Hair transplantation

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Hair transplantation
Hair-transplantation.jpg
A graft transplantation to cover the scar of a hidradenitis suppurativa operation on the back of the head

Hair transplantation is a surgical technique that removes hair follicles from one part of the body, called the 'donor site', to a bald or balding part of the body known as the 'recipient site'. The technique is primarily used to treat male pattern baldness. In this minimally invasive procedure, grafts containing hair follicles that are genetically resistant to balding (like the back of the head) are transplanted to the bald scalp.

Contents

Hair transplantation can also be used to restore eyelashes, eyebrows, beard hair, chest hair, pubic hair and to fill in scars caused by accidents or surgery such as face-lifts and previous hair transplants. Hair transplantation differs from skin grafting in that grafts contain almost all of the epidermis and dermis surrounding the hair follicle, and many tiny grafts are transplanted rather than a single strip of skin.

Since hair naturally grows in groupings of 1 to 4 hairs, current techniques harvest and transplant hair "follicular units" in their natural groupings. Thus modern hair transplantation can achieve a natural appearance by mimicking original hair orientation. This hair transplant procedure is called follicular unit transplantation (FUT). Donor hair can be harvested in two different ways: strip harvesting, and follicular unit extraction (FUE).

Procedure

Pre-operative assessment and planning

At an initial consultation, the surgeon analyzes the patient's scalp, discusses their preferences and expectations, and advises them on the best approach (e.g. single vs. multiple sessions) and what results might reasonably be expected. Laxometers are used to measure the looseness (or more specifically, laxity ) of the scalp. Pre-operative folliscopy will help to know the actual existing density of hair, so that postoperative results of newly transplanted hair grafts can be accurately assessed. Some patients may benefit with preoperative topical minoxidil application and vitamins. [1]

For several days prior to surgery the patient refrains from using any medicines which might result in intraoperative bleeding and resultant poor grafting. Alcohol and smoking can contribute to poor graft survival. Post operative antibiotics are commonly prescribed to prevent wound or graft infections. [2]

Harvesting methods

Transplant operations are performed on an outpatient basis, with mild sedation (optional) and injected local anesthesia. The scalp is shampooed and then treated with an antibacterial agent prior to the donor scalp being harvested.[ citation needed ]

There are several different techniques for harvesting hair follicles, each with their own advantages and disadvantages. Regardless of the harvesting technique, proper extraction of the hair follicle is paramount to ensure the viability of the transplanted hair and avoid transection, the cutting of the hair shaft from the hair follicle. Hair follicles grow at a slight angle to the skin's surface, so transplanted tissue must be removed at a corresponding angle.[ citation needed ]

There are two main ways in which donor grafts are extracted today: strip excision harvesting, and follicular unit extraction.

Strip harvesting (FUT)

Strip harvesting (also known as follicular unit transplantation or FUT) is the most common technique for removing hair and follicles from a donor site. The surgeon harvests a strip of skin from the posterior scalp, in an area of good hair growth. A single-, double-, or triple-bladed scalpel is used to remove strips of hair-bearing tissue from the donor site. Each incision is planned so that intact hair follicles are removed. The excised strip is about 1–1.5 x 15–30 cm in size. While closing the resulting wound, assistants begin to dissect individual follicular unit grafts, which are small, naturally formed groupings of hair follicles, from the strip. Working with binocular Stereo-microscopes, they carefully remove excess fibrous and fatty tissue while trying to avoid damage to the follicular cells that will be used for grafting. The latest method of closure is called 'Trichophytic closure' which results in much finer scars at the donor area.

The surgeon then uses very small micro blades or fine needles to puncture the sites for receiving the grafts, placing them in a predetermined density and pattern, and angling the wounds in a consistent fashion to promote a realistic hair pattern. The technicians generally do the final part of the procedure, inserting the individual grafts in place.

Strip harvesting will leave a thin linear scar in the donor area, which is typically covered by a patient's hair even at relatively short lengths. The recovery period is around 2 weeks and will require the stitches/staples to be removed by medical personnel or sub cuticular suturing can be done.

