trico_inglese

ENNIO ORSINI

Manual of dermopigmentation applied to baldness and scalp scars

to Evan

Ennio Orsini

Edited by: Anna Leombruno Illustrations & pictures: Ennio Orsini, Antonio Silvestri Layout, graphics and printing: TREBITComunicazione.it Printed in July 2015

Š2014 Ennio Orsini DECO STUDIO Via Aragona 23, 67039 Sulmona (AQ), Italy e-mail: info@ennioorsini.com web: www.ennioorsini.com The reproduction of this work or part of it by any means, unless expressly authorised by the author, is strictly forbidden.

DermopigmentazioneŠ is a trademark registered by Orsini&Belfatto s.r.l.

The use of the information contained in this text is protected under Italian law and, in particular, by law No. 633 of 22 April 1941, and subsequent amendments, on the protection of copyright and related rights and, unless otherwise specified, it belongs exclusively to the author. Therefore, any use or reproduction, even partial, which has not been authorised by the right holders will be prosecuted both civilly and legally. The reproduction, even partial, of all or part of the contents, by any means and for any reason whatsoever, is strictly forbidden without the prior written consent of Orsini&Belfatto s.r.l.

Requests for this authorisation can be sent to the following email address: info@ennioorsini.com

Manual of dermopigmentation applied to baldness and scalp scars

PREFACE

“In nova fert animus mutatas dicere formas corpora” My mind leads me to speak of bodies transformed in a new manner.

- Ovidio, Metamorphoses -

For the first time I am writing about a subject that I have approached only recently and about a person who is like a crazy butterfly flying into my life, whose beauty and variety of its most intimate nuances I can rarely grasp. Yet, as it often happens, a new passion creates small gaps of perfection where we enter, to understand, learn, get excited, arouse emotions and set limits for ourselves, only to be carried away, then, to travel through unknown and seemingly distant worlds, both real and imaginary.

But now, without dwelling too much on rhetoric, I would like to say a few words on this adventure in the universe of Tricopigmentation, ruled by King Ennio Orsini.

This young king makes me think of a Dobermann, whose brain does not stop growing.

But this is just a myth. Ennio, on the other side, is real. A real volcano of ideas, experience, research and innovations. He’s like a flowing river. Never the same man.

That’s because he always seeks new targets, without bragging about his success, like a true champion. This is his strength. And he drags you into his world with all the seriousness, dignity and creativity of a real artist.

If that weren’t the case, there would not be today a crowd of incredibly grateful people who worship this man because, thanks to him, they no longer have large shapeless spots in their head, emerald eyebrows, crazy lips, and many psychological problems to be solved.

He took all the old techniques to study and improve them, with the help of other professionals that maybe did not event belong to this world, but whose contribution was essential for the progress of the matter. He has overcome the limits of the old techniques to create perfection.

Yes, his technique is perfect. And I can say it from the results: the people he has treated, their heads, their smiles, their serenity. People who decided to rely on the expert hands of King Ennio.

This manual was written to disclose Tricopigmentation history and techniques, for purely educational purposes.

There is one last thing I would say to you readers, of you know dermopigmentation and tattooing techniques, just like me: love your job as you’d like to be loved.

Only in this way you will be fortunate enough to hear someone saying “thank you”, with a smile on their face. Maybe the same person who, until just before, could not even look into the eyes of his children.

Anna Leombruno September 26th 2012

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Table of contents INTRODUCTION What is Tricopigmentation?

10

Is this treatment permanent or not?

21

Things you are supposed to know

24

I. BASICS

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I.1

History of Tricopigmentation

I.2

91

IV.1 Definition

92

IV.2 The right depth and the consequences of a wrong depth

94

IV.3 Timing of tissue healing after a dermopigmentation treatment

96

IV.4 The 3 basic manoeuvers

99

IV.5 The 5 basic parameters of dermopigmentation

100

IV.6 General rules of dermopigmentation

105

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V.

EQUIPMENT AND SPECIAL PRODUCTS

107

Limits of hair transplant: fields of application of Tricopigmentation

37

V.1

How important it is to use specific equipment

108

I.3

Psychological condition of a patient who underwent hair transplant;

V.2

Suitable and unsuitable colours

39

111

I.4

Who’s it for?

42

I.5

The emotional state of our customers

45

II. BALDNESS

47

II.1 Overview

48

II.2

Various types of baldness

50

II.3

Description of Androgenic Alopecia

II.4

VI. TRICOPIGMENTATION®

115

VI.1 The current situation: analysis of errors due to improvisation

116

VI.2 The Bounce technique VI.3 The Short Hair technique

128

57

VI.4 Timing and block diagram of a Tricopigmentation treatment

131

The Hamilton Scales

61

VI.5 The Shaved effect technique

136

II.5

The Norwood Scale

63

VI.6 The Dermatoppik technique

143

II.6

The Ludwig Scale

66

VI.7 Technique used to cover F.U.T. scars

148

VI.8 Technique used to cover F.U.E. scars

155

VI.9 Treatment procedure for prosthesis wearers

158

VII. BUREAUCRATIC AND LEGAL ASPECTS

161

III.

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9

IV. DERMOPIGMENTATION

HAIR TRANSPLANT

69

125

III.1 Technical glossary with comments

70

III.2 The F.U.T. method

75

III.3 The F.U.E. method

81

VII.1 The first consultations

162

III.4 Scars

86

VII.2 Pre-treatment instructions

163

III.5 Costs of a transplant

89

VII.3 Informed consent

164

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VII.4 The Project file VII.5 Post-treatment memorandum

INTRODUCTION

165 165

VII.6 Interaction with other products or systems: Minoxidil, Finasteride, prostheses, etc.

166

VII.7 Recommended costs

173

VIII. Before & after treatment EXAMPLE

179

Conclusions

195

Acknowledgements

197

Bibliography

199

Site links

201

Biography

202

W

hy am I writing again about a topic so debated? Because I think I have established some important principles to work in this field, I tried to improve the existing rules and I have investigates some common intuitions. This is mainly because I needed to reset my mind, putting into this book everything I have learned over time. Only a free mind can fly high, mine had been filled with so much information that I had to keep into this precious book.

This book is the result of a study that has lasted for years, showing you a proven technique that has been tested by me so many times that I can finally say “It really works” and is now yours.

It is, of course, an advanced approach to dermopigmentation. I will take many principles for granted and, therefore, if you have just started practicing, you should start with “Eyebrow dermopigmentation”, my first work, before reading this manual.

Perhaps you will find more images than theory and this is because, if you have been practicing for a while, you are certainly already filled with too many notions.

That said, I just have some questions for you “Would you like to revolutionise the way you work? Do you want to change your certainties? Do you want to abandon your reference points and start a new journey? “.

If your answer to all the three questions above is YES, then you are now ready to leave your family and friends for a few days. Make sure you have paid your dues.

Turn off your phone. And now that your mind is free, you are finally ready to fly high.

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What is Tricopigmentation?

Tricopigmentation means just scalp micro-pigmentation, or tattooing. It is a littleknown, but effective and convenient solution for those suffering from hair loss and baldness. Discredited by several unfounded rumours, used by just a few dermopigmentation specialists, it is, unfortunately, often represented by works that are poorly executed. The use of tattoos to hide baldness is extensive and sometimes providential. Listed below are the main cases where Tricopigmentation can give significant aesthetic improvements: • Scars due to Follicular Unit Transplantation (linear), fig. 1; • Scars due to Follicular Unit Extraction (punctiform), fig. 2; • Scalp scars, fig. 3; • Alopecia areata, fig. 4; • Alopecia universalis, fig. 5; • Androgenic alopecia, fig. 6; fig. 2: Scars due to Follicular Unit Extraction (punctiform)

fig. 1: Scars due to Follicular Unit Transplantation (linear)

fig. 3: Scalp scars

INTRODUCTION

• General hair loss, fig.7.

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fig. 6: Androgenic alopecia

fig. 5: Alopecia universalis

fig. 7: General hair loss

INTRODUCTION

fig. 4: Alopecia areata

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One of the basic techniques of this discipline is called Bounce®.

It’s just an implementation of old techniques already existing for this purpose: the same manual technique and working parameters were revised and improved to create a real operating procedure, which is called, as already said, “Bounce®”.

This development has led to a working system capable of producing shaved and realistic effects, with less chance of colour changes and colour migration. These problems, indeed, are quite common with old treatments which do not take into account some important factors that could affect the final result.

A realistic and natural scalp micropigmentation treatment, namely Tricopigmentation, should show some punctiform micro deposits of brown/greyish pigment, located in the superficial dermis at a suitable distance from each other. This will create a shaved or darkening effect of the areas affected by hair loss, depending on the techniques employed.

BEFORE

fig. 9a: Before the treatment

AFTER

fig. 9b: After the treatment

Below (figs. 8-18), some examples of Tricopigmentation treatments. fig. 9c: After 2nd session

AFTER

BEFORE

fig. 9e: Macro

AFTER

INTRODUCTION

BEFORE

fig. 9d: Macro HL

fig. 8a: Before the treatment

fig. 8c: After 2nd session

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fig. 8b: After the treatment

fig. 8d: Macro HL

fig. 8e: Macro

fig. 10a: Before the treatment

fig. 10c: Brocq Pseudopelade

fig. 10b: After the treatment

fig. 10d: After 2nd session

fig. 10e: Macro

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fig. 11a: Before the treatment

fig. 11c: Side view

AFTER

fig. 11b: After the treatment

fig. 11d: Front view

BEFORE

fig. 12a: Before the treatment

fig. 12c: After 1st session

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fig. 11e: Macro

AFTER

fig. 12b: After the treatment

fig. 12d: Front view

fig. 12e: Macro

BEFORE

fig. 13a: Before the treatment

fig. 13c: After 2nd session

AFTER

fig. 13b: After the treatment

fig. 13d: Front view

BEFORE

fig. 14a: Before the treatment

fig. 13e: Macro

AFTER

INTRODUCTION

BEFORE

fig. 14b: After the treatment

fig. 14c: Pre-treatment dermatitis fig. 14d: Front view

fig. 14e: Macro

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BEFORE

fig. 15b: Front view

fig. 16a: Back view

DURING

fig. 15c: Back view

fig. 15d: Front view

DURING

fig. 16c: Back view

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fig. 15f: Front view

fig. 16d: Front view

AFTER

AFTER

fig. 15e: Back view

fig. 16b: Front view

fig. 16e: Back view

INTRODUCTION

fig. 15a: Back view

BEFORE

fig. 16f: Front view

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BEFORE

AFTER

Is this treatment permanent or not?

Please, remember that in this volume, we will focus on dermopigmentation treatments performed with bioabsorbable pigments (fig. 19).

fig. 17a: Before the treatment

fig. 17b: After the treatment

Tricopigmentation treatments performed with bioabsorbable pigments

When micro-pigmentation is performed with bioabsorbable pigments, (improperly called “semi-permanent”), it’s called “Bioresorbable Tricopigmentation”, and it may last from 4-6 months, up to 14/16 months. It could last even longer, and no one can say in advance when it will disappear completely. But, if well performed, it will disappear completely, this is the only sure thing.

The factors that may accelerate the disappearance of the pigment in the dermis are many, but the most important are:

fig. 17c: After 1st session

fig. 17d: Front view

fig. 17e: Macro

• the individual phagocytosis; • the age of the individual (closely related to the previous factor); • the individual healing ability after the treatment; • the individual anatomy of the scalp; • the type of pigment pushed into the dermis; • the manual technique used to perform the treatment; AFTER

INTRODUCTION

BEFORE

• prolonged sun exposure or use of tanning lamps; • the use of corticosteroids and anticoagulants.

According to the above, therefore, we can say that the duration of a Tricopigmentation treatment is subjective.

fig. 18: Before & After

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fig. 19: Tricopigmentation treatments can be performed in two different ways: one using bioabsorbable pigments (first case), and the other using permanent pigments (second case)

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Tricopigmentation treatment performed with permanent pigments

In some special and very rare cases, Tricopigmentation can be performed with permanent pigments. This choice must be pondered very carefully.

Being a permanent treatment, it attracts many customers who think they can solve all their hair problems once and for all, but this is not true.

Over time, nothing remains exactly the same, including iron oxides used to create pigments. In other words, there is no guarantee that a treatment performed with permanent pigments remains unchanged throughout life. It may happen that certain colours, such as brown, may turn into other colours. Although this problem can be relatively kept under control with an appropriate balance of chromatic components of brown colours, it still remains a significant bottleneck for dermopigmentation in general, as well as a very risky choice.

Among the factors that may contribute to or, somehow, interfere with colour change of brown colours used in Tricopigmentation, we find: • excessive exposure to ultraviolet rays of the treated area: sun or tanning lamps; • extreme temperature swings;

Please, note that if you treat an area without considering the above factors, your customer will experience irritations with inevitable and consequent migration of white blood cells around the punctiform deposit of pigment. This may cause a real enlargement of the edges of the original “dot”, which then will be less defined (migration of pigment). This phenomenon, therefore, is attributable to abnormal phagocytosis, caused by the inflammatory conditions listed above. Moreover, trying to remove the pigment through other Tricopigmentation treatments, could further enlarge the “dot” in question (fig. 20). Often I hear about some “miraculous” techniques able to remove Tricopigmentation treatments through the use of goat milk, hydrogen peroxide, hyaluronic acid and many other substances normally used for other purposes. Of course, I do not recommend to use these procedures.

BIOABSORBABLE COLOURS JUST AFTER THE TREATMENT

AFTER A MONTH

AFTER THREE YEARS

• alkalinity of extracellular fluids in the dermis; • purity of raw materials used in the colouring preparation used for Tricopigmentation treatments;

So, it may happen that the “small dots” you have created during the treatment session become large dots, thus generating the so-called phenomenon of colour migration. These dots will become larger, but they will also turn into greenish dots. Among the factors that may contribute to or, somehow, interfere with colour migration, we find:

INTRODUCTION

• autoimmune diseases of the individual undergoing the treatment.

PERMANENT COLOURS JUST AFTER THE TREATMENT

AFTER A MONTH

AFTER THREE YEARS

• sun exposure, tanning lamps, saunas, hot baths or showers, but generally anything that might increase the body temperature; • the application of alcoholic substances, hair lotions, as well as the use of chemical exfoliants (glycolic acid, mandelic acid, pyruvic acid, salicylic acid, trichloroacetic acid, phenol, resorcinol); • the attempted removal of implanted pigments, with systems different from laser therapy.

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fig. 20: Difference between the use of bioabsorbable pigments and the use of permanent pigments

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Things you are supposed to know Since with this manual I just want you to give you an overview of Tricopigmentation treatments which, together with a training course (required!), will provide you with the tools you need to work in this field, I will not focus on other topics related to other techniques which are part of this discipline. Possibility of infections, hygiene, legislation, and other matters should be examined individually. Of course, I will mention them in this manual, but I assume you already know the following principles: • preparation of a workstation; • use of disposable tools (always!) and proper hygiene practices to ensure standard sanitary conditions as much as possible; • protection from infectious diseases; • sterilisation processes; • obtaining a regular sanitary authorisation to perform permanent makeup treatments in your studio; • knowledge of the general rules of this sector: health and safety at work Consolidated Act, European ResAP on tattoos, ministerial guidelines, disposal of hazardous waste, regional decrees and municipal regulations; • colour theory; • anatomy, physiology and skin histology.

CHAPTER ONE

Basics

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you, once again, that this fundamental manual can not replace, in any case, professional training courses, but it’s still a great business tool.

Tricopigmentation was founded in 2008 by Ennio Orsini, a makeup artist who was just starting his career in the world of micro-pigmentation and Toni Belfatto, a tattoo artist and trichologist, as well as a micro-pigmentation specialist.

Today, Tricopigmentation is a viable alternative to surgical solutions, but also to the use of wigs and hairpieces; and it’s maybe the only solution for scars due to hair transplants. The experience gained in the field has shown an extremely important lack of skilled operators, able to support the intense activity carried out by hair transplant surgeons and operators dealing with problems related to baldness. This issue, together with the lack of a real specific operational protocol, led Orsini & Belfatto to create a new know-how identified with the name of Tricopigmentazione® (Tricopigmentation).

Several years ago, driven by our desire to explore new fields and to create professional innovations, we started to experiment with new techniques of corrective dermopigmentation, and that professional curiosity was only the beginning of a new era for micro-pigmentation. Our project has been a journey through insights, technical and colour tests, years of research and results to be interpreted, successes and disappointments. Finally, that dream became reality in 2009, when we founded our service company: Orsini & Belfatto s.r.l. and later with the registration of Tricopigmentazione® (Tricopigmentation) and Bounce® trademarks and patents (fig. 21).

fig. 21: Our Tricopigmentation patent

But, before getting straight to the point, let me tell you more about the story that led me today to be the “father” (that’s how they call me) of Tricopigmentation.

About ten years ago, I was working at Silverlips, a German company manufacturing equipment and colours for permanent makeup, both as a distributor and as a teacher in charge of its many training courses, when I had an intuition. At the time, scalp micro-pigmentation treatments were becoming quite popular but I realised that there was the need to use special tools other than those that were usually used in dermopigmentation. So, I spoke with the company management and I offered them an agreement that would satisfy both my skills and their economic interests. After thinking about it, Silver-lips refused my offer, but, of course, I did not give up: I knew my idea was innovative, I knew I could make a change in this discipline, and that I could help those people who were striving to find a solution for all those problems related to baldness. And today, thanks to my idea, my stubbornness and my tenacity, I can say I was right. But, let’s get back to the story: after that episode I was invited as a speaker to a conference in Pisa (fig.22) and, with me, also the manager of Biotek (fig.23), another important company in the industry, and, on that occasion, I had the chance to share the car with him.

That day changed the future of Tricopigmentation forever.

I. BASICS

I.1 History of Tricopigmentation

Tricopigmentation treatments are performed to solve different types of imperfections, including baldness and the presence of scars on the scalp. The whole process is quite delicate, because it represents the true solution to many psychological complexes relating, in most cases, to important and sudden changes.

That is why a real dermopigmentation specialist should know much more than simple notions or principles related to permanent makeup, including trichological and dermopigmentation techniques. Let me take this opportunity to remind

26

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and launched on the market our hair dermograph (Tricoderm® system), supported by some presentation days in Milan, to record the method as a real innovation in the field (figs. 24-26).

fig. 22a: A.T.E.C. National Congress – My speech on Tricopigmentation

fig. 23: Massimo Froio (Biotek CEO) and Ennio Orsini A.T.E.C. National Congress, Pisa

fig. 24: Presentation of Tricopigmentation Biotek Academy, Milan. In the pictures: Ennio Orsini, Massimo Froio and Toni Belfatto

I. BASICS

fig. 22b: A.T.E.C. National Congress – My speech on Tricopigmentation

fig. 22c: A.T.E.C. National Congress – My speech on Tricopigmentation

Yes, because I did not share just a car with him, I shared my thoughts and my ideas. The same I had shared with the German company, but he was definitely more forward-looking. Needless to say, I started working almost immediately at Biotek.

It was 2009 when, thanks to Biotek Medical avant-garde laboratories, we created

28

fig. 25: Best Italian operators present the first official event TRICOPIGMENTAZIONE ITALIA. Biotek Academy, Milan

29

So, we had the chance to talk about Tricopigmentation and to present our patent, designed to treat hair loss and scalp scars (fig. 28), before about 300 people, including doctors and operators (fig. 29), and to introduce also our training course for Russian professionals which was held in May 2011 (figs. 30, 31).

fig. 26: Our first HAIR DERMOGRAPH (Tricoderm system) by Biotek-Orsini & Belfatto

fig. 28a: Our presentation on Tricopigmentation, Moscow

I. BASICS

fig. 27a: Launch of Tricopigmentation on the Italian market. Cosmoprof, Bologna

fig. 28b: Our presentation on Tricopigmentation, Moscow

fig. 27b: Launch of Tricopigmentation on the Italian market. Cosmoprof, Bologna

Success was almost immediate, also thanks to important trade fairs that allowed us to promote our product, such as Cosmoprof, in Bologna (fig. 27). I say this because, right after that occasion, me and my partner Tony were invited to Moscow at the Congress Palace of the Chamber of Commerce and Industry of the Russian Federation, to attend the fifth edition of the International Congress of Medicine.

