Hair Transplant principles and

advances

By:Dr.Ayush Antil
JR2 Dermatology
History:
• In late 19th century, a German surgeon performed the first
transplant.

• In 1959, Norman Orentreich,credited as the “Father of modern hair

transplantation”, introduced the concept of Donor dominance on
which the basic principle of hair transplantation is based.
History continued..
• Punch grafting
• In this technique, full thickness grafts of 2-4mm plugs were punched
out by a hair transplant punch from donor occipital area and were
then inserted into holes made by the same punch in the recipient
bald areas.
• Unfortunately, punch graft technique
gave an unnatural “doll like” or “paddy
field look” over the recipient areas
resulting in highly unsatisfied patients.
 Mini/micrografts
• To overcome the doll like appearance from the early 1980’s, smaller grafts
called mini and micro grafts were introduced.
• Minigrafts had 6-8 hairs, while micrografts had 1-3 hairs that were
dissected randomly, without the aid of a microscope.
• The donor harvesting- punch grafts-changed to strip harvesting.
• Multistrips- higher degree of transection - favoured single strip
harvesting.
Follicular unit:

• Each unit consists of –

• 1-4 terminal follicles
• 1 or rarely 2, vellus follicles
• Asssociated sebaceous lobules and
insertion of arrector pili muscles
• Perifollicular vascular plexus and neural
network
• Perifollicular- circumferential band of
fine adventitial collagen that defines
the unit.
Follicular unit contd…..
• The units usually contain
1-4 hairs and since the
hair are tightly packed
without any intervening
dermis;the size of the
units is quite small.
• Hence require small
recipient
sites.
• In contrast minigraft have 3-
4FU’s and micrograft have 2 FU’s.
• Also, since no of FU‘s in the donor can
be easily determined either by a hair
scan or a stereomicroscope,
calculation of req no of grafts for the
recipient area is easy.
• Current methods of autograft transplantation are:

• Follicular unit transplantation

• Follicular unit extraction

Indications of Hair Transplant
•Male pattern (MPB) and female pattern baldness 
•Scarring alopecia
•Traction alopecia
•Beard reshaping
•Scar reconstruction - Burns/Injury scars
•Long standing cases of Alopecia Areata
•Hairline corrections
•Moustache reshaping
•Eyebrow and eyelash transplant
•Revision hair transplant
•Pubic hair transplantation
Criteria for rejection of a patient

•Inadequate donor hair and too low a density, especially in patients with class VI or VII
Norwood patterns.
•Patients who may have little available usable donor hair because of too much scarring
from previous grafting that was healed by secondary intention.
•The patient who has unrealistic expectations.
•There are also patients with medical problems that can interfere with grafting, such as
hypertension.
FIVE BASIC CRITERIA FOR ASSESSING CANDIDATES FOR HAIR
TRANSPLANTATION :

1.Age :
• Pts >25 years are preferable.
• < 25 years of age often seek consultation, there is a hesitancy to
operate.
2.Hair shaft caliber:
• Large-caliber hair shafts (greater than 70 microns) obtain much
denser coverage than individuals with corn silk quality hair.
• Very small volume increases in hair shaft diameter result in
exponential increases in surface area coverage
3.Donor hair:
• A variety of instruments are available to measure donor hair density.
• Measuring a 0.25 cm² field and multiplying by four is the preferred
method.
• Patients with >80 follicular units/cm² - excellent candidates.
• Donor hair density <40 follicular units/cm2 - poor candidates.
4.Degree of baldness:
• Most important criterion in candidate selection.
• Those with complete baldness of the frontal scalp as opposed to
baldness limited to the vertex are excellent candidates.
• When frontal baldness is corrected, this creates the most dramatic
positive change in appearance.
5.Hair color :
• Follicular unit grafting has made haircolor less of an issue than when
punch grafts were employed.
• Individuals with “salt-and-pepper” hair, red hair or blonde hair are
preferential to those with jet-black hair.
• Black-haired individuals are not exempt as hair transplant candidates ,
but should receive only one-hair follicular units in the frontal hairline
for the most natural result.
Other Factors affecting outcome in hair transplantation

• Technical factors
• a. Cooling-
• b. Heat and drying of grafts- Inimical to hair growth, cooling is advocated
• c. Graft handling
• d. Duration of surgery- prolonged surgery are associated with death of
follicles ( after 6 hours- grafts tend to die)
• e. Recipient site density- 35-40 units per cm² is adequate to give good results.

