CHAPTER SIX: HAIR RESTORATION

Comprehensive Facial Rejuvenation: CHAPTER SIX: HAIR RESTORATION

CHAPTER SIX: HAIR RESTORATION

Overview
Cosmetic surgery for men has dramatically increased in popularity over the past decade, spurred in part by mass media images that portray the idealized male form. Aesthetic surgery is a natural extension of the fitness fixation that has captivated the male ego and propelled it on a quixotic quest in pursuit of the Adonis physique. Although many men seek global rejuvenation of the face, societal norms dictate two principal facial regions that receive disproportionate attention: the eyes and the hair. Blepharoplasty offers the male patient who thrives in the competitive workplace a targeted approach toward rejuvenation: the aging eyes often betray fatigue, anger, and sadness that may belie the patient’s true emotional state or youthful vigor. Similarly, hair restoration has become a principal concern for the mature, or not quite so mature, male individual who faces the tragic loss of hair. The ubiquitous media engine often portrays the balding male as a Samson, who stripped of his virile lock, has lost his sexual vitality. Unfortunately, the counterfeit claims of miracle cures that abound on the Internet, on television, and in print do little to provide any meaningful remedy to the bewildered male. Undoubtedly, men fall prey to hormonally incited hair loss to a greater frequency and extent than the opposite sex. Nevertheless, women are susceptible to hair loss, whether androgen-driven or otherwise, and they have sought medical and surgical therapy for their condition as well.
The history of follicular transfer dates back two centuries to Dieffenbach’s early experiments. It was not until Orentreich introduced his elegant punch-grafting technique in the 1950s that follicular grafting was more precisely understood and widely implemented. Nevertheless, the original punch graft left an indelible image in the public mind that has been likened to the cornrow appearance of a doll’s head. These unsightly “plugs” hindered widespread acceptance of this technique. In the early 1980s, Nordstrom and Marritt pioneered the use of micrografting, or single follicular transfer, that offered a more natural appearance to the grafted scalp. , Alternatively, scalp reduction with extender placement (see below) has been useful to correct crown, or vertex, baldness, as grafting in this area may appear unnatural. Scalp rotation flaps, e.g., the twice-delayed Juri flap, are beneficial for patients who desire rapid, dense coverage to the fronto-temporal region. , Beyond these varied surgical options, advances in medical treatment have provided sufferers of alopecia a less invasive alternative. The physician who treats alopecia should be acquainted with the diverse treatment methodologies to combat follicular loss and exercise erudition in the selection of the appropriate course of action. This chapter will review the many surgical and medical treatment strategies that currently exist for hair loss and emphasize a systematic appraisal that will guide therapy.
The surgeon whose primary talent is brandishing the scalpel may find the multi-faceted approach to hair restoration a daunting ordeal. Accordingly, many disciplines may need to converge, including a medical therapist or physician, an operative technician, and a hairpiece specialist, to provide the balding patient the optimal care that he deserves. Oftentimes, a patient may not be ready to undertake surgical hair restoration due to financial constraints, fear, lack of motivation, or insufficient hair loss to justify transplantation. These patients may be better candidates for medical therapy, e.g., minoxidil and/or finasteride, until surgery becomes a more suitable option. Herbal remedies, albeit often clinically unsubstantiated, may offer an unconventional, yet perhaps beneficial, regimen for alopecia. A physician or a therapist may play a valuable role in dispensing medical or herbal treatments, respectively. Alternatively, the same or another provider can tender services that rely on hairpiece camouflage. Clearly, the field of hair restoration is broad and complex and may require a team working independently or together to achieve the aesthetic objectives of the patient.

