H a i r Tr a n s p l a n t a t i o n U p d a t e

Procedural Techniques, Innovations, and

Applications
M.J. Kristine Bunagan, MD, Nusrat Banka, MD,
Jerry Shapiro, MD*

KEYWORDS
 Hair transplantation  Update hair transplantation  Follicular unit transplantation
 Follicular unit extraction  Applications hair transplantation  Follicular unit grafts

KEY POINTS
 Follicular unit transplantation yields the most natural looking results and is considered as the
current gold standard in hair transplantation.
 Basic steps in hair transplantation consist of donor area harvesting, graft dissection and storage,
recipient slit creation and placement of grafts.
 Aside from strip harvesting, follicular unit extraction (FUE) is another newer technique in donor
harvesting. Variations in the FUE technique include the use of manual, motorized and automated
punches and the utilization of robotic technology.
 Indications for hair transplantation has gone beyond male and female pattern hair loss of the scalp
to include transplanting hair over non scalp areas with hair loss such as the eyebrows, eyelashes,
moustache, beard and pubic area.
 Scarring alopecias due to secondary causes such as burns, surgery and trauma are mostly
amenable to hair transplantation however the utilization of this procedure for primary cicatricial
alopecias remains controversial.

INTRODUCTION natural pattern of hair follicles on the human scalp,

the procedure yields the most natural-looking
Hair transplantation has evolved throughout the results and is considered the current gold standard
years from the larger punch grafts to the smaller in hair transplantation. There are unifying concepts
mini grafts and finally to the more refined follicular and general steps that characterize this type of
unit graft transplantation performed by most hair surgery; however, there are likewise a lot of varia-
restoration surgeons today. This advancement in tions and innovations in the techniques and applica-
hair transplantation has its basis in the identification tions of this procedure.
of the follicular unit as the naturally occurring struc-
ture of hair follicles on the human scalp. This histo- PROCEDURAL TECHNIQUES
logic structure was first described by Headington1
as a circumscribed unit containing 1 to 4 hair follicles The basic steps in hair transplantation, including
along with its associated sebaceous glands and ar- follicular unit transplantation, consist of donor-
rector pili muscle insertion (Fig. 1). Because follicular area harvesting, graft dissection and storage,
unit transplantation follows the aforementioned recipient slit creation, and placement of grafts.
derm.theclinics.com

All authors have nothing to disclose.

Department of Dermatology and Skin Science, University of British Columbia, 835 West 10th Avenue, Vancou-
ver, British Columbia, Canada
* Corresponding author.
E-mail address: [email protected]

Dermatol Clin 31 (2013) 141–153

http://dx.doi.org/10.1016/j.det.2012.08.012
0733-8635/13/$ – see front matter Ó 2013 Elsevier Inc. All rights reserved.
142 Kristine Bunagan et al

the donor area, some surgeons use magnification

devices, such as a loop with 1.5 to 4.0 lens
magnification. The ideal donor strip should be
taken from the safest and most permanent part
of the donor scalp, which is, in most cases,
located in between the superior and inferior border
of the donor hairs.5
To further decrease follicular transection, some
surgeons have made some modifications to the
basic technique. The Haber spreader is a device
with a set of jaws with 4 sharp staggered prongs.
The goal is to harvest the strip by separating the
skin along the natural tissue dissection plane. A
superficial scoring incision is first made to delin-
eate the strip edges, then the instrument is in-
serted into the incision, and finally the handles
Fig. 1. Horizontal section of a scalp biopsy showing are pressed together to separate the wound
follicular units containing hair follicles, sebaceous edges. Although this device may be helpful in
glands, and arrector pili muscle. (Courtesy of Magda- some patients, there a certain cases when it may
lena Martinka.)
be difficult to separate the skin tissue with the
spreader, thus, the surgeon may have to use
The technique of follicular unit grafting was origi- a scalpel blade to excise the area.6
nated by Limmer2 and further detailed by Bernstein Another modification to the strip harvesting
and Rassman3,4 in the early 1990s. Since then, the method is through strip excision with the aid of
basic procedure remains the same with some vari- skin hooks. The skin is superficially scored with
ations, modifications, and added applications. a scalpel blade and then skin hooks are inserted
just below the rim of the wound edges. Once in-
serted, the skin hooks are then lifted and pulled
DONOR HARVESTING in opposite directions to allow direct visualization
Strip Method of the follicular units. A scalpel is then used to
Currently, the most common approach in harvest- gently excise the strip without transecting the
ing the donor area is by surgical excision of a strip follicles.7
from the occipital and parietal areas of the scalp, The general guideline for obtaining donor strips
using a single blade or a double-bladed scalpel that result in very thin linear scars is to obtain strips
(Fig. 2). To minimize follicular transection, the that are long and narrow. For instance, for regular
blade must be held parallel to the angle and the hair transplantation sessions (1500–2500 grafts),
direction of the hair shafts and excision must be the width may range from 1.0 to 1.5 cm, whereas
made up to the subcutaneous level where the the length would vary greatly from 20 to 30 cm de-
hair bulbs are located. For better visualization of pending on the patient’s follicular unit density and
the total graft requirement. Another factor that
influences the width size of the strip is the laxity
of the donor area. The more lax the skin, the wider
the strip that can be excised while still being able
to close the donor wound with minimal tension.
For patients who may need more than one hair
transplantation session, subsequent procedures
may lead to multiple linear scars if the strips are
obtained from donor areas separate from the
previous scar. To avoid this from occurring, the
technique is to incorporate the old scar with the
current strip, thus, resulting in a single scar even
after multiple surgeries. In general, the subsequent
strip has to be narrower than the prior surgeries for
lesser tension when closing the wound. In addi-
tion, other techniques, such as scalp massage to
improve laxity and double-layer closure for wider
Fig. 2. Single-strip harvesting. scars, may help improve the outcome.
 Hair Transplantation Update 143

