Overview of Hair Transplant

What is Hair Transplant

The hair transplant is a surgical procedure in which live hair follicles are taken from one area of the body called the ‘donor area’ and transferred to the area where the hair is needed, the ‘recipient area.’

Hair Follicles Donor Area – The body area from where the donor hair follicles are harvested is called donor area. The most common donor area is the backside of the scalp, where the hair roots are permanent because they are not genetically programmed to fall. Other donor hair follicles donor areas are the beard, chest, abdomen, and other parts of the body.

Recipient Area – The body area where the donor hair follicles are implanted is called as recipient area. Usually, it is the bald area of the scalp, but some want to rebuilt or reconstruct their beard and mustache, and other parts.

Importance of Hair Transplant

The importance of the hair transplant is to re-establish the aesthetic balance lost in the process of balding. The purpose of hair transplant shall be to restore normalcy in the short term as well as in the long term, as the balding process is progressive. In the scalp bald area, the main purpose of transplant is framing the face.

History of Hair Transplantation

The first hair transplant of intact hair follicles was performed by Japanese physician Dr.Shoji Okuda and Tamura. Because of the II world war and his article was in Japanese, the work could not reach other parts of the world for many years. He transplanted full-thickness hair-bearing skin pieces so-called graft to the hairless area. He performed almost 200 cases, mostly post-traumatic alopecia.

Okuda’s concept of hair transplant and instrumentation were almost the same as the modern principle of transplant.

Norman Orentreich gave a concept of donor dominance, meaning that hair follicles are taken from the occipital region and implanted in the front part of the scalp survived and continued to grow.

This discovery was a significant breakthrough in the field of modern hair transplant, and for this, Dr.Orentreich is known as the ‘father of modern hair transplant surgery.’ Another landmark work of Headington in 1984.

He gave the concept of the follicular unit. The follicular unit of the adult human scalp usually consists of two to four terminal follicles, one or rarely two villus follicles, associated sebaceous lobules, and insertion of the arrector pili muscles.

Both the above concepts could not be utilized for long until 1988. Bobby Limmer was the first t to utilize the concept of naturally occurring follicular units. In 1994 he gave the concept of implantation of individual follicular units by taking a strip and dissecting follicular units under a microscope. Natural-looking hair growth can be achieved by implanting these individual units.

The return of the punch method of harvesting follicular units using small trephines has been advanced by several surgeons like Masumi Inaba, Ray woods, Rassman, Cole, Harris, and Rose. (The follicular extraction was first described by Japanese aesthetic surgeon Dr.Masumi Inaba in 1988.

In the following years, Dr.Ray Wood began using FUE successfully with patients. Dr.Wood was the first to prove that body hair, when transplanted to the scalp, will grow.

In 2002 Dr. Rassman and Dr. Bernstein published an article about the method commonly known as Follicular Unit Extraction. The technique of follicular unit extraction was initially known as FOX or FUSE (follicular unit extraction /follicular unit separation extraction) procedure. In 1998, Bernstein and 20 other physicians gave precise definitions of various types of grafts obtained. The follicular unit definitions remain the same as described by Headington; the only change was the number of terminal follicles 2 to 5 instead of 2 to 4, which was initially described by Headington. Seager proposed the term ‘follicular unit family.’

In 1999 Cole introduced the term ‘follicular groups.’ The problem with FUE was that the learning curve was longer, the procedure time was time-consuming, and the surgeon’s involvement in the procedure was much more in comparison to strip methods of follicle harvesting. However, over the period, the use of motorized devices and the high quality of punches the FUE has improved. The FUE procedure became popular because it looked non-surgical, with no long linear cut and no sutures, so the demand for FUE by patients kept on increasing. The invention of a Robotic device has made the FUE procedure much simpler, reduction in the learning curve, and surgeon’s time. The robotic device, the ARTS, has certain limitations and much more expensive in comparison to other available FUE devices.

Method of Hair Transplantation

The two studies are the basis of hair transplants.

• The concept of the Donor dominance’ given by Dr. NormanOrienteric, stating those hair follicles taken from the occipital area and implanted to the bald area maintains their characteristic and do not fall.

• The second concept of Dr. Headington showed that hair follicles lie in naturally occurring groups having 1 to 4 hair follicles, now modified as 1 to 5 follicles. If these naturally occurring units, so-called follicular units (FUs) are implanted elsewhere, they will grow and give a natural look.

