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Hair restoration modern techniques

In the recent years three basic types of surgical hair transplant procedure are being carried out such as; surgical excision or scalp reduction, scalp flaps, and free autografts. Of these the technique of autografting, viz. micrografting, minigrafting and follicular unit grafts, is the most commonly used.

In the surgical excision technique the patient had part of his bald region removed by making incisions and pulling the skin together closer to give a visual appearance of a smaller area of baldness. The extra skin was removed while suturing and the skin held in place using extenders. This method, that sounded simple initially and was carried out on a large scale, had disadvantages. The stretched skin stretched further, or further baldness set in due to the trauma caused by the procedure. If the patient was a case of hereditary alopecia, then with the loss of hair, the scars on the stretched skin were visibly ugly. Although many scientists tried alleviating these problems by devising new methods such as Frechet extender, Seery periosteal anchor flap, Unger prolonged acute tissue tension, and Nordstrom silastic suture, or using incisions in shapes such as “M” or inverted “Y” to minimize the effect of visual scarring, this technique however has been restricted to a very few select cases.

The flap technique got a boost in the mid 1970s by Dr. Jose Juri due to its seemingly easy application of harvesting a flap and placing it in the recipient bald scalp. Longer and shorter flaps were experimented with, but in some of the cases the wound broke down and the entire grafted scalp got rejected. To avoid this problem, expanders were used so that the wounds could be closed without scalp tension. When it came to scarring however, no amount of scalp covering procedures were effective. The flap procedures are conducted by a very few highly skilled surgeons these days. They can work, but only in the hands of an expert.

Autograft surgery was considered a better alternative to the above two procedures. The initial grafts were in the form of small punches of up to 5mm in diameter. With the evolution of the technique, the grafts decreased in size and now the follicular unit transplant is the most popular method available to patients. Minigrafts involved the use of hair follicles surrounded by some scalp skin and inserted in the scalp using a scalpel blade. The follicular units used by most hair transplant surgeons today are refined minigrafts and they have only the intact follicles with no extra tissues surrounding them. In general, a follicular unit transplant is carried out by harvesting donor hair as a single strip, dissecting this strip into follicular units according to need, and inserting these separated follicles in the recipient area. Since the technique involves the use of microscopes for dissection, the procedure is time consuming. However, the use of microscopes has lessened the amount of damage to the follicles and hence the survival rate of inserted hair is high.

Surgeons use slight variations in their technique depending on their patient and available resources. Most of the variations depend on the patients. Here are some of the variables that are addressed by the surgeon in a broad perspective.

1. Graft number and graft density – depending on the type of the patient, the number of hairs necessary for a hair transplant is determined. For example, in a man with a type 6 Norwood balding pattern the bald area requiring treatment is about 200 sq. cm. The usual density for recipient site insertion is 60 hairs / sq. cm. If the available density is only 40 hairs / sq cm, even then he would require about 8,000 hairs which can be achieved using 3500 follicular units. It is seen that the frontal region hair insertion is always denser as compared to the crown. To achieve consistent results, it is mandatory that the surgeon use naturally grouped single or double hair units instead of dissecting larger natural groups of 3, 4 or 5. The maximum hair density possible still remains a topic of debate.

2. Tumescent anesthesia – Alcohol, aspirin, vitamin E and narcotics like marijuana delay blood coagulation and hence the doctor has to monitor the intake of these prior to a surgery. In this method of tumescent anesthesia, anesthesia is injected as a dilute solution along with a vasoconstrictor like epinephrine which decreases the diameter of the blood vessels. When the tumescent anesthesia is uniformly injected into the donor and recipient regions, the dermal layer gets thickened and this thickening helps the surgeon avoid injury to larger blood vessels thereby reducing bleeding. Because a certain pressure is maintained in the dermis, the popping out of inserted follicles is also avoided. Since patients do not suffer from post operative edema, this anesthesia is widely used in hair transplant procedures. In some European countries and in New Zealand and Australia, a synthetic vasoconstrictor called 8-ornithine vasopressin is used instead of epinephrine although epinephrine finds greater usage in the rest of the world.

3. Use of blades for hair transplantation – prior to the use of stereomicroscopes, most surgeons used multi blade systems for harvesting donor hair. In the multi blade system, the surgeon has visible access only with respect to the first blade and the rest of the blades cut through the scalp layers blindly. To lessen the damage of follicles while using multi blade systems, Dr. James Arnold has suggested the use of large amount of tumescent anesthesia in the donor region followed by use of ultra sharp blade for cutting, slow wrist and finger movement while excising and constant monitoring of the direction in which the blades are excising the tissues, all of which when done with precision would yield near perfect strips. Sometimes, the scalp skin of the patient may be very soft and is generally referred to as the ‘mushy dermis’. In such patients, the use of a multi blade system is not recommended. While dissecting the strips for individual follicular units, care must be taken to slice them without damage because once the strips have been harvested, they lose turgidity. Hence the use of stereomicroscope is very useful during dissection.

