James E. Vogel

Standardizing the Classification and Description of Follicular Unit Transplantation and Mini-Micrografting Techniques

&NA; Previous attempts at classifying small graft transplants have focused mainly upon graft size and have not taken into consideration other technical factors involved in graft production that may influence the outcome of the surgery. The proposed classification attempts to consider these factors by including various technical aspects of harvesting, dissection, and placement, all of which impact the quality and quantity of the small grafts used in the procedure. By standardizing the nomenclature, as well as the description of the other factors involved in the surgery, communication between physicians and patients may be facilitated. In addition, different procedures may be more accurately studied and compared.

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.

Calf Augmentation and Reshaping with Autologous Fat Grafting

BACKGROUND Despite multiple advantages of fat grafting for calf augmentation and re-shaping over traditional silicone calf implants, few reports have been published. OBJECTIVES To report our technique and results with autologous fat grafting for calf augmentation and reshaping. METHODS A retrospective review of the senior authors (JEV) experience with autologous fat grafting for calf augmentation was performed. Medial and lateral calf augmentation was accomplished with injection of prepared autologous lipoaspirate intramuscularly and subcutaneously. RESULTS Over a 5-year period, 13 patients underwent calf augmentation and reshaping with the described technique. Ten cases were bilateral (77%), and 3 cases (23%) were performed for congenital leg discrepancies. Mean 157 cc of prepared lipoaspirate was transferred per leg, with roughly 60% and 40% transferred into the medial and lateral calf, respectively. Four patients (31%) underwent a second round of autologous fat injection for further calf augmentation because they desired more volume. At mean 19.6 month follow-up, durable augmentation and improvement in calf contour was documented by comparison of standardized preoperative and postoperative photographs. CONCLUSIONS Autologous calf fat grafting is a viable alternative to traditional implant-based calf augmentation for congenital calf discrepancies and the aesthetic pseudo-varus deformity. This technique provides results comparable to those obtainable with traditional methods. LEVEL OF EVIDENCE 4: Therapeutic.

Hair Transplantation in Women: A Practical New Classification System and Review of Technique

Alopecia in women is often overlooked as a major cosmetic problem. For women with hair loss, the psychological effects are often more severe than for men. Advances in modern hair transplantation have allowed successful hair restoration in many cases of female alopecia that might not have been possible to treat with older techniques. A classification of female hair loss patterns into 5 different categories is proposed. On the basis of these categories, a variety of techniques are demonstrated to restore alopecia. Careful preoperative patient evaluation, including analysis of the donor and recipient features, is emphasized. In addition, womens psychological reactions to hair loss and the expectations for hair restoration are discussed. (Aesthetic Surg J 2002;22:247-259.).

Follicle trauma and the role of the dissecting microscope in hair transplantation. A multicenter study.

During hair transplantation, large numbers of follicles must be dissected from sections of donor scalp tissue prior to being placed in the recipient area. To avoid transecting these follicles, clear visualization is essential. The use of the dissecting stereomicroscope during graft dissection, first described by Limmer, 8,9 improves visualization but has not been universally adopted because of the added time and expense associated with it. The extent to which use of the microscope decreases follicle transection during dissection is not known. The purpose of this article is to evaluate the prevalence of follicle transection during graft dissection and determine whether this is effected by use of the dissecting microscope. Experienced surgeons, some of whom use the microscope for graft dissection, provided randomly selected grafts for analysis. The use of the dissecting stereomicroscope was determined by blindly evaluating the proportion of transected hair follicles in grafts cut with and without the use of the microscope by these surgeons.

Commentary on: Use of Nape and Peri-Auricular Hair by Follicular Unit Extraction to Create Soft Hairlines and Temples: My Experience with 128 Patients

For many professionals, as well as the lay public, the results of hair transplantation still evoke images of a pluggy or dolls hair appearance. However, the standard of care today is to create a hairline that appears completely natural and not surgically created. Advances which have led to this current expected level include improved instrumentation, clinical observation of normal hairlines, and recognition of the different qualities of hair that reside in the safe donor area (SDA). Another recent advance in the field of hair restoration surgery is the donor harvest technique known as follicular unit transplantation (FUE).1-4 The primary advantage of FUE is the absence of a donor site scar following traditional strip excision. While there are several additional advantages to the FUE technique, the ability of a patient to wear a short hair style without a concern for donor scar visibility is the major reason patients choose this approach. Another important concept of hair restoration surgery which is germane to this article is the “variable” permanence of the most inferior aspect of the SDA. The concept of donor dominance, which is the principle reason transplants work, was originally described by Oreintreich,5 who demonstrated the “permanence” of occipital and temporal hair (ie, the donor fringe or SDA) when transplanted into areas of alopecia. Not recognized at the time of Orentreichs original description, but addressed by Unger and Cole6 and recognized by others subsequently, is the often progressive nature of hair loss in the SDA from the bottom up. Dr Umar7 has focused this article on the use of nape and …

The Aesthetics of Hair Restoration

The hairline and frontal hair volume are frequently overlooked aspects of attractive facial proportion and overall facial aesthetics. The author contends that patient benefit from hair restoration surgery is significant, and these procedures should be routinely considered as part of a complete facial rejuvenation.

Standardized Hair Photography

background Photographs currently published or used clinically in hair restorative surgery vary greatly in positioning, lighting, posing, and technique. objective The purpose of this work is to aid in standardizing these variables and to review the necessary equipment and techniques required to achieve these goals. methods Nine standardized views are shown. Also addressed is hairline depiction taking into account variable hair styles. conclusion Standardization is achieved with consistent reproduction of patient photographs in hair restoration.

Comments on "Paradoxical Adipose Hypertrophy (PAH) After Cryolipolysis".

In the recent article, “Paradoxical Adipose Hypertrophy (PAH) After Cryolipolysis” by Strouzma et al, the incidence of PAH is estimated to be approximately 1/100 based on their reporting on 4 cases in 398 patients.1 The authors state that this incidence is still most likely under-reported, and our experience with this technique is completely in agreement with this impression. We started performing CoolSculpting in 2014, and the enthusiasm we generated with this technique quickly generated about 150 patients over an 18-month period. During that short time, we experienced 2 patients with fulminant PAH. By personal recollection, at least 10 other patients had what we considered unchanged or even worsened “girth,” which in retrospect may represent a new classification of PAH considered to be mild to moderate. The 2 patients that had fulminant PAH (Figures 1 and 2), both required follow-up liposuction. In one case, the skin retraction following liposuction was so poor that a second surgical procedure involving skin excision was necessary to produce a smoother abdominal contour. In both cases, the most significant area of PAH was seen in the central abdomen, and both patients were male. In one patient, the love handles were also affected. Both patients who underwent surgery following CoolSculpting were exceedingly upset because a nonsurgical approach was the method they initially requested, but they had to pursue a surgical method instead. It is sobering to review the reported incidence of this complication rise from the manufacturer’s initial quoted rate of 0.0032% in 2013 to a 1% incidence as just reported by Strouzma et al.1 A literature review by Ho and Jagdeo reported only 16 cases in the world literature in 2017.2 The fact that we experienced (unpublished) 2 cases out of approximately 150 treated patients in my solo practice alone speaks volumes about the under-reporting and likely true incidence of PAH. The cited article is likely to be a landmark publication opening the door to more frequent reporting of PAH—and hopefully research into its etiology, treatment, and avoidance. In the meantime, our loss of enthusiasm for this technology persists.