Preoperative Considerations: Patient Selection & Relevant Anatomy
The first step toward successful surgical hair restoration is proper physician-patient dialogue to establish the desire, motivation, and expectation that the patient harbors. Despite what may be glaringly obvious to the transplant surgeon as the most deficient area of alopecia, the patient may hold an all-together different opinion of what troubles him or her. The consultation should aim at unifying patient concerns with the surgeon’s objectives in a realistic, achievable fashion. Despite the most talented and extensive grafting efforts, some patients who desire significant density may be left unsatisfied with conventional graft transplantation. Conversely, a patient who expresses trepidation about extensive surgery may not be a suitable candidate for scalp rotation and reduction procedures. Besides the psychological aspects of hair transplantation, the anatomic constraints of a patient’s particular hair, scalp, and donor areas should also be entered into the equation when selecting the appropriate surgical approach. The following section will highlight the salient points regarding proper patient selection given the above-enumerated limitations.
First, a thoughtful and thorough history should always be obtained in regard to a patient’s onset, rapidity, and evolution of hair loss. As will be discerned, a mature, stable hairline will afford the surgeon a wider range of surgical options than a rapidly progressive hairline of a younger patient. Nevertheless, an apparently very stable hairline may become less so due to both intrinsic or extrinsic factors at any time; and the surgeon should never hold an unwavering conviction that the past is an absolute predictor of the future. Prior medical history that may contribute to the development of alopecia should also be elucidated, including radiation exposure, medication abuse, hormonal imbalances, dietary deficiencies, or other inciting factors. A history of prior medical therapy using approved (finasteride and minoxidil), herbal (saw palmetto and vitamins), experimental (dutasteride), and other medicinal or quasi-medicinal compounds should be elicited. The duration of medical therapy may hint at the length of time that the patient has been troubled by his or her hair loss, and to what extremes he or she has pursued various avenues to ameliorate the condition. Prior surgical efforts should also be properly assessed, as well as the patient’s satisfaction or displeasure with those interventions.
A focused physical examination should follow of the scalp and hair. Hair color, texture, density, curliness, and distribution should be assessed along with scalp color, elasticity, and integrity. These attributes will determine the overall success of the transplantation, as succeeding portions of this chapter will more readily reveal. For instance, dark, thick, straight hair contrasted against a milky white scalp may be the least forgiving combination and may yield a less natural look despite best efforts at follicular-unit or micrografting, especially in the region of the vertex. Donor density must also be evaluated: a thick occipital fringe will provide ample donor source for grafting transplantation, whereas a robust parietal fringe may contribute more to the success of a scalp flap rotation or reduction. The fronto-temporal recession should also be attentively studied, as surgical blunting or effacement of these “character lines” will often lead to an unnatural look and may make further camouflage in a rapidly receding hairline difficult. Obviously, the surgeon must plan his or her procedure to provide both immediate benefit but also aim at overall longevity: these twin goals should always be kept in mind.
As alluded to, the psychological dynamics that motivate the patient are central to success of any hair transplantation. The patients’ expectations of the transplantation session must be met to ensure surgical triumph. First, the patients’ desire for density versus coverage should be determined. Some patients, especially those who have been accustomed to synthetic hairpieces, may not perceive simple coverage in the areas of alopecia to be sufficient and may insist on greater density than can be afforded by grafting sessions. If the photographic results of patients who have undergone “megasession” grafting sessions are nevertheless uninspiring, then scalp rotation and reduction may be entertained to resolve this perceived inadequacy. Most men, however, are quite satisfied with any coverage that they may achieve; and therefore they are usually excellent candidates for transplantation.
In contradistinction, the authors have noted that women, who naturally tend to exhibit less widespread hair loss, often remain discontented with their surgical result despite very extensive transplantation. Unlike discrete areas of androgenic alopecia that preside in the fronto-temporal and crown regions, female pattern baldness is more evenly distributed across the scalp and less extensive in nature. Accordingly, women tend to be less satisfied with follicular grafting because the amount of hair loss is less perceptible to begin with and surgical enhancement of more dispersed alopecia may be similarly less noticeable. The generalized thinning that occurs in the female sufferer of alopecia has been classified according to the Ludwig scale (Figure 6-1) as opposed to the Norwood scale for men (Figure 6-2). As part of an informed preoperative consultation, the surgeon must ensure that the limitations of surgical hair restoration for the female patient are well understood before surgery is contemplated.
Similarly, patients who desire significant density may also express impatience with the 6 months to a year period of time that is required to see the incipient regrowth of the newly transplanted hair. In addition, several transplantation sessions that are necessary to achieve considerable density may further delay noticeable growth and also add overall expense if the cumulative number of grafting sessions is tallied. For the minority of patients who are unwilling to wait and who desire rapid, dense growth of hair, a scalp rotation or reduction may be the optimal surgical approach for them. All these concerns again must be tempered with the added morbidity of staged flap/reduction procedures that may contribute to an undesirable convalescence.
Patients who may be good candidates for scalp reduction techniques are those who suffer from exclusive crown, or vertex?, alopecia and who are of a mature age (> 40 years old), with stable hair recession. Patients who continue to lose significant hair may expose their suture line and require further sessions of scalp reduction in an already tight and incompletely distensible scalp. In addition, patients should be counseled preoperatively on the likely further loss of some hair near the incision line. As mentioned, preoperative scalp elasticity should be assessed before consideration of scalp reduction. Curiously, scalp distensibility is less of a concern if an extender is used as part of the procedure, as the implanted device tends to overcome some of the unfavorable tensile forces of the inelastic scalp.
Scalp reduction is really only possible as a serious alternative to follicular grafting as a result of Patrick Frechet’s brilliant invention, the scalp extender, in 1993. The technique of scalp reduction was first introduced in 1977 by the Blanchards but has undergone a variable course of success due to two complications: stretchback and slot deformity. Prior to the implementation of an extender, the reduced bald scalp would stretch back partially: the surgical equivalent of taking two steps forward and one step back. The Frechet extender consists of a central extensible silastic sheet with titanium hooks attached on both ends: the device is implanted below the reduced scalp so that no stretchback occurs in the reduced bald area (unfavorable stretchback) but only takes place in the hair-bearing periphery (favorable stretchback). Slot deformity refers to the remaining slot-shaped bald area that persists along the incision line after all the scalp-reduction sessions have been completed. The authors have relied on a multiple z-plasty closure to camouflage this potential deformity and occasionally follicular grafting to disguise the defect further if necessary during the last session.
Scalp reduction has proven a reliable method in the authors’ hands for select patients with crown baldness. On the other hand, successful follicular grafting of the exposed crown may yield at times a less favorable result. Even the best transplantation efforts may produce a “pluggy” appearance if the grafts are viewed from above, such as seen from a bleacher-stand position. If the patient, however, demonstrates a favorable combination of dark-complected skin and light-colored hair then follicular grafting to the vertex may be much more forgiving and yield a more natural result. Interestingly, the most labor-intensive grafting sessions in the vertex may still be unrewarding, as patients often fail to appreciate an area that is not directly in their daily view unlike the comparatively more ecstatic reviews received for the transplanted fronto-temporal region.
As briefly mentioned, the younger patient (< 40 years old) or the patient with unstable and rapidly progressive hair loss may not be a suitable candidate for scalp reduction. After closure of the exposed crown, this type of patient may continue to lose significant hair and make incision-line camouflage challenging. As will be discussed, flap design principally involves recruitment of parietal hair into the central defect. Accordingly, donor hair in the parietal fringe should be sufficiently thick to provide density to the exposed crown and to tolerate some degree of stretch-back in the donor area. The occipital-fringe donor site is also recruited for closure but tends to be less distensible in tissue advancement due to the adherence of the occipitalis musculature to the posterior nuchal line.
The patient who desires rapid, dense coverage of the fronto-temporal region and who possesses adequate parietal donor hair may be eligible for scalp rotation with the Juri-designed, twice-delayed, temporo-parietal-occipital flap. In the authors’ experience, even patients who have undergone multiple, extensive transplantation sessions are exulted by the unparalleled density that they receive from a single flap rotation procedure. If needed, the contralateral parietal bed may be recruited as a second Juri flap to add density behind the first flap. Unlike scalp reduction, which mandates a more stable pattern of hair recession, fronto-temporal coverage with a flap rotation does not demand this pre-requisite. Nevertheless, rapid, ongoing hair loss of the fronto-temporal region may make a scalp rotation less than desirable, as future follicular grafting sessions will be required to camouflage the exposed posterior aspect of the flap. However, a detailed history should also delve into tobacco usage that may unnecessarily jeopardize flap viability. The authors elect to abstain from undertaking any flap procedure in an individual who is actively smoking. Complete cessation of this habit must be ensured two weeks prior to the initial flap elevation and maintained for the duration of all three phases of the procedure; and record of patient compliance must be documented in the medical chart. Once more, it should be also emphasized that most patients are more psychologically disposed to hair grafting transplantation, and this technique serves as the primary means by which to address androgenic alopecia and has provided very satisfying results for surgeon and recipient alike.

Evaluation of the Surgical Candidate

Psychology
What area troubles the patient? (Fronto-temporal vs. crown)
What are the patient’s expectations? (Natural hairline, dense coverage)
How long has the patient been concerned about the hair loss and what steps has he or she tried to ameliorate the condition (hairpieces, sprays, medications,
surgery?)

