Hair Transplant basics

[Mickey85]

Overview:

-Hair transplant: A hair transplant involves extracting hair follicles from the areas that are immune to balding such are the rear and sides of the scalp and implanting them into the desired areas. The process is surgical and does not involve the creation of new hair follicles but rather the transfer of follicles into the balding areas.

 

Excellent example of cutting edge hair restoration:

*Work of Dr. Feriduni

 

 

-Male Pattern Baldness: Male Pattern Baldness(MPB also known as "androgenic alopecia") is the loss of hair that occurs due to an underlying susceptibility of hair follicles to androgenic miniaturization. Genetics play a pivotal roll in its occurrence but external influences such as steroids, bad health, diet etc are said to play a role also. Typical MPB usually begins at the temples and crown and can progress, the sides and rear of the scalp are generally immune and unaffected. The "Hamilton-Norwood" scale has been developed to grade androgenic alopecia in males. One individual can progress to a Norwood 3 and remain there for life whilst another individual can progress to a Norwood 7.

 

A visual document demonstrating the different Norwood ratings:

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Folllicular and non-follicular units:

 

-Follicular Units: Follicular Units(FU) grafts naturally occurring groups of 1 to 4 hairs. Follicular units also contain sebaceous (oil) glands, nerves, a small muscle, and occasional fine vellus hairs. Prior to the discovery of follicular units, hair transplants involved the use of much larger grafts often containing 5-8 hairs called plugs. This resulted in an utterly un-natural look. The discovery and implementation of follicular units resulted in a much more natural and undetectable appearance due to the ability to mimic natural hairlines. Surgeons can attempt to replicate nature by using only single-hair grafts in the hairline and temples. FUs also allowed surgeons to implant grafts closer together because they do not feature the amount of skin and surrounding tissue that plugs and multi-grafts exhibited. Natural hairlines consist of fine single-hair grafts in the hairline. The use of FU's can help replicate natural hairlines through the use of single-hair grafts into the hairline:

 

A natural hairline showing single hairs

 

An entirely man-made hairline using single-hair grafts:

*Work of Dr. Feriduni

 

A close up of the donor showing naturally occurring single, double and triple-hair follicles:

*Credit to Dr. Feriduni for the photo

 

Surgeons can attempt to replicate nature by using only single-hair grafts in the hairline and temples. FUs also allowed surgeons to implant grafts closer together because they do not feature the amount of skin and surrounding tissue that plugs and multi-grafts exhibited. The single hair-grafts can be used for the frontal hairline whilst the 2 and 3(and 4 at times) hair grafts can be used behind the hairline for more density.

 

Simplified graft placement protocol:

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Non-follicular units: Non-follicular units are hairs that are not naturally occurring in nature for example a bundle of 6 hairs or 8 hairs. This is an example of a transplant that used non-follicular units(often called mini-grafts or multi-grafts):

A result derived from the use of non-follicular units:

 

The use of follicular units in hair transplantation superseded the inferior use of non-follicular units(multi-grafts, mini-grafts and plugs) and became the new standard in hair restoration. The term "Follicular Unit Transplantation(FUT)" was created. At the time FUE was not invented so FUT and strip surgery became synonymous. However with the advent of FUE(which also uses follicular units), the exact terminology was mishandled as both strip surgery and FUE involve the use of follicular units.

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Modern methods of hair transplantation:

 

-FUE(Follicular Unit Extraction): FUE(Follicular Unit Extraction) revolves around the extraction of grafts one by one using a surgical punch, directly from the donor and implanting it into the recipient area. No scalpel, sutures or staples are needed for the extractions or closing of the small wounds as are small enough to heal themselves. FUE was developed after FUT but follows similar principles such as the utilization of DHT-resistant hair follicles and the use of follicular units. Tiny punctuate scars are the remnants of the extracted follicles

 

An illustration of the FUE method. The grafts are extracted via punch and implanted into the bald areas:

 

The FUE punching process:

 

FUE extraction via forceps(graft within yellow circle):

 

 

*Work of Dr. Devroye

 

 

For even more on FUE:

Click here

 

