Hair Transplantation

Fundamentals

1. Introduction
2. Donor Area
3. Follicular Unit Transplanting (FUT)
4. Planning & Progression of baldness
5. Results

About The Procedure

1. Anesthesia
2. Strip Harvesting of Donor Area
3. Trichophytic Wound Closure
4. Follicular Unit Extraction (FUE)

 

Fundamentals

 

1- Introduction

Hair fall is a major problem that affects almost all men and women at some point in their lives. There are many causes of hair fall. The most common factor is androgenetic alopecia. The cause of androgenetic alopecia is hereditary and there is usually a genetic history of it, up to three generations, on either the mother’s or the father’s side. Balding in androgenetic alopecia is caused by the action of DHT (dihydrotestosterone), which is the active form of the hormone testosterone on the receptors present in the hair follicles. We classify balding in Hamilton–Norwood range of 1–7 for men and Ludwig range of 1–3 for women, to assess the severity of balding as depicted in the picture below. There are mainly two treatment options of androgenetic. The first option is medical treatment and the second option is surgical hair transplant. Medically, there are only two medicines, namely Minoxidil lotion and oral finasteride tablets, that have a proven role in treating hair fall. Medicines work only in the early stages of balding, namely stages 1–4. They may stop the hair fall and retain the hair that are present. But these medical treatments have to be taken regularly, they have to be used lifelong, and they cannot help a bald person grow a head full of hair. When the balding has progressed to stage 4 and beyond the “gold standard” for hair restoration the solution is hair transplant procedure. This procedure offers a permanent solution to baldness. The transplanted hair are permanent, i.e. they stay for life; never fall, and need subsequent haircuts. The principle of hair transplant is that all of us have a zone of hair on the back and the sides of our scalp that are permanent or, in other words, are maximally unresponsive to the DHT hormone, therefore, they never fall. We, a team of trained plastic surgeons & dermatologists, aim at redistributing these permanent hair follicles to the area of balding where they can add significant value. The hair that are transplanted to the bald area are permanent, appear absolutely natural, and do not look different from the existing or natural hair in appearance or direction of growth. You can comb them, oil or shampoo them, and even shave them. The procedure is done under local anesthesia on an outpatient basis. You would stay awake throughout. You can watch TV, listen to music, and take your lunch during the break. You go home immediately after the procedure. Depending on the area and number of follicle units, it usually takes approximately 2–6 hours for one session of hair transplant

 

2- Donor Area

Hair Transplantation depends primarily on the now well-established principle that transplanted hair follicles (roots moved from their original location to another area) will behave as they did in their original site. For example, even in the most advanced cases of common Male Pattern Baldness (MPB), a horseshoe-shaped fringe of hair persists. Hair follicles moved from this appropriate donor area to a bald or balding area the recipient area will take root and grow. Continuing hair growth in such transplants has been observed since 1958, and it is believed that the hairs will continue to grow for the individual’s lifetime – provided that it would have done so at its original site.

3- Follicular Unit Transplantation

For approximately the last 20 years hair transplanting has been increasingly carried out using a surgical technique referred to as Follicular Unit Transplanting (FUT), and since at least 2004-2005 the majority of plastic/cosmetic surgeons have been using FUT virtually exclusively. What is FUT?

Hairs emerge from the scalp as “follicular units” (FU), comprising of single hairs or majority have 2 to 5 hairs. These naturally occurring follicular units, as well as the single hairs, are usually carefully dissected out of a strip of hair-bearing tissue that has been excised from the donor area. The grafts are created in a tear-drop shape so that there is minimal skin surface, but a significant amount of protective tissue surrounding their deeper “roots”. These FUs are placed into tiny incisions, made with an ordinary hypodermic needle or a small blade, at the same angle and direction as the original hair in the recipient area. This results in a natural-looking growth of hair even after only one session in a bald area. This technique is called as Follicular Unit Transplanting (FUT).

 

4- Planning & Progression of Baldness

The three most important facts that anybody who is thinking about having a hair transplant should know are:

1. Transplanted hairs will only last in the new area as long as they would have in the area from which they came. (Not only do you want the results to be as natural/undetectable as possible – in recipient and donor areas – you also want them to be as permanent as possible)
2. The areas of hair loss will intermittently enlarge for his/her entire lifetime. The periods of loss and stability vary from person to person. Finasteride and Minoxidil may temporarily slow this process or even temporarily reverse it in some areas.
3. There are only a limited number of hairs in the preferable donor area that are very likely to be permanent in balding men and women. The question is “how many are there?” It is especially important to recognize that the younger you are when you begin transplanting, the more difficult it is to accurately predict the long-term donor/recipient area ratio, and how many “permanent” hairs will be available in the long run to treat an intermittently enlarging bald area. Thus, the more cautious a young individual should be, before using up large numbers of grafts and choosing “dense packing” of grafts and/or low youthful hairlines like you once had – even though it is understandable that you might want to return to the most youthful appearance possible. Put differently, the more grafts you use today, the fewer you leave “in the bank” to treat the unknown extent of future areas of hair loss. However, it is the youngest patients who most want the lowest hairlines, the densest results and “more now” rather than later, and who often seek out doctors who are advocates of these commonly unwise objectives for young people. (Ironically, older patients, for whom it is more reasonable to want those objectives, often are content to aim for higher hairlines and less hair density).

