Hair Transplantation
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Hair transplantation is a
surgical Surgery is a medical specialty that uses manual and instrumental techniques to diagnose or treat pathological conditions (e.g., trauma, disease, injury, malignancy), to alter bodily functions (e.g., malabsorption created by bariatric surgery ...
technique that removes
hair follicle The hair follicle is an organ found in mammalian skin. It resides in the dermal layer of the skin and is made up of 20 different cell types, each with distinct functions. The hair follicle regulates hair growth via a complex interaction betwee ...
s from one part of the body, called the 'donor site', to a bald or balding part of the body known as the 'recipient site'. The technique is primarily used to treat
male pattern baldness Pattern hair loss (also known as androgenetic alopecia (AGA)) is a hair loss condition that primarily affects the top and front of the scalp. In male-pattern hair loss (MPHL), the hair loss typically presents itself as either a receding front ...
. In this minimally invasive procedure, grafts containing hair follicles that are genetically resistant to balding (like the back of the head) are transplanted to the bald scalp. Hair transplantation can also be used to restore
eyelash An eyelash (also called lash) (Neo-Latin: ''cilium'', plural ''cilia'') is one of the hairs that grows at the edges of the top and bottom eyelids, spanning outwards and away from the eyes. The lashes grow in up to six layers on each of the upper ...
es,
eyebrow An eyebrow is an area of short hairs above each eye that follows the shape of the lower margin of the Supraorbital ridge, brow ridges of some mammals. In humans, eyebrows serve two main functions: first, human communication, communication thro ...
s, beard hair, chest hair, 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 graft Skin grafting, a type of graft (surgery), graft surgery, involves the organ transplant, transplantation of skin without a defined circulation. The transplanted biological tissue, tissue is called a skin graft. Surgeons may use skin grafting to ...
ing in that grafts contain almost all of the
epidermis The epidermis is the outermost of the three layers that comprise the skin, the inner layers being the dermis and Subcutaneous tissue, hypodermis. The epidermal layer provides a barrier to infection from environmental pathogens and regulates the ...
and
dermis The dermis or corium is a layer of skin between the epidermis (skin), epidermis (with which it makes up the cutis (anatomy), cutis) and subcutaneous tissues, that primarily consists of dense irregular connective tissue and cushions the body from s ...
surrounding the hair follicle, and many tiny grafts are transplanted rather than a single strip of skin. Since hair naturally grows in groupings of 1 to 4 hairs, current techniques harvest and transplant hair "follicular units" in their natural groupings. Thus modern hair transplantation can achieve a natural appearance by mimicking original hair orientation. This hair transplant procedure is called
follicular unit transplantation Follicular unit transplantation (FUT) is a hair restoration technique, also known as the strip procedure, where a patient's hair is transplanted in naturally occurring groups of 1 to 4 hairs, called follicular units. Follicular units also contai ...
(FUT). Donor hair can be harvested in two different ways: strip harvesting, and
follicular unit extraction Follicular unit extraction (FUE; also follicular unit excision or follicular transfer, FT) Performed under local anaesthetic, FUE procedure involves the harvesting of individual hair follicles from the donor site at the back of the head using a t ...
(FUE).


Procedure


Pre-operative assessment and planning

At an initial consultation, the surgeon analyzes the patient's scalp, discusses their preferences and expectations, and advises them on the best approach (e.g. single vs. multiple sessions) and what results might reasonably be expected. Laxometers are used to measure the looseness (or more specifically, '' laxity'') of the scalp. Pre-operative folliscopy will help to know the actual existing density of hair, so that postoperative results of newly transplanted hair grafts can be accurately assessed. Some patients may benefit with preoperative topical minoxidil application and vitamins. For several days prior to surgery the patient refrains from using any medicines which might result in intraoperative bleeding and resultant poor grafting. Alcohol and smoking can contribute to poor graft survival. Post operative
antibiotic An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting pathogenic bacteria, bacterial infections, and antibiotic medications are widely used in the therapy ...
s are commonly prescribed to prevent wound or graft
infection An infection is the invasion of tissue (biology), tissues by pathogens, their multiplication, and the reaction of host (biology), host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmis ...
s.


