This document summarizes techniques for hair transplantation. It discusses three categories of hair restoration including scalp flaps, surgical excision, and hair autografts. It provides details on follicular unit transplantation including definitions of micrografts and minigrafts. Key steps in the transplantation process are outlined including patient evaluation, donor strip extraction, graft preparation, and recipient site preparation. Factors that influence hairline design and density outcomes are also summarized.
1. Operative Session : Hair Transplantation
Presented By : Dr. Shamendra Anand Sahu
Burn, Plastic & Maxillofacial surgery
VMMC & SAFDARJUNG HOSPITAL
NEW DELHI
2. HAIR RESTORATION TECHNIQUES
• There are three broad categories of surgical restoration procedures:
• 1. scalp flaps (advancement flaps, rotation flaps and free flaps)
• 2. surgical excision (alopecia reduction)
• 3. free auto grafts of hairy scalp from the well haired to the bald area.
3. Hair Transplantation
• Hair transplantation involves relocation or transfer of
hairs from the occipital area to the bald area.
• The discussion of transplantation refers to micrografts or
minigrafts or, more specifically in current nomenclature,
follicular grafts.
4. Hair Transplantation
• Micrograft : one to two hairs
• Minigraft : three to six hair .
• Single FU : one to two / three to four hair
• Multi FU : two to three unit/two to six hair grafts
5. The anatomy of the normal hairline
• Critical anatomic landmark in the mature male hairline is
the frontal-temporal recession.
6. landmark is formed by the emergence of two convex
lines making up the frontal and the temporal
hairlines
Appearance of a patient who had undergone hair
transplantation in the frontal area in which the acute
frontal-temporal angles were maintained, resulting in a
normal-appearing recession
7. The normal hairline
• Young males usually do not have this recession.
• Both women and children tend to have a continuous line between the frontal
and temporal areas without this recession .
• Design of the frontal-temporal recession is critical to a natural result.
9. The normal hairline
• 2. Natural hairlines are not straight and regular.
• 3. Other important factors are that the hair follicle sits about 3–3.5 mm
below the surface of the scalp and that scalp thickness varies between 5.5
and 6.5 mm
10. PATTERNS OF BALDNESS
• Most common type of hair loss in both men and women is referred to as
androgenic alopecia.
• The mechanism of androgenic alopecia is inherent in each individual hair
follicle as it responds to external stimuli, essentially androgens.
• The progressive loss of hair is predetermined by genetic characteristics
associated with these responsive scalp follicles.
• The mode of action of androgens on the target cells occurs at the bulbar
region of the follicle.
11. PATTERNS OF BALDNESS
• In most men with hair loss, the hair follicles in the frontal and crown regions
of the scalp appear most likely to be affected .
• Hair loss in women is frequently of a diffuse nature.
• The pattern of hair loss, because of its diffuseness, often results in a lack of
appropriate donor hair.
• However, there is a subgroup of women who demonstrate hair loss similar
to the male pattern.
12. PATTERNS OF BALDNESS
• The family history in these women is also compatible with a male pattern type of
hair loss.
• The history these women give is fairly typical and is one of slow but progressive
hair loss, and it is most evident on the superior scalp with good density on both the
sides and posteriorly.
• These are appropriate candidates for hair transplantation because the posterior scalp
area has adequate donor hair.
13. Other Important Causes Of Alopecia
• Secondary to numerous factors, such as surgery, metabolic disorders,
chemotherapy, stress, and autoimmune disease.
• This type of hair loss is often of an acute nature most.
• Most of these patients are not candidates for transplantation.
14. Post chemotherapy Alopecia
In the patient who has had hair loss after chemotherapy, if enough time has
transpired to allow recovery and there still has been no regrowth,
transplantation may be appropriate.
However, the take of the grafts has not been ideal in these patients.
15. Traumatic alopecia
1. Secondary to ischemia of the hair bulbs.
2. Secondary to direct tissue loss as in post burn alopecia.
Prolonged pressure on the scalp in a single area –
1. Patient who lies in a comatose position for hours at a time.
2. Patients undergoing prolonged surgical procedures under general anesthesia.
3. Aesthetic surgery of the face and scalp area.
16. Traumatic alopecia
• Significant ischemia, which reduces blood flow to the follicles, can explain
the temporary loss of hair in hair transplantation.
