Follicular unit transplantation: dissecting and planting techniques

FUT was designed to move hair from the donor area to the recipient area in such a way as to duplicate naturally occurring hair and to minimize trauma to the follicles in the process. With the exception of a few factors such as the "vellus blush" of the frontal hairline or the anterior temples, FUT can accomplish these goals. This article has outlined the basic requirements for the dissection and implantation of follicular unit grafts and provided evidence provided by research data, where it exists, to support the contentions and requirements of FUT. With adherence to defined standards, surgeons can accomplish certain aesthetic goals with this technique on a consistent basis.     

简易毛发移植联合外用米诺地尔酊治疗毛发缺稀的临床观察

目的寻求一种治疗头发、眉毛缺失或稀疏的简单有效的方法。方法在枕后发际内切取一条带毛发的完整头皮,制备成微小单位毛发移植物,用16号空心针头在头发、眉毛缺失或稀疏区皮肤上行简易打孔,以显微镊辅助,把制备好的毛发植于孔隙内。术后7d植发区开始外喷米诺地尔酊,连用3～6个月。结果25例34处头发、眉毛缺失或稀疏患者,通过本方法治疗均取得良好疗效。结论用16号空心针头行简易打孔,移植微小单位毛发,治疗毛发缺失或稀疏,方法简单,取材方便,适合推广;辅助外搽米诺地尔酊,可使毛发成活率更高,毛发生长更为自然。     

Eyebrow transplantation

The eyebrow has a powerful influence on the appearance of the orbital region. Because the person without eyebrows has an unnatural look, drawing everyone's attention, eyebrow restoration/reconstruction should be viewed as an esthetic surgery performed to improve the patient's appearance and self-esteem. Although hair-bearing pedicled flaps and free composite strip grafts have been the most widely used approaches in clinical practice formerly, follicular unit transplantation (FUT) has gained more and more importance nowadays in eyebrow restoration because of its more rewarding results. The process and results of FUT have been greatly improved thanks to advances in hair transplantation techniques, instrumentation, and practice. In this article, we discuss the restoration of 14 eyebrows in 8 patients (5 males and 3 females) using FUT. The procedure and the results also are discussed here under in light of literature.     

雄激素型脱发患者高密度毛囊单位移植并发症分析

目的分析高密度毛囊单位移植治疗雄激素型脱发术后并发症发生原因,以期减少并发症的发生。方法回顾性分析2008年11月至2010年10月期间毛发移植后86例雄激素型脱发患者随访结果,统计各种并发症的发生情况,分析发生原因,总结干预措施。结果随访至移植后2年,发生表皮样囊肿和毛囊炎5例、发际线轮廓不自然2例、毛发生长方向和角度不一致2例、移植后继发性脱发2例和供区瘢痕显露3例。在高密度毛囊单位移植技术开展后期,通过精密的术前设计及使用高倍显微镜等方法减少了上述并发症发生。结论高密度毛囊单位移植治疗雄激素型脱发可发生表皮样囊肿和毛囊炎、发际线轮廓不自然、毛发生长方向和角度不一致、术后继发性脱发、供区瘢痕显露等并发症,通过术前精细设计、术中仔细操作和术后加强护理可有效减少上述并发症发生。     

The Distribution of Follicular Units in the Chinese Scalp: Implications for Reconstruction of Natural-Appearing Hairlines in Orientals

