1. Introduction to hair transplantation

Hair transplantation is the surgical solution to baldness. It allows a thickening of the scalp in the areas affected by hair loss or hair thinning.

The technique consists in the extraction of the follicular units (or grafts) from the occipital area of the scalp, called donor area, and in their insertion in previously done incisions in the hairless area of the scalp (recipient area).

The hair transplant has developed a lot in the last years and nowadays allows to obtain a natural result. Of course, an essential role is played by the choice of the right clinic.

The principle behind hair transplantation is pretty easy. Hair that grows on the nape and at the sides of the scalp are permanent, in most of the people. This hair does not fall even in people with an high level of androgenic alopecia. The follicles of that area are not attacked by the diidrotestosterone hormone (DHT), the rensponsible of the hair miniaturization.

 

The hair of the nape is not going to fall

The individual resistance or sensitivity of the hair follicles to the action of DHT is a genetic characteristic that does not change when the follicle is moved from one part of the head to another one. This phenomenon is called “dominance of the donor”, since the hair keeps the same insensitivity to the DHT that had in the donor area.

 

Genetics is not the only thing to consider talking about hair transplantation.

It is interesting to notice how not all the features of the hair are controlled by genetics. For example, the fact that the hair is straight or curly depends on the surrounding area of the scalp. Straight transplanted hair from the donor area will become curly in the frontal area, if there it originally was curly.

The regrowth speed of the hair and its final lenght are going to be determined both depending on the characteristics of the follicle and on the surrounding skin.

It is important to understand that with an hair transplant the permanenet hair is redistributed in order to cover the hairless areas of the scalp or those which present an hair thinning. With an hair transplant it is not possible to create new hair, the only thing that changes is the position of the hair that already was on the head. However, a well performed transplantation can really improve the appaerance of a person with androgenic alopecia. If the treatment is performed by an expert the result will be totally natural and the transplated hair will grow for the rest of the life of the patient.

 

How much hair is involved in hair transplantation? 

The amount of permanent hair in the doner area is a key factor in order to establish if a person is a good candidate for hair transplant. This factor influences every single aspect of the surgical pianning and defines the achievable thickness. A deep evaluation of the available doner area is therefore very important. The most accurate way to evaluate the doner area is with a densimeter or a microscopic video, instruments tha allows the surgeon to examine the follicles adequately.

  1. The origins of hair transplantation

Since ancient times, men have always been looking for a cure for baldness. Thick hair has always represented streght and manhood.

Already the ancient aegyptians, more than 4.000 years ago, imagined a possible connection between hair loss and the activity of the blood vessels. Ippocratus, around 2.000 years later, foresaw the role of the adrogenic hormones as a trigger for baldness.

During the 19th century, hair transplant surgery started to exist when Dieffenbach assumed the possibility to tranplant hair, skin and feather on the birds. Then, in 1939, the japanese Okuda talked about grafting eyebrows, mustaches and pubis. Orentreich has been the first to carry out those intuitions. That is why he is considered the father of baldness surgery and hair restoration. Starting from that moment, hair transplantation lives a constant develop that will keep on going also in the future. Nowadays there are new, sophisticated and complex approaches to it.

If the transplant is performed by an expert it is possible to obtain excellent results.

Nowadays, there are two transplant tecnhiques available: Strip and FUE.

  1. Strip or FUT (Follicular Unit Transplantation) transplant

This techinque foresees the removal of a lozenge of skin from the doner area. From this strip of skin the follicular units will be removed. The follicolar units, once cleaned, will be grafted in the recipient area, in previuosly made incisions.

The Strip surgery brings to the formation of an elongated shape scar that can extend between the two hears. This is one of the most controversial aspects of this techinque. In fact, if the surgery is not well performed, the scar can be visible and represent a big beauty problem for the patient. Nevertheless, the number of follicolar unit extracted with this method is very high: up to 4.000-5.000 in just one session.

  1. FUE (Follicular Unit Extraction) transplant

The FUE extraction method consists in the exctraction of sigle grafts directly from the scalp. The following phases of the transplant are identical to those performed with the strip method.

This techinque is spreading a lot in the international market, since it is less invasive. The scars in this case will be copiuous, but very small and circlular. If the surgery is well performed the scars will not even be visible through the hair.