History
What are the onset, rapidity, and pattern of hair loss?
What is the patient’s general overall health? (diabetes, immunosuppression)
What medications has the patient tried to correct hair loss (including prescribed,
herbal, experimental medications)?
Has the patient undergone any surgery or trauma to the scalp and/or hair?
Has the patient exposed to any radiation insult to the hair-bearing region?
Any related auto-immune diseases?
Does the patient smoke or use any form of tobacco? Any illicit drug history?

Physical
Hair- color, texture, curliness (lighter, thinner, curlier hair is preferred for a
a natural, less “pluggy” hair transplantation)
Scalp- color and elasticity (darker color is preferred for a natural, less “pluggy”
hair transplantation)
Donor site- the density, extent, nature, and location of the hair
Recipient site- determine the extent of the area that the patient desires for
transplantation

Selection of Surgical Technique

Follicular Grafting
Fronto-temporal region is area of primary concern
Good occipital and/or temporal donor sites

Scalp Reduction
Crown, or vertex, is area of primary concern
Dark hair and light skin make follicular transfer in crown region more noticeable
(the bleacher-stand effect). Therefore, scalp reduction may be preferred
The area of exposed crown does not exceed 12 cm
Good scalp distensibility
No significantly progressive hair loss in the crown area.

Scalp Rotation
Fronto-temporal region is area of primary concern
The patient is accustomed to the density provided by a synthetic hairpiece
The patient desires rapid, dense coverage of the fronto-temporal region
Good temporo-parietal-occipital donor site(s)
Non-smoker

Intraoperative Considerations: Technique & Salient Technical Points
Instrumentation/Equipment for Follicular Grafting

Prep/Surgical Stand:?
Non-sterile gloves
Surgical marking pen
Electric Razor
Wide paper tape to hold hair away from donor site
Hair comb
10 cc syringe (4), 18-gauge needle with
0.9% normal saline
10 cc syringe (4), 27-gauge needle with
lidocaine 1% and 1:100,000 epinephrine
Needle holder
Tori triple-blade handle outfitted with 3 No.10 blades
18-gauge Nikor needle (for graft insertion)
Jeweler’s forceps (2)
Babcock (or tenaculum)
Adson-Brown forceps
Robbins hand drill with 1.75-mm hollow drill bit
2-0 prolene C-3 (CE-2) [C17]? for donor-site
closure

Graft Dissection/Preparation Table:
Powder-free gloves (sterile)
Petri dishes (4)
Single-edged razor blades
Magnification visors (, loupes, or dissecting microscopes)
Small bowls with normal saline (2), to wash the grafts

Disposable plexiglass platforms, for graft dissection
Illumination viewboxes, upon which to dissect the grafts
Adson-Brown forceps (2), to separate the strip grafts
Jeweler’s forceps (4), for individual graft dissection
Spray bottle with sterile water or normal saline

Instrumentation/Equipment for Scalp Reduction

Prep Stand:
Non-sterile gloves
Surgical marking pen
10 cc syringe (2), 27-gauge needle with
lidocaine 1% and 1:100,000 epinephrine

Surgical Table:
Basic soft-tissue instrument set (see Chapter 4)
Scalp Extender?

Instrumentation/Equipment for Scalp Rotation

First Stage:
Non-sterile gloves
Surgical marking pen
10 cc syringe (2), 27-gauge needle with
lidocaine 1% and 1:100,000 epinephrine
Doppler probe and Instrumentation
Surgical lubricant for Doppler probe
Basic soft-tissue instrument set (see Chapter 4)
Bipolar cautery
Skin stapler

Second Stage:
10 cc syringe (2), 27-gauge needle with
lidocaine 1% and 1:100,000 epinephrine
Basic soft-tissue instrument set (see Chapter 4)
Bipolar cautery
Skin Stapler

Third Stage:
Non-sterile gloves
Surgical marking pen
10 cc syringe (2), 27-gauge needle with
lidocaine 1% and 1:100,000 epinephrine
Doppler probe and Instrumentation (optional to confirm patency of vascular
pedicle)
Surgical lubricant for Doppler probe
Basic soft-tissue instrument set (see Chapter 4)
Bipolar cautery
Monopolar cautery
Skin stapler
6-0 prolene suture NEED NEEDLE SIZE
3-0 or 4-0 prolene suture NEED EXACT SUTURE AND NEEDLE SIZE
Jackson-Pratt closed suction drain

A. Follicular-Grafting Techniques
Although scalp reduction and rotation methods have been used with success in the treatment of alopecia, follicular grafting remains the mainstay of therapy for surgical hair restoration. In the authors’ practices, follicular grafting accounts for over 95% of surgical hair restoration; and this technique is the only acceptable method for female pattern baldness. Over the past decade, the term follicular-unit grafting has captured the imagination of the surgical community, but the authors have found that this methodology is only partly appropriate for optimal surgical hair restoration, as this section will elaborate in greater detail.

Hairline Design
Prior to administration of anesthesia, the surgeon should review with the patient exactly which areas of alopecia concern him. Accordingly, the surgeon should mark out the proposed hairline and other deficient areas that require surgical attention. The most crucial aspect to achieving a natural result with follicular grafting is recreating a natural-appearing hairline. Two anatomic regions should be kept in mind, the central frontal tuft and the respective fronto-temporal recesses. The new hairline should be recreated using the principle of an irregularly irregular insertion of grafts to mimic a natural hairline. As mentioned, a patient’s fronto-temporal recession should be carefully examined and the angle of the fronto-temporal hairline should be retained to some extent. Advancing the hairline too far forward (usually less than 10 cm from the orbital rim in the central frontal forelock and less than 12 cm from the orbital rim laterally in the fronto-temporal recession) may yield a less natural result and also make camouflaging difficult in a younger, rapidly progressive hairline. The textbook ideal of facial aesthetics that dictates the face be divided equally into vertical thirds (trichion to glabella, glabella to subnasale, subnasale to menton) should not apply to hair-restoration surgery. Even if surgery is planned in a younger patient in his early 20s, the surgeon should consider that this youthful hairline will remain unchanged for the duration of that person’s life and begin to appear unnatural as that individual matures. Furthermore, the geographic region of hair loss that occurs behind the transplanted hair will be more sizeable (especially in a younger patient who already requires surgical hair restoration) and may demand a considerable effort to camouflage. The isolated island of transplanted hair in an ocean of naked scalp is a dreadful telltale sign of past success and present failure. One should always be cognizant of the long-term outcome that a transplant will exhibit.
When planning the frontal hairline, the surgeon can rely on the Norwood method as a reliable guide to avoid the creation of an unnatural hairline. The construction of the anterior hairline is undertaken by defining three key points: the central, most anterior point of the hairline and the two peaks of the fronto-temporal recession (Figure 6-3). The central, anterior point of the hairline should not descend past a level that is situated two finger breadths above the highest forehead furrow created when the patient gazes upward. This line is the absolute lowest that is suitable for position of the hairline and should only be used as a starting, reference point. The surgeon should gauge how much higher the hairline should be positioned based on several factors: the patient’s age, fronto-temporal recession, existing hairline, rate of hair loss, and aesthetic opinion. The lateral two points that define the new peak of the fronto-temporal recession should lie along a vertical axis drawn through the lateral canthus, or slightly medial to this line. All three points are then connected to form an open oval shape that should appear as a straight line or slightly upward (but never downward) sloping line on lateral view (Figure 6-4). As these guidelines are only meant as a starting point, the hairline should be adjusted to fit the above-enumerated criteria based on aesthetic judgment.