BACKGROUND: Follicular transplantation using hair in its naturally occurring groups, called follicular units (FUs), has become the most popular technique in hair restoration surgery. Recently follicular transplantation was performed with a qualitative and quantitative concept to achieve the best clinical result. The characteristics and distribution of FUs are well studied in Caucasians and widely applied in hair transplantation surgery. OBJECTIVE: In order to understand the normal distribution of FUs in the Chinese scalp, we counted the number of hairs and FUs in normal Chinese scalp to provide general information for surgical planning and design in bald Chinese patients. METHODS: A total of 50 normal and 50 bald Chinese adults were enrolled to count the hairs on their scalp. One hundred bald patients receiving hairline reconstruction were also prospectively quantitatively evaluated. RESULTS: In normal Chinese scalp, an average 71.78 FUs/cm(2) and 137.08 hairs/cm(2) were calculated with a follicular density of 1.91 hairs/FU. Two-hair FUs are the predominate group (50.29%). In bald patients, an average of 68.07 FUs/cm(2) was found, which was less than that of the occipital scalp in normal nonbald patients. In reconstruction of the frontal hairline, a total of 700-1000 FUs were implanted with an average density of 30 FUs/cm(2). CONCLUSION: We found the average number of FUs (0.72 FU/mm(2)) was less than that in Caucasian patients (1 FU/mm(2)). The average density of 30 FUs/cm(2) implanted was suitable to reconstruct a natural frontal hairline in bald Chinese patients, which can achieve about 40% of normal hair density. Our results could provide the hair surgeon with general information about hair distribution on the Chinese scalp for surgical planning and design in their patients.     

The state of the art. Donor site harvest, graft yield estimation, and recipient site preparation for follicular-unit hair transplantation

The field of hair transplantation has moved beyond the provision of a dense frontal hairline to techniques that are designed to provide a natural appearance in as few sessions as possible. The concept of the follicular unit has revolutionized the preparation of both the grafts and the recipient sites. We will describe the mathematics of hair restoration and our techniques for determining the length and height of the donor strip for a given number of desired follicular-unit grafts. We will also elucidate our technique for cutting the follicular-unit grafts using microscopes and transillumination. We now use specially designed blades or punches to make shallow slits or slots for recipient sites. Striving for teamwork and efficiency is of paramount importance in hair transplantation, and we will describe our coordination and training methods as well as the role of the surgeon.     

“Micrografts” for improvement of the frontal hairline after hair transplantation

The frontal hairline is the most important and difficult part of hair reconstruction. A technique is presented that uses micrografts to correct a frontal hairline that looks less than natural, a condition often seen after punch hair grafting (or strip grafting or scalp flaps). With these micrografts, it is possible to produce a natural-looking, soft frontal hairline, hiding an unnatural-looking, dense hairline that starts abruptly with coarse hairs. It is also possible to hide disturbing visible scarring or cobblestoning of the foremost punch grafts and differences in color between the grafted skin and the recipient area.     

单位毛囊和单株毛囊移植修复发际缺陷

目的探索毛发移植技术修复发际线轮廓缺陷的应用效果。方法术前仔细设计发际线和计算所需移植毛发的数量。切取枕后带发皮片，在4～5倍放大镜下精细分割，制备成不同粗细的单株毛囊和单位毛囊。根据受区毛发的走行及自然生长方向，用1．5mm蓝宝石裂隙刀制备微小裂隙，将制备好的单株毛囊和单位毛囊间隔插入裂隙。结果临床随访6个月显示，发际处移植毛发生长良好，与原有毛发融为一体，成活率达到95％。403名发际缺陷患者中有361例对美容效果表示满意，但是仍有部分颞额角脱发明显和瘢痕严重的患者需要二期加密手术。结论用单株毛囊和单位毛囊移植技术改善发际线缺陷，对毛囊分离技术的要求较高，手术设计合理，术后恢复迅速，外观自然、逼真，是较理想的治疗手段。     

Follicular Transplantation for the Correction of Various Stigmas After Rhytidoplasty

