Follicular Unit Extraction: Minimally Invasive Surgery for Hair Transplantation

BACKGROUND: Follicular Unit Transplantation (FUT) is performed using large numbers of naturally occuring individual follicular units obtained by single-strip harvesting and stereo-microscopic dissection. Donor wound scarring from strip excision, although an infrequent complication, still concerns enough patients that an alternative solution is warranted. OBJECTIVE: The purpose of this paper is to introduce Follicular Unit Extraction (The FOX Procedure), in which individual follicular units are removed directly from the donor region through very small punch excisions, and to describe a test (The FOX Test) that determines which patients are candidates for this procedure. This paper explores the nuances, limitations, and practical aspects of Follicular Unit Extraction (FUE). METHODS: FUE was performed using 1-mm punches to separate follicular units from the surrounding tissue down to the level of the mid dermis. This was followed by extraction of the follicular units with forceps. The FOX test was developed to determine which patients would be good candidates for the procedure. The test was performed on 200 patients. Representative patients who were FOX-positive and FOX-negative were studied histologically. RESULTS: The FOX Test can determine which patients are suitable candidates for FUE. Approximately 25% of the patients biopsied were ideal candidates for FUE and 35% of the patients biopsied were good candidates for extraction. CONCLUSION: FUE is a minimally invasive approach to hair transplantation that obviates the need for a linear donor incision. This technique can serve as an important alternative to traditional hair transplantation in certain patients.     

Corrective Photoepilation for Improper Hairline Placement After Hair Transplantation

BACKGROUND: Noncoherent filtered flashlamp pulsed light has not been used for correction of surgical problems after hair transplantation. OBJECTIVE: To evaluate the clinical results of photoepilation in a patient with improper hairline placement after hair transplantation. METHODS: A noncoherent filtered flashlamp pulsed light source was used to photoepilate the misplaced frontal hairline in a 37-year-old Caucasian man, skin phototype IV (Fitzpatrick scale), who suffered from common baldness grade IV (Ebling scale) and had undergone a hair transplant 6 years before. The frontal hairline received three treatment sessions at 2-month intervals with the following treatment parameters: 695 nm cutoff filter, fluence 38 J/cm2, 3.5-msec pulse duration, triple-pulse mode, and 30-msec delay. The gulfs received two treatment sessions with the same protocol. RESULTS: Final clinical aspect was good and no hair regrowth in the frontal hairline has been observed after 1.5 years of follow-up. CONCLUSION: Noncoherent filtered flashlamp pulsed light is a novel therapeutic choice that offers a nonsurgical solution to unnatural hairline after hair transplantation.     

Oxidative Stress in Follicular Units During Hair Transplantation Surgery

Background  

Hair transplantation surgery currently is a well-established procedure in plastic surgery. It consists of harvesting a strip of scalp from the back of the head, then obtaining grafts called follicular units (FUs) from this strip and implanting them in the bald area. The FUs undergo oxidative stress during cold ischemia and after their implantation.     

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.     

Follicular Unit Transplantation: The Option of Beard Construction in Eunuchoid Men

BACKGROUND: Psychosocial problems are very common in eunuchoids and may be related to the impact of underlying disorders on the physical appearance which makes them unable to overcome the sense of inferiority of childhood. A beardless patient treated with follicular unit transplantation (FUT) is reported here. OBJECTIVE: Such patients desire to get rid of a boyish appearance and want to achieve a masculine appearance. One of the easiest methods to achieve this goal is FUT. METHODS: By using an 18-gauge needle, the recipient bed was prepared under local anesthesia after premedication, and 1200 one- or two-hair micrografts were transplanted to the perioral (goatee) and its extensions to the sideburns. RESULTS: After completion of the procedure to the planned area, we achieved restoration of a masculine appearance which made the patient seem quite satisfied. CONCLUSION: The process of beard reconstruction is time consuming and tedious, but highly effective.     

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.     

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.     

Graft Anchoring in Hair Transplantation

BACKGROUND: Since it is not known precisely how long it will take for grafts to be securely anchored after hair transplantation, the advice that the medical profession has offered patients regarding postoperative care has been somewhat arbitrary. OBJECTIVE: This study attempted to provide scientific data that can be useful in refining postoperative hair transplantation protocols. METHODS: Forty-two patients participated in the study. During their postoperative period, each had several grafts pulled to determine at what point they could no longer be manually dislodged. RESULTS: For the first 2 days, pulling on a hair always resulted in a lost graft. By the sixth day, pulling on a hair no longer dislodged the graft. Pulling on an adherent scab always resulted in a lost graft through day 5. At 9 days postoperatively, grafts were no longer at risk of being dislodged. CONCLUSION: The presence of crusting extends the interval that grafts are at risk of being dislodged postoperatively. If one can prevent crust formation following hair transplantation, this would both shorten the time patients are at risk of losing their grafts and enable them to return to their normal hair care routines more quickly.     

Vertical Harvesting in Hair Transplantation

BACKGROUND: There are several methods for harvesting from donor area, including punch graft, multiple bladed knife, or single bladed knife excision followed by excision of an ellipse. Vertical harvesting is excellent for avoiding follicular transections because of complete visualization of the angle of the hair exiting the scalp. Also, the donor area is easier to visualize because of rock-hard tumescence achieved during the totality of procedure. Only an experienced surgeon using a multiple bladed knife would have fewer follicular transections. OBJECTIVE: Optimal yield of the donor area: ie, minimal transection, thus less hair follicle transection. METHOD: Vertical harvesting of slivers of hair measuring 0.75-1.85 cm in height, and 3-4 millimeters in width using #10 solitary bladed knife and Optivisor (as magnification). RESULT: In our opinion, there is less transection of the follicular bulbs leading to an increase in yield. CONCLUSION: Patient comfort is maximized because the patient lies on one side. Another advantage is the reduced role of the technician, therefore requiring fewer technicians.     

