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Hair transplantation is the most common surgical hair replacement treatment. Hair transplantation is the surgical removal of hair grafts from donor sites on the side and the back of the head, places where balding men still have plenty of hair. These hair follicles are not inhibited by DHT (dihydrotestosterone) because they lack the genetic instructions to be inhibited by DHT. They remain healthy permanently. Hair grafts from these DHT-resistant hairs are re-implanted into the balding and thinning areas of the scalp. This provides permanent hair since the donor grafts have healthy hair follicles which are genetically programmed not to shed.
Hair transplants have been performed since the late 1800s. The modern technique of transplanting hair from areas of the scalp where hair is genetically coded to resist the effects of DHT, was started by Dr. Norman Orentreich in the late 1950s. While hair transplantation was successfully performed over the next 35 years, recent advances that use mini-grafts and micro-grafts have dramatically improved the positive results of hair replacement surgery. The transplanted hair grows for the remainder of your life.
Refinements in hair restoration surgery, such as modified scalp reduction procedures and improved mini and micro-grafting techniques, such as angling of grafts, have resulted in better cosmetic results.
Women are increasingly having hair transplant operations. But in general, women are less suited to transplants than men because their hair loss tends to be more of thinning than hair loss in a specific area.
Older hair transplant methods practiced in France often turned out making the scalp and hair look like a forest, with each hair shaft neatly planted as a part of a symmetrical grid pattern. Some have called the old method the "corn row" look. Newer techniques give less scarring, more dense hair growth, and a more natural looking hairline than older transplant methods.
Best Candidates for Hair Transplants and the Cost
The very best candidates for hair transplants are men in their 40s who have black, wavy blond, or gray hair, who have balded slowly, and whose relatives experienced only limited hair loss. Men who are in their 20s are more difficult to treat since the future pattern of hair loss is unknown. But there are no age limitations for receiving transplants.
The
most critical factor in getting a transplant is the patients's expectations.
Re-establishing the hairline of a teenager is difficult and the reserve
for hair transplants is limited. Financial considerations are also important.
Men in their late 30s or 40s are usually more financially stable. In almost
all cases, 3 to 5 transplant sessions will be required, with the cost running
from $5,000 to $15,000. Wavy and curly hair looks denser and requires less
transplants to achieve a cosmetically acceptable look.
After anesthetizing the hair donation scalp site, a strip of scalp about ½" to 1" wide and 4 to 5" long is removed. Since the scalp is very elastic, the resultant gap is easily pulled together and sutured shut. The hair on the back of the head conceals the small thin suture line.
The surgery team then divides the donor hair strip, which contains thousands of hairs, into individual "grafts”. Micro-grafts each contain 1 or 2 shafts of hair. Mini-grafts contain 3 to 8 shafts of hair per graft. With these techniques, the surgeon transplants as few as 1 or 2 hairs at a time, which creates a more natural look rather than the "toothbrush" or "plug" effect.
These hair grafts are then implanted into recipient sites in the balding area. Micro-grafts are inserted into tiny punctures in the skin and mini-grafts are inserted into extremely small (0.5mm to 2mm) openings. This achieves a more natural appearance and is an improvement over previous techniques, where transplants were inserted into slits in the scalp. This often resulted in an abnormal, compressed hair.
Recipient sites are made in several ways. Some physicians use punch holes, some use linear slits, and others use a "slot" method that creates a narrow, elongated oval incision. As techniques develop, it can be expected that in time a standardized method will emerge. The goal of all these procedures is to obtain a more dense, natural appearance for the patient, while allowing the hair to grow in its natural manner.
The
cosmetic effect of the placement of the grafts, the insertion angles, and
the combinations of grafts are dependent on the skill and “artistry” of
the transplant surgeon. The shape of the patient's face and predictions
of areas of future hair loss must be considered carefully for optimal cosmetic
results.
A new advancement in grafting was developed by Dr. B. L. Limmer and his research team. They perfected a technique referred to as Microscopically Magnified Micrografting. Their procedure produces minute grafts of 1 to 4 hair follicular units which are transplanted into balding areas. Hair follicles and shafts naturally grow in from the head in follicular units consisting of 1 to 5 hairs. Some physicians claim a hair growth rate from implanted follicles in excess of 110%, due to the fact that they recover and utilize the resting hairs in the teleogen phase from the donor site. These hairs would otherwise go unused with non-microscopic techniques.
