To Hair Transplant or Not Hair Transplant

The Principle

Hair transplantation depends on the well-established principle that transplanted hair follicles (roots) moved from their original location to another area will behave as they did in their original site. For example, even in the most advanced cases of common male pattern baldness (MPB), a U-shaped fringe of hair persists at the back and sides of the head. Hair follicles moved from this hair- bearing fringe (donor) area to a bald or balding area on the same patient’s scalp (recipient) area will take root and grow.

Continuing hair growth in these transplants has been observed since the 1950s, and a majority of hairs will continue to grow for the individual’s lifetime. Many other types of hair loss, in addition to ordinary MPB, can be helped by this procedure. These include female pattern hair loss; scarring from prior injuries or surgery; and a number of diseases that sometimes cause hair loss.

The Procedure.

1. Sedative–At the beginning of each session, the patient may be given a mild sedative (Valium or Ativan), either orally or intravenously. This minimizes anxiety, reduces discomfort, and helps to prevent side effects of excessive local anesthetic use.
2. Hair Clipping–Hair in the donor area is clipped to a 2mm length. If the donor area is on the scalp, then hair above and below this area can be left longer to help camouflage the donor area while it heals.
3. Anesthetizing–The donor area and recipient area are anesthetized using a very small needle about the size of an acupuncture needle to inject a local anesthetic. To reduce any stinging sensation, we will use a anesthetic adjusted to a “neutral” pH as opposed to stock anesthetic which is usually acidic and causes much of the “stinging” felt during such injections.
4. Follicular Unit Extraction (FUE)
   1. Part 1–After the anesthetic has taken effect, 0.9 to 1.1 mm punchesare used to make elliptical “punch” incisions around each Follicular Unit (FU). Each FU consists of 1-4 hairs that are grouped together naturally.
   2. Part 2—using micro-surgical instruments, each FU is extracted (pulled) and placed in a cooled solution of saline to keep them hydrated and ready for insertion.
5. Follicular Unit Transplanting (FUT)

   

   

   

   
   
   1. Transplanting with FUT creates a completely natural appearance.
   2. Tiny recipient sites are made on the bald/balding areas of scalp orbody by using standard hypodermic needles or micro blades. These recipient sites are made mimicking a natural pattern of hair growth and loss, hair depth (4-6mm), direction (forward, etc), and angulation (15-40 degrees).

6. Graft Adherence—Grafts are held in place by coagulated blood. To keep them secure, a wrap-like bandage is usually applied after the operation and left in place overnight. The following day, the bandage is removed and the area is cleansed. If only the top/front of your scalp is transplanted, and there is only minimal to average bleeding, you may be able to go home without a bandage. Most patients prefer the security of having a bandage to go home with, and studies suggest that most wounds heal faster and better if the wound is covered for the first 12-24 hours.
7. Follow up—you should still return the next day for follow-up cleansing, hair washing, and a check-up.

Number of Transplant Procedures Needed

The balding scalp should be conceptualized as being composed of three areas:

1. a)  Frontal area—extends from frontal hairline to the ears (1000-2000 FU)
2. b)  Midscalp area—behind the Frontal area; the “top” of the head (1000-2000FU)
3. c)  Vertex area—“back” of the head above the remaining fringe U-shaped area ofhair (1000-2000 FU)

In a fully bald male scalp, each area usually requires about 2000 grafts to fully restore. We can typically perform 500-1000 FUE/FUT per day/surgical session. So a reasonable estimation to restore a fully bald scalp region is approximately 2 sessions. In a man with less baldness, 1 session may suffice, whereas an extraordinarily bald person may require 3 or more sessions. Fortunately, just transplanting the Frontal and Midscalp areas is usually sufficient to produce a full appearance from the front and side views, and a bald Vertex is a very normal and natural pattern of milder baldness that many men naturally have.

Transplant sessions may be done as far apart as the patient wishes; however they are not done in the same area without at least a 3 to 6 month interval between the sessions. This is intended to allow the scalp to heal, as well as to begin to appreciate growth of transplanted hairs before undertaking a premature repeat transplant procedure.

Early transplants—it is getting more common for patients to have one or two smaller transplanting sessions before balding has reached an advanced stage. This provides camouflage for the primary and any subsequent sessions better than transplanting directly to bald scalp.

Body-to-Head Transplants (BHT)– Additionally, we perform Body-to-Head hair transplantation in patients who do not have sufficient scalp donor supply. The ideal candidate is a hirsute (hairy) man who otherwise does not have sufficient scalp donor to completely cover his bald scalp. Body hair has a slightly lower survivability of transplanted grafts (75-90% vs 95% from scalp donor), and also retains its thicker and curlier texture (Hwang et al). However, it does approach the length of normal scalp hair (growing up to 5 inches in length per limited studies). It is certainly in option in men who otherwise are not candidates for Hair Restoration Surgery.