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-Strip Excision(commonly referred to as FUT): Strip excision involves the extraction of hair follicles via a strip of hair-bearing skin excised from the sides and rear of the donor area(scalp). Given that that area is generally immune to balding due to Male Pattern Baldness(MPB), that hair extracted from that area will generally last a lifetime. The hair-bearing strip is excised via scalpel, the resulting wound is closed via sutures or staples and the hair extracted from the strip is transplanted into the desired areas. A linear scar is the remnant of the excised strip. Strip excision is commonly but erroneously referred to as FUT(Follilcular Unit Transplantation). Follicular Unit Transplantation is a method involving the transplanting of grafts in their naturally occurring groups(1,2,3 and 4) and was an update of older methods that involved grafts of 5-8 units(un-natural). Strip excision and FUE both involve the use of follicular units and hence, they are subtypes of FUT.

 

An illustration of the strip excision/FUT method. The open wound is closed and the hair extracted is implanted into the bald areas:

 

Dissection of the strip to extract the grafts(done under strong magnification):

*Credit to Dr. Bernstein for the photo

 

 

The differences between the FUE and FUT have been outlined here:

Click here

 

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Donor Area:

 

-Donor area/Safe zone: The donor area used for harvesting grafts consists of the sides and rear of the human scalp. Those areas are general immune to thinning and can be transferred to balding and/or bald areas. Other areas of the body such as beard, chest, leg and back hair can also be harvested if additional grafts are needed or the scalp donor area is exhausted. The grafts are transferred rather than multiplied and hence, they are not of infinite quantity and must be used wisely.

 

Donor area(safe zone) shown here and accentuated in green:

*Credit to Dr. Mwamba for the photos

 

-Donor hair quantity/Expectations: This section is VERY important in realizing what can and can't be done with a HT. The average Caucasian individuals entire scalp contains are 50,000 FUs with an average density of 100FUs per cm2. A Norwood 6 or 7 has about 300 cm2 of bald area which means to restore him back to his original density you would need 30,000(area x average density per cm2) grafts from the donor. This is impossible as you would not be able to harvest 30,000FUs from the donor there simply is not enough and/or would look absolutely bizarre. The average male will generally have between 5,000-8,000 grafts that can be extracted from the donor(scalp) before complications in the aesthetic(thinning appearance of the donor) and/or functional(tightness in the scalp) traits arise. 7,000 grafts will not transform Bruce Willis into Elvis but with clever techniques it can give the illusion of density.

 

 

Donor eligibility : One of the most common questions that are asked on this forum and others is how good or bad a forum member's donor hair is. While one size does not fit all as factors such as density, caliber and texture can all affect what can be done via surgical hair restoration:

 

Poor donor area:

 

Average donor area:

 

Above average donor area:

 

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Implantation tools:

 

Choi/Lion Implanter: The Choi implanter was invented by Yung Chul Choi and has been in circulation since the early 90's. The Lion implanter is an implanter that Dr Lorenzo helped design, it differs from the Choi device in some ways. Both devices allows the surgeon to create an incision point and implant the graft simultaneously.

 

 

Advantages:

-Protects the graft and dermal papilla whilst making the incision and implanting. Avoids handling of the dermal papilla, overhandling of the dermal papilla can lead to a damaged graft.

-Keeps the grafts out of the body for less time as incision and implanting are done at once.

 

Disadvantages:

-The implanter resembles a needle which has a circumference much like a circle. If the implanter is .8mm, the is present all the way around. Unlike a blade which is only .8mm at its widest point and much thinner in length(akin to a rectangle). Hence the implanter is more invasive.

 

 

*Video of Dr Lorenzo using the Lion implanter for inserting grafts into the recipient.

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Custom cut flat blades: Custom cut blades allow for the surgeon to customize the blade for each situation and/or patient. Thinner blades are used for the single hair grafts in the hairline. The flat edge of the blade produces a very minimally invasive slit compared the the equivalent sized needle. The surgeon makes the recipient sites via the blade using lateral and/or sagittal slits(compared above) and once completed, the techs place the grafts into the sites.

