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
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
restoration modern techniques references
- Shiell RC.
Modern hair restoration surgery.
Clin Dermatol. 2001 Mar-Apr;19(2):179-87.
- 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.