30

fig. 29: Conference room at the Chamber of Commerce and Industry in Moscow. The event was also broadcasted live on the Internet with more than 1,600 people connected

31

fig. 32: A phase of the permanent makeup competition. Judges are examining a permanent makeup to express their opinion

fig. 30b: The first international Tricopigmentation course at BIOTEK academy

fig. 33: The permanent makeup competition

The next edition, in fact, saw the participation of Mexican and Japanese operators and, as for me, I was asked to participate as a judge for the second consecutive year (figs. 32, 33). My presence in that competition emphasized the importance and prestige of Italian style in the world of dermopigmentation. fig. 31: Conclusion of the first international Tricopigmentation course held in Milan at the prestigious BIOTEK WORD academy, with enthusiastic Russian operators

On the occasion of the congress, also an international competition of permanent makeup was organised with the participation of 80 operators from all over Europe, essaying the eyebrow hair stroke technique. Being the only European competition in the field, the organisers aimed to open it to other countries.

32

I. BASICS

fig. 30a: The first international Tricopigmentation course at BIOTEK academy

I apologize, I know I’m long-winded sometimes, but I feel the need to share my personal and professional path with you and sometimes I run faster than the story itself. Where were we? Oh, sure.

After this exciting experience, I started looking for the most effective and fastest way to promote this discipline, to reach both the market in general and targeted operators: a blog was undoubtedly the best possible solution.

So, I joined a popular forum and I was immediately contacted by its owners who asked me to manage a specific section of the forum dedicated to Tricopigmentation. Within a very short time, it became the most visited and clicked section

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of the forum, but soon I realised it was too much for me, since I could not devote enough time to my real job and I was promptly replaced by Silver-lips or better, by some of my students and colleagues at the German company.

as qualification training courses for operators who are required to follow a specific protocol. From that moment on, I was invited to many different congresses to talk about Tricopigmentation in many other countries. I went to Miami, Colombia recently also in Norway (fig.36).

The innovation represented by my method was elementary, but significant: it was all about the equipment used for Tricopigmentation, because it was completely different from the traditional equipment used in the past for permanent makeup in general.

In 2010, I was invited to a conference of medical doctors only held in Capri, and I was the only speaker without a medical degree who was invited to talk about Tricopigmentation, a subject that was then still quite unknown (figs. 34, 35).

fig. 36: One of my presentations of Tricopigmentation around the world

Today Tricopigmentation is a constantly evolving discipline, but its results are indisputable and they will increase its success even more. Its development will lead to new methods and products that will be more innovative than those used today, with even better results. fig. 34: My speech on Tricopigmentation at the congress held in Capri

I. BASICS

I had not only invented a method, then, but also a new profession, that of Tricopigmentation specialists, and not just a treatment, but a whole set of tools, such

Now, I know that if I ask you to use Rollerblades, you will know exactly what I am talking about. You would know that I am just asking you if you can skate. What you may not know is that the words “rollerblade” and “roller blades” are now used indistinctly to refer to any pair of in-line skates, equipped with wheels, but Rollerblade is just a brand of a company which chose this name for its inline skates.

This is exactly what is happening with the brand Tricopigmentazione® (which is Tricopigmentation): this term is now used for all scalp micro-pigmentation treatments, but in reality I have created, coined and spread this neologism with the words “trico” (hair) and “pigmentazione” (pigmentation).

fig. 35: Table of speakers at the Congress of Capri before the most important and renowned hair transplant surgeons

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No one had ever used this word to refer to this treatment, and the word had never appeared on any vocabulary. When I started thinking about using this word, I

35

considered only the fact that it had a pleasant sound and that it recalled the word Micro-pigmentation, who use was pretty common.

So, I decided that it could be the right word to describe what I had in mind: creating a container able to collect all the innovations, insights and know-how that I had developed over the years. But, to be precise, the word Tricopigmentation is even incorrect, since during this treatment only dermis is pigmented, not the hair.

I must say that it’s quite disheartening knowing that many colleagues (or assumed to be so) are exploiting this word, also probably unaware of this linguistic nuance, that is the result of many years of research and professional and expensive investments. Unfortunately, this also happened because of us and of our lack of experience in the field of patents. In fact, we decided to record only the brand image and not the trade name, as suggested by the Patent Office Manager of a Chamber of Commerce in Abruzzo. And that is why today all our competitors can use the word Tricopigmentazione to publicise their activities, even if they are just talking about scalp micro-pigmentation treatments, performed with traditional tools and using permanent makeup needles and pigments. So unfair, don’t you think?

fig. 38: Current version of Tricopigmentazione brand image

Finally, the last thing I would say is that I have created also the brand image associated with the word Tricopigmentazione, and it was conceived as a top view of the hairline created with small dots (fig. 37), as in the image below, which is the first version of the brand image, then updated to its latest version (fig. 38).

Let me start this paragraph by saying that what many scientists say about hair, namely that it does not have any functional purpose and that we could all live without it, is not that obvious. The issue is much more complex and it involves many psychological and social factors. That’s why a considerable amount of people suffer the discomfort created by baldness and is willing to do anything to find a solution. Basically, there are 3 major solutions to this equally gigantic problem.

I.2 Limits of hair transplant: fields of application of Tricopig-

The most common solution is hair transplant, through which the hair of the patient, that is neither increased nor thickened, is just moved from one side to the other. Despite its limit, it is a valid technique, but it entails some problems, which are not negligible:

I. BASICS

mentation

• scalp scars; • the hair is collected from an area, which is called donor, that has a limited supply; • the treated area is traumatised.

fig. 37: First version of Tricopigmentazione brand image

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Furthermore, some areas, for example those affected by Norwood hair loss type 7, can not be treated (fig. 39).

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Tricopigmentation does not want to replace hair transplant surgery, but a complementary treatment, since it is able to solve some technical problems, as scar formation and I believe that soon it will become a valid support to cosmetic surgery.

I.3 Psychological condition of a patient who underwent hair transplant

I think this paragraph is extremely important. Moreover, the sensitivity and the ability to understand and handle the fragility and moods of customers, and therefore, to anticipate and convey certain attitudes, typical of someone who has a problem which is aesthetic and psychological at the same time, are essential qualities for those who want to work in this field.

I’ll just tell you the story Manuele. But this is also the story of Federico, Giovanni, Giuseppe and it is completely different from the story of Luca, Alfredo, Gaetano.

His story begins with a hair transplant, performed with the Strip technique due to alopecia of the fourth degree of the Hamilton Scale. Unfortunately, it must be said that performed poorly transplant surgeries often lead to total patient dissatisfaction. And, if before the surgery his main problem was the lack of hair, after surgery not only Manuele had not solved his problems, but also had a 27 cm neck scar, from ear to ear, for which he had spent a lot of money.

fig. 39: A typical situation observed when the donor area can no longer provide follicular units and alopecia progresses, thus creating a bare area where implanting follicles is no longer possible

Manuele, deeply dissatisfied and disappointed, was trying in every way to hide the cut, that aroused people’s curiosity. So, the best solution he had find was to cover that scar with a black eye pencil that he borrowed from his wife. It took about “20 minutes” to draw small dots covering the entire area. Yes, it was a good but ephemeral and time-consuming solution. Coloured powders, hats and strange hair-cuts were also useless. He no longer went to the beach and tried to avoid friends and relatives, but nothing seemed to help him.

I. BASICS

Usually, when we experience disappointment, we become wary and sceptical.

And, when he came for his first consultation, Manuele was even too much wary.

He had a lot of questions, which showed all his weakness and pain, but also his desperate need of help.

After the consultation, he booked his treatment. We decided to schedule two sessions, the second of which after about 50 days, but I warned him that he could need further sessions to see better results. We chose to cover the scar using bioabsorbable pigments, which meant that he had to repeat the treatment about once a year.

38

39

When he came for his first session, Manuele was really nervous. I had asked him to shave his head, leaving about a millimetre, and this had clearly made his scar quite visible. Some scars have the same colour of the scalp, while others are lighter and pearly and this is because melanocytes, damaged by scar tissue, are no longer able to produce melanin in that specific area.

And Manuele had exactly that type of scar. So, I started by selecting the right colour to be used and I choose a very cold brown nuance.

under the skin, I changed the pigment used, so that the future outcome could look even more like the surrounding hair. The second session lasted a little more than thirty minutes, and the end result was certainly less visible than that of first session. In the following days the colour change was less noticeable and, after

BEFORE

AFTER

The colours used for Tricopigmentation are different from those used for the permanent makeup.

We said goodbye after scheduling his next appointment, after about two months.

During that period, Manuele sent me many emails, asking for advice on the posttreatment procedure and, although I had clearly informed him on the outcome of the first session, he was concerned since the whole area was considerably lighter than expected.

fig. 40: Manuele before and after the treatment

Post-treatment macro view

Concluded treatment

I. BASICS

I used the Bounce technique to cover the entire area. The result of this first application was a shaved effect: with a special needle, I created some micro-dots that, after a few weeks, became larger, thus covering the scar. Then, I applied the pigments where the scar was still light and visible, between a dot and another, using a colour similar to that of the skin. I asked Manuele if he was in pain several times during the session, but his answer was always negative. Finally, after about an hour and a quarter of work, the scar appeared slightly swollen and the dots smaller than expected, the skin colour was almost orange, but the end result was able to hide the initial imperfection.

He had been probably carried away by the exciting initial result, when the area seemed almost perfectly covered. Then pigments disappeared, as expected, and the process of regeneration of the epidermal layer resulted in a greyish film which made the skin considerably more opaque and lighter than the colour injected.

Everything was normal, but he was afraid to be disappointed, once again, as happened after his hair transplant, when countless transplanted follicles fell, and his happiness turn into an unbearable sense of failure. The day of his second session came and, as expected, the treatment needed to be defined.

This strategy increases the chances of successful of the treatment, in fact, you can always add colour, but you can not remove it. The risk of putting an excessive amount of colour and the wrong nuance is too high. After analysing the colour

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fig. 41: Manuele when the treatment was concluded

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I want to conclude this paragraph by suggesting you to be delicate, but also resolute. People who undergo hair transplant are usually shocked and disappointed, so you need to be immediately clear on the real chances of success of the Tricopigmentation treatment and you should refuse to perform the treatment, when you already know that the end result will not meet the expectations of your customer.

I.4 Who’s it for?

Over the past decade, sociologists, and not just them, have shown how important it is to look attractive. The implication of this is that people who are less attractive or unappealing are potentially disadvantaged in all human relationships. Soon a quarter of the population will be over 65 years and the fear of becoming bald is growing in a culture obsessed with youth and beauty. It is not surprising that millions of euros are spent every year for hair care, and that there are so many unprofessional hair specialists, selling treatments and products which promise “a miraculous growth of hair”. Physicians, in particular, should take baldness more seriously, considering that the number of people who decide to undergo a hair transplant is growing exponentially: in 2007, there were about two hundred thousand hair transplants in the world, but many people, we are talking about 7 out of 10, are not satisfied with the results, because of the limitations of this type of solution.

Hair loss has always been associated with aging. Some important cultures of the past attributed beauty, youth, manhood and wellness to people who had a head full of hair. The desire to remain eternally young, in particular, explains the widespread fear of hair loss associated with aging.

In Italy, nine million people suffer from more or less severe hair loss. About 50% of them are young people and 50% are over 50 years of age. The relevant fact is that most of these people, regardless of age, struggle to live with this problem and are looking for a solution (fig. 42).

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Tricopigmentation helps these people to regain their serenity. It allows them to shave and to look great, just with a treatment. Therefore, Tricopigmentation can be the right solution for all those people, young and old men and women who have problems with their hair. It is certainly an ambitious project, but, as someone said, “Always aim for the moon, even if you miss, you’ll land among the stars”.

Also in these situations, the question you have to ask yourself to truly understand your objective, is: Who needs us? But please, do not think that your work is merely technical, and that you are just dealing with a cosmetic problem: in many cases, with your professionalism, you give back happiness and confidence to people who are asking for your help.

In many cases, you’ll see, you will be working on the imperfections caused by hair transplants: those who the FUE technique will have a head full of white gaps; those who chose the FUT technique, on the other hand, will show huge horizontal scars, even 30 cm long, from ear to ear; but you will also treat patients affected by localised alopecia, people who have lost hair after an emotional shock or women who have just given birth ... in short, there can be many different variables, and it is not always about a disease. People will ask for your help because they feel uncomfortable.

So, Tricopigmentation specialists must necessarily be open to the medical world, because they will implement some techniques which, in most cases, are the same of a surgery, and they will often be working on the negative results of a medical treatment. Today, there is not a mutual collaboration, but this is mainly due to the fact that Tricopigmentation is a new discipline. However, medicine is now opening to Tricopigmentation: I have already seen several patients who came to me because a doctor suggested them to undergo this treatment. We should definitely work on this synergy, to get even better results. What we should point out is that this treatment is not irreversible, and therefore, the patient should schedule another session after about 8-12 months from the previous one, if he is satisfied with the results and he wants to keep them.

I. BASICS

about three months, Manuele sent me an email to thank me for the excellent results and to schedule his next session, after about a year from the second session (figs. 40-41).

In this profession you should not leave anything to chance. That is why I think that professional training courses are extremely important: this manual is a great tool, but it does not replace a training course.

You should remember that you will meet many prosthesis wearers, so, I think we should clean the air before you start working with these people. Prosthesis wearers have a skin regeneration which is different from other customers, so you

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Prosthesis wearers struggle to abandon that solution and they are usually lookingfor an immediate replacement.

To be more specific, the dots created on a scalp which has never been covered by any prostheses, will turn into ping-pong balls: you must use different pressures, different techniques, different colours and also different timing. It sounds pretty obvious, doesn’t it? But this is a key concept, and we can not skip it.

LEGEND 61.000.000 inhabitants

70% unsatisfied

9.000.000 bald

30% satisfied

fig. 42: Pie chart showing the number of Italian people suffering from problems related to baldness. Only 30­% of them is satisfied with hair transplant

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I will use this paragraph to make a few comments on the emotional aspect of this disease. I believe that many people suffering from hair loss tend to suppress their real feelings. I think they’re afraid of being judged, since most people would say that baldness is not a real problem. Yet, despite the progress of science and the profound change of aesthetic standards, the partial absence of hair, even more than a total lack of hair, is still a very difficult problem to overcome for many people. Perhaps this is due to the monstrous turnover generated by hair products and treatments, which is fed by issues related to baldness and hair loss: trichology, hair transplants, prostheses, miraculous products and systems, etc. Time runs, but hair problems remain. In the past, the lack of hair was seen as a punishment: in ancient Rome, betrayers, adulterers and prisoners were completely shaved. The tonsure used by some monastic orders had, and still has, a deep symbolic value: cutting or shaving hair to show their indifference to worldliness, to be anything but attractive. We could find many other historical references related to the lack of hair with a negative connotation. On the other hand, always in ancient times, people with a head full of hair were associated to powerful leaders and kings. With this historical background, it is not easy to get rid of this strong and entrenched mind-set. That is why baldness has become an enemy to be defeated, and many bizarre and cruel scalp thickening systems have been invented over the years. It is almost laughable to think that our ancestors used to fight baldness using dog paws, donkey manes buried and cooked in oil. Or lion, hippopotamus, crocodile, goose and snake blubber and ibis applied directly to the bald head. And also donkey or horse teeth, bear fat and bone of deer, myrtle leaves, pine bark, white wine, radish seed oil, juniper berries, wormwood, fern roots, linseed oil, crushed almonds, wheat bran, powdered mastic and much more.

I. BASICS

I.5 The emotional state of our customers

should use a specific approach.

It seems that a “bald spot” on the nape, a strong receding hairline or total baldness, can be very harmful to self-esteem: men who suffer from these problems are more likely to be depressed and introverted and less likely to hit the big time.

Many researchers think that we think of hair as a “sexual attribute” and, when there is a total or partial loss of hair, we can experience this condition as if it were a regression to an infantile state, when genders and roles are not yet differentiated.

Hair loss is, therefore, unconsciously experienced as a castration, as loss of virility, strength, youth, masculinity or femininity. To date, about nine million people suffer from more or less severe hair loss only in Italy and 20% of them are young men between twenty and thirty years, while the remaining 50% is represented by

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men over fifty years.

To be fair, if a disease is something that causes physical and psychological pain, we should start by admitting that baldness is a disease, since a disease can be cured only if recognised as such. Only in this way baldness can be effectively treated.

Clearly, your customers are not all the same. They may belong to different categories, such as: • customers suffering from general hair loss; • prosthesis wearers; • people who underwent hair transplant.

CHAPTER TWO

BALDNESS

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II.1 Overview Common baldness is the most common form of alopecia, and it consists of a total or partial lack of hair, but each case is a special case.

It is characterised by initial hair loss involving the vertex of the head (vertex baldness), to cover then the whole upper area of the scalp, usually not affecting the nape and temples, to become then crown baldness.

Why does hair fall out?

The most aggressive form of this type of baldness occurs around 18 years; it starts with a massive fall of hair that becomes thinner and less coloured at each cycle, due to the atrophy of follicles which are no longer able to produce healthy and strong hair, as they did before.

DHT. But also because it is the most peripheral part of the scalp blood circulation and, therefore, it is more affected by atrophy of the vessels. The cause of androgenetic alopecia is dihydrotestosterone (DHT), (full name: 5α-dihydrotestosterone, abbreviated: 5α-DHT; INN: androstanolone). In addition to promoting the growth of body hairs and the beard, it may adversely affect the prostate and even the hair.

DHT is produced by males already in the womb and is responsible for the formation of male characteristics. DHT contributes actively also to other characteristics generally attributed to males, including hair growth and a lower-sounding timbre.

However, hair bulb blood circulation is a critical factor. As already mentioned, the scalp is the most peripheral area of blood circulation and, therefore, it suffers from peripheral vasoconstriction. For simplification, I will divide baldness types in three main groups, as they were three large families: • non-cicatricial alopecia; • cicatricial alopecia; • pseudo-alopecia.

About 88% of the male population is affected by this type of baldness during their lives. In these individuals, certain areas of the scalp have follicles that are “sensitive” to male hormones (androgens) and it is almost certain that some individuals are predisposed to baldness due to several genetic factors.

A second pathological process is the loss of individuality of papillary cycles (characteristic of the scalp of a normal adult) and, therefore, of their synchronisation.

This phenomenon is due to the reduction of the duration of the differentiation phase.

NON CICATRICIAL ALOPECIA

A third phenomenon is an increased activity of the kenogen phase: when the hair shaft comes off, at the end of the telogen phase, the follicle is already occupied by another in anagen advanced phase. There can be an interval between the fall of the hair in the telogen phase and its replacement in the anagen phase: during the physiologic interval (kenogen), the follicle remains empty.

In androgenetic alopecia, hair loss affects only the frontal region, because in this area 5-alpha reductase inhibitors are more active, so there is a greater amount of

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Non-cicatricial alopecia is a temporary and reversible form of baldness, characterised only by a temporary functional inhibition of the hair follicle: androgenetic alopecia, male frontoparietal alopecia, post pregnancy alopecia, alopecia due to radiation, traction, psycho-physical stress, infections, malnutrition, medications, alopecia areata, congenital alopecia… they all belong to the family of non-cicatricial alopecia.

II. BALDNESS

Hamilton, one of the first researchers to study this phenomenon, created a scale to classify the degree of baldness of patients, but it was Norwood who completed his studies and identified 7 different stages of baldness, that we are going to examine in the following paragraphs.

