The basics of hair transplantation remain the same no matter which graft is utilized. Here, I will try and explain the basics and also illustrate the various most common techniques used. The concept of donor dominance is to be understood before we go ahead and talk about the basics.
Figure 1. Different areas in the recipient area.
The scalp can be divided into two areas. The first is the area that is more susceptible to balding and the other area is the one that is not. The horseshoe fringe area that is usually left behind on a bald mans scalp is the area from which hair can be easily and safely donated. When hair from this area is used, it will not be susceptible to balding, even when it is transplanted on to the area, which is right in the middle of the bald scalp. The new hair that is transplanted retains the exact same characteristics as the hair that is left behind on the donor area no matter where it is going to be implanted. This is what donor dominance is.
Figure 2. Transplants were originally performed by removing 4 mm plugs from the shaved donor area and then transferring them into 4 mm holes in the recipient area.
This hair can be harvested in multiple ways. Earlier, hair was removed in plugs of 4mm, which is roughly the size of a pencil eraser. A few plugs were removed and the area from where it was removed was allowed to heal by itself. Even though there was some distress from the areas where the hair was removed from due to an open wound, the areas healed well eventually. The only problem was that a cobblestone pattern was left behind, which was rectified when plugs started being taken own in rows to ensure that the edges would be sown together eventually.
This gave birth to the idea of excising tissues instead of plugs. This enabled suturing the open area more easily. Once the grafts that were being transplanted became smaller, multi bladed scalpels came into the picture. Just a single pass of a multi bladed scalpel, multiple thin strips were produced that helped in facilitating quick dissection of grafts. However, since follicular unit transplantation has come in to the picture, physicians will excise the strip only using a single scalpel to minimize transactions of the follicular units. The transaction rate with multi bladed scalpel tends to be very high, which often tends to lead to reduced hair growth of hair that is transplanted.
Figure 3. Hair transplants are now performed by excising a strip from the donor area, suturing the open area shut, dissecting the strip into small grafts, and then transferring them into small holes in the recipient area
When considering the recipient area, earlier, the 4mm plugs that were removed from the donor area were implanted onto the balding area, which is the front of the scalp. While this gave some volume to the thinning hair, there was a feeling of ‘pluginess’ which constantly reminded one that the hair which was there earlier had disappeared. These grafts were downsized eventually to a quarter of 4mm plugs and then to mini grafts.Minigrafts are basically small plugs of hair that contain about 3 – 10 hairs each. These are created by cutting excised strips into smaller sizes without them being magnified and without any attention to follicular units. This may reduce the plugginess to a certain extent but the problem still exists. What happens is, that there are many more smaller plugs as apposed to less larger plugs. Micrografts were actually introduced to hide the plugginess in the hairline. Micrografts are basically one or two hairs that have been dissectedwithout magnification and have paid no attention to follicular units. These are great as they help to disguise the artificialness of hairlines that are caused as a product of minigraft.
Figure 4. Close up of shaved scalp showing the individual follicular units as bundles of 1 to 4 hairs.
The next major milestone in hair transplant was follicular unit transplantation. Here, the follicular unit is the natural unit of hair that grows on the scalp. If the scalp was shaved and magnified, you would note that there are 1 – 4 hair groupings that exit from the scalp through single points.Each individual unit has a single root. The dissection as done underneath a microscope of individual units that is followed by the implantation of single follicular units onto the balding area is known as Follicular unit transplantation. While dissecting the 1 – 4 hair grafts, care should be taken that the root systems are not disturbed. To ensure that the visualization is adequate and hence are microscope is used to prevent transection of the root system. Since these hair grafts are picked and transplanted individually, the plugginess will not be there.
Physicians have to ensure that the top or front of the scalp, which is the recipient area is ready to accept these grafts. The recipient site for 4mm plug ins was typically a similar sized hole made with a punch. A punch is typically a cookie cutter type knife, which is circular and small and makes holes in the skin. For minigrafts, the recipient site is prepared with the help of scalpel blade incisions punches of 1.5 – 2.0 mm. Laser technology has also been used to quiet an extent to prepare recipient sites for minigrafts, while the advantage was miniscule, the cost was a lot. For follicular units tiny needles are inserted into the scalp to create tiny holes. Implanting these grafts is the most difficult step of the procedure. The reason is that the grafts are really small and they have to be gently inserted with the help of forceps, which requires much skill. If the tissue is traumatized in the process, during the process of the grafts being grasped and inserted, poor growth is risked.A planter with patience, good hands, perfectionism and gentles is important.
The process of hair transplantation is not very painful as most physicians will anesthesize the area or will have their patient take drugs like Xanax or Valium that will help them relax. Intravenous medicines are not the best idea, while the pain may be less, as the patient is asleep, there is a higher level of risk involved.It may lead to the patient to stop breathing himself and special monitoring equipment would then be required. I would not want my patients to be subjected to the risk, when other medicines are available that can relax them as much. A good surgeon with gentle hands can do wonders without too much pain to the patient.
A number of agents can be topically applied to the skin as well before the injections to reduce the sensation that is caused by the needles. Tumescent anesthesia and nerve blocks are injection techniques that facilitate patient comfort. In tumescent anesthesia, dilute anesthetics are injected deep into the fatty tissue first. The fatty tissue experience less pain as compared to the skin. Once the portion is numbed, the skin injections are not as painful. Nerve blocks are basically anesthetic injections that are pierced at the base of one’s nerves that service the front of the scalp region. These are just above the eyebrow. Once the basis are numbed, the procedure for the frontal scalp is absolutely painless.The only reason that injections hurt is because the anesthetic is pushed in to the skin too rapidly, simply because the person performing the injection is uncompassionate or impatient.
I have had a number of patients say that if they knew how easy the procedure was, they would have done it much earlier. However, if the surgeon is not an expert, the procedure could hurt.
Today, with follicular grafts and mini grafts becoming common, the process of hair transplantation is not just the work of a surgeon. A lot of time and effort is required to prepare and implant the grafts, for which more people are needed. Only small follicular unit transplants will be able to be organized if a surgeon were working alone. In most cases a surgeon wouldbe involved in planning the procedure, he will perform the excision and repair, and then he would supervise a team of technicians who would dissect the grafts and implant them. Over here, a typical follicular transplantation would take about 4 – 6 sessions and I would need at least four skilled technicians to perform the transplantation, two to dissect and two to plant. The patient is relaxing in a reclining position during most part of the procedure. The patients usually spend their time by napping, chatting with the staff or watch movies and listen to music.
No bandaging is required after the transplant is complete. Only if the patient is oozing a little from the donor area, then a bandage will be applied like a headband for many hours. Patients cover their head with a cap when they are done with the procedure. It takes about ten days after the procedure is complete to remove the sutures or staples from the donor area. There will be no sutures in the recipient area.
The hair shafts that have been transplanted will fall off in the first month after the surgery. The root system will however remain, just like it has been plucked. New hair will start growing in about 3 – 5 months. This hair will now grow normally and will not be susceptible to male pattern baldness. The hair implanted may start thinning when the patient becomes 7- or 8- years old, but this condition is common and is known as senile alopecia and here, the hair all over the scalp begins to disappear. The new hair is otherwise permanent. The hair that has been transplanted will be a little coarse and kinky in the first year after transplant, but it will become normal like the hair in the donor area. When it grows, one has to ensure to cut it more frequently as compared to the surrounding preexisting miniaturized hair. The hair can be styled or colored depending on what the person wants. If a patient wishes to undergo another transplant, it is advisable that they wait for at least six months, to learn how the new hair looks and only then will I conduct a new procedure, an maybe transplant between the previous grafts as well.