• With severe ischemia, death of the bulb can lead to permanent alopecia
25. Follicular Units
• Follicular units - scalp hairs grow naturally in small
compartments containing clusters of one to four follicles
surrounded by concentric layers of collagen fibers.
• Peripheral areas such as the hairline have one and two-hair
follicular units (FU), whereas the more dense central regions
have more three and four-hair FU (and coarser hair shafts).
27. THE PREOPERATIVE PERIOD
• Patient care coordinator :
• Discontinue medications and diet supplements that can cause bleeding :
aspirin, anticoagulants, ibuprofen-type anti-inflammatories, vitamin E, garlic
pills, fish oil capsules, and herbal supplements, starting 2 weeks prior to
surgery.
28. THE PREOPERATIVE PERIOD
• Twice-daily application of topical Minoxidil 2% to 5% to the recipient area
beginning 1 week prior to surgery.
• Patients are instructed to massage their scalp during the final 4 weeks prior
to surgery in order to increase scalp laxity within the donor area, thus
enabling a wider strip harvest and a greater FU yield.
29. THE PREOPERATIVE PERIOD
• Written consent for the procedure, anesthesia, and photography must be
obtained from the patient on the morning of the surgery.
30. Patient Evaluation
• It is critical in the early phases of a patient's evaluation to design a hair pattern that
will be appropriate not only as the patient ages but also on the basis of progressive
hair loss .
• Patients who demand an inappropriate hairline should be rejected for surgery
because they are unrealistic and will be dissatisfied later like :
Example : a young patient in his late teens or early 20s who has significant hair loss to
wish to redesign the hairline to a juvenile appearance.
• Patient must be counselled that they are going to undergo extensive further surgery
31. Planning of the hairline
• 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.
34. • The temporal angles : form relatively sharp right angles or acute angles in
most men
• but these angles should be more rounded in women.
The micrografts in the hairline should be placed in an irregular saw-toothed
• pattern to give a natural appearance.
35. It is useful to draw a specific pattern on the scalp to demonstrate as the patient is
looking in a mirror where the most appropriate hairline pattern should be
Widow's peak."
Throughout the hairline. the transition zone should contain both
microirregularities(intermittent density clusters more noticeable
under close examination than from a distance) and
macroirregularities (protrusion along the path of the hairline that
cause it to appear less linear when viewed from a distance).
36. • Usually 250–300 single hair (micro)grafts will be necessary to create a new
hairline in any individual.
• Behind the hairline, two hair FUGs are used to provide new hair.
• Three or four hair FUGs are used just further behind.
37. • In most patients, the anterior level of the hairline in the midline should be at
least 8 to 10 cm above the glabella. In addition, the anterior hairline appears
more natural if it runs parallel to the ground when viewed from a lateral view.
38. • The colour, quality, and density of the donor hair, as well as the contrast
between the hair and the skin colours, are important factors that affect the
result. The lesser the contrast between the donor hair and the skin, the better
is the result.
• It is also noted that frizzy, curly, or wavy hair are advantageous characteristics
in transplanted hair
39. • Hair diameter is the other major factor in determining the coverage achievable with
a transplant.
• Hair volume (hv) is defined in the following formula:
• hv = π(r)2 (h) (d) (a)
• It is key to note that a doubling of the radius results in a quadrupling of hair
volume, making hair diameter the most important single variable in the
coverage achievable in a transplant.
• It is also the variable that is most beyond control.
40. 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.
41. • Some authors avoid using adrenaline in the recipient area :
• because it increases telogen effluvium in the immediate postoperative period,
and it also may diminish the uptake of the grafts.
• Adrenaline must definitely be avoided in the recipient area in women because
severe effluvium has been reported after its use.
42. THE DONOR SITE
• Objective of donor area evaluation : determine the area from which hair is
most likely to be permanent and thus will persist in the recipient area long
after transplantation.
• Theses has been determined by various studies and called as “Safe Donor
Area”
45. THE DONOR SITE
• The ideal donor site is the region containing hair follicles that are not subject to the
gradual miniaturization process that causes baldness (invisible hair)
• Hair density is greatest at the midline and diminishes laterally above the ears and
again below the inferior border approaching the nape of the neck.
