FUT- Follicular Unit Transplant

Overview of FUT

• The strip method of hair transplantation commonly referred to as FUT is a method of donor hair follicle harvesting in which a strip of scalp is harvested under local anesthesia from the safe donor area of the occipital region and the wound is closed primarily. the correct technical name for FUT is FUSS-Follicular Unit Strip Surgery

• The strip is divided into multiple single rows of follicular units called “slivers.”

• The sliversare dissected into ‘grafts’ containing single follicular units (FUs). the follicular units may have one to four, rarely five follicles.

• Before performing strip harvesting, there must be a detailed examination of the donor area to see the density of hair, percentage of telogen, and anagen hair (to look for diffuse un-patterned hair loss) and determine the scalp laxity.

• The width of the strip to be harvested depends primarily on laxity of scalp. (For beginners, 1cm width is advised)

• The width of strip needs to be narrower in the mastoid region as skin laxity is less compared to the occipital region.

• Tumescence is infiltrated in the subcutaneous plane; never below galea.

• The depth of the strip incision is restricted upto supra-galeal plane, never deep to the galea as all neurovascular structures lie over the galea. When the galea is incised thereis risk of injuring neurovascular structures.

• The skin incision is closed preferably in two layers. The deep subcutaneous layer is closed by either Vicryl or PDS absorbable suture, and also skin is closed by absorbable suture may be rapid vicryl, although it depends on surgeon’s choice.Some surgeons use non-absorbable suture or staples for skin closure.

• For a better scar atrichophytic closure is preferred.

• In a trichophytic closure,the lower wound margin is de-epithelized, before the wound is closed. When the hair from lower margin grows, they grow through the scar, making it less appreciable.

Introduction – FUT Method

Follicular unit transplantation (FUT)isa surgical procedure, in which follicular units are harvested from the donor area and implanted in the recipient area. Headington¹ in 1984 described that hair grows in bundles of 1 to 4 or more individual follicles called follicular units (FUs).

The term FUT was first proposed by Limmer in 1994, in his articlepublished in Dermatologic Surgery, in which he described harvesting of a single strip of tissue from the SAFE area of the occipital scalp. The strip underwent stereo-microscopic dissection to produce single follicular unit grafts. Since its inception the strip harvest procedure has become the “Gold Standard” of hair restoration surgery. Over time the technique has undergone a series of refinements.It is better to call FUSS means Follicular Unit Strip Surgery

Strip Harvesting

A strip of skin with follicular units is excised from the safe donor area of the scalp under local anaesthesia. This is called a strip harvesting method or commonly called the FUT method of hair transplantation.

After the strip is harvested multiplethin strips a single FUs wide are separated from the scalp strip.This separation is called slivering and the strips are called slivers. From a sliver, individual FUs are dissected. These individual FUs are transplanted to the recipient area. During the entire process, from strip harvesting to FUs dissection, use of magnification is recommended, in order to prevent/reduce follicle transection and micro trauma to the delicate follicles.A hair transplant surgeon should have a good quality of prismatic magnifying loupe (preferable magnification more than 3.5X) for harvesting of the strip and stereo-microscopes are necessary for sliver and graft dissection. Stereo-microscopes provide virtual colour, depth perception and white hair follicles are easier to perceive and to dissect.

When To Do Hair Transplantation

Any patient having baldness affecting his/her self-esteem, who is systemically otherwise fit for surgery and has suitable scalp characteristics (donor area and recipient area factors) can undergo a hair transplant procedure. It is advisable to stabilize hair loss with medical treatment in young patients and avoid doing transplantation before the age of 23 years, but for young patients with advance grade of baldness, the transplant can be considered. Patients who start losing hair when very young even in their teenage years typically progress to extreme levels of baldness very rapidly. They ultimately may not be suitable for transplantation at all. In such cases, detailed counseling of the patients along with their parents is necessary. It is essential to explain the long-term outlook and treatment limitations and to discuss the role of long-term medications and hair transplantation.

