Surgical Restoration

Hair restoration using hair transplantation

The terminology used today in the field of hair restoration – FUT, FUE and BHT.

Follicular Unit Transplant or FUT has been commonly but incorrectly come to signify hair transplantation using strip harvest it should have been follicular unit micrografting. FUE refers to follicular unit extraction which is the individual surgical extraction of follicular units using a punch device. BHT or body hair transplant refers use of non-scalp hair follicles (beard, chest back etc.) using FUEto restore hair on the scalp.

Follicular Unit Transplant using single strip harvest (FUT)

Strip technique has been the traditional method of donor harvest for some time, and is still a good option in majority of hair loss patients, especially for men with advanced thinning, looking for the maximum hair coverage with minimum inconvenience. It is one technique which utilizes the most permanent and best follicles for transplantation and helping to achieve a natural looking and long lasting result.

Follicular Unit Transplantation (FUT) is a hair restoration technique where a patient’s hair is transplanted in naturally occurring groups of 1 to 4 hairs, called follicular units.

Strip procedures, are a team effort; the surgeon heads the transplant team, guides and directs the cutting and placement, but it would not be possible to place the amount of grafts without an efficient and technically adept team.

Myths associated with FUT/Strip harvest hair transplant

It has been a strong belief at Hairrevive, that unbiased patient information is an important aspect of the consultation and in continuation with that the website also aims to do the same.

1. It is an old or dated procedure
2. Causes severe scarring
3. Very painful.

Philosophy of follicular unit micro grafting

Hair transplantation is a surgical procedure by which permanent hair from regions of the scalp that normally never go bald, such as the sides and lower back of the head, is transferred or redistributed into areas of permanent hair loss or thinning.

Hair naturally grows, in clusters of one, two, three, and sometimes four hairs, these clusters are called “follicular hair units. This procedure imitates nature by relocating these naturally occurring “follicular hair units” from the donor area (i.e. the back and the sides of the head) to the recipient site (balding area)

It has been shown that when single-hair micrografts are generated from breaking up larger follicular units, their growth is less than when the follicular units are kept intact, demonstrating the fact that “the whole is greater than the sum of the parts” and supporting the concept of the follicular unit as a physiological entity.

It has been shown that when single-hair micrografts are generated from breaking up larger follicular units, their growth is less than when the follicular units are kept intact (Rassmann Bernstein (1995)), demonstrating the fact that “the whole is greater than the sum of the parts” and supporting the concept of the follicular unit as a physiological entity. Advantages of follicular unit grafts over micro and mini grafts: The follicular unit grafts are trimmed under magnification and have a better hair /skin ratio. This allows us to keep the recipient sites small and space them closer together, while at the same time maximizing the amount of hair that can be placed into them.

Strip procedures, are a team effort; the surgeon heads the transplant team, guides and directs the cutting and placement, but it would not be possible to place the amount of grafts without an efficient and technically adept team.

A typical transplant preparation

You will arrive at the centre at 8 am after having had a light breakfast at 6 am and nothing taken orally after that. You would have taken the prescribed medications and shampooed your scalp with the medicated shampoo.

You will be asked to change into the OR clothes. You will be given a head wash with an antiseptic shampoo. Dr Sattur will go over the proposed plan of the procedure, mark the hair line and the area to be transplanted. This is done according to mutually agreed plan. The donor area is trimmed depending upon the number of grafts planned, which is usually a cm wide and about 20-25cm long. Then the hair above is taped so that it does not interfere with the operative area.

How are the dimensions of the donor strip calculated?

The dimensions of the donor strip depend upon the follicular density(decides the length) and the elasticity of scalp(decides the width) in the donor area. Firstly, during the initial consultation a rough estimate of donor density is made using the folliscope. Readings are taken from three different locations in the donor area are averaged. The number of hair per unit area and average calibre is estimated.

On the day of the surgery after the hair is trimmed, an area of one square centimetre is marked and digital pictures taken. Accurate count of the density is made. If the average density is 80 FU/sq.cm and if the requirement is of 1600 grafts then the strip dimensions should approx. 1cm X 20 cm. Generally the width is between 1 – 1.5 cm but the length can be upto 30 cm depending upon the shape and size of the person’s head, density and the number of grafts planned. It is important not to cross the safe donor area limits.

