Maxillofacial Surgery and Hair Transplantation: Ethics with Expertise

Abstract

Background

The hair transplantation has become widely popular aesthetic procedure. Hair transplantation being a relatively new field in maxillofacial surgery, several aspects raise issues and controversies. Follicular unit transplantation (FUT) and follicular unit extraction (FUE) are two commonly used and accepted techniques. Further, hair transplantation has been successfully used in correction of alopecia, cleft lip scars, post-burn or surgical scars, vitiligo and as an adjuvant to other maxillofacial procedures. Several maxillofacial surgeons have incorporated hair transplantation procedure into their aesthetic practice successfully. Sound knowledge of surgical technique, armamentarium and proper surgical planning are important for good results. A lot of debate has been there on minimum qualification for performing hair transplantation.

Purpose

The aim of this review is to highlight that an oral and maxillofacial surgeon can perform hair transplant surgery with perfection and can manage all associated complications with expertise.

Introduction

Predicting the future is always a tricky business. However, it is important to make an attempt to scientifically mine for information that can indicate trends in a profession. This is particularly true of maxillofacial surgery which is in constant overlap with other surgical specialities. Moreover, Oral and Maxillofacial Surgery (OMFS) sits on the cusp between dentistry and medicine, throwing up numerous challenges in learning and adapting.

As mentioned, there have been significant overlaps and turf conflicts between OMFS and several other surgical specialities like plastic surgery, surgical oncology and otolaryngology [11]. OMFS as a speciality has taken ownership of several procedures that were traditionally with other surgical specialities, like cleft and craniofacial surgery, oral oncology and emerging speciality of hair transplant. It is therefore not surprising that many surgical specialities consider it as an infiltration to their fields.

Jegannathan [13] has questioned the scope of Dental trained maxillofacial surgeons by scrutinising the credibility of surgical and medical training in dental curriculum. The answer to this lies in the uniqueness of OMFS being a surgical speciality of dentistry. While it is obvious that a comprehensive knowledge of dentistry and gnathic system is a pre-requisite to master many areas of maxillofacial surgery practise, it must be remembered that an extended medical and surgical training is also imperative. The privilege to operate in a complex area must therefore come from a convincing training structure that incorporates both medical and dental skills.

History from the Lost Pages

• The earliest written record of successful hair transplant to treat baldness in humans is from Wurzburg, Germany in 1822 from the work of a medical student named Diffenbach and his surgeon mentor Professor Dom Unger. They performed experimental surgery in animals and in humans. They successfully transplanted hair from one area of a patient's scalp to another area. Professor Unger was said to believe that hair transplantation would make baldness a rarity [12]. But for unknown reasons, it never got much popularity and reorganization at that time or even later and the chapter went closer with them.

• Several Japanese dermatologists like Sasagawa [25] Okuda, Tamura and Fujita had already used small autografts containing hair follicles for correction of scars and cicatricial alopecias, but this knowledge and technique remained hidden from the rest of world due to World War II. Other major obstacles were the lack of fast and effective ways of communication and language barrier as all literature published by them were in Japanese language. Okuda's paper was published in the year 1939 [19] which mentioned the use of self-made sharp circular punches with varying diameters from 1 to 4 mm for hair transplantation in Japanese Journal of dermatology, almost 20 years before Orentreich. It contained most of the principles of modern hair transplantation. He reported nearly 200 cases but did not mention male pattern hair loss as an indication, which is perhaps why Orentreich is credited with being the first to use this technique for male pattern hair loss.

• Although, the concept of use of follicular unit came in vogue in 90′s. But, it was already described in horizontal scalp biopsies by Headington in his publication in 1984 [10]. Both Rassman and Kim were unaware of that and developed the technique on their own without this information independently.

Surgical Anatomy of Scalp

A good knowledge of the anatomy of the scalp and its layers is essential for a clear understanding of management of surgeries/injuries, pathologies in this region.