Their technique uses a binocular stereoscopic microscope of 20X power for dissection and isolation of the delicate hair follicle units. After a strip of hair is removed from the donor site, it is dissected under the microscope so the follicular units for grafting are produced intact. In particular, care is taken to keep the pilosebaceous structure (oil producing) which lubricates the hair shaft and aids in hair growth. These follicle units must be preserved intact during dissection to insure the best survival and growth of the hair follicle. They report that this method obtains 10% to 30% more hair from a donor area. This is important for patients with gray or blonde hair because light-colored grafts are difficult to see with the naked eye.
On the average, 6 to 7 hours of work are required to transplant 1,000 grafts by this method.
Hair follicle units as small as one hair are used mainly for the frontal hairline, and larger units of 2-5 hairs for coverage of balding areas.
Lasers are used to create micro-incisions in the scalp for the insertion of hair. There is less bleeding at the recipient sites and the laser forms scalp holes of a very consistent size and depth. The main disadvantage of using lasers is the skin trauma produced by the thermal effects at the recipient site.
Lasers were first used for hair transplantation in 1992. Early results were variable due to thermal injury of the skin. However, newer, pulsating lasers let the laser's light beam be rapidly pulsed up to hundreds of times per second. This pulsating avoids excessive build up of heat and preserves the surrounding tissues. With the pulsing laser, hair insertion holes in the scalp from 0.3mm to 0.8mm are created. Then a small metal probe is used to further open the insertion point so that the blood vessels and the inserted hair follicle can interact. Hair follicle grafts are prepared with a dissecting microscope and inserted into the laser-made holes.
The transplantation surgery takes 3-4 hours in an outpatient facility and patients return home after surgery. Normal hair transplant sessions plant 200 to 500 grafts with about 4 total sessions needed. Megasessions are long surgical hair transplant sessions performed by teams, where a large number of micro-grafts are inserted in a single day. Megasessions allow for the achieving of more micro-graft transplants in less time. One to two megasessions often produces very cosmetically attractive results. During a session, 1,000 to 1,500 hair grafts are placed in the patient's scalp in a 4 to 5 hour span.
After surgery, a bandage is applied, then removed the following morning at a follow-up appointment. Many patients can return to work the day after surgery.
At times, because of earlier unsatisfactory transplantations, later transplants are used to improve the results. Micro and mini-grafts are prepared from hair on the back and sides of the head and re-plant scalp areas as described above. The grafts then establish themselves in the new scalp area and resume normal growth by 8 to 10 months after surgery.
Local Anesthetic Used for Surgery
Most techniques use small amounts of locally injected anesthetic and some physicians freeze the skin prior to injecting the pain-reducing agent.
After surgery, small scabs form over the graft sites, then after 10 to 14 days, the small scabs fall off.
This procedure allows bald scalp areas to be reduced and is probably the most common hair restoration procedure other than transplantation. The scalp is usually somewhat loose and the balding area may be reduced. This can be very effective for persons with midline or posterior ("monk spot"). Most people have a limited amount of hair for transplantation and reducing the bald area reduces the amount of hair needed for transplants. Rather than increasing the hairs available, scalp reductions reduce the amount of scalp you have to cover with transplants.
Although different physicians have different techniques, in general, several reduction procedures may be needed to achieve the desired results. Since the skin will only stretch so far, several small stepwise reductions must be done. This allows the skin to stretch and grow after each reduction. Another technique is to expand the scalp before the reduction so that the entire scalp is looser and the bald area can be even further reduced.
After the scalp reduction has healed, hair transplants are implanted to cover any scarring and to achieve the desired results of the patient.
There are a few possible drawbacks to this procedure. One is that a scar is normally left after the reduction operation. Another problem is called 'slippage'. This is when the reduced skin expands somewhat and slips back down the scalp. In such cases, further reductions may be necessary. Another drawback is the possibility that the balding will advance beyond the area that was reduced and create an odd balding pattern. Further transplants and/or another reduction might be necessary to correct this. Finally, this is a more complex operation than a regular transplant and so increases the cost of the transplant.
On the up-side, the reduction may allow good transplant results and the appearance of a full head of hair. However, some physicians no longer perform these reductions, being of the opinion that new transplant techniques are cosmetically effective, and without requiring a reduction of the scalp.
