Expert Dr Bessam Farjo takes us to the root of hair transplant surgery
Two types of hair transplant surgery exist today. The difference between them is the method of harvesting from the donor. FUE, which stands for follicular unit extraction, can either be done manually, mechanically, or it can be automated and robot-assisted. FUE involves extracting grafts or small units of hair individually using very small drill bits. The second more traditional technique, is the strip or follicular unit transplantation (FUT) technique, where a block of skin or graft is removed from the back of the scalp and then it’s microscopically dissected into the individual grafts.
FUE uses punches that are between 0.7 and 1.2 mm in diameter. It can be done manually—the punch is attached to a handle and can be manually spun. It’s very controlled, but very labour-intensive. It can also be done mechanically in the same way. In the majority of cases the back and sides of the scalp will need to be shaved for the surgery. The tiny round wounds will ultimately heal in the form of very small dot scars scattered amongst the hairs.
The alternative to the manual spin, is to do it robotically. After reading the fiduciary readings or grid readings, a robotic arm automatically finds the grafts, while the surgeon manually oversees it, or manually controls it. The robot has a camera system that detects the hairs, calculates angles, and calculates the appropriate depth to extract these grafts. The surgeon can look at a grid on a screen, watching the action on magnification. All the other readings on the screen are essentially various variable parameters, from depth of the punch, to the angle of entry and so on. Essentially, it is a robotically-assisted variation of follicular unit extraction.
FUT Strip Harvesting
In the FUT strip harvesting method, a narrow but long strip is removed from the back of the scalp. The patient has a wound that’s either sutured or stapled. Then the harvested strip is microscopically dissected into the individual grafts. Usually this procedure needs a bigger team and a more elaborate, more involved set-up.
For strip harvesting, the area is marked and only the part that needs to be removed is shaved. The strip is removed, carefully dissecting in the subcutaneous fat, preserving the roots.
This technique relies on the scalp being reasonably elastic. A trichophytic closure could be used, where epidermis is removed from one edge, to be overlapped by the other edge in order to force hairs to grow through the cut—to further disguise the obvious linear scar that the patient will end up with as a result of this surgery. Obviously, the hair will cover it up either way.
Once the strip has been removed, a technical team prepares the strip into individual grafts, dissecting in two different planes under dissecting stereoscopes. The result is grafts that would have otherwise been obtained directly using the FUE method.
After slivers are produced in one plane (see fig 6) any excess of fat is trimmed and then and dissection is carried out in the opposite plane and the individual groupings separated.
Sometimes there are two hairs, three hairs, or even one hair, and sometimes four or five hairs. The idea is to preserve them the way they are, minimising the amount of tissue there, so that the transplant is mainly hairs, rather than skin.
Influences on procedure choice
I recommend a strip-type operation over the FUE if the patient is unwilling to have the back of their head shaved. In order to drill the hairs out in the FUE method, the hairs need to be shaved to a grade one. If a patient is unwilling to shave the entire back of their head, we cannot do enough work. For those unwilling to shave their head, the strip gives them an alternative way for this operation to be done.
If the donor area at the back is of limited size and only the very centre of that area can be utilised, then it’s a good way of getting high numbers of grafts. Perhaps the patient has a financial issue and this operation is cheaper. The strip is popular in women, because although the FUE procedure is possible, the patient has to grow the hair long to hide the shaved bit. Most women in my experience, would be unwilling to have their head shaved for this operation and they would be happier with this strip method.
Who chooses FUE procedure?
Some patients have a preference for FUE because they’ve read about it and this is the way they prefer to have it done. I may recommend it because of their hair character—people with hair that is spiky and coarse in nature or where the hair comes out at obtuse angles, no matter how long they keep their hair, the scar will always be at risk of being visible with a shorter cut and therefore FUE is a more suitable operation. It also appeals to men who like to have their hair short or cropped all the time.
If the patient has a history of unattractive looking scars, it’s advisable to avoid giving them a linear scar. FUE is also preferable if the patient has a tight scalp. Young men, with an uncertain future of hair loss, may wish to have the option to have their hair short and they may not necessarily need to have further transplants in the future. FUE gives them that option and that freedom.
Regardless of the method of harvesting these grafts need implanting. Once harvesting has been done, what follows after that is the same; whether you’re doing the strip method or the FUE.
Most practices, like to create implant incisions first. These are recipient sites that are going to receive the grafts. They can be made with blades or hypodermic needles of a variety of sizes—controlling angles and controlling direction—that will then be followed by inserting the grafts. It’s important to test these grafts to see if the incisions made are of suitable size. If they’re not of suitable size, after about ten or 20, the size of that blade can be made smaller or larger as needed.
Since some of the grafts have one hair, some of them have two, three or four, they should be replanted in specific locations where deem most suitable. For work on somebody’s hairline, it’s best to put single hairs first, followed by double hairs on the hairline, and three- and four-haired grafts further back. When working on the crown, this many change to three and four-hair grafts near the top and middle of the crown and double hairs near the lower part and the whorl. It’s possible to create incisions at different angles and in different ways so that you can simulate the growth of the hair in the natural direction.
