IDEAL PATIENT FOR SURGERY
Here we will discuss the risk patients from whom we should ALERT.
1. Patients at their young age with unclear hair loss patterns.
2. Patients with unclear psychological maturity.
3. Extreme hair loss with poor donor area.
4. Patients with body dismorphic disorder in which minor hair problem creates a maximum concern.These people they never get satisfaction inspite of good results.
Hair transplantation is a simple & superficial procedure that involves extracting live root bearing hair follicles from the donor area (back & sides of the head) and implanting them on to the recipient area (bald area). These transplanted hair roots behave and grow similarly to the hair from where they are extracted.
After re-growth, these transplanted hairs can be managed just like natural, existing hair. They can be shampooed or dyed and doesn’t require any medicines to maintain growth. Even after complete shaving or tonsuring, these hairs will grow back and continue to do so for the rest of the life.
It is primarily aimed to treat baldness in both men and women. It is also used to restore eyebrows, moustache and beard and to fill the scars caused by accidents, burns and surgeries like facelifts etc…
As the hair follicles grow in groups of 1 to 4 or 5 today’s most advanced techniques help in transplanting these groups of follicles also called as Follicular Units (grafts) and thus achieving almost natural looking
Latest techniques like…
Ultra Refined Follicular Unit Grafting (URFUG)
Mega & Super Mega Sessions
STRIP METHOD or FUT
FUE or DHT Technique
The very latest method is combining both FUT and FUE techniques in a single session.
The graft or unit usually consists of a small group of hairs in a configuration that naturally exists on the scalp. On an average 1.8 to 2.5 hairs per follicular unit are seen. With the help of Stereo microscopes and Video microscopes the strip extracted from the donor area is separated into individual grafts or units containing 1 to 4 or 5 hairs.
From the beginning of the hair transplantation surgery there are various types of grafts that are implanted on to the bald area. They are …
The father of HT was Dr. NORMAN ORENTREICH who used the standard 4mm round punch graft. Over the past 10 yrs there is a great revolution in graft preparation. Initially they are like round grafts (8 to 20 hairs), Slot grafts which consists of (6 to 15 hairs), Traditional Slit grafts containing (3 to 10 hairs) and Micro Slit grafts as Double FU (DFU), Triple FU (TFU) and Quadruple FU (QFU) are found. All these grafts are cut to the size and implanted through a punch or slot or slit created on the bald area, giving the odd, tufted appearance and causing dimpling, pigmentary changes depression and elevation of grafts over the recipient area. The most advanced technology leads to the development of ULTRA REFINED FOLLICULAR UNIT GRAFTING which consists of naturally occurring intact group of hairs as a separate unit. These can be implanted on the recipient area through needle and micro slit technique which makes the latest transplants as undetectable transplants.
The natural density of the follicular units per square centimeters ranges to 80 - 120 grafts on an average we consider 100 grafts per sq.cm. Sometimes it may be low less than 60 per sq cm (blacks) or more greater than 140 per sq cm (hispanic, whites).
Initially due to mini grafts able to implant only 10 to 15 or 20 grafts per sq cm was done giving corn-row pattern or dolls head appearance.
Due to the advanced URFUG technology able to implant 35 to 45 grafts per sq cm i.e, Dense packing giving undetectable appearance.
But this technique needs good team work and experience. For the dense packing the stick and place method gives excellent result.
Mega & Super Mega Sessions:
Normally the routine sessions include grafting of 1000 to 1500 (in abroad).
Mega session includes implantation of 2000 to 2500 grafts in a single session.
Super mega session includes implantation of 3000 to 3500 grafts in a single session.
Giga session includes 5000 grafts and more.
Our center average ranges from 2500 to 3000 grafts per session, of course it depends on the individual need and supply of donor area.
In FUT method we excise a narrow strip of the hair bearing donor area from the permanent zone. We immediately close the edges of the excised area which leaves a permanent scar on the back. Normally this scar doesn’t show hair growth. To minimize the scar we do a specialized technique to close the wound edges. In this method we deepithelize the upper or lower or both edges and suture it with 4-0 vicryl (delayed absorbable). Later the hair grows through the scar.
Exception: Inspite of our efforts wide scar is seen in cases of Keloid tendency and connective tissue disorders as they are hereditary in nature.
For slivering we use Mantis microscope.
For dissection we use Video microscope and Stereo Microscopes.
For Implantation we use Binocular Loupes (2X to 4.5X).
For FUE technique we use Safe Scribe Machine for graft extraction.
All these help to create almost natural looking and undetectable transplants.
The donor hair can be harvested in 2 methods.
The process of removing a strip of hair bearing scalp from the back and sides of the head (donor area) and dissecting the strip into ultra refined follicular units which are then transplanted onto the bald area (recipient area) is called as Follicular Unit Transplantation (FUT).
As the follicular units are harvested from a strip, this method is commonly called as “Strip Method”. This method can leave a scar on the donor area which can be concealed under the patient’s own hair on the day of the surgery itself. But due to the recent advancements in this field of hair transplantation, the scar can be minimized by using a technique called “Trichophytic closure”. This method helps in minimizing the scar which is almost invisible after few months and even new hair growth is seen through the scar in most of the patients.