When Not To Do Hair Transplantation

Systemic factors

1. All diseases and conditions making the patient unfit for any surgery are also contraindications to hair transplant surgery

2. Uncontrolled systemic diseases like hypertension, cardiac diseases, diabetes, epilepsy, and other diseases.

3. Psychologically unstable patients having unrealistic expectations in terms of coverage, densityand a very low anterior hairline.

4. Patients with major mental disorders like schizophrenia, psychosis.

5. Patients having body dysmorphic disorder.

Local factors

1. Patients with scarring alopecia or inflammatory scalp diseases affecting hair follicle survival.

2. Diffuse un-patterned hair loss (DUPA). And Patients with diffuse pattern hair loss involving the occipital area.

3. A patient with a keloidal or hypertrophic scarring tendency is a relative contraindication.

When Not To Do FUT or Strip Harvest Method of Hair Transplantation

Apart from the general contraindications to hair transplantation, patients with a very tight scalpsarenot good candidates for the strip harvest method, because, unless the strip is very narrow they are at risk for wider scars due to high wound closure tension.Also, a patient who wishes to keep very short hair in the donor area after surgery may find that the linear scar is visible to others and therefore is not advised to havethe strip method. A patient who does not want a linear scarin his/her donor area is one of the most common factors for not opting for the strip method of hair transplantation.

What To Do Before Strip Harvesting

1. Planning of recipient area (for detail see chap no 2)-Norwood stage of baldness and size of bald area in square centimetre

2. Detailed counselling with patients and attendants explaining the importance of medical treatment and limitations of hair transplantation.

3. Assessment of the donor area including scalp laxity.

4. Calculation of the required number of hair follicles to cover the recipient area

5. Explanation to patient of how much density he /she will have after surgery

Donor area assessment:

The success of a hair transplant surgery depends on the quality of the donor area. The donor area is to be evaluated forskin elasticity and laxity, the number of available FUs, the number of hairs in the FUs. The thickness, curvature andcolour of the hair are also important characteristics and is the contrast between scalp and hair colour.

Scalp laxity & elasticity

Collagen and elastic fibres are present in the dermis of the skin, which gives elastic property to skin. The laxity of the scalp is the ability move and stretch the scalp.The ability of the skin to return to its normal stage after stretching is called elasticity.

Scalp that is more elastic is also laxer.

Scalp laxity andelasticity are important in determining the potential tissue tension during wound closure. A wider scalpstrip in individuals with limited laxity can lead to excess tension over the suture line which may result in a wide scar, hypertrophic or keloid scar, and/or hair effluvium near suture line or tissue necrosis leading to a gap in the suture line.

Mobility of scalp skin not only depends on skin elasticity but also on the “glidiability” of the scalp. This is the ability of the scalp skin to glide over the pericranium and it is facilitated by a loose layer of fibro-areolar tissue below the galea.

Other than surgical factors the intrinsic property affect the quality of scar.

Donor hair density

Hair density is a measurement of hairs per centimetresquare of the scalp. Follicular unit density is the number of follicular units per cm^2.The average Hairs/FU varies from area to area of the donor scalp area. It is maximum in the centre of the occipital area andlower in the areas closer to ears.

Instructions Before Hair Transplant

Once the detailed consultation is completeand the patient and surgeon agree tothe surgery,there are a few important topics that need to be discussed with the patient.

Instructions before hair transplant

1. Current medications – the patient shall inform to his surgeon each and every thing about his medical history,medicines or allergy. As part of the consultation a detailed and precise history of medical illness and medical treatment has been obtained. Generally, all prescribed medications should be continued but some are discontinued, such as anticoagulants, aspirin and medications that interact with anaesthesia. Discontinuing medications should be cleared with the patient’s primary physician. Stop aspirin 3 to 7 days prior to a hair transplant.

2. If the patient is taking medicines daily for hypertension, diabetes, epilepsy, etc he/she shall take the usual doses the morning of the procedure unless the medication must be held for the procedure

3. Re-affirm any history of allergy.

4. As a routine protocol,check any possibility of drug interaction with medicines he/she is taking and medicines which you are going to use.

5. Stop smoking 3 weeks prior to a hair transplant. Smoking can result in poor healing and poor growth.

6. If the surgeon is planning body hair follicle harvesting, the patient is advised to shave chest/extremities hair 7 to 15 days before; beard shaving should stop 3 days before the date of the hair transplant.