Follicular unit extraction (FUE)

With Follicular Unit Extraction or FUE harvesting, individual follicular units containing 1 to 4 hairs are removed under local anesthesia; this micro removal typically uses tiny punches of between 0.6mm and 1.0mm in diameter. The surgeon then uses very small micro blades or fine needles to puncture the sites for receiving the grafts, placing them in a predetermined density and pattern, and angling the wounds in a consistent fashion to promote a realistic hair pattern. The technicians generally do the final part of the procedure, inserting the individual grafts in place.

FUE takes place in a single long session or multiple small sessions. The FUE procedure is more time-consuming than strip surgery. An FUE surgery time varies according to the surgeons experience, speed in harvesting and patient characteristics. The procedure can take anywhere from a couple hours to extract 200 grafts for a scar correction to a surgery over two consecutive days for a megasession of 2,500 to 3,000 grafts. [3] With the FUE Hair Transplant procedure there are restrictions on patient candidacy. [4] Clients are selected for FUE based on a fox test, [5] though there is some debate about the usefulness of this in screening clients for FUE.

FUE can give very natural results. The advantage over strip harvesting is that FUE harvesting negates the need for large areas of scalp tissue to be harvested, so there is no linear incision on the back of the head and it doesn't leave a linear scar. Because individual follicles are removed, only small, punctate scars remain which are virtually not visible and any post-surgical pain and discomfort is minimized. As no suture removal is required, recovery from Micro Grafting FUE is less than 7 days. [6]

Disadvantages include increased surgical times and higher cost to the patient. [7] It is challenging for new surgeons because the procedure is physically demanding and the learning curve to acquire the skills necessary is lengthy and tough.[ citation needed ] Some surgeons note that FUE can lead to a lower ratio of successfully transplanted follicles as compared to strip harvesting.

Robotic hair restoration

Robotic hair restoration devices utilize cameras and robotic arms to assist the surgeon with the FUE procedure. In 2009, NeoGraft became the first robotic surgical device FDA approved for hair restoration. [8] The ARTAS System was FDA approved in 2011 for use in harvesting follicular units from brown-haired and black-haired men. [9]

Applications

There are a number of applications for hair transplant surgery, including:

If donor hair numbers from the back of the head are insufficient, it is possible to perform body hair transplantation (BHT) on appropriate candidates who have available donor hair on the chest, back, shoulders, torso and/or legs. Body hair transplant surgery can only be performed by the FUE harvesting method and, so, requires the skills of an experienced FUE surgeon. However, there are several factors for a potential BHT candidate to consider prior to surgery. These include understanding the natural difference in textural characteristics between body hair and scalp hair, growth rates, and having realistic expectations about the results of BHT surgery.

Cost

The cost of hair transplantation depends on the individual hair loss and consequently on the number of necessary grafts. The average price per graft ranges between US$1.07 in Turkey up to US$7.00 in Canada. Some clinics also offer all-inclusive packages. [10] [11] In the UK the cost can be between £4000–£8000 depending on location and area of implant. [12]

Side effects

Hair thinning, known as "shock loss", is a common side effect that is usually temporary. [13] Bald patches are also common, as fifty to a hundred hairs can be lost each day. Post-operative hiccups have also been seen in around 4% of transplant patients. [14]

History

The use of both scalp flaps, in which a band of tissue with its original blood supply is shifted to the continue bald area, and free grafts dates back to the 19th century. In 1897, Menahem Hodara successfully implanted hair taken from the unaffected areas of the scalp on to the scars that were left bald by favus. Modern transplant techniques began in Japan in the 1930s, [15] where surgeons used small grafts, and even "follicular unit grafts" to replace damaged areas of eyebrows or lashes, but not to treat baldness. Their efforts did not receive worldwide attention at the time, and the traumas of World War II kept their advances isolated for another two decades.