Both methods of hair transplant utilized the above two concepts.

1) The one is a strip method commonly called FUT, in which a strip of full-thickness skin having multiple hair follicles is excised from the occipital area and dissected to produce multiple hair follicle units and transferred to the bald area.

2) Another method called FUE, follicular unit excision in which a circular knife called punch is used to harvest individual follicle units and implanted in the bald area. By implanting follicular units, the large area of the scalp can be covered, and when hair from these follicular units grows, they give a natural look.

Both methods of hair transplant utilized the above two concepts.

1) The one is a strip method commonly called FUT, in which a strip of full-thickness skin having multiple hair follicles is excised from the occipital area and dissected to produce multiple hair follicle units and transferred to the bald area.

2) Another method called FUE, follicular unit excision in which a circular knife called punch is used to harvest individual follicle units and implanted in the bald area. By implanting follicular units, the large area of the scalp can be covered, and when hair from these follicular units grows, they give a natural look.

Hair Transplant Guidelines

As the procedure of hair transplant is surgery and done for aesthetic restoration of the face. This has certain rules, named as a guideline which a surgeon shall follow before planning and executing the hair transplant

1. The priority of the frontal zone

The transplant of the frontal zone is of the highest priority as the main objective of transplant is the framing of the face by restoring the anterior hairline area. Initially, if the limited donor hair follicles are consumed to transplant other areas like vertex, the future scope to transplant the front area may be compromised. If such a situation arises, surgeons should strive to leave enough donor hair for the frontal area coverage at a later time.

2. Less is always better than being aggressive

The process of balding is progressive, and future bald areas may need more hairs. This rule especially applies to the younger one, whose future balding pattern is uncertain.

3. The technique of gradient density is graft economical

It is advisable to keep the density highest in the anterior-most midline center area called “egg.” Density decreases as we go posteriorly near the fringe of permanent hair.

4. Do not make hair transplants “too perfect’ in terms of density, location, and design of anterior hairline

Making one area densest will give a transplanted look. A straight hairline with obtuse/round-off on both lateral ends of the hairline (frontotemporal angle) will look un-aesthetic.

5. It is advisable to transplant the future balding area,

which avoids the repeat of transplant at a shorter interval.

ELEMENTS OF HAIR TRANSPLANT

There are four essential elements of hair transplants.

1. First, understanding the goals of the patient;

2. the examination of the patient, which includes general examination with recipient and donor area examination;

3. the ability of the surgeon to meet with the expectations of the patient, and

4. executing those abilities successfully to the patient.

A hair transplant is a surgical procedure performed by a trained, qualified surgeon. Every bald one is not a candidate for a hair transplant. There are a few criteria that affect the planning of a hair transplant in a patient. Dr.Norwood in 1992 gave categorized the factors that affect the planning of hair transplant, later on, his factors were further extended. Eight major and 11minor factors are to be taken into consideration before planning the hair transplant. Out of all, the age of the patient and donor-recipient ratio are the most important. However, any of these factors are not appropriate and or worrisome enough to defer any plan for surgery.

Who Is Perfect Candidate For Hair Restoration Surgery

A successful hair transplant depends on the appropriate selection of patients by the surgeon and the appropriate selection of a surgeon by the patient. There are four essential elements of hair transplants.

First, understanding the goals of the patient; second is the examination of the patient, which includes general examination with recipient and donor area; third is the ability of the surgeon to meet the expectations of the patient, and last is executing those abilities successfully to the patient.

Every bald one is not a candidate for a hair transplant. A hair transplant is a surgical procedure performed by a trained, qualified surgeon. There are a few criteria that affect the planning of a hair transplant in a patient.

Norwood, in 1992 categorized the factors that affect the planning of hair transplant; later on, his factors were further extended. Eight major and 11minor factors are to be taken into consideration before planning the hair transplant. Out of all, the age of the patient and donor-recipient ratio are the most important. However, any of these factors are not appropriate and or worrisome enough to defer any plan for surgery.

Table—Factors For Considerations For Hair Transplant

If a young patient with a family history of baldness demands more density and lower hairline. Comprehensive counseling is needed to make him understand that the need for medicines is the first important step before undertaking HR surgery as his hair loss is still in the progressive stage. The less is better and prefers to have a higher anterior hairline, keeping in mind that he may need hair transplantation in the future also.