Closure Techniques The general guideline is to perform a very super-

ficial excision just below the epidermis not
To close the donor wound, commonly used closure
exceeding 1 mm to avoid damaging the permanent
materials include nylon, polypropylene, Vicryl or
portion of the hair follicles at the area of the bulge.
monocryl sutures, or staples. Techniques include
This coincides with the results of a study whereby
continuous single-layer closure, combined contin-
morphometric analysis of the hair follicle and
uous and retention sutures, or the application of
measurement of the depth of the bulge area was
staples. Closure with staples may take less time to
done. The mean follicular length was approximately
accomplish; however, patients may complain of
4.16 mm, whereas that of the bulge area was from
more discomfort during the postoperative period.
1.0 to 1.8 mm. The depth of the bulge area was
Here at the University of British Columbia (UBC)
determined through immunoreactivity of CK15,
hair transplant center, for first-session surgeries,
a bulge stem cell marker. Thus, to avoid damaging
a continuous single-layer closure with 3-0 nylon or
the bulge portion, the trichophytic cut should be
prolene sutures is typically performed. These
less than 1 mm from the surface of the skin.12
nonabsorbable sutures are then removed after 1
The instruments used to remove the edge
week. For subsequent surgeries, when the donor
varies, with some surgeons advocating the use
area has less scalp laxity, a double-layer closure
of a scalpel11 to make a right-angle edge, whereas
with absorbable monocryl or Vicryl may be used.
others use scissors.8,10 Observed effects of the tri-
chophytic closure revealed that there can be prob-
Trichophytic Closure lems with resultant hair angles, more so with
The main concern with strip harvesting is the superior edge de-epithelialization, thus, inferior
appearance of the resultant donor scar. In most edge removal is preferred.11 For surgeons using
cases when the surgeon has excised a long, thin the trichophytic closure technique, improvement
strip with narrow width (eg, <1 cm) and closure in the appearance of the resultant donor scars is
was done without tension, the donor scar would observed in many patients (see Fig. 3B).
usually be very minimal. However, there are cases
Follicular Unit Extraction
when wider strips may have to be excised for larger
graft requirements. In addition, for most patients With the natural looking results of follicular unit
and surgeons, improvement of even a minimal transplantation over the recipient area, more atten-
scar has some benefit. Toward this end, Marzola, tion is being given to improving the scars at the
Rose, and Frechet8–10 introduced the application donor area. Although properly done donor strip
of the trichophytic closure in hair transplantation at excision commonly results in minimal linear scars,
about the same time period. This technique is per- some surgeons and patients prefer less visible,
formed after the excision of the donor strip and nonlinear scars. Thus, another technique in donor
involves the de-epithelialization or removal of the harvesting, known as follicular unit extraction
epidermis of either the superior or inferior wound (FUE), was introduced.13 The basic procedure
edge (Fig. 3A). The two sides would then be approx- involves identifying a follicular unit at the donor
imated together with the de-epithelialized edge area and extracting the individual follicular unit via
underneath the other donor rim. The purpose of a punch devise. Variations in the FUE technique
removing the epidermis at the wound edge is for are discussed later. Although a linear scar is not
the hair follicles, which were superficially cut, to produced, this procedure still results in scars that
grow within the resultant scar, thus, minimizing the usually appear as dotted hypopigmented macules
appearance of the scar.11 over the donor area. The proponents of this