The risk of transection (percentage of follicular unites damaged during the extraction) is higher. However, thanks to always more sophisticated technologies and systems, the numbers reached by specialized surgeons by now are high. In some cases, it is possible to extract up to 3.000-5.000 units in just one session.

Depending on the area to treat, usually is grafted a number between 1.000 and 5.000 follicular units. If the transplantation is well performed, both the techniques (FUT and FUE) will guarantee excellent results. The surgeon can be able to obtain a density between 30 and 40 follicular units for every cm2.

  1. Key aspects of an hair transplantation

 

Pay attention to the naturalness

The main aspect that needs to characterise a well done transplant is a natural effect result. The natural result has to be achieved both on the frontal line, that has to be conservative and not too linear, and on the correct density level of hair in the previously hairless areas. The aim is to pretend that the patient has never undergone the surgery. Thanks to the technological developements of the last years and to the experience of the surgeons it is possible to reach very natural results.

 

Dimension of the punch used to extract the follicular units

The punch is the instrument used by the surgeon in order to extract the follicular units from the skin. Its dimensions are very important. In order to perform a good transplant, it is not enough to extract an high number of grafts, but also is essential to grant the survival of the follicles once grafted.

To choose a puch with the right diameter allows to minimize the risk of transection. Moreover, the smaller is the damage caused to the surrondig skin, the smaller will be the scars in the doner area.

 

Pay attention to preservation of the follicular units

When the grafts are extracted from the donor area, they get dehydrated, since all the cellular mechanisms are interrupted and modified. Consequently, it is essential that the units are handled with extreme attention. They are stored in a physiological solution that simulates the human organism. They always have to be wet even when they are analysed to the microscope.

 

Pay attention to the incisions

The incisions in the recipient area play an essential role too. In the incisions, the follicular units will be inserted. The incisions are made with a scalpel or with specific blades, chosen depending on the characteristics of the skin of the patient and on the result that he wants to achieve.

Other elements to keep into account are the depth, the lenght and the angle of incision. The aim is to recreate the real angle of the growing hair of the patient. If the incision is well performed, the grafted follicle will immediately receive the nourishment from the blood. Recently, the following kinds of incisions are recognised:

  • Coronal incision: Perpendicular to the direction of the hair growth, but not opposite.
  • Sagittal incision: Parallel to the direction of the hair growth.
  • Lateral slit: this kind of incision is often confused with the coronal one, but is different. To make a lateral slit it is necessary to use a blade, not a needle, and it has to be perpendicular to the growth of the collagen of the hair. The blade needs to be large enough, depending on the dimensions of the follicular units.

 

Avoid the overharvesting

With “overharvesting” we refer to the risk of demaging the doner area by extracting too many follicular units. It is opportune to respect the available density and to always consider the possibility of further sessions. About this issue, the FUT extraction is safer, since the same suture can be reused without touching the surronding area.

A combitation of FUT + FUE translpants is not excluded. It is an innovative technique, increasingly used by the maximum experts in order to maximise the results.

 

Surgeon’s skills in hair transplantation

  • Deep knowledge of the anatomy and of the phisiology of the hair and of the scalp + the full knowledge of the pathologies of the scalp.
  • Perfect understanding of the facial anatomy, excellent surgical skills, complete knowledge of the different techniques of the surgery and of the repair cases.
  • Commitment to keep on learning about the newest techniques and to play a part for always new progress. It is preferable that the surgeon spends most of its time in performing hair surgeries. It is basically impossible that a surgeon who dedicates just a little quantity of its time to the surgeries could offer an high quality standard.
  1. Is the transplant painfull?

The level of pain depends of the sensitivity of the single individual. During the operation the treated area is desensitized thanks to the local anesthesia. It is possible to feel a soft feeling of tensions on the scalp, because of the anesthesia, but this phenomenon spontanuosly fades in a few days.

Since it is necessary to make a suture after the extraction of the FUT kind, this surgery is generally more invasive and it is possible that the client complains an insensitivity in the doner area, that could last many months.

Of all the physiological phenomenon due to both the tecnhiques we remember: swelling in the recipient area, in the frontal area and in the area of the eyes. These problems will last around maximum 8 days.