• 50% of hair can be harvested before the donor site becomes noticeably depleted.
46. THE DONOR SITE
• SDA fall short of helping practitioners determine the quantity of
"permanent" FU that may be transplanted over a patient's lifetime.
• Respondents suggested that the aforementioned patient presenting with an
average density donor area could yield a lifetime harvest of 6,404 or 5,393
FU when destined to develop MPB types V or VI, respectively.
47. NUMBER OF PROCEDURES
• Patients will be pleased after only one procedure with limited hair loss
• But usually with one procedure, the frontal hairline lacks adequate density. It is
appropriate to prepare most patients for at least two sessions to give a refined result.
• With current techniques of 1000 to 1500 grafts, many patients with limited hair loss
require only on two procedures.
• The patient with more extensive hair loss, however, may require as many as three or
four procedures.
48. Preoperative preparation
• The patient is asked to shampoo his head with Betadine surgical scrub on the
day before, and on the morning of the surgery.
49. Preparation of the donor area
• The hair in the donor area (occipital region) is trimmed to a length of 2–4 mm.
• The local anaesthetic solution is injected just below the donor area.
The donor strip can be harvested with a single bladed knife or a multiple bladed knife
containing three to seven blades.
• It is very important that while harvesting the donor area, the blades remain parallel
to the direction of the hair so that the hair roots are not damaged.
50. Strip Excision
• Most important tenets for strip harvesting includes:
1. minimizing the amount of hair follicle transection
2. extracting donor strip widths with caution in order to minimize closing
tension .
3. producing only a single scar regardless of the number of session.
51. Strip Excision
• To minimize the transection of hair follicles during strip harvesting :
1. Use magnification
2. Use tumescent solution at the dermal level
3. Skin hook technique
53. A long section of scalp that varies in width from 0.5
to 1.5 cm, and in length from 10 to 25 cm.
The multibladed knife harvests numerous (two to six) parallel
strips of varying width (depending on the spacer used), which
may be 1.5, 2, or 2.5 mm.
Incision should be angled
so that the blade passes parallel to the follicles
54. The donor area is closed by a running/interlocking suture of 3-0
nylon suture .uture removal to be done after 14 days .
55. The "slivering" of the
donor strip
• The harvested donor strips are immediately immersed in chilled normal
saline.
• A typical strip is 1× 20-cm (20 cm2) and contains 2,000 units.
• Donor strip should be fixed to a cutting board with steady tension applied to
sustain inter-follicular spacing and ease the "slivering" process.
• A size 15 bladed scalpel is used to slice sections of tissue 1 or 2 FU.
56. The "slivering" of the
donor strip
• Harvested donor strip obtained using the single-blade excision method is cut
into tiny slices that vary from 1 to 3 mm in width.
• The subcutaneous fatty tissue below the hair roots or bulbs is stripped
leaving up to 2 mm of fat below the hair bulb.
57. A “sliver” produced by sectioning of the donor strip
obtained with the single-blade technique showing how the follicular bulbs
extend into the subcutaneous fat.
58. Dissection of individual FU
from the "slivers."
• The grafts may be cut on wooden tongue depressors or on a clear vinyl
dissecting surface with a backlighting system.
• Loupe magnification of 2X or 3X power is useful in creating FUGs.
• Graft preparation with a dissecting stereo microscope makes the dissection a
little slower, but it is much more accurate.
59. Dissection of individual FU
from the "slivers."
• The grafts are kept in gauze-lined, chilled, normal saline-filled petri dishes to
prevent rapid dehydration (the primary cause of nonviable grafts).
• Survival of transplanted grafts decreases about 1% per hour out of body.
60. The ideal "pear-shaped" graft possesses little or no surplus epidermis and retains an appropriate amount of
protective dermis and subcutaneous adipose tissue around the follicle, the intact sebaceous glands, and the dermal
papilla in order to reduce their sensitivity to traumatic handling, temperature changes, and graft desiccation (the
main cause of poor graft survival)
61. • If a multibladed knife has been used, it is possible to perform graft preparation
using a device called the Mangubat graft cutter. This is a rectangular-shaped,
stainless steel base containing a series of parallel, closely spaced (1- to 2-mm) blades.