7. Avoid alcohol and late-night party, a night or two before the hair transplant.

8. If the surgeon feels the patient is apprehensive ananxiolytic/sedative can be prescribed for the night before the hair transplant.

9. Discuss the details about payment and the timing of arrival to office.

10. The patient can have a routine meal before the hair transplant.

11. Prophylactic antibiotics on the day of hair transplant (if surgeons give?) There is no scientific evidence to support the need for prophylactic antibiotics in patients undergoing hair transplant surgery, unless they have a specific indication.

12. The patientshould wear loose clothes, avoid a T-shirt, and leave expensive valuables, at home.

13. Blood investigations are not mandatory for all patients, rather determined on a case by case basis. The author advises –CBC (Haemoglobin, blood cells count), Blood sugar, HbA1C, HIV, Australia antigen, SGOT, SGPT, Serum creatinine, or other as per medical history. Now test

Events Before Beginning Surgery

Consent

A detailed informed consent is taken. The author prefers to mention in consent form- the area of baldness (Norwood stage), number of FUs to be transplanted in this procedure, method of hair transplant. list of possible complications. Fees and taxes. also mention about future loss of unstable hair and need of medical treatment to control unstable hair and for future hair transplant. It is preferable that the consent form should be in the local language i.e. the patient’s language.

Xylocaine sensitivity test

The author prefers to do a sensitivity test. 0.1ml of Xylocaine using an insulin syringe is injected intradermally in the forearm and the area is marked. Wait for around 30 minutes to see any hypersensitivity reaction in the form of redness, itching or other local or systemic reaction.

Vital Parameters

Pulse, blood pressure, and oxygen saturation are taken and recorded. There should also be an operative sheet in which all parameters and medications should be recorded. We also note operative details for our medical records.

Preoperative medication

As a routine author give a dose of oral antibiotic, second-generation cephalosporins. Some surgeons do not give at all or some give a single preoperative dose of oral antibiotics.

Shaving of the donor area and head wash

The donor strip area is marked, and trimming is done using the motorized trimmer. The author prefers to keep hair relatively short, less than 10 mm. A length of more than 10 mm gives an idea about the curvature of the hair. After trimming, the head is washed using antibiotic scrub (povidone-iodine scrub)

Tricoscan of donor area

The follicle unit (FU) density, follicles density, anagen telogen ratio, and thickness of hair can be taken by Tricoscan or Folliscope. The FUs density is needed to calculate the length and width of the strip to be harvested.

The FUs density is calculated at the mid-occipital region, above the superior helix, and at a point between these two points in the parietal region in the safe donor area. The average of three is the average donor density.

Hairline design

The final plan of the hairline with the temporal area is discussed with the patient and the area to be transplanted is finalized and marked. Photographs are taken. It is advisable to have the patient and companion sign on a print of the photographs as a record.

Shifting to the operating room

The patient is escorted to the operating room after changing his/her dress.

Events in The Operating Room

A senior nurse attends the patient in the operating room. A few questions are asked again about drugs taken, allergy history, history of diabetes and hypertension, and he has taken medicines or not. Also, the patient is re-informed about the procedure. Everything is recorded on the operating record sheet.

In the author’s operating room there is a whiteboard on which a short history of the patient, his parameters, drugs with the doses used are written so everyone knows everything about the patient. Also, the detailed plan of the recipient area with number of grafts to be implanted in each zone is noted.

Position of Patient

One of the important factors for the success of surgery is that both patients and surgical staff should be in a comfortable position.

The operating table can be a routine surgery table with a head attachment in which horseshoe-shaped opening allows the patient to breathe freely while in the prone position.

Vital parameter monitoring in the prone position

Vital parameter monitoring in the prone position is very important to avoid complications. The author monitors blood pressure, pulse, and oxygen saturation, also communicates orally with patient during strip harvesting.

Preparation of anesthetic solution

While the patient is positioned, and other things are getting ready the two anesthetic solutions are prepared either by surgeon or by a senior scrub nurse.

