A Visit to the office of Dr.Kenichiro Imagawa
On Tuesday August,27,2003 ,while on a visit to Japan,Iwas invited to
visit the office of Kenichiro Imagawa MD in Yokahama. This is a satellite city of Tokyo and said to be 30 kilometers distant but in reality one city blends almost imperceptively with the other.Dr.Imagawa was an early member of the ISHRS and is well known to most of us as one of the Japanese “regulars ” at our meetings. He speaks excellent English and is a Past President of the Japanese Society of Hair Restoration Surgery. A Plastic Surgeon by training he now concentrates almost entirely on Follicular Unit Hair Transplantation and has a team of 7 Assistants (all RNs) performing two operations per day, 6 days each week.
■New Patients
Many come from Internet inquiry via Dr.Imagawa’s Website.
■Planning
Dr.Imagawa performs a careful assessment of the donor site for hair diameter and density. He measures with a micrometer and a densitometer at several regions along the donor site to gauge the number of 1-2- and 3- haired groupings that might be obtained from the strip. He says that Japanese hairs vary from 70-90 microns and have a density of approximately 160 hairs per sq cm in the occipital zone and around 120 at the temple area.He usually obtains around 80 FUs per sq cm from occipital donor strips.
■Anaesthesia
The patient is placed in a prone position and carefully draped with the hair held clear of the operative field with paper tape. Dr.Imagawa likes to use intravenous midazolam as a premedication and dilutes 5 mgm of this drug with 5 cc N. saline prior to inject over a 2 minute period.
1% Xylocaine with 1:100,000 epinephrine is injected slowly and superficially via a 30-gauge needle. This is followed by 0.5% Xylocaine intradermally and finally 0.1% Xylocaine to the deeper tissues to raise the scalp and harden the donor tissues.
■Removal of Donor strip
The strip is measured in advance at 1 cm width and marked with gentian violet. Following the method of Thai HT surgeon Damkerng Pathomvanich, he then gently scores the surface with the fine blade and makes his incision deeper by stretching the scalp with skin hooks, and dexterously dissects around the hair follicles. He stays above the galea at all times and en-counters only mild bleeding. Very little cautery is required and in his expert hands the strip removal takes only about 15 minutes.
■Wound Closure
Because of the relative sparseness of the donor hair and the propensity of Orientals to thick scar formation, Dr.Imagawa likes to close in two layers. He uses 4-0 PBS interrupted sutures every 1.5 cm to the deep layer and the same thread( or sometimes 4-0 PDS) continuous for the superficial layer. ( It was my impression that in spite of these precautions the scar was a little lumpier than in the average Caucasian patient but certainly better than the usual donor scar in Asian scalps).
■Slivering and dissection
The strip was pinned to a silicon rubber surface and the slivering was performed horizontally rather than in the vertical direction seen more commonly elsewhere. Interestingly ,the assistant performing this used a head loupe and scalpel rather than the Mantis microscopes and razor blades used by all the other assistants at the Clinic.
The FUs were expertly dissected and placed into individual, color-coded groupings of 1,2,3 and 4 hairs. It was amazing to me to see five girls sitting in a row and working intently at their microscopes without one word of conversation passing between them. I have never seen this degree of concentration in Clinics in the West.
■Implantation
A further 5 mgm of midazolam is given and the recipient site is anaesthetised in the same fashion as the donor site. An iceblock is sometimes found to be useful to minimize discomfort at the frontal injection site.
Dr.Imagawa makes the recipient sites personally with squashed 21 and 19 gauge need;es and tailored mini-blades for any two FU grafts. The smaller graft sites are made perpendicular to the hairline and the larger ones placed parallel to the hairline to distinguish between the two as some shrinkage occurs before the assistants complete their implantation.
The assistants, working one on each side, have the FUs in a rectangular graft holder on the left index finger near the implantation site. They have a pair of No 5 curved forceps in each hand and are as quick as lightening. They hold the slit open with the left forceps and pick up the FU and insert with the right. They seem to each plant one graft about every 6 seconds and once again working without any chatter, the entire 600 grafts were implanted and the scalp checked and cleaned within an hour.
■Postoperative care
The patients require no bandage but are given an elasticised cotton head-band to wear at night to minimize the forehead edema. Oral steroids and antibiotics were given and an appointment made for check-up and suture removal at 7-10 days. Additional operations are suggested at 6-9 months.
■Price
Dr.Imagawa charges US5$ per graft for an average session with a little more for small sessions.
■Results
The resulting growth was very natural and as good as I have seen anywhere in the world. Dr Imagawa does not favor dense packing of FUs in a single session and encourages his patients to return for further sessions if greater density is desired.
■Comments
I was most impressed at the quiet workmanship and
professionalism seen at this Clinic with a large staff working quietly and harmoniously to produce outstanding results. Oriental hair is not the greatest hair to work with and the majority of Asian surgeons seem to use the Choi and Kim Implanters. It was interesting to see a Japanese surgeon using a relatively standard FU implant technique and achieving wonderful results. He is pretty good at staff relations also and the day after my visit he took his family and the entire staff off to Phuket, Thailand, for a week’s holiday.
Hair Transplantation Forum International November/Decenber 2003