Fig. 3. Trimming of the inferior edge in trichophytic closure (A) and minimal donor scar after 1 year (B).
144 Kristine Bunagan et al

procedure have put forth other advantages, such on the recipient site as directed by the physician.
as less postoperative pain over the donor area The surgeon still has to manually create the recip-
and the ability to obtain grafts from patients with ient slits using regular methods, after which the
very tight donor skin caused by multiple surgeries. handpiece can then be used to insert the grafts.16
Critiques of this procedure include potentially high A study of 40 FUE cases comparing manual and
transection rates that may occur with the blind powered FUE punches showed that the mean har-
extraction of individual grafts and much longer vesting time of the latter group was faster at
completion times. And because this procedure is approximately 100 grafts per 8.9  1.3 minutes.
operator driven, a successful outcome would The transection rate reported was 5.5%.17
largely depend on the skill of the surgeon.
Robotics
Manual Punches
Trying to address the disadvantages of FUE, such
The FUE procedure basically uses punches that as long procedural times and high transection rates,
range from 0.8 to 1.5 mm in diameter. Punches a company has come up with a robotic machine
may also have sharp or dull tips, with the choice (ARTAS System, Restoration Robotics, Mountain
of tip dependent on the technique preferred by View, California) to extract grafts. This machine
a particular surgeon. One of the main techniques has recently obtained approval by the Food and
described by Rassman and colleagues13 is the Drug Administration. This FUE system has an
FOX procedure, which uses a sharp 1-mm punch image-guided set of cameras and computer
to make a superficial incision up to level of the programming to improve accuracy in extracting
mid-dermis followed by the extraction of the indi- follicular units. Physicians control the settings of
vidual follicular unit with a forceps. Not all patients the machine. The multiple cameras first capture
are good candidates for this procedure; thus, the images of the scalp, and then the computer’s soft-
proponents of this technique have proposed the ware analyzes the data through complex algorithms
FOX test, which is a test session to determine tran- and computations. Through the aforementioned
section rates and, hence, identify which patients process, the system maps out and monitors the
would yield positive results.13 follicular unit location and patient motion. The
Another modification of the FUE technique is the computer-guided robotic arm with a 1-mm needle
Surgically Advanced Follicular Extraction system and blunt punch then harvests at random based
described by Harris.14 In this procedure, first on the follicular unit spacing set by the physician.
a sharp punch creates a superficial scoring inci- Their reported transection rate is less than 10%
sion, which is then followed by a blunt dissecting and the extraction rate is 500 to 600 grafts per
punch to separate the follicular unit from the hour. The surgeon and/or nurses then implant the
surrounding tissue. A variation is the use of grafts manually after the recipient slit creation using
a serrated dull tip. A study on patients with male hypodermic needles or miniblades.18,19
pattern hair loss showed transection rates of Lin X and colleagues20 reported another hair-
6.14%, with a range of 1.7% to 15.0%. A potential harvesting robot with an end-effector arm.20 This
side effect of this procedure is the possible occur- machine has a digital microscope that first local-
rence of buried grafts with the use of dull tips.15 izes and determines follicular units and then
guides the punch with a motorized shifting mech-
Motorized and Automated Punches anism and rotary guidance design to harvest
grafts. The reported end-effector bias and preci-
Punch devices used for FUE now include motor-
sion was 0.014 mm.
ized and automated punches, such as the auto-
mated FUE and implantation system NeoGraft
Nonscalp Donor Area
(Medicamat, Malakoff, France). This machine
uses pneumatic pressure and automated control There are patients who are not considered good
to extract individual follicular units. The physician candidates for hair transplantation because of
controls the harvesting hand piece, which has a poor scalp donor area. Some may have depleted
a rotating and cutting canula for excision of grafts. donor supplies from previous hair transplantation
After extraction, the grafts are suctioned into procedures. For this subset of patients, there is
a canister. Trimming of the grafts are not neces- a need for additional sources of donor supply.
sary. Multiple punch diameter sizes with a depth Alternative sources from other hair-bearing areas
limiter are provided. Another feature of this of the body may provide an expanded pool in
machine is the implantation handpiece. A combi- a select group of hirsute individuals. FUE of non-
nation of pneumatic pressure automatically loads scalp hairs has been performed by some surgeons
the graft into the implantation canula then implants with moderately good outcomes. In a case report,
 Hair Transplantation Update 145