The degree of baldness is classified as various grades. The most commonly used classification for males is Norwood Hamilton, and for females is Norwood, Ludwig, and Oslen. The higher the grade of baldness, the more demand for donor hair follicles. The detailed examination of donor area in terms of skin elasticity, laxity, skin condition, donor hair quality, thickness, curl, color, and percentage of vellus hair are essential points to be taken into consideration. The donor density provides the information on how much grafts can be extracted safely from a safe donor area, and with this much, how much bald area can be covered for desired density, and is it achieving the goals of the patient?

Patient medical conditions, detailed history of medicines taking, and history of allergy shall be taken to avoid any untoward event during or after surgery. For a surgeon, it is essential to understand the patient’s expectations, are they realistic? Can they be achieved? The psychological status is one of the crucial things to know, especially for any patient wishing for cosmetic surgery. The surgeons should also critically know about himself and his team if he and his team are capable enough to do this?

Precaution Needed Before Hair Transplant

• Medical ‘Red flags – Patients’ medical conditions affecting the procedure during and after hair transplant are diabetes, hypertension, cardiac diseases, heavy smoking, alcohol, and other various medical conditions.

• Objective Red Flags – Detail evaluation of donor supply, hair characteristics, and bald area shall be assessed. if there is a large discrepancy, then only the major aesthetic area can be covered like frontal forelock with adjacent lateral humps.

• Subjective Red Flags – The patient’s expectations and capability to meet with has to be assessed and explained to the patient. A patient falling into the category of Body Dysmorphic Disorder is a contraindication to surgery.

Counselling Before Hair Restoration Surgery

The counseling before hair restoration surgery is of utmost importance. The progressive nature of hair loss, as well as the benefits of medical treatment and limitations of surgery, shall be explained to the patient. Surgeons need to explain the mathematical facts of surgery. There is a big gap between the amount of hair loss and the supply of donor’s hair. He cannot get the average density even after the maximum transplant he can stand for. Hair transplant provides coverage but not the average density. Here lies the importance of medical treatment, and explains that he shall try to retain the maximum number of hair in the balding area of the scalp. The fact of medical treatment for hair loss is that there is no one-time treatment for it and to be continued till he wants to retain that hair.

The post-transplant density, the covered and uncovered bald area of the scalp, operative technique, need for shaving shall also be clearly explained to him, and it is better to have a note of this. All preoperative pictures shall be taken.

If at any point in time, during the consultation, the surgeon feels that patient expectations are much beyond the scope of the surgery, it is better to say ‘No’ rather than increasing unsatisfied patients numbers. Every patient shall be evaluated for body dysmorphic disorder.

Pre-operative Assessment And Instructions

Once the detailed counselling is done, and the patient is planned for surgery, a pre-operative detailed assessment, investigations, and pre-operative instructions are given.

Apart from scalp donor and recipient area examination, general physical examination, recording of vital parameters are done.

Ask for any existing medical or surgical problem he has and any medication for this.

History of medicines, any allergy, bleeding tendency, keloidal tendency, major surgery, epilepsy. Is the patient taking any herbal medicines, a blood thinner, anti-platelet, anti-epileptic, anti-depressant, acne treatment, anti-allergic, microlite antibiotics, non-selective beta-blockers like propranolol and or other medicines? History of alcohol, tobacco, opium derivatives, smoking shall also be taken.

Detailed instructions sheet should be given to the patient.

Instructions before Hair transplant

• 4 weeks prior
  (For strip surgery cases) If scalp donor laxity is low
  Scalp massage three times a day. Each time 15 to 20 mins
  If diabetic, hypertensive or other prolonged standing diseases
  Consult the Physician for control of the existing diseases
  Inform the surgeon about all medications, allergy history.

• Three weeks before
  Stop smoking and or tobacco.
  Stop Herbs, Vitamin E, and fish oil.

• One week before
  Stop applying minoxidil.
  Stop food supplements and other non-approved medications for hair loss.
  Stop Alcohol.

• 5 days before
  Stop blood thinner, aspirin. (follow the instructions of physicians)
  Check the blood pressure and blood sugar. Fitness from a physician.

• One day before
  Stop Ibuprofen, naproxen.

• A night before
  No night party, good sleep, if needed anxiolytic can be prescribed.

• Day of surgery
  No exercise, breakfast or meal as usual without onion and garlic.
  Shampoo and regular bath.
  Wear loose clothes, avoid tight clothing like T-shirts. all valuables shall be left home.

