82 Preview Long Hair Transplantation

Marcelo Pitchon and Ricardo Gomes de Lemos

Summary

Preview long hair transplantation (PLHT) is a unique methodology in which the surgeon transplants the patient’s real hairs, not just the hairless follicle, as is normally done.1^,2,3,4,5 The surgeon, in fact, extracts and implants the hair follicles without shaving or trimming the patient’s donor area, in order to keep the external extension of hair that is visible outside the skin attached to the follicle. In PLHT, the surgeon can “preview,” with actual hairs, the look of the transplant result that is being three-dimensionally sculptured over the recipient bald area, be it on the scalp, face, or body. This preview element gives the surgeon, during the placement phase, the unique power of precise visual control over the progressive hair mass construction in the recipient area. Having visual control over implantation angle, hair direction, and hair curvature increases the artistic precision for naturalness and optimizes the use of the extracted hair, transforming surgery from a shaved “hair-shaft-blind” method into a “hair-shaft-non-blind” method of hair transplant. That visual control also allows for a “donor-ecologic” management of the finite number of hairs available over the patient’s lifetime. While being able to view each patient’s minimum number of hairs that are sufficient to produce satisfactory aesthetic improvement, PLHT optimizes the use of the donor hair, potentially saving hair extractions and implantations over the patient’s life. As a secondary benefit, the patient’s visualization of the postoperative “preview” of the future result generates an emotional reaction and an understanding of his image’s maximum potential improvement, both of which favorably impact the immediate and the late postoperative periods.

Keywords: preview long hair transplantation coverage behavior satisfaction density satisfaction coverage minimum density concept

82.1 History

Preview Long Hair Transplantation (PLHT) is a unique technique, developed by the author, in which the surgeon transplants a patient’s hair at its natural length, as opposed to shaving it down to a hairless follicle.^{1,,,2,,,4,,,5}

Long-hair grafts were used in the past by some surgeons , but with objectives different to the “Preview” concepts created and developed by the author. In his 1943 report, Hajime Tamura from Japan described the use of long, donor-hair grafts with the specific objective of facilitating their manipulation by grasping them by their shafts.⁶

He suggested that the donor hair should not be shaved, but kept 3 to 4cm long, in order to facilitate its manipulation by the shaft and hence not traumatize the follicles. In 1980 Robert Flowers reported7 the use of long-hair grafts for eyelid, eyebrow and temporal areas’ hair replacement. He developed “The Pluck and Sew Technique”, in which he worked with 3 to 4 inches long hair grafts, in order to thread the hair shaft into a needle’s eye, as if it was a suture. Dr. Flowers informed me during a telephone call in 2013, that he believed this gentle manipulation of the grafts followed by immediate implantation , allowed for continuous growth of the hair, without postoperative shedding.

In 1988 Pierre Bouhanna suggested that the use of a topical solution of 2% Minoxidil could prevent shedding of transplanted hairs in the immediate postoperative period, sometimes resulting in transplanted hairs growing immediately and continuously after surgery. This benefited patients by making the unesthetic postoperative appearance less visible. To maximize this effect , he advocated using minoxidil both 4 to 6 weeks before surgery as well as well as three months after surgery. He also reported that it was “this effect of Minoxidil that led to his development of a long-haired graft procedure.” He felt long hair grafts would add the benefit of “masking” the postoperative unaesthetic appearance of the large grafts and their associated crusting used at that time. Patients could now at least resume their activities in 24 to 48 hours without being “embarrassed” by the transitory unaesthetic presence of such crusts,“ even if the long-haired grafts were rejected at the third or fourth week”. He considered this procedure “especially useful for coverage of completely bald areas” but less so for thinning areas that still had some native hair which could naturally camouflaged the post-operative unaesthetic appearance. In such thinning areas, he used “a shaft length of only 2 to 3 mm.”^8,9

I published the first article on my Preview Long Hair methodology in the Hair Transplant Forum journal in August 2006 and did my first presentation of the method at the 2006 San Diego World Congress of the ISHRS (International Society of Hair Restoration Surgery). After this physician began to visit my clinic in Belo Horizonte, Brazil to learn the technique. Two of the first were Drs. Vance Elliot (Edmonton, Canada) and Edmond Griffin (Atlanta, USA). Soon afterward, Bobby Limmer (San Antonio, USA) came with his staff to observe, and subsequently invited my staff and I to demonstrate the Preview Long Hair procedure back at his clinic. During this visit he invited many recognized hair surgeons in the USA and Canada to come and watch. After that the popularity of the procedure increased as I was invited to present, perform and teach the Preview Long Hair Hair Transplant procedure at many conferences around the world.

