Hair transplant success
How do you achieve the best results in the art of hair transplantation? Is it about FUE, strip surgery or the tools? Dr Bessam Farjo discusses how to achieve success using state-of-the-art techniques
Achieving the best result depends on a wide variety of factors. As with any treatment you always start with assessing, consultation and patient selection. You can have the best tools, the best skill but if you choose the wrong patient you’ll never achieve the right results. For example, you treat somebody surgically, you produce a good result but they continue to lose more hair and the transplant looks very silly. This patient should be on finasteride, minoxidil, lasers or perhaps PRP and the like before you get into surgery.
One of the most common causes of dissatisfaction with surgery is that the hairline is not in the right place. When you’re designing, it’s important to have macro-variation and micro-variation—once you’ve done an irregular hairline, irregulate it even more so that there’s no evidence of a pattern.
Donor area management
The donor area yields a limited amount of hair. When we remove the hair we must extract these hairs intact, avoiding transecting the follicles. If more than a third of the follicle is transected then you get no regeneration and these hairs are lost to the patient forever.
There are two methods to harvest the donor area: follicular unit extraction, FUE, and strip technique, commonly referred to as FUT.
Manual FUE requires a high level of skill, using punches between 0.7mm and 1mm. You can use a mechanised drill, which is faster; perhaps less precise. Whether it’s manual or motorised, you drill cylindrical shapes out and pick out the grafts with fine forceps.
The advantage of FUE is that you get no linear scar. You do, however, end up with these little dot scars that may or may not be visible when the hair is almost shaved depending on the patient. You get minimal post-op pain, much less than the strip operation. You have less donor dissection involved so you need fewer staff. The disadvantage of FUE is that it’s time-consuming and therefore more expensive for the patient, and it generally requires that the patient shave their head on the day.
People with spiky hair, where you can see right through to their scalp, they tend to be good candidates for FUE as a linear scar is more difficult to hide. Or a young patient with uncertain future family history, if you do FUE they keep the option to have their hair short in the future and not have any more transplants if they don’t want to.
The advantage of strip surgery is it’s less time-consuming and therefore cheaper. You can move higher numbers of grafts per operation and shaving the scalp is not required. Usually you get a lesser rate of transection because you can visualise everything under the microscopes. The main disadvantage of strip harvesting is the linear scar. Done skilfully, it will be very difficult to find, but no matter how thin it is, it’s there. They do get more pain after the surgery either because of the stitches or staples. The scalp elasticity can be an issue. But it is good for people unwilling to shave their donor hair and people who have small donor areas, where you don’t have enough space to remove the spread-out FUEs.
There’s not much point doing all these grafts and then a significant number of them die because you’ve not preserved them well. We used to keep them in normal saline, now we use Ringer’s lactate. We add ATP to it, some people use organ transplant solutions with a variable level of success.
In the strip type procedure, the initial dissection step is called slivering, producing this slices that are passed on to technicians who separate the individual groupings. We don’t want to be transplanting skin; we want to mainly transplant hairs. But you don’t want to trim too much and skeletonise the graft, because then it can be damaged easily and may not grow correctly. But if you leave too much skin then it can lead to unnecessary scarring. Then you separate the individual follicular units, which can range between one and four hairs.
You then design the process—most of us would choose to put single hairs at the front, two hairs behind and the three and four hairs are used to produce density in areas that are not directly visible.
Some surgeons use a needle and implanter in one, an implanter that makes the incision and you plunge the graft at the same time. It’s a matter of personal preference. The incision has to be right. If it’s too big the graft will move within the incision and grow differently. If the incision is too tight it can compress the graft and heal in a dip or the hairs compress together and it gives you an angry and artificial look.
When you walk into a transplant room it’s more like a manufacturing plant than an operating room. There is so much happening, everything has to be right, every single part of the process that goes wrong could result in an undesirable result.
Dr Bessam Farjo is a Hair Transplant Surgeon and Founding Director of the Farjo Hair Institute W: farjo.com