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Table of figures

Figure 1: Total number of follicles depending on hair colour. (Source: Own creation)
Figure 2: Visual effect by smooth (left) and curly (right) hair on visibility of the scalp. (Source: Own creation)
Figure 3: Crosspunch technique and its effects on the chaplet. (Source: Own creation)
Figure 4: Illustration of the Crosspunch method. (Source: Own creation)
Figure 8-11: Photographs before and after surgery

The specially developed crosspunch method


Dear Sir or Madame
with this article I would like to briefly introduce how the transplantation technique Crosspunch may be used to ensure a highly aesthetic result. Firstly, you should learn which indications exist for a hair transplantation. Secondly, the differences of Crosspunch to others methods will be highlighted and you will get to know which hair types are best suited for Crosspunch. For this reason, this article should serve as a preparation for an informative conversation in my medical practice, if you are interested in further information concerning this topic.

Enjoy reading!
Yours sincerely, Angela Lehmann

Which types of hair loss exist?

In general, there are two types of hair loss (medical: alopecia, which have different influences on the decision for or against a hair transplantation. This differentiation is based on the cause of hair loss. On the one hand, there is the so-called reversible alopeciae diffuse hair loss. In contrast to circular hair loss, this means loss of hair on the complete scalp, i.e. not as in the case of a receding hair line where clearly defined areas are affected; but the total number of hairs decreases. Another type of reversible alopecia may affect women after having given birth. Also, metabolic diseases and alterations, for example malfunction of the thyroid), a strict diet, the intake of too much vitamin A, an incorrect insulin adjustment or intoxication by heavy metals (thallium, cadmium or mercury) may be associated with reversible alopecia. Often, also people who underwent a radiation therapy may be affected. For such types of hair loss, no transplantation is indicated because normal hair growth can be expected again.
In comparison to that, people who suffer from an irreversible type of hair loss should think about a hair transplantation This type of alopecia also has different causes. The most common type is the so-called androgenetic alopecia. In this case, the hair follicle atrophy is caused by the sexual hormone testosterone. In addition to that, scars, surgical interventions, injuries or burns lead to an irreversible loss of hair. The irreversible alopecia type is also caused by psychological disorders like trichotillomania (compulsive pulling out one’s own hair). Another reason for a hair transplantation may also be alopecia areata, which is actually reversible. This is an autoimmune response against one’s own hair but in most cases temporary. A transplantation may be indicated if the alopecia persists over years.

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Which type of hair fits best for a hair transplantation?

As commonly known, human hair exists in many colours and forms and is, hence, a symbol of individuality. For this reason, the appearance of the hair is important for the aesthetic perception of most people. However, not every hair type fits best the needs for a hair transplantation. The following chapter will provide an impression of which type of hair is best suited for transplantation.
Concerning the colour, blond or white hair fits best because, in general, blond people have a higher number of hair follicles, hence, more hair is allocatable for transplantation. Furthermore, blond hair contains less pigments than dark hair. In the case of transplantation, this leads to a less accentuated contrast on the light, bald scalp.
Another advantage is to have curly hair. Visually, this type of hair is perceived bulkier than smooth hair. This makes it easier to coat bald scalp areas and helps to ensure a therapy result of high quality.

On the other hand, the transplantation of light and curly hair provides a special challenge for the surgical assistant. This is due to the fact that, in most cases, such hair has elliptic follicles. Hence, a high degree of precision is needed while extracting and implanting the grafts.
At the same time, the assistant must act very carefully while splitting the grafts (also see “Possibilities and Limitations of Modern Hair Transplantation Techniques”) to exclude possible injuries of the extracted follicles, which would lead to loss of donor follicles.

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Which type of hair is suited best for producing single-hair transplants?

For producing single-hair transplants also called micro grafts smooth and dark hair is suited best because it is easily visible for the surgical assistant. Furthermore, follicles of this hair type are normally straight, which makes splitting of the tissue easier.
In contrast to light and curly hair, a disadvantage of smooth hair is the lower total number of follicles available. Also, the higher optical volume of curly hair becomes a disadvantage when straight hair is transplanted. Furthermore, dark hair creates a more accentuated contrast to the bald scalp. Hence, scalp areas with a lower number of hairs create an eye-catching effect and the assistant must be very skilled in transplantation techniques to generate an aesthetic result. The dominant contrast is mainly visible at the hair line.

Figure 1: Total number of follicles depending on hair colour. (Source: Own creation)

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Besides surgical technique, what must be considered during every transplantation?

To achieve an aesthetic result, in most cases, two hair transplantation sessions are necessary. This is due to the fact that the number of follicles that can be extracted during one session is limited, and a certain time and area are needed to establish a so-called collateral circulation. This phrase refers to a physiological bypass line, e.g. blood flow, which provides nutrients for the implanted follicles within the recipient site to ensure to become well ingrown and later able to produce new hair. If there is not enough place to establish a collateral circulation or if there is not enough time left for tissue regeneration, the affected cells may die, which leads to a necrosis (dead tissue). Furthermore, after each hair transplantation session, the tissue contracts slightly, which results in more space left for the collateral circulation. This area may be visually optimised within a second session.