Cicatricial alopecia, on the other side, is a permanent and irreversible form of alopecia: the dermal papilla is damaged and follicles and the germinative papilla disappear. Certainly, this diagnosis hides much more serious diseases.

CICATRICIAL ALOPECIA 49

You can easily imagine that the expectations of these two types of customers are quite different. But you have a solution: Tricopigmentation, that will help them to accept their problem.

II.2 Various types of baldness There are countless forms of baldness (alopecia), whose causes are, of course, different, or, in some cases, patients are affected by different forms of alopecia which contribute, in different percentages, to hair thinning or hair loss. Therefore, when it comes to hair loss, we can not mention only androgenetic alopecia, although, of course, it is the most common form of baldness and I will focus mainly on this type of baldness in this manual.

But, as the Romans used to say, repetita iuvant, so, I will discuss now some ideas already expressed in the previous paragraph, and you will see how many different situations you can encounter.

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1. NON CICATRICIAL ALOPECIA

1.A 1.B 1.C 1.D 1.E 1.F 1.G 1.H 1.I 1.J 1.K 1.L

Androgenetic Alopecia Front-parietal male alopecia Post-pregnancy alopecia Radiation alopecia Traction alopecia Traumatic alopecia Post-infectious alopecia Malnutrition alopecia Amino acids and proteins Iatrogenic alopecia Alopecia areata Congenital alopecia

1. A - ANDROGENETIC ALOPECIA (“ANDROGENETIC BALDNESS, COMMON BALDNESS”).

Androgenetic alopecia (also known as androgenetic baldness) is the most popular form of non-cicatricial alopecia, that is why it is also known as common baldness.

It is also called seborrheic alopecia, premature alopecia, male pattern baldness, although these terms are all simplistic. It is characterised by initial hair loss involving the vertex of the head (vertex baldness), to cover then the whole upper area of the scalp, usually not affecting the nape and temples, to become then crown baldness. Androgenetic alopecia is often, but not always, accompanied by seborrhea and furfuraceous desquamation.

II. BALDNESS

PSEUDO ALOPECIA

Pseudo alopecia occurs when the hair has been torn off or is broken as a result of traumatic events, chemical effects, infections or due to congenital abnormalities involving the hair shaft (such as trichotillomania: a nervous tic causing visible hair thinning). For Tricopigmentation specialists, this classification does not change anything.

Knowing the type of disease can help only in the diagnostic and theoretical phase, and will make you understand the type of person you are dealing with and how you can help him or her. If, for example, your customer suffers from trichotillomania, you will need to make him understand that you can be the breaking point between his problem and its resolution, and, therefore, that you can really help him. If, on the other hand, your customer suffers from androgenetic alopecia, the first thing he should know, is that Tricopigmentation may become a traveling companion until he has accepted his problem.

1.B - FRONT-PARIETAL MALE ALOPECIA Clinically, it is characterised by the M shaped hairline (“receding hairline”), especially for men. It corresponds to stage I of the Hamilton Scale and to stages 1 and 2 of the Hamilton-Norwood Scale, and it does not necessarily mean that it will turn into androgenetic alopecia. In fact, we often see individuals affected by hair loss whose hairline is intact, and vice versa, and more frequently, individuals with a receding hairline whose vertex is totally intact. Androgenetic alopecia and fronto-

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1.C - POST-PREGNANCY ALOPECIA It occurs with effluvium, 2-3 months after birth: it tends to regress spontaneously and is due to a sudden decrease in circulating oestrogen levels (thus resulting in a temporary deficiency) and to the action of prolactin (physiologically very high during pregnancy and breastfeeding) associated with the stress of the moment.

1.D - RADIATION ALOPECIA Scalp radiodermatitis can be due to radiation treatments necessary for therapeutic purposes (malignant tumours, etc.), to diagnostic tests, war events or accidents at work. Acute radiodermatitis, which is quite rare, can lead to temporary alopecia, while chronic radiodermatitis, which may occur even after 20-30 years and more from exposure to radiation, the scalp becomes dry and atrophic (thickness is reduced), there is a lack of pilosebaceous follicles and a presence of telangiectasia (permanent dilation of small superficial vessels of the skin), together with discolorations (variations of colour type and tone). Chronic radiodermatitis may also cause squamous cell epithelioma, even after many years.

1.G - POST-INFECTIOUS ALOPECIA It occurs during or after some specific diseases. The alopecia that occurs because of typhoid during severe fever causes, in general, anagen effluvium, while alopecia caused by less severe febrile illness, secondary syphilis, viral hepatitis and chronic infections, usually causes telogen effluvium.

1. H - MALNUTRITION ALOPECIA There is a direct relationship between nutritional status and the synthesis of hard keratin of the hair and nails. According to Rook, excessive dieting and unbalanced nutrition have contributed to the increase of alopecia and hypotrichia observed in recent years, especially in women. Certainly, an inappropriate diet can contribute to aggravate a situation which already exists, sometimes permanently.

1.E - TRACTION ALOPECIA

1.I - AMINO ACIDS AND PROTEINS

It is a quite common alteration and is the direct result of repeated and continuous hair traction: pony tails, braids, curlers, hair styling, perms, etc. In less severe cases, the damage is detectable only with a microscope, due to the presence, in the percentage breakdown of fallen hair after a wash, of anagen and broken hair, normally absent. In severe cases, however, a clinical examination shows already perifollicular erythema, pustules and slight scaling, as for trichotillomania, and, in the long run, it may cause irreversible damages. The areas most affected by traction alopecia, are those at the edges of the application, since that’s where mechanical traction is maximal.

Since there is a direct relationship between nutritional status and the synthesis of hard keratin of hair and nails, restrictive and/or poorly balanced diets may cause hair structural weakness and hair loss. The alterations of the hair bulb and the hair shaft occur when blood signs of protein deficiency are not yet evident, as if our body wants to save proteins for essential functions, and synthesis is not one of them. Blood tests, therefore, even if normal, do not guarantee the absence of protein deficiencies and minerals at the level of the hair.

1.F - TRAUMATIC ALOPECIA

It is characterised by telogen, or sometimes anagen effluvium. For example, in the past, alopecia due to thallium acetate, used to treat scalp ringworm, and contained today in rat poison (risk of accidental ingestion or suicide), was pretty common.

We must point out that all forms of iatrogenic alopecia regress spontaneously after discontinuing the medication, but here is a list of medications and substances

Physical traumas, such as burns or pressure sores can cause hairless areas. Sunburn or prolonged freezing, of course, destroy certain areas of the skin and hair follicles.

Follicles develop when we are already in an embryonic state, and their default

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number will be the same over the course of our lives. We can not spontaneously create new follicles, just as we can create new internal organs, although we are able to produce new hairless skin during the healing process. Long-term pressure simply stops the supply of blood to the skin, and follicle cells die “of hunger”. This type of baldness can occur when you are unconscious for a long period, such as during a surgery on the operating table. Surgeons and anaesthesiologists should always place the head of their patients in different positions during a surgery.

II. BALDNESS

parietal male alopecia are characterised by different dynamics, as if they were two independent forms, probably determined by different genes and not necessarily coexisting in the same individual.

1.J - IATROGENIC ALOPECIA (DUE TO MEDICATIONS)

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Boric acid, Nicotinic acid, Retinoic acid, Allopurinol, Anabolic steroids, Androgens, Arsenic, Bismuth, Bleomycin, Captopril, Cyclophosphamide, Carbamazepine, Cimetidine, Cytostatic medications, Clofibrate, Clomiphene, Clonazepam, Chloramphenicol, Chloroprene, Colchicine, Corticosteroids, Danazol, Dicumarol, Dietilpropionato, Dixyrazine, Heparin, Progestogens, Ethambutol, Ethionamide, Griseofulvin, Ibuprofen, Hydantoin, Imiprazina, Indomethacin, Iodine, Levodopa, Lithium, Mercury, Methyldopa, Methysergide, Metoprolol, Methotrexate, Carbon monoxide, Morphine, Naprossina, Nitrofurantoin, Penicillamine, Potassium thiocyanate, Probenecid, Procainamide Propranolol, Gold salts, thallium, Thiamphenicol, thiouracil, sulfasalazine, Verapamil.

There is also a form of alopecia caused by toxic substances contained in certain foods (mushrooms containing muscarine, cashews containing dicumarolic substances, large amounts of garlic etc.).

1.K - ALOPECIA AREATA After androgenetic alopecia, it is definitely the most “extensive” form of non-cicatricial alopecia. It is usually characterised by one or more roundish or oval patches, with an average diameter of 3-4 cm, with no hair or hairs, showing no alterations (sometimes there is slight and reversible atrophy of the epidermis) or clinical signs of inflammation (only in rare cases the skin may be pinkish and associated with non-serious forms of edema) and with preserved and apparently unharmed hair follicles. The scalp may appear slightly hypotonic (hyperlaxity probably due to the disappearance of the hair roots). At the edges of the patches, which tend to expand centrifugally, we find short and broken thin hair in the anagen phase (4-12 mm long), showing a dystrophic condition, characteristically increasingly thinned from the distal end (dark and swollen) toward the bulb (thinned and discoloured), called “exclamation point hair”. This is typical of alopecia areata and a consequence of an altered function of matrix cells. This hair can be easily removed with tweezers, because of the lack of root sheaths. Both the trichogram and the microscopic examination of hair fell after a wash show anagen dystrophic effluvium.

1.L - CONGENITAL ALOPECIA Alopecia and hypotrichia may have a genetic origin and, in this sense, also androgenetic alopecia can be included in this group, but there is a number of syndromes, which can be very similar to each other, which may cause, among other

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things, hypotrichosis or alopecia.

2.A Brocq Pseudopelade 2.B Scleroderma 2.C Lichen Planus 2.D Folliculitis decalvans 2.E Ringworm

2. CICATRICIAL ALOPECIA

2.A - BROCQ PSEUDOPELADE Brocq described a form of atrophic-cicatricial alopecia affecting many small areas, typically at the vertex of the head, characterised by a slow and progressive evolution in the absence of significant inflammatory phenomena and by white-ivory and hairless patches. Not infrequently atrophy save some hair within individual patches, which can be easily removed with modest traction. Both this hair and the hair at the periphery of the patches show, if removed, a translucent, gelatinous sheath, which can be more or less thick, covering a few millimetres of the root.

Who is affected by this disease? Pseudopelade affects mostly women aged 20 to 40 years and, while gradually expanding centrifugally, usually it does not lead to total alopecia.

2.B - SCLERODERMA

II. BALDNESS

whose use (and abuse) may cause alopecia:

Scleroderma , also known as Systemic sclerosis, is a form of chronic dermatosis, an autoimmune disorder, characterised by an insidious and slow transformation, restricted or diffuse, of the skin which looks like thickened scar tissue, with no wrinkles and with a colour similar to that of wax or alabaster. It may refer both to forms of localised, purely dermatological scleroderma, creating patches with clear edges, sometimes surrounded by a distinctive purple-red border, with self-limited benign course, and more extensive forms that have a progressive course where a non-severe form of scleroderma may affect the hands, chest and face, and then it spreads to adjacent areas. In its final stage, it creates a sort of “armour”, that makes joint movement difficult or stops them completely; later, also other organs are involved, such as the esophagus, intestines, lungs, heart, etc., often causing death.

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2.C - LICHEN PLANUS Lichen planus is a frequent rash characterised by the appearance of papules (abnormal cluster of cells) that: a) have a characteristic polygonal shape (3-10 mm diameter) and a red-purple colour (especially on the flexor surface of forearms and wrists, back of hands, genitals, lower limbs); b) become simple corns (or calluses) in the palmoplantar regions; c) turn into whitish papules, arranged as leaf veins, on mucous membranes (buccal mucosa, that is, inside of the cheeks), or rounded papules (on the tongue).

2.D - FOLLICULITIS DECALVANS Fairly rare disease, more common in men than women, especially in adulthood, it is initially characterised by follicular inflammation with pinhead pustules (small bumps on the skin with pus), located in correspondence of hair follicles, and later by the destruction of the follicles themselves with hair loss and the formation of round or oval patches of cicatricial alopecia, with pustules arranged at the periphery. Sometimes we find some pustules or some isolated follicles, within the patches.

3.A Trichotillomania

3. PSEUDO ALOPECIA

3.A - TRICHOTILLOMANIA Trichotillomania is an impulse disorder characterised by the compulsive urge to pull out one’s hair, which is difficult to diagnose and even more difficult to accept, especially for the parents of the patient. We are talking mainly of children that, more or less consciously, take the habit of twisting and pulling their hair with their fingers.

The term ringworm indicates the aggression of the hair by a fungus. Scalp ringworm occurs with one or more erythematous and scaly patches, in which the hair is broken and dusty. Depending on the type of fungus, we may have small individual roundish patches, with sharp edges and a diameter up to 5 cm, where the hair is cut off 2-3 mm above the root (Microsporum species); or we may find many patches with indistinct edges, irregular shapes and a width not exceeding 1-2 cm, with hair cut off at the roots, associated with other sporadic hair within the patch (Trichophytic species). The infection can be caused by contact with pets, farm animals, soil, other human beings. Ringworm, if properly treated, will regress in 4-6 weeks.

II. BALDNESS

2.E - RINGWORM

II.3 Description of Androgenic Alopecia Androgenic Alopecia is a common form of hair loss in both men and women. It is the most common form of hair loss and hair thinning, but it is also the most dangerous and dreaded form of alopecia, due to its false nature and to its slow progression: if not treated quickly, its progression will be irreversible.

Androgenetic alopecia is not caused by the little energy that reaches the bulb or by a lack of keratin etc. It is a progressive miniaturisation of hair follicles.

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For men, the severity of baldness increases with age, involving mainly the frontotemporal area and the vertex of the head, according to the Hamilton-Norwood Scale (fig. 43, we will discuss it in the next paragraphs).

In women, it affects mainly the crown, while it usually does not involve the hairline, and we can find three main forms of hair loss: diffuse thinning of the front crown and preserved hairline; thinning and expansion of the central part of the scalp; a third form shows thinning associated with bi-temporal recession.

The enzymes involved in the conversion and collection of androgenic hormones, are probably transmitted genetically, namely: the two isoenzymes of 5-alphareductase (type 1 and type 2), the P 450 aromatase and the cytosolic receptor of androgens. In men predisposed to androgenetic alopecia, hair loss can begin at any time after puberty, when serum levels of androgen grow, but it usually starts around 18 years.

There is another form of baldness, which is slower and starts around the age of 30, progressing slowly. If hair loss occurs later (around the age of 40 or 50), the evolution is generally progressive. Men who have few signs of hair loss after the age of 50 are less likely to become bald. In women, on the other side, androgenetic baldness starts around the age of 35, typically in the three stages proposed by Ludwig.

LEGEND I section

II section

IV section

V section

III section

fig. 43: Baldness according to the Hamilton-Norwood Scale

It might be helpful for you to know the eating habits of the person you are about to treat and the medications he or she takes, since may cause effluvium. Clinical evaluation is based on the examination of the scalp, that is usually normal in androgenetic alopecia but often shows a seborrheic dermatitis which is potentially an aggravating factor. There are some tests that can be performed to confirm the diagnosis of androgenetic alopecia, but androgenetic alopecia remains fundamentally a clinical diagnosis, whose guidelines provide essential information to the doctor for a rapid and correct diagnosis.

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Individuals affected by baldness do not to have different hormone levels. It is not about the amount of testosterone in the blood. What is important is the concentration, at the pilosebaceous level, of the enzymes necessary to turn the weakest androgens into more potent androgens, as well as the concentration of the androgen receptor. The presence or lack of this enzyme, both in men and women, or in different areas of the scalp, can cause different effects. The cytosol androgen receptor is present in the dermal papilla and in the pilosebaceous duct. Not all androgens have the same affinity with the receptor. Androgens that have greater affinity are, in order: DHT, testosterone, estrogens, progestins.

II. BALDNESS

Hormones are chemical messengers, carried by the blood and acting on the body, where they find receptors. They are produced and controlled by the endocrine system (pituitary gland, thyroid, parathyroid, adrenal cortex and medulla, insular pancreas, gonads or sex glands, namely testis and ovary, some also add thyme and epiphysis). Estrogens, on the other side, are steroid hormones with a feminizing action. Androgenetic alopecia is not caused by androgens, but by their genetic message.

The 4 major androgens are: • Testosterone; • DHT; • DHEA; • Androstenedione.

17-beta-estradiol the most important and powerful estrogen in women, and it is

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T 5aR

T T

T

5aR 5aR DHT DHT

DHT

ii.4 thE hamiltoN scale Dr. James B. Hamilton was the first to scientifically classify baldness, when he developed, in 1951, the first useful grading system to measure the extent of androgenetic alopecia, both in men and women (fig. 45). Hamilton examined 312 men and 214 women aged between 20 and 89 years and classified them into five stages: I

minor recession of the frontotemporal hairline with possible subsequent recession of the frontal hairline: it does not necessarily evolve into baldness;

II

further frontal loss and hairline recession, with a first involvement of the vertex region of the scalp;

III

the front and back region affected by alopecia tend to merge, leaving only a narrow strip of hair: at this stage, many people start to use a prosthesis;

IV

full-blown alopecia: frontoparietal and vertex hair loss, leaving only a crown of hair in the temporo-occipital region;

V

the last stage of alopecia.

II. BALDNESS

produced by the ovary and the placenta during pregnancy. It is converted by the liver into estrone and then into estriol. For men, DHT is the most important factor, while in women a major role is played by DHEA, produced by the adrenal glands in the amount of 95%, and androstenedione, produced by the ovary and adrenal glands (50% and 30%, respectively). These hormones have a weak androgenic activity and yet, at the peripheral level, some of them are converted into hormones which are characterised by a more powerful androgenic activity. DHT is toxic to genetically predisposed scalp hair follicles, and it is this hormone that turns vellus hair into terminal hair in adolescents. 5-alpha-reductase enzymes are abundant in the scalp, enough to promote the accumulation of DHT. The production of pigment decreases, so much to give the impression of a lack of hair. Actually there is no lack of hair, but it appears thinner and devoid of pigment. This reaction is probably responsible for the future “death” of the follicle; after a few years, follicles no longer produce terminal hair, but vellus hair, similar to that of infants: unpigmented, tiny and almost invisible hair. After a few more years, hair follicles disappear, then the hair will be definitely dead (fig. 44).

No hair loss is usually termed “Type I” Hamilton described it as “the absence of bilateral recession along the front hairline in the frontoparietal regions”.

It is therefore important to point out that a high hairline is not necessarily due to a recession, but is the result of genetic inheritance and family traits, therefore, it is to be considered as a normal condition.

fig. 44: The role of hormones in the balding process

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III

IV

II

III VERTEX

V

II.5 The Norwood scale In the 70s, Nordwood investigated the studies conducted by Hamilton in the 50s and created what is now known as the Norwood Scale of baldness (fig.46), adding stage IIIA, stage III vertex and stage IV a. Over 25 years later, Norwood improved this classification “to stage” androgenetic alopecia. The Norwood Scale is more detailed and analytical, enough to be considered as a reference model, but being an integration of the Hamilton Scale, it is called the Norwood-Hamilton Scale. This scale includes 7 stages, some of which are further fractionated, so as to obtain 12 possibilities.

I

While Hamilton did not include a so-called normal stage, the Norwood Scale did: stage I includes normal healthy subjects, with no problems.

II

It corresponds to Hamilton stage I, considering only minimal frontotemporal recession.

II.A

VI

III

It corresponds to Hamilton stage I, which means that the vertex of the scalp is not involved, but there is frontotemporal recession, which is more accentuated.

III.A

Like stage III, it involves frontotemporal recession, which is even more accentuated, but the vertex is still intact.

III

It is an extension of stage III. It combines stage III and stage IIIA with thinning vertex: recessed hairline and thinning vertex. It corresponds to stage II of the Hamilton Scale. Most men over thirty years suffer from III vertex alopecia which is, in my opinion, the most common form of alopecia.