this procedure was done because of the extensive bisected or partial follicular units. A study by To-
scalp scarring with limited donor area. Chest hairs scani and colleagues23 bisected hair follicles hori-
served as donor grafts for the recipient scalp. After zontally resulting in upper and lower portions. The
more than 1 year, there was acceptable trans- upper part was cut just below the insertion of the
planted hair growth. Another observation was the arrector pili muscle and was approximately one-
change in length of the chest hairs from 4 cm to third of the length from the dermal papilla. The
and 15 cm (4 times) at about 1.5 years after the donor hair follicles were then implanted on the
hair transplantation.21 recipient area of a patient with male pattern hair
In another case series whereby some patients loss. Both the upper and lower portions were
had severely depleted donor areas caused by stained for epithelial stem cell markers. The hair re-
previous surgeries, grafts were sourced from growth evaluation done after 1 year revealed the
chest, abdomen, beard, arm, and leg areas. There presence of epithelial markers CD200, beta 1 in-
was a reported 80% to 85% survival of the trans- tegrin, and p63 detected over both portions, signi-
planted grafts. In this study, procedural details fying the possibility of a reservoir of progenitor
included the shaving of the donor areas 1 week stem cells capable of regenerating an entire hair
before surgery to ensure extraction of anagen follicle. Hair regrowth was 72  0.4% of the trans-
hairs and the use of hypodermic needles custom- planted upper portions and 69.2  1.1% of the
ized at the tip and mounted on a rotary tool as the lower portions. The hairs from the bisected follicles
punch device. The cases had, on average, around had slightly finer caliber hairs compared with intact
1500 to 1800 grafts per session, with several 2 to 3 hairs.
consecutive daily sessions done to achieve the Another study extracted partial longitudinal
total graft requirements. The aforementioned follicular units. The vertically divided hair follicles
patients were very hirsute individuals, thus, allow- (100 and 150 grafts) extracted from the occipital
ing for the extraction of a large number of grafts.22 areas of 5 patients were transplanted into their
The success of this type of procedure depends respective recipient areas. After 1 year, there
heavily on the skill of the surgeon. Other disadvan- was a mean growth of 95.9% of the partial follic-
tages include hairs of lesser quality when ular units transplanted on the recipient area, with
compared with scalp hairs (eg, caliber and length the growing hairs possessing the same character-
differences). Although there are some reports of istics as the donor hair.24
an increase in the length of the transplanted hairs,
other surgeons were not able to observe this
finding. In certain patients, the body hair supply GRAFT DISSECTION AND HANDLING
may be insufficient. In terms of the best source
After the hair-bearing strip is harvested from the
of nonscalp hair, the beard area would most likely
donor area, it is cut into slivers of 1 to 2 rows of
yield grafts with the potential to grow longer than
follicular units (Fig. 4). These slivers are then
the hairs from the other areas of the body.
further dissected into follicular unit grafts with 1,
2, 3, or 4 hairs, depending on the observed natural
Hair Regeneration from Bisected Follicles
grouping of the follicular units on a patient’s scalp
To further expand the donor supply, various (Fig. 5). Proper dissection into follicular unit grafts
studies have looked into the growth potential of involve carefully trimming the tissue surrounding

Fig. 4. Slivering technique (A) and slivers of single rows of follicular units (B).
146 Kristine Bunagan et al

ensuring that grafts are properly hydrated

throughout the hair transplantation procedure is
paramount to graft survival.

Magnification
The binocular stereoscopic microscope provides
magnification and proper illumination while dis-
secting follicular unit grafts (Fig. 6). This is espe-
cially important in follicular unit transplantation
when there can be difficulty in identifying and dis-
secting tiny follicular unit grafts with the naked eye.
This device, with a magnification of 5 to 20,
enables better visualization of the follicular units
to minimize transection of the hair follicles.
Surgical technicians commonly use the 10
magnification setting.26

