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Background: Postoperative folliculitis is a common complication of hair transplantation (HT) requiring effective preventive interventions. This study characterized postoperative folliculitis and determined risk factors in patients undergoing HT., Methods: The authors retrospectively reviewed 1317 patients who underwent HT and completed 9-month follow-up between January of 2018 and June of 2021 at 4 medical centers. The incidence of postoperative folliculitis and demographic characteristics were assessed. Logistic regression analysis was used to identify risk factors, and the characteristics of different types of folliculitis were compared., Results: The overall incidence of postoperative folliculitis was 12.11%, and clinical characteristics varied among the different types of folliculitis. Surgery in summer (OR, 1.772 [95% CI, 1.05 to 2.992]), number of transplant grafts 4000 or greater (OR, 4.818 [95% CI, 1.45 to 16.014]), transplant density greater than 45 grafts/cm 2 (OR, 2.152 [95% CI, 1.376 to 3.367]), and first nursing time greater than 3 days (OR, 1.555 [95% CI, 1.088 to 2.223]) were the main risk factors for postoperative folliculitis., Conclusions: Postoperative folliculitis after HT presents different characteristics. Surgical factors and postoperative nursing care were demonstrated to be related to folliculitis. The authors propose a preventive folliculitis model based on preoperative, intraoperative, and postoperative factors., Clinical Question/level of Evidence: Risk, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: Follicular vitiligo is a distinct subtype of vitiligo characterized by the selective destruction of the follicular melanocytic reservoir. Treatment of follicular vitiligo-associated leukotrichia has always been a clinical challenge., Methods: Twenty participants (mean age, 29 years) with stable follicular vitiligo were recruited between 2020 and 2021 for 2-stage surgery. In stage 1, an incision around the vitiligo lesion was performed to subcutaneously dissect and scrape the leukotrichia. In stage 2, healthy follicles obtained from the occipital donor site were transplanted into the vitiligo area. Follow-up examinations were conducted for 1 year postoperatively using a camera and dermatoscope to observe the growth rate, color, and surviving number of the transplanted hairs. Patient satisfaction was recorded to evaluate the potential surgical improvement., Results: The transplanted hair grew with natural texture, as expected. The average survival rate of the transplanted hair follicles was 93.8%. No recurrence of leukotrichia was observed in the recipient area. No complications were observed, and the postoperative scars in the recipient area were entirely covered by black hair. All patients were satisfied with their resulting appearance., Conclusion: Minimally invasive removal of leukotrichia combined with hair transplantation might be an appropriate surgical option for stable follicular vitiligo to create natural and stable pigmented hair., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons.)