Local Anesthesia in Hair Transplantation

BACKGROUND: Safe and effective use of local anesthesia is essential in hair transplantation. OBJECTIVE: To review the agents and techniques of local anesthesia as applied to hair transplantation. METHODS: Information was retrieved from texts, journal articles found by MEDLINE searches, and related references. RESULTS: Agents, vasoconstrictors, maximum dosages, toxicity, and techniques are discussed. CONCLUSION: Effective local anesthesia can be maintained throughout hair transplantation. Care must be exercised to minimize discomfort through proper technique and to minimize toxicity through judicious use of vasoconstrictors and nerve blocks and by monitoring total dosage. Constant monitoring for toxicity is required, as is early intervention in the unlikely event that warning signs should appear.     

Does the Recipient Site Influence the Hair Growth Characteristics in Hair Transplantation?

BACKGROUND: Recently hair transplantation has been widely applied not only to correct androgenetic alopecia, but also to correct hair loss on other parts of the body such as the eyebrows and pubic area. It is believed that the transplanted hairs will maintain their integrity and characteristics after transplantation to new nonscalp sites. OBJECTIVE: To evaluate whether the transplanted hairs maintain their hair growth characteristics after transplantation to a new anatomic site other than the scalp. METHODS: Three study designs were used. Study I: Hair transplantation from the author's occipital scalp to his lower leg was performed and clinical evaluations were made at both 6 months and at 3 years after the transplantation. Study II: After finding changes in hair growth characteristics, transplanted hairs were harvested from the leg and retransplanted to the left side of the nape of the neck (group A). As a control study, occipital hairs were transplanted to the opposite side (group B). Observations were made at 6 months after the operation. Study III: An observational study was done in 12 patients with androgenetic alopecia about 1 year after transplantation of occipital hair to frontal scalp. At each step, survival rates were documented and the rate of growth and the diameter of the shafts were measured for both recipient and donor sites. RESULTS: Study I: Surviving hairs on the lower leg showed a lower growth rate (8.2 +/- 0.9 mm/month), but the same diameter (0.086 +/- 0.018 mm) compared with occipital hairs (16.0 +/- 1.1 mm/month, 0.088 +/- 0.016 mm). The survival rate 3 years after transplantation was 60.2%. Study II: There was no significant difference in the growth rate, shaft diameter, and survival rate between retransplanted hairs (group A) and controls (group B). Groups A and B showed a lower growth rate, but the same diameter, compared with occipital hairs. Study III: There was no significant difference in the growth rate and shaft diameter between the transplanted hairs on the frontal scalp and the occipital hairs. CONCLUSION: These results strongly suggest that the recipient site affects some characteristics of transplanted hairs, such as their growth and survival rates.     

The Changes in Hair Growth Pattern After Autologous Hair Transplantation

BACKGROUND: Recently donor dominance has been emphasized in autologous hair transplantation while the influence of the recipient site has been considered negligible. In fact, there have been few studies that show this. OBJECTIVE: This study was performed to examine the influence of the recipient site on transplanted hairs. A clinical study of 19 leprosy patients was performed. These patients had received single hair transplantation due to madarosis and were admitted to The Leprosy Mission, Jesus Hospital, Taegu, Korea, or had visited its outpatient clinic. METHODS: In this study, the rate of growth, thickness of shaft, and graying rate between the transplanted eyebrow hair in the recipient site and scalp hair near the donor site were compared to observe the changes in the growth pattern of the hairs after transplantation. RESULTS: For most of the patients, the growth rate and graying rate of transplanted hairs were lower than those of hairs in the donor site. CONCLUSION: It seems that the recipient site may have an influence on the transplanted hairs. Further studies are needed, including clinical, histopathologic, and molecular biological methods.     

Effects of Cooling Micrografts in Hair Transplantation Surgery

BACKGROUND: When isolating hair grafts in hair transplantation procedures, it is generally recommended to preserve the grafts at a low temperature (1 degrees C- 4 degrees C) in order to enhance the survival rate of the grafted hairs. This study was carried out to test the real benefits provided by cold-storing hair grafts. OBJECTIVE: The aim of this study was to evaluate, in an in vitro model, the effects of cooling micrografts during hair transplantation procedures to experimentally assess the soundness of this approach to enhance the survival and growth rates of hair micrografts. METHODS: A total of 240 anagen hair follicles were obtained from 10 healthy male patients. Follicles were thus randomly assigned to one of the following groups: group A (control; n = 120 follicles), or group B (experimental; n = 120 follicles). Follicles from group A were preserved for 5 hours at room temperature (26 degrees C), and follicles from group B were preserved for 5 hours at 1 degrees C. Immediately after that 5-hour period, follicles from both groups were then cultured for 10 days. The length of each follicle was measured immediately following the 5-hour test period and at the end of the 10-day culture period. RESULTS: No statistically significant differences were found between the survival and growth rates of follicles from the control (survival rate = 87%, mean 10-day growth rate = 2.68 mm) and experimental (survival rate = 88%, mean 10-day growth rate = 2.54 mm) groups. CONCLUSION: Although, at present, it is generally assumed that lowering the metabolism of grafts by reducing their temperature may be of some utility for enhancing their survival rate, our data indicate of that there are no effects when performing hair transplantation surgery.