Anesthesia
Intravenous sedation is the preferred method of anesthesia that should be maintained during the initial portion of the procedure – i.e., while the local anesthesia is infiltrated and the donor site is harvested (Figure 6-5). The substantial quantity of local anesthesia required for hair transplantation warrants some sedation to minimize discomfort and to achieve amnesia. Patients receive a regimen of intravenous midazolam (Versed) sedation, from 4 to 8 mg. Additional medication, usually at an incremental bolus of 2 mg of midazolam, is administered according to patient requirements. The amount of anesthesia needed for sedation is observed to be directly proportional to the patient’s daily or weekly alcohol consumption. Before delivery of intravenous anesthesia, the surgeon may discreetly inquire as to the amount of alcohol that the patient consumes in order to ascertain the necessary amount of anesthetic agent. Generally, this same anesthetic regimen is suitable for all scalp-reduction sessions as well for the first two stages of the Juri flap procedure. (The reader is referred to the appropriate sections that describe scalp reduction and rotation techniques for greater detail regarding the proper protocol for anesthesia in those cases.)

Surgical Technique
(1) Preparation of the Donor Site
The initial step in follicular grafting surgery is selection of appropriate donor hair. The surgeon should evaluate the donor site, typically the occipital region, carefully for density, color, and quality of the hair. Generally speaking, the area immediately below the occipital protuberance but still above the inferior border of the hairline is ideal for donor harvesting (Figure 6-6). Removing hair above the occipital protuberance predisposes toward harvesting hair genetically programmed for future hair loss; and doing so at the inferior border of the hairline will leave behind a conspicuous scar. The more inferior-based hair (near the occipital hairline) tends to be well suited for placement along the anterior-most hairline as single- or two-hair grafts, as these grafts are finer in nature than the coarser hair situated more superiorly in the occipital region. The surgeon should attentively evaluate the suitability of the hair for this purpose and direct the technicians accordingly to use this hair to dissect one-and-two follicle sized grafts. If this area does not appear to be well suited for anterior hairline grafting, the surgeon should entertain the option of harvesting select temporal hair for this purpose (see below for technique). In addition, the temporal region can serve as an excellent reserve for donor hair when the occipital region has been near depleted. When deciding on temporal hair harvesting, the surgeon should be advised to take smaller swaths of hair from targeted areas (e.g., bilateral harvesting of discrete areas) rather than larger passes that may lead to ultimate asymmetry and tension on closure.
After the surgeon has decided upon which hair will be harvested, the technician or assistant, who is in charge of preparing the surgical instruments (Figure 6-7), local anesthesia, tumescent solution, etc., should shave the occipital or temporal region to prepare the donor site. The amount that the occipital region needs to be shaved depends upon the extent of the graft session (small, medium, or large). Although these terms are arbitrary in nature, they serve well to communicate to all surgical team members the number of grafts that will be required and, therefore, the number of technicians, the operative-time allocation, and the extent of the donor site that should be shaved. In addition, the surgeon can establish unambiguous dialogue with the patient in regard to the intended surgical effort and thereby set a commensurate surgical fee. For convenience, the authors have used the following guidelines: a small session equals approximately 500 to 700 follicular grafts; a medium size session, 700-1000; a large, 1000-1500; and a megasession, over 1500 grafts.
Based on the size of the grafting session, the technician should shave the occipital region with an electric razor without a guard (Figure 6-8). An electric razor is preferred over a straight razor because shearing is less traumatic, faster, easier, and more precise. Also, a short amount of follicular height, or stubble, remains after use of an electric razor that facilitates graft orientation. Wide paper tape can be used above and below the shaved area to hold the untrimmed hair out of the surgeon’s way. The patient should then have an absorbent chuck secured around the neck to avoid soilage of his clothing during the operation. The preferred patient position for most of the procedure is sitting upright except during recipient-site creation, at which time a supine position is favored.