Storage Solutions
Fig. 5. Follicular unit grafts with 1, 2, and 3 hairs. Currently, unbuffered normal saline, Plasma-lyte
A, and Ringer lactate solution are the most
commonly used holding solutions in hair trans-
the follicular units, thus, ending up with a pear- plantation.27 Graft survival studies and the surgical
shaped graft that is wider at the base where the experience of hair transplant surgeons with
bulbs of the follicles typically splay and narrower successful outcomes provide a good basis for
at the top where the hairs converge as they exit the use of normal saline solution. At the author’s
the skin. Instruments used for the slivering and dis- center, chilled normal saline used for surgeries
secting of follicular unit grafts commonly include lasting for 6 to 8 hours have consistently yielded
the number 15 or 10 scalpel blades or double- a high percentage of graft survival as evidenced
edged razor blades depending on the training by good cosmetic results. The concern of some
and preference of the surgical assistants. surgeons is for longer hair transplantation sessions
The possible effect of graft handling injuries on that extend beyond 6 to 8 hours because previous
the morphology of the follicular unit graft was studies have shown a decrease in graft survival
analyzed in a study through the use of a light or with extended duration times.28,29 More research
scanning electron microscope. The grafts were studies are looking into the use of other holding
crushed, bent, stretched with forceps, or left solutions to improve graft survival.
drying for 3 minutes. The results showed that there Intracellular solutions, such as hypothermosol
was no change in morphology in the grafts that and custodial, have a lower Na1 concentration.
were stretched, crushed, or bent. Damage was For surgical durations within 6 to 8 hours, the
observed only in the grafts left to dry.25 Therefore, survival of grafts in these intracellular solutions

Fig. 6. Stereoscopic microscope (A). Dissecting follicular unit grafts with magnification and illumination (B).
 Hair Transplantation Update 147

may not vary significantly from grafts in normal ethnicity, with Caucasians usually having shorter
saline; however, for much longer sessions, the follicles and Asians having more on the longer
use of these solutions may have some benefit.30 end of the spectrum.
Some studies were focused on the effect of addi- For the frontal hairline, to frame the face well and
tives to storage solutions primarily in terms of to create a natural-looking hairline, the slits should
enhancing graft survival. In one study, adding be made in an irregular pattern to try to mimic
ATP–magnesium chloride and deferoxamine to natural hairlines, which are mostly very irregular
normal saline solution led to moderate improve- and slightly asymmetric. Hairlines should only be
ment in graft survival. There was 98% graft survival transplanted with grafts with 1 hair. The 2- to
seen with normal saline plus additives compared 3-haired grafts should be transplanted behind
with 87% with normal saline alone.31 In another the 1-hair grafts going more posterior to create
study, DMEM with AMG improved hair shaft elon- more volume or coverage.
gation after 5 hours. There was also a decrease in Slit orientation can be sagittal or parallel to the
cHADF, a measure of apoptotic cell death. DMEM direction of hair growth or they can be coronal
with arachidonic acid inhibitors and AMG (inhibitor slits, which are created perpendicular to the hair
of nitric oxide synthase) showed improvement in flow. Traditionally, sagittal slits have been the
hair shaft elongation in in vitro and in vivo studies.32 type of slits created by most surgeons, with
EET also improved hair shaft elongation.33 good outcomes seen most patients. Surgeons
Uebel34 conducted a study on the use of who prefer coronal slits point out that this type of
platelet-rich plasma (PRP) obtained through the slit orientation causes less tissue damage than
manual centrifuge method. Results revealed that sagittal slits, permits closer graft placement, and
after 1 year of transplanting 20 grafts per centi- makes hair strands shingle, creating the illusion
meter, the hair regrowth was 18.7 grafts per centi- of more volume.36 A microscopic analysis of the
meter with PRP compared with 16.4 grafts per natural hair orientation in 100 men showed that
centimeter with the control group, signifying an multi-hair follicular units were mostly coronal or
approximately 15% difference in follicular perpendicular to the radial line from the whorl
density.34 Another study by Perez-Meza and over the peripheral and midscalp areas.37
colleagues,35 which obtained PRP via an auto-
mated centrifuge machine, had a different finding. Density Goals and Size of Sessions
After 1 year, hair counts showed similar results for
Twenty five to 40 follicular unit grafts per square
both the PRP and the placebo group.35
centimeter are the transplanted densities made by
most hair restoration surgeons. This density goal
RECIPIENT GRAFT CREATION AND shows a cosmetically acceptable outcome over
PLACEMENT the recipient area, with most patients being satisfied
Slit Creation by the results. Generally, noticeable hair thinning
occurs only after a person has greater than 50%
In creating slits over the recipient area, important
hair loss; thus, in most cases, it is not necessary
considerations include slit size, depth of incision
to transplant densities greater than 50%.
and angle, and direction. In general, over the
In terms of magnitude of sessions, many
frontal to midscalp area, the hairs are in an anterior
surgeons are performing hair transplantation
or forward direction with acute angulation. Over
surgeries ranging from 1000 to 3000 grafts per
the temples and parietal area, the direction is
session, which is usually adequate to cover small-
more inferoposterior with very acute angles, espe-
to moderate-sized areas of hair loss at one time.
cially over the temple points and sideburn areas,
For patients with larger areas, 2 to 3 sessions
which have angles almost flat to the skin. The
may have to be performed, although the possibility
vertex area can be a complicated area to trans-
of subsequent sessions would depend on the
plant because hairs may follow a whorl pattern.
availability of the donor supply.
In terms of the size of the slits, mostly grafts with
1 hair correspond to slits created by 20- to
Implanters
21-gauge hypodermic needles or 0.7- to 0.9-mm
miniblades and 2- to 3-haired grafts to 18- to 19- Transplanting over the recipient area is commonly
gauge needles or 1.0- to 1.1-mm miniblades. The done manually using jeweler’s forceps. The graft
depth should depend on the length of the hair placer gently grasps the follicular unit graft and,
follicle, which can be measured along the length ideally, in one motion should insert the graft inside
of the needle or miniblade to guide the surgeon the recipient slit. This skill requires several months
as to how deep to make the incisions. Follicular to years to master. This part of the procedure is
lengths range from 4 to 6 mm depending on usually the rate-limiting step, which lengthens the
148 Kristine Bunagan et al