VII

VERTEX

IV fig. 45: The Hamilton Scale

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Like stage II, but it is associated with complete hairline recession.

II. BALDNESS

I

Let’s start talking about the most problematic stages, which can also occur in relatively young age with a large strip of hair between the front

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II. BALDNESS

VA VII

It corresponds exactly to stage V of the Hamilton Scale.

VI

VI

IV A

It corresponds exactly to stage IV of the Hamilton Scale: the vertex will be so thinned that it has invaded the receding hairline. Only a thin line of hair remains at ear height.

V

VI

IV

Like stage IVA., with receding hairline, and a first involvement of the vertex. However, this is not a rule. Stage corresponds to stage IV of the Hamilton Scale, but is less accentuated.

III A

V.A

III VERTEX

Like stage IV, but more accentuated. It corresponds to stage III of the Hamilton Scale and then we have a further recession of the hairline and thinning is more visible.

III

V

II

Significant recession of the front hairline, involving also the virtual line, which is the one connecting the top of the two ears. If recession involves this line, well that is stage IV.A. This phenomenon affects the superficial area, since the temporal crown still has hair: not always there is thinning vertex, but the strip of hair is still absent.

I

IV.A

II A

and back areas affected by alopecia: it corresponds perfectly to stage III of the Hamilton Scale.

fig. 46: The Norwood Scale

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II.6 The Ludwig Scale Female-pattern hair loss was classified by Ludwig (hence the name of the relative scale, fig. 47), even though its evolution is much simpler than the male-pattern models seen in the previous paragraphs, since we have only 3 stages of development.

Ludwig divided arbitrarily female-pattern androgenetic alopecia into three species based on hair density, classifying the intensity of female pattern baldness from a less serious stage (type I) to the most problematic situation (type III).

Despite the fact that there is an increase in the number of women suffering from hair loss (probably related not only to hormonal and genetic factors, but also to environmental, nutritional and psychological conditions), stage III is very rare and only 5% of women suffering from problems of common baldness fall into this category.

I1

I2

I3

I4

II1

II2

III

ADVANCED

FRONTAL

Basing his studies on the observation of 468 cases, Ludwig developed the following scheme:

TYPE I

TYPE II

TYPE III

Noticeable hair thinning on the crown, limited to a line located 1-3 centimetres behind the front line

Accentuated hair thinning on the crown

Visible hair loss on the whole area affected by alopecia stage I and stage II

Female-pattern baldness (although it is not uncommon to see this kind of baldness in males) is characterised by a uniform thinning over the entire area at the top of the scalp, apparently leaving the front line intact: those affected by this type of baldness have hormonal levels and genetics that they are different from those affected by male pattern baldness (receding hairline and vertex thinning) and it could also explain why for those individuals whose baldness pattern is not the same of general male-pattern baldness, medical treatments solve the problem only partially.

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II. BALDNESS

Androgenetic alopecia seems to be common in women as in men. In women, a decrease in hair density can be observed especially during menopause and it may include also the recession of the bitemporal region. However, the adrenal gland undergoes changes in androgen production in women over fifty years and can have a role in this hair loss.

fig. 47: The Ludwig Scale

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CHAPTER THREE

HAIR TRANSPLANT

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I think it is absolutely essential that you stand out in this field, not just for your high professionalism, but also for the use of a specific terminology, which proves that you master the techniques and the relevant terms. Therefore, I suggest you to learn well both the technical terms below and their meaning and, if it can help you, to investigate them. Never underestimate the power and the crucial impact of a decent vocabulary.

1. BTH;

15. HT;

2. HAIRLINE;

16. TRANSECTION;

3. DONOR (DONOR AREA);

17. TRANSECTION RATE;

4. RECEIVING AREA;

18. SHOCK LOSS;

5. PUNCH;

19. HAIR MULTIPLICATION;

6. STRIP;

20. PLUG/PLUGS;

7. TRICOPHITYC CLOUSURE;

21. SCAR;

8. FUE/FIT/FUS;

22. BROW LIFT;

9. FU;

23. CROWN

10. GRAFT;

24. MID

11. PUNCH GRAFT/GRAFTING;

25. MID VERTEX;

12. MINI GRAFT;

26. HAIR IMPLANTS;

13. MICRO GRAFT;

27. FLAP ROTATION;

14. FOLLICULAR UNIT GRAFT;

28. SLIT.

1. BHT: Body Hair Transplantation (transplantation of body hair) is an experimental technique involving the transplantation of body hair instead of hair, collected with the FUE method. Some studies show that body hair, transplanted into the scalp, tends to take on the characteristics of the hair, increasing its maximum length and diameter. Success rates, however, seem lower than those of a hair transplant and hair grows more slowly.

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2. HAIRLINE: abbreviated as HL, it is the edge of a person’s hair, especially on the forehead, and rebuilding the frontal hairline means re-thickening this area to make it more visible. A receding hairline is often associated to hair loss and baldness.

3. DONOR (DONOR AREA): it is the area from which the hair is taken for transplant.

Usually, this area does not show hair loss, because genetically it is not affected by the effect of DHT. 4.RECEIVING AREA: the area where the hair collected is transplanted to the suffering from thinning hair/hair loss.

5. PUNCH: a circular scalpel used to extract individual follicular units with the FUE method. Currently, its diameter ranges from 0.5 mm to 1.3 mm.

6. STRIP: classic type of hair transplant. It is a hair transplantation method that involves removing a strip of scalp from the occipital area, which provides the hair to be transplanted into hairless or thinned areas. After removing a strip, the two edges of the scalp are brought together and sutured. This suture can cause a scar, which can be more or less thin, according to various factors. The hair, or rather, the grafts of the scalp that have been taken, are removed from the strip and transplanted. As for the scar, a good scar is 1-2 mm large, average scars are 3 to 5 mm large, while bad scars can exceed 5 mm. An average scar can be made invisible by leaving 1,5-2 cm of hair. This is the most performed technique and is capable of ensuring high rates of growth of transplanted hair.

7. TRICOPHITYC CLOUSURE: it is a new technique used to make the scars caused by the removal of the strip practically invisible, by overlapping the two parts of the strip, so that the hair will grow “inside” the scar, that will be then less visible.

8. FUE: English acronym for Follicular Unit Extraction. According to various surgeons who perform it, it can be called FIT (Follicular isolation technique), or FUS etc.

It is a more recent type of hair transplantation, which provides for the extraction of individual follicular units from areas of the scalp which are not affected by hair loss. Once removed, the grafts are transplanted into hairless or thinned areas, like in traditional hair transplant methods. The scars caused by this surgery are less visible than those left by the Strip method (although still depending on various factors) and almost invisible when leaving 3-5 mm of hair. This technique is much less invasive and has definitely many advantages, but is more expensive than the Strip technique (on average, twice the price), but the success of this surgery depends a lot on the skills of the surgeon. Usually the donor area is shaved.

III.HAIR TRANSPLANT

III.1 Technical glossary with comments

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10. GRAFT: it is the group of hair that is placed into the incision made by the surgeon into the area to be treated. Normally a graft corresponds to a follicular unit, but sometimes it is split to create more grafts, considering the FU. One thing to keep in mind is that usually the cost of a surgery is formulated according to the grafts inserted and not the follicular units extracted, both when using the Strip method and the FUE technique.

11. PUNCH GRAFT/GRAFTING: a circular graft with a diameter up to 4 mm, containing from 15 to 20 hairs.

12. MINI GRAFT: a circular graft with a diameter of 1.5 to 2.5 mm, containing from 5 to 10 hairs.

13. MICRO GRAFT: a graft with a diameter of 1 to 1.5 mm, which, however, did not consider the follicular units and resulted in low rates of regrowth.

14. FOLLICULAR UNIT GRAFT: the current grafts.

15. HT: hair transplant or hair transplantation.

16. TRANSECTION: is the damage caused to the hair “close” to the extraction area or close to the hair to be transplanted. The damages caused in this case are very often irreversible, since the structures necessary for the growth of the hair are physically damaged. In the case of the Strip method, the transection can occur for the hair close to the two cuts of the scalpel. While, for the FUE technique, the transection can “virtually” occur anytime there is an extraction, since follicular units are extracted individually and the neighbouring follicular units can still be damaged. The transection in the receiving area may occur as a result of “wrong” incisions, which damage the neighbouring hair. This only happens if thinned areas, and not hairless areas, are transplanted, since in the second case there is no hair to be damaged. This is one of the reasons why a transplant in areas which still have hair is more “difficult” than a transplant in hairless areas. However, there is a considerable risk reduction when these treatments, both with the Strip and the

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FUE technique, are performed by the best surgeons.

17. TRANSECTION RATE: percentage of hair subject to transection on the total number of follicular units transplanted.

18. SHOCK LOSS: this term is used to indicate the loss of indigenous hair following the trauma of a grafting procedure. It is more common when treating thinned areas and it is impossible to predict with certainty. The hair fell after shock loss, usually grows back, but its growth depends on its health. If the shock loss affects weakened hair, its regrowth can be more difficult. The fundamental difference between shock loss and transection is that as shock loss is not caused by an error of the surgeon and that does not result from a damage to the follicular unit.

19. HAIR MULTIPLICATION: often abbreviated as HM, it is a research field that deals with the study and development of products and methods designed to multiply the number of hair used to treat baldness. It does not uses single hair follicle grafting, but it uses some micro-injections of a cellular matrix derived from their cells (obtained with a biopsy) to induce hair regrowth.

20. PLUG/PLUGS: poorly positioned grafts that do not reflect the natural groups of hair inside the follicle and cause the so-called “doll effect”.

21. SCAR: a mark left on the skin or within body tissue where a wound, burn, or sore has not healed completely.

22. BROW LIFT: if old-style grafts (plug islands) are impossible to remove with the FUE technique without causing any damage (scar tissue) and I they have the wrong direction, or if the patient needs to recover all the plugs and re-use them, they use this technique (brow lift). It involves removing a small strip of skin (lozenge) containing the plugs or grafts to be removed, which are dissected, so that they can be immediately reused. Obviously this extraction leaves a scar on the hairline, that is sutured but, being in a stretch zone, it has a reduced width (typically 1 mm).

III.HAIR TRANSPLANT

9. FU: abbreviation of follicular units. A follicular unit is a group of hair that grows together. In adults, usually we have 1-4 hairs per group, that are taken and transplanted without separating them. But frequently, this does not happen, especially in the case of low availability of FU and you have to reconstruct the hairline (to create a more natural appearance). Dividing follicular units and transplanting them individually may result in a slower regrowth and reduced thickening.

23. CROWN: top.

24. MID: medium.

25. VERTEX: apex of the scalp.

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27. FLAP ROTATION: this technique consists in rotating the skin from side to side or in approaching of the two flaps.

28. SLIT: a fissure created by the surgeon to insert single follicular units or grafts.

III.2 The F.U.T. method The word F.U.T. stands for Follicular Unit Transplant. It got its name from a magazine published by a group of surgeons in 1998. Of course, this is not an obsolete technique, but it started with the molecular dissection performed by Dr Hillmer in 1988. The theory is quite simple. The hair from the back of the scalp is transferred to the front area. The hair transferred is genetically different. The procedure lasts a few hours, under local anaesthesia and is virtually painless. The Strip, a band of hair which will later be minutely cut, is removed from the upper part of the nape.

The scar, 1mm wide, is totally invisible, since it is hidden by the hair. If this operation is performed several times, the new Sliver will be extracted from the old scar. To cut the grafts more easily, the strip is divided into Slivers or bands with the help of a microscope. These Slivers involve a single row of follicles which are subsequently divided into grafts. Each micro graft is placed manually. The grafts will adapt quickly to the skin and will not come out when touched, already from the following day.

The hair will grow in the days following the surgery. Generally, the hair, including the bulb, starts falling from the tenth day and this often frightens patients. But there is nothing to worry about. In fact, the mother cells that produce the new hair, are always present in the scalp and ensure hair regrowth in about two or three months. The goal of a hair transplant should be to place the largest possible number of hairs in the smallest possible volume. Thanks to the cut under a microscope, the grafts prepared are very fine because the surface skin is eliminated, together with the fat present in depth and the tissue present between a follicle and the other. Patients should not wait to be bald to undergo a hair transplant.

It is common to see small scars at the base of each graft when surgeons use little sharp tools that destroy the tissues or, even worse when punches are used for the incisions. On the other hand, when the incisions are made with small sharp tools, the scar is invisible. As you can see, this technique is quite invasive, but to date, the F.U.T. method is still the best solution for baldness issues and is also considered as a golden standard and, therefore, the technique most used and discussed in hair surgery congresses (fig. 48).

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III.HAIR TRANSPLANT

26. HAIR IMPLANTS: a special implanter is used to hook the reversible knots made on natural hair of healthy donors or synthetic hair, which is covered by a substance used to protect it, and finally, the hair is shot into a specific area. This operation is carried out with a hair at a time and, of course, it is not a permanent solution. In addition, there are very few centres performing this technique.

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step 1: ANESTHESIA

fig. 48a

step 3: THE LOZENGE THAT HAS BEEN TAKEN

fig. 48c

step 4: APPLICATION (staples)

III.HAIR TRANSPLANT

step 2: SWELLING (tumescence)

fig. 48b

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fig. 48d

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step 5: SLIDERING

fig. 48e

step 7: ANAESTHESIA OF THE RECEIVING AREA

fig. 48g

step 8: CREATION OF THE SLITS ON THE RECEIVING AREA

III.HAIR TRANSPLANT

step 6: GRAFT DISSECTION

fig. 48f

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fig. 48h

79

step 9: GRAFT IMPLANTATION

III.3 The F.U.E. method The F.U.E. (Follicular Unit Extraction) is a minimally invasive method for restoring hair, which does not require the use of strips of scalp taken from the nape. So, it does not use any scalpels and stitches throughout the procedure and hair follicles are extracted one by one from the donor area (nape) and re-implanted with a single instrument. The F.U.E. method does not involve those procedures commonly known as strip extraction or hair plugs and therefore, there is no scalp cut or removal, and the final effect is much more natural.

I can say, based on my long experience, that the optimal density to be applied should be 50 FU/ cm2 and I also believe that, if this threshold is exceeded, the blood circulation will not reach all grafts and this would reduce the success rate.

Since the tools used are very thin, the FUE method leaves only some dots in the donor area, which are only visible at close distance: a person who has undergone hair transplant with the FUE method can easily shave his hair in the following years, since no one will notice the scars.

Tricopigmentation will give you the opportunity to treat people who underwent hair transplant with the FUE method, getting excellent results: you will be able to cover the scars of your customer almost completely.

III.HAIR TRANSPLANT

This method was called F.U.E. in early studies conducted by Masumi Inaba and Rassman in the mid-90s, when hair follicles were extracted one by one from the donor area with the help of extremely thin surgical tweezers. The diameter of the tweezers is chosen based on the thickness of the hair follicle to be taken, choosing between 0.7 mm, 0.8 mm or 0.9 mm. Since the extracted grafts are relatively thin, we have a greater density compared to the FUT method (70-80 FU/cm2). Since the dermal structures, which support the follicle, are thinner when compared to the FUT method, the percentage of regrowth in some individuals can be 10-15% lower (fig. 49).

fig. 48i

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81

step1: ANAESTHESIA

fig. 49a

step 3: EXTRACTION OF FOLLICULAR UNITS

fig. 49c

step4: CONTROL OF FOLLICULAR UNITS (divided by size)

III.HAIR TRANSPLANT

step 2: CREATION OF INCISIONS USING A PUNCH

fig. 49b

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fig. 49d

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step 5: ANAESTHESIA OF THE RECEIVING AREA

step 7: GRAFT IMPLANTATION

fig. 49e

III.HAIR TRANSPLANT

step 6: CREATION OF SLITS ON THE RECEIVING AREA

fig. 49f

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fig. 49g

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Scars are areas of fibrous tissue that replace normal skin after injury and are due to the proliferation of the dermis and epidermis. During the healing progress some alterations may occur: hypertrophy (hypertrophic scar) or atrophy (atrophic scar).

Hypertrophic scars are characterised by large amounts of tissue, which is always raised and sore, while in atrophic scars, there is not enough tissue and wounds, apparently healed, might reopen. Its shape reproduces the pathological process that caused it. The scar tissue is not identical to the tissue it replaces, and it usually has a reduced functionality.

Scars shall be treated according to their cicatrisation. That is why it is important to distinguish a hypertrophic scar from a keloid: in the second case, the surgical removal should be avoided. In any case, the only possible treatment for scars is cosmetic surgery.

Wounds can heal in three different ways: • for cutting wounds, the loss of substance due to soft tissue approximation is reduced to a minimum, which favours the filling by the granulation tissue, with rapid healing time and good aesthetic results; • in wounds that have not been sutured and, then, have been left open, for one reason or another, the granulation tissue, which is formed on the bottom of the lesion, is filled from the bottom to the surface, with a process that requires more time and that can cause even serious imperfections; • surgical wounds showing a partial or total dehiscence, in the post-operative course, shall be reopened and cleansed, and areas suffering from dehiscence shall be removed. Later, after assessing the local situation and after excluding the presence of foci of infection, the flaps can be re-sutured.

The healing process consists of a series of events aimed at the neo-formation of connective tissue, which will be different from the original tissue. This process is divided into distinct stages that, in some moments, may overlap, and are preceded by haemostasis.

1. Haemostasis is the local response to haemorrhage caused by the rupture of

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blood vessels, through the action of platelets and the activation of coagulation factors. This phase is characterised by the formation of a clot, a structure consisting of a fibrin network in which the corpuscular elements of the blood remain imprisoned, thus occupying the wound. This clot does not always stick to the walls and can be removed easily with minor injuries.

2. Inflammation is the typical response of the body to pathogenic attacks; in case of injury, it surrounds and eliminates microbial agents, any foreign bodies and necrotic cells, but it also activates those factors that are the basis of the subsequent proliferative processes and, therefore, it will repair or replace the damaged tissue. The inflammatory reaction starts immediately after the injury and lasts a few days, involving also the next phase.

3. The proliferation begins already a few hours after the injury and aims to replace the clot with a solid and final structure. It is characterised by the proliferation of epithelial, endothelial and connective structures present on the edges of the wound, that gives rise to the so-called granulation tissue, for its distinctive granular appearance.

4. Maturation corresponds to the stage where the wound, initially edematous and sore, is stably and permanently closed by a scar with very different characteristics: pale, smooth, inelastic, devoid of skin appendages, with reduced blood supply and innervation. This phase lasts at least three weeks, but sometimes it continues for months or years.

The process of wound healing may be affected by some local and other general factors.

III.HAIR TRANSPLANT

III.4 Scars

LOCAL FACTORS • Blood supply alterations: caused by a deficiency of the arterial supply or the venous drainage, due to general or local vascular diseases; • local diseases: such as skin diseases, ulcers and varicose eczema, infections; • presence of foreign bodies: consisting of dirt, splinters, fragments of tissue, but often also the materials used for sutures, which may be rejected by the body;

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• location and direction of the wound: skin wounds heal better if they follow some virtual lines and if they are not in contact with the bony prominences; • presence of large hematomas or serous collections.

do not produce positive effects, if systemic deficiencies are not corrected; • keloid, which is different from hypertrophic scars, since it is characterised by an overgrowth od scar tissue and is much more visible and disfiguring. The individual or family predisposition, gender (female) and age (youth) seem to play an important role in this case.