• Staff factors: Training and experience.

Preoperative Examination
•Pre-procedure investigations should include basic investigations:
•CBP
•LFT
•FBS,RBS
•BT & CT
•PT
•HEP-B
•ECG
Advice of physician may be sought if there is any underlying systemic illness.
•It is advised to stop minoxidil at least 2-3 days prior to surgery ( range 1-
14 days) to minimise skin irritation and to reduce vasodilatory effect of
minoxidil.
•Minoxidil can be restarted between 2 and 14 days after surgery.
• Finasteride use is uninterrupted in pre and post surgical period.

Dermatol surg, 2002

Hair line design:
• Construction of the hairline is the most important aspect of donor insertion.
• In men, the hairline defines the cosmetic success of a hair transplant.
• Women have stable frontal, temporal and posterior hairlines, recreating
a hairline in them is usually not necessary.
• The design of the frontal hairline should be such that it will remain balanced
with the temporal and posterior hairlines.
Hairline design
•Single hair grafts are used to create a natural hairline.
•To locate the ideal hairline in a bald patient, it is necessary to divide the face into
three equal segments.
•In the midline, the hairline starts 7-10 cm from the glabella.
•A curve sweeps around to the lateral side of the forehead from the center. At
this point, the sides of the hairline should be oriented parallel to the curve when
the subject is looking straight ahead.
•The lateral hairlines are usually 9.5–11.5 cm above the lateral canthus of the
eyes.
•The temporal angles : form relatively sharp right angles or acute angles in most
men but these angles should be more rounded in women.
Donor Region:
• The amount of available donor hair is the primary limiting factor in
hair transplantation.
• 65–85 follicular groupings/ cm2 - occipital donor scalp.
• If there are <40 follicular units/cm2-poor candidate.
• The mid occipital scalp between the upper and lower occipital
protuberances is the recommended donor site,
• given its density of hair and
• the ability to camouflage the donor scar
• given the lack of involvement by AGA.
Local anesthesia of donor region
• Surgery is done under local anesthesia and sedation.
• It is a challenging task to give effective, safe local anesthesia during hair
transplant surgery, which should be effective for 3–5 hours.
• Preoperative anxiolytic such as lorazepam,clonidine is helpful.
• Lidocaine is the main local anesthetic used.
• Its action starts within 2–3 minutes and lasts for maximum of 2–3 hours if
used with adrenaline.
• The dose when used with adrenaline is 7 mg/kg. It is often combined with
bupivacaine to prolong the anesthetic effect to 4–5 hours.
• Once anesthesia is obtained, 20 ml of normal saline can be injected to provide
further anesthesia, hemostasis and dermal turgor; the latter helps to reduce the
transection of hair follicles.
• Some hair transplant surgeons use nerve blocks to facilitate the local anesthetic
effects.
• Harvesting of donor hair is performed via two different techniques:

Elliptical donor harvesting(single strip dissection)

Follicular unit extraction

Elliptical donor harvesting:

• Elliptical donor harvesting is safe and allows rapid removal of large numbers
of hair follicles, with minimal transection of hairs.
• The width of the donor ellipse ranges from 7 mm to 1.2 cm, while the length
should be less than 30 cm.
• The number of follicular groupings required determines the
dimensions of the donor ellipse.
Elliptical donor harvesting:

• For example, if 1000 follicular groupings are needed for the frontal scalp
and a patient has an average donor density of 75 follicular units/cm2, a
13.5 cm by 1 cm strip should contain approximately 1000 follicular
grafts.