The modern era of hair transplantation in the western world was ushered in the late 1950s, when New York dermatologist Norman Orentreich began to experiment with free donor grafts to balding areas in patients with male pattern baldness. Previously it had been thought that transplanted hair would thrive no more than the original hair at the "recipient" site. Orentreich demonstrated that such grafts were "donor dominant," as the new hairs grew and lasted just as they would have at their original home. [16]

Advancing the theory of donor dominance, Walter P. Unger, M.D. defined the parameters of the "Safe Donor Zone" from which the most permanent hair follicles could be extracted for hair transplantation. [17] As transplanted hair will only grow in its new site for as long as it would have in its original one, these parameters continue to serve as the fundamental foundation for hair follicle harvesting, whether by strip method or FUE.

For the next twenty years, surgeons worked on transplanting smaller grafts, but results were only minimally successful, with 2–4 mm "plugs" leading to a doll's head-like appearance. In the 1980s, strip excisions began to replace the plug technique, and Carlos Uebel in Brazil popularized using large numbers of small grafts, while in the United States William Rassman began using thousands of "micrografts" in a single session. [5]

In the late 1980s, B.L. Limmer introduced the use of the stereo-microscope to dissect a single donor strip into small micrografts. [18]

The follicular unit hair transplant procedure has continued to evolve, becoming more refined and minimally invasive as the size of the graft incisions have become smaller. These smaller and less invasive incisions enable surgeons to place a larger number of follicular unit grafts into a given area. With the new "gold standard" of ultra refined follicular unit hair transplantation, over 50 grafts can be placed per square centimeter, when appropriate for the patient. [19]

Surgeons have also devoted more attention to the angle and orientation of the transplanted grafts. The adoption of the "lateral slit" technique in the early 2000s enabled hair transplant surgeons to orient 2 to 4 hair follicular unit grafts so that they splay out across the scalp's surface. This enabled the transplanted hair to lie better on the scalp and provide better coverage to the bald areas.[ original research? ] One disadvantage however, is that lateral incisions also tend to disrupt the scalp's vascularity more than sagittals. Thus sagittal incisions transect less hairs and blood vessels assuming the cutting instruments are of the same size.[ citation needed ]

One of the advantages of sagittals is that they do a much better job of sliding in and around existing hairs to avoid follicle transection.[ original research? ] This makes a strong case for physicians who do not require shaving of the recipient area. The lateral incisions bisect existing hairs perpendicular (horizontal) like a T while sagittal incisions run parallel (vertical) alongside and in between existing hairs. The use of perpendicular (lateral/coronal) slits versus parallel (sagittal) slits, however, has been heavily debated in patient-based hair transplant communities. Many elite hair transplant surgeons[ who? ] typically adopt a combination of both methods based on what is best for the individual patient.[ original research? ]

Research and future techniques

Stem cells and dermal papilla cells have been discovered in hair follicles. [20] Research on these follicular cells may lead to successes in treating baldness through hair multiplication (HM), also known as hair cloning. [21] [22]

Notable people

Related Research Articles

<span class="mw-page-title-main">Hair loss</span> Loss of hair from the head or body

Hair loss, also known as alopecia or baldness, refers to a loss of hair from part of the head or body. Typically at least the head is involved. The severity of hair loss can vary from a small area to the entire body. Inflammation or scarring is not usually present. Hair loss in some people causes psychological distress.

<span class="mw-page-title-main">Rhinoplasty</span> Surgical procedure to enhance or reconstruct a human nose

Rhinoplasty, commonly called nose job, medically called nasal reconstruction is a plastic surgery procedure for altering and reconstructing the nose. There are two types of plastic surgery used – reconstructive surgery that restores the form and functions of the nose and cosmetic surgery that changes the appearance of the nose. Reconstructive surgery seeks to resolve nasal injuries caused by various traumas including blunt, and penetrating trauma and trauma caused by blast injury. Reconstructive surgery can also treat birth defects, breathing problems, and failed primary rhinoplasties. Rhinoplasty may remove a bump, narrow nostril width, change the angle between the nose and the mouth, or address injuries, birth defects, or other problems that affect breathing, such as a deviated nasal septum or a sinus condition. Surgery only on the septum is called a septoplasty.

Tissue expansion is a technique used by plastic, maxillofacial and reconstructive surgeons to cause the body to grow additional skin, bone, or other tissues. Other biological phenomena such as tissue inflammation can also be considered expansion.

