Alfonso Barrera

The use of micrografts and minigrafts in the aesthetic reconstruction of the face and scalp.

Hair transplantation by use of micrografts (one- to two-hair follicular unit grafts) and minigrafts (three- to four-hair follicular unit grafts) used in large numbers (>1000 grafts) in a single session was initially described for the treatment of male pattern baldness. More recently, the author has found many other applications, particularly in facial and scalp reconstruction. The most common causes for aesthetic hair restoration of those areas in the author’s experience include hair loss resulting from aesthetic facial rejuvenation surgery, revision of unsatisfactory results from previous hair transplantation, burn alopecia, congenital reasons, and hair loss after oncologic resections. The basic technique is described in detail, with variations given for each of the challenging anatomic areas, including the sideburns and temporal hairline, eyebrows, eyelashes, mustache, beard, and remaining scalp. Special attention is given to the direction of hair growth, hair texture, aesthetic planning, and absence of detectable scars, in order to mimic nature and to result in a minimal number of procedures. The use of micrografts and minigrafts in the aesthetic reconstruction of the face and scalp has been found to be safe and predictable, and has provided a high level of patient satisfaction.

Micrograft and minigraft megasession hair transplantation results after a single session

The purpose of this article is to share observations made after performing 90 consecutive micrograft and minigraft megasessions for the treatment of male pattern baldness. Micrograft means grafts with 1 or 2 hairs, minigrafts are those with 3 or 4 hairs, and a megasession is a procedure in which more than 1000 micrografts and minigrafts are inserted in a single session. Between March of 1994 and June of 1996, the author performed 90 consecutive micrograft and minigraft megasessions on 86 men and 4 women ranging from 21 to 67 years of age (average age, 42 years). The surgical team consisted of three surgical assistants and a plastic surgeon. Today, usually between 1500 and 2000 grafts per session are performed in about 4 to 6 hours, with up to 2495 grafts done in a single session. All procedures were done under intravenous sedation and local anesthesia. A donor horizontal ellipse of scalp is harvested from the occipital area; the grafts are made out of it and then inserted through small slits. The procedure has been found to be safe and predictable with natural and aesthetically pleasing results, and there were no serious complications. The only complication found in this group was self-resolving inclusion cysts (ingrown hairs) occurring in 9 of 90 patients (10 percent). Even though the hair density achieved in a single megasession is limited, there is a high level of patient satisfaction: 83 of 85 patients were satisfied (97.65 percent).

Survival of transferred intestinal segments after vascular pedicle interruption

Rat intestinal segments with intact vascular pedicles were transferred from the abdominal cavity into the subcutaneous space. After 30 days, the vascular pedicle was severed. The intestinal segments, now completely dependent on wound neovascularization, survived completely. We conclude that early survival of intestinal transfers requires perfusion through the vascular pedicle. With time in a favorable bed, new vessel ingrowth from the recipient wound into the intestinal segment provides adequate circulation so that the vascular pedicle can be safely divided with no ill effect or at most a minor mucosal slough which quickly heals. Further clinical opportunities are necessary to determine the time course for these phenomena in humans.

The Use of Micrografts and Minigrafts for the Correction of the Postrhytidectomy Lost Sideburn

A tell-tale and unsightly deformity that can result from a rhytidectomy is the loss of the sideburn. As redundant skin is lifted, the hairless skin of the cheek may be advanced into the sideburn area. Several techniques have been described for sideburn reconstruction, mainly punch grafts and various scalp flaps. I use micrografts and minigrafts to effectively correct this deformity in a single session, under local anesthesia and mild intravenous sedation. I use basically the same technique previously described for the treatment of male-pattern baldness, with the direction of graft insertion being at a very acute angle to obtain the growth of hair in a natural downward direction. I found the procedure safe and predictable, and the patients treated were very satisfied with the aesthetically pleasing and natural result.

Office-Based Outpatient Plastic Surgery Utilizing Total Intravenous Anesthesia

BACKGROUND Office-based plastic surgery procedures continue to increase in popularity and a range of anesthetic techniques can be utilized, from light conscious sedation to general anesthesia requiring intubation. Total intravenous anesthesia (TIVA) is well suited for the office environment because it allows for moderate to deep sedation without the need for intubation. OBJECTIVE The authors review plastic surgery procedures performed in an outpatient office-based operating room under TIVA to assess patient outcomes and complications. METHODS A retrospective chart review was conducted of patients who underwent surgical procedures performed by 2 senior surgeons at American Association for Accreditation of Ambulatory Surgery Facilities-certified outpatient operating rooms between 2003 and 2011. TIVA was always administered by a board-certified anesthesiologist because it required the use of propofol. Conscious sedation with midazolam and fentanyl was always administered by the plastic surgeon. Patient outcomes and complications were analyzed to assess the safety of TIVA in an office operating room. RESULTS A total of 2611 procedures were performed on 2006 patients. No deaths, cardiac events, or transfers to the hospital occurred in any patients, regardless of the type of sedation utilized. Six hundred forty-two patients were given TIVA, which included propofol and/or ketamine, in addition to midazolam and fentanyl. The remaining 1364 patients received conscious sedation. There was 1 documented case (0.05%; 1/2006) of deep vein thrombosis/pulmonary embolism in a patient who had an implant exchange under TIVA; this patient was taking oral contraceptive pills at the time of surgery. CONCLUSIONS Office-based surgery is an attractive option for many patients. This review suggests that a variety of procedures can be performed in a safe manner under TIVA. Although patient selection for outpatient surgery is paramount, TIVA offsets the risks of general anesthesia and is associated with minimal postoperative complications. LEVEL OF EVIDENCE 4.

