Overview of Hair Transplantation
Hair loss is a common problem. Around 67% of men and 24% of women are affected by it. There are many non-surgical treatments like minoxidil, finasteride, dutasteride, low-level laser light therapy, a treatment using your own blood called platelet-rich plasma, adenosine, and ketoconazole which can help slow down hair loss and even promote new hair growth. Hair transplant is a preferred surgical method for people who have certain types of hair loss and want to restore their hair. This procedure can help them get more natural and thicker looking hair.
The most common reason people lose hair is something called androgenic alopecia. You might also hear it called male pattern hair loss (MPHL) for men, and female pattern hair loss (FPHL) for women. People with this condition have smaller hair follicles in certain areas of their scalp. People with this stable condition who have enough hair elsewhere on their head make good candidates for hair transplant.
It’s fairly simple to tell if someone has androgenic alopecia. Doctors look for particular patterns of hair loss, smaller and lighter-colored hair, and no signs of swelling or redness. If they don’t see these signs, more tests might be needed. For men, the Norwood system is used to describe the patterns of hair loss, and for women, the Ludwig system is used. In women, androgenic alopecia usually doesn’t affect the hairline, but causes the top and upper sides of the head to thin.
During a hair transplant, medical professionals move hair that’s resistant to the effects of androgens, the hormones that cause hair loss, from the back of the head to the areas affected by hair loss. There are mainly two ways to get the hair from the donor: hair follicular unit strip surgery (FUSS) and follicular unit extraction (FUE). Follicular unit extraction is often better for younger men and those who like short hair since it doesn’t leave a noticeable scar. Because the hairs at the back of the head are resistant to androgens, they keep their thickness and other properties after they’re moved.
Anatomy and Physiology of Hair Transplantation
The scalp is made up of five layers starting from the outermost to the innermost layer: the skin, connective tissue under the skin, a tough layer called the galea aponeurosis, a loosely attached connective tissue, and finally, a layer covering the skull known as the periosteum. The skin and the tissue beneath it house the hair follicles, which are the tiny sacs from which hair grows. These two layers can thin out in people with hair loss, also known as alopecia. The tissue under the skin has a lot of blood vessels, and during hair transplants, care is taken not to damage this layer to avoid disrupting the blood flow.
Let’s talk about the hair follicle a bit more. Each hair follicle consists of a hair shaft (the part that you can see), inner and outer surrounding layers, and a part at the bottom known as the germinative bulb. This bulb contains three crucial elements – the hair matrix that forms the hair shaft, the dermal papilla that controls hair growth, and melanocytes that give your hair its color.
The hair follicle can be divided into three sections. The first one starts at the skin’s surface and goes down to where an oil gland opens up into the hair follicle. The second section starts from this opening and extends to the area where a tiny muscle is attached to the hair follicle. Lastly, the lower section extends from this muscle attachment site downwards to the base of the follicle.
A follicular unit or FU is a group of 1 to 4 hairs along with its oil gland, duct, and muscle naturally dispersed throughout the scalp. This unit is surrounded by a band of collagen, a protein that provides structure to the skin. Transplanting these units is the best way to achieve a natural-looking result after a hair transplant.
Our hair grows in cycles: the growing phase (anagen) lasts 2 to 6 years; a short, transitional phase (catagen) lasts 2 to 3 weeks; a resting phase (telogen) that lasts 2 to 3 months, and a shedding phase (exogen) where older hairs fall out and are replaced by new ones.
In hair transplantation, hair is taken from a site that isn’t affected by hair loss – known as a donor site – and is used for implantation. Usually, this site is at the back of the head. In general, the donor site has around 65 to 85 FUs per square centimeter. The hairs at the lower part of the donor site tend to be softer than those in the upper part. The availability of hair from the donor site limits the extent of the transplantation. Over-harvesting of hairs can lead to thinning in the donor site. If necessary, other areas such as the sides of the scalp, under the chin, the chest, and other body parts may also be used as donor sites.
Androgenic alopecia is the most common type of hair loss. In this condition, certain hormones, namely testosterone and dihydrotestosterone (DHT), disrupt the hair growth cycle, leading to a decrease in the number of growing hairs relative to the number of resting hairs. Testosterone is converted to DHT by an enzyme called 5-alpha reductase in the bloodstream and the scalp. DHT interacts with susceptible hair follicles, causing them to shrink. Over time, thick, pigmented hair on the top of the scalp, beard, underarms, and pubic regions start thinning and eventually convert into short, fine, light-colored hair. The hair on the sides and the back of the scalp is typically unaffected as they are not sensitive to these hormones.