Background: Postburn scarring alopecia on hair-bearing aesthetic subunits causes cosmetic disfiguring and psychological problems. Follicular unit extraction (FUE) hair transplantation is an effective technique for camouflaging postburn scarring alopecia. However, poorly vascularized and fibrotic scar tissue limits the viability of grafts. The mechanical and vascular characteristics of scar tissue can be improved by nanofat grafting. This study aimed to present the results of postburn scarring alopecia treatment using nanofat-assisted FUE hair transplantation., Methods: Eighteen patients who had postburn scarring alopecia in and around the beard were enrolled. Patients underwent single-session nanofat grafting and FUE hair transplantation at 6-month intervals. Twelve months after hair transplantation, the survival rate of transplanted follicular graft, scar improvement, and patient satisfaction were assessed by counting each transplanted follicle individually, using the Patient and Observer Scar Assessment Scale, and using a 5-point Likert satisfaction scale, respectively., Results: Nanofat grafting and hair transplantation were successfully performed without complication. All scars significantly improved in mature characteristics ( P < 0.00001 for patients; P < 0.00001 for observers). The survival and density rates of transplanted follicular units ranged from 77.4% to 87.9% (mean, 83.2% ± 2.5%) and 10.7% to 19.6% (mean, 15.2% ± 2.46%), respectively. All patients reported significantly satisfying cosmetic results ( P < 0.00001)., Conclusions: Scarring alopecia is an inevitable and challenging late complication of deep burned hair-bearing units. Combining nanofat injection and FUE hair transplantation is among the most innovative and effective treatments for postburn scarring alopecia., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: The long-face morphology is associated with aesthetic concerns, and surgery is often necessary to correct excess length in the frontal plane, in the upper, middle, and lower thirds of the face. However, correcting midline facial length in the frontal plane alone does not provide facial harmony. This study introduces a novel approach to correcting long-face morphology using measurements in the frontal, oblique, and lateral views, and reducing hairline measurements using hair transplants., Methods: Eighty-three patients were enrolled in the study. The authors measured the midline facial length in the frontal plane and the lengths of the upper, middle, and lower thirds of the face. The authors also measured four additional distances in the oblique and lateral views, including the distance from the infratemporal hairline to the chin and from the sideburn to the chin. The patients' midfrontal hairlines were lowered, and the distances from the infratemporal hairline to the chin and from the sideburn to the chin were also shortened. The results were evaluated by patients and the surgeon using a five-point Likert scale., Results: The mean patient Likert score was 4.5 (range, 3 to 5), and the mean surgeon Likert score was 4.9 (range, 3 to 5). No patients experienced adverse events. Three patients required touch-up surgery at the recipient sites to increase the hair density., Conclusion: This novel approach to correcting long-face morphology using hair transplants to decrease hairline measurements provided excellent facial harmony and symmetry., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Background: The scar that occurs after cleft lip surgery poses a serious cosmetic problem. One of the methods used to solve this problem in adult male patients is hair transplantation. However, satisfactory results with this method cannot always be achieved because of possible graft loss. The corrective feature of fat grafting has been reported in many studies. The authors' aim with this report is to share their results with hair transplantation combined with fat grafting in patients with cleft lip., Methods: This study included 20 patients who had both a scar and alopecia in the cleft lip area. The patients underwent fat grafting from the periumbilical region by means of miniature liposuction harvesting cannulas. Three months after fat injection, hair transplantation was performed with hair from the submental area and scalp using the folliculate unit extraction technique. Patients were followed for 12 months. Survival rate of transplanted hair and patient satisfaction were analyzed after the procedures., Results: After this camouflaging technique with fat grafting and hair transplantation, the scar was hidden quite well. The graft survival rate was also better compared with results from similar studies. Patient and observer satisfaction results with the scar tissue were significantly improved, which was confirmed statistically., Conclusions: This study demonstrates that this combined camouflaging technique is a very effective treatment in male patients with cleft lip who have serious secondary upper lip scars. The authors present a series of patients treated with this technique, which resulted in a high level of patient satisfaction., Clinical Question/level of Evidence: Therapeutic, IV.

Background: Reconstruction of the frontonaso-orbital complex is one of the best-described and most commonly used procedures in the field of facial feminization surgery. To a large extent, this complex determines the facial expression and plays a key role in the visual identification of facial gender. After the forehead, the hairline pattern is the second most important feature of gender identification within the upper third of the face. The combined evaluation of these two features should be a basic premise of facial feminization surgery., Methods: The authors present a new surgical sequence developed by their group in which reconstruction of the frontonaso-orbital complex and redefinition of the hairline by means of an autologous hair transplant are carried out during the same operation: forehead reconstruction and simultaneous hair transplantation., Results: Sixty-five male-to-female transgender patients treated with forehead reconstruction and simultaneous hair transplantation are presented along with the surgical technique, sequence used, and the results obtained. A classification method for hairlines in male-to-female transgender patients is proposed based on the observation of 492 patients. A modified temporoparietooccipital coronal (posterior coronal) approach is also described., Conclusion: The forehead reconstruction and simultaneous hair transplant technique makes it possible to address the entire upper third of the face in a single facial feminization operation.

Orbitomaxillary, skull, scalp, and hair restoration covers a broad segment of reconstructive surgery. The purpose of this article is to review considerations in available options for reconstruction, flap selection, relevant anatomy, and potential hazards. Although there are a variety of methods available to treat these complex defects, core principles are presented as a guide to obtaining a sound result specific to the priorities appropriate to an individual patient.

