Dr. Cam Simmons - 3088 grafts for a man with a Norwood 4A pattern with a persistent midfrontal forelock and a cowlick

[Cam Simmons MD ABHRS]

This 26 year-old man had hair loss in front but still had a strong midfrontal forelock (or 'island' or 'central tuft'.) He also has a strong cowlick which is like an S-whorl in his frontal hairline. He hoped to be able to brush his hair backward without the recessions showing but agreed that a mature hairline would be sensible in view of his potential to lose more hair as he ages.

 

He uses Minoxidil regularly but stopped Finasteride due to side effects after 2 separate trials.

 

He has fine hair but has more hairs per graft than average. We don't keep separate graft counts but did note that he had more 3s than 2s or 4s and had more 5s than 1s.

 

We transplanted 3088 follicular unit grafts in front, excluding his midfrontal forelock, at densities of 56 -> 49 -> 42 grafts per square cm. He had 373 1-haired follicular units in his hairline. We had to follow his natural direction in his cowlick.

 

At that time, I was routinely undermining only the lower edge, whereas I now routinely undermine both edges. He is happy with his trichophytic scar. I think it is OK but undermining both edges works better for me.

 

Patients with acne seem to have a higher risk of getting post-op scalp pimples but using Tetracycline immediately post-op worked well at prevention.

 

Some men keep their midfrontal forelock for life but others eventually lose hair there too. He knows that he will need more hair transplantation if and when he loses the hair in the midfrontal forelock and may want more hair transplantation if and when he loses more hair in his midscalp and crown.

 

[hair_care]

Nice work doc, the patient has beautiful hair.

[rpachigo]

Great documentation and nice work. Why only undermine one side though?

[NW4recession]

This is amazing work. Nice job!

[Bill - Seemiller]

Dr. Simmons,

 

What a beautifully crafted and natural looking hairline reconstruction.

 

In my opinion, your work is very impressive.

 

Best wishes,

 

Bill

[Cam Simmons MD ABHRS]

Thanks hair_care and rpachigo

 

Originally posted by rpachigo:

Great documentation and nice work. Why only undermine one side though?

 

I am asking that myself!

 

Actually, in Dr. Frechet's original article on trichophytic closures, he said that you could either undermine both edges about 1/2 the width of the donor strip or 1 edge the full width of the strip. Dr. Frechet limits the strip width to 10 mm but I will take a wider strip if the VSL (vertical scalp laxity) allows.

 

If the results were equal, it would be easier and faster to undermine one edge the width of the donor strip than to undermine both edges half the width.

 

I felt the results weren't quite as good so I switched back to undermining both edges.

 

Even when the strip is 10 mm wide, in my hands, the scar is narrower if I undermine both edges.

 

It may be different for other doctors.

 

This patient is content as he is. If he has more hair transplantation in the future, I will remove the donor scar with his strip and undermine both edges.

[Cam Simmons MD ABHRS]

Thanks very much Bill

[Raphael84]

Amazing transformation. Great natural hairline. Patient must be thrilled. Obviously, as you have explained, if the frontal forelack does recede thin, then a further session would be necessary as this would look extremely unnatural.

[rpachigo]

That's very interesting regarding the minutiae of undermining. Articles have been written describing undermining one side the whole length of wound vs. undermining half the length on both sides - very academic but useful I suppose.

 

That's brings up a few other questions in my mind. If you are underming, are you doing so subgaleal or above the galea above the occipital protuberance? Also I guess you are undermining above the galea b/c when you go laterally, the galea blends with the temporal fascia. So is there any time you would go subgaleal and score the galea and maybe be less tension on closure with the deep stitches placed into the galea - also possibly less chance of deep sutures catching the follicles? Does this make any sense? Also with suture closure of the skin, I have seen some using locking sutures - I don't remember who that was. Would it make more sense to use a horizontal mattress everting suture which may possibly be less asphyxiating to the follicles or does this not matter? Ideally if deep sutures approximated the wound like they should, you could put steri-strips for the skin - that's extreme of course.

 

My only experience with this is doing bicoronal flaps for frontal sinus obliteration for chronic frontal sinusitis and also flap closure of large scalp defects after skin cancer removal which I haven't done in a long time. I remember scoring the galea to release some tension - not sure if it helped a little or a lot.

 

Any observations appreciated Dr. Simmons.

[Cam Simmons MD ABHRS]

Originally posted by Raphael84:

Amazing transformation. Great natural hairline. Patient must be thrilled. Obviously, as you have explained, if the frontal forelack does recede thin, then a further session would be necessary as this would look extremely unnatural.

