Hair Transplant Surgery is a very broad term that generally refers to all hair restoration techniques utilized by man to treat hair loss, from the past up to the present. Looking back in hair transplant’s history, one may find that there were already several hair transplant surgeries formulated by experts to end hair loss problems. These techniques include the mini-micro grafting (which was the popular procedure ten to twenty years ago), and up to the modern hair surgery that is utilized today called as – Follicular Unit Transplantation.
Among the various hair transplant surgical techniques available over the past decades, modern hair transplant facilities have already generally disregarded the use of obsolete hair transplant methods, such as mini-micro grafting and embraced the more advanced features of follicular unit transplantation. FUT is now considered as the gold standard hair transplant surgery.
As described on the Hair Transplant History Section, Dr. Robert Bernstein established Follicular Unit Transplantation or FUT, with the assistance of other hair experts last 1995. Since the conception of this idea, the popularity of FUT became increasingly unstoppable. On the contrary, although FUT has almost become the “talk of the town” in the hair restoration community, it is sad to note that only a few prospective patients know the real nature of this technique. The common knowledge of patients about FUT is that it is a surgical hair procedure, which transplants hair from a healthy area of the scalp to the balding area using hair follicles that occur in one to four groups. Although this idea is indeed correct, it is but a tip of the iceberg considering the whole definition of FUT.
Follicular Unit Transplant – Definition
Simply defined, Follicular Unit Transplantation is a hair transplant surgery technique that utilizes follicular units as the primary tissues to be transplanted from a healthy area of the scalp, or what is called as the “permanent zone” (usually found on the back and sides of the scalp where hair is growing) into the scalp area affected by balding (usually found on the center of the scalp). It is believed that the transplanted follicular units from the permanent zone would still grow in their new area after being transplanted.
What are Follicular Units?
As the term that became the foundation of the most applied hair transplant procedure in this modern era, follicular unit is such a powerful word. A follicular unit refers to a group of one, two, three, or four hair strands. It is not just apparent, but hair strands on the scalp do not actually grow independently. Instead, hair strands on the scalp grow together in groups. These groups can be seen with the use of a densitometer if the hair is cut into a 1-mm length and magnified about 30x using the said device.
Follicular hair units are delicate structures; they do not consist of merely hair strands but also blood vessels, nerves, and even a muscle termed as erector pilorum that are packed inside a collagen. The erector pilorum is the muscle responsible for making the hair strands stand, as when one gets Goosebumps.
Since follicular hair units are easily destructible, it is then advised that surgeons conduct the harvest with utmost care and skillfulness. A device is used in harvesting the follicular unit grafts and in dividing each follicular unit independently. That device is called a dissecting stereo-microscope. It is one of the products of science that’s behind the success of FUT.
Pre- Hair Transplant Surgery
Prior to the FUT procedure, the surgeon is going to do series of assessments first to the patient, physical examinations and health history interviews are usually done. This is important to reveal facts that can affect the treatment of the patient such as allergies, and as well as to determine the number of grafts that need to be harvested and transplanted. The type of hair that the patient has, and its density determines this factor. Hair density refers to the preponderance of each hair grouping. For instance, if most of the patient’s follicular units are grouped in 4 hair strands, the hair density is high. The hair density is low if the follicular units are grouped in 1 to 2 hair strands only. Patients with a high hair density usually need more grafts so that the transplanted hair would follow the appearance of their normal hair.
In addition to this, hair surgeons use a special guide in determining the number of grafts to be harvested in the first hair transplant session. This guide is called as the Norwood classification. Aside from determining the number of grafts needed, the surgeon marks the recipient area with ink, clearly delineating the scalp area that needs the transplant. Furthermore, pre-surgery standard protocols apply to the patient even weeks before the procedure such as:
- Avoiding alcohol
- Avoiding aspirin and vitamin E
- Restricting a haircut
- Removing hair replacements
- Avoiding alcohol one day prior to the surgery
- Having a light meal before the procedure
- Wearing a button-down shirt before the procedure
- Some hair transplant facilities may have additional protocols.
Intra- Hair Transplant Surgery
At the day of the hair transplant surgery, the patient is made to assume the appropriate position for the harvesting of grafts. Usually, the position is upright. The patient should be made comfortable. The hair in the donor area is cut short to facilitate the harvesting of the follicular units. The patient may be given a mild sedative. An anesthesia is given. After the induction of anesthesia, the FUT procedure is ready to be executed. The FUT procedure itself can be divided into three sections: a) harvesting or extraction, b) dissection, and c) transplantation. These sections are discussed accordingly.
A) Harvesting or Extraction
Harvesting refers to the acquisition of follicular units grafts from the donor site. The harvesting of the follicular unit grafts can be done in two ways: either by using the Strip FUT (otherwise called as FUT alone) or the Follicular Unit Extraction (FUE) technique. Most commonly, FUE is viewed as a separate hair transplant surgery from FUT. The truth is, FUE actually falls under as a type of FUT harvesting technique, which is why it is just a part of the whole FUT surgery.
A.1 The difference between FUT and FUE
The main difference between the Strip FUT and FUE is the way the grafts are being manipulated. In Strip FUT, the surgeon incises a strip of the patient’s scalp, which contains a number of grafts. These grafts are then divided and dissected further.
