window stripping with hair down.Courtesy: Dr Piero Tesauro.
Consent regarding complications during harvesting from non-conventional sites like beard and chest should be taken. Patient should be clear that he has given consent for the procedure. He should be given realistic expectation according to his donor quality and grade of baldness. The physician should also discuss other treatment alternatives available to restore hair loss. Need for concomitant medical therapy should be emphasized. Patients should understand that proper hair growth with good density will take 6–9 months after transplantation.
POSTOPERATIVE CARE
The most important aspect of postoperative care is to keep the graft hydrated by spraying normal saline on the recipient site. We recommend the patients to spray every 2 hourly for next 7 days with 5–7 hours of sleep at night. Normal saline spray is also recommended to soften the crust formed around the grafts. It also helps in rapid re-epithelization due to moisture around the grafts.
It is important that there is no trauma in any form to the recipient sites. Trauma can happen in any form, for example patient can rub the graft against the 8pillow during sleep or he can bang his head while entering his car. The sleeping posture is determined by the area which is transplanted. He cannot sleep prone if hairline restoration has been done. He cannot sleep supine if crown restoration has been done. He can sleep only on the sides if there is complete restoration from hairline to crown. There should be no bandaging around the donor scalp if temple has been restored as there is a risk of dislodgment of grafts. He should take prophylactic oral antibiotic. He should be on anti-inflammatory drug. Regular massaging of forehead should be done to minimize periorbital swelling.
CONCLUDING THOUGHTS
Selecting the right patient for hair transplant surgery will help in ensuring success. Right counseling, developing a rapport and gaining the confidence of the patient are the key steps in making the patient happy.
Comments by Dr Piero Tesauro
Every line of this chapter starting from the first: “a good patient selection is of utmost importance” is a pearl of wisdom! Even though many of the concepts outlined in the paragraphs may seem a repetition of all the warnings I have heard in the last 20 years, here they are divided into clear steps and written down to outline all of the “red flags”.
But what is selection in reality?
Selection is essentially the collection of subjective parameters that we can put together by looking, touching and listening to our patients.
In fact, we can often immediately understand our patients’ expectations and how they live their hair loss situation. When we first examine our patients, moving our fingers from the base of the neck throughout their scalps, we can frequently be quite confident that our evaluation will coincide with the objective data we can retrieve with a dermoscope or any other instrument.
All the objective parameters are a formidable confirmation of our good instincts. They are necessary, especially to avoid being overconfident, but human understanding in this phase is unique and irreplaceable.
Listening is the most difficult part of our job, it presumes that we gain the confidence and the trust of our patients. To do so we must show them we care and understand their problem.
For example to be realistically useful, and not to simply clear our conscience, the therapeutical assignment must be based on three fundamental pillars: 9(1) results, (2) irrelevant side effects, and (3) most of all, long-term compliance. So far, our clinics can play, during this first consultations, a wonderful and ethical work in patients education.
REFERENCES
- Boden AS. FUE donor evaluation and surgical planning. In: Lam SM, Williams Jr KL (Eds). Hair Transplant 360, 1st edn. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd. 2010;4:116–7.