Importance of scalp laxity

With good scalp laxity, a wider strip may be harvested from the donor area without the risk of a wide scar(but a totally loose scalp means easy closure and but not necessarily a good scar (scalp elasticity paradox)). If the scalp is too tight, taking a normal size strip may be impossible. In such cases, scalp exercises are recommended generally 4-8 weeks prior to the hair transplant. These exercises help in loosening the skin tightness and thus permitting strip harvest. These scalp exercises are shown below.

Clasp your hands and place on the back of your scalp as shown in the photos below.

Place your hands slightly above the bony ridge that runs laterally (horizontally) at the back of your head.Pull your hands forward toward your forehead while at the same time moving your scalp up and hold it there for a count of ten. Press hard enough against your head so that your scalp moves and your hands don’t simply slip over your hair.

Do the similar stretch by moving the scalp down and it there for a count of ten.

Place your hands firmly at the side of your head as in the photo below.

Move the scalp in as far as possibleas scalp movement will allow without your hands slipping on your head and hold the position for a count of ten.

Repeat the same stretch but move the scalp outwards and hold for a count of ten.

Perform all exercises for 5 minutes in the morning and 5 minutes in the evening and if possible once in between if you find the time.

A good clinical judgement acquired with experience will to keep optimal strip dimensions (not too long and not too wide) and help in achieving a fine scar.

Even large strip procedures with 2500 FU plus grafts, can be repeated over again if the donor area is suitable.One must allow the scalp to heal and gain tissue strength, so we advise a gap of 6-8 months before the next session is planned.

Anaesthesia of the donor area:

Once you are ready you will be made comfortable in the chair and hooked onto a machine which monitors your pulse rate, blood pressure. An IV line is secured. For the initial part of the procedure the chair will be completely flattened and you will be asked to lie with your face down.

After making sure you are comfortable,Dr Sattur will inject the local anaesthetic on to the prepared area on the back of your head. This is probably the most discomforting part of the operation. Various aids to reduce the discomfort are used like vibratory tools, ice packs etc. In all likelihood, the injection of the local anaesthetic is the only part, in which you will feel an occasional sharp but tiny pain. By now the back of your head would feel numb and after confirming this Dr Sattur would proceed with next step of the surgery. Using a scalpel a strip measuring 1 cm – 1.25 cm wide and up to 25 cm long (on an average) is removed from the donor area.Dr Sattur will remove the strip in small sections of 5 cm at a time and hand it over to the surgical assistants for dissection. By taking the strip out part by part he ensures that out of body time is not very high. While the assistants are dissecting the donor strip, Dr Sattur will be closing the donor area with stiches (which can be absorbable and do not need removal or non-absorbable one which are removed after 10-12 days). During this part you will not feel any pain or discomfort. The donor area is sutured to leave a thin, almost invisible line that the surrounding hair grows through and over to cover. The suture line is well covered by the hair around it and is not visible ordinarily and in time, would be virtually impossible to detect it even if one were to look for it while combing. The closure causes minimal tension allowing minimum invasiveness and cosmetic change to scalp.After the closure a long acting anaesthetic is injected in the numb skin below the suture area, this helps to ensure further 6-8 hrs of pain free period.

After this the recipient area is marked and anesthetized in a similar manner.

After this point you will be allowed a break and you could take some refreshments and generally relax.

Understanding the donor scar:

Achieving a fine scar is one of the critical goals of a successful hair transplant.

A fine scar enables the patient to keep his hair relatively short after the procedure and also increases the amount of hair that can be harvested (removed) in subsequent hair transplant procedures.

We use many techniques to optimize the utilization of the donor area and minimize the scar like careful dissection, complete hemostasis, tumescent anaesthesia, minimal undermining, and closure in two layers with Trichophytic closure.

In ensuring a fine scar it is important to place the scar in the right location (not too high, not too low) and using optimal width of the strip (wide strips can lead to broad scars).

A very important factor is stretch back and you as the patient must ensure over the first two months that minimum pressure or stretching is applied to the scalp; this generally involves less activity or heavy work out sessions due to skin laxity returning to normal without being pulled in differing directions. Even the best closed suture can stretch if too much pressure is applied.

Trichophytic closure

In the past several years there has been increased concern about the appearance of the donor scar created with strip harvesting. Partly this is because some patients like to wear their hair short without revealing any evidence of any surgical procedure. The trichophytic closure technique helps in reducing the hairlessness of the scar. With the trichophytic closure technique,Dr Sattur trims one of the wound edges (upper or lower), allowing the edges to overlap each other and the hair to grow directly through the donor scar. This can significantly improve the appearance of the donor area in patients who wear their hair very short.