Frechet Extended Scalp Reduction
This new development in reduction technology uses a small elastic band which is placed under the skin during the reduction. This band applies a gentle tension to the healing scalp, causing the hair-bearing skin on the scalp to stretch or extend. In some cases, 3 to 4 Frechet Extended Scalp Reductions can eliminate the crown bald area in 3 to 4 months.
In this procedure, a portion of hair-covered scalp is stretched beforehand to allow for a release of tension and a greater reduction of balding scalp. This expands the amount of hair-covered skin available to shift to the bad areas. This treatment is usually combined with a scalp reduction to reduce the size of the balding area.
Scalp expansion and extension surgeries are both based on the same concept. When a constant force is applied to skin, the skin will start to grow new skin cells to allow the skin to adjust to the force that's being applied to it. To expand the scalp, a balloon is inserted under the scalp and expanded over a period of months to force the skin to expand. Over a period of time, the skin adjusts to the new situation. Scalp expansion and extension surgeries insert medical devices into the scalp that slowly expand the skin over a period of weeks. Each involves two surgical procedures: one to insert the device(s), and one to remove them and perform the final reduction of the bald scalp, using the newly grown skin with hair.
The benefit of a scalp expansion or extension is that unlike Male Pattern Reductions which may have several operations to get similar results, the expansion and extension require only two operations. However, they are more complex surgical operations and require the use of devices which are hard for the patient to conceal when at work or social events.
The first step in a scalp expansion is a medical procedure in which medical balloons are inserted beneath the scalp. In a scalp extension, a different medical device with hooks is attached to the scalp which applies force to the skin without needing to insert balloons underneath the skin.
The second step in the process is the slow expansion of the balloons over a period of weeks. The slow expansion expands the skin with non-balding hair which can be used in a reduction or as part of a flap. This leads to one of the drawbacks of the surgery, which is that the person's head appears contorted during this period of the process.
The third step involves the removal of the balloons and the unnecessary bald flap of skin which will be reduced. The newly expanded skin now covers the area of balding skin which was removed.
The final step in the procedure is to close the reduced area and let the healing process begin. A transplant surgery is usually done as soon as the affected area has healed.
Obviously, these surgical procedures are fairly complex and so should not be taken lightly. They offer a distinct advantage over traditional male pattern reduction and can make it easier to achieve cosmetically acceptable transplant results in those who are already very bald. They are not for everybody, but they are appropriate for certain individuals.
This procedure is a more radical form of scalp reduction which allows for further reduction in fewer operations. Some physicians assert that, in most patients, one scalp lift can provide the same results as 3 or more scalp reductions. A scalp lift is a surgical procedure that combines the removal of a patch of bald scalp from the top and back of the head, followed by an upward movement and stretching of the surrounding area of hair-bearing skin in order to close the opening. The procedure involves extensive undermining (loosening) of the skin at the back of the neck and on both sides of the head to allow the hair-bearing skin to move upward easily. Scalp lift procedures are normally performed under general anesthesia. The procedure takes one day, but some surgeons re-route blood vessels away from the surgical site a few weeks before the scalp lift. A successful scalp lift creates the most dramatic results of all hair replacement methods.
This procedure takes a flap of hair-bearing scalp and repositions it, usually, as part of the hairline, producing greater density than normal transplant procedures. Scalp flaps are used mainly for reconstruction purposes, such as hair-free areas of the scalp caused by accidents or skin cancer removal procedures. Although this technique was once used as a hair transplant procedure, newer hair transplantation techniques have replaced most flap work. Flap surgery is technically more difficult than the new transplant methods and requires more surgical skill. Long-term complications of surgery, such as eventual necrosis of a flap, are more common.
When scalp flaps are done right, they offer the best results. Flap surgery can give you a perfect hair line with dense hair that looks normal in just a couple of weeks. Unlike transplants, the hairs do not fall out after transplantation. The drawback is that it is very expensive and it is much more serious than most other hair restoration surgeries. Complications are rare when performed by an experienced doctor.
Flap surgery is performed in three steps. First, the sides of the flaps are separated from the surrounding skin. The front and rear end of the flap are not separated. The incisions are then closed and a dressing is applied. A week later, the second procedure is performed. The procedure is identical to the first except the rear of the flap is now separated from the underlying tissue, then closed again. The purpose of these procedures is to force the flap of hair-bearing skin to get its blood supply from one end of the flap. A week later, the previously cut, free end of the flap is transferred to a nearby balding area at the hair line, performed under general anesthesia. Within a week, the stitches at the front hairline are removed and the stitches within the hair are removed within two weeks. The flap reattaches itself to the new area and the formerly bald area now has hair.