duration of most hair transplantation procedures. resulted in the prevention of edema after hair
Some physicians have come up with instruments transplantation in 97% of patients (n 5 117). Other
to aid in this graft-placement process. Implanters, methods (eg, intramuscular methylprednisolone,
such as the CHOI and KNU implanters, are used triamcinolone with 2% Xylocaine, and oral predni-
more commonly in Korea and Japan. The original sone) had much lower percentages of patients
CHOI implanter and the improved KNU version without edema (47%–70%).43
come from Kyungpook National University in
Korea. These implanters are shaped liked pencils COMPLICATIONS
with a hollow needle at the tip. There are 3 sizes
that correspond to 1-, 2-, or 3-haired follicular In general, complications encountered in hair trans-
unit grafts. A single follicular unit is placed inside plantation surgery are uncommon. Exact figures on
the hollow end of each device. The device, with the incidence rates are not available. In a study of
its sharp end, can then be injected into the recip- 533 hair transplantation cases, the overall compli-
ient site where it simultaneously creates a slit cation rate was low and included enlarged scars,
and inserts the graft inside the slit at the same folliculitis, keloid, and necrosis in the donor
time. On withdrawal of the implanter, the graft is area.44 Other complications that may occur over
left inside the incision.38 A study done to assess the donor area are neuralgias, donor hair effluvium,
the survival rate of 1- and 2-haired follicular unit and arteriovenous fistulas.45 Over the recipient
grafts using the KNU implanter revealed graft area, some complications may include central
growth of 92.0% after 6 months and 90.4% after recipient area necrosis, folliculitis, cyst formation,
1 year.39 Graft survival at different transplanted and an unnatural appearance of transplanted
densities was also studied, and the results showed hairs.45 Although there may be some complications
that survival rates were higher at 20 to 30 grafts that are unpredictable and may not be avoided
per square centimeter compared with higher because of unforeseen factors, in most cases,
transplanted densities of 40 to 50 grafts per square complications can be prevented or at least mini-
centimeter. The recipient-area density suggested mized through meticulous planning and utilization
for the KNU implanter is 30 FU/cm2 per procedure of proper surgical techniques.
and to perform repeated sessions as necessary.40
Possible drawbacks to the implanters include
INDICATIONS
potential difficulty in loading finer Caucasian hair;
Pattern Hair Loss (Male and Female)
some grafts may be inserted below the skin, re-
sulting in pitting; and blades may not be as sharp, Hair transplantation is most commonly done for
leading to popping of grafts.41 male pattern hair loss. According to the 2011
statistics of the International Society of Hair Resto-
POSTOPERATIVE CONSIDERATIONS ration Surgery, approximately 85% of hair trans-
plantation surgeries performed were for genetic
It is critical for patients during the postoperative hair loss. The reported success rate and effectivity
period to ensure that extra care is taken to not of this procedure for this hair loss indication is
cause any trauma to the transplanted grafts quite high; the benefit to patients is substantial,
when handling the recipient area. Study findings with excellent growth rates of transplanted grafts
revealed that grafts can still be pulled out 2 days (Fig. 7).
after surgery and that adherent scab removal at Although women make up the minority of
2 to 5 days after the operation resulted in lost patients undergoing hair transplantation for
grafts. At 9 days, there was no risk of graft removal pattern hair loss, the advent of the more refined
over the recipient area. Prevention of crusting technique of follicular unit transplantation, which
helps in decreasing the possibility of graft yields natural-looking results, opens up this proce-
dislodgement during the first 7 days after the hair dure as an effective treatment option for appro-
transplantation procedure.42 priate female patients (Fig. 8). The procedural
A common sequela following hair transplanta- technique for female patients mainly follows the
tion is the development of forehead edema. The same basic steps as for male patients. For the
edema may range from mild to severe, with Ludwig pattern of hair loss, which mainly affects
some patients experiencing involvement of both the central aspect of the scalp, transplanting in
eyelids. A study evaluating the effectivity of several between the preexisting hairs may lead to the
methods to decrease the occurrence of postoper- possibility of temporary telogen effluvium or shock
ative edema was conducted. The findings showed loss to these hairs, thus, this has to be discussed
that incorporating triamcinolone acetonide with with patients. For women who have frontotempo-
the tumescent solution for the recipient area ral recession similar to men, the restoration of
 Hair Transplantation Update 149

