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Current Hair
Restoration Options
1) Micrografts,
Follicular Units,
Double and Triple
Follicular Unit
Grafts, Slot Grafts
and Round Grafts
A)Follicular Unit
B)Multi-FU Grafts
C)Double Follicular
Units and Triple
Follicular Units
D)Slot Grafts
E)Round Grafts
2) Alopecia
Reduction
3) Hair cloning
4) Laser - aided
Hair Transplantation
Hair transplantation
depends on the now,
well established
principle that
transplanted hair
follicles (roots
moved from their
original location to
another area) behave
as they did in their
original site.
For example, even in
the most advanced
cases of common,
male pattern
baldness (MPB), a
horseshoe-shaped
fringe of hair
persists. Hair
follicles moved from
this hairy fringe
(the donor area) to
a bald or balding
area on the same
patient's scalp (the
recipient area)
takes root and
grows. Continuing
hair growth in such
transplants has been
observed since 1958,
and it is believed
that it will
continue for the
individual's
lifetime.
Many less common
types of hair loss,
in addition to MPB,
can be helped by
this procedure.
These include
thinning hair in
many women, scarring
from prior injuries
or surgery, and a
number of diseases
that sometimes cause
hair loss.
Currently, there are
numerous options
available to people
seeking a surgical
solution to their
hair loss problem.
The option or
options best suited
for you is a choice
you should make
after a discussion
with your physician
and after exploring
the possibilities
listed below
1) Micrografts,
Follicular Units,
Double and Triple
Follicular Unit
Grafts(DFU and TFU),
Slot Grafts and
Round Grafts
In modern hair
transplanting,
grafts are prepared
from a strip of
donor area skin that
is sectioned under
various types of
magnification into
whatever kind of
graft or grafts that
are required.
A strip of donor
area
The donor site is
sutured closed and
produces a hairless
scar that is usually
only 0.1 to 0.5 mm
wide. A small number
of patients develop
slightly wider scars
because of their
personal healing
characteristics. The
donor site can
always be easily
camouflaged,
immediately after
surgery, by combing
the hair above it.
Any resultant scar
can also always be
easily camouflaged
in the same way.
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First day |
After 2
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Scar in Donor area
The scar from any
previous session is
excised as part of
the donor strip in
any subsequent
session so that
usually only a
single scar is
present, regardless
of the number of
sessions that are
carried
out.(Sometimes two
donor areas are used
in order to obtain
hair with different
textures and
colors.)
We employs five
types of grafts.
They are chosen on
the basis of:
1)
ultimate density
objectives of the
patient
2)the
amount of persisting
hair in the
recipient area
3)hair
characteristics such
as color, wave and
curl
4)the
estimated long-term
donor area/recipient
area ratio.
Each of these types
of grafts is
described below with
a summary of their
advantages and
disadvantages.They
can broadly be
categorized as
grafts which
contain:
A) a single
“follicular unit”
(FU)
B)
grafts that contain
two, three, or more
FUs (multi-FU
grafts).
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A)Follicular
Unit(FU):
We use the terms
“follicular unit”
“follicular group”
and “micrograft”
interchangeably.
Most scalp hairs
grow in small groups
of two or three
hairs, separated
from adjacent groups
by small areas of
bald skin. Usually,
15–20% of hairs exit
the scalp as single
hair follicles and
approximately the
same percentage exit
as groups of more
than three
follicles.
Donor tissue can be
dissected into
grafts that contain
only one hair
follicle or,
alternately, one FU
that as noted above,
can contain two,
three, or more
hairs—as they
naturally exist in
the donor site. The
empty skin between
these groups is
dissected away from
the groups of hair
and is discarded.
The FUs are inserted
into holes made in
the recipient area,
with small blades or
ordinary hypodermic
needles, such as
those used to give
intra-muscular
injections or dental
anesthesia. When FUs
are the only type of
graft used for hair
transplanting, the
technique is
referred to as
Follicular Unit
Transplanting (FUT)
The main advantage
of transplanting
exclusively with FUs
is that they produce
the most even,
natural-looking
coverage. If the
recipient area is
totally or nearly
hairless, the
difference between
transplanting with
FUs, as opposed to
grafts containing
more than one FU
(multi-FU grafts),
is virtually always
more natural looking
when FUs are
exclusively utilized
(white hair and/or
curly hair are
sometimes exceptions
to this general
statement). Thus, a
single session of
FUT can “stand on
its own” and look
natural in an area
that is bald or
destined to become
bald. As soon as one
also employs
multi-FU grafts, at
least two sessions
and sometimes three
sessions will
ultimately be
necessary to produce
results that look
sufficiently natural
to be undetectable
except with very
close inspection.
