Hair transplantation

Example of a graft transplantation. (scar of a Hidradenitis suppurativa operation on the back of the head.)

Hair transplantation is a surgical technique that involves moving individual hair follicles from one part of the body (the donor site) to bald or balding parts (the recipient site). It is primarily used to treat male pattern baldness, whereby grafts containing hair follicles that are genetically resistant to balding are transplanted to bald scalp. However, it is also used to restore eyelashes, eyebrows, beard hair, chest hair, and pubic hair and to fill in scars caused by accidents or surgery such as face-lifts and previous hair transplants. Hair transplantation differs from skin grafting in that grafts contain almost all of the epidermis and dermis surrounding the hair follicle, and many tiny grafts are transplanted rather than a single strip of skin.

Since hair naturally grows in follicles that contain groupings of 1 to 4 hairs, today’s most advanced techniques transplant these naturally occurring 1–4 hair "follicular units" in their natural groupings. Thus modern hair transplantation can achieve a natural appearance by mimicking nature hair for hair. This hair transplant procedure is called Follicular Unit Transplantation (FUT). Donor hair can be harvested in two very different ways;

1. Strip Harvesting - a strip of scalp is removed under local anesthesia, the wound is then sutured back together and this piece of scalp tissue is then cut in to small pieces of tissue called grafts which are then transplanted back in to the thinning area of the patients head. This method will leave a linear scar in the donor area, which should be covered by a patients hair (if long). The recovery period is around 2 weeks and will require the stitches to be removed by medical personnel.

2. Follicular Unit Extraction or FUE Harvesting - individual follicles of hair are removed under local anesthesia; this micro removal uses tiny punches of between 0.6mm and 1.25mm in diameter. Each follicle is then reinserted back in to the scalp in the thinning area using a micro blade. Because this is single follicles and no large amount of tissue is removed there is no visible scars or post-surgery pain, with no stitches to be removed. Recovery from FUE is within 7 days.

History

The use of both scalp flaps, in which a band of tissue with its original blood supply is shifted to the bald area, and free grafts dates back to the 19th century. Modern transplant techniques began in Japan in the 1930s, where surgeons used small grafts, and even "follicular unit grafts" to replace damaged areas of eyebrows or lashes. They did not attempt to treat baldness per se. Their efforts did not receive worldwide attention at the time, and the traumas of World War II kept their advances isolated for another two decades.

The modern era of hair transplantation in the western world was ushered in the late 1950s, when New York dermatologist Norman Orentreich began to experiment with free donor grafts to balding areas in patients with male pattern baldness. Previously it had been thought that transplanted hair would thrive no more than the original hair at the "recipient" site. Dr. Orentreich demonstrated that such grafts were "donor dominant," as the new hairs grew and lasted just as they would have at their original home. Today Dr. Orentreich's practice still performs hair transplants.

Advancing the theory of donor dominance, Walter P. Unger, M.D. defined the parameters of the "Safe Donor Zone" from which the most permanent hair follicles could be extracted for hair transplantation. As transplanted hair will only grow in its new site for as long as it would have in its original one, these parameters continue to serve as the fundamental foundation for hair follicle harvesting, whether by strip method or FUE.

For the next twenty years, surgeons worked on transplanting smaller grafts, but results were only minimally successful, with 2–4 mm "plugs" leading to a doll's head-like appearance. In the 1980s, Uebel in Brazil popularized using large numbers of small grafts, while in the United States Rassman began using thousands of “micrografts” in a single session.

In the late 1980s, Limmer introduced the use of the stereo-microscope to dissect a single donor strip into small micrografts.

The follicular unit hair transplant procedure has continued to evolve, becoming more refined and minimally invasive as the size of the graft incisions have become smaller. These smaller and less invasive incisions enable surgeons to place a larger number of follicular unit grafts into a given area. With the new "gold standard" of ultra refined follicular unit hair transplantation, over 50 grafts can be placed per square centimeter, when appropriate for the patient.

Surgeons have also devoted more attention to the angle and orientation of the transplanted grafts. The adoption of the “lateral slit” technique in the early 2000s, enabled hair transplant surgeons to orient 2 to 4 hair follicular unit grafts so that they splay out across the scalp's surface. This enabled the transplanted hair to lie better on the scalp and provide better coverage to the bald areas. One disadvantage however, is that lateral incisions also tend to disrupt the scalp's vascularity more than sagitals. Thus sagital incisions transect less hairs and blood vessels assuming the cutting instruments are of the same size. One of the big advantages of sagitals is that they do a much better job of sliding in and around existing hairs to avoid follicle transection. This certainly makes a strong case for physicians who do not require shaving of the recipient area. The lateral incisions bisect existing hairs perpendicular (horizontal) like a T while sagital incisions run parallel (vertical) alongside and in between existing hairs. The use of perpendicular (lateral/coronal) slits versus parallel (sagital) slits, however, has been heavily debated in patient-based hair transplant communities. Many elite hair transplant surgeons typically adopt a combination of both methods based on what is best for the individual patient.

With the latest improvements in surgical procedures, the recovery time is immediate. There is no bed rest or hospitalization required after the hair transplant and the patient can immediately get back to home after the OPD procedure. He can even get back to office from Day 2 after surgery (provided the hair transplant is done by a qualified and skilled / experienced surgeon). Also the procedure is made almost painless by these experienced surgeons whereas it used to be associated with lots of pain in earlier days.

The procedure

At an initial consultation, the surgeon analyzes the patient's scalp, discusses his preferences and expectations, and advises him/her on the best approach (e.g. single vs. multiple sessions) and what results might reasonably be expected.

