How a Modern Hair Transplant is Performed

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How a Modern Hair Transplant is Performed
Dr. Blake Bloxham Feller Bloxham Medical, PC
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What is a Modern Hair Transplant?

• Todays hair transplant is very different from
  the plug procedures of yesteryears. A modern
  hair transplant is known as Follicular Unit
  Transplantation, because the procedure involves
  the removal and re-implantation of follicular
  unit groupings the natural units follicles grow
  in.
• By removing only true follicular units and
  implanting these into the bald and thinning
  regions -- typically in large numbers and densely
  packed together when appropriate a modern hair
  transplant can be extremely natural.

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How is a Modern Hair Transplant Performed?

• A modern hair transplant can be broken down into
  several steps
• 1) Surgical Planning
• 2) Donor tissue harvesting
• 3) Implantation of follicular unit grafts into
  the recipient area

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Surgical Planning

• Surgical Planning refers to both defining the
  parameters of the safe area for harvesting in the
  donor region and demarcating and designing the
  areas where the new grafts will be placed IE
  new hairline design.
• Donor Area Planning It is imperative that only
  dihydrotestosterone (DHT) resistant follicles
  from the safe zone be used in hair transplant
  surgery. Follicles from outside this zone may
  thin and fall out over time. The donor
  harvesting area must be carefully demarcated to
  fall safely within this region.
• Although several models exist, most agree that
  the safe donor begins in the occipital region at
  the nuchal ridge/occipital protuberance and
  extends superiorly approximately 6cm this area
  extends in the same fashion across the
  parietal/temporal scalp up to the pre-auricular
  area. During some Follicular Unit Excision (FUE)
  cases (to be discussed under Donor Harvesting),
  doctors will take from safer areas in the donor
  region in specific patients (older, less active
  androgenic alopecia, limited loss in general,
  limited family history of loss, etc) as long as
  these patients consent and understand that the
  grafts from these areas are still not as
  resistant to future loss as those taken from the
  true safe donor

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Surgical Planning

• Recipient Area Planning
• Planning in the recipient plays a crucial role in
  the overall result. This planning includes
  designing new hairlines, rebuilding temporal
  regions, reconstruction of the natural whorl
  pattern in the crown/vertex, etc.
• Education, experience, and a conservative,
  long-term approach is crucial for creating
  natural results which will age well and look
  appropriate at all times.

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Donor Tissue Harvesting

• Modern Follicular Unit Transplantation can be
  performed via two different harvesting methods
• Follicular Unit Strip Surgery also known as
  FUSS, FUT, and Strip Surgery
• Follicular Unit Excision also known as FUE
  or Follicular Unit Extraction

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Follicular Unit Strip Surgery

• During an FUSS procedure, a small strip of
  hair-bearing skin is demarcated in the safe donor
  region. The area is trimmed, cleaned
  (chlorhexidine, iodine, alcohol, etc), and numbed
  with local anesthetic (typically 2 lidocaine
  with differing amounts of epinephrine). The strip
  is then excised with a scalpel, and then
  immediately closed with sutures or staples
  which can be done in a variety of ways including
  multiple layer closures and even in a
  trichophytic manner where hair is encouraged to
  grow through the resulting scar itself.
• The strip is then handed to highly skilled and
  experienced surgical technicians who will
  carefully dissect the tissue down into individual
  follicular units under high-powered stereoscopic
  microscopes.
• The FUSS procedure leaves behind a linear
  incision line scar in the donor area.
• Strip harvesting must be performed by the
  physician.

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Follicular Unit Excision

• During an FUE harvest, small dermal punch-like
  tools are used to carefully score around
  individual follicular units after cleaning and
  trimming. These tools are very small typically
  anywhere from 0.7mm to up 1.3mm (though tools
  this large are now less common). The tool may be
  a manual punch powered only by the doctors hand
  or may be attached to a motorized tool wherein
  a motor provides the rotation or oscillation of
  the punch. There are various devices which
  partially automate the process, and even some
  robotic devices controlled via software. The
  punches themselves can also be sharp, dull, or a
  hybrid of a sharp and dull punch.
• Once the follicular unit is scored, forceps are
  used to grasp and apply traction to free the
  follicular unit from the surrounding tissue.
• Typically, these units are placed under the same
  stereoscopic microscopes and examined for
  quality. Some clinics also slightly trim the
  grafts to remove any excess tissue.
• Despite how the procedure is sometimes marketed
  online, FUE is a surgical procedure which does
  leave scars in the donor area. The resulting
  scars are small, punctuate, hypopigmented dots,
  which can be very subtle.
• FUE harvesting must be performed by the
  physician.