 

 

Intra-operative photo showing the recipient incisions for the grafts to be placed via custom cut blades:

*Work of Dr. Feriduni

 

www.youtube.com/watch?v=xATdgg7anoU

*Dr. Hasson explaining the device he invented for customizing blade size and demonstrates recipient incisions via blades

 

*Graft placement after slits have been made via custom-cut blades. Work of Dr. Hasson

 

I will be elaborating on the Choi implanter and the custom cut flat blades soon.

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What is achievable:

 

-The illusion of fullness/density: The illusion of density operates on the notion that you only need circa 50% of the patient's original density to trigger the optical illusion. If the average non-balding Caucasian has 100FU per cm2 you only need 50FU per cm2 in the balding areas to give off an effect of fullness. This is especially paramount in the hairline but it can taper down as it progresses to the mid scalp and crown.

The shingling effect illustrated shows fewer open spaces then a random pattern:

 

-Lateral/Sagittal slit technique: The difference between Lateral(or coronal) and Sagittal slit techniques are best understood via this photo:

 

Lateral(CAG) and Sagittal(SAG) slits, side by side

*Credit to Dr. Ron Shapiro and Dr. Paul Shapiro for the photo

 

Lateral Slit: Lateral(or coronal/horizontal) slits change the orientation the hairs within the follicular unit which can give better coverage when viewed front on. If you have a 3 hair graft with all three hairs standing side by side instead of in a line(front to back), you have basically tripled your coverage. Now imagine that same effect with thousands of grafts. Single-hair follicles do not benefit from that advantage however. It also allows for better direction and angle as you can implant at much flatter angles by using lateral slits. The incisions also tend to be more parallel to the scalp less invasive to the scalp’s underlying vascular structure. This parallel alignment also allows more grafts per square centimeter without the grafts compressing or popping up since the pressure exerted on the grafts does not push them upward from the scalp. The lateral slit was invented by Dr. Wong

An example of the coverage advantage that lateral slits and graft orientation can allow:

*Credit to Dr. Ron Shapiro and Dr. Paul Shapiro for the photo

Sagittal slit: Sagittal slits are more precise when mimicking changes of direction and cowlicks

 

 

Clever layering, angles and other trickery can give the illusion of density and coverage:

*Credit to Dr Lorenzo for the photo

 

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How many grafts will I need?: The quantity of grafts that you will require for an acceptable impression of density and coverage can depend on many things such as level of loss,hair caliber, hair color, color of your scalp, donor density etc. Different surgeons might recommend different numbers. Here is a vague and general guideline:

 

Norwood 1: 800 - 1,000 grafts

Norwood 2: 1,000 - 2,000 grafts

Norwood 3: 2,000 - 3,000 grafts

Norwood 4: 3,000 - 4,000 grafts

Norwood 5: 4,000 - 5000 grafts

Norwood 6: 5,000 - 6,000 grafts

Norwood 7:6,000 - 8,000 grafts

Alternatively, you can use the graft calculator developed by this very forum:

Hair Transplant Calculator

 

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Factors and Limitations:

Age: The older the patient, the more likely the loss has stabilized and the surgeon can better evaluate a strategy. The younger a patient the more uncertain what the level of loss can be and can lead to a depleted donor if a conservative strategy is not used.

Norwood level: The higher the Norwood, the more grafts needed. This ties in with the age and donor density(and laxity if FUT is chosen) factors.

-Donor density: The denser your donor area is, the more hair can be transplanted. That part is simple enough.

-Hair strand cailber: The thicker the actual hair itself is, the more area it can 'fill' visually and the better the illusion.

-Hair/scalp color: If the patient has a dark color scalp and black hair, the illusion of density will be more impressive compared to a light-skinned scalp and dark-haired patient.

-Donor laxity(Strip Excision only): Donor laxity can inhibit the width of a strip in strip excision(aka FUT) and if the patient has a tight donor then the amount of grafts that can be harvested more limited in number.