• It is important to remember that increasing the width of a donor ellipse

creates more wound tension which may lead to a hypertrophic or wide
scar.
• Initial scoring of the excision
may be done with a single or
double #15 blade scalpel.
• The blade should be oriented
parallel to the exiting
follicles, again to avoid
transection of hair follicles.
• The incision should be into the subcutaneous
fat and not deeper, in order to avoid
transecting the occipital arteries and nerves.
• Lateral retraction using fine skin hooks exerts
tension away from the excision and creates
good visibility for the surgeon harvesting the
ellipse
• The ellipse can be removed by scissors or a
scalpel, being careful to avoid damage to any
follicles in the subcutaneous tissue.
• If the incision does not go any deeper than the
subcutaneous fat, the ellipse can be removed
without the use of electrocoagulation or
thermal coagulation.
• The donor ellipse can often be primarily
repaired with no undermining if it is <1 cm in
width.
• Some surgeons utilize a two-layer closure while
others perform a single-layer closure.
• Staples or sutures can placed and
then removed 7–10 days later.
• Absorbable sutures may also be
used.
• A wide donar scar is a common complication of strip dissection.
• To overcome this-
• A refined donor closure technique, k/a “trichophytic closure”, is
designed to allow hairs to grow through residual scar.
• This technique has been successful in providing a thin scar, which is
no more than 1mm wide.
•This is achieved by snipping a 1mm ledge of
epidermis from one edge of the donor wound
before its closure, in the expectation that the
underlying hair will grow through the linear scar
making it less conspicuous.
• Follicular Grafts:
• Over several hours, surgical teams can carefully separate 500–2000
follicular units from the donor strip.
• Cutting instruments include #11 and #15 blades as well as #10 prep
blades.
• Some surgeons believe microscopic dissection or magnification
reduces transection of follicles during the separation process.
 Graft dissection:
• Imp aspect-stereomicroscopic graft
dissection-which minimize the transection
rate .

• Donar strip-20-25cms*1-1.3cm-yield
2000-2500
grafts of 1-4 hairs-4000-5000 hairs
• 1st step-
• Cut the strip into “silvers”
that are smallest sections
of 2- 2.5mm width.
• 2nd step- dissect the slivers
into FU’s by trimming
excess epidermis, dermis
and fat.
• Grafts are
immersed in
chilled NS or RL
solution,which
otherwise render
them non viable.
Follicular unit extraction:
• Follicular unit extraction was first described by Bernstein and Rassman,
who referred to it as the ‘FOX’ procedure.
• However, it has been described by other workers under different
names such as Wood’s technique, FU isolation method.
• It has been also referred to as sutureless method of transplantation.
• Follicular unit extraction (FOX procedure):
• Follicular unit extraction (FUE) represents the
removal of individual follicular groupings from
the posterior scalp via an approximately
0.75–
1.2 mm punch device.
• The arrectore pilori which holds the hairs
together in a bunch.
• The bulge area, is the narrowest part of the
unit, with the hairs splaying below, resulting
in a pyramid shaped unit.
• The site of attachment of arrector muscle to
the FU is the zone where the hairs are held
at their tightest.
• The inferior segment is therefore held loosely
and once the hold of the arrectores in the unit
is weakened, the inferior segment can be
extracted easily.
Indications of follicular unit extraction:

• Pts who do not want linear scar

• Limited hair loss on scalp, eyebrow, eyelashes and moustache area
• Pts without adequate scalp laxity
• Pts in whom the donor area is the body or beard hair
• FUE is recently also being used along with FUT to perform larger sessions.
Procedure of Follicular Unit Extraction
• The entire donor area from the occipital scalp
is trimmed to 1–2 mm length.
• The grafts are then extracted from the donor
area with the help of 0.8, 0.9 and 1 mm micro
punches.
• The extraction of follicles is done under 2.5–5X magnification.
• The punch is introduced along the direction of hair, up to a depth of about 2–3
mm, till a sensation of ‘give in’ is felt.
• While this is being done, traction is applied downwards by the assistant to
render the hair as vertical as possible to facilitate smooth entry of punch.
• The extracted grafts are then preserved in saline or cool Ringer’s
lactate solution.
• The extraction has been greatly facilitated by introduction of
automated machines (jack Yu’s extracter).
Techniques of Extracting the Grafts
• One-Step Procedure
• A single punch is used to mark the skin and then rotated in one direction by
two to three turns till it suddenly gives way (when the bulge level is reached).
• At the same time, assistant pushes the skin down in the direction opposite
to that in which hair is being pulled.
• Single step procedure, the quickest, is often associated with higher
transection rates than two and three-step procedures.
• Two-Step Procedure

• If the unit does not pop out as above after introduction of the punch, a fine
forceps is used to apply gentle upward traction to the top of FU while another
forceps is used to push it up from below the bulge level.
• Three-Step Procedure
• The sharp punch is used to score the epidermis and then dull punch is used to
bluntly dissect the FU with twisting movement from the surrounding epidermis
and dermis.
• Lastly, the graft is held with forceps and pulled out.
• This variation may be more accurate, but is considerably slower.
 FUE
:Advantages :
• Less manpower than follicular unit transplant (FUT)
• The procedure is less aggressive and advanced surgical expertise is not
essential
• Graft dissection and preparation is minimal
• Less space and equipment are needed
• Patient can cut hairs short
• Minimal postoperative pain and recovery time
• Small scars in donor area are less visible
• The technique can be used for extracting body hair, for additional density
Disadvantages:
• It is slow and tedious
• There is a long learning curve in follicular unit extraction (FUE)
• Higher transection rate
• Finally, the number of grafts extracted per day is limited, leading to
multiple sessions
• Very fine trimming of donor hair which may be unacceptable to many
people
• Because of the time consumed, the procedure is more costly, almost
three times that of FUT.
Anesthesia of recipient
site:

• Infiltration at the hairline extending as an arc to the temporal area.

• A combination of supraorbital/ supratrochlear nerve blocks, field
blocks and local infiltration with 1% lidocaine with epinephrine can be
performed.
• Most of the surgeans use off the shelf 1:200000 epinephrine conc.
• Tumescent anesthesia is helpful in elevating the skin and in achieving
vasoconstriction.(lignocaine+NS/RL).
Recepient site creation:

• Recipient sites should mimic the natural 30–

45° angle of hair growth on the scalp.
• In case of advanced baldness direction of
miniature hairs should be noted.
• There are a variety of needles, including 19,18 and 20-gauge
needles,blades, noker needles that are used to make sites large enough
to place individual follicular units.
• The depth should be 4-5mm to avoid damage to deeper vessels.
• The key to success is to create recipient sites in
a random, highly irregular pattern with 10–30
follicular units/cm2, depending on the density
of existing hair on the scalp.
Graft placement:
• There are several methods of insertion –
• “stick and place method”-
• making a recipient site and insertion of grafts immediately by an assistant into
recipient site.
• “preformed slits”-
• creating all the required recipient sites in the beginning and then placing the
grafts one by one.
• “Implanters”-
• such as CHOI,KNU implanters.
• Ill-defined “feathering zone” is re-created by
randomly placing, in an irregular pattern,
follicular unit grafts along the newly created
hairline.
• Dense packing of grafts should not be
performed because this will lead to a hairline
with an unnatural appearance.
• The major challenges include hemostasis and “popping” of grafts
from recipient sites after they are placed.
• This phenomenon is overcome by applying light pressure over a
placed graft for 5–15 seconds with a saline-soaked cotton swab
before placing the next graft.
• Avoiding Popping
• Popping is a frequent problem faced by beginners and can be avoided
by following tips:
• Insertion of grafts from back to front.
• Using the right sized graft for the right-sized holes.
• Placing the grafts smoothly, without rigorous handling of the grafts.
• Placing the grafts into alternate sites, rather than contiguous sites.
Post operative instructions:
Day of the procedure • Apply non-adherent dressing overnight
• Oral acetaminophen (paracetamol) 300 mg(4-6hrs)
• Oral prednisone 40 mg daily for 3 days to reduce
frontal scalp edema
• Resume regular activities, but no heavy lifting or
strenuous exercise until staples/sutures removed
• Sleep with head elevated
• Postoperative days 1–3 –
• Day 1 – remove dressing
• Shower each day and allow water to run over grafts
• Comb hair without allowing comb's teeth to hit perifollicular crusts
• Do not pick or scratch at perifollicular crusts
• Apply emollient to the donor site daily
• Days 1, 2 – continue prednisone
Postoperative days 4–7- • Resume light exercise
• Follow instructions outlined for showering
• combing and emollient application
• Postoperative days 7–10 - Staples/sutures removed
• Resume regular exercise regimen
• Perifollicular crusts gradually disappear
Natural course aftertransplantation:
• The majority of the transplanted hairs will fall off in 2–4 weeks due to
telogen effluvium.
• Growth begins in the 4th month and thereafter hair grows 1 cm every
month.
• The optimum results are seen by 9 months after them surgery.
• Delayed but temporary thinning of hair is seen in few patients due to
postoperative telogen effluvium.
Complications:
• Complications are rare and minor. They include:

• Immediate Complications
• Bleeding during surgery and in immediate postoperative period. This can be
controlled with firm cold saline compresses.
• Pain on the day of surgery with a pulling sensation over the sutured area
• Swelling around eyes is seen from 5th day onwards and can be prevented
by sleeping on left or right lateral sides and use of cold compresses
• Crusting may persist for a week if cleaning is not done properly.
Late Complications
• Delayed growth may be seen rarely
• Postoperative follicular pustules may be seen in 2–3 months. This is due to a
foreign body reaction and is commonly seen if grafts are improperly placed or
grafts contain damaged hair fragments.
• Sterile pustules and usually self limiting.
• If persistent, they can be treated by drainage.
Transplantation in Difficult Areas
• Vertex Transplantation:
• This area is large, circular in shape and therefore hairs emerge in a radiating
pattern, like spokes of a wheel.
• Therefore, it needs a large number of grafts and these have to be arranged
in different directions.
• Because the baldness is circular, in future, it could expand in a centrifugal
pattern.
• Hair transplantation in the central circular area could result in a situation in future
wherein grafted hairs remain in the center and new area of baldness is seen all
around it.
• Hair Transplantation in Other Areas:
• Eyebrows: Eyebrows are transplanted with only single hair units,
which are extracted either by strip or FUE technique.
• Eyelashes:
• Corneal protection and proper anesthesia is vital.
• Only single hairs are to be used.
• Can be performed by any of the following techniques:
• Using slit and place as in scalp hair transplantation
• Using KNU implanters
• Using long hairs which are inserted into the eye of curved
needles. The needles are then inserted in the conjunctival side of the
eyelid and then pushed to emerge on the skin side.
• Moustache:
• Since it is a mobile area, proper immobilization is important.
• Transplantation for cleft repair scar is commonly sought.
• Postoperative edema is common as it is a vascular area.
Transplantation in Women:
• In women, there are multiple causes
for hair loss. These should be
investigated and treated before
transplantation.
• Women have long hairs and do not
accept trimming of hairs. Hence
transplantation should be done amidst
these hairs. This is more time
consuming and needs experience
• Since women wants hairs to be long,
results take almost 1.5 years to grow to
required length in contrast to the nine
months needed in men
• Finally, women often have exaggerated
expectations about their results.
Body Hair Transplantation:
• Body hair transplantation, first reported by Woods depends on the
principle of recipient influence demonstrated by Tommy Hwang.
• In addition to donor dominance, there is also the recipient influence
which determines the response in a transplant of hairs from another
area.
• He demonstrated that body hair when transplanted to scalp would
grow longer and thicker.
• BHT, which has the following characteristics:
• Extracted by FUE technique and,it may takes 12–14 hours for a 2,000
graft session.
• Occurs mostly as single hair units with less diameter and hence gives
less density & volume.
• BHT is possible only for patients who have good body hair on chest,
shoulder and other areas
• Body hair transplantation is associated with tiny scars on chest.
• Hence, BHT is performed only when scalp donor is exhausted.
Advances in Hair
transplantation
Robotic
s:
• Since the hair transplant surgery is repetitive, it has been thought the procedure
is ideally suited for a robotic application.
• Recently, a machine called ARTAS has been introduced to perform robotic
assisted FUE.
• The robot has mirror assisted calculation of hair emergence angles to enable
smooth extraction and it has been claimed that it can extract up to one
thousand units in an hour
• While the claims are to yet to be proven, robotic hair transplantation remains
an exciting option.
•Several new drills have been developed to which FUE punches can be
attached.