(2) Infiltration of Anesthesia and Harvesting of Donor Site
After the appropriate sedation, 1% lidocaine mixed with 1:100,000 epinephrine is infiltrated into the donor (occipital hair) and the recipient sites (fronto-temporal, midscalp, and/or vertex). Sterile normal saline is then infiltrated into the subcutaneous plane of the donor site using an 18-gauge needle on a 10-cc syringe for tumescent effect and ease of harvest (Figure 6-9). The endpoint of saline infiltration should be when the scalp appears tense and blanched and resistance is met when the plunger of the syringe is depressed. Tumescence yields several distinct advantages: (1) the follicles assume a more perpendicular orientation permitting ease of harvest, (2) the increased tension provides a more stable platform for the incision, (3) the proper plane of dissection (i.e., the subcutaneous plane) is more easily maintained due to hydrodissection and increase in overall depth of the subcutaneous plane, and (3) superior hemostasis is achieved by the added pressure of the saline on the vascular bed.
A Tori-style scalpel with 3 No.10 blades, spaced 2 mm apart, and directed parallel with the hair follicles at 20 to 30 degrees upward is used to harvest two rows of donor hair (Figures 6-10A, B). Although the tumescent solution tends to straighten the hair follicles somewhat, the overall follicular direction in the occipital region remains downward. During harvesting of the donor site, the surgical assistant should stand in front of the patient to observe for any signs of discomfort, e.g., wincing of the eyes, and should also hold the patient’s head steady, as the patient should be quite heavily sedated during this interval. Usually two rows each 17 cm long will be sufficient to yield approximately 170 grafts that bear 3 to 6 hairs (“minigrafts”) and about 2 to 3 fold that number of grafts that bear 1 to 2 hairs (“micrografts”). (This estimated total of 3-to-6 hair minigrafts is simply calculated by multiplying 2-mm width minigrafts over a 1-cm distance, which yields 5 minigrafts. In turn, 5 grafts x 2 rows = 10 grafts/cm x 17 cm = 170 minigrafts in two rows.) (Figure 6-11) Generally, no more than 3 passes of the Tori scalpel should be undertaken to avoid excessive tension on wound closure.
Of note, if the temporal region is to be harvested, several key points should be kept in mind. To reiterate, only smaller patches of temporal hair should be removed from any given site to minimize the chance of asymmetry and wound tension upon closure. When dissecting the temporal hair bed, the Tori scalpel should also be directed slightly upward at 20 to 30 degrees (just like in the occipital region) to parallel the direction of the hair follicles. The preferred location for temporal harvesting is several centimeters above the auricle running in an anterior to posterior direction. Unlike occipital-based harvesting, the depth of the incision cannot be as indiscriminate because the posterior branch of the superficial temporal artery resides immediately below the hair follicles and may be transected during harvesting. Therefore, care should be taken to harvest the graft as superficially as possible without violating the base of the hair shaft. Transection of the superficial temporal artery does not have any adverse effect on wound healing but only makes the task of hemostasis an avoidable nuisance.
After all the parallel rows have been dissected with the Tori scalpel, they can then be harvested from the scalp. First, a No.10 blade is used to taper each collective end of the rows into a fusiform point: the back of the head should resemble the outline of a long football after dissection of all the rows. A tenaculum is affixed to one fusiform end to grasp all the collective rows in its tines, and a No.10 blade is used to cleave all the rows in the mid-subcutaneous plane (Figure 6-11). The surgeon should carefully observe that the follicular shaft is not being transected during harvesting and that only a small cuff of adipose tissue (about 1 to 2 mm) remains below the hair follicle, as excessive fat below the hair bulb requires additional trimming at the time of graft preparation. The harvested strip grafts are then deposited into a bowl of saline for individual graft dissection and preparation. The donor site is closed with a running, locking 2-0 prolene suture that will be removed two weeks postoperatively (Figure 6-12A, B). In the past, surgical staples were implemented but perceived to be irritating by the patients and provided less hemostasis than a locking suture. Of note, any bleeding that appears before wound closure should not be cauterized, as the locking suture will preclude any hematoma or seroma from arising.
(3) Graft Preparation
After the donor site has been harvested, the team of technicians should begin to dissect the individual grafts. Typically, three to four technicians are needed to expedite the dissection process, which can be the most arduous aspect of hair transplantation, followed only by graft insertion for level of technical labor. Graft preparation should be carried out on a large flat surface with good illumination and proper loupe or microscope magnification. Magnification visors are recommended because they are inexpensive and induce less eye strain than use of a dissecting microscope. Generally, 2 1/2 times magnification is sufficient for proper inspection of the grafts and reduction of eye fatigue Flat, tabletop viewboxes provide transillumination of the tissue, which facilitates ease of graft dissection. Disposable, plexiglass sheets should be placed atop the viewbox as a cutting board upon which the grafts may be dissected without injury to the underlying viewbox screen. In order to reduce the glare of excessive light from the viewbox, a surgical drape should cover most of the viewbox except for the immediate field of dissection. (
All the collected strip grafts should bathe in a bowl of sterile saline until time for graft preparation. The saline will remove any excess blood that may cling to the grafts and prevent desiccation. Gentle handling of graft material and constant moisture are critical for graft viability. A spray bottle with saline should be kept nearby that can be used to moisten the grafts periodically during the period of preparation and insertion. After the strip grafts have been properly cleansed, they should be separated from one another at both ends with a No. 10 blade (The reader is reminded that after strip-graft harvesting all of the individual strip grafts are still joined together at both ends.) Any excess adipose tissue (greater than 1 mm) that remains below the base of the hair shafts should be trimmed before further graft dissection.
At this point, the strip grafts are dissected into discrete follicular grafts for transplantation using a straight razor.The amount of epidermal, dermal, and adipose tissue that should remain on each graft is negligible with only about a millimeter cuff surrounding the graft on all sides. In order to achieve the density of grafts in a particular area, the follicular graft must be relatively devoid of excessive tissue. To obtain this degree of accuracy, the technician must rely on magnification and illumination, as previously discussed. In contradistinction, the larger grafts that are distributed across the midscalp, i.e., behind the 3-cm anterior hairline, are larger in size and can have a 2-mm adipose cuff surrounding the hair shaft. Precise insertion techniques and placement of different sized grafts will be discussed in the following section. During graft preparation, the surgeon and two assistants can begin graft insertion with the grafts that have already been dissected (as will be discussed in the following section). The grafts should be dissected mainly along follicular units for ease of graft harvesting and to achieve an optimal aesthetic result. However, the principle of follicular-unit transfer is not strictly adhered to, as larger grafts (4 to 6 hairs per graft) are also dissected. Furthermore, the finer-caliber hair grafts that are harvested more inferiorly along the occipital or temporal fringe should be cleaved into 1 or 2 hair grafts (despite follicular-unit divisions) so that they can be destined for anterior hairline placement. After dissecting each graft, the technician should position the grafts on a Petri dish according to graft size. A line of demarcation should be drawn on each Petri dish that separates 1 hair grafts, 2 hair grafts, 3 hair grafts, 3-4 hair grafts, and 5-6 hair grafts. Alternatively, a Petri dish can be dedicated to each of the above graft sizes.
Before completing the surgical narrative, the authors would like to digress for a moment to clarify the terms “follicular-unit grafting” and “mini- and micrografting” and to elaborate upon the philosophy behind the surgical technique advocated in this text. Follicular-unit grafting has been a popular method of hair restoration over the past decade. Hair follicles do not tend to be distributed evenly across the scalp but grow in discrete clusters of 1 to 4 hairs, so-called “follicular units”Many hair-restoration surgeons promote dissection of all follicular grafts along follicular units. However, the authors believe that slightly larger grafts of 5 to 6 hairs remain well camouflaged if placed sufficiently behind the hairline and provide the increased density that the patient desires. The terms micrografting (1 to 2 hair grafts) and minigrafting (3 to 6 hair grafts)represent an alternative method to partition grafts. . However, these terms also lack refinement, and graft sizes that are named according to the precise number of hairs that reside on a graft may be the most accurate and clinically useful description. In summary, the authors rely on “follicular unit” divisions at times and “minigrafts and micrografts” designations at other times. Following the formula outlined in the preceding paragraph for graft preparation will provide the optimal aesthetic improvement (most natural appearance and greatest density) than either micro-/minigrafting or follicular-unit grafting alone will afford. The method by which these different size grafts are inserted will be elaborated in the following section.