BACKGROUND: Rhytidoplasty may cause permanent and unwanted stigmas, such as dislocation of the temporal and cervical hairline. Widened scars inside the hairline may cause considerable social embarrassment. Furthermore, pretrichial incisions, even if well placed, may widen or become hypochromic, thus revealing that an aesthetic procedure has been performed. Various procedures for the correction of these undesirable telltale signs of a face-lift have been published. This report aims to present the results of correction for postrhytidoplasty stigmas using follicular transplantation. Patient assessment is discussed, and relevant technical aspects are detailed and illustrated. METHODS: A prospective study at the Ivo Pitanguy Clinic investigated patients who underwent hair transplantation to correct unaesthetic signs secondary to rhytidoplasty from January 2001 to December 2004. The aesthetic results and complications were evaluated, as well as the patients' satisfaction rate. The patients presented in this series either were referred from another service or had their rhytidoplasty originally performed in the authors' service. RESULTS: A total of 33 female patients were included in this study. Two patients were lost to follow-up evaluation and not included. The complications were minor. In the late follow-up assessment, 24 patients classified the result as excellent, 4 as satisfactory, and 3 as unsatisfactory. Only the patients who classified the results as unsatisfactory requested a second procedure (i.e., another follicular transplantation). CONCLUSIONS: When performed by an experienced surgical team, the follicular unit transplantation technique is a simple, safe, and efficient way to correct stigmas secondary to a rhytidoplasty, such as a visible scar or a displaced hairline, with satisfactory results and a very low complication rate.     

Corrective Hair Restoration Techniques for the Aesthetic Problems of Temperoparietal Flaps

BACKGROUND: Temperoparieto-occipital flaps (Juri flap) and temperoparietal flaps (Elliott) were commonly performed in the previous decades but have fallen out of favor for the most part with the development of follicular unit hair transplantation. Besides high complication rates, these procedures created straight abrupt hairlines in many cases, posterior hair direction, hair density that was disproportionately thick, and blunt temperofrontal angles. OBJECTIVE: Because there are many patients who live with cosmetic deformities created by previous flap procedures, the objective of this article is to present a series of techniques that will restore these patients to normal cosmesis. METHODS: The techniques for amelioration of poor cosmesis secondary to flap procedures are (1) undulating follicular unit grafting anterior to the hairline, (2) removal of 2- to 3-mm cylinders of hair-bearing scalp at the anterior hairline, (3) removal of 2- to 3-mm cylinders of hair-bearing scalp from within the flap itself, and (4) appropriate fusiform excision techniques to create a normal temperofrontal angle. RESULTS: The combination of the aforementioned techniques has restored a very natural cosmesis in patients who have poor aesthetics after flap surgery. CONCLUSION: Many patients exist who have had Juri and Elliott flaps. Although the cosmetic deformities that are created from these flaps are difficult to improve, they can be ameliorated effectively through a series of maneuvers that are described in this article.     

国人自体头发移植术的研究

自１９８８年９月至１９９２年１２月，共已施行９８０次自体头皮打孔皮片头发移植术，主要用于供区发源充沛的脂溢性秃发和瘢痕性秃发者３９５例。根据国人的头发数量较白种人约少１／３，毛干呈直线型，以及头发与头皮色泽反差大等特点，采用了Ｌ形排列移植、圆皮片间插入半圆皮片，术后头皮文身及烫发等相应措施以提高疗效，并认为成人秃发适宜头发移植，而儿童则更适宜头皮扩张术。     

A Method for Evaluating and Treating the Temporal Peak Region in Patients with Male Pattern Baldness

BACKGROUND: In the past, hair restoration surgeons have focused most of their attention and efforts on the reconstruction of the hairline region and the area on top of the head. However, little attention has been given to the temporal peaks and the areas immediately posterior to them. OBJECTIVE: The goals of this article are to describe the pattern baldness process at the temporal peaks and the region immediately posterior to them, and to describe a method for the evaluation and treatment of these very important and often neglected areas. METHODS: A method for evaluating and grading the temporal peak region is given. A surgical technique for treating this problem is described. This method consists of making 1.0 mm spear blade incisions at a very acute 10 degrees angle in the newly designed anterior peak and in between the hair follicles that remain in the area posterior to the peak. The grafting of the finest one-haired grafts available in between existing hair follicles is accomplished with the help of 3.5x expandable loupes. The anterior temporal peak design is coordinated with the position of the frontal hairline restoration; the more anterior the hairline, the more anterior the temporal peak and vice-versa. RESULTS: The results of evaluating the temporal peak areas and treating them appropriately have consistently restored the cosmetic harmony between the frontal hairline and the temporal peak region. It is important, however, to only utilize the finest hairs available to create an aesthetically pleasing result. CONCLUSION: When evaluating patients for hair restoration surgery, it should be a common practice to evaluate the temporal peak regions and the areas immediately posterior to them. These areas should be appropriately treated so that the frontal hair restoration coordinates with that of the temporal peak. The further anterior one comes with the hairline, the more anterior must come with the temporal peak restoration and vice-versa.     