The scalp denotes the soft tissues which cover the cranial vault. It extends from the eyebrows covering the supra-ciliary line of the frontal bone anteriorly to the superior nuchal line posteriorly. The latter is a low ridge which extends on either side from the midline external occipital protuberance of the occipital bone to the corresponding mastoid process. Laterally the scalp extends down to the level of the zygomatic arch and the external auditory meatus.

The Layers of the Scalp

The scalp is made up of five tissue layers, which can be remembered by the convenient mnemonic SCALP.

• The skin is thick, variably hair-bearing and is the area of skin most richly endowed with sebaceous glands, hence its greasy feel. In consequence of this concentration of sebaceous glands, the scalp is the commonest site for sebaceous cysts, which are often multiple.

• Connective tissue is made up of fat lobules bound in tough fibrous septa. The principal blood vessels and nerves of the scalp lie in this layer (see below) and the scalp has, indeed, the richest blood supply of any area of the skin in the body. When the scalp is lacerated, the divided vessels retract between the fibrous septa and therefore cannot be picked up by artery forceps in the usual way precious time will be wasted if one tries to do so. Two techniques are employed to stem the bleeding that results from lacerations to the scalp; the surgeon or his assistant presses firmly down on the underlying skull with his fingers, thus compressing the spurting vessels, or he places a series of artery forceps on the underlying third, aponeurotic layer and flips them backwards on either side of the wound, again compressing the vessels. In closing the wound, the surgeon sutures the laceration firmly in two layer aponeurosis and skin. A consequence of this excellent blood supply is that a flap of scalp with even a narrow pedicle has a high chance of survival compared with a similar cutaneous flap elsewhere.

• Aponeurosis this fibrous sheet is found over much of the vertex of the skull, where it connects the occipitalis muscle posteriorly, (arising from the superior nuchal line), to the frontalis muscle, which inserts into the dermis of the skin in the region of the eyebrows and bridge of the nose. Laterally, the aponeurosis extends as a thin sheet overlying the temporalis fascia and becomes indistinct over the zygomatic arch.

• Loose connective tissue layer accounts for the mobility of the scalp on the underlying skull. It is in this layer that:

  • the surgeon is able to mobilize a scalp flap.
  • machinery which has caught the hair may avulse the scalp (Fig. 1).

Fig. 1.

Layers of scalp

Blood Supply

Each side of the scalp is supplied by a total of five arteries. From the external carotid artery derive:

• occipital, whose pulse can usually be felt at careful palpation above the superior nuchal line.

• posterior auricular.

• superficial temporal, whose pulse can be felt over the zygomatic arch immediately in front of the tragus of the ear.

From the internal carotid artery derive:

• the supraorbital artery.

• the more medial supratrochlear artery.

Both of these derive from the ophthalmic artery.

• All these vessels are accompanied by their corresponding veins.

• Owing to the rich anastomoses between these vessels, the viability of the scalp may be retained when only one artery survives a major scalp avulsion (Fig. 2).

Fig. 2.

Blood supply

Sensory Innervation

The cutaneous nerve supply of the scalp is derived from all three diversions of the trigeminal (V) nerve and from the second and third cervical nerves:

• From the ophthalmic—supratrochlear and supraorbital nerves.

• From the maxillary—zygomaticotemporal nerve.

• From the mandibular—auriculotemporal nerve, lesser occipital nerve (C2), greater occipital nerve (C2, 3), third occipital nerve (C3) (Fig. 3).

Fig. 3.

Cutaneous innervation of scalp

The Skull Vault

This comprises the frontal, parietal, occipital and squamous part of the temporal bone. The skull vault has an adherent outer periosteal layer, or pericranium, and an inner endocranial layer. The latter is firmly fused with the dura mater (the outermost of the three meningeal layers). These two adherent layers are separated by the sagittal and the lateral venous sinuses. The periosteal and endocranial layers meet at the suture lines between the individual bones. The medullary cavities of the vault bones (the diploe) contain red bone marrow and are not uncommon sites of deposits of secondary tumours and are often involved in multiple myelo-matosis.