  1. Grafted hair fall

One of the less loved aspects of the hair transplant is the grafted hair fall that occurs around 2/6 weeks after the operation. Most of the transplanted hair will fall and this phenomenon may also affect the indigenous hair.

It is a fully physiological process that foresees the loss of the lenghts, not of the follicles. If well grafted, the follicles will give birth to new hair around 3/6 months after the transplant.

  1. The significance of the prior consultation

The first meeting between the surgeon and the patient plays an essential role for two main reasons:

  • The realization of a detailed medical history;
  • The definition of the possible course of the condition.

 

During the prior consultation the surgeon establishes a detailed intervention plan with the analysis of the:

  • State of health of the patient;
  • Current hair situation;
  • Quality of the structure of the hair;
  • Quality of the skin;
  • Size of the alopecic area;
  • Hair follicles density per cm2;
  • Presence of scars or grafts from previous transplants.

 

To conduct this analysis, the surgeon uses specific machineries, such as the densitometer (to measure the follicular units density per cm2) and the macrophotography to make a phototricogram (to measure the growth and the calibre of the hair).

The pshycological dimension of the client has to be taken into consideration too. His expectations has to be compared with the possible results. If the patient is very young and has high expectations, it is opportune to show him the possible evolution of his bladness.

The choice of the tecnhique of extraction plays a crucial role too. During the consultation, the surgeon will tell the patient his choice and will explain to him:

  • How many follicular units will be extracted;
  • How the surgery will take place;
  • How many sessions will be necessary;
  • Which is the achievable result;
  • Which are the possible complications after the surgery.

The patient has the right to ask any question, to look over other cases with pre and post surgery photos and to ask for an explication if he did not understand something. After that, he will sign a clar and detailed informative form.

  1. The ideal candidate for an hair transplantation

Here below a short list of some ideal candidates for an hair transplantation:

  • Men and women who suffer from androgenetic alopecia;
  • Women and men who wish to amplify the density in the areas of the scalp affected by an hair thinning;
  • Men and women who wish to restore the hair of eyebrows, brows, burnt parts of the body, pubis;
  • Women and men who has after transplant, after trauma or after skin illnesses scars.
  1. BHT (Body Hair Transplant)

The BHT, Body Hair Transplant, represents one of the greatest innovations in the field. Almost every surgery technique uses follicular units extracted from the scalp, but, when a patient needs many grafts, all the other hair of the body  become a good resource. The follicular units are usually extracted from the chest, the beard or the back, but also from arms and legs, and then grafted on the scalp. It is better to avoid using these grafts for the hairline. It is preferable to use them in order to add density on the mid scalp or on the vertex.

The first surgeon who tested this new method was Ray Woods in 1998. Nowadays, it is a developing technique, only performed by some specialized clinics. It is possible to extract between 500 and 4.000 grafts in one session or in two days in a row. The technique of extraction is the FUE, so every graft is extracted individually. In this case, the hair will fall in a couple of weeks, just like in the other cases, and then regrow after 4 months.

Of course, in order to be a good candidate for the BHT, the patient has to present some physiological characteristics. The hair of his body has to be appropriate to be extracted and then grafted into the scalp. It is also important to remember that the hair of the body has a different cycle of life. All these aspects make BHT a complex and elicate technique.

  1. Hair cloning. When will it be possible?

Theoretically, when it will be possible to clone hair, there will be no more limitations due to the quantity of extractable hair from the donor area.

In that case, all the people affected by baldness will be good candidates for the transplant and will be able to achieve the density they wish. However, currently it is not possible to do so and the amount of transplantable hair is limited.

The hair transplant surgery requires the surgeon to have both technical and aesthetic skills. The doctor has to create a natural result that combines the availability of hair in the donor area, the characteristics of the hair and the expectations of the patient.

The surgeon has to choose an appropriate design not only for the short term, but also for the future, always keeping in mind that the patient will age. The aesthetic ability is not enough to guarantee a good looking result. The relocation of thousands of follicular units requires high technical skills. That’s why the surgeon has to be supported by a good and prepared staff that will help him in carrying out such a long and complex surgery.