Arrangements for travels to reach in time, payment methods all shall be organized. Any specific instructions of shaving shall be followed. If the donor’s hair is to be harvested from the beard, stop shaving of beard 3 to 5 days before, shaving of other parts of the body like chest, abdomen, and other body parts shall be done 12 to 15 days before.

What is a Safe Donor Area?

The ‘donor area’ of hair transplant means the body area from where the donor hair follicles are extracted for implantation in the recipient area. Usually, the donor area is the backside of the scalp, but the donor area other than the scalp donor area is also available for hair transplant.

The concept of “safe donor area” is based on a study and experience of Dr. Walter Unger. It is clinically difficult to be completely accurate in defining this area. Furthermore, there is no guarantee that all follicles within a “safe donor area” are permanent. Based on the Unger study, the defined “safe donor area” will be safe in approximately 80% of patients under the age of 80 years.

Rassman&Bernstain have suggested that the “safe donor area” consists of approximately 25% of the scalp & only half of this should be removed. They also confirmed that the hair-bearing scalp is ± 520 cm square & the average scalp contains approximately two hair/mm.

1. Cole advised that the total size of the safe donor area is 203 cm square & average FUs in Caucasians are 16649 FUs & Asian are having 15718 FUs.

While harvesting hair roots for transplant if hair beyond the safe zone is taken there will be a risk of future hair loss.

How To Outline Safe Donor Area

Lowermost limit of safe donor area three points are marked

1) point A is the midpoint in a sagittal plane over external occipital protuberance.

2) Lateral point is 1.5cm behind the postauricular hairline and 1.5 cm above the superior aspect of the helix. The C point is the lateral most limit of a conservative length of the strip.

3) The point (C) is 2 cm. above the superior aspect of the helix along a line drawn vertically through the anterior tragus. This is a more extensive lateral limit of the strip.

The line joining these three points A, B, C, is the lower limit of the safe hair zone. The area below occipital protuberance is not the scalp but the neck region. Hairs harvested from this region are susceptible to fall. Also, strong neck muscles are present in this area so tension over the suture line is high & the scar may get widened. While planning for strip one should look for existing miniaturization in this region. This miniaturization is called retrograde hair loss.

Upper limit of safe donor area

The width of the safe donor area at the most anterior (Lateral) limit is 6-7 cm wide. In the centre of the safe zone, width is decided by taking a horizontal line drawn from point ‘C’ (i.e. 2 cm above superior helix in a plane anterior to helix) which will intersect the midline of the occiput. This will be a superior limit of safe donor area in the midline. While planning for the strip, 1 cm below & 2 cm above permanent hair-bearing area should be left so as to camouflage donor scar.

Hair transplant surgeons should carefully examine the donor area for a progressive pattern of hair loss in the crown, retrograde hair loss, thinning or miniaturization.

Although in the donor area 90% of hair remains in anagen and 10% in the telogen phase, if telogen hair is more than 30% hair, transplant surgeons should avoid the surgery and treat the cause first.

Boundaries of Safe donor area of scalp

Donor Area Assessment

The success of a Hair Transplant depends on the quality of the donor area. The donor area is to be evaluated for skin elasticity and glidability( for FUT cases ), number of available follicular units (FUs), number of hair in FUs. The thickness, curvature & colour of hair are as important as the number of follicles.

Methods For Calculation Of Donor Density

There are two methods for calculating donor area density of follicles: – One is subjective depending on the experience of the physician. Another is the objective in which information is driven through instruments. Several instruments from simple to advance are available. Digital dermo scope or folly scope gives the density, anagen, telogen ratio, the thickness of hair. The author feels every hair transplant surgeon shall have a dermo scope.

1) Use of 1 cm square box: A simple rubber stamp having one square centimetre area. The rubber stamp mark is created over the scalp to calculate the density of hair follicles in one square centimetre donor area.

2) Hair Densitometer: The simple device in which magnifying lens with illumination is used to count hairs in 1 sq. cm area.

Limitations of Hair Transplant

Despite refinement in technique and instrumentation, there are limitations of hair transplants. The demand for donor hair follicles to cover the bald area is much more in comparison to the available donor supply. All the more, the baldness is progressive also. A surgeon has to meet the expectation of the patient with a limited number of donor follicles supply.