The advantages of this method are:
- Wider bald area can be covered even in a single session.
- Dense packing is possible giving a more natural looking appearance.
- Less expensive
- Higher survival rate of the grafts
- Very minimal / negligible graft wastage (up to 1 %)
- Quick recovery time.
- More team is required for performing this method.
- Scar at the donor site….but, can be minimized by “trichophytic closure”.
- Experience, good equipment with excellent team work play a major role.
Also commonly called as “Suture less technique” or “No Scalpel technique”. In this method, individual follicular units are extracted by using tiny punches of sizes between 0.7 mm to 1.25 mm in diameter. These follicular units are then transplanted on to the bald area using either micro-blades and forceps or stitch and place method. This method also leave very tiny pointed dot like scars on the donor site, scattered all over the area which heals by 72 hrs post operatively.
- Suture less surgery.
- Minimal tissue damage.
- Doesn’t require a large team to perform.
- It is only method for transplanting body hair.
- Preferred method for restoration of hair on burnt patches, eye brows and moustache & beard.
- Donor area heals within 3 days. No typical scar seen.
- Graft wastage may be 3 to 10 %.
- May give mottled appearance in the donor area if not done properly.
- Require more no. of sessions when compared to FUT to cover an identical bald area.
- Expensive when compared to FUT.
- Demands more concentration and time from the surgeon / doctor.
- Not ideal for covering wider areas in a single session.
Who should consider this procedure?
- Patients who like to keep their hair short (<2 mm)
- Patients who require eyebrow transplants where single hair grafts are needed for better aesthetic outcome.
- Patients who require their scars to be repaired which occurred due to their previous transplantation surgery.
- Some patients simply refuse to have a scar on the donor site and hence don’t prefer FUT.
- For tight donor areas FUE is the preferred method.
- Athlets preferred this method due to early ambulation.
Laser hair transplantation-This refers mainly to creating recipient sites with laser ,but this is not successful due to tissue damage and poor growth.Nobody is now doing laser HT.
Fortunately follicular unit transplantation ,if performed with care is exceedingly safe and has a low complication rate.
Often more than one consultation is necessary to assimilate all the information ,especially in anxious patients.
1.Ongoing hairloss-Always plan the donor harvesting and the placement pattern with an eye to an advanced hairloss pattern.
2. Low unesthetic hair lines.
3. Incorrect positioning of donor scar.
4. Bad hair direction.
The last three factors depends purely on the surgeons skill and competency.
PAIN-Oral sedatives are given.Local anesthetic with epinephrine is injected with ice or vibrating instrument to minimize discomfort.In this way pain will not be an issue during the operation.
Restlessness Usually this is due to Anxiety.All patients respond differently but some need additional sedatives.
Hair in the Anagen phase can suddenly shed at about 2-3 wks post operatively along thesutureline.Regrowth of the hair occur at around 3 months.
Infection This is exceedingly rare. Routine Pre operative anti biotics are not recommended.
Dehiscence Very rare,may occur due to very tight closure,infection and necrosis.
Hyper and Hypoesthesia Only minor and temporary numbness may occur for sometime.
Undesirable scars-It may occur due to tight closure or hypertrophic scarring and Keloid scar can be seen inspite of our effort due to genetic tendency.we do double layered closures,trichophytic closure,and dissolvable sutures with little or no tension.
FUE technique can be done at wide scar areas with good results.
Forehead swelling and ecchymosis Applying pressure bandage around head for 3 days continuously can prevent this problem. If it happens it takes app. 7 to 10 days for spontaneous resolution.
Surgical effluvium Shedding of existing or native hairs in the recipient area can occur after 2-3 wks but regrowth of the same can occur with transplanted hair.
In female patients this is more common ,so make them aware of it.
Cysts,Pustules,Pimples and Folliculitis Many patients experience 1-2 eruptions in the grafted area after 1 month and upto 6 months.They will usually subside themselves rarely they need acne treatment.
Pitting & Tenting Where the hair exits the scalp the epidermis is either inverted in the shape of a pit or elevated in the shape of a tent .It may occur due to natural healing of the skin or placement errors of the grafts.
Poor growth Apparent poor growth may happen due to individuals with very fine hair.Usually > 90% of growth is seen with latest aseptic and fast technique.
Sometimes patient’s honest co-operation is important to solve the problem,like any grafts fell out in the 1 wk during the shower or through combing or brushing etc...If he has used any hair piece or hard hat or he isa closet smoker.Sometimes native vellous hairs may fall after the surgery which leads to appearent thinning.
It is always better to stay for 1 year for the final assessment as in some cases it may happen.
Sometimes doctors and patients stringent care poor may really happen ,it may be due to “X FACTOR” in some cases.
Ridging & hypertrophic scarring—It is seen with large 4 mm punch grafts .Due to excessive scar tissue deposited it will happen.Now a days it is usually not seen due to “ULTRA REFINED FOLLICULAR UNIT GRAFTING”.