Strip harvesting

The author uses a No. 20 surgical blade in a single-bladed knife handle. First scoring of the epidermis and dermis is done along the lower border of the strip. The knife blade is moved deeper parallel to the direction of the hair. To avoid follicle transaction, the gap between incision margins is increased using two double skin hooks. This separation can also be done using Haber’s spreader. Some use fine mosquito forceps to deepen the incision. Whatever means is adopted, it is advisable to choose one and practice the method, so you master it to achieve zero transaction while strip harvesting.

Wound Closure

After careful haemostasis wound closure is started. The usual recommendation is if the strip width is less than 1 cm. then a single layer of absorbable suture (monocryl 3’0 or vicrylrapide) is used. The author prefers the rapid vicryl because it absorbs fast and while monocryl takes a long time, but some surgeons use non-absorbable suture or staples.

Dressing

After wound closure proper cleaning of the area is done, antiseptic ointment applied and the suture line is dressed in gauze and a cotton pad, and the patient is finally put in the supine position.

After strip harvesting, patients can relax for a while and can have a glass of juice or water.

How To Increase Laxity of Skin

The scalp laxity is important part of donor scalp area examination. In case of the tight scalp, 4 to 6 weeks pre-operative scalp laxity exercise are advised.

Method

With the two hands clasped together at the back of the scalp, the donor skin is pushed and stretched up and down and side to side, as far as it will go, for 4-5 minutes at a time for 8-10 times a day. This will increase the laxity of donor scalp skin, which will help in both being able to take a wider strip and close the wound under low tension.

Trichophytic Closure Technique

A long linear scar in the donor area is the sequelae of the strip technique of hair transplant.

When the scar is wide and hypopigmented it may show through hair. The risk of a visible scar the major reason that patients will be hesitant to undergo the strip method of hair transplantation. Avoidance of excessive tension over the suture line, careful dissection, and using an atraumatic technique of suturing can solve most of the problems of the scar. But even with the best results, long linear scar is there and can be visible if the hair is worn short.

The trichophytic technique of closure solves the problem of hairless scar. The basic principle of trichophytic closure is de-epithelization of one edge of the wound (usually the lower edge) while keeping the underlying hair follicles intact. During the closure of the wound the upper edge overlaps the de-epithelized lower edge. After healing, hairs start growing through the scar line. These intermittent hairs growing through the scar can significantly make the scar less visible even with very short hair. Hair growing through scar also act as reinforcement to hold the wound together helping to prevent widening of the scar. The trichophytic technique does not always assure complete camouflage of the scar. There can be a possible widening of some areas of the scar where hair may be absent. In such cases, follicles can be implanted by FUE into non-hair-bearing scar areas.

The trichophytic closure technique does not bypass basic surgical principles of wound closure as well as on an intrinsic property of skin.

The presence of intact hair follicles on the upper and lower edge of the wound gives the desired result of trichophytic closure. Damaged or transected follicles at the wound edges may compromise the final outcome of the technique.

During de-epithelization of the lower edge, avoiding damage to the sebaceous gland and the bulge region is essential, as both are required for follicular regrowth. For this reason the epidermis removed from the lower edge should not exceed 1 mm in depth and width. This shallow depth also reduces cyst formation.

Method of Trichophytic closure

After harvesting strip, a sharp scissor is used to cut the lower margin of the wound. A skin that shall not be wider than 1mm and also in-depth less than 1mm is cut from one end to another end of the lower margin of the wound. The wound closure is done as a routine. Some surgeons performing the de-epithelization of lower end of wound after taking deep suture closure, as this stabilizes the wound edge and making de-epithelization easier.

Slivering

A sliver is a single row of FUs dissected from the scalp strip. Dissecting a sliver from a strip must be done under magnification to have a good visualization of follicles. A range of 3.5X to 6X loupes or a stereo-microscope are commonly used for slivering.

The process of slivering is done with the strip is fixed to a wooden spatula and wrapped by moist gauze, and a single row of follicles cut with the tip of a scalpel blade. B. A small sliver is obtained by horizontal slivering. C.A long sliver is obtained by vertical slivering.

