Pierre Bouhanna provides an overview of the most popular hair transplantation procedures currently available, including technique, advantages, and indications for their use.
Aesthetic surgery for male and female androgenetic alopecia and scarring alopecia has benefited from considerable scientific and technological advances over the past few years. The three techniques currently in favour are follicular unit transplantation (FUT), follicular unit for long hair (FUL), and follicular unit extraction (FUE). Indications are guided by many parameters, such as the area and the location of the alopecia; the sex, age, and ethnicity of the patient; characteristics of the scalp and hair; and the degree of alopecia evolution. The Bouhanna multifactorial classification1 combines all of these parameters allowing for a treatment suitable to each case.
Follicular unit transplantation
The oldest hair transplant techniques, such as the punch graft procedure, are now obsolete. Currently, the main objective is to prepare micrografts or follicular units of one to four hairs, using either:
- Follicular extraction with a micropunch of less than a millimetre (FUE)
- Follicular segmentation using a stereomicroscope of a strip of unshaved scalp (FUL) or shaved scalp (FUT).
Hairs harvested from the occipital region keep their ability to grow definitively even once implanted on the bald or sparse area. With the consent of the patient, a preliminary sketch can be drawn with a dermographic marker to delimit the area to be transplanted. A local anaesthetic of 1% lidocaine with epinephrine is used on the surface of the scalp.
Follicular unit transplantation
After pre-shaving the donor area, the conventional technical progress of removing a strip of hair and its segmentation into follicular units is similar to that of FUL described below2.
Follicular unit for long hair
For this technique, the hairs are not shaved and are therefore harvested at their full length (Figure 1)3,4. The FUL technique described has been used and refined since 19895 and allows for the removal and transplantation of long hair grafts of various shapes and sizes. The strip is segmented under a stereo microscope onto micrografts or follicular units.
The FUL process allows the patient to mask the scabs from the grafted area immediately after surgery and thereby avoid a source of postoperative aesthetic embarrassment (Figure 2).
The strip removed is approximately 10–30cm long and 10–20 mm wide.
Th closure of the edges of the donor area is made with a resorbable suture with 3/0 thread or with skin staples. On average 500–1500 grafts (1000–4500 hairs) will be prepared.
Preparation of the recipient area
Perforation of the skin surface is performed with Nokor or intramuscular needles of 16 to 18 gauges, or ophthalmic microsurgical blades (spear point or chisel).
For implantation in the recipient area, the author uses a set of fine jewelers forceps. Using this method, it is possible to transplant up to 1500 follicular units in one session.
The advantages of FUL
- For the patient:
>> The harvested donor area is immediately hidden by long hair
>> The can see the results immediately (Figure 2)
>> The scabs are hidden by long hair. Therefore, the patient can quickly resume professional and social activities after 24 to 48 hours.
- For the physician:
>> A better assessment of the direction and angle of the hair
>> It allows for a better evaluation of the orientation and the obliquity of transplanted hairs, as well as refinement of the frontal hairline with thinner or lighter hairs
>> A large amount of hair can be harvested (4000 hairs per session).
The disadvantage of FUL
The main drawback of the FUL technique as well as with conventional strip harvesting (FUT) would be that it leaves a fine scar line. To avoid this, it is possible to use the ‘trichophytic technique’. Later, if a patient decides for personal reasons to shave his scalp and the fine scar line becomes visible, it is very easy to transplant in more hair using the follicular unit extraction technique.
Follicular unit extraction
Follicular unit extraction consists of a preliminary shaving of the donor area and then harvesting of the follicular units with the use of a punch (0.7–1 mm in diameter) (Figures 3–4)6.
On average, an area of 100 cm2 (20 cm x 5 cm) can provide 500 to 1500 follicular units. FUE punches with diameters ranging from 0.7 to 1 mm are used to extract the hair follicles. During the first step, two parameters must be respected: depth and inclination.
The micropunch is rotated either manually or by a motor. Each graft is then extracted with the forceps. A total of 1000 follicular units are removed in 2–3 hours, approximately 1000–3000 hairs.
The insertion of follicular units is again achieved using forceps or a Choi implanter. Sometimes the process is called ‘stick and place’: one operator performs the perforation and the other operator inserts each FUE. The Choi implanter allows the assistant to store the graft in the micro-slot while insertion is carried out.
Indications of FUE
- Patients who have a habit of shaving their hair
- Patients with limited laxity of the scalp (a limiting factor for strip harvesting)
- Patients with sufficient hair density in the donor area
- Patients who do not want a scar line after strip harvesting.
Advantages of FUE
- The micro-scars in the donor area are, usually, almost imperceptible
- There are no sutures
- In some cases it is possible to harvest body hair, such as chest hair, for small FUE reconstruction.
Disadvantages of FUE
- Usually FUE is selected for small and medium baldness
- In women, a sparse donor area contraindicates FUE
- It is more difficult to accurately predict the number of FU harvested during any subsequent sessions
- The FUE method makes it more difficult to choose the best angle and orientation of the im
- In post-op FUE, scabs are not hidden by hair shafts
- Another essential point is that there is no regrowth of hair in the donor area for the hairs that have been harvested.