On the other hand, in FUE or follicular unit extraction, there is no linear incision made anymore as the grafts are directly plucked from the patient’s scalp. By punching a 1-mm small circular incision over the follicular unit, the grafts are then harvested. This technique proves to be less invasive as compared to the former.Dr. Woods of Australia first discovered follicular unit extraction and called it as the “Wood’s Technique”. However, he did not publish his work. Later on, Rassman and Bernstein published this concept in 2002. And this technique was even refined more by Dr. Jim Harris by adding a step to this technique, which is called as “blunt dissection.”
Since FUE requires no donor strip, the dissecting part often applies primarily to Strip FUT. In strip FUT, the harvested grafts in the donor strip are “dissected” into single follicular units applying the principles of stereo-microscopic dissection technique. Utmost care and skills are rendered by the dissectors, usually the assistants of the hair surgeon, so as not to damage the follicular units.Stereo-microscopic dissection technique has three steps. The first step involves dividing the donor strip into follicular units. In this step, the donor strip is cut into smaller sections (about 2-2.5 mm width) by using a scalpel and carefully passing it through the strip without damaging the follicular units.The next step consists of isolating and categorizing the follicular units. The follicular units are isolated individually and are categorized accordingly by its naturally occurring hair strand groups. Groups of one or two hair strands in one follicular unit are grouped respectively. The same grouping principle applies to groups of three to four hair strands per follicular unit. The dissectors then get rid of the excess fat and dermis on the follicular units.Lastly, the follicular units are stored carefully. The grouped follicular units are stored in separate containers and are soaked in Ringer’s solution. This type of solution is used because it closely resembles blood plasma. The containers are then refrigerated at 40 degrees Fahrenheit to ensure the optimal survival of the grafts.
The Transplantation process is the most important part of the whole hair transplant surgery. This is where the harvested and dissected grafts are finally placed into the patient’s scalp. This process can be further subdivided into three phases: 1) preparation of the recipient site, 2) graft insertion, and 3) closing the donor sites
C.1 Preparation of the Recipient Site
Once the dissection procedure is done, the transplantation process is initiated by preparing the recipient site. The recipient site is the scalp area, which will receive the follicular units. The surgeon prepares the recipient site by creating lateral slits, otherwise known as coronal or horizontal slits over the scalp using either gauge 18, 19, or 20 hypodermic needles. These lateral slits allow the surgeon to control the direction of the hair follicles, thereby facilitating a more natural look of the transplanted hairs, and it also contributes much to the accuracy of the transplanted hairs’ depth, density, and distribution. Preparing the recipient sites entails a lot of skill, precision, and judgment on the part of the surgeon.
C.2 Graft insertion
After the recipient sites are properly prepared, the dissected grafts are then made ready to be transplanted. Even the placement of the follicular grafts during graft insertion is given much consideration.Follicular units with one hair strand are usually inserted in the front part of the hairline to give a smooth and natural look to the hair. On the other hand, units consisting of two, three, or four hair strands are situated on the center to give much depth and fullness to the head’s appearance once the hairs grow.Graft insertion is the most time-consuming part of the whole surgery. During this time, patients are asked to entertain themselves either by reading, watching a movie, or doing recreational activities that do not involve moving the head. And since the head needs to be held in a non-moving position so that the hair restoration surgeons can perform the surgery properly, frequent breaks for stretching and for answering other necessities are allowed.
C.3 Closing of Donor Sites
Once the graft insertion has been completed, the donor sites, or the scalp area where the grafts where excised (as in the case of FUT) need to be closed. There are two standard methods used in closing the donor sites. Some surgeons prefer using staples because these cause fewer traumas to the tissues thereby reducing inflammation and potential damage to the grafts. With less damage to the donor sites, grafts are well preserved for future use.On the other hand, some surgeons opt for sutures since it is much more comfortable for the patient and it gives the surgeon more freedom in approximating the wound edges.A much complex closure technique is also available, but is not that widely used by surgeons. This technique is called as the trichophytic closure. This technique also uses sutures, but minimizes the trauma to the grafts.
Post- Hair Transplant Surgery
After the FUT procedure, the patient is made to wear a tennis bandage. All post-operative considerations (which are discussed further here in a different section) are given to the patient. The facility may also furnish the patient a hard copy of these after hair transplant instructions. Indeed, Follicular Unit Transplantation is one wonder hair transplant surgery to behold. Medical hair engineers, in the efforts of further improving this procedure are undergoing researches and experiments as of today. Since the discovery of this technique, hair transplant has totally been revolutionized. Gone are the days when getting a nice set of hair involves too much risks, blood, incisions, and money on the part of the patient. Today, with the benefits of FUT, patients would be able to enjoy a nice set of hair with minimal risks, less personal sacrifice and with great satisfaction with the hair transplant’s results.
Patients must be well aware of the nature and procedure done during hair transplant surgeries. It is significant to note that more knowledge about these hair procedures develop a sense of responsibility not only on the part of the hair surgeons and his team but also on the part of the patient since the success of the hair transplant surgery is highly influenced by these two principal players