(4) Graft Insertion
Follicular grafting of the balding scalp may be divided into two principal areas of concern: the frontal hairline and the more posteriorly situated midscalp. The area that is most noticeable to the patient and casual observer alike is the frontal hairline, which deserves commensurate attention and labor by the surgical team. The technique to address the anterior hairline differs markedly from that used to recreate the density required for the remaining scalp. Accordingly, this section will be subdivided into management of the frontal hairline and then that of the posterior scalp.
A. Anterior Hairline
The creation of a natural hairline in both height and configuration has already been addressed (See Hairline Design). This section will focus on the technique of graft insertion into the anterior hairline that will ensure maximal density yet retain a non-surgical appearance. Three key surgical aspects of frontal hairline creation will be explained: (1) the concept of cross-hatching, (2) the importance of the frontal forelock, and (3) the technique of graduated follicular grafting.
Placement of individual follicular grafts at different angles to one another permits maximal camouflage of the bald scalp. This technique is known as cross-hatching. If grafts are all placed in the same alignment, the bare scalp will be more visible to the naked eye than if they are placed in varying orientation to one another. Therefore, cross-hatching increases the perceived density of the hair. Similarly, the frontal forelock should be targeted for placement of a greater concentration of grafts because this central area can be observed from both sides of the head. Accordingly, every graft that is placed in this region is seen when the observer is viewing the patient from either the right or the left side. Conversely, grafts placed along the right side of the hairline are only visible when the observer is situated to the right of the patient. The same limited view that the observer has on the left side of the patient is applicable to the left side of the hairline. The grafts placed along the central forelock have double the exposure time than laterally placed grafts. Further, because the central tuft of hair can be seen from either vantage point, the hair in this area appears to gain twice the perceived density, as twice the number of grafts are being viewed concurrently.
Besides overall height and configuration of a hairline, several other key factors contribute to its natural appearance. The hairline should assume an irregularly irregular pattern, i.e., the hairs should not be situated in a straight-line configuration across the proposed hairline. When creating the hairline (as will be discussed), the surgeon should attempt to stagger each graft a bit anterior or posterior to the previously placed graft without any consistent pattern. This haphazard arrangement will mimic a natural hairline. The aforestated principle of cross-hatching will further enhance the irregular design of the hairline. The anterior most row of the hairline should consist of fine, single hair strands as opposed to coarse, 3 to 4 hair follicular grafts. By placing finer-caliber and single hair grafts along the anterior most hairline, the surgeon will emulate a natural hairline and also prevent a “pluggy” appearance to the surgical result. Each successive row posterior to the most anterior row should show an increase in the number of hairs/per graft and thickness of the hair-shaft caliber. (The precise method by which this task is accomplished will be elaborated in the next paragraph.) By following all the above tenets, the surgeon will ensure optimal density and a natural result.
As mentioned, local anesthesia in the recipient site should be administered at the inception of the case when the midazolam is delivered. During graft insertion, the patient may be fully awake and express anxiety over his lucid state. However, the surgeon should resist the temptation to grant additional intravenous sedation, as the more protracted recovery period that ensues typically does not justify another bolus of medication at this point.
The anterior hairline to be constructed constitutes on average a 10-cm distance along its length and a 3-cm distance from anterior to posterior extent. Therefore, the total scalp void that must be typically transplanted is approximately 30 cm2. Per square centimeter, approximately 20 to 25 follicular grafts should be inserted to achieve maximal density. Accordingly, 600 to 750 grafts should be placed to occupy a 3-cm recession of the anterior hairline. Additional grafts may be placed posterior to this 3-cm deep hairline if required for additional camouflage. However, generally speaking, larger 2-mm, 3 to 6 hair “minigrafts” may be used behind this anterior hairline to achieve more rapid density (see the following section B. on the midscalp.)
The surgeon and two assistants should be in charge of graft insertion. The technique involves the surgeon creating a recipient site, the first assistant then filling that recipient site with an appropriate graft, and the second assistant handing the first assistant another graft for insertion. More precisely, the surgeon uses an 18-gauge Nikor needle to create the recipient site using the principles of cross-hatching and irregularly irregular placement (as explained before). The first assistant is handed the appropriate size and caliber graft by the second assistant with a pair of jeweler’s forceps, who then in turn places the graft into the recipient site according to the direction that the surgeon created the site. The first assistant must maintain his or her line of vision constantly on the surgeon’s hand in order to recognize what direction the recipient site was created so that placement of the graft will match that same direction. Therefore, the role of the second assistant is critical so that the first assistant need not look away from the hairline to obtain the appropriate graft for insertion. Graft insertion proceeds across the entire hairline row by row. As the surgeon returns to fill in the next row, which should be 1 to 2 hairs per graft larger than the row immediately anterior, some of the previously placed grafts may be noted to have fallen out of the recipient site. Unfortunately, this problem is rather frequently encountered, as edema increases and as the crowding of densely packed grafts force neighboring grafts out of their nestled position. Care must be taken to return these displaced grafts back into recipient site. After a fibrin clot has formed in the recipient site, dislodgement of the graft is less likely.

B. The Midscalp
Behind the hairline and extending over the midscalp, the surgeon should create larger recipient sites that can accommodate 5 to 6 hair grafts. These larger sites are created with a rotating hand drill that carves out 1.75-mm circular defects into which these 2-mm sized grafts may be inserted. It is important that the same principle of cross-hatching be applied to achieve maximal density. It is very easy for the rotating drill to ensnare the neighboring hair and thereby temporarily depopulate more hair than will actually be grafted. This unnecessary hair removal can be quite distressing to the patient, who will already undergo additional hair loss in several weeks to months (a condition known as telogenic effluvium due to the trauma caused by surgical manipulation). The inadvertent entanglement of adjacent hair by the rotating instrument can be reduced by the following techniques: (1) wet the hair and hold the hair out of the way with the non-dominant hand and (2) limit the time that the hand drill is in rotation, i.e., start the drill rotating when the instrument is in contact with the scalp and stop the drill rotating before removing the instrument from the scalp. If a foot pedal is used to control the hand drill, the foot should only briefly tap the foot pedal rather than depress it for any sustained duration. After each graft is created, the tissue core within each site should be removed with a Brown-Adson forceps so that the larger grafts can be placed into the resulting divot.
At the end of the case, a commercial hair dryer that uses radiating heat rather than a dynamic airstream can be used to dry the hair before placement of a bandage. Several layers of 4 x 4 gauze is applied directly on top of the transplanted hair and kept in place with a baseball cap. As the hair has been air dried, the 4 x 4 gauze does not tend to adhere to the scalp or the inserted grafts.