Follicular-unit hair grafting: state-of-the-art surgical technique

The goal in hair restoration is natural-appearing results. Improvements in the field of hair transplantation have developed with this goal in mind. The most recent development is the follicular-unit grafting technique, which relies on microscopic dissection to produce grafts, each containing a follicular unit, the natural bundling of 1 to 4 hairs, with a minimum amount of non-hair-bearing surrounding skin. For patients desiring surgical hair restoration, proponents of follicular-unit grafting advocate the technique for its superior results. Detractors point to the technical challenges of performing the procedure and the need for a staff of trained assistants for the microscopic dissection. What is clear is that this demanding procedure is taking the field of hair restoration the closest ever to its ultimate goal-undetectability.     

Dispelling the Myth of the Required High Hairline in Follicular Unit Hair Transplantation

BACKGROUND: Hair restoration surgeons have historically taught that the hairline should be placed high on men undergoing hair restoration surgery. OBJECTIVE: To evaluate the position of the anterior-most aspect of the frontal forelock on men experiencing type III-V male pattern baldness. METHODS: Twenty men, ages 20-46 years, with type III-V male pattern baldness were evaluated for the distances between the chin to nose, nose to eyebrows, and eyebrows to frontal forelock. RESULTS: The mean distance from chin to nose was 6.96 cm. The mean distance from nose to eyebrows was 6.55 cm. The mean distance from eyebrows to hairline was 6.8 cm. The distance from chin to hairline was 20.3 cm. Therefore the eyebrows to hairline distance was 33.4% of the whole. CONCLUSION: When using follicular transplantation, it may be appropriate at times to divide the face into thirds at the time of hairline development.     

Avoiding the operated on look in multiple face lifts

SUMMARY AIM: Reviewing 43 patients of ours who have had three or more face lifts, we wanted to demonstrate that it is possible to avoid the multi-operated on look. MATERIAL AND METHODS: Forty-three patients have been operated on three times or more: 42 females and one male. Thirty-six patients had three face lifts, six had four face lifts, one patient had five face lifts. The mean age at time of surgery was 50.3 years for the first face lift, 56.7 for the second, and 64.2 for the third face lift. These patients were operated on by the same surgeon using a technique which has evolved over the years but with the same basic goal of hiding the scars and of minimising hairline displacement. General appearance, scars and hairline displacement were evaluated in patients who had had three or more face lifts. RESULTS: The results of the evaluation of our 43 multi-operated on face lift patients were as follows: 35 patients did not appear to have had face lifts, eight patients did appear to have had face lifts, but with satisfactory appearance, 30 patients had no visible scars at a conversational distance, 10 patients had slightly visible scars when their hair was lifted, five had obvious scars when the hair was lifted, 34 patients had a normal hairline, six patients had a slightly receding hairline at the temporal level and three had hair loss at the level of the temporal scar. CONCLUSIONS: New technical improvements allow the preservation of a natural appearance, with well-hidden scars and a well-placed hairline. The common opinion that several repeated face lifts should be avoided because they give an unnatural appearance and severe sequelae in terms of scars and hairline displacement has not been confirmed by our clinical experience with 43 patients having undergone at least three face lifts.     

