Hair restoration

The introduction of micrografts (1-2 hair follicular unit grafts) and minigrafts (3-4 hair follicular unit grafts) has made a most significant advancement in the care of male pattern baldness and female androgenic alopecia. Finally, natural and aesthetically pleasing results are possible. Additionally, many other applications in the reconstruction of facial hair and scalp have been found, some of these include: restoration of hair loss due to (iatrogenic) post-surgical causes, ie, after facial rejuvenation procedures or procedures involving incisions on hair bearing facial skin or scalp; scalp and facial hair due to burns or to traumatic injuries; post-oncologic resections; hair loss due to congenital reasons such as in cases of complete bilaterial cleft lips (no mustache hair in the prolabium).     

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.     

The Art of Mixing Follicular Units and Follicular Groupings in Hair Restoration Surgery

BACKGROUND: Follicular grafting yields good results, but takes an excessively long time to perform the procedure. Iatrogenic damage can also occur to the follicular units during the dissection phase when two follicular units are very close together. OBJECTIVE: The objective was to minimize the length of time to perform the procedure and to limit iatrogenic damage to the follicular units during the dissection phase. METHODS: A donor strip is divided under a stereoscopic microscope into one-, two-, three-, and four-haired follicular units and three- and four-haired follicular groupings. Three- and four-haired follicular groupings are formed when 2 two-haired follicular units or a three-haired follicular unit and one-haired follicular unit are very close together. These hair grafts are then inserted into incisions that are 1.0 to 2.5 mm in length and are arranged in accordance to the particular hairstyle desired by the patient. RESULTS: The technique used in this article accomplishes consistently excellent results while creating an environment that prevents damage to follicular units that are extremely close together. This technique requires less time and damages fewer follicular units. CONCLUSIONS: When performing hair restoration surgery, it is many times counterproductive to use follicular units exclusively.     

Chest hair micrografts display extended growth in scalp tissue: a case report.

Conventional follicle harvesting techniques for hair transplantation are limited by the available scalp donor hair. The development of an innovative technique of microsurgical single follicular unit extraction has made it possible to exploit body hair grafts for scalp transplantation. This case study reports on 18 months of follow-up on a patient with extensive scalp scarring who underwent a transplantation procedure using donor chest hair. The photographically documented results show a change in the length of the chest hair measuring an average of 4 cm at transplant to 15 cm by 18 months post-transplant. The transplanted chest grafts provided an excellent cosmetic result for hair replacement.     

A Simple Device for Incision Retraction and Protection in Endoscopic-Assisted Brow and Forehead Lifting

BACKGROUND: Endoscopic-assisted cosmetic surgery has revolutionized various procedures. Forehead and brow lifting performed with endoscopic technique has been shown to be predictable and has fewer complications than open techniques. Providing surgical access and protecting the hair follicles is paramount in endoscopically assisted brow and forehead lifting. OBJECTIVE: To describe a simple retraction device to assist in incision retraction and protect hair follicles. METHODS: A simple, inexpensive retraction device is described that has been used in 60 endoscopic brow incisions to effectively protect the hair follicles and retract incisions for operative techniques. In addition, other methods of follicular protection are discussed. RESULTS: Decreased incisional alopecia and improved surgical access are provided by the use of a simple retraction device and attention to follicular preservation. CONCLUSION: Endoscopic-assisted brow and forehead lifting is becoming the preferred method of upper facial rejuvenation. There is a steep learning curve and often the lack of attention to hair follicle protection results in localized incisional alopecia. In addition, improper surgical access complicates the procedure. A simple device is described to assist in retraction and follicular preservation.     