<span class="mw-page-title-main">Hair follicle</span> Organ found in the dermal layer of the mammalian skin that regulates hair growth

The hair follicle is an organ found in mammalian skin. It resides in the dermal layer of the skin and is made up of 20 different cell types, each with distinct functions. The hair follicle regulates hair growth via a complex interaction between hormones, neuropeptides, and immune cells. This complex interaction induces the hair follicle to produce different types of hair as seen on different parts of the body. For example, terminal hairs grow on the scalp and lanugo hairs are seen covering the bodies of fetuses in the uterus and in some newborn babies. The process of hair growth occurs in distinct sequential stages: anagen is the active growth phase, catagen is the regression of the hair follicle phase, telogen is the resting stage, exogen is the active shedding of hair phase and kenogen is the phase between the empty hair follicle and the growth of new hair.

<span class="mw-page-title-main">Scalp</span> Anatomical area bordered by the face at the front, and by the neck at the sides and back

The scalp is the area of the head where head hair grows. It is made up of skin, layers of connective and fibrous tissues, and the membrane of the skull. Anatomically, the scalp is part of the epicranium, a collection of structures covering the cranium. The scalp is bordered by the face at the front, and by the neck at the sides and back. The scientific study of hair and scalp is called trichology.

<span class="mw-page-title-main">Cardiac surgery</span> Type of surgery performed on the heart

Cardiac surgery, or cardiovascular surgery, is surgery on the heart or great vessels performed by cardiac surgeons. It is often used to treat complications of ischemic heart disease ; to correct congenital heart disease; or to treat valvular heart disease from various causes, including endocarditis, rheumatic heart disease, and atherosclerosis. It also includes heart transplantation.

<span class="mw-page-title-main">Corneal transplantation</span> Surgical procedure of repairing corneal tissue to treat corneal blindness

Corneal transplantation, also known as corneal grafting, is a surgical procedure where a damaged or diseased cornea is replaced by donated corneal tissue. When the entire cornea is replaced it is known as penetrating keratoplasty and when only part of the cornea is replaced it is known as lamellar keratoplasty. Keratoplasty simply means surgery to the cornea. The graft is taken from a recently deceased individual with no known diseases or other factors that may affect the chance of survival of the donated tissue or the health of the recipient.

The management of hair loss, includes prevention and treatment of alopecia, baldness, and hair thinning, and regrowth of hair.

<span class="mw-page-title-main">Buttock augmentation</span> Cosmetic and corrective surgery

Gluteoplasty denotes the plastic surgery and the liposuction procedures for the correction of congenital, traumatic, and acquired defects/deformities of the buttocks and the anatomy of the gluteal region; and for the aesthetic enhancement of the contour of the buttocks.

Follicular unit transplantation (FUT) is a hair restoration technique, also known as the strip procedure, where a patient's hair is transplanted in naturally occurring groups of 1 to 4 hairs, called follicular units. Follicular units also contain sebaceous (oil) glands, nerves, a small muscle, and occasional fine vellus hairs. In follicular unit transplantation, these small units allow the surgeon to safely transplant thousands of grafts in a single session, which maximizes the cosmetic impact of the procedure.

Follicular unit extraction is one of two primary methods of obtaining hair follicles, naturally occurring groups of one to four hairs, for hair transplantation. The other method is called strip harvesting. In 2018, Mejia published the updated guidelines adopted by the International Society of Hair Restoration Surgery. This name change came about to accurately describe the procedure which involves surgically cutting or incising a full thickness hair follicle skin graft with a circular scalpel, punch or motorized drill and subsequently carefully extracting it from the scalp to be placed in the donor balding scalp. Due to the new developments of incision punches and devices and a variety of different extraction techniques, it was necessary to more accurately define the procedure. Additionally, many places were incorrectly marketing the extraction procedure as a simple plucking of hairs and deceiving the public.

Eyebrow restoration is a surgical procedure to reposition the eyebrow. With advancing age, a common occurrence is descent of the eyebrow, or brow ptosis. A similar condition is eyelid ptosis. Eyebrow repositioning is a commonly performed procedure in cosmetic surgery. The brow is repositioned, optimally, for the wishes of the patient as well as to correct the descent.