I suggested to colleagues that they begin learning by using shorter hair lengths of only 1 to 3 mm, in order to facilitate their staffs’ adaption of the technique. Starting at the full natural length demands greater effort and changes in the staffs’ routines. However, even this small increase in hair lengths cause patients to love the immediate temporary postoperative vision of the result. As their skill and ability to use longer hair lengths increased, they would gain the additional visual and density optimizing advantages of this technique. In Brazil the first surgeons to fully adopted the Preview Long Hair method were Drs. Ricardo Lemos and Mauro Speranzini with many others following. While adopting the concept surgeons would also begin to add their own surgical styles to the procedure. Some used stick and place( like myself) while others used a 2 person buddy technique in premade incisions

In conventional hair transplantation, the surgeon handles grafts containing shaved hairs and places them in scalp incisions, and, as if drawing a map, produces a result on a two-dimensional plane. Preview long hair transplantation (PLHT), however, transforms the scalp with a three-dimensional intervention, as longhair grafts are placed to create volume and form, like a sculpture (Fig. 82.1a–c). The use of the donor area is greatly optimized with PLHT, allowing for smaller or fewer hair transplant sessions. By having visual control and understanding the “coverage behavior” of different hair types, the surgeon can precisely move the axis of the hair transplant equation “density × area of coverage” toward “lower density covering larger areas” for favorable coverage behavior types of hair or toward “higher density covering smaller areas” for unfavorable coverage behavior types of hair. One cannot fully understand the coverage behavior of hair by only seeing or touching it on the donor area examination, as compared to planting it in the recipient area and seeing how it behaves in terms of its recipient site coverage capacity.

82.2.2 Coverage Behavior

Each type of human hair is unique in its capacity to cover or create a shadow effect on the skin. This capacity varies from very good to very poor in each patient with regard to giving an impression of fullness, opacity, and coverage of bare skin. “Coverage behavior” refers to the ability of an individual hair type to produce opacity of coverage, appearance of fullness, and shadow intensity effect to make bare skin less visible. Be it high or low, the coverage behavior is determined by the physical characteristics of each patient’s hair type, such as thickness, color, waviness, stiffness, hardness, flexibility, weight, length, etc. Further, some hair types “behave well” in horizontal coverage to efficiently create a shadow effect, while other hair types perform better in vertical coverage to create height and a three-dimensional appearance of volume. The best coverage behavior hair types are efficient both in horizontal and in vertical aspects for producing shadow, opacity, and volume with the minimum number of grafts per square centimeter.

82.2.3 Satisfaction Density

Experience using PLHT has shown that each hair type hair, in accordance with its coverage behavior, has a different minimum hair density sufficient to create “satisfaction density,” which refers to the minimum hair mass that creates a satisfactory aesthetic coverage and change in the bald appearance.

In early days of performing PHLT, it was believed that the large amounts of hair being added to the patient’s head, immediately transforming their appearance, would make it obvious that the patient had undergone surgery. It was thought that this would cause the patient to view the procedure in a negative manner, especially for those reserved individuals who wished to be discrete about their hair transplant surgery. However, the exact opposite was found to be true. Transplanted long hair has the advantage of more efficiently camouflaging postoperative scalp trauma and crusts. Despite a significant transformation and improvement in appearance, and with a natural result mostly absent of visible crusts, observers often believe that the patient has simply styled the hair differently or let it grow out, and instantly forget the image of a person who had been experiencing hair loss (Fig. 82.2a, b).

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