follicular-unit hair grafting
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Follicular-unit hair grafting

The main goal of hair transplant surgeons is to minimize detectability of hair transplantation procedures and retain natural look and flow of the hair. Hair transplantation has been in vogue for more than 50 years now. During its initial stages of conception, hair surgeons transplanted about 20 hairs at a time using as big as 4mm circular grafts. Over a period of time, with refinement in techniques, the grafts became smaller in size with the circular grafts replacing semicircular grafts and these in turn were replaced by quarter grafts and now grafts as small as a single hair is being used. It was during the 1990s that the micro and mini grafts became popular. A micro graft contains 1 or 2 hair follicles while the mini grafts have 3-4 hair follicles per graft respectively.

The latest trend is the follicular unit hair transplant with which a natural look can be mimicked to a great extent to obtain excellent results. This method was first described by Dr. Headington in 1984. Follicular unit transplantation is a process in which the hair follicles are harvested from the head [donor site] and all extra material, such as the supporting tissues and the sebaceous glands [found in the base of hair shaft that protect the hair from drying] are removed, retaining only the undamaged hair follicles in a minimal amount of scalp skin. The process is however time consuming and has to be done by experts to achieve greater finesse.

The potential advantages of this technique are as follows:-
1. smaller grafts with minimum scalp skin
2. grafts possible on smaller recipient sites
3. smaller graft sites correspond to greater hair density
4. faster healing
5. less shock and damage to already existing hair near and around the site of transplantation
6. more limited pigmentation of the scalp as a side effect of transplantation
7. recipient scalp texture maintained
8. isolation of grafts according to individual needs
9. minimal damage to the hair follicles during micro dissection and hence 20% increase in hair follicle yield as compared to other techniques.

The technique in detail:-
Evaluating a patient is the most critical part of this procedure. The number of hairs to be transplanted depends on his hairline, thinning pattern, available donor hair, individual requirement and preference. In the first transplant, the number of grafts transplanted may vary between 1500-2200. Although in one transplant the required hair density can be achieved, a second transplant could be necessary if the patient shows further progress in hair loss.

1. The natural hair line of the patient is marked and the extent of hair transplant required analyzed.

2. The patient is administered a slow anesthesia both at the donor and recipient site that keep the areas numb.

3. A 20 cm2 strip is harvested from the back of the head and the area sutured. A 20 cm2 strip typically means a strip 20 cm long and 1 cm wide. This strip would ideally have between 1400-2400 hair follicles depending on the natural hair density of the patient. Hence on an average, 1600 follicles can be expected out of this harvest.

4. The harvested strip is then dissected in two steps. In the 1st step groupings of 2-3 follicular units are teased out. In the 2nd step, these are further teased to obtain single follicular units with the dissection done under a binocular microscope. All unnecessary and excess non-hair bearing tissues are removed leaving only the follicles. The single follicular units may have 1, 2, 3 or 4 hairs per unit with the average in most grafts being 2 or 3.

5. The separated and ready to use follicles are stored in chilled saline until the site for transplantation is prepared.

6. The site of transplantation is already evaluated by the surgeon for number of transplants for optimum hair density and the angle of hair growth so that the transplanted hair can retain its natural flow.

7. Sharp pointed blades ranging from 0.7 mm to 1.3 mm width are used in sites requiring transplants of 1-2 and up to 4 hair grafts respectively. Hydrogen peroxide is used to clean the area and using a jeweler’s forceps the grafts are placed in position. Use of hydrogen peroxide prevents drying of both the site and follicles. The grafts are placed at the same level depth with the scalp skin to avoid dimpling of the skin surface. The whole procedure takes about 3-5 hours to perform and involves no post operative bandage. The hair is washed under the surgeons care the following day and within a weeks time the patient can get back to his normal hair care.

8. Like the rest of the hair, the transplanted hair undergoes fall out 3 weeks after transplantation. 8-10 weeks post transplant, the patient can use minoxidil for about 4 months so that the natural hair cycle is restored and hair grows in tandem with the naturally retained hair.

9. Depending on the necessity, a patient can undergo another session as suggested by his surgeon.

10. By this method over 90% of the transplanted hair grew. However about 90% of them also experienced hair fall called as telogen effluvium which was alleviated using 5% minidoxil.

The final results of this procedure have been remarkable with most of the patients being satisfied. Just as in all other procedures, there were a few discrepancies encountered which were minor and solvable.

1. low percentage of hair growth in some patients requiring another session of replacement.

2. redness of skin caused due to capillary congestion mainly due to infection. Such patients were administered antibiotics to combat the infection.

3. initial shock to the existing hair follicles due to which they thinned down but picked up strength again once all the hair follicles reorganized their growth pattern.

4. active smokers faced a threat of skin breakdown in their forelock region and hence needed both scalp repair and re-grafting.

According to Dr. Epstien, follicular unit transplantation is most effective in patients from Mediterranean region, Asians and Hispanics mainly because of their thicker, darker hair which makes handling easier.

Follicular-unit hair grafting references

  • Epstein JS. Follicular-unit hair grafting: state-of-the-art surgical technique.
    Arch Facial Plast Surg. 2003 Sep-Oct;5(5):439-44. PMID: 12975146
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