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On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.79 no.2 Rio de Janeiro Mar./Apr. 2004
Improvements in CO2 laser hair transplantation - presentation of three clinical cases*
Cristina MansurI; Leonora MansurII; João MansurIII; Maria Teresa FeitalIV; Itabyba Martins Miranda ChavesIV; Aloísio Couri GamonalV
UFJF; Ph.D. (UFRJ); post-doctoral fellow (University of California, San Francisco,
IIResident on General Surgery at "Hospital Universitário de Juiz de Fora"
IIIPh.D. in dermatology (UFRJ); residency in Plastic Surgery, Universidade Santa Cecília, Santos, São Paulo State
IV Professors, UFJF
VProfessor of Anesthesiology, FMUFJF; Head of CET/SBA, Hospital Universitário de Juiz de Fora; Editorial Board Member of the Revista Brasileira de Anestesiologia
The authors present three hair transplantation cases in which the receptor incisions were made in a variety of ways: CO2 laser vaporization orifices, in addition to which a lateral cold incision was performed. This lateral incision makes it easier to introduce micrografts by allowing air to be released and improves the fixation of the grafts by giving some elasticity to the orifice. The patients were previously beta blocked to prevent the beta-adrenergic action of epinefrin.
Key words: hair/transplantation; carbon dioxide; lasers.
This paper discusses the effectiveness and final result of hair transplantation aided by a CO2 laser.1,2,3 In this study, the authors present the final cosmetic result in three hair transplantation patients (three sessions per patient). Each patient had had CO2 laser used at the receptor site which was complemented with small lateral incisions made with a cold blade.
Hair transplantation began at the end of the 1950s with a technique that withdrew large punches from the occipital and fringe regions. The techniques progressed into micrografting (from one to three hair follicular units) and minigrafting (from four to eight hair follicular units), which are either round or linear in shape.
The receptor sites for these minigrafts were made with motors, small or sharp blades and special expanders.4
The micrografting technique allows grafting an amount of hair that varies between one and three hair follicular units. It is used on the frontal hairline to give a natural look. Minigraft transplanting, varying between four to eight hair follicular units in the central area behind the hairline, aims for greater density and support for the front line.
The first studies demonstrating CO2 laser use at the receptor site of the micrografts were published in the early 1990s.5,6
Its use in transplantation has several advantages: reduced bleeding, reduced surgery time, less trauma at the minigraft, vaporization of the baldness site allowing for greater density to be given to transplanted hair (i.e. vaporizing the tissue, forming the space at which the microimplant will be introduced with greater ease), less compression on the minigraft, less adrenaline and the reduction of post-operative complications.5-8
Any doubt as to its effectiveness is due to the fact that the laser leaves a fine burnt layer on the orifice walls, which hinders how the graft 'takes'.2,9
Papers comparing the hair tufts at a blade-performed incision site to another one where the laser was used showed less bleeding at the receptor site that was operated on with the CO2 laser. In addition, the number of hairs that ended up growing was identical to that at the blade-prepared site. The only disadvantage was a greater formation of post-operative crusts at the laser-treated site.10,11
Case 1 - A 57-year-old male showed Hamilton male pattern baldness type V (Figure 1a), with hair loss beginning slowly. He had made use of a 5% minoxidil solution two years earlier. The condition was stable, and the patient opted for hair transplantation. Three sessions were performed (at intervals of eight months and a year and three months, respectively). The picture in figure 1b was taken eight months after the third and last transplantation session.
Case 2 - A 49-year-old male showed Hamilton male pattern baldness type VII (Figure 2a), beginning at age 17 and progressing rapidly. At the time of the consultation, it was stable. He used minoxidil without any improvement. Three transplantation sessions were performed at intervals of 10 months and two years between them, respectively. Figure 2b reproduces the picture taken six months after the second session, and figure 3c, 12 months after the last transplantation session.
Case 3 - A 35-year-old male showed Hamilton male pattern baldness type III. From age 16 on he showed a clearly receding hairline (Figure 3a), which was characteristic for his family. Three transplantation sessions were performed at intervals of nine months and a year and a half between them. Figure 3b reproduces the picture taken six months after the first transplant, and figure 3c a year and three months after the last transplantation session.
MATERIAL AND METHOD
Each patient underwent three transplantation sessions with the aid of a Sharplan 80-watt flashscanner-enhanced CO2 laser system, in association with small lateral incisions made with a cold blade (blade 11).
The procedure was performed under local anesthetic with a 120 ml solution of 0.125% saline bupivacaine with 1:200,000 adrenaline. As the scalp is richly vascularized, part of the adrenaline quickly falls into the blood circulation not only through quick absorption, but also because a small amount ends up being randomly injected directly into the vessels.