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Growth timeline: After the procedure, the grafts will shed on the lonesome or after softly massaging the scalp under water(depending on your surgeons instructions) and the grafts will go into their dormant cycle. It is unknown why a hair transplant triggers the recipient grafts to have their cycle reset. After about 3 months some grafts will become present and growth should blossom shortly after that. Here is a basic idea of the timeline of growth:

 

3 months - 10%

4 months - 25%

5 months - 40%

6 months - 60%

7 months - 70%

8 months - 75%

9 months - 80%

10 months - 90%

11 months - 95%

12 months - 98%

18 months - 100%

 

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The "Ugly Duckling" stage:[/b ]After a procedure, the recipient area can stay red for a few months as the surgeon has used very tiny but sharp blades to make 100s or 1,000s of recipient sites. Small pimples might occur in the recipient and/or donor area. Temporary shockloss may occur in the recipient and/or donor area. These events and period are named the "ugly duckling" phase. It is usually a time where things look worse than pre-operative but they do diminish and then disappear. These factors will be gone through in more detail very soon.

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Work in progress....Constantly making additions and alterations...

Edited July 28, 2013 by Mickey85

[Mickey85]

Post left intentionally empty for future updates

[TommyLucchese]

I've been looking into it for years, on here hardcore for a year and 5 months, 9 months post op ........... yet I still found this very interesting. Please keep going Mickey!

 

Rather curious about what is to follow about the poor donor part etc

[Mickey85]

I've been looking into it for years, on here hardcore for a year and 5 months, 9 months post op ........... yet I still found this very interesting. Please keep going Mickey!

 

Rather curious about what is to follow about the poor donor part etc

 

Hey there my friend I will be posting examples of average donor density, above average and possibly exceptional donor density. After that it's basically whatever I can come up with. I might go into potential complications like shockloss cause I get a few questions on that. I get alot of questions via private mail which gave me the idea to basically make a thread revolving around the questions asked and of course venturing into other areas that people may have concerns with. My other two threads are basically 90% wrapped up so this thread will be receiving the bulk of my attention

Edited May 3, 2013 by Mickey85

[TommyLucchese]

One could say I haven't researched too diligently if I'm finding the basics interesting ha! Keep it up though champ......and expect a mail from me soon

[Mickey85]

Hehehe thanks for the kind words Tommy Hope you have been well.

[Mickey85]

Feel free to give suggestions as to what you guys want to see on here or just feedback in general.

[james84]

I like it, plain and simple and informative. I was honestly thinking about this the other day, why some threads could seem quite complicated for new comers and even veterans. How about creating a hair loss for dummies book?? Like the ones you buy when you learn a new language or skill:D

[KO]

What is the time gap between FUE HT's? I'm wondering if in case you wanted to do 5k grafts, can it be broken up over multiple surgeries say every 2 mos?

[Jotronic]

Photos of donor hair can be deceptive. Case in point...

 

 

Most people would say this guy has a strong donor zone as you indicated whereas I see a guy that has strong quality hair but potentially low donor density. I've seen this misinterpretation many times.

 

I also think that chart talking about how many grafts one will need is way off. I mean, why would a NW1 need anything at all but the chart says 800 to 1000 grafts. What is a NW1 aspiring to?

[Blake Bloxham]

Mickey,

 

As usual, great work!

 

My only suggestion would be changing some wording in the "methods of hair transplant surgery" section. While the terms "FUT" and "FUE" are commonly used to describe two different types of hair transplant surgery, they are actually two subtypes of the same procedure: Follicular Unit Hair Transplantation. This means that "FUT" is technically called "Follicular Unit Hair Transplantation via Strip Excision" and "FUE" is "Follicular Unit Hair Transplantation via Follicular Unit Extraction."

 

Granted, the terms "FUE" and "FUT" are well understood by patients, but just because you're writing such an excellent overview, you may want to throw that in there.

 

Again, great work!

[james84]

Photos of donor hair can be deceptive. Case in point...

 

 

Most people would say this guy has a strong donor zone as you indicated whereas I see a guy that has strong quality hair but potentially low donor density. I've seen this misinterpretation many times.

 

I also think that chart talking about how many grafts one will need is way off. I mean, why would a NW1 need anything at all but the chart says 800 to 1000 grafts. What is a NW1 aspiring to?

 

Jotronic why do you think this patient potentially has low donor density? Or are you just making a point that nothing is clear until a patient has a face to face consultation in regards to finding out donor density?