For several days prior to surgery the patient refrains from using any medicines, or alcohol, which might result in intraoperative bleeding and resultant poor "take" of the grafts. Pre-operative antibiotics are commonly prescribed to prevent wound or graft infections.

In recent years hair transplants have become less expensive.

Surgery

Transplant operations are performed on an outpatient basis, with mild sedation (optional) and injected topical anesthesia, and typically last about four hours. The scalp is shampooed and then treated with an antibacterial chemical prior to the donor scalp being harvested.

In the usual follicular unit procedure, the surgeon harvests a strip of skin from the posterior scalp, in an area of good hair growth. The excised strip is about 1–1.5 x 15–30 cm in size. While closing the resulting wound, assistants begin to dissect individual follicular unit grafts from the strip. Working with binocular Stereo-microscopes, they carefully remove excess fibrous and fatty tissue while trying to avoid damage to the follicular cells that will be used for grafting. The latest method of closure is called 'Trichophytic closure' which results in much finer scars at the donor area.

FUE harvesting negates the need for large areas of scalp tissue to be harvested and can give very natural results with the right experienced surgeon.

The surgeon then uses very small micro blades or fine needles to puncture the sites for receiving the grafts, placing them in a predetermined density and pattern, and angling the wounds in a consistent fashion to promote a realistic hair pattern. The assistants generally do the final part of the procedure, inserting the individual grafts in place.

Post-operative care

Advances in wound care allow for semi-permeable dressings, which allow seepage of blood and tissue fluid, to be applied and changed at least daily. The vulnerable recipient area must be shielded from the sun, and shampooing is started two days after the surgery. Some surgeons will have the patient shampoo the day after surgery. Shampooing is important to prevent scabs from occurring around the hair shaft. Scabs adhere to the hair shaft and increase the risk of losing newly transplanted hair follicles during the first 7 to 10 days post-op.

During the first ten days, virtually all of the transplanted hairs, inevitably traumatized by their relocation, will fall out ("shock loss"). After two to three months new hair will begin to grow from the moved follicles. The patient's hair will grow normally, and continue to thicken through the next six to nine months. Any subsequent hair loss is likely to be only from untreated areas. Some patients elect to use medications to retard such loss, while others plan a subsequent transplant procedure to deal with this eventuality.

Modern techniques

There are several different techniques available for the harvesting of hair follicles, each with their own advantages and disadvantages. Regardless of which donor harvesting technique is employed, proper extraction of the hair follicle is paramount to ensure the viability of the transplanted hair and avoid transection, the cutting of the hair shaft from the hair follicle. Hair follicles grow at a slight angle to the skin's surface, which means that regardless of technique transplant tissue must be removed with a corresponding angle and not perpendicular to the surface.

There are three main ways in which donor grafts are extracted today: strip excision harvesting, follicular unit extraction and direct hair implantation.

Strip harvesting is the most common technique for removing hair and follicles from a donor site, most commonly the area at the back and sides of the scalp. A single-, double-, or triple-bladed scalpel is used to remove strips of hair-bearing tissue from the donor site. Each incision is carefully planned to ensure intact removal of hair follicles. Once removed, the strip is dissected into follicular units, which are small, naturally formed groupings of hair follicles.

Follicular Unit Extraction (FUE) takes place in a single long session. If meticulous technique is used there is no need to be afraid about any transplanted graft, according to literature 98.7% is the possible live graft outcome rate. There is a school of thought that not all hair transplant candidates are suitable for FUE hair transplants. Currently a pre procedure test called the "fox test" is applied to determine the suitability of the available donor tissue for grafting. However excluding potential candidates based on the fox test may not be necessary. A recent RCT study conducted by doctors at the FUE hair transplant clinic in Sri Lanka show that by establishing a quality control protocol to manually change the accuracy of punch direction and cutting depth into dermis for each follicular unit significantly improves the quality of the graft yield. Maintaining strict quality control during graft extraction from one graft to the next may be all that is required to perform successful FUE for all candidates. This is important as the quality of grafts is a principle determinant of outcome of the FUE hair transplant. Wider acceptance of this extraction protocol developed by FUE hair transplant clinic Sri Lanka may remove the need for performing a fox test and excluding clients for FUE hair transplants based on it.

The NeoGraft Transplant Machine is a device that is used to both extract follicular units from the donor area and implant them in the recipient area via a suction-based system. The Neograft procedure requires no scalpels, sutures, or staples and does not leave a linear scar on the back of the scalp, although it leaves miniature circle-shaped scars in the punctured areas, just like the traditional FUE method. The downsides of the NeoGraft method are increased follicle fragility and desiccation (drying) due to exposure to suction.

Side effects

Hair thinning, known as "shock loss", is a common side effect that is usually temporary. Bald patches are also common, as fifty to a hundred hairs can be lost each day.

Other side effects include swelling of areas such as the scalp and forehead. If this becomes uncomfortable, medication may ease the swelling. Additionally, the patient must be careful if his scalp starts itching, as scratching will make it worse and cause scabs to form. A moisturizer or massage shampoo may be used in order to relieve the itching.

Several years after the surgery, more hair loss can occur, with the transplanted patches staying in place. This results in odd patches of hair, unless they are removed, or unless more hair is transplanted.

References

• Bernstein RM, Rassman WR, Seager D; et al. (1998). "Standardizing the classification and description of follicular unit transplantation and mini-micrografting techniques. The American Society for Dermatologic Surgery, Inc". Dermatol Surg. 24 (9): 957–63. doi:10.1016/S1076-0512(98)00108-3. PMID 9754083. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
• derm/559 at eMedicine

External links

Hair Transplant at Curlie

• Hair transplant in the news
• Article on Hair Transplant Surgery