As a corollary to
the preceding, one
can also choose to
transplant larger
proportions of the
bald area with
single sessions of
FUT— for example, a
single session to
the frontal area and
a single session to
the
mid-scalp—without
having to worry
about whether the
treated areas will
look natural after
only one session.
Whether an area
ultimately needs to
be treated more than
once with FUT can be
decided upon after
full growth of the
first session has
occurred
(approximately one
year after the
transplant session);
additional sessions
are done only to
create more hair
density rather than
because they are
necessary to produce
a more natural
appearance. The
decision as to
whether one treats
any area more than
once should take
into account the
patient’s hair
density objectives,
the long-term
donor/recipient area
ratio, the
proportion of the
existing or evolving
bald area the
patient wants to
treat, and the
amount of money, as
well as the time,
the patient is
prepared to expend
in the pursuit of
his/her goals.
Another advantage of
FUT is that small
needles or blades
are used to make the
recipient sites.
These sites can be
created between any
existing hair in a
thinning area, so
none of that hair is
removed or injured
if enough care and
skill are employed
making them. (Some
temporary hair loss
may occur because of
temporary decreased
blood supply but
this usually affects
no more than 10% to
20% of the hairs in
the area and it is
temporary.)
Because of the above
noted advantages of
FUT, a large number
of Hair Restoration
Surgeons (HRS)
prefer to use only
FUT in their
practices and some
have declared it the
“gold standard” of
transplanting.
Unfortunately,
however, as will be
discussed below,
there are some
disadvantages to FUT
that make it a less
attractive way to
treat some patients.
The disadvantages of
FUT are:
1)
Less hair density:
Multiple sessions of
FUT cannot produce
the degree of hair
density that can be
produced by multiple
sessions of a
combination of FUs
and multi-FU grafts
(a single session of
FUT can match—and
even exceed—the hair
density produced by
a single session of
“combination
grafting”). This
inability to produce
high-hair density is
due to two factors:
a) individual FUs
can never be
transplanted as
close together as
they existed in the
original donor area.
Getting them even
half as close as in
the donor tissue
requires two or more
sessions in most
offices. Thus,
transplanting with
FUs has never
resulted in hair
density comparable
to the hair density
within a multi-FU
graft and, b) the
spaces between
multi-FU grafts
allow for an equal
number of grafts and
hairs to be
transplanted in a
second or third
session while that
is not possible with
the usual FU
densities that are
employed by most FUT
practitioners—hence
the higher hair
density that can be
achieved after
multiple sessions of
“combination”
grafting vs. FUT. In
brief, while we may
attempt to put hair
into the scalp the
way nature did
it—one FU at a
time—we cannot
ultimately get them
nearly as close
together as nature
did.
2)
The hair in FUs is
more susceptible to
potentially lethal
damage during graft
preparation,
storage, and
insertion into the
recipient area. This
is because there is
less “insulating”
tissue around the
hairs in an FU than
hairs in a multi-FU
graft. This results
in the need for a
large staff of
highly trained
technicians who must
be constantly
supervised and too
frequently replaced
as they move from
one doctor’s office
to another. Put
differently, the
need for staff
“perfection”
increases as the
size of the graft
decreases, with FU
being the smallest
and therefore most
unforgiving type of
graft. Nevertheless,
although hairs in an
FU can more easily
be killed than hairs
in a multi-FU graft,
good quality control
of office staff is
possible and
high-hair survival
(90 to 100%) is
therefore
achievable—it is
just more difficult
to achieve.
3)
The smaller the
graft the more of
them that are
necessary to
transplant the same
amount of
hair—therefore the
smaller the graft,
the larger the staff
and physician time
that is required and
the more expensive
the procedure
becomes. The cost
factor of FUT can
often be managed
because a single
session of FUT will
look natural so the
patient can, if
necessary, only do
one session or even
spread treatments
far enough apart to
be affordable.
Despite the
disadvantages noted
above, hairline
zones and the
“crown” in all
patients are treated
exclusively with FUs
because of the
superb naturalness
they produce after
only one session. In
addition, as noted
earlier, because it
will produce
naturalness in a
single pass, it
allows the patient
the option of either
treating the same
area again, for more
density, or “saving”
those grafts for use
elsewhere. Patients
with totally bald
recipient areas are
strongly encouraged
to do at least the
first session with
FUT for the same
reasons. FUT also
remains the best
option for most
(though not all)
patients who can
afford it. (See
below.) This is
because most
patients do not
require high hair
density to be
satisfied.
Furthermore, they
should not seek it
because most
patients do not have
good enough
long-term
donor/recipient area
ratios for dense
coverage of large
areas. Currently,
approximately 60% of
Dr. Vafaei’s
patients choose FUT
when they are shown
photos of what can
be expected from
this approach and
what can be expected
from a mixture of
FUs and multi-FU
grafts.