The trichophytic donor closure is applicable to most first time patients and can also be used on patients who have had previous hair transplant procedures and are looking for improvement in the camouflage of their donor scar. We offer the Trichophytic closure to most of our patients by default and without any additional charges.

Dissection of follicular unit micro-grafts

Previously micro grafts and mini grafts were prepared by trimming them with naked eye. The use of binocular stereoscopic microscope has made it possible for surgeons to see these follicular units and dissect them intact by sculpting the surrounding tissues and removing excessive skin. One of the most important aspects of Follicular Unit Hair Transplantation is stereo-microscopic dissection.

This technical advancement is alone responsible for increasing the donor yield, in some cases up to 20% from the same sized strip.

During the dissection, it is critical that the whole follicular unit is kept intact as this will maximize its growth. Intact follicular units will also give the most fullness to the hair restoration, as they contain the full, natural complement of 1-4 hairs.

The stereo-microscopes needed for the follicular unit dissection are located in the operating room, so that graft dissection can occur simultaneously with other steps of the hair restoration and so that the hair transplantation can proceed seamlessly.

The first step in graft dissection is a process called “slivering”. Slivering involves dissecting the donor strip into smaller pieces/slices called slivers. By identifying rows of follicular units the assistant creates thin slices of tissue which contain one or two rows of follicular units. This is again a critical step. Good slivers generate more and better grafts.

Graft dissection

The slivers are then handed over to the next set of assistants who isolate individual follicular units containing tissue known as follicular unit grafts from these small sections by trimming away excess dermis and fat. These grafts may contain one to four hair depending on the density in the donor area. As soon as these grafts area generated they are kept immersed in chilled Ringer’s lactate solution which closely mimics blood plasma and is more physiologic than the more commonly used saline solution (PICTURE – graft holding solution). There are other graft holding solutions which are being used refer to PRP hair transplant

Graft Implantation

While the assistants are preparing the grafts, Dr Sattur will start the anesthetization of the recipient area. You will receive a couple of shots over the front, above the eyebrows and some over the top. Again these needle shots may give you a few sharp pains but only temporarily. Once the anesthesia takes effect your scalp will be completely numb.

The recipient sites are made with 18G, 19G or 20G depending on the size of the grafts. Dr Sattur makes the recipient holes and places the graft simultaneously in a manner quite similar to putting ones foot into the shoe using the shoehorn. Care is taken to match the direction of the graft insertion with that of the surrounding hair. Spacing and the natural pattern is maintained. All through this you will not feel the pain of the needle pricks.

Once the recipient sites have been created, a portion of the grafts are removed from the refrigerated storage and placed into Petri-dishes that sit on a wall-mounted placing stand at the head of the operating table (above left). The grafts are bathed in the same Ringer’s lactate (above right), but the temperature is now held at 59 degrees Fahrenheit while they await placement into the patient’s scalp.

The size of the grafts allows Dr Sattur to place the grafts as close as it is possible with minimal injury to the scalp. Graft placement is a procedure that requires the surgical skill and aesthetically-trained eye and hand of the physician hair restoration specialist. Graft placement will take 2-4 hrs depending on the number of grafts. You can spend this time listening to some light music. During this period if need be you may take a break and have some refreshments.

The density of recipient sites (the number of sites per area) determines how close together the follicular grafts are placed. The spacing of recipient sites depends upon a number of factors. These include: the available donor supply, area to be covered, patient expectations regarding the final density, size of the FUs, team’s ability to harvest and implant large number of grafts etc.

We try and achieve optimal density.Trying to achieve very high density has a potential problems like poor growth caused by poor perfusion of grafts (due to a compromised blood supply) and increased popping that can lead to graft desiccation (drying out of grafts) and crush injury from their re-insertion. Our goal is to achieve optimum growth and this is never be compromised in order to achieve short-term goals of maximum density.The idea of hair transplantation is not to replace lost hair for hair but to redistribute the follicles in such a way that it creates an illusion of more hair and achieves the cosmetic benefit.

What Happens After Graft Placement?

By 2.30 pm all the grafts will be in place and after reviewing the grafts you would be sent out from the hair restoration room. There is no dressing on the grafted area.