 

Thanks Raphael84

 

Hair transplantation is a team sport and I am very lucky to have a great team.

 

If this man's midfrontal forelock does get thin, he and I will notice it before the general public does. We won't wait until he goes bald there but will transplant it as soon as there is enough room to put enough hair to finish it.

[Cam Simmons MD ABHRS]

rpachigo

 

It was clear early on in your post that you were a physician. You ask excellent but very technical questions. I hope that I can answer them clearly and well.

 

Let me first state clearly that I am not a plastic surgeon or a researcher so there are others who can probably answer your questions better than me. What I know about donor closure I have learned from others and from experience. I have been doing hair transplantation since 1999 and had always done office and emergency room procedures as a family doctor/emergency physician from 1989-1999.

 

Originally posted by rpachigo:

If you are underming, are you doing so subgaleal or above the galea above the occipital protuberance?

 

I undermine through the fat layer, above the vessels and nerves that sit just above the galea. (i.e. supragaleal undermining)

 

So is there any time you would go subgaleal and score the galea and maybe be less tension on closure with the deep stitches placed into the galea - also possibly less chance of deep sutures catching the follicles?

 

I usually undermine. Occasionally, I use deep sutures. I rarely do both.

 

So far, I have not scored the Galea to make a relaxing incision.

 

I find that the hair transplant literature is not really clear about the depth of deep sutures. The Dermis, the Galea, and the Pericraneum are strong and can hold sutures. You might as well try to sew a tomato as to try to sew fat.

 

Hair follicles grow through the dermis so sutures placed into the dermis can affect hair follicles. My surface layer reaches into the dermis just above the dermal papillae and below the bulge. Deep sutures coming up into the dermis will reach above the dermal papillae and so will be creating some tension around the papillae. I have no proof or knowledge that this has any affect but I feel like I may have lost a few follicles when I used to carry deep sutures up too high into the dermis.

 

When you look at live surgeries, "subcutaneous" sutures often seem to be going into the Galea. Dr. G. Seery wrote about deep plane fixation where sutures would go from the dermis on one side of the undermined incision to the galea on the other side and vice versa.

 

Dr. Seery also wrote about suturing Galea to Pericraneal flaps as a way to keep the tension away from the skin surface. What he wrote makes sense but I feel like the deeper I work the more chance I have of causing problems. Since I do not come from a plastic surgery background and don't have experience with scalp reductions or flaps, I plan to keep working above the Galea. If there was a clear benefit to doing this deeper work, I would want to train with someone who is experienced before doing it on my own.

 

 

Also with suture closure of the skin, I have seen some using locking sutures - I don't remember who that was.

 

I don't use locking sutures because they theoretically leave more suture material on top of the skin that can cause pressure when the skin swells. Not locking the suture also allows some movement and equalization of tension along the suture. That being said, I am sure that doctors who use locking sutures have their own reasons for using them and can get excellent results with locking sutures. It is probably more important that there be no tension on the suture than whether it is locked or not. I think Dr. Lindsey used locking sutures in his "2-edged sword" case.

 

Would it make more sense to use a horizontal mattress everting suture which may possibly be less asphyxiating to the follicles or does this not matter?

 

Incisions tend to flatten and contract as they first heal. We suture incisions so that the incision sits a bit higher with the edges turned a bit outward in what we call eversion.

 

Mattress sutures pull from further away from the incision so the incision is more everted and sits higher than with simple sutures. Horizontal mattress sutures are like a square with the 2 sides on the skin surface parallel and on either side of the incision and 2 sides that cross underneath the incision. The knot is tied on one of the sides on the surface of the skin.

 

I have not tried using horizontal mattress sutures. I would rather not have the suture travelling too far on either side of the incision in case swelling causes pressure and hair loss under the suture. If that happened the marks would be parallel to the scar and could make the scar look wider.

 

Ideally if deep sutures approximated the wound like they should, you could put steri-strips for the skin - that's extreme of course.

 

I think the steri-strips wouldn't stick unless you shaved too much hair above and below the incision.

 

My only experience with this is doing bicoronal flaps for frontal sinus obliteration for chronic frontal sinusitis and also flap closure of large scalp defects after skin cancer removal which I haven't done in a long time. I remember scoring the galea to release some tension - not sure if it helped a little or a lot.

 

You have more experience with scoring the Galea than I do. Thanks for these thoughtful and challenging questions.

