Follicular Transplantation for the Correction of Various Stigmas After Rhytidoplasty

I read with great interest the scientific article of Radwanski and colleagues on this important topic frequently not mentioned and often ignored in aesthetic plastic surgery. If we are honest with ourselves, we must admit that many patients with alopecia have stigmas related to rhytidoplasty (face-lifting procedures). We often see beautiful results after face-lifting procedures performed by reputable surgeons, with obvious hairline displacements and certainly no comments about it. The patient does not know any better, but we do, or we should! Rawdanski and colleagues report on 33 patients. According to their description, cephalic displacement of the sideburn, increased distance from the tail of the eyebrow to the temporal hairline, and step deformity of the retroauricular occipital hairline are the most common problems. The authors describe various techniques for the correction of the sideburns, primarily rotation flaps (including tissue expansion), and note that they all tend to leave scarring along the margin of the new hairline, resulting in additional hair growth in an unnatural direction. The authors use xilocaine with epinephrine to anesthetize the area locally. I prefer using 0.5% bipuvacaine (Marcaine) with epinephrine 1:200,000 for the initial infiltration. This approach offers comfort during the procedure and for a longer time postoperatively. I could not agree more that the use of follicular unit grafts currently provides the best correction results for all alopecia stigmas, without scars at the margin of the reconstructed hairline and with hair growth in a natural direction [1 5]. I also use conscious sedation and local anesthesia. I agree that this is the best approach for these and many other procedures in plastic surgery. The authors use 18and 19-gauge needles, which are a good choice. I have a personal preference for 22.5 Sharpoint blades or 1.5to 2-mm chisel blades (cut from Personna prep blades). They mention 20 to 30 follicular units/cm in the area grafted. This is a good rule of thumb per session. Often that will be sufficient for the sideburns, but it is not uncommon to do a second session for the more demanding patients. I tell the patients in advance that it may well take two sessions to get more optimal density so there are no surprises or disappointments. As the authors indicate, wide scars on the hairbearing scalp (e.g., on the temporal areas) tend to widen when revision is attempted by excision and closure alone, and I totally agree. Here, too, follicular unit grafting is the best approach. Wide donor scars and donor-site iatrogenic alopecias can be avoided by harvesting long but narrow horizontal strips from the occipital area. As a general rule, these strips will be less than 7 or 8 mm in the vertical dimension and as long as needed, and 5 to 15 cm in the horizontal length or more depending on the donor area hair density. In selected cases, wider strips can be used safely. Each patient is assessed individually. The only way that displacement of the hairline can be completely prevented cephalically and posteriorly with face-lifting procedures is by using a prehairline (pretrichial incision) meticulous closure to prevent detectable scarring. Depigmentation along the scar or unfavorable scaring can occur. When this happens, it can be camouflaged easily with follicular unit grafts. Correspondence to A. Barrera M.D.; email: abarrera@ lookinggood.com, http://www.lookinggood.com Aesth. Plast. Surg. 31:69 70, 2007 DOI: 10.1007/s00266-006-0198-1