 

The reason i ask, is to my untrained eye it seems like a strong donor so would like to know if i am missing something:confused:

[Jotronic]

James,

 

Both actually. You cannot really tell the density until you lift the hair and see the hairs exiting the scalp. I can but I'm just damned good at what I do:) I happen to know who this patient is, not just professionally but personally as well. The donor density is not above average but not below average, at least that is the way it was the last time I saw him.

[james84]

Jotronic thank you for clearing that up, so would you say it is better for potential patients who may live in other countries to send Docs videos of their hair instead of pics to give the patient and Doc a better idea of the donor?

[Jotronic]

Video is always better but most of the time a photo of the donor area with the hair flipped up is sufficient. Here is an example that we have on our online consultation page...

 

[Questionmark]

Jotronic,

 

I think Mickey was referring to the donor quality, not only the donor density. Isn`t the quality determined by the density combined with hair characteristics such as caliber etc.? So while this gentleman may have an average count of grafts/area, imho he although has an above average donor due to his hair characteristics.

 

Anyway, I think this is only to help absolute newbies to estimate roughly which donor quality they have, and I think the picture is more than adequate to this purpose.

[Jotronic]

QM,

 

Donor density is a more important part of the same equation. Donor hair caliber is certainly important but without density you have nothing. Regardless, if he is talking about donor hair quality and not donor density then there is no distinction between the quality of the hair he has listed as "average" vs. "above average".

[Questionmark]

So has the guy listed as "average" a better donor than the one listed as "above average"? Or do you think Mickey should take another picture? Anyway, I think I get your point, but as I said, this thread is not about knowing if he has got a worse quality/density than it may appear, but to help newbies out a bit. For those, the picture is quite significant. Hope you get my point, too, cheers!

[Jotronic]

So has the guy listed as "average" a better donor than the one listed as "above average"?

 

Well, I guess that depends on what we're talking about, lol! In my opinion, the "average" donor area guy does not represent the average donor in that he is a hybrid NW6/ NW7. His parietal humps are closer to a NW6 but his crown, the way it drops down, is like that of a NW7. Regarding his density, it appears to be average and his hair texture seems slightly coarse.

 

I know what you are saying, QM but I think it is important to point out that just because a donor zone may appear to be good or very good at first glance does not necessarily mean it is. To answer your question, is the "average" guy's donor zone better than the "above average" guy? The answer is "maybe".

[Mickey85]

 

I also think that chart talking about how many grafts one will need is way off. I mean, why would a NW1 need anything at all but the chart says 800 to 1000 grafts. What is a NW1 aspiring to?

 

Really Joe?? Really? If you are going to talk the talk at least walk the walk. Talk about contradiction:

 

Classic NW1. Not only did he have very little loss. Instead of 800-1000 grafts, Dr Hasson (Joe's employer) transplanted 1,999 grafts!! Is something a miss? I guess you could say I am way off as you guys felt content to implant 999 more grafts than my estimation.

 

As for the donor density. 99% of clinics on this forum use photos to determine how good the donor is. Are they wrong? Photos can be deceptive yes but it is a common standard used in the industry. Either most clinics are wrong or they are right. This is a basic guide. I strongly believe that patient has an above average donor. Comparing it to the average donor case makes it abundantly clear.

 

So about that NW1 that H&W implanted 1,999 grafts on?

[KO]

I think Joe has a point. There is a distinction between "hair caliber" and "hair density", there are many guys, especially white men with fine blond/light brown hair who have good density, but the hair calibre is thin, on the other hand there are people of east asian descent who have thick caliber hair, but low density.

 

That being said, I agree with your point, I think that thick hair caliber is more important than the actual density, assuming you could pick one.

[socates123]

Good and informative. Was wondering about how to combine the science and the art together - some people maybe discouraged because they have high calibre hair but low density like asians for example.

[HARIRI]

Great JOB Mickey85. You should start your own website. Your topics and valuable information has opened our eyes on FUE and its potential if done by a great Doctor. How I wish I knew about it before

[Mickey85]

Thanks again for all the kind words Hariri. I made all these threads to prevent people going through what we went through I should have some nice surprises for the fue threads in next few weeks

[Mickey85]

Good and informative. Was wondering about how to combine the science and the art together - some people maybe discouraged because they have high calibre hair but low density like asians for example.

 

That gives me an idea actually. Stay tuned.