In contrast to the dense areas further back, it’s important to keep hairlines looking natural and feathery in order to simulate a natural hairline. A transplant will not look natural if the hair follows a line that’s too straight or a line that’s too thick. The angle is also important in order to avoid planting hair that grows straight up or growing in the wrong direction.
When inserting a graft, a variety of tools and forceps can be used to insert. Smooth forceps cause the least damage to the graft. The biggest problem with the grafts is that they can easily get dehydrated and the most likely cause of damage to the grafts is dehydration.
Different zones of the scalp have different importance. At the hairline, it’s important to pay attention to the part line where the patient going to lose further hair, so that if they do lose hair, that edge look feathery to simulate natural hair loss. At the very back, if the patient has been left with a bald area behind, it’s important to feather it out so it looks like they’re balding naturally, rather than having a sudden partition line.
Transplanting for women
There are important considerations when it comes to women. Women can have hair transplant surgery by either method, but it’s important to remember, women have a more diffuse pattern of loss behind the hairline. Very rarely do women go completely bald, so it’s necessary to work amongst the existing hairs and pay much more attention to avoid trauma to these hairs.
On initial consultation it’s vital to exclude various conditions, when determining why the hair is being lost. Only when you actually establish that the loss is actually female pattern hair loss is surgery the answer. Women tend to be thinner on the parietal areas. The good donor area tends to be restricted to the very back, so harvesting sites are more limited in numbers. For some reason, women have tighter scalps, which means it may be necessary to remove a thinner piece, or perhaps do FUE.
It’s essential to warn women that because you’re working amongst existing hair, it’s possible they may get traumatic loss because of the surgery. So they may end up with a worse situation a month or two after surgery, before their hair grows back and the result of the transplant comes through.
Another area that can be treated, especially in women, is patients with a naturally high hairline. Care is needed if a man asks for intervention at the hairline, because obviously a man is more likely to lose hair through androgenetic alopecia in the future. A woman who has a naturally high hairline and no evidence of female pattern hair loss, could achieve a lower hairline with a hair transplant. A hairline lowering or forehead reduction procedure could do that as well, but that gives a scar around the hairline, which can then easily be disguised with a hair transplant procedure.
Other applications of hair transplant surgery
For eyebrows, transplants work extremely well. A lot more attention to the angles and growth direction is needed and it’s also necessary to warn patients that the hair is taken from the scalp and therefore the hair will grow like scalp hair—they need to trim their eyebrows possibly every week, maybe every two weeks. As yet, I’m yet to treat a patient who thought that was a problem. This isn’t just a solution for over-plucking, it’s possible that as a result of trauma or burns, this kind of procedure could also be called for.
The same principle can be applied to beards. I recently treated a patient who had a trauma to the chin area as well as the beard on the side from a dog bite. I often get asked if transplanted hair can grow very well in scar tissue, if certain precautions are taken. Obviously not all scars are the same, but in general, it responds reasonably well.
In face-lift surgery patients, hair can be lost in front of the ear if the lift was a bit aggressive, where it’s also possible that a scar becomes exposed. These are both things that can be tackled with hair transplantation. Triangular alopecia, congenital areas of loss like that, usually on one side, can be treated perfectly with hair transplantation. Traction alopecia, much more common in Afro-Caribbean women, also can be treated. Sometimes it can require two operations but it can work reasonably well as well. Patients who have had radiotherapy and the hair was lost and did not grow back can be treated similarly.
Caution is needed in cases of scarring alopecia, or cicatricial alopecia like lichen planopilaris. It’s vital to ensure that the condition is dormant on biopsy and certainly, clinically, for a minimum, of two or three years. Patients must be warned that the condition can come back and if it does, then the hair will possibly fall out. There are certain conditions for which a transplant is not probably a good idea, like lupus and frontal fibrosing alopecia. Success is extremely variable with those kind of conditions.
Today’s hair transplant surgery offers alternative techniques to suit different stages of hair loss and different desired hairstyles and lifestyles in healthy men and women. All round skill and expertise by the surgeon offers the patient the solution that is in their best interest.
Dr Bessam Farjo is a fellow of the International College of Surgeons (FICS); A Diplomate and Past Board Director of the American Board of Hair Restoration Surgery (ABHRS); Past President, Ambassador & Fellow of the International Society of Hair Restoration Surgery (ISHRS); Founder Member and Past President of the British Association of Hair Restoration Surgery (BAHRS); Fellow and Medical Director of the Institute of Trichologists and Founder Member of the Trichological Society. He has numerous hair-related peer reviewed publications and has clinics in London & Manchester exclusively dedicated to medical & surgical hair restoration. Joint recipient of the 2012 ISHRS Platinum Follicle Award for ‘outstanding contribution to hair research’.