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B) Multi-FU Grafts
General comments:
The oft-repeated
charge that using
anything larger than
an FU always results
in noticeable
plugginess is
inaccurate and
overly simplistic.
“Plugginess” is not
simply a function of
graft size. Other
factors play an
important role in
whether a graft
might or might not
be noticeable.
1)
The finer the hair
texture, the larger
the graft can be
without looking
pluggy.
2)
The less contrast
between hair and
skin color, the
larger the graft can
be without looking
pluggy. Patients
with white hair, for
example, can have
grafts with many
hairs in them
without looking at
all pluggy). Those
with salt and
pepper, blonde, and
light brown or red
hair can also
frequently use
multi-FU grafts
without fear of
looking “pluggy”.
3)
The more curl or
wave to the hair,
the larger the graft
that can be without
looking “pluggy”,and
4)
The more persisting
hair in the
recipient area, the
larger the graft can
be without looking “pluggy”.
Most of Dr. Vafaei’s
patients come to him
well before they are
totally bald and
therefore do not
have to be concerned
about the multi-FU
grafts being
noticeable.
What is true,
however, is that
even in ideal
circumstances, very
close inspection
will always reveal
less than the
perfectly even
coverage that is
produced with FUT.
Because of this, a
single session of
multi-FU grafts is
rarely cosmetically
acceptable. As noted
earlier, a second
and sometimes third
session in the same
area will ultimately
be necessary to
produce a
satisfactory
naturalness. On the
other hand, as was
also discussed
earlier, more hair
density can be
created with
multi-FU grafts and
with greater safety
to the hairs and
less cost to the
patient. As long as
hair characteristics
are suitable and
additional sessions
are carried out in a
timely fashion—for
example, keeping
pace with hair loss
in a recipient area
that initially was
not bald—no
plugginess need ever
be noticed. The
result is that a
majority of Dr.
Vafaei’s patients
still choose a
combination of FUs
and multi-FU grafts
over FUT, in order
to ultimately
achieve more density
(or sometimes
because it is more
cost-effective).
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C) Double Follicular
Units (DFU) and
Triple Follicular
Units (TFU)
These grafts consist
of two FUs lined up
one behind each
other like soldiers
in a row while TFU
grafts contain three
FUs aligned in a
similar fashion.
They are inserted
into incisions made
with ultra-sharp
small blades. The
finer the hair
texture, the less
skin/hair color
contrast, the more
hair curl or wave
and the more
persisting hair
present in the
recipient area, the
more likely these
will be used behind
the hairline zone
without being
noticeable. As noted
above, two or more
sessions of these
types of grafts
produce greater hair
density than the
same number of FUT
sessions and do so
with more hair
follicle safety and
less cost. A session
consisting of a
mixture of FUs and
DFUs (with or
without TFUs) can
also be followed by
a second session of
FUT or FUs and slot
grafts or even small
round grafts (see
below); the latter
two in order to
produce even greater
hair density, and
greater follicle
safety. It is
important to repeat,
however, that if
DFUs, TFUs, or any
other type of
multi-FU grafts are
used in the first
session, at least
one more session
will be necessary at
some point to create
enough naturalness
if the area is bald
or destined to
eventually become
bald.
Just as with FUs, no
existing hair in the
recipient area is
removed during the
preparation of the
recipient sites.
These are made
between the hairs
with small blades.
Because virtually
all women with
Female Pattern Hair
Loss (FPHL) are not
destined to lose all
of their scalp hair,
a mixture of FUs and
DFUs/TFUs is usually
used in hair
transplanting in
females. Keep in
mind also that
whether the patient
is a male or female,
FUT can be used for
the first session
and a mixture of FUs
and DFUs/TFUs can be
used in a second
session (or vice
versa). Once a
session of FUT has
been carried out,
however, slot or
round grafts cannot
be employed without
removing some of the
previously
transplanted hair.
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D) Slot Grafts
Slot grafts are
three FUs long and
approximately two
FUs wide. They
typically contain 10
to 12 hairs and are
inserted into
“slots” created with
a special “slot
punch”. They are
particularly
suitable for
patients who want
substantial hair
density and who have
a sufficiently good
long-term
donor/recipient area
ratio. Once again,
good hair
characteristics, for
transplanting, such
as low hair/skin
color contrast,
frizz, curl and
existing recipient
area hair, increase
the likelihood that
these larger grafts
will not be
noticeable behind a
hairline zone of FUs
(and usually a zone
of DFUs or TFUs
behind the area
treated with FUs).
The disadvantages of
slot grafts are:
a)
unless hair
characteristics are
good for
transplanting, and
the recipient area
is suitable, these
grafts may be
temporarily
noticeable,
b)
when they are used
in an area that
still retains some
of its original
hair—as they usually
are—some of that
hair is removed as
the recipient sites
are punched out.