Why do People Need Hair Transplantation
Hair transplant surgery might be a good option for you if you’re generally healthy, have a healthy scalp, and have a good amount of hair in areas of your head where hair can be taken and used as a donor. Also, it’s important for you to have realistic expectations of what the surgery can achieve.
People commonly have hair transplants due to hair loss patterns. For men, those with a Norwood stage between III and V might be suitable candidates, while for women, Ludwig stage II could indicate a need for the procedure. Essentially, these stages reflect the severity of hair loss.
A condition called traction alopecia, which refers to hair loss caused by tight hairstyles, might also justify a hair transplant. Similar reasons include frontal fibrosing alopecia and lichen planopilaris – both uncommon skin conditions that can result in hair loss. Another reason is folliculitis decalvans, a rare disease that causes hair loss and scarring.
Hair transplants could also be undertaken by transgender patients seeking to have pubic, facial, and body hair placed in particular ways, or by people who have experienced facial trauma or burns which have resulted in the loss of eyebrows, beards or sideburns.
However, some conditions may prevent you from having a hair transplant. If you have frontal fibrosing alopecia, lichen planopilaris, and folliculitis decalvans and they are in the active stage, these conditions are contraindications to hair transplants. This means that you should not have the procedure until the disease is no longer active. In the case of folliculitis decalvans, you would need to be free of active disease for several years before a hair transplant is considered.
When a Person Should Avoid Hair Transplantation
If you are considering a hair transplant, your doctor will need to conduct a detailed assessment of your medical history and physical condition. Here are some of the things your doctor will look out for:
* History of Hair loss and associated symptoms
* Fever, itchiness, flaky skin, redness, or rashes may hint at an inflammatory condition.
* Your overall health history
* Conditions like skin issues, thyroid disease, diabetes, metabolic syndrome, auto-immune disorders, infections, malnutrition, deficiency in vitamins and minerals, childbirth, tendency to form scars, history of chemotherapy, and exposure to radiation can all potentially impact your hair transplant results.
* Medications
* Certain medications like propranolol, coumadin, and amphetamines can affect hair growth. Stopping blood thinning and clot preventing medications before the transplant can reduce the risk of bleeding.
* Mental health history
* Conditions like stress, anxiety, eating disorders, compulsive hair-pulling (trichotillomania), emotional trauma, and body dysmorphia can all increase the risk of dissatisfaction.
During a physical examination, the doctor will look for localized, scarring or inflammatory hair loss which might hint at a cause for hair loss other than male-pattern baldness. A positive hair pull test may also suggest a different cause for your hair loss.
Here are some conditions where a hair transplant may not be advisable or might lead to complications:
* Diffuse Unpatterned Alopecia
* This is when a person’s entire scalp is affected by hair loss. The hair for transplant is usually taken from a non-affected area. If this entire region is affected, a transplant wouldn’t be successful.
* Cicatricial Alopecias
* These are inflammatory conditions that destroy hair follicles, leading to scarring and permanent hair loss. If the condition is active, a transplant wouldn’t be advisable as it can make the disease worse and has a high chance of failure. However, if the disease has been inactive for two years, a transplant can be considered with the understanding that results may not be optimal.
* Alopecia Areata
* This is an autoimmune condition that affects the hair follicles. After two years of no active disease, a transplant could be considered – although results may not be as expected and disease recurrence is possible.
* Patients with Rapid Hair Loss
* For those who are rapidly losing hair or have a high rate of miniaturization in the transplant area, it’s advisable to stabilize the hair loss with medical treatments before considering a transplant.
* Patients with Minor Hair Loss
* At least 50% of hair must be lost before it becomes noticeable. Hence a transplant is only recommended after this stage. If hair loss is less than 50%, medical treatments should be the first step.
* Young Patients
* Young patients who develop male-pattern hair loss often lose hair rapidly. Performing a transplant too early may not provide optimal long-term results, and it’s usually advised to delay the transplant and opt for medical treatments for at least a year.
* Patients with Unrealistic Expectations
* Patients should be aware that a transplant cannot completely restore hair to the pre-balding abundance. Some scalp will still be visible and scarring is inevitable. The goal is to create the illusion of density.
* Patients with Body Dysmorphic Disorder
* Those with Body Dysmorphic Disorder may be unhappy with the results. This disorder makes patients focus on minor or even imagined defects.
Given these factors, your doctor will also take into account specific health conditions that might complicate a hair transplant such smoking, diabetes leading to damage in small blood vessels, advanced balding, hypertension, and advanced sun damage to the scalp.