- After follicular transplant
- A bandage is sometimes applied for one night
- Shampoo can be applied the next day
- Swelling in the forehead may appear within 24–48 hours
- Small crusts and implanted hair shafts will take approximately 7 to 10 days to fall out
- Regrowth of new hair is expected 3 to 4 months after surgery
- The final outcome can be evaluated 12 months after surgery.
New instruments for hair transplants
- The automatic FUE transplanter7 (SAFER®, NeoGraft®, NeoGraft Solutions, Inc., Dallas, TX) (Figure 5) may be recommended in the absence of any contraindication to FUE. Compared to the conventional manual FUE technique, it avoids the need for additional assistance. The SAFER®/NeoGraft® both extracts follicular units from the donor area and implants them in the recipient area via a suction-based system
- The Robotic FUE (Artas® system, Restoration Robotics, Inc., San Jose, CA)6 (Figure 6) is an interactive, computer-assisted, and physician-controlled robotic system used for FUE harvesting. Stereo cameras precisely measure and calculate the angles and direction of each follicular unit. Each follicular unit is then extracted manually with forceps and the extracted follicles are inserted manually after processing.
Schematically, the main advantage of the Robotic FUE is it minimizes the chance of human error. The disadvantage is that it needs a long apprenticeship and a significant financial investment.
Indications for micrografts
The goal is to obtain a harmonious balance between the aesthetic requirements — taking into account the age, ethnicity, and gender of the patient; the evaluation of parameters for different classifications; the degree to which the alopecia has evolved; the capacity of the donor area — and the technical possibilities of the surgery.
As mentioned previously, indications are guided by many parameters, such as the area and the location of the alopecia, the characteristics of the scalp and hair, and the degree of alopecia evolution.
Male androgenetic alopecia
The degree of baldness is graded to one of three schematic stages of the simplified classification (Figure 7).
An essential point is to precisely estimate the number of transplanted hairs needed rather than the number of FU transplants (Figure 8).
- Stage I (fronto-temporal recession) implantation of 1000 to 3000 hairs in one session (Figure 9), also associated with crown alopecia (Figure 10)
- Stage II : implantation of 2000–3000 hairs (Figure 11)
- Stage III : up to 7000 hairs in one to three sessions are implanted (Figure 12).
The transplantation of micrografts may be
combined with a local anti-hair loss treatment (minoxidil 5%), injection of PRP, or finasteride 1 mg orally.
Female androgenetic alopecia
The degree of female androgenetic alopecia can
be graded using the Ludwig9 (1977) classification
- Stage I: moderate baldness, implantation of 1000 hairs in one session (Figure 14)
- Stage II: 1500–2000 hairs in one or two sessions
- Stage III: 3000–4000 hairs in two sessions.
The frontal recessions should be filled with the aim of creating a fine frontal line with a feminine pattern.
- Traction alopecia caused by repeated strain (blow drying, straightening, braids, etc.), especially in African-American patients, can induce alopecia10 (Figure 15)
- Pseudopeladic alopecia, if stabilized can be treated as long as the hair bulbs in the donor area are still intact
- Scarring alopecia after burns or radiotherapy
There is a contraindication to perform a hair transplant on a scalp that has an evolutive inflammation and/or infection, such as folliculitis decalvans.
Follicular transplantation is a simple surgical technique that corrects the majority of the definitive eyebrow alopecias5. The transplantation is performed under local anaesthesia. The strip is segmented under a microscope in order to obtain micrografts containing one or two follicles. After completing all the needle perforation, taking care of the various orientations, micrografts are gently introduced with microsurgical forceps. The refinements are easier to achieve with the follicular unit for long hair. No dressing is necessary.
Alopecia of the beard and the moustache
Alopecia of the beard and the moustache often
presents as a lack of facial hair due to the individual’s ethnic origin. A denser concentration of hair in the beard or moustache is often requested for ethnic
and religious wishes. The procedure is similar to
the one carried out on the eyebrow and
transplantation is performed with hair follicular units or sometimes with FUE. In a few cases FUE is performed by harvesting chest body hair. No dressing is necessary7.
Alopecia of pubic hairs
Reconstruction and densification of pubic hair is achieved with a procedure similar to that used for the eyebrows. No dressing is necessary7.
Follicular units for long hair, manual or motorized follicular extraction (FUE), automatic or robotic FUE, and conventional FUT can remedy most problems of hair thinning (scalp, beard, eyebrows or pubis) for men and women.
The appropriate follicular unit procedure should be selected according to the patient’s ethnic origin (Afro-American, Asian), donor area density, and spread of baldness.
Declaration of interest The authors report no conflicts of interest.
Figures 1-15 © Dr Bouhanna; 3, 7, 8, 13 Illustrations © Kevin February
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- Rassmann WR, et al. Follicular Unit Extraction: minimally invasive surgery for hair transplantation. Dermatologic Surg., 2002, 28 : 720-28
- Bouhanna P, Bouhanna E. The alopecias: Diagnosis and treatments. CRC Press Editions, 2015; 245pp
- Bernstein RM. Integrating robotic FUE into a hair transplant practice. Hair Transplant Forum Intl. 2012; 22(6):228-29
- Ludwig E. Classification of the types of androgenetic alopecia (common baldness) arising in female sex. Br. J. Dermatol., 1977, 97:247-254.
- Bouhanna P. Les greffes de cheveux chez les patients afro-américains. Dermatol. Pratique, 2010, 344; 12-13