Hair restoration surgery: the state of the art.

Hair restoration is a highly sophisticated subspecialty that offers significant relief to patients with hair loss. An improved understanding of the aesthetics of hair loss and cosmetic hair restoration, hair anatomy and physiology, and the development of microvascular surgical instrumentation has revolutionized the approach to surgical hair restoration since the original description. Additional elements that contribute to the current state of the art in hair restoration include graft size, site creation, packing density, and medical control of hair loss. The results of hair restoration are natural in appearance and are provided with a very high level of patient satisfaction and safety. This aspect of cosmetic surgery is a very welcome addition to a traditional aesthetic practice and serves as a tremendous source for internal cross-referral. The future of hair restoration surgery is centered on minimal-incision surgery as well as cell-based therapies.

Rhytidectomy and parotidectomy combined in the same patient.

Until now, aesthetic goals in parotid surgery have seldom been addressed because oncologic concerns have largely overshadowed aesthetic issues for patients with parotid masses. Fortunately, the majority of parotid masses are benign pleomorphic adenomas that rarely recur, leaving a large group of patients healthy after their parotid surgery, with some desiring aesthetic improvement in their facial appearance. Traditional parotidectomy incisions leave a visible scar on the neck as well as a visible hollow in the retromandibular region, which can extend onto the cheek. A rhytidectomy approach to the parotid gland allows for a more concealed, aesthetically appealing scar while maintaining good visibility and access to the parotid gland. By performing bilateral sub-SMAS (superficial musculoaponeurotic system) rhytidectomy after a parotidectomy, facial symmetry and balance is enhanced, and these aesthetic deformities can be minimized. The SMAS flap can help to fill the hollow and form a tissue barrier over the resected gland to prevent gustatory sweating. Finally, the incision scarring is minimized with a rhytidectomy-type approach. Two cases are reported in which patients underwent both rhytidectomy and parotidectomy. In the one case, the procedures were performed in the same surgical setting. In the other case, they were performed in a delayed fashion. These cases exemplify the possibility of addressing facial aesthetic goals of rejuvenation in a patient requiring parotid resection.

Micrograft and minigraft megasession hair transplantation: Review of 100 consecutive cases

Exciting advances in hair transplantation have been introduced in recent years, particularly the use of a large number of micrografts (containing only one or two hairs) and minigrafts (containing three or four hairs) in a single hair transplantation megasession. A megasession consists of the placement of more than 1000 grafts in a single session. This study includes data from 105 consecutive micrograft and minigraft megasessions performed between March 1994 and August 1996 in 100 patients, with a follow-up of 5 months to 33 months. The patients included 96 men and four women whose ages ranged from 21 to 67 years, with an average age of 42 years. In this procedure a horizontal ellipse of scalp harvested from the donors occipital area is used to make grafts under 3.5 loupe magnification. The grafts are inserted through slits in the recipient area, and the donor site is closed primarily. All of the procedures were done at my office surgical suite with the patients under intravenous sedation and local anesthesia. This procedure was found to be safe and predictable. The only complications encountered were a hypertrophic donor site scar in one patient (1%) and selfresolving ingrown hairs (cysts) in nine patients (9%). Ninety-seven patients (97%) were satisfied with the results obtained after one session. Three patients (3%) who were dissatisfied with the results after one session were pleased with the results obtained after a second procedure.

Use of Hair Grafting in Scar Camouflage

Loss of hair-bearing tissue in the head and neck area can result from surgery, trauma, burns, tumors, and infection, as well as a diversity of inflammatory conditions, and the resulting defect can present a challenging problem for the reconstructive surgeon. Hair transplantation can be used as a reconstructive method alone or in conjunction with other techniques. The current method of using follicular unit grafts has led to natural restorations for a variety of areas including not only the scalp but also eyebrows, eyelashes, and beard areas. Camouflage provided by hair grafts can provide restoration not obtainable with other methods.

Correcting Retroauricular Hairline Deformity After Face Lift

According to the author, retroauricular hairline distortion resulting from face lift procedures may be corrected safely and effectively with micrografts (1 or 2 hair follicular units) and minigrafts (3 or 4 hair follicular units) implanted in a single session. He states that this procedure leaves no scars in front of the new hairline.