Fig. 7. Before (A) and 1 year after (B) hair transplantation of a patient with male pattern hair loss.

the hairline follows a different pattern, with hairs with finer hairs, 2-haired follicular units may occur
transplanted to cover the frontotemporal angles over the central aspect or the body of the eyebrow.
for a feminine look and with hairlines usually Donor hairs are obtained from the sides or the
brought lower than in men. back of the scalp. The follicular unit grafts contain-
ing 2 to 3 hairs are further dissected into single-
hair grafts and trimmed into skinny grafts before
Nonscalp Hair Loss
insertion into the recipient area slits over the
Eyebrow eyebrows. Smaller slits ranging from 22- to 23-
For various causes of eyebrow loss, such as gauge hypodermic needles and 0.6- to 0.7-mm
genetic thinning or hair loss caused by plucking miniblade sizes are used depending on the caliber
or trauma, hair transplantation over this area has of the patient’s hair. The direction of the grafts
been shown to have successful results (Fig. 9). would be to follow the natural pattern of the exist-
The basic steps of scalp hair transplantation still ing hairs if still present. Another technique is the
apply with modifications. In eyebrow transplanta- converging method whereby the grafts trans-
tion, mostly 1-haired grafts are used in keeping planted over the superior aspect are directed
with the natural pattern of human eyebrow hairs downwards and those over the inferior portion
occurring as singular follicular units. In Caucasians are made to converge upwards creating a more

Fig. 8. Before (A) and after (B) hair transplantation of a patient with female pattern hair loss Ludwig type.
150 Kristine Bunagan et al

Fig. 9. Enhancement of thin eyebrows (A) through eyebrow transplantation (B).

pleasing shape.46 In terms of the angulation, the hair grafts. The mean transplanted hairs was 929
grafts must by inserted as flat as possible to the  76. The modified horizontal pattern was the
skin creating a very acute angle. pattern created because of its close resemblance
to the natural pubic configuration. The reported
Moustache and beard survival rate was 73.6  6%.49
Hair transplantation over the moustache and Although rarely done in Caucasians, there are
beard area may be done for men with decreased few case reports of this procedure as was the
hair follicles over these areas. Some common case in a 41-year-old woman with thinning of her
causes include congenital absence, surgical or pubic hairs causing much psychological distress.
traumatic loss, folliculitis, and so forth. This proce- The procedure would be the same as mentioned
dure is more commonly performed for men of earlier except that, in some Caucasians with finer
Middle Eastern descent because of the cultural hairs, 2- to 3-haired follicular unit grafts, aside
and religious significance. The technique is the from the single grafts, may be used. In this partic-
same as scalp hair transplantation, with some ular case, grafts with 1 to 4 hairs per follicular unit
important considerations. In general, coarser hairs were used with a total of 410 grafts transplanted.
occur over the moustache and beard area relative One- and 2-haired grafts were placed over the
to the scalp; thus, the chosen donor hairs should periphery and 3 to 4 grafts over the central aspect.
come from the middle of the occipital area where The 1-year follow-up showed good growth, with
the thickest hair shafts are most likely to be found. the transplanted hairs developing curl similar to
The recommendation is to place 1- to 2-haired the preexisting hairs.50
grafts at a density of 25 to 30 FU/cm2 over the
beard area and 30 to 45 FU/cm2 over the mous- Cicatricial Alopecia
tache area following the common pattern in
mature male beards.47 Primary cicatricial alopecia
Hair transplantation in alopecic areas caused by an
Eyelash active primary scarring disease is contraindicated.
There are major concerns with transplanting hairs There may be some select cases were hair trans-
over the eyelash area, such as the difficulty in trans- plantation can be contemplated. This procedure
planting over delicate tissue, postoperative care can be considered in primary cicatricial alopecias,
problems, and lower graft survival rates. Many which has burnt out or has become inactive for
surgeons prefer to perform this procedure in recon- years without medication. At the UBC Hair Trans-
structive cases rather than cosmetic reasons. plant Center, a general guideline includes hair
Some surgeons have successfully transplanted transplantation over a small test area with a limited
grafts over the eyelashes for aesthetic purposes. number of grafts (eg, 100–150). The successful take
One technique is through the use of French eye of grafts can then be followed by hair transplanta-
needles to transplant single-hair grafts over the tion over the alopecia area. The growth rates are
rim of the upper eyelids. In one study, dense much lower than with hair transplantation for
packing of 30 to 40 grafts was done over a 4-cm common indications, such as pattern hair loss.
upper lid margin with good resultant growth of Even after acceptable graft survival rates after
more than 95%.48 surgery, there may still be the possibility of disease
recurrence, which may lead to the transplanted
Pubic hair grafts being affected by the underlying disease
Hair transplantation over the pubic area is more process. At this center, there have been moderately
commonly performed in Korean and Japanese successful outcomes in cases of inactive lichen
women. In one study, this procedure was per- planopilaris and frontal fibrosing alopecia (Fig. 10).
formed for pubic atrichosis or hypotrichosis in
507 Korean women of Mongolian origin. The Secondary cicatricial alopecia
main reason for seeking the procedure was feeling Scarring alopecias from secondary causes, such
inferior because of their condition. The donor as burns, surgery, and trauma, are mostly ame-
grafts from the scalp were dissected into single- nable to hair transplantation. Follicular unit grafts
 Hair Transplantation Update 151