Harvesting methods

Transplant operations are performed on an outpatient basis, with mild
sedation Sedation is the reduction of irritability or agitation by administration of sedative drugs, generally to facilitate a medical procedure or diagnostic procedure. Examples of drugs which can be used for sedation include isoflurane, diethyl ether, ...
(optional) and injected local
anesthesia Anesthesia (American English) or anaesthesia (British English) is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia (relief from or prev ...
. The scalp is shampooed and then treated with an antibacterial agent prior to the donor scalp being harvested. There are several different techniques for harvesting hair follicles, each with their own advantages and disadvantages. Regardless of the harvesting technique, 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, so transplanted tissue must be removed at a corresponding angle. There are two main ways in which donor grafts are extracted today: strip excision harvesting, and follicular unit extraction.


Strip harvesting (FUT)

Strip harvesting (also known as
follicular unit transplantation Follicular unit transplantation (FUT) is a hair restoration technique, also known as the strip procedure, where a patient's hair is transplanted in naturally occurring groups of 1 to 4 hairs, called follicular units. Follicular units also contai ...
or FUT) is the most common technique for removing hair and follicles from a donor site. The surgeon harvests a strip of skin from the posterior scalp, in an area of good hair growth. A single-, double-, or triple-bladed scalpel is used to remove strips of hair-bearing tissue from the donor site. Each incision is planned so that intact hair follicles are removed. 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, which are small, naturally formed groupings of hair follicles, 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. 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 technicians generally do the final part of the procedure, inserting the individual grafts in place. Strip harvesting will leave a thin linear scar in the donor area, which is typically covered by a patient's hair even at relatively short lengths. The recovery period is around 2 weeks and will require the stitches/staples to be removed by medical personnel or sub cuticular suturing can be done.


Follicular unit extraction (FUE)

With Follicular Unit Extraction or FUE harvesting, individual follicular units containing 1 to 4 hairs are removed under local anesthesia; this micro removal typically uses tiny punches of between 0.6mm and 1.0mm in diameter. 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 technicians generally do the final part of the procedure, inserting the individual grafts in place. FUE takes place in a single long session or multiple small sessions. The FUE procedure is more time-consuming than strip surgery. An FUE surgery time varies according to the surgeons experience, speed in harvesting and patient characteristics. The procedure can take anywhere from a couple hours to extract 200 grafts for a scar correction to a surgery over two consecutive days for a megasession of 2,500 to 3,000 grafts. With the FUE Hair Transplant procedure there are restrictions on patient candidacy. Clients are selected for FUE based on a fox test, though there is some debate about the usefulness of this in screening clients for FUE. FUE can give very natural results. The advantage over strip harvesting is that FUE harvesting negates the need for large areas of scalp tissue to be harvested, so there is no linear incision on the back of the head and it doesn't leave a linear scar. Because individual follicles are removed, only small, punctate scars remain which are virtually not visible and any post-surgical pain and discomfort is minimized. As no suture removal is required, recovery from Micro Grafting FUE is less than 7 days. Disadvantages include increased surgical times and higher cost to the patient. It is challenging for new surgeons because the procedure is physically demanding and the learning curve to acquire the skills necessary is lengthy and tough. Some surgeons note that FUE can lead to a lower ratio of successfully transplanted follicles as compared to strip harvesting.


Robotic hair restoration

Robotic hair restoration devices utilize cameras and robotic arms to assist the surgeon with the FUE procedure. In 2009, NeoGraft became the first robotic surgical device FDA approved for hair restoration. The ARTAS System was FDA approved in 2011 for use in harvesting follicular units from brown-haired and black-haired men.