GENERAL FACTORS • age of the subject: wound healing is slower in older adults; • nutritional status and vitamin deficiencies: individuals with serious nutritional deficiencies, especially proteins, show a significant delay of wound healing;

KELOID

HYPERTROPHIC

ATROPHIC

• systemic diseases and special treatments: some diseases, such as diabetes, may adversely affect wound healing. fig. 50: Pathological scarring

Also, pathological scarring (fig. 50), may lead to: • hypertrophic scars, when the scar is reddened, hard, raised and sore. The causes are due to local factors and individual predisposition. The situation does not change over time and requires surgical treatments, namely the complete excision of the scar and the immediate reconstruction of the tissue with suture using inert materials; • atrophic scars, when the scar looks depressed, pale, is subject to ulcers and bleeds. This is mainly due to the general conditions of the body, rather than to local factors and individual predisposition. That is why, in this case, surgeries

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III.5 Costs of a transplant Generally speaking, we can say that prices may vary depending on the clinic and also on the surgeon chosen for hair transplant, and also on his team or collaborators. In addition, some clinics are more popular than others, and some clinics may offer a wide range of additional services compared to others (flight bonus, hotel accommodation, individual or shared rooms, the possibility to have an interpreter, etc.). The main clinics that perform treatments with the FUT and the Strip methods are located in Beverly Hills, Cyprus, Brussels, Toronto, Dubai, but also in Istanbul.

III.HAIR TRANSPLANT

From an aesthetic point of view, every scar, thanks to the maturation phase, improves its appearance over time to become almost invisible, even if often it is considered as a more or less visible imperfection. In some circumstances, however, the results can be objectively disfiguring. It should be specified that, indeed, some technical errors during the surgery or the use of unsuitable or improper suture materials, can cause abnormalities in the healing process of a wound, but there are other reasons, which are definitely more important, such as: a contamination of the surgical site, the nature of the pathology that generated the wound, general conditions of the body, treatments based on cortisone or antineoplastic agents, an individual predisposition.

I will try to be more specific about the fees charged for the surgeries performed both with the FUT and the FUE method.

As for the F.U.T. method (or Strip method, if you prefer), costs can be $5 US for the first 2000 follicular units (FU) and $3 US for any additional follicular units, plus 12% tax rates. Other clinics calculate implanted follicles, not those they have extracted.

In this case, the cost can be of about $ 4.5 for the first 2000 FU and $ 2.50 for any additional follicular units.

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While, as for the F.U.E. method, costs could vary from 10 dollars up to a maximum of 20 dollars per graft (FU), or clinics may apply a fixed cost of $ 2000, for the use of 200 FU. But, please consider that one session is not enough in most cases, considering that follicles die. To sum up, the greater the number of grafts employed, the lower the amount to be paid, so prices could be 2.50 EUR/graft with less than 1000 FU and 2 EUR when using more than 1000 FU.

CHAPTER FOUR

Dermopigmentation

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IV.1 Definition

formed on eyebrows, lips and the eye area, to harmonise a face and make it more attractive.

First, I would like to clarify that, when we perform a dermopigmentation treatment, we push, mechanically, some sterile pigments into the dermis with the help of non-hollow sterile needles.

Cosmetic dermopigmentation: these treatments try to solve aesthetic problems when medicine, and thus surgeries, can not in any way improve certain situations (Tricopigmentation may fall into this category, even though, it could also represent a separate category).

The word dermopigmentation includes at least three target groups (fig. 51): • Makeup dermopigmentation; • Cosmetic dermopigmentation;

As for the EQUIPMENT used to perform the different treatments:

• Artistic dermopigmentation.

cosmetic

artistic

fig. 51: Dermopigmentation macro-groups

These macro-groups are quite different, because: • They have a different purpose; • They use different equipment, products and colours; • Operators have different skills; • They have different pseudonyms.

But now, let’s take a closer look at these treatments, so that you can have the information necessary to distinguish them, also based on their specific purpose.

Makeup dermopigmentation, or permanent makeup: these treatments are per-

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Equipment used for Cosmetic dermopigmentation: a dermograph is the best tool an operator can use in this case. However, this device it is a hybrid, since it can also be used to perform makeup and artistic dermopigmentation treatments.

This device can reach up to 15.000 pulses per minute, but, of course, the widest its range, the higher its cost, which can vary from 1000 to 5000 euros.

Equipment used for Artistic dermopigmentation: these treatments mainly use electromagnetic coil devices, rotary devices and compressed air devices, as well as permanent pigments. This equipment costs about 500 euros, and usually it does not have a CE label, since there are mainly handcrafted devices.

And, as for the specific SKILLS operator should have to perform these three treatments: Makeup dermopigmentation skills: of course, operators should know make-up professional techniques, as well as cosmetic and hygienic procedures, as any person who wish to work in the field of aesthetics.

IV. DERMOPIGMENTATION

Equipment used for Makeup dermopigmentation: for these treatments operators use a simple permanent makeup pen, working with a much lower power output (it can reach about 6000 pulses per minute), and bioabsorbable colours.

Unfortunately, about 99% of the pens on the market, are manufactured in China and do not bear a suitable CE label. They cost about 500 euros.

Dermopigmentation makeup

Artistic dermopigmentation: a form of artistic communication, but also a tool through which customers express their feelings and moods.

Cosmetic dermopigmentation skills: in addition to the above, operators should attend specific training courses to have knowledge of possible infections, sanitary procedures and scientific findings.

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Artistic dermopigmentation skills: in this case, operators should have a steady hand, as well as artistic and drawing skills.

So what is the right pressure?

IV.2 The right depth and the consequences of a wrong depth

This paragraph is quite important, since depth is a crucial parameter. But you will see more specifically what are the mistakes to be avoided (just a few) and what happens whit a wrong depth.

As I mentioned, there are two mistakes that you can commit and then you have to avoid: excessive pressure or too weak pressure; the right pressure allows the needle to reach the dermis through the epidermis (fig. 52).

pressure TOO LOW

pressure EXCESSIVE

OK

If you exert too much pressure, on the other hand, there are two main reactions that you can trigger. If the needle reaches the subcutaneous tissue, the body will respond with a very violent reaction: you will see blood, a lot of blood, and this will dilute the colour. This will cause a scab and, once this scab disappears, also the treated area will be removed and, during the healing process, some alterations may occur, such as a hypertrophic scar. At this point, you will see a transparent line with discoloured edges (see hypertrophic scar, keloid, scleroderma). In this case, scars will be smooth, concave, but also convex: if you exert too much pressure, you may reach the subcutaneous tissue, and this will cause a raised coloured scar, very similar to a tattoo. These are the risks related to excessive pressure.

Some people believe that more pressure leads to a better colour definition and, vice versa, that low pressure leads to worse results. But nothing could be further from the truth. The risk is that you can seriously damage the tissue (scar tissue and sclerotised tissue). But you could do worse. You could use even more pressure and then there could be a massive migration of colour, conveyed by the subcutaneous fat layer located below (fig. 53).

IV. DERMOPIGMENTATION

If you exert too low pressure, the colour you are going to inject will remain in the epidermis and, as you already know, the epidermis regenerates continuously.

Let’s say that our skin changes and regenerates about every month, therefore, if the colour is injected into the epidermis, it will disappear quickly. Now, maybe you are wondering how you will recognise the right pressure to be exerted. It is simple: you will know that you are exerting too low pressure, because you will not see even a drop of blood, and, in this case, the colour will disappear with the first skin exfoliation.

fig. 52: Wrong pressure and right pressure

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terised, starting from the outside, by three layers of tissue: 1. epidermis; 2. dermis; 3. subcutaneous tissue.

fig. 53: Colour migration due to excessive pressure

IV.3 Timing of tissue healing after a dermopigmentation treatment

To make you understand the importance of tissue repair, we must first talk about skin and, therefore, its function. The skin is the outer boundary between our body and the environment: it acts a protection barrier from the outside.

The skin is a sense organ which communicates with the outside through touch, pressure, pain and temperature receptors. The functions of the skin are multiple, including the protection against penetration of pathogenic microorganisms, and its barrier effect against harmful external factors: mechanical, chemical and thermal dangers (traumas, thermal and chemical burns, cold injuries). The variety of functions of the skin is made possible by its anatomical structure which is charac-

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The epidermis, which is the top layer of the skin, is a stratified squamous epithelium, consisting of five differentiated cell layers and with a thickness ranging from 0.1 to about 3 mm according to the cutaneous areas. Regeneration occurs at the level of the deepest layers, from which the cells rise to the surface of the skin and, during this migration, a complete cornification of cells (keratinization) occurs, with the loss of their core. The upper stratum corneum is removed in a continuous flaking process. Under normal physiological conditions, the renewal of the epidermis, from cell division to the elimination of cornified cells, requires 3 to 4 weeks. The epidermis has no vessels and is nourished by the diffusion of nutrients from the dermis capillary bed. Keratinocytes are the predominant cell types in the epidermis, and, as suggested by its name, it is able to synthesise the keratin. Keratins are insoluble structural proteins with a high resistance to temperature and pH. In the epidermis, in addition to keratinocytes, there are also melanocytes, that are localised in the basal layer of the epidermis and that produce the skin pigment called melanin which, according to its quantity, determines skin and hair colour; melanocytes increase melanin formation through solar radiation as a defensive reaction to ultraviolet rays.

The dermis, which has a mesodermal origin, is located below the epidermis and is directly connected with the basement membrane of the epidermis. It is a connective tissue rich in vessels and nerves divided into two layers that are not delimited, but that have a different thickness and different connective tissue fibres. From outside to inside, there are two layers: the papillary layer and the reticular layer, the deepest and thickest layer of the dermis.

IV. DERMOPIGMENTATION

Skin appendages (hair, nails, glands), which are located in the dermis, are also part of the skin. The skin thickness varies from 1 to 4 mm in relation to the stresses on the different parts of the body: the palms of hands and soles of the feet are the thickest areas.

“Chronic wounds�, according to the international terminology, are those wounds that do not heal. Wounds can be classified into acute and chronic, based on the time it takes to heal: a chronic lesion is, in general, an alteration of tissue structure

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But, getting back to what we were talking about, after a dermopigmentation treatment, skin will first crack and this will to bleeding, since we are in the dermis (which is vascularised). It’s like the colour that covers the tips of the needles soils, somehow, the dermis that, not having regenerative properties with tissue renewal, behaves differently from the epidermis. Then, after an inflammatory phase, there will be a proliferative phase. The dermis will be soon very dark and dirty, as well as the epidermis, after a dermopigmentation treatment. After a few days, the colour that has been injected will undergo oxidation and there will be a small amount of blood, thus turning the colour (any colour) into darker brown.

The scab that will result from this process will remain there for a few days. Then, the epidermis and the dermoepidermal junction, consisting mainly of proteins, will start their healing process, with some surface protrusions, that will appear within the first week and quickly. In this time range, your customers will notice that the treated area is not homogeneous but, after a while, it will be definitely lighter and almost grey, until the epidermis will be totally clean, since it becomes opaque and, after a few days, the colour will reappear (around the third week).

stage1

stage 2

stage 3

after 50 days

stage 3

after 50 days

fig. 54a: Timing of tissue healing: side view

stage 1

stage 2

fig. 54b: Timing of tissue healing: top view

Please, remember that the colour that you will produce, will undergo changes.

There will be a colour migration, almost imperceptible, around the fourth week, but the timing will vary from skin to skin, and from person to person: that is why I suggest you to tell your customer he will need a second session, to be scheduled after 50 days from the previous one (fig. 54).

IV.4 The 3 basic manoeuvers To be more precise - and correct – in order to become a dermopigmentation specialist, you only need to learn three manoeuvers: 1. dot;

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that does not evolve towards the normal repair processes and that does not show any healing tendency within 6 - 8 weeks.

2. line; 3. filling/blending.

However, the most important thing, is that you learn how to draw dots and lines, namely, point 1 and point 2.

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DOT

LINE

Parameter no. 1: PULSE

fig. 55b: Line

FILLING/BLENDING

fig. 55c: Filling/blending

IV.5 The 5 basic parameters of dermopigmentation Before you start working on real skins, you need to turn your attention to all the variables that regulate the pigmentation of the dermis and that will allow you to perform the three operations described in the previous paragraph: • dermograph pulses; • hand pressure; • speed of execution; • points of penetration of the needles; • colour dilution.

Through the knowledge and the modulation of one or more parameters, you will get a considerable amount of effects: from background filling (homogeneous fills a given shape), to blending, the hair effect and up to sharp, precise lines and the sketch. But, let’s analyse these parameters together!

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Parameter no. 2: PRESSURE

When a needle penetrates the skin with a lot of pressure, it manages to get deeper and drags a greater amount of pigment into the dermis. If you analyse a single penetration (a small dot produced by a single injection) in on healed skin, you will notice that the highest column of pigments produces a dot which is much darker than a shorter column of pigments, which will be more transparent. The fundamental concept to understand is that it is not necessarily true that a higher pressure will produce a darker line. If you use too much pressure, your needle will end up in the hypodermis, causing significant bleeding, that will result in a considerably lighter colour. But you could do even worse. If your needle reaches the fat layer, there might be a migration of colour that, pushed under the skin, will expand producing a stain characterised by blurred edges.

IV. DERMOPIGMENTATION

fig. 55a: Dot

This parameter is related to the technical characteristics of the equipment used.

It is measured in beats per minute. A pulse is defined by the motion of the needle tip that goes up and down, to the starting point. The more the oscillations of the needle in a minute, the greater the power of the dermograph. At constant pressure, speed and penetration points, a greater number of pulses will produce a more intense and dark dot. But be careful because, if you increase the number of pulses too much and you speed execution is slow, you are likely to cut the skin, causing a scar that will heal very slowly and losing the colour injected almost completely.

This parameter should always be chosen according to your habits. If you tend to be hasty when tracing dots, you have to slightly increase the pulses of your tattoo machine. While, if you realise that your speed of execution is quite slow, you need to reduce the pulses of the dermograph. This parameter, as mentioned above, is directly proportional: the higher the number of pulses, the greater the power of your dermograph.

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Moreover, too much pressure can cause keloids or raised scars.

The correct pressure must at least allow the needle to go beyond the epidermis, but not to let it get in the hypodermis. Only if you remain in the dermis you can create all the shades of colour directly related to different depths. I guess you must be wondering how to figure out whether you have reached the right depth or not. Excessive pressure, as already said, will cause excessive bleeding. This tells you that you are using too much pressure. Once you trace a dot, the bleeding should stop once you cleanse the treated area. Another element that will allow you to understand if you’re going too deep, is the vibration perceived by the other hand, the one stretching the skin. If the vibration is too deep, dull and muffled, the pigmentation is going too deep. On the other hand, if the vibrations are more perceptible and accompanied by a shrill and acute buzz, you’re probably working on the surface.

Finally, I want to point out that the pressure of your hand (HP) is a different from the depth reached by the needle (NP); these two parameters are functionally related to the penetration points (POP). The mathematical formula that governs this relationship is: NP =HP÷Pop Considering that the depth reached by the needle coincides with the writing power, it is easy to see how, with the same points of penetration, if the pressure of your hand increases, the writing power will increase too, thus producing a darker line: the pressure of your hand is directly proportional to the writing power.

Parameter no. 3: SPEED

This parameter indicates the time that our hand takes to cover a given distance, with the dermograph. Drawing a line at a constant speed, at constant pressure, we get a homogeneous line (segment). The same line, drawn with a certain acceleration, causes a degradation of the colour that is proportional to the instantaneous speed reached, thus creating a soft line. Basically, you must understand that the speed used to trace lines or dots, is inversely proportional to the writing power. If you are hasty when drawing lines or when blending or filling the treated area, you will inject enough colour. At first, you will tend to be fast, but, with time, you will understand that the skin should be pigmented slowly and effectively.

Parameter no. 4: POINTS OF PENETRATION

This parameter indicates the number of needles used to perform a dermopigmentation treatment. The higher the number of needles (POP) and the lower the covering effect, namely the depth reached by the tip itself, for the same principle expressed in the pressure paragraph, according to which the depth of penetration of the needles (and thus the writing power, NP) is inversely proportional to the contact surface, then to the number of needles of a tip: NP=HP÷Pop It is the same principle that climbers use when using rackets, mounted on the shoes, not to sink in the fresh snow. If they were wearing stiletto heels, they would not go very far.

IV. DERMOPIGMENTATION

Conversely, if the pressure is not sufficient to penetrate the needle at least beyond the dermoepidermal junction, the colour will completely disappear after about a month.

I will give you an example of the application of this formula. Let us assume that I’m drawing a line at a constant speed, and I am using a hand pressure (HP) equal to 30. The dermograph is working with a 5-needle tip. Then, HP = 10 and Pop = 5.

With the division we have: 30 ÷ 5 = 6.

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Therefore, NP is equal to 6, which means that the depth reached by the 5 needles, and then the writing power, is equal to 6. If we change later the tip of our dermograph, and we mount a 3-needle tip, always using the same pressure equal to 30, the formula would become: 30 ÷ 3 = 10. This means that the depth reached by the needle will be equal to 10, which is also the writing power.

If we compare the values we discover that, with the same hand pressure, using a 5-needle point, the writing power will be equal to 6. While, with the same pressure, but with a 3-needle point, the writing power will be equal to 10. So, with a 3-needle tip, my line will almost twice darker than a line traced with the same pressure but with a 5-needle tip.

You should know that I tried to explain these principles using some examples, but things are not that easy actually the calculation is a bit more complex, but the concept does not change.

IV.6 General rules of dermopigmentation During my training courses, I had the chance to observe many experienced operators and, very often, I realised that, despite their experience and the excellent results they achieved in permanent makeup, they were often complaining about the great physical effort required to maintain certain positions while working: flickering lines, poor definition of the hair. They also told me that some of their eyebrow permanent makeup treatments showed deep tonal differences between the right and the left side. Why this happens? For one reason: our posture. Unfortunately, too often we do not give due importance to this issues. Indeed, most of the training courses do not address the issue of how to recognise the correct working posture.

A good dermopigmentation specialist knows what is the most comfortable working posture when drawing a line.

Parameter no. 5: DILUTION This parameter defines the percentage of the excipient used to the detriment of the functional principle, namely the mixture of pigments, and it is crucial when it comes to blending. This will result, with the same pressure, speed, pulses and penetration points, in a greater transparency. By diluting the colour with a colourless excipient, you will get very transparent shades. You can also use another colour to dilute the basic colour, but in this case we are “cutting the colour”, which means that we are using this parameter to get a particular effect.

The mental effort required to watch and process an image in perspective is greater than the mental effort required to watch the same image from an front-orthogonal viewpoint. Already in the design phase, if you are working on eyebrows, you should work behind your customer. Because, in this way, the eyebrows are placed on an equal geometric level, and it will be much easier for our brain to notice the differences.

Actually, during the design phase, you should change various positions, often turn around the customer, ask him to stand up, so as to have a front view, and to perform micro-movements, you should change mirrors and lighting conditions.

In short, at this stage it is not essential to work from behind, but I recommend it anyway.

IV. DERMOPIGMENTATION

Most operators keep wondering: “Should I work behind or next to the customer?”.

I suggest you to sit behind your customer (head of bed). And I’ll tell you why.

However, it is important that you work behind your customer (that is lying on the bed) when performing the real dermopigmentation treatment. Only in this way you will be able to hold the dermograph and maintain the same position, both when you are working on the right side and on the left side. But there is more.

We have seen that our brain struggle to find differences on a pair of objects seen in perspective, so can you imagine how difficult it can be to modulate the same pressure (left-right), considering that we will have visual references that different

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from each other? In short, we need to facilitate the work of our brain, and a good way to do that is asking it to perform the same movement twice, and not to perform two identical actions at two different times.

Below is a step by step description of the working postures required during a dermopigmentation session.

WORKING POSITIONS How can we improve the technical result of a dermopigmentation treatment?

First, you should know that if you have just started this activity, you can not expect that your result will be impeccable. There is something called experience which has the power to improve everything we produce, but there are also many small things that can improve your results and your skills. Your working posture is undoubtedly one of these small things not to be underestimated.