Fig. 10. Before (A) and 5 months after (B) hair transplantation of frontal fibrosing alopecia.

transplanted over scars in hair-bearing areas defects of hair bearing scalp. Successful outcomes
provide camouflage resulting in an improved have been reported with the use of tissue engi-
cosmetic appearance, especially in highly visible neered dermal regeneration templates followed by
areas, such as the scalp (Fig. 11), eyebrow, and follicular unit transplantation to reconstruct large
eyelash area. Important considerations include scalp defects. A reported case of a traumatized
wider spacing of grafts compared with regular hair scalp with exposed periosteum/galea underwent
transplantation of pattern hair loss because of the a series of procedures consisting of initial coverage
decreased vascularity over these scarred areas. with the Integra Dermal Regeneration Template (In-
Staged procedures can be done to increase density tegra LifeSciences Corporation, Plainsboro, New
and improve coverage.51 Successful outcomes Jersey) followed by trial micrografting of 100 grafts
have been observed with follicular unit transplanta- into the regeneration template. After there was
tion to hide scars and restore hairs lost from rhyti- growth with the test grafts, 2 sessions of 800 grafts
doplasty and other plastic surgeries.52 per session was performed with a good outcome.54
Difficulties arise in cases when there may be Another study showed the same results with
larger areas of scarring relative to the scalp donor artificial dermis followed by FUT. Their 2-stage
area. Nonscalp body hair to be harvested via FUE procedure first started with the placement over
may be potential sources of donor grafts. Another the defect of an artificial dermis (PELNAC, Smith
method was undertaken in a study involving facial & nephew KK, Japan) that was then allowed to
and scalp burns with a limited donor area. Over the granulate for 1 to 2 months. The follicular unit
occipital scalp, graft harvest of partial longitudinal grafts were subsequently inserted into the granu-
grafts was done using hollow wave-tipped needles lation tissue. Two cases resulted in a 29% to
with an inner diameter of 0.6 mm. The postsurgery 43% reduction of the defect, re-epithelialization
evaluation showed that the donor area had repro- of the exposed area, and growth of hair grafts
duced hairs after 2 years. There was a good with acceptable coverage.55
cosmetic result over the recipient area.53 Transplanted follicular unit grafts have been
shown to result in repigmentation of depigmented
OTHER APPLICATIONS areas of vitiligo. Hair repigmentation may be seen
in white donor hairs as was observed in the case of
Hair transplantation may be part of reconstructive a 57-year-old woman who underwent hair trans-
procedures performed to improve extensive plantation for frontal scarring alopecia.56

Fig. 11. Before (A) and after (B) transplantation of scarring alopecia caused by hair straightening chemical.
152 Kristine Bunagan et al

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