The blood vessels which supply the meninges, of which the largest are the middle meningeal artery and vein, groove the inner aspect of the skull vault and lie between the bone and the dura. In addition to supplying the meninges, these vessels also supply the overlying bone and the diploe [9].

Local/Regional Anesthesia

Regional anesthesia is a type of local anesthesia and is aimed at anesthetizing a large part of the body such as a scalp, entire leg or arm compared to a smaller area such as a tooth or specific region of skin. Like local anesthesia, regional anesthesia is produced by any technique that causes an absence of sensation, local insensitivity to pain, and loss of local senses in a specific part of the body, and is performed by injection of anesthetic drugs either near a cluster of nerves or near the exit points of nerves from the bony skeleton [17, 18]. Regional anesthesia is safer than general anesthesia in many situations, and can be used for relief of surgical or non-surgical pain and distress. There are several types of regional anesthesia. Two of the most frequently performed types of regional anesthesia are spinal and epidural anesthesia, which are produced by precise injections made in specific areas of the back. Peripheral nerve block is another common type of regional anesthesia used to numb a desired area of an extremity, such as the arm, leg or facial region, and is produced with injections made with great exactness near a cluster of nerves [3].

Local anesthesia is used during many facial plastic or maxillofacial surgeries. In addition, regional anesthesia produced with a regional nerve block using lidocaine or bupivacaine is frequently and easily administered for procedures on facial structures for facial plastic/maxillofacial surgeries. For scalp surgeries like hair transplant, trauma, pathologies, etc., most parts of the skin of forehead including anterior scalp (recipient area in hair transplant) can be anaesthetized by bilateral supraorbital nerve blocks and bilateral nerve blocks at nuchal lines for occipiatal region (donor area in hair transplant), along with local infiltrations according to the need and patient's compliance. The specific requirements for regional anesthesia vary according to the location, size and depth of the pathologic lesion or trauma.

Further, local/regional anesthesia induces good muscle relaxation and reduces intraoperative bleeding through variable vasoconstriction effects, resulting in improved operating conditions. This can reduce surgery duration as well as the risk of requiring a blood transfusion. Additional benefits of regional anesthesia include analgesia without the risk of respiratory depression induced by opiate analgesia, the ability to administer with minimal equipment, and low risk of complications. With respect to maxillofacial regional anesthesia, it is important to consider anesthetic time in order to avoid evoking any pain in the patient. If a procedure will last more than 2 h, some local anesthetic agents must be added to the block injection site, and additional methods for pain control such as analgesics will be beneficial to prevent any pain felt by the patient. To this end, placing an intravenous line is recommended for regional or block anesthesia, and may also be considered for maxillofacial procedures. Indeed, due to the specific anatomy of the maxillofacial region, analgesics can be delivered by intravenous infusion or by intramuscular injection during maxillofacial procedures [27].

Fut v/s Fue

The two widely accepted techniques of hair transplant are follicular unit transplantation (FUT) also known as strip method and follicular unit extraction (FUE). While FUT involves excision of hair-bearing strip from donor area and dissecting into small follicular units, while in FUE, individual follicular grafts are harvested with the help of manual or motorized punches [26]. Follicular unit extraction, now called excision (FUE), was advocated as an alternative to traditional strip harvesting of the donor tissue in view of tendency for linear scar and greater postoperative pain in FUT. It was in 2002 when Rassman et al. [23] described FUE technique in detail and discussed various clinical and microscopic features of follicular grafts harvested from 1-mm punch. Despite the fact that hair transplantation has made considerble advancement to gain dramatic popularity because of its remarkable esthetical results, unfortunately, still many are not satisfied with results even after undergoing multiple, so called, mega sessions of hair transplant procedures [4, 8, 16, 29]. There is much debate on the desired density in hair transplantation. While it is generally agreed that minimum density for good cosmetic results is about 35–40/sq cm, several teams have claimed higher density, up to 55 and even 70/sq cm [20] (Fig. 4 and 5).

Fig. 4.

Showing follicular unit harvesting by FUE

Fig. 5.