4. Role of microscopes in dissection – Before Dr. Limmer introduced the use of microscopes in follicle dissection, most of this procedure was done using the naked eye or sometimes with a loupe. His technique was significant because the number of follicles that could be obtained when high power microscopes were used was of a much greater magnitude. And this directly affected the survival rate of the inserted hairs. This technique however is dependent on the skills of the surgeon’s assistants since the use of microscopes increases the time of the whole transplant procedure. The use of high power stereomicroscopes is extremely useful in patients who have limited donor hair and want maximum benefit.

5. Recipient site incisions – are carried out using different types of blades and gauges of needles. Usually for obtaining a high density of hair, solid or hollow 20-21 gauge needles are used. Most often the needles are selected according to the size of the graft to be inserted.

6. Use of lasers in surgery – It has been seen that the heat that the lasers produce is not suitable for hair transplant procedures. The heat related damage to both the hair follicles and the scalp skin would require corrective treatment. Since a lot of research is going on regarding the use of lasers in hair transplant surgery, we may use this procedure soon in the future, but currently most surgeons do not use lasers.

Do complications arise in follicular unit transplantation?

The procedure of follicular unit transplantation is the least complicated procedure. If any complications arise, it is mainly due to human error. One of the major contributions of human error is in the donor strip dissection. During mega sessions, the time factor may induce fatigue in the surgical assistants and this result in drying of the follicles and differential pressure on the blades may damage the follicles. The use of saline, alcohol, antiseptics and water and extensive use of vasoconstrictors and very close spacing of the grafts may also contribute to avoidable complications.

Other factors such as small sized grafts and use of very fine needles may damage the graft when the graft is inserted in the recipient site using pressure. This effect is often compared with the damage possible when a 100 pound woman is wearing stiletto heels. The pressure exerted by the heels is ten times more than a four ton elephant foot. Dr. Gandelman has found that most of the negligence occurs during preserving the hair grafts and their drying is the most common mistake. Keeping the grafts at a temperature of 20 deg F for 3 minutes also means they undergo irreversible damage. Keeping them cool is important.

Donor area scarring is a cosmetic problem rather than a complication. Since the scars are visible in patients who have thin hair and those with rapid hair loss, proper selection of the donor area is the only option available so far to minimize scar visibility. The size and number of strips harvested also contribute to the scarring process and there is high variability amongst the patients based on their scalp characteristics.

Customer satisfaction –

When the fee is high, the general public always expects the best for what they have paid. Even when the best of procedures is applied, there is always some amount of discontent with respect to the final hair density, pain and number of sessions necessary. Sometimes the dissatisfaction is so high that the patients seek legal help. Proper counseling of the patients and appropriate selection of patients for hair transplant procedure is very important for positive feedback.

Small populations of patients however are never satisfied even if they are given the best of everything and a smart surgeon usually identifies such patients during the counseling sessions and rejects them before any hair transplant surgery. Patients who can be rejected also belong to younger age groups who are likely to experience further hair loss later in their life. Most often patients in the age group of 32-35 and above are the most ideal for they not only have substantial predictable hair loss, but are also emotionally mature enough to comprehend the given situation.

The future hair transplant or restoration – In the surgical arena, not much may be added in the next few years, but with gene therapy and cloning taking center stage, there could be some developments on that front. Bypassing the telogen phase after transplantation, judicious use of minoxidil, better mechanical harvests and automation in harvesting donor hair will improve the prospects of hair transplantation in the future. In the present situation, a successful hair transplant is naturally the one conducted by a surgeon with skill.


Hair restoration modern techniques references

  • Shiell RC. Modern hair restoration surgery. Clin Dermatol. 2001 Mar-Apr;19(2):179-87. PMID: 11397597
  • Lam SM, Hempstead BR, Williams EF. A philosophy and strategy for surgical hair restoration: a 10-year experience. Dermatol Surg. 2002 Nov;28(11):1035-42; discussion 1042. PMID: 12460300
  • Whitworth JM, Stough DB, Limmer B, Limmer B, Seager D, Boudjema P, Barrera A, Choi YC, Mangubat A. A comparison of graft implantation techniques for hair transplantation. Semin Cutan Med Surg. 1999 Jun;18(2):177-83. PMID: 10385286
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