A small dressing is kept on the donor area for the first 48 hours to soak any collected blood and prevent soiling of the pillows. You may wear a lose cap with prior approval from Dr Sattur so as to prevent the grafts from sticking to the cap. You will receive a painkiller before you leave the hospital premises. You will be advised to take antibiotics for five days to prevent infection of the grafts. Painkillers may be required on the first few days. Cold compresses over the forehead are helpful.

After changing into your clothes, by 3 pm you will be ready to go home. Though it is possible for you to drive, it is not recommended and it is better to have someone pick you up and drop you home.

What happens after hair transplant surgery?

Hair transplantation is a very safe, relatively minor surgical procedure. Significant complications are extremely rare. There is usually little or no discomfort in the grafted area. Most patients feel some “tightness” in the donor area for 1-2 days and are prescribed a mild analgesic to help cope with this. Patients may be asked to use moist compresses or sprays and to sleep in a semi-upright position for 2-3 days following the procedure to minimize swelling and bruising. Small crusts may form on each graft, and these can usually be camouflaged by any existing hair that can be combed over the recipient area. These crusts will flake-off by 10-14 days after the surgery, the smaller follicular unit scabs often falling off at 4-6 days and the multi-follicular unit scabs taking longer. The transplanted hair seen growing out of the scalp may initially be shed; however, the roots remain and will be dormant for 10-14 weeks, at which time the new hairs will all begin to grow. Numbness that may occur in the donor or recipient area usually disappears within 2-8 months following surgery.

As stated above, complications are rare. Minor inflammation can occasionally occur around a newly transplanted hair follicle, similar to an infected ingrown hair or pimple, and usually responds to simple warm compresses. The scar that occurs in the donor scalp as a result of the removal of donor skin is usually quite narrow and can be easily hidden by the surrounding hair. The graft sites in the recipient frontal area heal with almost no visible scarring and are covered by the transplanted hair. A minority of patients may experience mild swelling in the forehead area for a few days following surgery. It typically appears around the 3rd post-op day and goes away after 3-4 days. Infection in either the donor or recipient area is extremely rare. Many patients experience a small area of numbness above the donor scar and in the rear central scalp that gradually disappears after a few months.

RISKS, SIDE EFFECTS, AND POSSIBLE COMPLICATIONS:

In the overwhelming majority of hair transplantation procedures there are no complications. However, a number of side effects, risks, and complications can occasionally occur. For the purpose of putting these things in perspective, we will divide them into two categories: those that occur occasionally and those that occur very rarely and are included here for the sake of completeness:

Side effects that occur only occasionally:

• Mild Swelling in the forehead, occurs in about 1 in 10 procedures
• Mild “Shocking” (shedding) of Existing weak Hair causing them to drop out for 3 months, after which they grow back.
• Epidermoid cysts,
• Temporary numbness of part of the head,
• Post-op pain or headache
• Minor and trivial side effect: Itching in the area of the new grafts or along the donor scar may occur occasionally.

Side effects or complications that occur only very rarely:

• Irregular or uneven or delayed hair growth
• Discoloration of grafts
• Elevation or depression of grafts
• Bleeding
• Scarring
• Dizziness or fainting
• Allergy or reaction to anaesthetics or medications used: Medications are kept at hand to immediately treat any allergic reactions.
• Failure to improve “quality of life
• Infections: Very rare because of rich blood supply.
• There is also the possibility that other effects or complications not presently known, recognized, or understood, may develop, now or in the future.

A continuation of good patient-physician communication is essential postoperatively to reassure the patient regarding the success of hair restoration. The rate at which newly transplanted hair grows, or is shed temporarily, varies from patient to patient; a passage of several months may be required before the outcome of transplantation is fully revealed.

The distinct advantages of follicular unit transplant strip harvest:

• Since follicular unit grafts are trimmed under a microscope they contain less excess tissue and are smaller. This allows the surgeon to place them closer together.
• Because follicular unit grafts are smaller, the surgical incision at each recipient site is smaller. This results in quicker healing without scarring or skin surface deformity.
• Due to the small size of the grafts and incisions, many more grafts/hairs can be transplanted in one session, making “mega sessions” of between 1500 to 2000 grafts practical and safe. This allows the patient to achieve much better results in less time, without numerous surgeries.
• Because the follicular units are not dissected or broken apart, graft growth and survival is better that when mini/micro grafts are used.
• Once transplanted these tiny hair grafts are indistinguishable from the natural groups of hair in the nearby area.
• Practiced by a skilled and artistic surgeon, follicular unit hair transplantation can produce a look that is undetectable and completely natural after only one procedure.