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.

Hair is an inseparable element of external appearance of every human being. Although various fashion trends come and go, the lack of hair is for many a major aesthetic and psychological problem. Even if men's balding can be accepted as a natural phenomenon, hair loss in children is considered to be a condition demanding correction. During an 18-year period, 8440 hair restoration operations were performed at the Hair Clinic Poznan, in Poznan, Poland. Most patients were men treated for androgenic alopecia. Among the patients were 57 children in whom hair loss resulted from hereditary factors, perinatal traumas, radiotherapy, and mechanical, thermal, and chemical damage. Methods of restoration were adjusted to type of hair loss, patient age, and ability to cooperate with the surgeon. In cases of single massive scars, skin flap correction was usually used. The flaps were prepared with the use of expanders. In cases of numerous scattered defects or considerable thinning of the scalp, the method of choice was hair transplantation. The "four-hand stick-and-place" technique developed by the authors enabled the surgeon to quickly and precisely carry out the procedure. Application of varied surgery techniques in scalp reconstruction procedures in children gave very good aesthetic results with a minimal complication rate.

In the field of surgical hair restoration, there is probably no greater challenge than treating the individual with advanced male pattern hair loss. Recent developments in follicular unit grafting and recognition of the natural appearance of the transplanted frontal forelock have now made it possible to obtain excellent, undetectable results in these patients. Over a 22-month period, the onset correlating with the time when the author began to use the technique of follicular unit grafting, 61 of 322 hair transplant procedures (approximately 20 percent) performed for male pattern hair loss were on men with, or at high risk of developing, advanced male pattern hair loss. Uniformly, the creation of some type of frontal forelock provided excellent results and high patient satisfaction. The concept of the frontal forelock is not new. Developments in aesthetic principles, enhanced understanding of its applicability, and the applied advantages of follicular unit grafting allow for the first time, truly undetectable results.

The authors compared the results of 10 scalp reductions using the "Nordstrom suture" with the earlier published results of scalp reductions without a device to prevent stretch-back and of reductions with extenders. At 1 month postoperatively, the Nordstrom suture eliminated the stretch-back of 8.3 mm seen in earlier studies and, in fact, it shrank the bald area. The average shrinking achieved with the Nordstrom suture was 16.9 mm (i.e., 143 percent improvement over scalp reductions alone). Scalp extenders shrank the bald area, but the Nordstrom suture shrank the area about three times more than extenders at 1 month postoperatively.

The use of a micrograft to camouflage upper lip scars is a simple and effective method. The authors used a microhair graft to camouflage upper lip scars in one patient. Unlike other methods of scar revision, additional tissue is not killed and new incision lines are not created.

A new flap is presented for sideburn reconstruction. It has good vascularity and hair direction. There is some tension in the closure of the scalp donor site that can be associated with alopecia. The flap should be advanced only to the desired sideburn level, with a cervicofacial flap covering any remaining defect. Follow-up at 2 years 4 months confirmed the satisfactory result. This flap adds another option to those discussed in this article for sideburn reconstruction.

Hair on a man's head is an important emblem of health, youth, and vitality. As in all areas of cosmetic surgery, the refinements of surgical technique and instrumentation have improved the results of hair transplantation. The state of the art in hair grafting today produces a result that is undetectable as being a surgical hair transplant. Many earlier techniques of plug hair transplantation are not aesthetically acceptable by today's standards. This is especially true in the face of progressive hair loss, which can unmask previously camouflaged cornrow plugs. A technique to reduce the plugs and recycle the grafts into smaller grafts is described. The recycled hair grafts can be combined with scalp lifting, scalp reductions, and occipital harvesting of grafts to improve the results of cornrow appearing hair transplants and other problems of surgical hair restoration.