 

5- Results

In the initial 1 month after the procedure, all the transplanted hair fall off. After a rest of another one or two months, the hair start to grow out of the scalp again. The hair then grow at a particular speed – on an average at a rate of 1 cm per month. Therefore, a waiting period of 6 months after the surgery is required to appreciate the results of the hair transplant procedure. Once the 6 months are complete, the hair that would have grown back would be your permanent hair. They would never fall, they will grow normally and would need haircuts. You can cut, style, shampoo, apply hair dye or colour them. The hair would grow back even if you shave your entire scalp!

There are no side effects of hair transplantation.

 

About the Procedure

1- Anaesthesia

At the beginning of each session, the patient is given a mild tranquilizer (Alprax) either orally or intravenously. This minimizes the anxiety of the patient.

The donor area and the recipient area are anesthetized using a very small gauge needle that is about the size of an acupuncture needle (Local & Regional Anaesthesia). Anesthetizing the areas is the only uncomfortable part of the session and although it may be hard to believe, many patients have told us that the above technique usually causes less discomfort than a visit to their dentist.

2- Strip Harvesting

After the anesthetic has taken effect, a scalpel is used to excise a narrow “strip” (10-15 X 1.5 cms) of hair-bearing scalp from the densest section of the donor area. After the tissue has been removed, the area is stitched or stapled closed. Following this a team of 4-5 expert surgeons sit under a microscope to dissect each FU from this strip. This is the most challenging and expertise requiring step of the whole procedure and which makes it much better than the other technique of hair transplant i.e Follicular Unit Extraction (FUE) technique. Each FU is visualized through the microscope and is dissected very delicately, without damaging any hair root.

3- Trichophytic closure

A very thin slice of superficial skin (epidermis) is removed from one side of the wound prior to closure. When the incision heals, the follicles lying under the scar grow through the middle of it, and increases the ease with which the scar is camouflaged. The very thin linear scar remaining after surgery, using the technique that we employ, is narrow enough in approximately 95% of patients to allow the patient to wear his hair very short. In approximately 5% it is wider – nearly always because of the individuals’ inherent healing characteristics – but rarely more than 3mm. Some patients consider the 5% possibility of such a scar the main draw-back to strip harvesting. However, even if the scar is 3mm wide, it can still be easily covered with the surrounding dense hair if it is left 1″ to 2″ long. Also, if a subsequent strip or strips are excised, the prior scar is included within that strip so no matter how many sessions are carried out, only one scar is ever present and it always runs through the densest hair.

The main advantage of strip harvesting over FUE is that because every FU in a strip can be utilized, excising a total strip width of only approximately 2 inches to 2.5 inches (over the course of 2 to 4 sessions) is usually sufficient to completely transplant an individual who is destined to develop huge bald area. Such a total strip width can commonly be removed from well within the “Safe Donor Area”. As discussed earlier, hair is lost sooner – and in some areas completely – the farther outside the “Safe Donor Area” you harvest and the closer you get to the frontal, upper and lower borders of the fringe hair in a man with evolving MPB. FUE increases the likelihood of this becoming necessary; the reasons for this will be discussed immediately below. Put simply, you can harvest the maximum number of the most likely permanent hairs by using strip harvesting, while staying within the “Safe Donor Area”.

4- Follicular Unit Extraction (FUE)

Using this technique, after the patient is asked to trim the whole donor area, each individual FU is carefully excised directly from the scalp using a small, sharp cylindrical punch (generally 0.8mm to 1.2mm in diameter). The punch can be manually driven or power driven. The skin surface around each FU is superficially incised before it is usually teased out with a combination of forceps traction and pressure on the surrounding skin. As it is somewhat a blind procedure, chances of transecting roots are there in upto 15-20% of FU harvested, which may cause sheer wastage of grafts available for grafting.