And by working position, I mean: • your position taking your customer as a reference; • the position of your hands on the face or on the head of your customer; • the position of the equipment and furniture around you (e.g. the height of your chair or of the bed. The size and the position of the magnifying glass. power cables of the dermograph, etc.); • your posture while performing the treatment.

So, let’s say that: • when you work, you should be sitting; • you have to work behind your customer (head of the bed); • if you are right-sided, the trolley with the dermograph should be located on your right; • your feet should touch the floor and not hooked to the stool; • you should be sitting with your legs spread, not crossed; • your forearm should always find a point of support; • precision lines (hair and contours) are always drawn toward the centres of your chest;

CHAPTER FIVE

Equipment and special products

• your wrist, if possible, should never be folded.

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V.1 How important it is to use specific equipment Although many operators perform scalp micro-pigmentation treatments, you should keep in mind that micro-pigmentation is a generic discipline, that is why you should not perform Tricopigmentation treatments with the same machines, needles and colours used for micro-pigmentation and permanent makeup: it would be quite risky and the results obtained, obviously unnatural.

If today there is an integrated system specifically designed for performing scalp treatments, it is because, over the years, with research, experimentation and passion, I became aware of the fact that adapting permanent makeup techniques and equipment to scalp treatments was not the best move, also in terms of final results. That is why a whole set of techniques and equipment was created for Tricopigmentation.

Tricopigmentation treatments are quite different from scalp micro-pigmentation. The Tricopigmentation system includes:

V. EQUIPMENT AND SPECIAL PRODUCTS

• a specific hair dermograph (a special tattoo machine), which is a modified patented system for the reduction of the duty-cycle capable of ensuring a very low risk of spots on the skin, but capable to write on scars, even on sclerosed tissue (fig. 56); • a specific machine unit containing a microchip that manages the pulse power through electronic control and equipped with programs which have pre-set parameters specifically for the treatment of scars and hairlines, for a safer and less risky work session. DERMATOPPIK and BOUNCE® programs are also available; • special cartridge needles, specifically designed for use on the scalp: they are totally different from those used for micro-pigmentation and permanent makeup treatments, since they are 15% thinner and have a modified tip to prevent the enlargement of the single dot in the shaved effect; • specific pigments chemically modified to ensure colour stability over time and dramatically reduce the possibility that colours turn red. These colours are very different from those used for permanent makeup, both for the excipient and the functional principle. Within these pigments there is a special patented fig 56: Specific hair dermopgraph - Morelia Plus

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• specific know-how, which is the result of my long experience and my partnership with Toni Belfatto. In fact, training courses, addressed only to operators with proven experience, aim to train operators, also from a cultural, not just from a technical point of view, for what concerns baldness and hair transplants.

The best strategies to treat FUT or FUE scars, prosthesis wearers or individuals affected by androgenetic and universal alopecia areata, are just some of the issues discussed during the training course.

Tricopigmentation is the ultimate solution for all these problems. Practicing scalp micro-pigmentation with improper needles and machines, and without the right skills, greatly increases the risk of having problems.

This disciplines requires specific skills and equipment, and be and my business partner are the only ones who have created a specific system for the treatment of hair loss and scars. In the future, we will still be the first ones who have designed a whole set of rules and techniques.

V.2 Suitable and unsuitable colours To be able to choose the colour to use to in your treatments, you have to know the composition of permanent makeup colours. A small vial of colours contains: • pigment mixture; • glycerin; • isopropyl alcohol; • water.

Bioresorbable colours are different from permanent colours, mainly because they do not contain acrylic resins and for other secondary factors. Bioabsorbable colours disappear completely after a specified period after the treatment, although this is not entirely true; it depends on many factors, so I suggest you not to be specific about the duration of the colour injected in the skin. It is better if you mention only “periods of time”, without being too specific.

PIGMENT MIXTURE Each colour used for Tricopigmentation treatments, is like a “cocktail” of key components and some also have a special corrective component. The key components are: black, white, red and yellow (fig. 57).

V. EQUIPMENT AND SPECIAL PRODUCTS

additive, which greatly improves the stability of the substance in the skin and reduces colour changes related to the enlargement of the dots (mega-dots);

fig. 57: Key components

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Since yellow and black are the first to disappear from the skin of your customer and, considering Green, namely chromium oxide, is a very stable chemical component that is not so easily swallowed up, as much as red is the colour that can neutralise it, turning it off and turning it into grey (the neutral colour par excellence, fig. 58).

That is why creams for Rosacea and Couperose are all basically green: by adding a small amount of green in the pigment that most of the colours have small quantities of white and that red is the most long lasting component, colours are more likely to turn pink/red. Mixture, it is possible to prevent the colour from turning red. This is because the chromium oxide is persistent enough to compensate for the disappearance of yellow and black. The price to pay for this “anti-red insurance”, however, is that, by adding green in advance, we will get an initial cold brown, greyish shade.

fig. 58: Neutralisation of red

EXCIPIENTS: GLYCERIN, ISOPROPYL ALCHOOL AND WATER Excipients are used for conservative and technical purposes. Isopropyl alcohol helps to avoid the formation of foam during dermopigmentation and to maintain a low bacterial charge. Glycerin performs a lubricating and softening action, retards evaporation and provides the preparation with a viscous and dense component that helps the colour to flow better into the needle. Water, of course, makes the preparation liquid and flowing.

LEGEND

black white red

You may think that a warm brown and reddish shade is better. But I assure you, on a shaved head in the world, every colour will look greyish on the scalp.

yellow grey orange purple green pink light yellow

V. EQUIPMENT AND SPECIAL PRODUCTS

The corrective component of Tricopigmentation colours is green. Each coloured component consists of a powder of micronized mineral pigments until they reach a size of the single grain that goes from 5 to 10 microns. These small grains are insoluble and, once released into the dermis, they will be swallowed up by “garbage collectors” of our body, called phagocytes. Black, red and yellow are iron oxides, white is a titanium dioxide and finally, green is a chromium oxide. Unfortunately, every component, once pushed into the dermis, has a different persistence, resulting from the relative stability of the molecule. In fact, the individual components will be “eaten” by phagocytes, following a precise order. This mechanism, in colours not specifically designed for Tricopigmentation, could create an important imbalance, which will result in a noticeable colour change. To be more specific, these four components tend to disappear in this order: yellow, black, red and finally white.

fig. 59: MP4E Reference system

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CHAPTER SIX

Tricopigmentation速

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VI.1 The current situation: analysis of errors due to improvisa-

1. pressure

tion Pressure is one of the most common mistakes: exerting too much pressure when creating the “dots” with the dermograph, causes a colour migration and, therefore, the enlargement of the edges of each single “dot” (fig. 60).

Tricopigmentation is a specific discipline and a real profession that was born as a result of the current situation: today, there are many operators who approach the world of dermopigmentation for issues strictly related to baldness, but often with no specific skills and without attending qualification training courses. This attitude, which is quite unprofessional, leads to risky moves and bad results.

There are mainly eight errors that lead people to think these are not reliable treatments: 1. presssure 2. movement 3. tilt 4. pulse 5. bounce distances 6. area delimitation

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7. hairlines 8. colour Let’s see these errors individually, to better understand and to try to avoid them.

fig. 60: Pressure error

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2. movement

3. tilt Errors due to the wrong tilt angle of the needle cause some strange, irregular bounces. The ideal angle for the penetration of the needle, in fact, should be 90째 and, therefore, perpendicular to the treated area (fig. 62).

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If there are some fluctuations of the needle within the dermis, both involuntary and voluntary, our movement it is not correct; they may be involuntary when the operator is not able to maintain a steady hand, and then the needle moves too much, thus impairing precision. They can also be voluntary, when the operator mistakenly believe that the end result can be immediately visible. So, they draw immediately more visible dots, with some extra movements, overlooking the fact that these dots will change over time (fig. 61).

fig. 61: Movement error

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fig. 62: Tilt error

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4. pulse

5. Bounce distances This situation results from wrong evaluation of the operator. An excessive distance between a bounce and the other, generates an unnatural effect, as well as a reduced distance. It would be more appropriate to observe the P.P.C. (dots per cm2) more suitable to the treated area (fig. 64).

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If you choose to work with a high number of pulses, you can create mega-dots: the needle fluctuates too much with a single bounce, thus creating a huge stain (fig. 63).

fig. 63: Pulse error

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fig. 64: Bounce distance error

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6. area delimitation

7. hairlines When an operator chooses how to draw the hairline, or the hairlines, he should avoid lines that are too sharp and improbable, since the final result could be very unnatural (fig. 66).

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Blending is an important part of a well-performed treatment. If you skip this passage, you can cause a clear gap between your “artificial work� and the natural progress of thinning, especially if there is advanced baldness (fig. 65).

fig. 65: Area delimitation error

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fig. 66: Hairline error

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8. colour

VI.2 The Bounce technique One of the basic techniques used for Tricopigmentation treatments is called the Bounce technique (Bounce®).

Errors related to colour are closely related to the choice of the colour preparation used to perform the treatment. The colour to be used must be chosen very carefully, based on the colour of the surrounding hair, customer expectations and on each single situation, which is different from all the other situations (fig. 67).

It is an implementation of the old techniques already used for this purpose.

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The same manual skills and operating parameters were revised and improved to create a real operational protocol which is called, as already mentioned, Bounce®.

The dynamics used to create the so-called “dots”, probably evokes the movement of an acrylic ball, both for its random movement and also for the time it takes to perform it. That is why I decided to call it the Bounce technique (Bounce®), which is now a registered trademark (I learned my lesson!) (fig. 68).

fig. 68: Bounce

fig. 67: Colour error

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The basic principle of this technique is a correct movement that is guaranteed, substantially, by these working parameters (fig. 69):

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USING THREE FINGERS

USING TWO FINGERS

1

use of a single tip needle

average pulse rate

average speed

average pressure

brow/dark grey colour

fig. 69: Bounce - working parameters

and by some fundamental factors, such as: • a correct working posture of the operator; • a correct stretching of the treated area (fig. 70); • pace of work;

fig. 70: Stretching the area to be treated in the right way

• a suitable movement of the needle; • a specific pulse rate; • the right p.p.c. (as already mentioned above, this acronym indicates the number of dots per cm2 and this value must always range between 90 and 120 dots, fig. 71);

80 ppc

90 ppc

100 ppc

110 ppc

120 ppc

130 ppc

• other factors discussed during specific training courses, designed to train operators to work in this field.

The development of these considerations and the detailed study of certain dynamics, led to the creation of a working system capable of producing a realistic shaved effect, with less chance of colour change or colour migration, which were both pretty common with the application of old working methods and which are still related to a lack of professional skills: if the operator does not take into account the importance of these factors, the risk of jeopardizing the end result becomes very high and almost certain.

A realistic and natural dermopigmentation treatment shows some punctiform micro-deposits of brown/grey pigments, located in the superficial dermis at a suitable distance from each other. This will generate a shaved hair effect or a darkening of the thinned areas, depending on the application of the techniques employed.

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• specific pressure,

fig. 71: The p.p.c. value (the number of dots per cm2) must always range between 90 and 120 dots

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VI.3 The Short Hair technique

DOUBLE SHORT HAIR TECHNIQUE When using this techniques, the dermograph moves in two directions and ways, back and forth.

The short hair technique is a crucial manoeuver in Tricopigmentation and is mainly used to cover scars due to F.U.T. and F.U.E. hair transplant. It is also used for Dermatoppik techniques. This is a manoeuver that aims to create a small hair with a length not exceeding 8-10 mm, and it can be performed using two techniques: • Single short hair technique

These are the working parameters of the double short hair technique (fig. 73):

• Double short hair technique

7

use of a seven-tip needle

SINGLE SHORT HAIR TECHNIQUE

1

fig. 72: Single short hair technique - working parameters

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SINGLE SHORT HAIR

DOUBLE SHORT HAIR

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CLASSIC STROKE

low speed

medium to high pressure

The peculiarity of this technique is that more pressure is exerted in the central part of the stroke and, conversely, lower pressure in the initial and in the final parts (fig. 74).

These are the working parameters of the single short hair technique (fig. 72):

medium to high pulse rate

medium speed

fig. 73: Double short hair technique - working parameters

This technique involves a one-way movement of the dermograph (single movement), towards the heart of the operator.

use of a single tip needle

medium pulse rate

medium pressure

fig. 74: Short hair differences

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The single short hair technique should be used when treating a particularly damaged scar tissue (concave and/or emptied and/or soft) or a vascularised tissue (reddish skin): in other words, when you have to treat areas predisposed to colour migration.

medium pulse rate in the double short hair technique; 5. pressure, both in the single and in the short hair technique, is medium to low; 6. the movement of the needle going in and out, resembles the motion of a plane that lands and, immediately after, takes off again: I mean that the movement of the needle should be soft and necessarily gradual (fig. 76);

fig. 76: Metaphor for the movement of the needle going in and out fig. 75: Short hair: the tilt angle of the needle must range between 30° and 45°

Please, consider that:

VI.4 Timing and block diagram of a Tricopigmentation treatment

1. you should use the double short hair technique when treating convex, but not necessarily hard and full scar tissues. Moreover, this technique is crucial when it comes to the pigmentation of light areas (skin colour);

3. one of the most important factors, when performing this technique, is the tilt angle of the needle which must necessarily range between 30° and 45° (fig. 75);

If you want to work in this field, I think you should know the chronological evolution of Tricopigmentation treatments and that you are able to explain it to your customers: only in this way you won’t disappoint their expectations. A first consultation is necessary, both for strictly technical and for legal reasons. In this regard, informed consent, that will be discussed in the next paragraphs and that should be signed shortly before performing the treatment, must contain the following statement:

4. we have a medium to high pulse rate in the single short hair technique and a

“Besides being sufficiently informed of all possible risks associated with this practice, I recei-

2. finally, the short hair is the manoeuver that will allow you to perform the Dermatoppik technique;

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7. with the single short hair technique, we have a medium speed of execution, while in the double short hair technique, we have a medium to high speed of execution.

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ved detailed explanations of undesirable phenomena, such as the rejection of the pigment; abnormal scarring; migration of pigment under the skin, that may also cause excessive deposits of colour (small dark spots), and finally pigment colour changes over time”.

Your customer should have the time to decide whether to undergo the treatment or not; if your customers decide not to undergo the treatment and to terminate the relationship, you have not considered this possibility, there will be an annoying gap in your schedule. That is why I suggest you to give your customer the time to decide what to do after the first consultation.

the case maybe talk to your business partner, if you have any doubts. You will need to examine the pictures you have taken and also the information gathered during the consultation. During this period, you could also get the supply you need to perform the treatment, maybe a specific colour that is not easy to find.

And your customer will have the time to clear his head and decide what to do.

FIRST SESSION

It lasts about 30 minutes, during which you will illustrate the generic aspects of dermopigmentation (possible allergies, rejections, infections etc.), but you will also give your customer more technical information: • you will explain your customer that the result obtained between the first and the second session is not the final result, so they could see something they did not expect. Always remember: “no expectations, no disappointments”; • you should take some pictures, so you can better study the whole situation; • you should run a colour test; • you will prepare a detailed estimate that your customer will sign, if he decides to undergo the treatment; • you will gather as much information as possible, so that you can have a full medical history of your customer: this information will be collected and stored in the project file; • you could send your customer some pictures showing treatments similar to the one he has requested, so that he can see the possible final result; • you should offer free consultations; • then you will schedule an appointment for the first session of treatment.

PERIOD BETWEEN THE CONSULTATION AND THE FIRST TREATMENT SESSION I suggest you not to schedule the first appointment before three weeks after first consultation; this is because, during this period, you will have the time to study

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PERIOD BETWEEN THE FIRST AND THE SECOND SESSION This is a quite delicate and important moment in the management of Tricopigmentation treatments. Most likely your customers will contact you to ask you some questions, many questions. He will have many doubts. He will be worried.

However, he will definitely contact you to update you on the progress of the healing process: between the first and the second session, the treated area will be characterised by several visible changes, already mentioned in your memorandum (delivered to your customer during the first session). You’ll have to be very patient and helpful, in answering the questions of your customers. I suggest you to ask him for some pictures, so that you can see and better control the progress of your performance.

VI. TRICOPIGMENTATION

CONSULTATION

The first session will last about 2 hours for each section treated, while, for the shaved effect, you will need about an hour and a half. But, first of all, your customer will have to sign informed consent: do not forget about it! Before starting, you will explain your customer what you are going to do: the kind of pain or sensation he is going to experience, the length of the session and the possible breaks you are going to take during the session and, for the shaved effect, you will have to decide, together with your customer, the type of hairline to create. Then, your work sessions can finally start. Once the session is over, you will need to give your customer the memorandum containing all the information and indications to take care of the treated area, once at home and you will also schedule a second session, after about 50-60 days, and you will ask your customer to pay a deposit for his second session.

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SECOND SESSION

POST-TREATMENT HEALING TIME

Considering that the second session will last about an hour and a half for each section, while for the shaved effect will need about one hour to cover the scars, I suggest you to schedule the appointment so that you can have enough time to do everything. The first thing you should to is taking a picture of your customer, so that you can evaluate the situation and the reaction of the skin of your customer.

After a short conversation aimed to clarify all these aspects, during the second session you must carefully assess the reaction of the treated area, in order to decide if need you change your strategy. Once the session is over, you will tell your customer that you will meet again after 12 months, since the treatment needs to be reinforced.

The most recurrent questions on post-treatment are always about recovery: “Can I go back to work the day after the treatment?” or “How long will the redness last?”, or “Can I drive after the treatment?”.

Use the diagram shown in figure 77 during your consultation so that even your customers will have a better idea on the timing of the treatment.

In fact, this treatment is much less invasive and painful than you may think. Immediately after treatment, the area shows a redness due to inflammation of the treated tissue. Such redness will take at most 48 hours to regress, but in most cases it disappears after 24 hours. Obviously, in order to accelerate this healing process, customers are asked to apply specific soothing ointments, recommended by the operator. Once the redness is gone, the treated area will be more clear, less opaque than expected and each single “dot” will be slightly darker than it will be in the future, as well as with more defined edges. This first situation is just temporary. It corresponds to the first period of the healing of the skin after the treatment.

Before the skin heals completely, each single bounce will become more clear at the beginning (sometimes very visible) and, finally, slightly darker. Once the healing is over and the tissue is repaired, the second period, with the adjustment of the pigment in the dermis, will begin.

50/60 days 30 minutes consultation

2/6 hours 1st session

8/12 months 1/4 hours

2nd session

I treatment

8/12 months 2/6 hours 1st

2/6 hours

Although the treated area may seem completely healed after about a week, actually tissue repair is still ongoing. This process may last up to a month and will end with re-epithelialization and subsequent greying of the colour used. Once this healing process is over, punctiform micro-pigment deposits will settle expanding their edges (each single bounce will fade, thus losing definition), and therefore their diameter, with a consequent increase in the total coverage of the treated area. This second phase, called adjustment, can last up to two months.

That is why a second session should be performed after about 40/60 days. If the second session is scheduled earlier, the risk is that we will darken an area that will probably darken anyway, creating an unnatural dark spot.

VI. TRICOPIGMENTATION

DIFFERENCES BETWEEN THE ADJUSTMENT PERIOD AND THE HEALING PERIOD

2nd

reinforcement

reinforcement

II treatment

III treatment

Basically, the result of a Tricopigmentation treatment session, should be assessed only after about 2 months. You should not consider the initial changes you could notice throughout the adjustment period. Do not be in a rush to see the final result, because this could be very dangerous.

fig. 77: Block diagram of the timing of a treatment

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VI.5 The Shaved effect technique

it comes to more serious forms of baldness, it’s definitely more difficult to determine its position. In order to solve this specific problem, you could use the rule of the four fingers. This system should be used only in these specific situations. But what is it? You just need to put your hand on the forehead of your customer, but starting from the eyebrow hairline; the hairline will start at the edge of your fingers, without being too strict.

