Hair transplantation


Introduction to Hair Transplantation

Hair transplantation represents the surgical solution to baldness. It allows a thickening of the scalp in areas affected by hair loss and thinning.

The technique consists of removing the follicular units (or grafts) from the occipital area of the scalp, which is called the donor area, and reinserting them into incisions previously made in the glabrous areas of the scalp (recipient area).

Hair transplantation has experienced a remarkable development in recent years and allows, today, to obtain natural results. Of course, an essential role is played by the choice of a specialized clinic.

The principle behind hair transplantation is quite simple. The hair that grows in theneck area and on the sides of the scalp is permanent in most people.

This hair is not prone to fall out even in people with a high degree of androgenetic baldness. The follicles located in those areas are not attacked by the hormone dihydrotestosterone (DHT), which is responsible for hair miniaturization.


The hair on the nape of the neck is not destined to fall out

The resistance or individual sensitivity of hair follicles to DHT is a genetic feature of the same and remains unchanged when the follicle is transferred, by transplantation, from one part of the scalp (or body) to another; this phenomenon is called “donor dominance” because the hair retains its characteristic of insensitivity to DHT that they had in the area from which they come (called donor area).

We must not only consider the genetic component in hair transplantation.

Interestingly, not all hair characteristics are controlled by the genetic information of the hair follicle. Whether a hair is straight or wavy, for example, is determined by the surrounding scalp. Straight hair transplanted from the back of the scalp into the frontal area will become wavy after a hair transplant if the native hair was originally wavy.

The speed of hair regrowth and its final length are determined by both the characteristics of the follicle and those of the skin surrounding the transplanted hair.

It is important to understand that in a hair transplant, permanent hair is simply redistributed to cover bald or thinning areas of the scalp. With a hair transplant, no new hair is created; it just changes the position of pre-existing hair. Nevertheless, a well-executed hair transplant surgery can significantly improve the appearance of a person suffering from androgenetic alopecia. If performed by experienced hands, the transplant will look totally natural and the transplanted hair will continue to grow throughout the patient’s life.


How much hair do we have available in hair transplantation?

The number of permanent hairs present in the donor area is one of the key factors in determining whether a person is a good candidate. This element affects every single aspect of surgical planning and determines the achievable hair thickness. A thorough assessment of the available donor area is therefore extremely important. The most accurate way to perform an assessment of the donor area is through a densitometer or video microscope, instruments that allow the surgeon to examine the follicles through adequate magnification.


The origins of hair transplantation

Since ancient times, man has tried to find effective solutions to baldness. A thick hair, in fact, has always represented strength and virility.

Already the ancient Egyptians, more than 4,000 years ago, had imagined there was a connection between the activities of the blood vessels and hair loss. Hippocrates, about 2,000 years later, had intuited the role of androgen hormones in triggering baldness.

Hair transplant surgery began to take its first steps in the 1800s when, Dieffenbach, hypothesized the possibility of transplanting hair, skin and feathers onto birds. Then, in 1939, the Japanese Okuda described the grafting of eyebrows, whiskers and pubes. It was Orentreich who was the first to put these insights into practice. For this very reason, he is considered the father of baldness surgery and hair restoration.

Since that time, hair transplantation experiences a steady development that will continue into the future. Currently, the approaches are innovative, sophisticated and complex. If the transplantation is performed by experienced hands, excellent results can be achieved.

There are two hair transplantation techniques available on the market today: Strip Technique and FUE Technique. Below is a brief description.


Strip transplantation or FUT (Follicular Unit Transplantation)

It involves the removal of an elongated longated strip of skin from the donor area. From this strip of skin, follicular units will then be removed, which, once cleaned, will be grafted into the recipient area in previously made incisions.

Strip surgery leads to the formation of an elongated scar that can extend from one ear to the other of the patient. This represents one of the most controversial aspects of the technique. In fact, if the transplant is not well performed, the scar can unfortunately be visible and represents a serious blemish and discomfort for the patient.

On the other hand, the number of viable follicular units extracted with this method is extremely high. Up to 4,000-5,000 follicular units can be extracted in a single session.


Extraction with FUE technique (Follicular Unit Extraction)

The FUE extraction method consists of extraction of individual grafts directly from the scalp. The subsequent transplantation steps are then identical to those performed with the Strip method.

The technique is becoming increasingly popular in the international market due to the less invasive nature of the removal of the follicular units. The scars in this case will be numerous but very small and circular in shape. If the surgery is well performed they will not even be visible in the hair.