Showing harvested grafts

FUE has definitely contributed to enhancement of donor area to other body parts and enhanced patient comfort. It has removed the fear of surgery and led to greater acceptance of HT among public. However, FUE has also led to “minimalization” or even trivialization of the surgery, leading to all claiming to be experts and to several ethical issues [15] (Table 1).

Table 1.

Differences between FUT and FUE [15]

FEATURES	FUT	FUE
Scar	Single linear	Multiple round
Donor healing	Long time required	Short time
Limitation in exercise after surgery	Yes	No
Post-op discomfort	Yes	Minimal
Applicability in people with greater scarring tendency	No	Yes
Body hair harvesting	No	Yes
Risk of harvesting beyond SDA	No	Yes
Follicular Unit yield	Good	Good, but can be low some times
Scarring is additive	No	Yes
Graft survival	Good	Good but variable
Time taken to complete	Shorter	Longer
Damage to grafts	Less	Higher
All types of hair can be harvested	Yes	No (tough for curly hairs)
Surgical set-up	Advanced set-up required	Basic set-up is sufficient
Surgical team	Depends upon centre of surgery	Depends upon centre of surgery
Grafts outside the body tissue	Shorter time	Longer time—not if you alternate between extraction and insertion. Shorter than FUT in cases of direct hair implantation
Narrowing donor area in future can expose scar	No (FUT scar remains hidden within the narrow fringe of occipital hair even in advanced grade of AGA)	Yes
Microscopic dissection in addition to extraction	Yes	No
Buried grafts and capping	No	Yes
Size of single session limited by time	No	Yes

Review of Literature

Despite worldwide interest, there is a general dearth of literarture in maxillofacial journals on hair transplantation. The dental qualified persons are governed by the statutes of Dental Council of India. Currently, the Dental Council of India provides for a comprehensive 3-year programme that includes a syllabus and curriculum that exposes them to standard procedures covering the full spectrum of oral and maxillofacial surgery [24]. This provides a legal framework for the OMFS to function in. Today, several options are available through the AOMSI as well as through University and Institutional support. Most of these (like hair transplant) are not formally recognised, but there are credible training records to certify a higher level of proficiency. The survival of OMFS is therefore strongly linked to both statutory approval and training records [21]. OMFS is a bigger known speciality today than it was a decade ago. Unfortunately, OMFS does not have the same public profile as other surgical fields. This is largely because OMFS is a surgical speciality and public perception about dentistry does not traditionally involve surgery. A number of published papers seem to suggest that the public as well as medical community are not very aware about OMFS [14].

With the advent of FUT and ultimately FUE technique of hair transplantation, new challenges have also come up in the form of non-physicians and unlicensed people doing the surgery. Physicians need to be aware that allowing non physicians to remove human tissue, monitor sedated patients, treat intraoperative complications, and exclusively perform hair transplant surgery without a physician's presence and direct oversight is unlawful and unethical [5].

Hair transplantation is a technique-oriented procedure; skilled manpower is a basic requirement. Scalp is a site which bleeds heavily and the surgeon needs to be competent in procedure. Hair transplantation, particularly donor dissection, needs appropriate surgical skills. Hence, surgeon performing hair transplantation needs to have appropriate “In theatre” or “Hands on” training in the procedure, in a centre that routinely performs the procedure, under a surgeon who has the required experience and expertise in the procedure. In addition, hair transplantation is a team effort. Particularly, performing large sessions, needs a well-trained team. Training of the team is a major exercise in organizing a transplant team and deserves particular attention. A team of assistants to cut the grafts and place grafts in the recipient area is an absolute necessity to ensure large sessions. Most transplant sessions last up to 4–5 h and team work is therefore essential [20].

The Role of Surgeon and Surgical Assistant

The role of surgeon in hair transplant procedure is planning, making hairline, administering anesthesia, placing microincisions at recipient site, graft extraction while the role of the technicians/nurses is limited to slivering of FUT strip, graft preparation, graft counting, loading implanters and graft implantation along with the surgeon [8].