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Is it right that more capillary implants lead to a more natural result?

This statement is true for the hair line on the forehead but not for every recipient site. The answer is mainly dependent on the type of hair and state of the recipient site (e.g. scars after surgical interventions resulting from tumor resection , skull injuries, burnings, infections, corrosion and others) and the surgical technique as well as how the recipient site has been prepared. In the case of curly hair, it may be advantageous to implant grafts containing three to four hairs in order to imitate a natural curl on the recipient site. Therefore, it is of high importance to prepare the recipient site with the same drill diameter as used for graft extraction. This method has the advantage that the natural space between the single hairs is maintained. The implantation by Slit Incision inevitably leads to hair clustering. Slit Incision is a technique based on many very small cuts on the recipient site in which the implants are later placed with tweezers. If only grafts containing one or two curly hairs are transplanted, the impression may arise that an artificial hair replacement was used. This optically leads to an unnatural effect.

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Which type of hair fits best to coat bald scalp with hair transplantation?

Most people have a genetically determined cowlick on the top of their heads, which determines the direction of hair growth. Black, smooth hair tends to divide itself into skeins, which leads to a more accentuated contrast to the bald areas. Independent of the hair colour, curly hair is best suited to coat the cowlick and parting. Hence, this type of hair is more advantageous for covering bald areas and it creates more visual volume.
This visual effect by use of either smooth or curly hair is illustrated by a women with two different haircuts. Curly hair coats the scalp better than smooth hair.

Abbildung 2: Optischer Effekt durch gerades (links) und lockiges (rechts) Haar auf die Sichtbarkeit der Kopfhaut. (Quelle: eigene Darstellung)

Figure 2: Visual effect by smooth (left) and curly (right) hair on visibility of the scalp. (Source: Own creation)

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Why was Crosspunch developed and what does it aim to do?

It is often described that the direction of hair growth has to be considered during transplantation. This is generally right because the loss of hair changes the situation. This means that, with progression of hair loss also the number of hair follicle decreases Due to the fact that hair is needed on the chaplet, it must be tried to achieve an optimal result with the remaining available donor site and remaining follicles. With the new hair transplantation technique Crosspunch, the result may be further optimised. This new method helps to better coat bald scalp areas. Furthermore, it is possible to decrease the dominance of bald skin along the chaplet that results from hair loss.

Abbildung 3: Haartransplantationstechnik Crosspunch und die Auswirkungen auf den Haarkranz. (Quelle: eigene Darstellung)

Figure 3: Crosspunch technique and its effects on the chaplet. (Source: Own creation)

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Which properties should hair on the recipient site have to operate with Crosspunch?

The Crosspunch method was originally developed for smooth hair but it may also be applied independent of hair colour or thickness. This is possible because curly hair naturally provides the effect which can partly be reached with Crosspunch for smooth hair on the hair line. The better result by use of the Crosspunch method is generated by the preparation of the recipient site in fine and balanced angles on the top of the head. Hence, a certain skill of the surgical assistant is required because hair structure, status of the recipient site and careful insertion of the implants have to be considered. To achieve a natural result from the hair line on during reconstruction, it is necessary to respect the natural growth direction of the hair. After this, it is possible to apply the Crosspunch method. Crosspunch may also be used in case of great bald areas, e.g. from the hair line to the middle of the head, from there to the cowlick or the whole top of the head.

Abbildung 4: Veranschaulichung der Crosspunch-Methode. (Quelle: eigene Darstellung)

Figure 4: Illustration of the Crosspunch method. (Source: Own creation)

Figure 5: Patient before surgical therapy with bald areas from hair line to the middle of the head.

Figure 7: Final result after two operations with Crosspunch method within 12 months. Within the two sessions, 1,666 grafts were transplanted.

Figure 9: Before self-grown hair transplantation.

Abbildung 11: Haaransatz nach der Eigenhaartransplantation.

Figure 11: Hair line after two self-grown hair transplantations.

The Crosspunch method may not be applied in case of receding hairlines or to small recipient sites. Here, Crosspunch may cause artificial, unnatural visual effects. For reconstruction of eyebrows or beards, this technique is also not suited.

Abbildung 6: Drei Monate nach erster Operation mittels Crosspunch-Technik, unmittelbar vor der zweiten Operation.

Figure 6: Three months after the first operation with Crosspunch method and short time before the second.

Abbildung 8: Hier wird das Endresultat nach 2 Operationen mittels Crosspunch-Technik in einem Zeitraum von 12 Monaten dargestellt. Dabei wurden in 2 Operationen insgesamt 1666 Grafts transplantiert.

Figure 8: Final result after two operations with Crosspunch method within 12 months. Within the two sessions, 1,666 grafts were transplanted.

Abbildung 10: Nach den Operationen mittels Crosspunch-Technik.

Figure 10: After the operation with Crosspunch technique.

Do you have any further questions?

hope that I was able to answer some of your questions concerning self-grown hair transplantation and Crosspunch. If you have got any further questions, please do not hesitate to make an appointment for an informative consultation in my medical practice; I would be pleased to welcome you.

Yours sincerely,
Angela Lehmann

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