Madarosis is a condition that results in the loss of eyelashes, and sometimes eyebrows. The term "madarosis" is derived from the ancient Greek "madaros", meaning "bald". It originally was a disease of only losing eyelashes but it currently is the loss of both eyelashes and eyebrows. Eyebrows and eyelashes are both important in the prevention of bacteria and other foreign objects from entering the eye. A majority of patients with madarosis have leprosy, and it was reported that 76% of patients with varying types of leprosy had madarosis.

Eyelash implants are a form of cosmetic surgery involving transplanting additional eyelashes around the eye. The process typically involves removing a section of hair from the patient, typically from the back of the head, and grafting the hair to the eyelids, replacing the existing eyelashes. The procedure typically involves 60 to 70 hairs per eye, and after removal and a thorough cleaning of the oil on the hair, they are reattached to patient by delicately sewing the lashes back on. Maintenance of the eyelashes is needed thereafter, as the hair continues to grow at the same rate as on other parts of the body.

Multiple follicular unit grafts is a hair transplant technique that has been developed to complement and enhance current micro grafting and follicular unit procedures by increasing density without sacrificing naturalness. A follicular unit (FU) is a naturally occurring bundle of hairs. This bundle contains anywhere from 1 to 4 hairs. A "multiple follicular unit" is a graft that contains more than one follicular unit. When combined these follicular units can total 5 to 8 hairs creating more significant results. These grafts are not to be mistaken with old style hair plugs harvested with a punch biopsy instrument, but instead are modern day slit grafts harvested from a thin donor strip in the back of the head and separated under magnification.

Alan J. Bauman is an American hair transplant surgeon and hair restoration physician. He is the Medical Director and CEO of Bauman Medical Hair Transplant and Hair Loss Treatment Center in Boca Raton, FL. Bauman is a Fellow of the International Society of Hair Restoration Surgery (FISHRS), a certified diplomate of the American Board of Hair Restoration Surgery (ABHRS), and member of the International Alliance of Hair Restoration Surgery (IAHRS). He is the founder of the non-profit 501(c)(3) Bauman Philanthropic Foundation, which provides pro bono hair restoration, surgical hair transplants, and medical treatments to patients in need.

Rashid M. Rashid is an American dermatologist, known for his work on hair loss and transplantation.

Hairline lowering is a surgical technique that allows an individual to have their frontal hairline advanced certain distances depending on variables such as pre-operative hairline height, scalp laxity, and patient preference. It can be used to address a congenitally high hairline or sometimes a hairline that has recessed from hair loss. It is performed mostly on women.

Hair multiplication or hair cloning is a proposed technique to counter hair loss. The technology to clone hair is in its early stages, but multiple groups have demonstrated pieces of the technology at a small scale with a few in commercial development.

Scalp reduction is a surgical procedure in which the hairless region of the scalp of a bald person is reduced. This procedure can reduce the area of the scalp in which hair transplantation is needed, or even eliminate the need for hair transplantation.