Equipment used for Hair Transplantation
For a medical procedure, the surgical room, also known as the operating room (OR), should be large, at least 3.6 x 3.6 meters (m) square with a height of 3.0 m. There’s also a need for another room of equal size for dissection, or a larger room of 6 x 3.6 m. The OR must have a door wider than 0.6 m to accommodate a stretcher in case of emergencies.
The room should be well-lit, using fluorescent lamps at a rate of 1 watt per 0.09 m². It’s essential to have an autoclave or chemical method to sterilize instruments, making sure that all tools are clean and germ-free before any procedure. Monitoring tools like a blood pressure monitor, stethoscope, pulse oximeter, glucometer, digital thermometer, and weighing scale are needed also to assess a patient’s vital signs.
Local anesthesia (numbing medication) is used to relieve pain in targeted areas of the body. Lignocaine, bupivacaine, and levobupivacaine are different types of anesthesia that can be used either alone or combined with epinephrine, a medication that helps by extending the effects of anesthesia and controlling bleeding.
The OR setup also includes items like comfortable chairs and tables, microscopes with magnification for detailed views of tissues, skin retractors, and specific devices for hair transplant procedures. The skin might be closed with sutures or staples if needed, and is then dressed with a non-adhesive bandage and ointment.
In case of an emergency, there’s a need for various medical supplies. These include tools for intravenous (IV) access (for administering fluids and medications directly into the bloodstream), airway management tools like laryngoscope, endotracheal tubes, and oxygen cylinders. Injectible medications – ranging from adrenaline (for severe allergic reactions), furosemide (for fluid build-up), metoclopramide (to prevent nausea/vomiting) to diazepam (for anxiety/seizures), and others will also be on hand. Intravenous fluids like 5% dextrose infusion and normal saline are also important to maintain hydration and balance of body fluids.
Who is needed to perform Hair Transplantation?
Modern hair transplant procedures need a few key people:
* A Surgeon
* The surgeon is like the manager of the operation. He or she decides where your new hairline will be, takes the hair grafts (small pieces of skin with hair) from the donor area (part of your body where these grafts are taken from), and closely watches over the process to ensure that everything is going smoothly.
* Hair Technicians
* Depending on the specific hair transplant method used, the complexity of the operation, and the number of hair grafts needed, you may have between 1 to 4 technicians involved. These are like the surgeon’s helpers, following his or her directions closely.
* A Nurse
* A nurse is also part of the team, providing assistance where needed.
* A Surgical Scrub Technician
* A surgical scrub tech helps prepare the surgical area and maintains cleanliness during the operation.
It’s important for at least one person on the surgical team, whether it’s an assistant or technician, to be trained in basic life support and advanced cardiac life support. This is an important safety measure to be prepared for any medical emergencies that might come up during the procedure.
Preparing for Hair Transplantation
When it comes to having a successful hair transplant, there are a number of factors to consider. Firstly, patients with thicker hair have an advantage because they can provide more coverage on the scalp than those with thin hair. If you’ve got more than 80 hair follicles per square centimeter on your head, you’re an excellent candidate for a hair transplant. However, if the number is less than 40 follicles per square centimeter, your results may not be as successful, which is something your doctor will discuss with you beforehand.
If you’re wanting to fix baldness at the front of your head, you can expect some really visible changes. Avoiding grafting only the topmost part of your scalp is better, as this can eat up potential future grafts and may also lead to an unnatural looking “doughnut” appearance. Placing grafts in the front of the scalp can provide long-term density and reduce any unsightly results. Also, remember that creating a new hairline should be done conservatively for a natural look.
People with lighter skin and hair color are preferable for hair transplants because the contrast between hair and skin is less noticeable. However, with the right techniques, dark-haired patients can also have successful transplants. Keep in mind that achieving the desired results may take more than one hair transplant session.
Before the procedure, your doctor might run numerous tests to ensure your safety and suitability. These may include checking your blood count, clotting time, and even certain hormone levels. Furthermore, if you have diabetes, your doctor will check your blood sugar levels.
Here are some instructions to remember before the surgery:
1. Stop using minoxidil 1 week prior.
2. Avoid alcohol the week before and after the procedure.
3. Try to quit smoking before the surgery for best results.
4. You might be given medicine to calm your nerves if you’re anxious.
5. Stop taking anti-inflammatory medicine 12 to 24 hours before surgery.
6. Continue taking blood pressure medicine except beta-blockers on the day of surgery.
7. Avoid vitamin supplements and herbal preparations 3 weeks before surgery.
8. Management of blood-thinning medications depends on individual risks and benefits.
9. Cleanse thoroughly with soap or a special shampoo the night before and on the morning of surgery.
On the day of surgery, you might receive a steroid treatment to help with swelling, and antibiotics to prevent infection. The surgeon will mark the areas for hair transplantation, and anesthesia will be applied.