B. Scalp-Reduction Techniques (Scalp Reduction with Extender)
General Considerations
As a quick review, the ideal candidate for scalp reduction is a more mature patient (> 40 years old) with a relatively stable pattern of hair recession who desires camouflage of his exposed crown, or vertex, area. The diameter of the bald vertex cannot exceed 13 cm for successful closure of the area. The patient must also be psychologically prepared for multiple sessions of scalp reduction to achieve complete closure. For 10 to 12 cm of exposure, four sessions are anticipated for complete closure. Similarly, 3 sessions should be sufficient for closure of 8 to 9 cm. As mentioned, greater than 13 cm of baldness proves to be difficult to close entirely despite numerous sessions.
Typically, the first session permits approximately 4 cm of tissue mobilization from the parietal fringe (2 cm from each side) and about 1 to 2 cm from the occipital fringe. Subsequent sessions permit less tissue advancement with about 3 cm of total tissue recruitment laterally and less than 1 cm posteriorly. Remaining scalp exposure may be addressed with mini- and micrografts to the central slot deformity after appropriate multiple z-plasty closure is performed. If the patient exhibits fronto-temporal recession and is motivated, then concurrent mini- and micrografting may be undertaken in that region even if significant undermining is planned in the area of proposed grafting. Although graft viability tends to be good despite undermining, the authors tend to discourage combined approaches (grafting and scalp reduction) to minimize risk of graft loss and the potential morbidity of protracted and extensive surgical manipulation.

Anesthesia
Generally, intravenous sedation using the protocol described above for follicular grafting is sufficient for all scalp-reduction sessions. In addition, local anesthesia of 1% lidocaine with 1:100,000 epinephrine is infiltrated as a ring-block around the perimeter of the area to be dissected and undermined.

Surgical Technique
A modified Mercedes configuration is designed over the exposed crown with the longer limb in the mid-sagittal plane and the shorter limbs extending postero-laterally. This inverted-Y incision has yielded the largest area of scalp recruitment by drawing more mobile parietal scalp centrally and by advancing less of the adherent occipital scalp. The rich occipital vasculature also makes surgical manipulation in this area less than desirable. The size of each limb of the Mercedes should follow the guidelines described above for recommended tissue advancement, e.g., a 4-cm width of the vertical limb to recruit 2 cm of parietal donor hair from each side and a 1-to-2 cm width of the horizontal limb to advance a respective 1 to 2 cm of occipital hair during the first session. In subsequent sessions, narrower limbs – e.g., a 3-cm wide vertical limb and a 1-cm, horizontal limb – should be used, as the scalp becomes less elastic.
After appropriate intravenous and local anesthesia are administered, the initial incision can be undertaken. The dissection is taken down through the galea aponeurotica and carried out in a subgaleal plane using Robbins instrument all the way down to the just above the ears laterally and over the occipital protuberance posteriorly As mentioned, use of an extender is mandatory to achieve maximal reduction, minimal unfavorable stretchback, and to shorten the interval between sessions?. Prior to extender use, concomitant stretchback could prolong total reduction time to upwards of 18 months, including all reduction sessions. Now, not only is unfavorable stretchback entirely eliminated, but also the biomechanical advantage imparted by the extender permits a markedly reduced interval between sessions, with an average of 30 days.
After the bald scalp is excised in the aforementioned modified Mercedes configuration and appropriate undermining is accomplished, the extender can then be positioned prior to scalp closure. The titanium hooks of the extender should be secured under one parietal wound edge first. As one assistant holds the scalp down in position, the surgeon advances the other free edge of the extender toward the contralateral parietal wound edge, grasping the device with a pair of clamps and placing the distensible silastic under tension. The second assistant maintains the free parietal wound edge in an elevated position with a wide, double-pronged retractor, as the surgeon positions the unsecured titanium hooks under the described free parietal edge. The cutaneous closure of the wound can then be properly undertaken after the extender device is securely fashioned to the underlying galea: a 2-0 prolene is used to close the wound in a running, locking fashion As mentioned, reduction sessions can be spaced one-month apart if an extender is used.

The number of reduction sessions is predicated upon the initial size of baldness and scalp elasticity that will permit complete closure. At the time of the final reduction session, a concurrent, multiple z-plasty closure is planned for several reasons. This type of closure visually disrupts the scar and reduces the risk of unfavorable scar contracture. With ensuing mild alopecia in the area of the z-plasty closure, the complex arrangement of transposition flaps camouflages any minor hair loss. In the authors’ practices, no revision cases have been needed over the past ten years, and satisfaction has been uniformly high.

C. Scalp-Rotation Techniques (The Juri Twice-delayed Temporo-Parietal-Occipital Flap)
General Considerations
In brief review, scalp-rotation procedures should be reserved for those patients who desire rapid, dense coverage to the fronto-temporal region and who will tolerate more invasive, multi-stage surgery. The density provided by this surgical method is unparalleled when compared with traditional grafting techniques. The rate of fronto-temporal recession usually does not pose a problem. However, the area immediately behind the flap may become exposed over time if excessive hair loss continues. A contralateral flap and/or micro- and minigrafting will disguise this problem, if it should arise. The temporo-parietal-occipital region should exhibit dense, undisturbed donor hair for rotation, and the patient’s vascular integrity must be ascertained (i.e., no recent smoking history or other vascular compromise). The patient should also understand that the frontal hairline might appear excessively thick and the fronto-temporal regions, blunted. For these reasons, the prospective patient should anticipate the potential for additional micrografting sessions to achieve the desired aesthetic result. Further, revision of a standing-cone deformity may be required in a few instances if this problem does not resolve after several months.
Although several variations of scalp rotational procedures exist in the literature , , , the authors have found consistently excellent results with the twice-delayed flap originally proposed by Jose Juri. Unlike the single-delayed temporo-parietal flap, the Juri flap yields twice the length and breadth of the aforementioned flap. The more abbreviated temporo-parietal flap is too short to traverse the entire frontal hairline and usually a contralateral flap is required to bridge the gap. Unfortunately, this more diminutive flap often appears unnatural, especially if further recession of hair arises behind the flap leaving an isolated, narrow strip of hair that serves as the manufactured frontal hairline. Conversely, the Juri flap provides a longer flap that usually spans the entire arc of the frontal hairline and gives adequate width (typically 4 cm versus the temporo-parietal’s paltry 2 cm girth, for a comparative four-fold increase in surface area). Again, a second Juri flap can be planned as a staged procedure after a 6-month minimum but preferably at 1-year post-final flap inset.