[thanatopsis_awry]

Righteous result; o' so lush.

[rpachigo]

Thanks for your informative reply Dr. Simmons!

 

I did think that the undermining was done superficial to the galeal layer which you confirmed and indeed, that would release tension on the edges possibly making deep sutures redundant. Throwing a deep suture in the galea or pericranium does not seem standard of care for hair transplantation overall although they would really release a lot of tension - maybe increased risks of hematoma/infection/blood supply, etc. And a suture in the fat does nothing as you stated. So there is some small risk to the follicle in placing your buried suture in the dermis - how big who knows? There is no other place to put the deep suture.

 

Thanks again for the reply.

[Dr. William Lindsey]

Dr. Simmons asked me to comment on locking sutures. Here is what I do and what works for me-- not necessarily what would work for everyone.

 

Undermining. I am a huge fan of undermining on the face for almost every wound closure. On the scalp, I simply haven't found it to be needed except very rarely. If I am closing a large scalp cancer defect, I will just rotate a flap into the space as needed. I have made one back cut into galeal, and to me its one of those things that looks good on paper but doesn't really work in the real world. Undermining for the strip widths I do is simply not necessary. Although I did need to do it in one of my posts on this site entitled "the double edged sword"; as it was a scar revision and hair transplant combo.

 

Deep sutures. Always. For me that is the key to taking tension off of the wound edges and getting a better scar. No guarantees, but I am sure my scars are better with deep sutures; and then I never worry when taking out skin sutures at day 6-8.

 

Locking sutures. Always. But I was taught by my fellowship director a running DOUBLE locked suture. I don't know anyone else who does this, and early on I thought it was kind of silly. But I completely agree with my teacher the 3 reasons for using it over any other technique. First, the second lock holds tension, but if the skin edges swell, the second lock allows expansion so there is no skin necrosis. Then when swelling goes away, that second lock keeps the closure tight. (this is the most impt reason in my opinion. just last week i took regular locking sutures out from a patient operated on by a prominent coalition member at 12 days, and there were railroad tracks and evidence of a couple of areas of skin necrosis that were healing) Second, the double locked sutures are easy to take out by staff and wives and other docs. Third, particularly on the face, they look very precise and regularly spaced when compared to single locked running sutures. I don't think that alters healing, but it looks better. So really the reason I do it is #1.

 

But every doc has their reasons for particular closure techniques and no one way is best for everyone.

 

Dr. Lindsey McLean VA

[Mick from Farjo]

Dr Simmons,

The work looks excellent.

 

Mick

[Cam Simmons MD ABHRS]

Thanks for your informative reply Dr. Lindsey

 

Originally posted by dr. lindsey:

... Deep sutures. Always. For me that is the key to taking tension off of the wound edges and getting a better scar...

To be clear, how low and how high do your deep sutures go? It looks like you use interrupted deep sutures.

 

... Locking sutures. Always. But I was taught by my fellowship director a running DOUBLE locked suture...

I have tried to do my homework but couldn't find a reference describing running double-locked sutures. Are you locking the suture then throwing another loop around the suture before moving on? This would be particularly interesting if it allows for post-op incision swelling.

[rpachigo]

Thanks Dr. Simmons and Dr. Lindsey.

 

Still trying to figure out the difference between a simple locking suture vs. this double locking suture that you mentioned Dr. Lindsey that allows some swelling and expansion. This august heat definitely causes some swelling and expansion and I could see how the pressure from a simple locking suture could lead to some superficial skin necrosis.

[Cam Simmons MD ABHRS]

This man has returned for his 12 month photos with shorter and darker hair. His donor scar has also faded and his hair around and in the scar has grown back. He is happy that he has the option to change his hairstyle, if he likes.

[Cam Simmons MD ABHRS]

Tilted Down

[Cam Simmons MD ABHRS]

3/4 Right

[Cam Simmons MD ABHRS]

3/4 Left

[Cam Simmons MD ABHRS]

Donor Scar

[Cam Simmons MD ABHRS]

Top View

 

P.S. I would appreciate it if someone could suggest a better way to add updated photos. I will add them to the gallery too.

[the B spot]

Tell him to keep the shorter hair.....the Mel Kuiper Jr look only works for, well....Mel =)

 

Nice work Dr. Simmons.

 

Take Care,

Jason

[hair_me_out]

Wow, this is a really nice result. Great work, Doc! The person looks 10 years younger, I'd be very pleased.