What to Expect After Each Session

A crust or “scab” will form over each graft shortly after the procedure and will remain in place for 3-14 days. The smaller the graftàthe smaller the scabà and the shorter this period will be. 4-5 days is a good average for FUE scabs. When the area has healed and the scab has fallen off, the underlying skin will be a clean, slightly pinkish area at each graft site.

Washing—we will take down your bandage and wash your hair the day after surgery. You may gently shampoo on the 2nd day following your procedure.

Swelling—when a large area is transplanted, swelling of the forehead frequently occurs. While this is usually mild and lasts only two to four days, occasionally it can be severe enough to cause puffiness around the eyes. About 1/50 patients will have swelling bad enough to cause “raccoon eyes” or bruised appearance lower in the face. This, too, is always temporary and has no harmful effect on the healing grafts. Generally it would begin two to three days after the procedure and is most noticeable for the first session; subsequent sessions are less notable or it does not occur at all. In view of this, it is advisable to schedule a vacation or time off to coincide with the first session.

Activity/Exercise—During the first 3 days, coverings such as hairpieces or hats are generally best to be avoided—warm/dark places can harbor bacteria and lead to infection. Individuals who have jobs that expose them to considerable amounts of dirt are advised to be away from work for at least 1 week after each procedure. Exercise/sex—any training or vigorous sex is prohibited for the first 5-7 days and moderate activities can be resumed in 1 week.

The hairs in the transplanted grafts are shed between the 2nd and 8th week after the procedure usually. Sometimes they fall out with the crusts, usually they fall later. Therefore, the new grafts are bare for 2-4 months after the operation; during this time the follicles are recuperating and preparing to produce new hair.

New generation of hair is usually visible at the surface of the scalp by the 3rd- 4th month after transplanting, sometimes sooner. They grow at the same rate as they did in their original location (approximately 1⁄2 inch per month). If donor areas were Body-to-Head transplants, these hairs will retain their original curl and caliber (often curlier and thicker than scalp origin hair); they will grow significantly longer than their original body lengths, often approaching maximum lengths of 5-6 inches according to some studies.

Shock-loss—in 10-20% of men and up to 50% of women, there will be some “shock loss” or telogen effluvium in the recipient areas. This is a temporary stress- related shock to the hairs already existing in the recipient areas. It is ALWAYS temporary (Unger et al) and the hairs will regrow at the same time as the transplanted hairs.

Ingrown hairs occasionally occur and are temporary problem, beginning at the first hair growth of transplanted grafts 2-4 months after surgery. This is more prominent if your hairs are naturally curly. It is easily controlled and does not cause any permanent damage.

Scalp sensation—there likely will be a temporary slight decrease or slightly increased scalp sensitivity as the small nerve endings are cut during the removal and placement of grafts. The nerves usually grow back and sensation is restored 6 months after the procedure. Rarely do these changes take longer (up to 18 months) or persist to some extent.

Final Results

Usually 95% of scalp-to-scalp and 75%-90% of body-to-scalp hairs will survive transplanting. Often, more hairs will grow than were transplanted because invisible hairs in “resting phase” were transplanted and will begin to grow. Every single patient will grow enough hair to produce a substantial cosmetic improvement.

Within six months, the skin surface of the grafts has usually blended in perfectly with the surrounding scalp. The grafts are usually level with the surrounding skin, but a few may be slightly elevated or slightly lower. These can be remedied in office by using an electric needle without interfering with hair growth, or the troublesome graft can be replaced with another.

The final goal and appearance is usually that of an early-stage thinning man. That is, an appearance of Norwood 1 or 2 pattern that many men in their 20s or 30s will have. You should not expect to have hair like you did when you were a teenager!

As one ages, the fringe area of hair at the back of the head (where most donor grafts are taken from) naturally thins over time. Therefore, the donated grafts from this area are expected to thin to some extent as well in their new locations. However, they will never go bald again. In addition, as the hair goes grey with aging, they become of a thicker caliber and can mitigate the lower-density effect.

Summary

With new FUE/FUT transplanting techniques and an artistic surgeon’s eye, a completely natural appearing, growing, healthy head of hair can be attained. The plugginess or strip scars of years past are no longer necessary. Additionally, patients who were previously denied eligibility due to limited donor supply may be candidates with the emergence of body hair as a donor source in Body-to-Head (BHT) Hair Transplant Surgery.

Happy growing!

–(Dr)MedicineMan

Amir Sean Nagavi, MD
Follicle Clinic
Surgical Hair Restoration, PLLC

References:
Unger, WP, et al. Hair Transplantation, 5th edition, pgs 69-71. 2011 Informa Healthcare. New York, NY.
Hwang, S, Kim JC, Rye HS, et al. Does the recipient site influence the hair growth characteristics in hair transplantation? Dermatol Surg 2002; 28: 795-9