For patients who are bald at the crown or who bald later after the operation, a second flap operation can be performed. If this does not cover the remaining bald areas, scalp reductions can be performed between the flaps to eliminate or nearly eliminate all the balding areas. Thus, flap surgery is really the only surgery so far that can give you a full head of hair with the density of a normal head of hair (or close enough to be undetectable).
Skin Repair Accelerators Used for Hair Transplantation
A new product, GraftCyte (sold by ProCyte Corporation), when used in the post-operative regimen, has resulted in faster healing of transplants and earlier regrowth of the hair shafts. GraftCyte is a copper-peptide product based on the Iamin tissue regenerative concept. (For details, see Copper Peptide Regeneration.) The GraftCyte dressing provides enhanced healing of the transplanted follicle. It results in less post-operative shedding along with a more immediate hair growth. Patients often see new hair growth in 6 weeks, versus the normal 10 to 14 weeks of other procedures. The normal skin crusting after transplantation has been reduced from 10 to 14 days to 5 days, in most cases. GraftCyte costs about $275 per procedure and can be obtained from www.procyte.com/.
In a study of Graftcyte by Perez-Meza et al (International Journal of Cosmetic Surgery (Vol. 6, 1998, pp 80-84)), it was found that men and women receiving transplants and using GraftCyte for post-operative treatment, achieved better results and a quicker healing time than with the conventional saline gauze dressing used after surgery. In a placebo-controlled, double blinded study, twelve patients were studied over a 13 week period. Each patient received 16 treatments during 4 days of post-surgery. On each patient, one side of the head was treated with a conventional saline gauze dressing and the other with Graftcyte, in a pre-assigned random scheme. Weekly results were documented by photographs and video microscopic scans. The study measured edema (excess fluid buildup and crusting), effluvium (shedding of transplanted hair), erythema (redness of the skin), the growth of transplanted hair that did not shed, the regrowth of transplanted hair that returned after shedding, and overall cosmetic results.
In the Graftcyte-treated areas, 42% of patients were found to exhibit less
redness and crusting than on the placebo side, versus 17% who were more
successful with the saline. Redness and crusting were slightly milder in
the Graftcyte treated group (75% none-to-mild for GraftCyte, and 58% for
placebo). The GraftCyte-treated side showed better hair regrowth at 4,
8, and 12 weeks, compared to the placebo side. The patients felt that the
GraftCyte-treated hairs had greater body, shine, and texture than those
on the placebo-treated side.
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Other, more advanced copper-peptide skin and hair growth accelerators are also available from Skin Biology, such as Protect & Restore and Folligen (www.folligen.com), of which some physicians have used after transplant. These accelerators have been proven effective in skin repair studies; they stimulate hair growth in mouse models, but as of yet, have not undergone controlled studies on hair transplantation.
For clinical data on Skin Biology’s (www.skinbio.com) skin healing accelerators, see: (1) Zhai, Leow, and Maibach, "Sodium lauryl sulfate damaged skin in vivo in man: a water barrier repair model", Skin Research and Technology, Volume 4, pages 24-27, 1998. Skin Biology's product markedly accelerated the repair of skin damaged by the application of an irritating detergent. (2) Zhai, Poblete, and Maibach, "Stripped skin model to predict irritation potential of topical agents in vivo in man", International Journal of Dermatology, Volume 37, pages 386-389, 1998; Skin Biology product increased skin repair after skin removal by repeated tape-stripping. (3) Zhai, Leow, and Maibach, "Human barrier recovery after acute acetone perturbation: an irritant dermatitis model", Clinical and Experimental Dermatology, Volume 23, pages 11-13, 1998. Skin was damaged by a fat removing agent, acetone, then treated with a Skin Biology product which rapidly rebuilt the damaged skin, and (4) Zhai, Chang, Singh, and Maibach, "An in vivo nickel allergy contact dermatitis human model for topical therapeutics", Presented in February 1998, American Academy of Dermatology Meeting. Skin was damaged by the application of nickel salts to persons with nickel allergy. The Skin Biology product increased skin repair and reduced skin irritation.