In USA, there are states where it is clearly illegal to have a nonphysician, nonphysician assistant or nurse practitioner perform such surgery. The laws in other countries may present similar medicolegal problems regarding who can harvest tissue. For example, in Austria, Israel. Italy, Korea, Georgia, Thailand, Turkey and Japan, only physicians are allowed to make incisions and regulations vary as to the role of assistants in graft insertions. International society of hair restoration surgery (ISHRS) [11] states that any procedure involving tissue removal from the scalp or body, by any means, must be performed by a licenced physician. Physicians who perform hair restoration surgery must possess the education, training and current competency in the field of hair restoration surgery.

While in India, this issue has been raised both in MCI and in consumer courts. There was an unfortunate case of death of a medical student after HT in Chennai, which was performed by a graduate physician doctor. MCI has vacillated on this issue and has not dealt with clarity as to who can perform HT. In a reply under Right to Information Act (RTI) MCI skirted the issue and said the syllabus of plastic surgeons contains HT, without mentioning who can and who cannot perform. In another RTI reply, DCI stated that Maxillofacial Surgeons can harvest flaps/grafts from iliac, rib, calvarial, free fibula, pectoralis major myocutaneous, forehead and other flaps/grafts [15].

It is a very well-established fact that maxillofacial surgeons are thoroughly trained, and their curriculum is very extensive which includes both autogenous and heterogenoues tissue grafting along with mandatory head and neck cadaveric dissections. Maxillofacial surgery curriculum apart from various other specialities also includes aesthetic facial surgery which covers detailed knowledge, and surgeries of structures of face and neck including skin, underlying soft tissues, diagnosis and treatment planning of deformities/conditions affecting facial skin, underlying facial muscles, bone, eyelids, external ear, etc. Theoretical knowledge with rigorous training of maxillofacial surgeons makes them expert in performing various head and neck surgeries involving scalp and associated structures like maxillofacial trauma (repairing routine and complex forehead, nasal, zygomatic, orbital and other cranial fractures), craniofacial surgeries like transcranial craniofacial surgery including fronto-orbital advancement and total vault remodelling, surgical correction of maxillofacial skeletal deformities, cutaneous malignancies/skin cancer surgery of head and neck (grafts and flaps), TMJ disorder surgeries, pathologies including cysts, benign and malignant tumours, reconstructive and aesthetic surgeries includes acne scarring, face lift, blepharoplasty, brow lift, otoplasty, facial bone recontouring, cleft lip/palate and facial clefts [24]. Various scalp/head incisions are used by maxillofacial surgeons like hemicoronal/bicoronal, preauricular/with temporal extension, Alkayat Bramley, Gillies temporal, pretrichial, upper eyelid, for orbitozygomatic complex and nasoethmoidal fractures like H-shaped, bilateral Z, midline vertical, W-shaped, etc. to carry out extensive surgeries of head/scalp and facial structures and represents ability of maxillofacial surgeons to return patients to optimum levels of appearance and function.

In past few years, several maxillofacial surgeons have expanded their practise in cosmetic and hair restoration surgeries. Moreover, hair transplant techniques have been successfully used in camouflage correction of cleft lip scars, face lift scars, post-burn or traumatic scars, reconstruction of eyebrows, eyelashes, beard, mustache, vitiligo and as an adjunct to various maxillofacial procedures [1, 2, 6, 7, 22, 28].

Conclusion

Oral and maxillofacial surgery is, today, an established surgical speciality of both dentistry and medicine. Hair transplantation has seen several developments, but still is in its inception stage. The procedure is a skill-oriented technique and maxillofacial surgeons are very well technically equipped to carry out hair transplant surgeries. It has fortunately obtained support from statutory bodies like DCI and Clinical Establishment Act [11]. The detailed curriculum and being one of the true experts of head and neck region makes maxillofacial surgery one of the most eligible speciality both ethically and clinically to perform hair transplantation with utmost perfection.

Compliance with Ethical Standards

Conflict of interest

The authors have none conflicts to declare.