•The WAW drills uses oscillating mechanism to facilitate extraction of

grafts.

•“ TRUMPET PUNCH” has been developed.

• Inner bore of punch is sloped and blunted to facilitate obtaining grafts

and external border is flat and sharp.
•Other development with punches- HEX punches ( Uses vibratory action
– associated with less transection as compared to other punches).

• Slotted punches – allow visualisation of hair angles and proper

centering for FUE harvesting. (suited for long hair)
•Traditional approach for placing of grafts – use of JEWELER’ FORCEPS’.
• Multiple implanters ( LION, OKT) have been introduced.

• A needle like cylinder with slit is attached to spring loaded stem that
push graft into skin after implanter has been loaded.
•Bioenhancements- Increase graft survival rate.

• Physiologic storage media- Hypothermosol (maintain ionic and

osmotic balance, aid support cellular metabolism- removal of free
radicals and decrease cellular death)

•Liposomal ATP has been developed for increasing graft survival.

•Use of liposomal ATP has also been suggested as post operative spray.
•Combination of hypothermosol and ATP is used as holding solution.

• Combination of 1 ml ATP to 100 ml hypothermosol is used.

Platelet rich plasma in hair transplantation

•Platelet rich plasma with its modifications platelet rich fibrin matrix
(PRFM), Plasma rich in growth factors (PRGF), Platelet lysate (PL) have
been used in HT at various satges to enhance results.
Platelet rich plasma- used as holding solution for graft( increase graft survival
rate.

•Also used for donor strip wounds and FUE wounds to enhance healing.
PRP can be topically applied over grafted site.

•Injectiion into recipient area immediately after implantation of grafts at end of

surgery.

•Injections into recipient area after surgery in several sessions over number of
months to enhance growth of grafted hairs.
•Faster healing of microdamge and faster growth of transplanted hair
even 2 months after procedure, with shorter telogen pphase.

J dermatol surg,2019
Key concepts:
• Both men and women should be made aware that AGA represents an ongoing
process, i.e. it will progress despite undergoing hair transplantation.
• Medications (e.g. oral finasteride) can help to maximize hair density from a
transplant by minimizing ongoing hair loss.
• Also, the progressive nature of AGA means that additional hair
transplants may be required, perhaps in another 5 or 10 years.
Conclusion:
• Hair transplantation technique has evolved from the earlier punch grafts to
later mini and micro grafts to the latest “ follicular unit transplantation”,
having distinctive advantages of giving a more natural look and increased
coverage of the bald area.
• Body hair offers an alternative source, but should be undertaken only after
proper counseling and in selected patients.
• In skilled hands, areas such as moustache, eyebrows can be
transplanted with gratifying results.
Thank
you……