提高毛发移植的覆盖率

目的探讨显微外科技术自体毛发移植的特点和方法,提高毛发移植成活的覆盖率。方法在较低温度(20°C)环境下,采用边切边缝方法取耳后或枕后毛发,在显微镜下分离成保留周围少量脂肪组织的毛囊族或单株,按需要移植部位不同进行不同的毛囊族或单株并套插的显微外科技术移植共31例。结果31例移植毛发后随访21例,随访时间6~38个月,移植后的毛发能基本覆盖无毛发区的皮肤和瘢痕,移植覆盖率较原来的移植方法提高33%,且外形自然,效果稳定。结论显微外科技术自体毛囊族状(微株小株)或单株移植,具有操作快、损伤小、低温保湿等特点,能较好地保留毛囊周围少量脂肪,在孔与孔的皮肤间隙内再用毛发移植针植入单株毛坯的“套插”移植,更有助于增加毛发覆盖率。     

国人自体头发移植术的研究

自1988年9月至1992年12月,共已施行980次自体头皮打孔皮片头发移植术,主要用于供区发源充沛的脂溢性秃发和瘢痕性秃发者395例。根据国人的头发数量较白种人约少1/3,毛干呈直线型,以及头发与头皮色泽反差大等特点,采用了L形排列移植、圆皮片间插入半圆皮片,术后头皮文身及烫发等相应措施以提高疗效。并认为成人秃发适宜头发移植,而儿童则更适宜头皮扩张术。     

Hair transplantation in mice: Challenges and solutions

Hair follicle cells contribute to wound healing, skin circulation, and skin diseases including skin cancer, and hair transplantation is a useful technique to study the participation of hair follicle cells in skin homeostasis and wound healing. Although hair follicle transplantation is a well‐established human hair‐restoration procedure, follicular transplantation techniques in animals have a number of shortcomings and have not been well described or optimized. To facilitate the study of follicular stem and progenitor cells and their interaction with surrounding skin, we have established a new murine transplantation model, similar to follicular unit transplantation in humans. Vibrissae from GFP transgenic mice were harvested, flip‐side microdissected, and implanted individually into needle hole incisions in the back skin of immune‐deficient nude mice. Grafts were evaluated histologically and the growth of transplanted vibrissae was observed. Transplanted follicles cycled spontaneously and newly formed hair shafts emerged from the skin after 2 weeks. Ninety percent of grafted vibrissae produced a hair shaft at 6 weeks. After pluck‐induced follicle cycling, growth rates were equivalent to ungrafted vibrissae. Transplanted vibrissae with GFP‐positive cells were easily identified in histological sections. We established a follicular vibrissa transplantation method that recapitulates human follicular unit transplantation. This method has several advantages over current protocols for animal hair transplantation. The method requires no suturing and minimizes the damage to donor follicles and recipient skin. Vibrissae are easier to microdissect and transplant than pelage follicles and, once transplanted, are readily distinguished from host pelage hair. This facilitates measurement of hair growth. Flip‐side hair follicle microdissection precisely separates donor follicular tissue from interfollicular tissue and donor cells remain confined to hair follicles. This makes it possible to differentiate migration of hair follicle cells from interfollicular epidermis in lineage tracing wound experiments using genetically labeled donor follicles.     

FUT+FUE治疗大面积脱发60例

目的:探索一种治疗大面积脱发的理想方法。方法:分别用FUT(follicle unit transplantation)技术切取梭形头皮条,用FUE(follicle unit extraction)技术于枕部散在提取毛囊,然后分离毛囊周围多余组织,用宝石刀在脱发区打孔后,用移植笔将分离好的毛囊植入脱发区。结果:60例通过本方法治疗的患者均达到了理想的植发效果。结论:FUT+FUE治疗大面积脱发是一种较理想的方法,值得推广。     

The latest developments in surgical hair restoration

Surgical hair restoration has evolved rapidly over the past 10 years. Patient outcome is paramount. Current developments in hair transplantation focus on using the most appropriate harvesting techniques to use this finite resource effectively and to relocate it quickly and efficiently to achieve the optimum effective aesthetic coverage. To date,follicular unit transplantation has afforded surgeons the greatest efficiency in hair trans-plantation. These units are unlikely to become smaller, so surgeons must look at what other means are available to improve the final result.