毛发移植术中单株毛囊单位分离技术的培训研究

目的:探讨毛发移植术中单株毛囊分离的培训方法.提高毛发移植手术人员单株毛囊分离速度和精度.方法:首先对培训对象进行毛囊结构理论教学,要求学员掌握毛囊的基本结构;然后进入镜下分离,裸眼分离结合的培训阶段,使学员掌握正确的分离技术和分离出毛囊单位的标准;最后对头皮扩张器手术的剩余头皮中的毛发进行裸眼毛囊分离培训.分离基本过程为皮条分割、粗胚制作、细胚制作,单株分离.培训过程中考核学员的分离速度和分离出的毛囊合格率.结果:理论培训后结合显微分离,显著提高了术者分离的精度;裸眼分离可以明显提高单株毛囊制作速度;经过累计超过6h或>1000个毛囊单位的分离的培训,术者分离细毛胚的速度可以达到(8±3)根/min,合格率达92±1%.与培训前有统计学差异P<0.05,和熟练术者无统计学差异.结论:毛发移植术的制约点是毛发分离速度,经过毛囊结构理论学习和体式显微镜下分离的培训,术者对毛囊结构从理论和实际上有了明确的掌握,从而提高了术者的分离精度;经过累计6h的分离训练,多数学员可以达到(8±3)根/min的分离毛囊单位速度,这一结果极大的缓解了毛发移植的限速关键点,为提高毛囊的存活率提供了坚实的技术保障.     

Improved hair restoration method for burns

Background

Extracted partial longitudinal follicular units can be used as complete follicular units to regenerate completely differentiated hair growth. The partial follicular units that remained in the dermis in the donor area can survive and produce hairs. This technique enables us to multiply hair follicles in vivo, while preserving the donor area and therefore is suitable in persons, who have a relative small donor area compared to the recipient area, as in scalp burns.

Objectives

With this study, we try to determine if partial longitudinal follicular unit transplantation (PL-FUT) can be used for facial and/or scalp burns.

Materials and methods

Four burn victims (age 22-39 years, mean 27.75 years) were treated in the face (eyebrows, and beard) and/or on the scalp with PL-FUT. The grafts were harvested with hollow wave-tipped needles with an inner diameter of 0.6 mm from the occipital area of the scalp. The suitable longitudinal partial follicular units were impregnated with a preservative medium, and implanted into the recipient area. Hair growth in the donor area as well as the recipient area was observed before treatment, and at intervals of 1 week, 3 months and 1 year after the treatment.

Results

After evaluation of the donor area, sometimes a few little white spots were visible, but almost all hair follicles in the donor site re-produce hairs after 2 years. All treated patients had satisfactory or very satisfactory cosmetic results in the treated area.

Conclusions

Longitudinal partial follicular unit transplantation (LP-FUT) may represent the first reliable patient-friendly method to generate two hair follicles from one hair follicle with consistent results and preservation of the donor area. Therefore, this method is very suitable for people with facial and/or scalp burns.     

Current status of hair restoration surgery

Hair restoration has emerged as a subspecialty of aesthetic plastic surgery practiced by a wide range of doctors including plastic surgeons, general surgeons, dermatologists, and even general practitioners. As a current trend, most doctors practice "Ultrarefined follicular unit hair transplantation" in which the entire procedure is done precisely with minimal donor scar. In selected cases, Mega or even Giga sessions are now done with natural appearance and almost undetectable scar, in a single session with good density. This article is an attempt to review the history of hair restoration surgery, describe a novel technique currently practiced in our center, and summarize possible future innovations.     

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.     

Hair Transplant with Strip Harvest: Indications,Contraindications, and Technique

The evolutionary process of modern hair transplantation began with the plug era and, transitioning through a period of minigrafting and micrografting, finally led to follicular unit transplantation (FUT). Apart from the expansion of donor:recipient ratio, this technique produces an excellent esthetic result, indistinguishable from the natural hair. The merit of strip harvest lies in the maximum amount of follicular unit harvest, minimizing the amount of hair follicle transection, and producing a single scar, irrespective of number of sessions. This article summarizes the prerequisites, indications, contraindications, and technique of strip harvest.     

Follicular unit extraction in hair transplantation: personal experience

Hair transplantation in the form of follicular units constitutes the cornerstone of hair-replacement surgery. Harvesting follicular units directly from the donor area by using punches is described as follicular unit extraction (FUE) technique, and it eliminates the need for excision of a hair-bearing strip.In this article, we presented our surgical approach for hair transplantation, which is based on performing follicular extraction in 2 phases: follicular unit isolation and follicular unit collection, and discussed some technical details of FUE and some advantages and disadvantages of this approach. We transplanted an average of 1651 follicular units in 1 day, 2610 follicular units in 2 days, and 3200 follicular units in 3 days.     

