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]
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
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%
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
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
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
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
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
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
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
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
3. initial shock to the existing hair follicles
due to which they thinned down but picked up strength again once
all the hair
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
of their thicker, darker hair which makes handling easier.
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.