Aftercare includes sleeping with your head elevated to reduce swelling, avoiding heavy lifting and strenuous activity for a week, and placing ice on your forehead for the first few days. You’ll also be advised to wash your scalp regularly with normal saline and baby shampoo.
How is Hair Transplantation performed
Doctors used to treat hair loss caused by hormonal changes, also known as androgenic alopecia, with a variety of methods including plug grafts, scalp reductions, and transposition flaps. But now, 99% of hair loss treatments involve a process called hair transplantation.
Hair transplantation can involve one of two methods: Follicular Unit Strip Surgery (FUSS) or Follicular Unit Excision (FUE). Nowadays, FUE is more common and it comes with several advantages over FUSS. These advantages include: more available grafts i.e., sections of hair, less noticeable scarring, less post-surgery pain, quicker recovery time, and the ability to choose specific hair follicles for transplantation. Moreover, with FUE, doctors can pick hair from places other than the typical place (called “the donor site”), like the sides of the head or even the chest, back, beard, or pubic area.
Yet, there are several reasons why FUSS may still be a better option than FUE for some patients. FUSS surgery can be quicker, cause fewer damaged follicles, result in less bleeding, provide a large amount of grafts from a single strip, and lead to a denser hair appearance. Even so, it’s still debated which surgery is better. While FUE usually takes longer than FUSS, the use of automated machines and robotic technology in FUE can make the process as quick.
FUSS involves cutting a strip of skin from the back of the head, which is then split into tiny hair grafts. The doctor closes the wound with sutures or staples. On the other hand, FUE involves removing individual hair follicles from various areas of the scalp. These follicles are then replanted in the target area. After the removal of follicles, a local anesthetic is used for pain relief.
Regardless of the method used to harvest hair, careful positioning and handling of the follicles is crucial during implantation. The dermatologist creates sites for the grafts to be placed. The scalp is prepared under a microscope, using surgical blades or needles. The grafts are then placed gently into these sites. Ensuring the correct angle and orientation of these grafts is key to achieving a natural-looking result. This means paying close attention to the natural patterns of the patient’s original hair.
More recently, robotic devices have been introduced to perform the task of harvesting and implanting hair follicles. These devices offer precision, speed, and accuracy, leading to improved outcomes for hair transplantation procedures. However, more studies are needed to compare these robotic devices with traditional methods.
Possible Complications of Hair Transplantation
The scalp is known for its strong blood supply, which allows it to heal quickly and helps avoid infections. However, there might be some complications after scalp surgery:
- Swelling (edema);
- Pain;
- Bleeding;
- Folliculitis (inflammation of hair follicles);
- Allergic reactions to the anesthetic, lignocaine;
- Too much lignocaine in your system;
- Scalp cellulitis (a skin infection);
- Temporary or lasting scalp numbness;
- Telogen effluvium (a condition causing hair to fall out);
- Epidermal cysts and ingrown hair; and
- Infection.
Telogen effluvium is a less common, but potentially worrying, complication. This is when a person’s own hair starts to fall out from the area that donated or received hair. This hair loss, which is likely due to the stress and small injuries caused by the hair transplant, doesn’t last forever. Patients should be reassured that most of the lost hair typically grows back in three to four months. Sensation in the front area of the scalp can decrease for several weeks after creating many new locations for hair grafts along the hairline.
Epidermal cysts and ingrown hair are usually harmless, but in rare cases, they might trigger a widespread inflammatory response that affects all the newly grafted hairs. If hairs get trapped, releasing them can help speed up recovery.
What Else Should I Know About Hair Transplantation?
Alopecia, or hair loss, can greatly affect a person’s self-esteem and may even lead to them avoiding social situations. Many people who are experiencing hair loss because of age, trauma, burns, or changes related to their gender identity can greatly benefit from a procedure called hair transplantation. This procedure can help individuals regain a younger look, restore facial hair that may have been lost, or aid in creating the hair appearance they desire.
When a person decides to undergo hair transplantation, it is very important for the doctor to properly assess them and create a detailed plan for their treatment. By doing this, the doctor can ensure that the procedure is done in the most safe and reliable manner, leading to successful results that the patient will be satisfied with.