In Vivo Follicular Unit Multiplication: Is It Possible to Harvest an Unlimited Donor Supply?

BACKGROUND: Follicular unit extraction is a process of removing one follicular unit at a time from the donor region. The most important limitation of this surgical procedure is a high transection rate. OBJECTIVE: In this clinical study, we have transplanted different parts of transected hair follicle by harvesting with the follicular unit extraction technique (FUE) in five male patients. MATERIALS AND METHODS: In each patient, three boxes of 1 cm(2) are marked at both donor and recipient sites. The proximal one-third, one-half, and two-thirds of 15 hair follicles are extracted from each defined box and transplanted in recipient boxes. The density is determined at 12 months after the procedure. RESULTS: A mean of 3 (range, 2-4) of the proximal one-third, 4.4 (range, 2-6) of the proximal one-half, and 6.2 (range, 5-8) of the proximal two-thirds of the transplanted follicles were observed as fully grown after 1 year. At the donor site, the regrowth rate was a mean of 12.6 (range, 10-14) of the proximal one-third, 10.2 (range, 8-13) of the proximal one-half, and 8 (range, 7-12) of the proximal two-thirds, respectively. CONCLUSION: The survival rate of the transected hair follicles is directly related to the level of transection. Even the transected parts, however, can survive at the recipient site; the growth rate is not satisfactory and they are thinner than the original follicles. We therefore recommend that the surgeon not transplant the sectioned parts and be careful with the patients whose transection rate is high during FUE procedures.     

Follicular unit transplantation for male-pattern hair loss: Evaluation of 120 patients.

The main aim in surgical hair restoration is to restore hair, making the scalp look natural. Interviews with earlier patients who received hair transplants revealed that their complaints were - a straight anterior hairline that looked unnatural, and hair that looked like 'sprouted grass'. The use of follicular unit transplantation (FUT) technique, where hair roots are harvested under magnification, is becoming widespread. In this technique, hair roots are harvested into natural follicular units that contain 1-4 hair roots. In this article, we present our results related to hair transplantation by FUT technique, performed on 120 patients between the ages of 21 and 75 years with male-pattern hair loss. We made simple yet useful interventions to avoid the occurrence of the above-mentioned problems. Initially, drawings based on the middle line and the two temporal regression points were made for a natural-looking anterior hairline. Following this, irregular seeding was done instead of seeding in rows, to obtain a natural hairline. To avoid the 'sprouted grass' look, single hair roots were placed on the anterior hairline taking into consideration the direction of hair growth. However, the FUT technique is not adequate on its own for natural-looking hair restoration. Good planning and creation of an anterior hairline suited to the individual's forehead structure is fundamental for successful results. In addition, we believe that hair texture is very important in hair transplantation and additional care should be given particularly to patients with dark-coloured and hard hair.     

Hair restoration

The impact of male hair loss as a personal and social marker of aging is tremendous and its persistence as a human concern throughout recorded history places it in the forefront of male concern about the physical signs of aging. Restoration of the frontal hairline has the visual effect of re-establishing facial symmetry and turning back time. Follicular unit transplantation has revolutionized hair restoration, with its focus on redistributing large numbers of genetically stable hair to balding scalp in a natural distribution. Follicular unit hair restoration surgery is a powerful tool for the facial plastic surgeon in male aesthetic facial rejuvenation because it offers high-impact, natural-appearing results with minimal downtime and risk for adverse outcome.     

Distribution of Human Hair in Follicular Units

BACKGROUND: Human hair emerges from the scalp in groupings known as follicular units. In follicular unit transplantation, the follicular unit is the exclusive element to be moved in the transplant. OBJECTIVE: To study the distribution of follicular units in the human occipital (donor) scalp. METHODS: Using digital photography, we counted in 50 patients the hair density, follicular unit density, and the proportion of 1-, 2-, and 3-hair units per square centimeter. We measured the median distance between the follicular units. All the data obtained was statistically analyzed. RESULTS: In the occipital (donor) scalp the number of follicular units per square centimeter ranges between 65 and 85, and the hair density ranges between 124 and 200. The proportions of the different hair groupings change according to the patient's hair density. We have developed a mathematical model that can predict the number and the most probable distribution of 1, 2, and 3 hair groupings, based on the patient's hair density. The distance between follicular units ranges from 1.0 mm to 1.4 mm. CONCLUSION: Hair transplant surgeons can now predict the total number of follicular units to be obtained from any given donor strip. In addition, the proportion of 1-, 2-, and 3-hair follicular units can also be anticipated. Some variance is to be expected due to the lack of uniform density in the donor area.     