Hence, in the
slot-grafted zone,
there is less hair
for the first three
months after surgery
than there was
before the surgery.
(No hair is removed
in front of or
behind the slot
grafted area),
c)
more hair is also
used in the frontal
area, and less hair
is left in reserve
for the treatment of
other areas. Two of
these potential
drawbacks of slot
grafts can obviously
be avoided if they
are only used in
people who do have
good hair
characteristics and
in those men who
have and are likely
to maintain a good
ratio of donor hair
to bald area. (Doing
the first two
sessions five to six
months apart—before
the previously
transplanted hair
gets long and
coarse—is also
helpful in avoiding
temporary
noticeably.)
However, such
individuals
constitute a
minority of patients
seeking hair
transplanting and
thus this approach
is used in only 10
to 15% of our
patients. It is
especially useful
for middle aged or
older men with salt
and pepper or white
hair.
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E) Round Grafts
“Round” grafts are
actually square
grafts placed into
holes made by round
trephines or
“punches” behind a
zone of FUs and DFUs,
TFUs and slot
grafts. The punches
usually have a 2 mm
diameter, but
occasionally larger
punches are
employed. Everything
that has been
discussed about slot
grafts applies to
the use of round
grafts but even more
so. The potential
for hair density and
hair follicle
survival are
increased, as are
the problems that
can occur and that
must be avoided.
Thus, only 10% of
Dr. Unger’s patients
are currently
offered this option.
Nevertheless, in
properly selected
patients, the
results can be
spectacular
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2)
Alopecia
Reduction(AR)
is a relatively
simple procedure
that reduces the
size of the balding
area. This is ideal
for patients whose
supply of
transplantable hair
may not otherwise be
sufficient to cover
the entire balding
area. Essentially,
an Alopecia
Reduction (AR)
consists of the
excision/removal of
a portion of bald or
balding area. The
normal laxity of the
scalp is used to
close the resulting
gap. A narrow scar
is usually all that
remains after the
procedure. Within a
few weeks, the scalp
will become loose
again and, often,
the bald area may be
further reduced by
additional ARs.
If one wants to
transplant all of
the frontal,
mid-scalp and crown
areas, most patients
are strongly
recommended that an
attempt be made to
decrease the size of
the bald area with
one or more AR. ARs
increase the
probability of being
able to transplant
the whole (reduced)
area before the
supply of available
donor grafts has
been completely
depleted.
Notwithstanding the
preceding, some
patients have enough
donor tissue to
cover the whole bald
without the need for
ARs—especially if
they are willing to
lower their hair
density objectives.
In addition, many
patients who are
seen for correction
of aesthetically
unsatisfactory prior
hair transplanting
can benefit from
having
untransplanted areas
—or lightly
transplanted
areas—excised
instead of
transplanting them
and using up already
depleted donor
reserves. (In the
latter case, any
excised “old” grafts
can be re-used
elsewhere.) This
approach maximizes
the number of grafts
that are available
for filling in and
camouflaging the
spaces between the
older grafts. While
AR may sound rather
frightening or
painful, it is, in
fact, a relatively
simple procedure. In
most patients, it is
no more
uncomfortable than a
transplant session.
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3) Hair Cloning
Hair cloning is
still in the
experimental stages.
Although the initial
laboratory results
are promising, it
will probably be at
least 5 to 10 years
before such an
option becomes
available. The
researchers are
studying on what is
popularly called
“cloning” of hair
but is more
accurately called
'cell therapy'.
Cells are removed
from a patient's
hair and millions of
similar cells can be
reproduced within
several weeks. These
cells, when injected
into
immune-compromised
mice, almost always
resulted in the
growth of human
hairs that lasted
until the mice were
very old. Two
studies on human
subjects have been
conducted. The
patients’ own
culture-grown hair
cells were injected
into their scalps.
In the first study,
hair grew in only
one of the 10
patients. In the
second study, hair
grew in three of 13
patients; however,
the growth of hair
at the treated sites
was not as vigorous
as it had been in
the one responder in
the first study. The
procedure has been
temporarily
discontinued these
studies because of
legal problems with
the funding.
Hopefully, this
problem will be
resolved soon.
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4)
Laser-aided Hair
Transplantation
This technique holds
great promise.
However, we
concluded that the
existing laser
equipment cannot be
counted upon to
produce consistently
superior results and
there were some
significant
disadvantages
associated with it.
Despite
advertisements and
media reports that
suggest laser
transplanting
produces superior
results with less
bleeding and pain,
there is, in fact,
no laser currently
available that will
produce these
advantages, and less
hair may grow in
some patients. So
we, for the time
being, stopped doing
laser hair
transplants. Laser
manufacturers are
still working on
producing a more
satisfactory
machine.
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