Recent controlled and multicentered studies12,13 demonstrate that preventing tachycardia with the use of a beta-blocker is extremely beneficial to patients.14 Patients having a cardiac frequency above 60 beats per minute at rest were therefore administered 25 mg of beta-blocker atenolol two hours prior to transplantation. A reduction in cardiac work reduces the oxygen consumption by myocardia, thereby preventing ischemia. A drop in arterial pressure occurs, which in turn prevents a hypertensive crisis with all of its consequences, and also avoids increased bleeding that makes hair transplantation difficult. All patients were sedated by an anesthesiologist with midazolam and phentanil under electrocardiograph and oximetric monitoring at a surgical center. All patients had prophylactic antibiotherapy used.
The donor zone was withdrawn in a strip measuring approximately 13 x 1.5 cm of the occipital region and fragmented with a magnifying glass.
The orifices at the receptor site were scanned using 55-watt potency for 0.06 seconds, which obtained 1.2 mm slits with a depth of 5 mm.
Such orifices were then scarified with a single and quick movement introducing the odontological drill installed at the tip of a fountain-pen-like instrument, with the objective of withdrawing the fine area of necrosis on the orifice edges and reanimating the receptor surface to help the transplant 'take' easier.
To facilitate the introduction of microtufts, the orifices were torn laterally with a 1.2 mm incision performed with blade 11.
After three sessions performed on the patients reported in this paper (Figures 1a, 2a and 3a), the cosmetic result of the CO2 laser-assisted hair transplant was good, without any immediate and/or delayed complications and without any cosmetically displeasing scars. The last photos were taken between eight months and a year and three months after the third session (Figures 1b, 2c and 3c).
Use of the CO2 laser has been controversial in hair transplantation. There has also been a fair amount of preoccupation regarding its effectiveness, namely with how the graft takes and whether scars remain, as well as with the growth of a lower number of hairs than expected at the receptor sites where the laser was used.8
Disadvantages of "cold blade method" incisions
In the conventional technique, in which simple incisions are made with a small or sharp blade at the receptor site, no bald tissue is actually removed and no space is generated. Grafts added to the scalp work as wedges. As such, for each micrograft, the lateral compression increases until reaching a saturation point, and several micrografts are pushed outward again. Repeated attempts at replacing them may traumatize the matrices. This tendency to extrude microimplants that are subject to lateral compression is called the "wedge effect".
Disadvantages of the laser
Being able to enter the laser-made cylindrical orifices requires the graft diameter to be much less than the orifice's. Once introduced, the grafts remain loose within the orifice. Effecting several vaporization orifices on the scalp with a laser also tends to withdraw the orifice's lateral elasticity, thereby compounding the lack of compression on the microimplants. The grafts placed in the laser-made cylindrical orifices function like emboluses, and the air withheld from within tends to expel them back out.
"Cold blade method" incisions and laser incisions involve directly opposite actions. Were they to unite and form a single procedure, they would cancel each other out. By placing slightly greater grafts than the laser orifice, good graft contact can be achieved with the bed as can ideal lateral compression with a lower tendency to graft extrusion.
The vaporizing of the CO2 laser removes the bald tissue, and generates space to introduce the microtuft in the receptor site where they are much more easily introduced. Consequently, they are much less subject to trauma.
It should be observed nonetheless that there is a limit to the amount and size of the laser-generated orifices, because excessive tissue removal causes the opposite effect, that is, insufficient pressure to keep the microimplants in place. To avoid this situation, the authors kept the orifice to within a limit of approximately 1.2 mm, corresponding to the average adjustment of the scanner in the laser equipment. After cleaning the orifices with an odontological drill, they completed the orifice with a lateral incision with the laser tip of the same size, thereby making a hybrid bed with partial tissue removal: one half of the orifice was vaporized by laser and the other was done with a blade incision.
Quickly cleaning the orifices with an odontological drill enables contact of the transplanted tissue with a perfect bed for the graft to take without increasing the bleeding significantly, because scarified vessels bleed less than cut vessels.
The lateral incision of the orifices made with a cold blade facilitates the introduction and fixation of the micrografts. It thereby allows air to be released and maintains the ideal lateral pressure to hold them. Another big advantage of the laser is less bleeding,8,9 which facilitates the introduction of transplants and prevents its traumatism.
Given that there is a large blood flow from the upper orbit and trochlear vessels, using the laser is particularly important for the frontal region.
Reason for the presentation
For some authors, CO2 laser use at the receptor site of a hair transplantation is not advisable and may lead to cosmetically displeasing scars at the site and/or to growth of a lower number of hairs than desired.
The aim of this study is to demonstrate the good aesthetic results achieved by using this technique, which facilitates the actual procedure and helps to avoid immediate and/or later complications. q
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in April, 29th of 2002
Approved by the Consultive Council and accepted for publication in March, 18th of 2003
* Work done at "Clínica Mansur".