References

  1. ↑ Mubki, Thamer; Shamsaldeen, Omar; McElwee, Kevin J; Shapiro, Jerry (2013). "An update on diagnosis and treatment of female pattern hair loss". Expert Review of Dermatology. 8 (4). Informa UK Limited: 427–436. doi:10.1586/17469872.2013.814858. ISSN   1746-9872.
  2. ↑ Singhal, Hemant. "Wound Infection Medication". medscape. Retrieved 30 May 2018.
  3. ↑ "FUE Hair Transplant Procedure - International Society of Hair Restoration Surgery". ishrs.org. 10 September 2014.
  4. ↑ Onda M, Igawa HH, Inoue K, Tanino R (Dec 2008). "Novel technique of follicular unit extraction hair transplantation with a powered punching device". Dermatol Surg. 34 (12): 1683–8. doi:10.1111/j.1524-4725.2008.34346.x. PMID   19018825. S2CID   21841027.
  5. 1 2 Rassman WR, Bernstein RM, McClellan R, Jones R, et al. (2002). "Follicular Unit Extraction: Minimally invasive surgery for hair transplantation". Dermatol Surg. 28 (8): 720–7. doi:10.1046/j.1524-4725.2002.01320.x. PMID   12174065. S2CID   33125094.
  6. ↑ Dua, Aman; Dua, Kapil (2010). "Follicular Unit Extraction Hair Transplant". Journal of Cutaneous and Aesthetic Surgery. 3 (2): 76–81. doi: 10.4103/0974-2077.69015 . PMC   2956961 . PMID   21031064.
  7. ↑ Harris JA (Nov 2008). "Follicular unit extraction". Facial Plast Surg. 24 (4): 404–13. doi:10.1055/s-0028-1102904. PMID   19034817. S2CID   902688.
  8. ↑ M, Rashid, Rashid; Morgan, Bicknell, Lindsay T (1 September 2012). "Follicular unit extraction hair transplant automation: Options in overcoming challenges of the latest technology in hair restoration with the goal of avoiding the line scar". Dermatology Online Journal. 18 (9): 12. doi:10.5070/D30X57S71R. PMID   23031379.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  9. ↑ "Hair transplant robot gets FDA approval, men with straight brown hair rejoice". Engadget. Retrieved 22 December 2017.
  10. ↑ "Hair transplant graft cost selected countries 2021". Statista. Retrieved 17 June 2021.
  11. ↑ Rose, Paul T (15 July 2015). "Hair restoration surgery: challenges and solutions". Clinical, Cosmetic and Investigational Dermatology. 8: 361–370. doi: 10.2147/CCID.S53980 . ISSN   1178-7015. PMC   4507484 . PMID   26203266.
  12. ↑ "Hair transplant UK Cost". UK hair Transplants. Retrieved 14 February 2023.
  13. ↑ "Hair Transplant Procedures: Average Cost, What to Expect, and More". WebMD. Retrieved 13 September 2019.
  14. ↑ "2020 Practice Census Results" (PDF). International Society of Hair Restoration Surgery. 1 May 2020.
  15. ↑ Okuda S (1939). "The study of clinical experiments of hair transplantation". Jpn J Dermatol Urol. 46: 135.
  16. ↑ Orentreich, Norman (1959). "Autografts in Alopecia and Other Selected Dermatologic Conditions". Annals of the New York Academy of Sciences. 83 (3): 463–479. doi:10.1111/j.1749-6632.1960.tb40920.x. PMID   14429008. S2CID   35356631.
  17. ↑ Unger WP (1994). "Delineating the 'Safe' Donor Area for Hair Transplanting". The American Journal of Cosmetic Surgery. 11 (4): 239–243. doi:10.1177/074880689401100402. S2CID   79005826.
  18. ↑ Shiell, Richard C (January 2008). "A Review of Modern Surgical Hair Restoration Techniques". Journal of Cutaneous and Aesthetic Surgery. 1 (1): 12–16. doi: 10.4103/0974-2077.41150 . ISSN   0974-2077. PMC   2840892 . PMID   20300332.
  19. ↑ Alam, Murad. Evidence-Based Procedural Dermatology. Springer November 2011; 382-3.
  20. ↑ "Functional hair follicles grown from stem cells". SBP. 27 June 2019. Retrieved 13 September 2019.
  21. ↑ "Hair Cloning Nears Reality as Baldness Cure". WebMD. 4 November 2004. Retrieved 13 September 2019.
  22. ↑ Lee, Jiyoon; Rabbani, Cyrus C.; Gao, Hongyu; Steinhart, Matthew R.; Woodruff, Benjamin M.; Pflum, Zachary E.; Kim, Alexander; Heller, Stefan; Liu, Yunlong; Shipchandler, Taha Z.; Koehler, Karl R. (1 June 2020). "Hair-bearing human skin generated entirely from pluripotent stem cells". Nature. 582 (7812): 399–404. Bibcode:2020Natur.582..399L. doi:10.1038/s41586-020-2352-3. ISSN   1476-4687. PMC   7593871 . PMID   32494013.

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