Overview of Follicular Extraction

Follicular unit extraction (FUE), now named as follicular unit excision, is one of the methods of harvesting hair follicles from the donor area for implanting in the recipient area. The occipital scalp area is the most common donor area, but nonscalp donor areas like beard, chest, and other hairy body parts can be used as donor hair follicle area. The extraction of the hair follicle leaves a tiny circular scar over the donor area. Over the past 20 years, various devices for FUE have been developed, starting from manual, simple motorized to highly advanced motors with rotation, oscillation, and vibration. Similarly, different types of punch are used: dull, sharp, ultrasharp, serrated, hybrid and specially designed punch blade for long hair follicles harvesting in various diameters from 0.7 mm to 1.1 mm. The follicles can be harvested either by manual method or by motorized method.     

Androgenetic Alopecia: Combining Medical and Surgical Treatments

BACKGROUND: Medical treatment or surgical reconstruction is used separately to treat androgenetic alopecia. Two drug molecules (5% minoxidil solution and oral finasteride 1 mg) have proven efficacy to stabilize hair loss and promote hair regrowth. Microtransplant of one to three hair follicular unit grafts can provide a definitive hair restoration with a natural appearance. OBJECTIVES: Aesthetic results can be optimized with a combination of drugs and transplantation of follicular unit grafts. The Dynamic Multifactorial Classification is used to select suitable candidates for this combined approach and also to assess follow-up results. RESULTS: Dynamic Multifactorial Classification assists the evaluation of the natural history of androgenetic alopecia evolution and also the effects of treatment. Regression of male androgenetic alopecia from Hamilton type V to type III can be achieved by combining drugs with hair grafts. CONCLUSION: Improvement of investigative methods and especially the Dynamic Multifactorial Classification makes it easier for a patient to follow the results of treatment adapted to their case.     

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.     

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.     

Evaluation of Survival Rate After Follicular Unit Transplantation Using the KNU Implanter

BACKGROUND: Many hair transplant surgeons have advocated the use of micrograft megasessions for the purpose of a more natural looking end result, especially in the Oriental with higher skin/hair color contrast and darker, coarse, straight hairs. But it also has some fundamental limitations. Most important are a low graft yield and a low density after transplantation. There are several reports about the survival rate of micrografts in Caucasians, though the results are variable, but few reports about the survival rate and fate of micrografts in Orientals. OBJECTIVE: To compare the survival rate of one-hair follicular units with that of two-hair follicular units using the KNU implanter, to ascertain the average survival rate of micrografts (one- and two-hair follicular units), and to evaluate the fate of grafted hair according to time. METHODS: Two templates of 1.5 cm2 were made by tattooing on both sides of the frontoparietal recess areas in 11 patients with male pattern baldness (beyond Norwood type IIIa). The authors planted one-hair unit micrografts in the left template and two-hair unit micrografts in the right template, which were prepared by the concept of follicular unit, and counted the surviving number of follicular units at 1 and 3 months and total hairs at 6 and 12 months after transplantation. RESULTS: The mean survival rate by the number of follicular units was 47.3 and 57.4% at 1 and 3 months after transplantation, respectively. The mean survival rate by the total number of hairs was 92.0 and 90.4% at 6 and 12 months after transplantation, respectively. CONCLUSION: About 50% of the transplanted hairs fell out in 1 month, but at 6 months the survival rate of follicular unit transplantation using the KNU implanter showed a good result (92%), and there were no significant differences in the mean survival rate of follicular unit and total hairs between one-hair and two-hair units at 1, 3, 6, and 12 months after transplantation.