Anesthesia
For the first two stages of the Juri flap (in which the flap is prepared for transposition), the protocol for intravenous sedation as outlined in the previous section on follicular-grafting techniques may be appropriate. However, the extensive undermining and surgical mobilization that is required for the third and final stage of the Juri flap usually requires deeper sedation or general anesthesia under the care of an anesthesiologist or trained anesthetist. As far as local anesthesia is concerned, 1% lidocaine with 1:100,000 epinephrine is injected circumferentially around the Juri flap taking care to avoid infusion of anesthetic agent directly into or near the nutrient arteries to the flap. At the time of the first stage of the Juri flap, the surgeon should carefully delineate the vascular pedicle with a Doppler device prior to infiltration of local anesthesia so that the safe perimeter for injection may be determined.

Surgical Technique
First Stage
The initial task that must be addressed is determination of a suitable hairline upon which the surgeon and patient can agree. The desired new frontal hairline should be constructed both in terms of configuration (peaked versus straighter with less fronto-temporal recession) and height (from the orbital rim). Clearly, the proposed hairline cannot extend 4 cm below the existing hairline, as the 4-cm width of the T-P-O flap must bridge this gap. If the patient and surgeon believe that the hairline should descend much more than 4 cm from the existing hairline position, then a contralateral flap will be required to bring the hairline down further. However, if the patient exhibits significant hair recession so that even two T-P-O flaps will not bridge the gap between the original and the proposed hairline, then a Juri flap may not be the ideal solution to the patient’s particular condition of alopecia. Alternatively, for the very bald patient, bilateral T-P-O flaps may be rotated into position to create a dense new hairline and micro- and minigrafting used to soften the transition with the naked scalp posterior to the flap.
The T-P-O flap is based axially on the posterior branch of the superficial temporal artery (STA) and distally on the postauricular and occipital arteries in a random fashion. As part of the first stage of the operation, the proximal flap should be mapped out according to Doppler analysis of the posterior branch of the STA. As the distal aspect of the flap is random, a Doppler reading is unwarranted. The proximal third of the flap lies behind the new hairline, whereas the distal two-thirds of the flap serves to recreate the new hairline. Therefore, the peak of the flap should be designed at the junction of the middle and distal thirds. The base of the flap should commence 4 cm above the helical crus and span a distance of 4 cm width at an angle of 30 to 40 degrees with the horizontal. The distal extent of the flap should remain on the ipsilateral side of the head and not reach the midline if possible, unless greater flap length is mandatory.
Proper flap and hairline design are imperative for a successful operation. Therefore, the surgeon must accord considerable deliberation and patience to this task rather than hasten forward to actual surgery. The flap length that is marked out should be confirmed to be adequate for hairline creation. An unraveled 4 x 4 gauze can be held at the base of the proposed flap and stretched across the constructed hairline, so that the gauze pivots to cover two-thirds the length of the flap. After the flap design has been established and corroborated with patient, the distal third of the flap is raised from its bed and placed back into position. A No.10 blade can be used for the incision and flap elevation. The level of dissection is subgaleal, which is a natural and bloodless cleavage plane. Hemostasis along the cut edges of the flap may be attained with bipolar cautery. Monopolar cautery should be avoided to minimize injury to the neighboring vascular pedicle. Because flap elevation is limited, placement of drainage devices is usually unnecessary. Compressive dressings that remain in place until the first postoperative day typically serve to eliminate the risk of hematoma or seroma. Surgical staples are the most efficient way to close the scalp, and they should also be placed along the proposed outline for the proximal flap so that the second stage flap elevation may be easily carried out.

Second Stage
The second stage of the Juri flap is the least demanding step of all three stages, lacking the deliberative effort required for the first stage and the technical labor for the third stage. Accordingly, the actual time expenditure for surgery is more cursory, and anesthesia requirements should be tailored to the limited nature of the surgical endeavor. Generally, short-acting intravenous sedation complements the infiltration of local anesthesia but may not be needed for the more stoic individual.
The second stage is undertaken one week after the first stage. However, delay of any stage of the procedure may be warranted if signs of impending flap compromise are evident. Using the staples from the first stage of surgery as a guide, the proximal portion of the flap – i.e., the remaining 2/3 of the flap that has not already been elevated – is then temporarily raised out of its native position and set back into position. The surgeon should be very careful not to raise inadvertently the distal one-third of the flap while elevating the proximal portion. This problem can be averted by removing the staples that hold the distal third of the flap only after elevation and inset of the proximal two thirds of the flap. The dissection of the proximal flap should follow the subgaleal plane, as outlined for the first stage of the procedure. In order to avoid injury to the vascular pedicle, the flap should be elevated gently with blunt scissors in a spreading fashion. After the proximal two-thirds of the flap have been elevated, the flap is returned to its original position and secured in place with staples. Of note, the previous staples placed along the distal extent of the flap can be removed at this time. No compressive dressing or drains are applied so as to minimize injury to the proximal vascular pedicle.

Third Stage
After an additional one-week delay, the entire flap may then be elevated, mobilized, and rotated into position. As flap viability is absolutely critical for this stage of surgery, any evidence of vascular congestion or arterial insufficiency should be sufficient reason to delay the stage another week or two. If the surgeon is uncertain as to the integrity of the flap, Doppler analysis may help render appropriate judgment. The proposed hairline should be redrawn with a surgical marking pen and confirmed with the patient before any incision is carried out along this line. In addition, flap length should be assessed to determine adequacy for hairline coverage, using a stretched-out 4 x 4 gauze as previously described. (The reader should review the salient points of hairline design as described in the first stage of flap surgery before embarking on the third stage.) This stage of surgery is the most labor intensive. Protracted surgery, extensive dissection, and significant blood loss justify general endotracheal anesthesia or deep intravenous sedation for patient comfort and compliance.