Grafts(FUs/ follicle)Dissection

Grafts or FUs may be a single follicle graft or they may have more thanone hair follicles with intact sebaceous glands. Follicular units should be kept intact during dissection. Splitting follicular units can cause damage to the follicles.

Follicle dissection under a stereomicroscope.B. De-epithelized follicles. C. Grafts are put in graft holding solution immediately after dissection.

Graft supply to the implantation team

Grafts are supplied to technicians for implantation. When implanters are used, the grafts are loaded by technicians into the implanters and supplied to the team for implantation. Some surgeons use a finger bowel containing saline in which few grafts are held and implanted one by one.

Graft implantation using a magnification loupe. B Patient lying comfortable and watching a video.

Instructions After FUT

After completion of implantation, the recipient and donor areas are cleaned with normal saline. The debris and blood are removed gently.

Care of Recipient Area

No antibiotic ointment or dressing is done over recipient area. Patients are advised notto use any cap or cloth to cover the recipient area. The grafts may stick to the cap and may come out in an attempt to remove the cap. The cap can be used after 48 hours. The common advice is to irrigate the recipient area with saline every 4 to 6 hours for 3-4 days to prevent drying. Plain water head wash without soap or shampoo is advised from fourth post-operative day. One should avoid rubbing the scalp for 8-10 days. After tenth post-operative day povidone-iodine scrub or shampoo head wash is given, which is continued for four to five days. is cleaned with saline and is dressed in an antibiotic ointment.

Medication – The author prefers to give oral antibiotics (for five days with analgesics and anti-inflammatory, (Routine use of antibiotics in hair transplantation is not supported by medical literature.¹⁸)

1. As per the preference of the surgeon advise usingof topical minoxidil application and other medical treatment to prevent the loss of existing hair.

Positioning – Patient shall sleep in a supine position and can use a soft pillow or preferable travel neck pillow.

Dressing of Donor area – The donor area dressing is removed after 24 hours and the donor area is left uncovered.The antibiotic ointment or liquid petrolatum is applied over suture line twice a day for ten days.

Recipient area – Some surgeons advise normal saline spray to the recipient area frequently, ranging to every hour to 4 to 6 hourly for two to three days. No ointment or any dressing is to be done.

Accidental removal of implanted graft – Some time there can be accidental removal of implanted graft which may lead to bleeding from the slit. Patient is advised to press the bleeding point for 5 minutes. If needed patient can call the doctor.

Head Wash – The patient can take routine body wash from next day, but plain water head wash from 4^th post-operative day, and shampoo head wash from tenth post-operative day.

Restriction for smoking for three weeks.

Suture removal – If surgeons has used metal clips or non-absorbable suture to close the strip wound, the sutures are removed on 7^th to 10^th post-operative day.

Routine day to day activity – Patient can resume his duty from second post-operative day,as per his comfort and type of work. He can use loose head cap from second post-operative day.

Strenous physical activity can be resumed 10 days after the procedure.

The scabs from recipient area start to come off after one week and may all fall by two weeks. The implanted hair may fall with scab. The patient is informed about this because some patients think that the implanted grafts have come out. Implanted hair begins to grow 3 to 4 months after the hair transplant.

During this period, patients shall be allowed to visit office or they can contact the office for any quarry.

Complications of FUT

Hair transplant surgery is low risk, safe and with minimal chances of complications; but it is a well-accepted fact that no procedure in medical science is without some risk and/or complications.

Complications may be a simple complaint in the form of pain, itching or dissatisfaction related to the final outcome of the procedure or a true surgical complication such as infection, nerve damage, wound dehiscence or skin necrosis, or a painful scar.

Inadequate counseling increases dissatisfaction and inadequate examination and patient medical history increases the occurrence of complications. Underestimation of laxity of donor areascalp will certainly increase complications related to suture line and wound healing. Medical history related to conditions like diabetes, cardiac illness, smoking, poor nutritional status will give poor outcome of transplanted follicles and healing.

So, to minimize complaints and complications, the key is providing carefully detailed counseling, and conduct a proper history and examination of patients.

In the author’s opinion hair transplant is a surgical procedure done for patients. It is not a product for sell to customers.