Surgical hair restoration has been performed as a treatment for male pattern hair loss for more than 40 years. Although techniques have changed dramatically over the past several years, making it possible to achieve natural-appearing results, there are still many patients with unacceptable outcomes. These patients may have had procedures performed in the past with antiquated techniques or performed recently with substandard techniques. The causes of unfavorable results can be classified into one of three categories: technical errors, poor planning, or complications. The results in these patients can be dramatically improved through a number of different reparative surgical techniques. The majority of these techniques can be performed in an office outpatient setting. More than 40 patients unsatisfied with previous surgical hair restoration have been treated with the different techniques reviewed in this article. All patients had successful outcomes with significant improvement in appearance. Despite the increased challenges when performing reparative surgery, outcomes were favorable in all patients, with small to significant improvements in appearance achieved. Some of these challenges include the limited supply of donor hairs, reduced scalp laxity, and theoretically reduced vascularity due to scarring and transected blood vessels, and patient skepticism. Furthermore, the few complications that occurred were minor and correctable, including one case each of poor hair growth associated with extensive small graft (consisting of one to four hairs) transplanting, and of scalp scarring associated with the removal and primary closure of a large number of "plug" grafts (typically grafts 3 to 4 mm in size consisting of seven or more hairs) in a single procedure.

Hair transfer from split-thickness skin grafts harvested from the scalp is not a widely reported problem. The authors present their experience with hair transfer from scalp autografts in a pediatric burn population, with particular emphasis on hair transfer to the face. They retrospectively reviewed 3307 acute and reconstructive pediatric burn admissions over a 4-year period at a single institution and identified 109 cases in which the scalp had been used as a donor site and in which the patient survived the acute burn period. Data from 73 male and 36 female patients were analyzed with respect to age, race, sex, percent total body surface area burned, graft thickness, number of scalp harvests and time between harvests, and presence of donor site alopecia. Eighteen of the 109 patients had noticeable hair growth from their scalp grafts (17 percent). Fourteen of 18 cases of hair growth involved face or neck grafts (13 percent); the remaining 4 patients had hair growth elsewhere on the body. There was no difference between the two groups (hair growth versus no hair growth) when compared by age, sex, or graft thickness. There was a correlation between larger burn size and greater incidence of hair growth. Those who had multiple harvests of the same scalp donor site were more than twice as likely to have hair transfer (9 of 34 versus 9 of 75 patients), although time between harvests was not a significant variable. Caucasian children represented 77 percent of the study population yet 100 percent of the cases of problem hair growth. Thirty-three percent of the hair growth group (6 of 18 patients) and 4 percent of the remaining patients (4 of 91) had some degree of donor site alopecia. The scalp is a reliable and valuable donor site for skin grafting in children, particularly for facial burns. The authors note a moderate incidence of hair transfer (17 percent) and propose both suggestions for prevention and recommendations for management.

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.

The aim of this study was to evaluate, in an in vitro model, the survival and growth rates of transversely sectioned human hair follicles to assess experimentally the soundness of this approach as a future possible method for "duplicating" available donor hair grafts in hair transplantation procedures. A total of 300 human anagen hair follicles was obtained from 10 healthy male patients. Follicles were thus randomly assigned to one of the following groups: group A (control; n = 100 follicles), cultured intact as dissected, and group B (experimental; n = 200 follicles), transversely transected, parallel to the epidermal surface and immediately below the bulge area, to obtain 200 lower-half follicles and 200 upper-half follicles. Isolated hair follicles from both groups were maintained in culture for 10 days. The length of each follicle was measured immediately following isolation and at the end of the 10-day culture period. No statistically significant differences were found between the growth rate of intact follicles (mean 10-day growth rate = 2.71 mm) and of lower-half follicles (mean 10-day growth-rate = 2.64 mm), whereas a statistically significant difference was found between the growth rate of follicles from the two above-mentioned groups and the growth rate of the "upper-half" follicles (mean 10-day growth rate = 1.07 mm). Histologic analysis demonstrated that both intact and lower-half follicles maintained a normal histologic appearance, whereas in upper-half follicle sections we invariably detected a region of intense cell proliferation, reminiscent of a regenerated follicular papilla, surrounding the lowermost part of the follicle. In our opinion, the reported in vitro survival rate of transected human hair follicles might represent an interesting starting point in striving to augment the number of donor hairs available during a hair transplantation procedure.