The risk of transection (percentage of follicular units damaged during extraction), is higher. However, thanks to increasingly sophisticated technologies and systems, the numbers of surgeons specialized in the FUE method are now very high. In some cases, up to 3,000-5,000 follicular units can be extracted in a single session.

Depending on the size of the area to be treated, generally between 1,000 and 5,000 follicular units are grafted. If the transplant is well performed, both techniques (FUT and FUE) offer excellent results. The surgeon may be able to achieve a density ranging from 30 to 90 follicular units per cm2.


Basic aspects of a hair transplant

Attention to naturalness

The main aspect that should characterize a successful hair transplant is the achievement of a natural result. This applies both to the creation of a conservative, well-broken frontal line and to the achievement of correct hair density in previously glabrous or thinning areas. The goal is to ensure that, in the eyes of an observer, surgery is never performed. Thanks to technological developments in recent years and the experience of surgeons and staff involved in the operation, it is possible to achieve completely natural results.

Dimensions of the punch used for the extraction of follicular units

The punch is the instrument used by the surgeon to extract the follicular units from the skin. Its size is of paramount importance. For a transplant to be well performed, it is not enough to extract a large number of grafts, but it is essential to ensure the survival of the follicles that must take root once grafted.

Choosing the right diameter punch will minimize the risk of transection. Moreover, the smaller the damage caused to the skin around the follicle, the less invasive will be the small scar that will form in the donor area.

Attention to follicular unit preservation

When grafts are extracted from the donor area, they are subject to dehydration as all cellular mechanisms are disrupted and modified. Consequently, it is essential that they be handled with the utmost care. Follicular units are stored in a physiological solution that mimics the parameters of the human organism and must always be moistened even when handled under a microscope.

Careful preparation of incisions

The incisions made in the recipient area, in which the extracted follicular units will be inserted, also play an essential role in the success of the transplantation. These are made with the help of scalpels or “custom-made” blades, i.e. chosen according to the characteristics of the patient’s skin and the result to be obtained.

Among the elements to be considered are in particular depth, length and angle of incision. The goal is to perfectly recreate the angle of growth of the patient’s hair. If the incision is well performed, the inserted follicle will immediately receive from the blood vessels the necessary nutrients for its survival. Recently, the following types of incisions are recognized:

  • Coronal incision: made perpendicular to the direction of hair growth, but not opposite.
  • Sagittal incision: made parallel to the direction of growth of the hair.
  • Lateral slit: a term often associated with coronal incisions but has a different meaning. For an incision to be lateral it must be made with a blade and not a needle, it must be perpendicular to the growth of collagen and hair, and a sufficiently wide blade must be used, based on the size of the follicular units.


Avoid the phenomenon of overharvesting

With overharvesting we indicate the risk of damaging the donor area during surgery by taking an excessive number of follicular units. The offered density should be respected, always taking into account the possibility of performing additional sessions in the future. In this context, the Strip extraction method is safer, since the same suture can be reused, without affecting the surrounding area.

The possibility of performing hair transplants using a combination of Strip + FUE is not ruled out. This is an innovative technique increasingly used by experts to maximize the results of surgery.


The surgeon’s skills in hair transplantation

  • Deep knowledge of the anatomy and physiology of the hair and scalp and fully understand all the pathologies that may affect the scalp.
  • Perfect understanding of facial anatomy, possess excellent surgical skills and have a comprehensive knowledge of the different intervention techniques and those necessary to remedy poorly performed interventions (so-called cases repair).
  • Commit to keeping abreast of the latest surgical and therapeutic advances and cooperate with progress. It is preferable for the surgeon to devote most of his or her activity in the operating room to performing hair transplantation. It is practically impossible that a surgeon who dedicates a minimal part of his temple to hair transplantation, performing a few operations per month, can offer results with excellent quality standards.


Is transplantation painful?

The level of pain is subjective and depends on individual sensitivity. During the operation, the affected area is desensitized due to local anesthesia. It is possible that you may feel a sensation of slight tension in the scalp due to the anesthesia, but this phenomenon disappears spontaneously within a few days.

Given the need to make a suture after the extraction of the strip of skin with a strip extraction, this method is generally more invasive and it is possible that the client complains of a numbness of the donor area that can last several months.

Physiological phenomena due to both transplantation techniques include swelling of the recipient area, the frontal area and the eyes. These discomforts last approximately 8 days at most.