In this paragraph I will discuss the technique most used in Tricopigmentation which is also the highest expression of the Bounce technique: the shaved effect.

Below, you will see how in Tricopigmentation the head is divided into sections.

Therefore, we are going to use the BounceÂŽ technique.

These are the working parameters of the shaved effect technique (fig. 78):

use of a single tip needle

medium pulse rate

medium speed

medium pressure

VI. TRICOPIGMENTATION

1

brown/dark grey colour

fig. 78: The shaved effect technique - working parameters

first section

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It is about 5 cm long and it is located behind the hairline. It is probably the most required treatment, when it comes to the shaved effect, since it is one of the areas most affected by baldness, showing a receding hairline. When we are treating a thinned area belonging to phase 1/2 of the Norwood Scale, we can get an idea of the old hairline point by observing the hair present on the area, but, when

fig. 79: First section

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About 5 cm wide, it is often the last affected area.

You will determine it with a top view of the head of your customer: it is the area that connects the two ears (fig. 80).

third section

It covers the apical area of the skull, that is the vertex the head: this section has a circular and rounded shape (commonly known as the “tonsure�, fig. 81).

VI. TRICOPIGMENTATION

second section

fig. 80: Second section

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fig. 81: Third section

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To locate it, you have to stand behind the head of your customer and identify the area in the shelter of an imaginary line joining the two ears. Treating this area means treating severe alopecia, corresponding to the seventh level of the Norwood Scale (fig. 82).

fifth section

This area, even when affected by alopecia type 7 of the Norwood Scale, still shows some hair. I’m talking about the nuchal region near the ears; only if your patient is affected by alopecia universalis, which is fairly rare, you will have to treat this area. The fifth section more extensive than the four others, which are quite homogeneous. It will take twice the time to treat this area, and the cost will be twice the cost for a treatment performed on the other sections (fig. 83).

VI. TRICOPIGMENTATION

fourth section

fig. 82: Fourth section

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fig. 83: Fifth section

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In most cases, your customers will ask you to treat the first and the third section, since androgenetic alopecia affects first these two areas. I personally recommend you to treat sections always in this consequential order, treating the first and the second section together, and the third section together with the fourth: this will ensure a more natural effect and, moreover, the treatment will hardly be noticed.

Operational strategies: MANAGING THE FIRST SESSION

VI.6 The Dermatoppik technique When Tricopigmentation is applied to long hair, we use the Dermatoppik technique. The name of this technique derives from a famous cosmetic product used to fight hair thinning.

• consultation, deciding the sections to be treated, budget, appointment; • informed consent; • colour identification; • HL design, ears line and nape; • start of the first session; • project file data entry; • delivery of the memorandum; • scheduling an appointment for the second session.

These products are primarily designed to simulate higher hair density and to darken the skin to camouflage thinning; their composition includes keratin fibres and it is available in different shades. Once applied on the head, they are electrostatically retained by the hair, making it thicker and, therefore, more opaque. The amount of products that does not stick to the hair, also, is deposited on the scalp, giving precisely the desired coating effect.

Operational strategies: MANAGING THE SECOND SESSION

Dermatoppik, therefore, can only darken the scalp, like a toppik, and, of course, it does not last over time, since it is no really able to thicken the hair. It’s like you can push the toppik into dermis, avoiding annoying spills on pillows, hats, etc…

• consultation (explanation of adjustment and healing phenomena), deciding the areas to be strengthened;

But, there are minimum requirements to use this technique, and they are quite important:

• pictures; • colour identification; • design of any changes on the HL, ears line and nape; • start of the second session; • covering mega dots with skin colour; • project file data entry; • final recommendations.

• presence of localised thinning (I strongly recommend you not to treat patients affected by alopecia type 4 of the Norwood Scale, and other serious cases); • the surrounding hair must be at least 2 cm long; • you need to decide, together with your customer, the direction of the surrounding hair, so that it will be the direction of the entire area to be treated.

Since we are talking about a technique which is much more invasive than the Bounce technique, I suggest you to treat the area to reduce the pain with topical anaesthetics (which must necessarily be prescribed by a doctor), to be applied just before the treatment.

VI. TRICOPIGMENTATION

• pictures;

Technically, we use a short hair technique but we create a Y-pattern design, to cover the area, but not in a homogeneous and full way.

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Here I will try to explain how to create this Y-pattern design. This pattern will help you to apply the following techniques: • The Dermatoppik technique; • The Tricopigmentation technique used to cover FUT scars on long hair (when using a light colour, fig. 84).

But now, I will show you the effect created by the X-shaped pattern, which is required to cover scars. This pattern will help you to apply the following techniques: • the Tricopigmentation technique used to cover FUT scars on long hair (when using a light colour); • the Tricopigmentation technique used to cover FUE scars (when using a light colour); As shown by figure 86, the short hair that make up the pattern, create a sort of “X”.

fig. 84: Covering alopecia on long hair

fig. 86: The short hair that make up the pattern, create a sort of “X”

But, back to the Toppik technique (figs. 88, 89), below you will find the list of the manoeuvers and the working parameters required (fig. 87).

VI. TRICOPIGMENTATION

As shown by figure 85, the short hair that make up the pattern, create a sort of “Y”.

fig. 85: The short hair that make up the pattern, create a sort of “Y”

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Manoeuver: double short hair

STEP 1

STEP 2

STEP 3

STEP 4

7

use of a seven-tip needle

medium pulse rate

medium speed

medium pressure

use of a colour similar to your customer natural hair

VI. TRICOPIGMENTATION

fig. 87: The Dermatoppik technique - working parameters

fig. 88: The Dermatoppik technique

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fig. 89: Dermatoppik treatment step by step procedure

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VI.7 Technique used to cover F.U.T. scars

Covering F.U.T. scars on long hair

There are two methods to treat FUT scars:

The operating strategy you need to adopt when covering FUT scars of long hair (fig. 92), is divided into two stages.

• on long hair (fig. 90); • on shaved hair (fig. 91).

fig. 92: Covering F.U.T. scars on long hair

fig. 90: F.U.T. scar on long hair

fig. 91: F.U.T. scar on short hair

During the FIRST STAGE, you will create a Y-shaped pattern on the scar, using a colour suitable to re-create the tissue between a hair and another, trying to reproduce the non-scarring tissue close to the scar. All this will be possible only by observing and following carefully the parameters shown in figure 93 and the manoeuvers shown in figure 94.

VI. TRICOPIGMENTATION

I want to clarify that, before working on the scar to be treated, you should advise your customer to shave the surrounding hair to the length desired. This is not an aspect to be underestimated, since there are different ways to work depending on the final effect desired. You’ll have to look closely at the hair of your customer and its length and the scar too: you will need to recommend your customer to keep the same length shown at the first session, in order to get better results.

During the SECOND STAGE, you will re-create the dark pattern, to reproduce the hair surrounding the scar, following the directions shown in figure 95 and in figure 96.

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STAGE I manoeuver: double short hair (back and forth)

1

7

use of a seven-tip needle

STAGE II manoeuver: single short hair

medium pulse rate

medium speed

medium to high pressure

beige/medium grey colour

fig. 93: Covering F.U.T. scars on long hair - working parameters (Stage I)

use of a single tip needle

medium to high pulse rate

low speed

medium pressure

brown or dark brown colour

fig. 95: Covering F.U.T. scars on long hair - working parameters (Stage II)

Note: the pattern will be created with vertical short hair movements, to create the Y shape.

fig. 94: Covering F.U.T. scars on long hair (Stage I)

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Note: this short hair technique must be used in the interstices of the light pattern created in the previous stage.

VI. TRICOPIGMENTATION

Figure 94 shows the effect obtained using the above parameters.

fig. 96: Covering F.U.T. scars on long hair (Stage II)

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Covering F.U.T. scars on shaved hair

STAGE I manoeuver: double short hair

Just to clean the air, in this case shaved hair means leaving not more than 2mm of hair length, but the procedure is the same used for the treatment above. Please, remind your customer to keep the same hair length (fig. 97).

7

use of a seven-tip needle

medium pulse rate

medium speed

medium to high pressure

Beige/medium-light grey colour

VI. TRICOPIGMENTATION

fig. 99: Covering F.U.T. scars on shaved hair - working parameters (Stage I).

fig. 97: Covering F.U.T. scars on shaved hair

The X-shaped light pattern This pattern (fig. 98) can be created using the same parameters (fig.99) and manoeuvers employed to create the Y-shaped pattern. The only different parameter is the tilt angle of the needle, since in this case the movements are not vertical, and try to reproduce the X shape (fig.100). fig. 98: X-shaped pattern

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fig 100: Covering F.U.T. scars on shaved hair (Stage I)

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STAGE II manoeuver: Bounce®

VI.8 Technique used to cover F.U.E. scars

In the second stage, you will perform the Bounce technique in the interstices of the pattern you have just created. The only thing you should remember is to exert a low pressure (fig.101), since you are treating a scar tissue and you never know how it will react.

When covering F.U.E scars, Tricopigmentation can give really excellent results.

This means that it is the best solution to be adopted in these cases.

The first thing you should know is that there are no differences when treating long or shaved hair, because, usually, white dots are covered by surrounding long hair (fig.103).

1

use of a single tip needle

medium pulse rate

medium speed

medium to low pressure

brown/dark grey colour

Figure 102 shows how in the second stage of the treatment performed to cover FUT scars on shaved hair, the Bounce technique is used within the “diamond pattern” created in the first stage with a light colour.

fig. 103: Covering F.U.E. scars on shaved hair

Covering F.U.E. scars on shaved hair

fig. 102: Covering F.U.T. scars on shaved hair (Stage II)

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VI. TRICOPIGMENTATION

fig. 101: Covering F.U.T. scars on shaved hair - working parameters (Stage II)

During the first stage, you will need to carefully evaluate whether the circular scars are small or large and, in the second case - namely when treating lesions with a diameter greater than 3 mm) - the first thing you will do is covering the area by creating a X-shaped pattern, following these directions (fig. 104)

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STAGE II manoeuver: Bounce速

STAGE I manoeuver: double short hair

Note: sometimes it is more convenient to create some bounces on the pattern you have just designed.

use of a seven-tip needle

1

medium pulse rate

medium speed

medium to high pressure

beige/medium-light grey colour

fig. 104: Covering F.U.E. scars on shaved hair - working parameters (Stage I)

use of a single needle

medium pulse rate

medium speed

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brown/dark grey colour

fig. 106: Covering F.U.E. scars on shaved hair (Stage II)

During stage II, you will need to fill the interstices created by this small pattern (figs. 105, 107) with the Bounce technique, using the same operating parameters (fig.106) already shown in the previous paragraph.

fig. 105: Covering F.U.E. scars on shaved hair (Stage I)

medium to low pressure

The F.U.E. hair transplant technique is definitely improving over the years and the scars caused by this treatment are becoming less and less visible. Of course, it could happen that you will have to treat circular scars with a diameter less than 3 mm. The procedure is the same, but you will have to skip the first stage, which means that you will not create the X-shaped pattern.

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7

fig. 107: Covering F.U.E. scars on shaved hair (Stage II)

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VI.9 Treatment procedure for prosthesis wearers I think it’s necessary to dedicate a specific paragraph to these cases, since usually these people show a really stressed scalp tissue, due to an intense use of adhesives or double-sided tapes. These skins appears swollen, full, smooth and often with dermatitis. Mycosis and flaking are also quite common. Colour migration is the most typical reaction of this type of skin. Figure 108 shows the typical look of the skin of prosthesis wearers, in the initial stages.

during the first session. Ask your customer to see a doctor who will help him treat the area in the proper way. Before starting the second session, you will notice that the area you have treated is not so defined and shows a lighter colour and there will be some light spots on the areas previously affected by dermatitis. Do not panic. This is part of the game. Ask your customer to wait 3-4 days before going back to use his prosthesis. Finally, you will ask your customer to shave the hair on the sides of his head for the third and last sessions.

Then, you can start filling the gaps, blending the crown and other areas, for a perfect and absolutely natural final result.

When working on prosthesis wearers, please use the following technique (fig.109):

fig. 108: Skin of prosthesis wearer

In this case, I suggest you to perform the treatment on three different sessions.

Do not ask your customer to shave his head before the third session. Start your session and ask to your customer to be patient and to wear his prosthesis for a few days. Once he starts wearing his prosthesis again, it will be more difficult for the pigment to adhere. That is why you need to perform an extra session. Moreover, you should remember not perform the treatment on areas affected by dermatitis

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VI. TRICOPIGMENTATION

Manoeuver: BounceÂŽ

1

use of a single needle

medium pulse rate

medium speed

low pressure

brown/dark grey colour

fig. 109: Prosthesis wearers - recommended working parameters

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CHAPTER SEVEN

Bureaucratic and legal aspects 160

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VII.1 The first consultation It’s the first real meeting with your potential customer and you need to take your time to carefully manage this situation: it’s both your business card and a real opportunity to get to know and understand what’s necessary to help your customer.

Here’s a list of all the things you can not forget to do during your consultation.

OVERVIEW: to begin, you need to briefly explain your customer what is Tricopigmentation and why it is used; TIMING OF THE FIRST FIELD AND MAINTENANCE: now you will explain to your customer the whole procedure and the relevant timing, you will show him a possible schedule and also the life and expectations of the product of each session.

agreed with you; • to stop taking any medication, maybe also Minoxidil or Finasteride for a short period (to be evaluated); • to shave the crown (for prosthesis wearers) before his first or second session (to be valuated); • not to shave his hair on the day of the treatment, but the night before.

• not to show up if he has flu symptoms, colds, allergies, etc.; • the person that will come with him (if any) can not access the room where the treatment will be performed; • to bring a clean cap with him; • to buy a soothing ointment; • to avoid sun exposure for at least 30 days after the first session; • not to shave his head or practice sports for seven days after the first session.

HISTORY: before performing your treatment, you need to know all physiological but also pathological aspects of your customer, both individual and of his family, also in order to identify the type of treatment to be performed.

PROJECT FILE: it’s now time to put all the information you have (plus other information) in a specific sheet that will contain personal information, a privacy box, the price agreed, the treatment to be performed, etc. A copy must be delivered to and signed by your customer.

PICTURE: Do not forget to take a picture on a light background, showing the current situation in detail.

APPOINTMENT: you will ask your customer for a deposit to schedule, once agreed, his appointment.

RECOMMENDATIONS: at this point, you will explain your customer what to do, and you will also tell him what he should not do, before his first session. For example, you will tell him: • to avoid sun exposure in the first seven days before his appointment; • to shave his hair (unless otherwise agreed) keeping the hair length desired and

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VII.2 Pre-treatment instructions Once again, to make things easier, here’s your list: • REASSURE YOUR CUSTOMER: This is mainly because your customer may be afraid of the pain he might feel. Reassure him, because the pain is really bearable; • NO BREAKS, IF POSSIBILE: It will be a race against time because, the longer the session the greater the skin inflammation, the less the colour will adhere.

Therefore, it is better to reduce the breaks as much as possible: no cigarettes, no text messages or phone calls (it’s better if your customer turn off his phone).

Tell your customer to use the toilet before the session starts;

VII. BUREAUCRATIC AND LEGAL ASPECTS

ESTIMATE: after explaining to your customer your operational strategy, you will also him and estimate.

• ADJUSTMENT PERIOD: I suggest you to carefully explain to your customer

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• INFLAMMATION: tell your customer that the area will be inflamed for the next 24-48 hours after the treatment, but that there’s nothing to be worried about.

It will disappear; • SILENCE: i suggest you tell your customer not to speak during the session, so that you will not be distracted and the final result will be definitely better; • CONFIDENTIALITY: Remind your customer that the use of the images produced is intended solely for internal use (work study). Any use for advertising purposes, will be subject to authorisation by the customer; • DOUBTS: During the period between the first consultation and the first session, it’s possible that your customer has some doubts or uncertainties. That’s because he’s nervous, but I think this is normal. Be patient. Answer his questions. Then you can start your session.

Your customer can decide if he wants to undergo the treatment you will discuss in detail and he has the right/duty to know all the information you have and to ask you any question he wants.

I strongly advise you to always attach the informed consent to the invoice, because in Italy it is required by law.

Figure 110 shows an example of informed consent I use in Italy. Feel free to make some changes according to the regulations of your country, but always remember to include all the necessary information.

VII.4 The Project file As already mentioned, it should contain as much information as possible, and it’s the only way to store all the information and data you need all together. Do not forget to include the colour used, the area treated, the pressure used to perform the treatment and every important detail you could need in the future.

Figure 111 shows the form I use for my customers. Its’ just an example. You can decide, of course, to make some changes.

VII.3 Informed consent In Italy, informed consent is required for any simple treatment, including medical treatments and surgeries. You need to get your patient’s permission before conducting any type of intervention, otherwise, you may be prosecuted. The purpose of seeking informed consent is therefore to promote the autonomy of the individual in the context of medical decisions.

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VII.5 Post-treatment memorandum Below, you will find some important and precise indications you must include in the memorandum to be delivered to your customer. I suggest you to ask him to sign it and to store a copy. As you will see, there some useful recommendations that can really help the customer to properly manage the situation and to recognise any abnormal reactions of the skin.

VII. BUREAUCRATIC AND LEGAL ASPECTS

that the pigment pushed into the skin needs to adjust, that is why at first he will notice a dark and thin dot or dash, that will become later in the following says, to become always invisible. It will also expand, thus creating a sort of surrounding shade. But that will be corrected during the second session;

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therefore, is partial and seems to persist only until it’s used. With regard to the possible side effects, it must be said that an initial telogen effluvium, lasting three to four weeks, is quite frequent.

Please, note the delivery of the memorandum is not an optional service offered to customers. Its is extremely important that your customer carefully reads and sign this document.

FINASTERIDE

VII.6 Interaction with other products or systems: Minoxidil, Finasteride, prostheses, etc.

MINOXIDIL Minoxidil is widely used for the treatment of alopecia, especially for androgenetic alopecia. But still, we do not really know how it works. What we know is that it acts on metabolic control systems and not on hormonal mechanisms: in particular, this medication seems to activate the Krebs cycle and to increase of the production of energy substrate with a consequent increase in protein synthesis. Basically, Minoxidil reproduces the action of a growth factor that could be the EGF (Epidermal Growth Factor) and causes the opening of the channels of the channels of the intracellular potassium at the level of smooth muscle cells of peripheral arterioles. This action produces a direct peripheral vasodilator, which is immediately evident, out of the microvasculature of the dermal papilla. It does not seem that the vasodilation promotes hair growth, but this mechanism - according to some researchers - could somehow encourage the prolongation of the anagen phase.

Recent studies indicate that Minoxidil may increase the vascularization of the dermal papilla inducing angiogenesis. This medication is able to stop and sometimes reverse the process of miniaturization of the follicle.

Minoxidil is able to fight the symptom, namely the progressive miniaturization of hair, but does not act on genetic-endocrine causes of baldness: its effectiveness,

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It is the first generic substance in the world registered for the treatment of androgenetic alopecia. To explain the mechanism of action of Finasteride on androgenetic alopecia, we must keep in mind that in the hair follicle there are some enzymatic systems which convert weak androgens into more potent androgens, including 5Îą-reductase enzymes, which plays the most important role in the pathogenesis of androgenetic alopecia. Clinical trials lasting up to two years have shown that 1 mg/day of Finasteride, slowed the progression of hair fall and increased hair growth (Kaufman, 1998). Another multinational long-term experience showed that Finasteride (1 mg/day over five years) was well tolerated and resulted in persistent improvements in hair growth and also slowed the further progression of baldness (Kaufman, 2002). Even counting the follicles in horizontal sections provided a useful complement to the clinical parameters obtained by studies on hair growth. In young and middle-aged men affected by androgenetic alopecia, Finasteride seems to be able to reverse the miniaturization of the hair that characterises this condition (Whiting, 1999). In a recent study, Finasteride increased hair weight in men with androgenetic alopecia. The weight of the hair increased much more than its number, which means that there are factors, other than the number of hairs, such as an increase in the growth rate (length) and hair thickness, which contribute to the beneficial effects of Finasteride in the men treated (Price, 2002). The most common side effects are related to the sexual function: impotence, decreased libido, decreased volume of ejaculate.