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FUT vs. FUE

• There is much debate online today over which
  technique is best. The reality is that each
  technique has its benefits and limitations, and
  patients should be evaluated individually and
  appropriate recommendations made.
• There is much discussion about this topic online,
  and we encourage interested parties to research
  further.
• What the ISHRS agrees is not debatable, however,
  is that donor harvesting in both FUE and FUT is
  scalp surgery and should only be performed by
  experienced, licensed professionals most
  typically physicians. Delegating this task is
  illegal in most US states.

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Graft Implantation

• The final step of a modern hair transplant
  involves implanting the follicular unit grafts
  into the recipient area IE the bald and
  thinning regions previously demarcated.
• Grafts are typically implanted one of two ways
  into pre-made recipient sites or in conjunction
  with recipient site creation using implanter
  devices.

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Graft Implantation

• During placement into pre-made recipient sites,
  the process starts by the physician numbing the
  recipient region. This is typically done via a
  ring block or a supraorbital/supratrochlear block
  (done with the same local anesthesia used for the
  donor region).
• After the area is numb, the physician will make
  recipient incisions or sites using either a
  blade (typically a small, custom-cut flat blade)
  or a needle. These sites are made in specific
  directions, angles, and densities in order to
  create a natural result.
• After the recipient sites are created, surgical
  technicians carefully place each follicular
  unit graft into each slit.
• Most commonly, the technicians will use jewelers
  forceps (typically curved) and needles to
  carefully and expertly place grafts. However,
  implanter devices can be used as well. These
  implanter devices are typically open bore sharp
  or dull needles attached to a loading port. The
  grafts will be loaded into the port, the needle
  will be inserted into the slit, and the graft
  will be slipped through the needle and into the
  slit. Some devices even have a spring-loaded
  action to push the graft. The device will then be
  removed leaving the graft in place -- and will
  be reloaded for the next slit.

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Graft Implantation

• Graft placement can also be done via simultaneous
  slit creation and graft placement using implanter
  devices.
• These devices are the spring-loaded, sharp
  needle type discussed in the previous slide.
• The implanted pen is loaded with graft and
  handed to the physician. The physician will
  determine where he/she wants the graft to be, and
  use the sharp needle to make the recipient
  incision. The doctor will then push the plunger,
  which slides the graft into the site that was
  just made. The device is then removed, the graft
  remains placed, and the implanter is re-loaded
  with another graft.
• Once all grafts are placed, the case is
  complete and the patient is discharged (usually
  with a brief course of antibiotics and pain
  medication) to rest, recover, and wait for the
  new hair to grow starting 3 months later.

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How a Modern Hair Transplant is Performed

• Arguably one of the most important aspects of a
  modern hair transplant is that it is performed by
  an experienced, licensed physician. Procedures
  where surgical responsibilities are being
  delegated to non-licensed personnel are wrong,
  illegal, and severely hurting patients. Hair
  transplantation is scalp SURGERY, and should be
  treated as such.
• ISHRS statement on Qualifications for Scalp
  Surgery
• The position of the International Society of Hair
  Restoration Surgery is that any procedure
  involving a skin incision for the purpose of
  tissue removal from the scalp or body, or to
  prepare the scalp or body to receive tissue,
  (e.g., incising the FUE graft, excising the donor
  strip, creating recipient sites) by any means,
  including robotics, is a surgical procedure. Such
  procedures must be performed by a properly
  trained and licensed physician. All FUE
  harvesting tools, including robotic devices, are
  considered extensions of the hand of the
  operator, and as such, all operators of these
  devices must be physicians.
• Physicians who perform hair restoration surgery
  must possess the education, training, and current
  competency in the field of hair restoration
  surgery.
• The ISHRS believes the following aspects of hair
  restoration surgery should only be performed by a
  licensed physician
• Preoperative diagnostic evaluation
• Surgery planning
• Surgery execution including Donor hair
  harvesting, Hairline design, Recipient site
  creation, and Management of other patient medical
  issues and possible adverse reactions
• Post-operative care
• The ISHRS believes it is unethical for an
  individual to travel to a state and/or country in
  which he or she is not licensed and perform the
  surgical aspects of hair restoration.
• The ISHRS also believes it is unethical for a
  doctor to train an individual to perform surgery
  who is not an accredited health professional
  licensed to do so.