Fall of grafted hair after transplantation

One of the least loved aspects of hair transplantation, which meets with the disfavor of the general public, is the fall of grafted hair in the recipient area that occurs between 2 and 6 weeks after the operation. Most of the transplanted hairs will fall out and it may happen that the phenomenon also affects the native hairs.

This is a completely physiological phenomenon. It is the lengths that are lost, not the follicles, which, if well grafted, will be able to give birth to new hair about 3-6 months after transplantation.


The importance of the preliminary consultation

The first meeting between surgeon and patient plays a fundamental role for two main reasons:

  • Realization of a detailed history;
  • Defining the likely course of the condition.

It is during the preliminary consultation that the surgeon defines a detailed plan of action by analyzing:

  • Health status of the subject
  • Current hair situation
  • Quality of the hair structure
  • Large size of the alopecic area
  • Density of hair follicles per cm2
  • Presence of scars or grafts from previous hair transplants


To perform this analysis, the surgeon uses special equipment, such as the densitometer (instrument to measure the density of follicular units per cm2) and macrophotography for the realization of a phototrichogram (to measure hair growth and caliber).

The psychological dimension of the patient must also be taken into account and his or her expectations must be compared with the possible achievable results. In case a patient is very young and has high expectations, it is appropriate to illustrate the evolution that the baldness could have.

The choice of extraction technique plays a fundamental role. During the consultation, the patient will be informed about the surgeon’s decision, who will explain to him:

  • What is the number of follicular units that will be extracted;
  • How the surgery is performed;
  • How many sessions will be required;
  • What is the result that is possible to obtain;
  • What are the possible complications as a result of the operation;

The patient has the right to ask any questions, to view clinical cases with pre- and post-surgery photographs and to request explanations if any of the above aspects are unclear. After that, a detailed and clear informed consent is signed.


The ideal candidate for a hair transplant

Below is a brief list of who represents the ideal candidate for a hair transplant:

  • Men and women who suffer from androgenetic alopecia;
  • Women and men who wish to increase density in areas of the scalp affected by thinning;
  • Men and women wishing to restore hair on eyebrows, eyelashes, burned body areas, pubes;
  • Women and men who have scar areas post-transplant, post trauma, or skin disease.


BHT (Body Hair Transplant)

BHT, from the English Body Hair Transplant, represents one of the biggest innovations in hair restoration surgery. Almost all hair transplant procedures use follicular units taken from the scalp, but when faced with a patient who needs a lot of grafts, which are impossible to find in the occipital area, hairs from other areas of the body can be an important resource. Generally, follicular units are taken from the forehead, beard or back, but also from the arm and legs, and are grafted onto the scalp. We tend to avoid grafting these grafts to reconstruct the hair line, and prefer to use them to increase density in the mid-scalp or vertex.

The first surgeon to test this new method was Ray Woods in 1998. To this day, it is still a technique in development, performed by only a few specialized clinics. It is possible to harvest a variable number of follicular units between 500 and 4,000 in a single session or on two consecutive days. The technique used is FUE, so each graft is extracted individually. These hairs, just like hair taken from the scalp, also fall out within a couple of weeks, and then regrow after about 4 months.

Of course, for a patient to be a good candidate for BHT, he or she must exhibit certain physiological characteristics, as the body hair must be suitable for extraction and reinsertion into the scalp. It should also be taken into account that body hair is subject to different life cycles than scalp hair. All of these aspects make BHT a complex and delicate technique.


Hair cloning in hair transplantation. When will it be possible?

Theoretically, when it will be possible to clone hair, the limitations imposed by the availability of hair in the donor area will disappear.

In that case all people with baldness will not only be candidates for a hair transplant but will be able to achieve the desired density. Currently, however, this is not possible and the conscientious surgeon will always have to take into account the finite nature of the available donor area.
Hair transplant surgery requires the surgeon to have both artistic and technical skills. The doctor must create a natural result that is in accordance with the availability of hair in donor area, the characteristics of each individual person’s hair and the patient’s expectations.

The surgeon must choose an appropriate design not only in the short term but also in the future, keeping in mind that the patient will age. Artistry alone, however, cannot ensure successful surgery. The transfer of thousands of small follicular units requires high technical skills. This is why the surgeon needs to be supported by an experienced and well-prepared staff capable of carrying out a complex and time-consuming procedure such as a hair transplant.


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