Applications

There are a number of applications for hair transplant surgery, including: * Androgenetic alopecia * Eyebrow transplant * Frontal hair line lowering or reconstruction (naturally high hairlines without an existing hair loss condition) If donor hair numbers from the back of the head are insufficient, it is possible to perform body hair transplantation (BHT) on appropriate candidates who have available donor hair on the chest, back, shoulders, torso and/or legs. Body hair transplant surgery can only be performed by the FUE harvesting method and, so, requires the skills of an experienced FUE surgeon. However, there are several factors for a potential BHT candidate to consider prior to surgery. These include understanding the natural difference in textural characteristics between body hair and scalp hair, growth rates, and having realistic expectations about the results of BHT surgery.


Cost

The cost of hair transplantation depends on the individual hair loss and consequently on the number of necessary grafts. The average price per graft ranges between US$1.07 in
Turkey Turkey, officially the Republic of Türkiye, is a country mainly located in Anatolia in West Asia, with a relatively small part called East Thrace in Southeast Europe. It borders the Black Sea to the north; Georgia (country), Georgia, Armen ...
up to US$7.00 in Canada. Some clinics also offer all-inclusive packages. In the UK the cost can be between £1,000–£30,000 depending on location and area of implant.


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.


History

The use of both
scalp The scalp is the area of the head where head hair grows. It is made up of skin, layers of connective and fibrous tissues, and the membrane of the skull. Anatomically, the scalp is part of the epicranium, a collection of structures covering th ...
flaps, in which a band of tissue with its original blood supply is shifted to the continue bald area, and free grafts dates back to the 19th century. In 1897, Menahem Hodara successfully implanted hair taken from the unaffected areas of the scalp on to the scars that were left bald by favus. 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 An eyebrow is an area of short hairs above each eye that follows the shape of the lower margin of the brow ridges of some mammals. In humans, eyebrows serve two main functions: first, communication through facial expression, and second, preve ...
or lashes, but not to treat
baldness Hair loss, also known as alopecia or baldness, refers to a loss of hair from part of the head or body. Typically at least the head is involved. The severity of hair loss can vary from a small area to the entire body. Inflammation or scarring ...
. 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 Dermatology is the branch of medicine dealing with the skin.''Random House Webster's Unabridged Dictionary.'' Random House, Inc. 2001. Page 537. . It is a speciality with both medical and surgical aspects. A dermatologist is a specialist medi ...
Norman Orentreich began to experiment with free donor
grafts Grafting refers to a surgical procedure to move tissue from one site to another on the body, or from another creature, without bringing its own blood supply with it. Instead, a new blood supply grows in after it is placed. A similar techniqu ...
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. Orentreich demonstrated that such grafts were "donor dominant," as the new hairs grew and lasted just as they would have at their original home. 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, strip excisions began to replace the plug technique, and Carlos Uebel in Brazil popularized using large numbers of small grafts, while in the United States William Rassman began using thousands of "micrografts" in a single session. In the late 1980s, B.L. 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 sagittals. Thus sagittal incisions transect less hairs and blood vessels assuming the cutting instruments are of the same size. One of the advantages of sagittals is that they do a much better job of sliding in and around existing hairs to avoid follicle transection. This 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 sagittal incisions run parallel (vertical) alongside and in between existing hairs. The use of perpendicular (lateral/coronal) slits versus parallel (sagittal) 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.


Research and future techniques

Stem cells and dermal papilla cells have been discovered in hair follicles. Research on these follicular cells may lead to successes in treating baldness through hair multiplication (HM), also known as
hair cloning Hair multiplication, or hair cloning, is a proposed technique to counter hair loss. The technology is in its early stages, but multiple groups have demonstrated pieces of the technology at a small scale, with a few in commercial development. Sc ...
.


References


Further reading

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External links

* {{Authority control Cosmetic surgery Transplantation medicine