The strip is stretched and placed over these blades so that the hair follicles are
parallel to the cutting edges. Next, a wooden tongue blade (“force spreader”) is laid
on top of the strip and a rubber mallet is employed to strike (“impulsive force”) the
wood surface with several rapid strokes. The entire strip is cut into grafts instantly.
This saves a great deal of time for microdissection, but carries an increased risk of
splitting follicular units and transecting follicles.
63. Preparation of the recipient area
• Anesthesia : The recipient site is anesthetized using a local ring block with
1%Xylocaine with 1:100,000 epinephrine followed by infiltration of the
recipient site with normal saline with 1:100,000 to 1:150,000 epinephrine.
• Regional nerve blocks of the supraorbital and supratrochlear nerves in their
respective foramina located above the eyebrow can also reduce discomfort at
the recipient site.
64. • The best long-term results are obtained by transplanting from front to back
rather than back to front.
• While making slits or holes in the recipient area, it is very important to follow
the direction of the existing hair in that region.
65. Transplanting the Midscalp region
improves density from a lateral and overhead view but also
provides a thickened backdrop to a thinning frontal area as well
as providing indirect coverage of a crown as transplanted
midscalp hairs cascade posteriorly over it .
66. Transplanting The Vertex region
• Patients should also be advised that coverage may not have the same
cosmetic impact in this region as elsewhere. (shingling effect).
• Decision to transplant a progressively thinning and expanding vertex carries
an increased risk that an unnatural distribution of hair will result in the future
in which an isolated island of transplanted hair may be surrounded by an
alopecic scalp.
• May require one or more additional sessions to the "whorl" of the vertex.
67. Transplanting The Vertex region
• For the majority of patients, the front and midscalp have first priority and
most of the donor hairs should be reserved for those regions.
• The best candidates for vertex transplantation are patients past the age of 40
years with ample donor reserve and a minimal hair-to-scalp color contrast.
68. Halo head” hair pattern produced by transplanting the
vertex area followed by loss of hair in the peripheral
regions.
69. • Incisional instruments : needles, miniblades, and micropunches.
• For one to two hair grafts, the most commonly used instruments are probably an
18-gauge hypodermic needle for coarse hairs and a 19-gauge hypodermic needle for
finer hairs.
• Nokor needles (16/18 gauge) / 1.5-mm tribevel (Rossati Starr) punches : large
(three- to four-hair) single-unit and small (three- to five-hair) double-unit grafts.
• 2-mm tribevel (Rossati Starr) punches : larger (two- to three-unit/four- to seven-
hair) grafts
70. Nokor Needle
Left: A Redfield excisional slot punch. Right: One-mm
and 1.5-mm tribevel incisional punches.
71. Excisional devices : Punch
• Excisional devices : Redfield and Butterfield punches
• Round and elliptical/slot
• The grafts must be “cut to fit” the site, which may necessitate breaking up follicular
units.
• If the grafts are of smaller diameter than the site, there will be a gap between the
sides of the graft and the walls of the recipient well. Healing will then occur by
secondary intention, which may reduce graft survival.
• It may also result in “pitting” or even epidermoid cyst formation if the graft “sinks”
below the surface and gets “buried alive.”
72. Excisional devices : Punch
• USE : employ these instruments in very fibrotic/inelastic scalps, where it is
necessary to remove some tissue in order to place grafts with more than one
to two hairs.
• lower-density donor sites and finer hair texture : larger grafts may be needed
to achieve optimal density with fewer sessions.
73. • Recipient site incisions are made 0.5 to 2.0 mm apart, depending on the size
and location of the grafts.
74. Graft insertion
• It is important to employ an atraumatic technique for graft placement.
• The grafts are placed into the recipient slits / holes using fine angled forceps.
• To avoid damage, the FUGs are grasped by the 2 mm of subcutaneous tissue
left below the hair bulbs to position them into the recipient sites and not by
the follicle
75. Graft insertion
• Steady pressure is applied to ensure that the grafts are flush with the
surrounding skin .
• Burying the grafts beneath the level of the skin avoided
1. because it can give a pitted appearance
2. lead to the formation of epidermal cysts
If the grafts are too elevated from the surface : cobblestone appearance
76. Postoperative care
• The patient is discharged the same day, usually without any bandage.