In general, FUE involves no suturing as well as slightly less post-operative discomfort. But it has mostly gained popularity amongst those who want to wear their hair less than 2mm in length because – unlike the classical “strip” technique – it does not leave a linear scar in the donor area of a patient’s scalp. To accomplish this, FU removal is ideally performed in a random distribution within “The Safe Donor Area”. If done properly, after a single session or even multiple sessions of FUE, hair in the donor area appears slightly less dense than previously. However, if done less than ideally, purulent cysts can develop and the donor area hair density can be noticeably sparser and small round scars will be obvious if the hair is too short

One of the often unmentioned, but major, potential drawbacks of FUE versus FUT, is that if very large numbers of grafts are likely to be required in a single or multiple sessions over the patient’s lifetime, a larger percentage of the transplanted hair is more likely to be lost in the future than would be the case with FUT. This is because all of the FU in a strip are utilized, whereas only every third to fifth FU can be extracted from a FUE donor area; taking more than that with FUE would result in that area being left with hair that would be too sparse and/or the small round scars being noticeable. Thus, to get the same number of FU as you would from a strip requires a donor area that is 3 to 5 times as large. A consequence of that is a FUE session of 1000 to 1500 FU spaced every 3rd to 5th FU apart, generally can be accomplished within “The Safe Donor Area”, a 3000 FU session would require harvesting from twice that scalp area and a 4500 FU session would necessitate FU extraction from over three times that scalp area, etc. The latter two sessions would nearly always exceed the established “Safe Donor Area” boundaries. This would result in non-permanent FU transplantation and potential small round scars becoming visible as that area loses the original hair. As implied from the preceding, the younger the individual is, and therefore the less certain one can be about the ultimate width of the safe donor area, the more likely that this will occur. The older the patient, the less likely this will happen. A less important additional potential drawback of FUE is that the grafts produced via FUE have less protective tissue surrounding the hair bulbs within them and may result in a lower hair survival than that seen with grafts that are microscopically produced from a strip.

Despite these limitations, there remain specific populations of doctors who specifically only perform FUE and criticize FUT technique. There are two reasons, one because of lack of expert team to perform microscopic dissection (which is an inherent important step in FUT) and ability to achieve good trichophytic closure of the wound; and lack of time. FUE is far from the panacea that some of these doctors through Internet & marketing forces, suggest it is – especially for young men in whom the ultimate size of the bald and donor areas are not certain.

However, having said that, there still are some indications of using FUE technique. Patients with poor scalp laxity who may have excess tension upon closure after a strip harvest (this problem is usually more pronounced after multiple strip harvest excisions). Fortunately, scalp laxity does not significantly impact the cosmetic recovery of the scalp after FUE. Also for very large for large bald areas, combination of donor strip harvesting, followed by one (or more) FUE session(s) is optimal to achieve the largest number of safe, long-term FU from the donor area while minimizing or eliminating any resultant scarring (i.e. the best of both worlds).

Body-to-scalp FUE has also been utilized when the patient has insufficient donor hair density in the scalp. The density of results utilizing body hair suggest that the survival is significantly less than scalp hair. Beard hair has particularly good survival, and may be a good solution for camouflaging donor scars or adding density behind hairlines that are created with finer hairs. Also FUE can be used as a touch up procedure after having transplanted and covering majority of the bald area with FUT technique, and it is still desired to use 500- 1000 grafts more in second or same sitting.

Summary

Because transplanted hair will only survive in the new area for as long as it would have from where it was taken, the most important thing all hair transplant patients should remember is that reality. The second most important thing to remember is that there are a limited number of scalp FU that contain permanent hair. The more you use up in one area,for example with low hairlines and “dense packing”, the fewer you will have left to treat other areas that are or will become bald as you age. The younger you are, the more important it is to remember both of the preceding.

The main disadvantage of strip harvesting is that a linear scar is always produced; unfortunately, if the excision isn’t done properly or a complication occurs it can be quite wide, but it is important to emphasize that such complications are very rare in an experienced surgeon’s hands, such as ours.

On the other hand, the main disadvantages of FUE are that hair survival of FU harvested via FUE can be reasonably expected to be lower than in microscopically-prepared FU from strips, and if large numbers of grafts are, or will one day need to be harvested, more of the grafts will only have temporary hair. Not incidentally, the punctuate scars that are present in only temporarily hair-bearing fringe areas today, will become noticeable when that hair is lost in the future. If you are relatively young and contemplating FUE, we urge you to now re-read the above paragraph.

FUE is far from the panacea that some of its Internet proponents suggest it is – especially for young men in whom the ultimate size of the bald and donor areas are far less certain than in older men.

We are a team of trained dermatologist and plastic surgeons, regularly doing hair transplants, offering multiple techniques of hair transplantation to our patients. We plan, discuss and perform the best technique suitable for each individual patient.