Now, after briefly explaining what we are taking about, we can discuss what are the possible effects of this medication, if used during Tricopigmentation treatments. I must say, though, that there are no special technical contraindications.

The only thing to consider is the psychological aspect of your customer. You will have to take into account the fact that if your customer is taking Finasteride during the treatment, once he will stop taking it, he will probably ask you a lot of questions, and he will have a lot of doubts. But this is quite understandable, since your customer will notice a visible slowness in the process of hair regrowth. Of course, this is due to the fact that he does not take his medication, Tricopigmentation has nothing to do with it. The only thing you can do is tell your customer in

VII. BUREAUCRATIC AND LEGAL ASPECTS

The memorandum (fig. 112) is an extremely useful tool that must contain all the information your customer need not to make mistakes and not to panic after noticing possible changes.

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advance not to worry about it. So , you need to ask your customer if he is taking this medication, when gathering all the information you need. But please, do not underestimate the psychological aspect and carefully study the situation, to decide what’s the best strategy to be adopted. You should also ask him whether he’s planning to use the medication for a long time or if it’s just a temporary solution and, based on his answer, you will then decide your strategy. Finasteride is quite expensive. We are taking about a thousand euro per year.

him to wear his prosthesis when he comes for his first session and to remove it before starting the treatment.

Minoxidil, as we have seen, is a definitely milder medication, and it’s also the first treatment doctors prescribe. Being a topical medication, it comes as a lotion often prepared by pharmacies, which is applied locally on thinned areas, but it should not be used during Tricopigmentation treatments: it should not be used during the 15 days preceding the treatment, since it could change and then alter, the ability of the skin to retain pigments, thus causing colour migrations.

• to choose a low pressure, especially during the first session, a low pulse rate, but a high speed, to avoid colour deposits.

I also recommend you: • to plan, together with your customer, a tanning program, in order to make the area that has been covered by the prosthesis more homogeneous;

Dermaroller is a treatment which promises miraculous results, but actually, it’s pretty mild. It’s a sort of rolling pin that uses the needling principle, according to which, if a tissue is properly and frequently stimulated, it tends to regenerate itself, thus strengthening the existing hair. The psychological aspect of your customer, once stopped using this medication, is the only thing to take into account.

Of course, you have to ask him to stop using it during the 15 days preceding the treatment and also for 15 days after the treatment. Then, he can go back using it. But the inflammation caused by Dermoroller will make necessary to schedule reinforcement sessions earlier than normally planned.

Milder mechanical systems: I will mention only infrared hair brushes that use some light sources with a specific wavelength (infrared), that heat the scalp frequently, to induce a vascularisation that would cause a thickening of the involved area. Ask your patient to stop using it during the 15 days preceding the treatment and also for 15 days after the treatment.

Prosthesis wearers usually have an altered scalp, which can be swollen, spongy, smooth and full of liquid, also caused by a frequent use of adhesives or double sided tapes. In this case, you should carefully choose your strategy. I suggest you not to ask your customer to remove his prosthesis before the first session (but this is not a rule), but only between the first and the second session. So, you will ask

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VII. BUREAUCRATIC AND LEGAL ASPECTS

Once again, it’s important that you tell your customer, and maybe more than once, to stop using this medication. Of course, the first thing to ask is if he takes this medication.

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VII. BUREAUCRATIC AND LEGAL ASPECTS fig. 110: Informed consent

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fig. 111: My project form

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VII.7 Recommended costs

PRICE LIST SHAVED EFFECT (P. 1/4) GRAPHIC SCHEME

SECTIONS RECOMMENDED

Stage I: it corresponds to a normal individual

/

Stage II: it corresponds to stage I of the Hamilton Scale, with recessed frontotemporal hairline. *Stage I of the Hamilton Scale: Minor recession of the frontotemporal hairline with Subsequent possible recession of the frontal hairline: it does not Necessarily evolves into baldness;

Stage IIa: as stage II, associated with a recession of the frontal hairline.

COST (â‚Ź)

800,00 + VAT I

800,00 + VAT I

Price list valid until ___ / ___ / ___

VII. BUREAUCRATIC AND LEGAL ASPECTS

STAGE DESCRIPTION (NORDWOOD)

fig. 112: Post-treatment memorandum

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STAGE DESCRIPTION (NORDWOOD)

GRAPHIC SCHEME

SECTIONS RECOMMENDED

Stage III: it corresponds to Stage I of the Hamilton Scale, but with a more visible recession of the frontal hairline. *Stage I of the Hamilton Scale: Minor recession of the frontotemporal hairline with subsequent possible recession of the frontal hairline: it does not necessarily evolves into baldness.

COST (€)

1.600,00 + VAT

STAGE DESCRIPTION (NORDWOOD)

I II

I II

Stage IVa: significant recession of the front hairline, involving also the virtual line, which is the one connecting the top of the two ears. If recession involves this line, well that is stage IV.A. This phenomenon affects the superficial area, since the temporal crown still has hair: not always there is thinning vertex, but the strip of hair is still absent.

1.600,00 + VAT

Stage III vertex: like stage III or IIIa, but associated with a thinning of the vertex.

GRAPHIC SCHEME

SECTIONS RECOMMENDED

Stage IV: a large strip of hair between the front and back areas affected by alopecia (Stage III of the Hamilton Scale, but not very pronounced).

Stage III of the Hamilton Scale: the front and back region affected by alopecia tend to merge, leaving only a narrow strip of hair: at this stage, many people start to use a prosthesis.

Stage IIIa: like stage III, but associated with a recession of the frontal hairline.

Stage II of the Hamilton Scale: Further frontal loss and hairline recession, with a first involvement of the vertex region of the scalp.

PRICE LIST SHAVED EFFECT (P. 3/4) COST (€)

2.400,00 + VAT I II

IV

2.400,00 +VAT I II III

2.400,00 + VAT I II

IV

Price list valid until ___ / ___ / ___

Stage V: like Stage IV, but more pronounced Stage III of the Hamilton Scale.

Stage III of the Hamilton Scale: the front and back region affected by alopecia tend to merge, leaving only a narrow strip of hair: at this stage, many people start to use a prosthesis.

3.200,00 +VAT I II III IV

Price list valid until ___ / ___ / ___

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VII. BUREAUCRATIC AND LEGAL ASPECTS

PRICE LIST SHAVED EFFECT (P. 2/4)

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IMPORTANT

PRICE LIST SHAVED EFFECT (P. 4/4) GRAPHIC SCHEME

SECTIONS RECOMMENDED

Stage Va: like stage V, with receding hairline, and a first involvement of the vertex.

However, this is not a rule.

Stage corresponds to stage IV of the Hamilton Scale*, but is less accentuated; *Stage IV of the Hamilton Scale: fullblown alopecia: frontoparietal and vertex hair loss, leaving only a crown of hair in the temporo-occipital region.

3.200,00 + VAT

PRICE LISTS FOR COVERING SCARS

I II III IV SCAR DESCRIPTION

GRAPHIC SCHEME

F.U.T. Scar: maximum individual size:

Stage VI: it corresponds exactly to stage IV of the Hamilton Scale*. *Stage IV of the Hamilton Scale: fullblown alopecia: frontoparietal and vertex hair loss, leaving only a crown of hair in the temporo-occipital region.

COST (€)

Reinforcement sessions must be scheduled 90 days after the first session, at a cost € 150,00 + VAT per section.

After 90 days, reinforcement sessions could have a cost ranging from € 150,00 to € 400,00 + VAT per section.

The costs showed in the table refer to theoretical ideal situations. Therefore we invite you to request a custom quote by sending a picture to info@tricopigmentazione.com.

650,00 + VAT (cost for single scar)

• length 20 cm

3.200,00 + VAT

• average height 1 cm

I II III IV F.U.E. scar: maximum size

Stage VII: it corresponds to stage V of the Hamilton Scale*.

Stage V of the Hamilton Scale: like stage IV, but with a reduced size of the “crown”.

650,00 + VAT (cost for single scar)

• About 50 cm2 3.200,00 + VAT I II III IV

Alopecia Universalis

Price list valid until ___ / ___ / ___

5.000,00 + VAT IMPORTANT

I II III IV V •

Price list valid until ___ / ___ / ___

• •

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COST (€)

Reinforcement sessions must be scheduled 90 days after the first session, at a cost € 150,00 +VAT per section.

After 90 days, reinforcement sessions could have a cost ranging from € 150,00 to € 325,00 +VAT per section.

The costs showed in the table refer to theoretical ideal situations. Therefore we invite you to request a custom quote by sending a picture to info@tricopigmentazione.com.

VII. BUREAUCRATIC AND LEGAL ASPECTS

STAGE DESCRIPTION (NORDWOOD)

• • •

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CHAPTER EIGHT

before & after treatment EXAMPLES

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AFTER

Table I: Tricopigmentation of the Hairline

BEFORE

Table III: Tricopigmentation on alopecia stage VII

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AFTER

Table IV: Tricopigmentation on F.U.T. scar

AFTER

Table II: Tricopigmentation on vertex, nape and scars caused by hair transplant

BEFORE

BEFORE

AFTER

BEFORE

AFTER

Table V: A 24 cm hypopigmented and vascularised scar

BEFORE

AFTER

VIII. before & after treatment EXAMPLES

BEFORE

Table VI: Hairline reinforcement after hair transplant bad results

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AFTER

Table VII: Tricopigmentation on androgenetic alopecia stage V

BEFORE

Table IX: Tricopigmentation on alopecia stage IV

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AFTER

Table X: Tricopigmentation on alopecia stage IV

AFTER

Table VIII: Tricopigmentation on FUE scar (just performed)

BEFORE

BEFORE

BEFORE

AFTER

Table XI: Tricopigmentation on FUE and Strip scars (just performed)

AFTER

BEFORE

AFTER

VIII. before & after treatment EXAMPLES

BEFORE

Table XII: Tricopigmentation performed on a former prosthesis wearer

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AFTER

Table XIII: Treatment performed on the I and II sections

BEFORE

Table XV: Tricopigmentation on a triple nape scar

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AFTER

Table XVI: Tricopigmentation on a FUT scar/Detail/Macro

AFTER

Table IV: Tricopigmentation performed to cover hair transplant bad results

BEFORE

BEFORE

AFTER

BEFORE

AFTER

Table XVII: Tricopigmentation on FUE white dots + crown

BEFORE

AFTER

VIII. before & after treatment EXAMPLES

BEFORE

Table XVIII: Tricopigmentation performed on a former prosthesis wearer, stage VII of the Nordwood Scale

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AFTER

Table XIX: Tricopigmentation performed using the short hair technique

BEFORE

AFTER

Table XX: Tricopigmentation performed on stage II of the Nordwood Scale

BEFORE

AFTER

Table XXI: Tricopigmentation performed on stage VI of the Nordwood Scale + plug

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BEFORE

AFTER

Table XXII: Tricopigmentation performed on stage Va of the Nordwood Scale

BEFORE

AFTER

Table XXIII: Tricopigmentation performed on stage VII of the Nordwood Scale

BEFORE

AFTER

VIII. before & after treatment EXAMPLES

BEFORE

Table XXIV: Tricopigmentation performed on a prosthesis wearer

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AFTER

Table XXV: Tricopigmentation performed on a prosthesis wearer

BEFORE

AFTER

AFTER

Table XXVII: Tricopigmentation performed on stage IV of the Nordwood Scale

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AFTER

Table XXVIII: Tricopigmentation performed on stage V of the Nordwood Scale

Table XXVI: Tricopigmentation performed on stage VII of the Nordwood Scale

BEFORE

BEFORE

BEFORE

AFTER

Table XXIX: Tricopigmentation performed on stage III of the Nordwood Scale

BEFORE

AFTER

VIII. before & after treatment EXAMPLES

BEFORE

Table XXX: Tricopigmentation performed to cover FUT hair transplant bad results

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AFTER

Table XXXI: Tricopigmentation on Brocq pseudopelade

BEFORE

AFTER

AFTER

Table XXXIII: Tricopigmentation performed on a prosthesis wearer with plug

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AFTER

Table XXXIV: Tricopigmentation performed to cover hair transplant bad results

Table XXXII: Tricopigmentation performed on stage VII of the Nordwood Scale

BEFORE

BEFORE

BEFORE

AFTER

Table XXXV: Tricopigmentation performed on a prosthesis wearer

BEFORE

AFTER

VIII. before & after treatment EXAMPLES

BEFORE

Table XXXVI: Tricopigmentation performed to cover hair transplant bad results

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AFTER

Table XXXVII: Tricopigmentation performed to cover hair transplant bad results and on a prosthesis wearer BEFORE

AFTER

Table XXXVIII: Tricopigmentation performed on hair transplant (flap rotation)

BEFORE

AFTER

Table XXXIX: Tricopigmentation performed on hair transplant (flap rotation)

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BEFORE

AFTER

Table XL: Tricopigmentation performed on hair transplant (flap rotation)

BEFORE

AFTER

Table XLI: Tricopigmentation performed on alopecia universalis

BEFORE

AFTER

VIII. before & after treatment EXAMPLES

BEFORE

Table XLII: Tricopigmentation performed on dark skin

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BEFORE

CONCLUSIONS

AFTER

Table XLIII: Tricopigmentation performed on a former prosthesis wearer. Stage VII of the Nordwood Scale BEFORE

AFTER

At the end of this journey, I guess it’s now time to talk about future projects. Well, I feel good vibes, that is why this will be not an arrival point, but only a stop on my long journey. Because research is the only tool I have to improve my skills and myself. What I mean is that I love my job, but I need more. Tricopigmentation is something I have created and I am really proud of it. But I know there is still a lot I can do to improve this technique, so that it will no longer be a treatment designed for an elite of people. I also think that the whole procedure should last less and that are a couple of other things I could work on to improve this amazing technique and my professional skills.

So, what can I say? Some big news coming soon! Stay tuned!

Table XLIV: Dermatoppik

PRIMA

Tavola

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DOPO

Ennio Orsini 195

ACKNOWLEDGMENTS

After publishing my first work, it has been quite difficult to write another book that could replicate the success obtained by its predecessor. That’s why my first thought goes to them, the people who chose to buy my first book. If Tricopigmentation is now reality, it’s also thanks to all of you guys!

A big thanks to Toni, by business partner and friend, with home I gave birth to this creature.

Thanks also to Mr. Froio, who helped me to implement this project with his experience and with his company. Then, of course, my lovely wife and my daughter, for their tireless support.

Last, but not least, Anna Leombruno, who helped me with her experience and her talent and, above all, her respect.

Ennio Orsini 196

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BIBLIOGRAPHY • Rook Dawber, Masson - Malattie dei capelli e del cuoio capelluto, 1982 • Zviak, Masson - Scienza e cura dei capelli, 1987 • Orfanos, Spinger-Verlag - Hair and hair diseases, 1989 • Rebora, Dermatology - Le alopecie, 1992 • Olsen, Mc Growth-Hill - Disorders oh hair growth, 1993 • Marliani, Etruria Medica - Appunti e schemi di Tricologia e Trichiatria, 1995 • Marliani, Etruria Medica - Tricologia: diagnostica e terapia, 1996 • Tosti, Bibliotechne - Le malattie dei capelli e del cuoio capelluto, 1996 • Camacho-Montagna, Ala Medica - Trichology: diseases of the pilosebaceus follicle, 1997 • Kaufman, Am Ac Dermato - Finasteride nel trattamento dei soggetti maschi affetti da alopecia androgenetica, 1998 • Tosti, Simposio nazionale - Nuove prospettive nella terapia dell’alopecia androgenetica, 1999 • Michael Goodman - I capelli e l’alimentazione, 1999 • Rossi-Guarrera- Piraccini-Vena - AGA, Alopecia androgenetica, EDMES 2000 • Camacho-Randall-Price, Martin-Dunitz - Hair and its disorders, 2000 • Kaufman, Eur J Dermatol - Esperienza multinazionale a lungo termine (5 anni) con la finasteride 1 mg nel trattamento di uomini con alopecia androgenetica, 2002 • Orsini Ennio - Un sorriso conquistato, 2011 • Orsini Ennio - Altri motivi che possono causare l’allargamento dei “puntini” in un trattamento di Tricopigmentazione, 2011 • Orsini Ennio - Alopecia: Un sogno virtuale che diventa realtà, 2011 • Orsini Ennio - La cicogna … che porta i capelli!, 2011 • Orsini Ennio - Coprire i segni di un autotrapianto, 2012

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SITE LINKS

• Calvizie.net - www.calvizie.net • Società Italiana di Tricologia - www.sitri.it • Gruppo Italiano di Tricologia - www.gitri.it • Anagen - www.anagen.net • Portale Italiano di Tricologia - www.tricologia.it • Associazione Mediterranea Alopecia Areata - www.alopecia.it • Capelli che fare - www.capellichefare.it • Salusmaster - www.salusmaster.com • Hairtoday - www.hairtoday.com • Ennio Orsini - www.ennioorsini.com

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Biography

ENNIO ORSINI

W

hen only a few exams were separating him from graduation, Ennio Orsini decides to abandon his studies in electrical engineering at the University of Ancona to pursue a career in the world of cosmetic treatments. Then, everything changes for Ennio Orsini, but, actually, his passion for makeup was born when he was only a child, as Ennio preferred to say at the beauty centre of his mother, Giovanna, rather than playing with his friends. Here, Ennio grew up surrounded by creams, massages and makeup, which became his career.

So, he decides, after leaving a respectable career as an engineer, to change direction. He starts studying makeup, and soon he starts working as a makeup artist for about four years, dividing his time between television productions, theatres, walkways and entertainment agencies. His technical background grows and leads him to leave his job as an employee to

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open his first makeup school, which gave him the chance to test his teaching skills, with great results. Ennio also finds the time to become a beautician specialized in body-art, combining permanent makeup, artistic tattooing and piercing to create what he calls “Extreme Make Up”.

During those years, he also writes articles for some magazines (Les nouvelles Esthetiques, La Pelle Beauty, Esthetitaly, Trucco e Bellezza, etc.) on makeup, micro-pigmentation and cosmetics in general. Today, he owns “DECO STUDIO, a body decoration studio” where he also holds his courses, designed to train new highly specialised dermopigmentation professionals; he collaborates with prestigious beauty centres and clinics as a dermopigmentation specialist; he teaches makeup and micro-pigmentation, at regional and private schools, including GIM international in Latina; he he also works as a technical

consultant and developer for some renowned companies producing equipment for micro-pigmentation; he owns a company that sells micropigmentation equipment and products. He took part in an international project, as the co-author of a book on micro-pigmentation (“Micropigmentazione: tecnologia, metodologia e pratica”) translated into 5 languages.

He invented Tricopigmentation® and a new protocol to create men’s eyebrows and women’s realistic eyebrows. He has been selected four times as the Italian judge for makeup world competitions. He collaborates with the Italian courts as a technical expert, for legal disputes involving tattooing and permanent makeup. In 2014 he was awarded by the province of L’Aquila and the Abruzzo region as a young talent. He is invited as a speaker at major conferences on cosmetic surgery and aesthetics, organized

by Italian and European associations (including: ATEC Associazione Trucco Estetico Correttivo, ISHR società Italiana di cura e chirurgia della Calvizie).

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Did you like this book?

Leave your comment on my website www.ennioorsini.com or you can send an email to info@ennioorsini.com

A revolutionary and complete guide to dermopigmentation applied to baldness and scalp scars, discussed stage by stage

by Ennio Orsini, with an historical analysis, detailed theoretical explanations and practical step by step examples.

Then dream, create, improvise because nature has already created everything you can imagine.

Ennio Orsini

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