• Traditional dressing is a bilayered protective and absorptive affair with the
first layer made from several nonstick Telfa pads covered with a thin layer of
an antibiotic.
• Some swelling is obvious after a hair transplantation surgery and the patient
should be informed of this prior to the procedure. Headband worn
immediately after the operation is useful in preventing the swelling from
coming down on to the face and creating a puffy appearance.
77. Postoperative care
• The patient is instructed to wash his hair with a mild shampoo on the 2 or 3
postoperative day.
• While combing the hair in the transplanted area for three weeks, the tooth of
the comb should not strike against the transplanted grafts.
• Wearing clothes like T shirts or pullovers which have to be taken off over the
head should also be avoided for three weeks.
• Hair oils or other stronger shampoos as well as helmets are also to be
avoided for the same period.
78. Postoperation Adjunctive Therapy
Topical minoxidil application (2-5 %) :
1. not only for its vasodilatory effects that may enhance wound healing but also
because data suggest that minoxidil decreases postoperative effluvium .
2. Continued minoxidil use is encouraged for to 5 - 12 weeks postoperatively.
To slow or prevent further hair loss : 1 mg of finasteride to slow or prevent further
hair loss and thus prevent or delay the need to “chase baldness” with multiple
procedures.
79. Post operation Complications
1. The common complication is the occurrence of variable numbers of
lesions (pustules, papules, nodules, and cysts) due to transplanted tissue
becoming trapped beneath the surface in the recipient region. They appear
8 to 12 weeks after the surgery.
2. It is also fairly common to have a small number of grafts extruded in first
24 hours after surgery, with some associated localized bleeding in the
recipient site.
81. Recipient Site Complications
a) Change in hair texture usually characterized as being coarser or “frizzy,”
(b) Poor graft survival ( related to tissue handling that cause follicular bulb
transection)
(c) Elevated (“cobblestoning”) or depressed (“pitting”) grafts that occur when
grafts do not fit well into excisional recipient sites or are placed below the
surface during implantation.
(d) Chronic folliculitis caused by bacterial infection or foreign-body type
reaction to “spicules” of transected hair shafts left in grafts
82. Recipient Site Complications
e) Postfrontal tissue/graft necrosis caused by inadequate blood supply to the
postfrontal region where “dense packing” of grafts is commonly performed to
achieve maximum density.
(f) Hyperfibrotic frontal ridging caused by an overreaction to larger grafts or,
perhaps, spicules of transected hairs associated with these grafts. This reaction
has not been reported with single (one- to two-hair) FU grafting in the frontal
line.
83. Postoperation Follow-up Visits
1. 1 day after the operation : for dressing change
2. 14 days : Sutures are removed
3. 8 weeks : wound-healing check
4. 16 weeks early regrowth check
5. 6 to 12 months : final visit for photography
84. Outcome
• In healthy individuals with unscarred recipient sites, it is reasonable to expect
90% to 95% of the grafts to grow successfully.
85. Follicular Unit Extraction
• This is technique that involves the removal of the intact follicular unit directly from
the donor area using a 1 mm punch.
• The yield by this harvesting technique can decrease due to transection and avulsion
injury to the follicular unit.
• Although marketed as a technique that leaves no scar in the donor area, it leaves
multiple ‘dotscars’ in the donor area, which are larger than those left by the strip
method.
86. Sequel
• The epidermis and dermis along with the shaft of the transplanted hair outside the skin fall off
as scabs in the two to three weeks after the surgery, but the follicles remain and go into a resting
phase.
• New hairs start growing about three- six months after the procedure.
• It usually takes six to nine months to appreciate the result of a hair transplant.
• If a second procedure has been planned, it must be at least three to six months after the first
sitting
87. Hair transplants in special sites
• the direction of the eyebrow hairs while creating a new line.
• Around 150 micrografts are usually required for an eyebrow of one side.
• The donor site for eyebrow transplantation : should be of finer hair preferably from
• the nape of the neck or the temporal region.
• Recipient holes are made with : No. 20 or 21gauge needle or a 0.7 mm micro blade
• The immediate postoperative period : Cyanoacrylate glue may be used over the
grafted areas to keep the grafts in place