Hair Transplant

Hair Transplantation:
Principles and Practice
Presented by: Dr.Mir Laieeq
Moderator: Prof. Iffat Hassan.
Introduction
• Hair transplantation is a procedure performed
in an outpatient setting under local
anaesthesia.
• It is based on the theory of donor dominance
i.e. terminal hair from the unaffected
posterior scalp will continue its growth
pattern even when transplanted to the
balding frontal scalp
Introduction
• In past,3–4 mm grafts containing 15–30 hair follicles
were used. But it resulted in unnatural appearance
due to obvious “plugs”(“Barbie-doll”)
• Currently grafts with one to four hair follicles,
referred to as individual follicular units are used
giving transplanted hair having a more natural
appearance.
• The net perceived density from a hair transplant is
equal to the number of follicles transplanted minus
ongoing hair loss.

Timeline
• 1939 Japanese dermatologist, Dr. Okuda, published a revolutionary method using
small grafts from donor area to correct lost hair from scalp, eyebrow, and
moustache areas. No impact in the Western Hemisphere due to the interruption
by World War II.
• Late 50’s Dr. Norman Orentreich, experimented with transplanting the hair on the
back and sides of the head to the balding areas. Transplanted hair maintained their
bald resistant genetic character
• 60’s and 70’s involved the use of larger grafts that were removed by round
punches and often contained many hairs
• In 80’s large punch grafts were gradually replaced with “combination mini micro
grafting” Minigrafts (4-8 hairs) were used to create fullness and density, while the
(1-3hair) micro grafts were used to create a refined and feathered hairline in front.
• 90’s introduction of “follicular unit hair transplantation” the
current "Gold Standard”.
• Transplants hairs in their naturally occurring one, two, three,
and four hair “follicular unit groupings” in which they grow
naturally.
• 1995,Dr. Robert Bernstein proposed creating hair restoration
using exclusively follicular units.
• Dr. Limmer was first to use the binocular microscope to
examine the donor tissue to successfully isolate and trim the
naturally occurring follicular units into individual graft
Indications
• Androgenic alopecia(in men and women)
• Male pattern alopecia
• Cicatricial alopecia
• Traumatic alopecia
• Traction alopecia.
Contraindications
• Diffuse female pattern baldness
• Non–donor-dominant alopecia
• Alopecia areata.
Scarring alopecias are nondominant and, while
active, do not respond to hair transplantation.
Hair transplant is inappropriate in active phases of
Lupus, infections and poor general health.
Vitiligo and psoriasis can be aggravated by hair
transplantation

Candidate Selection

• Selection of appropriate candidate needs to be
done from a medical and a psychological
perspective.
• Assessment of areas of greatest concern and
Whether the patient has realistic expectations
• A complete medical, surgical and hair loss history
• Previous hair transplants and scalp surgeries as
well as scar formation.
• The etiology of the hair loss is determined,
primarily via physical examination of scalp
• Clinicopathologic correlation(occasionally
needed)
• The stage of patterned hair loss.
• Medications review with regard to their
effects on hair growth and haemostasis.
• Appraisal of the density and caliber of donor
hair in the occipital scalp as both have an
impact on the perceived density of the
transplant



FIVE BASIC CRITERIA FOR ASSESSING CANDIDATES FOR HAIR
TRANSPLANTATION

(1)Age Patients >25 years are
preferable.
Unpredictability of future
hair loss in individuals
between 15 and 25 years of
age.
This subgroup also tends to
desire a return to a full head
of hair as opposed to a
mature pattern of restoration
done in older age groups
(2)Hair shaft caliber
Those with large-caliber(>70
microns) obtain much denser
coverage than those with
corn silk quality hair.
• (3)Donor hair density
• Measuring a 0.25 cm sq.field
and multiplying by four is the
preferred method.
• Patients who have >80
follicular units/cm sq.are
excellent candidates.
• Those with donor hair
density <40 follicular
units/cm Sq.are considered
poor candidates





FIVE BASIC CRITERIA FOR ASSESSING CANDIDATES FOR HAIR
TRANSPLANTATION

(4)Degree of baldness (most
important criterion)
 Those with complete
baldness of the frontal scalp
as opposed to baldness
limited to the vertex are
excellent candidates.
When frontal baldness is
corrected, there is dramatic
cosmetic appearance.
(5)Hair color Follicular unit
grafting has made hair color
less of an issue than when
punch grafts were employed.
 Color contrast between hair
and skin can make grafts
apparent if not transplanted
with great care.
Individuals with “salt-and-
pepper” hair, red hair or
blonde hair are preferential
to those with jet-black hair.
Black-haired individuals are
not exempt as hair transplant
candidates, but should
receive only one-hair
follicular units in the frontal
hairline for the most natural
result.
Proper technique eliminates
most problems with dark-
haired candidates
Ideal candidate(summary)
• High density in donor area(80hair/cm.sq)
• Mixture of fine caliber hair to create hairline and
coarse hair for density
• Minimal contrast between hair and skin color
• Some wave, curl and/or fizz
• Existing hair in recipient area which may be used for
camouflage post operatively.


Donor density
• Type A – 200 hairs per cm.
sq.
• Type B – 150 hairs per cm.
sq.
• Type C – 100 hairs per cm.
sq.
• Type D – 50 hairs per cm. sq.
• (type D’s are not good
candidates for hair
transplantation)
• Class I represents an adolescent or juvenile hairline and is not
actually balding. The adolescent hairline generally rests on the
upper brow crease.
• Class II indicates a progression to the adult or mature hairline that
sits a finger’s breath (1.5cm) above the upper brow crease, with
some temporal recession. This also does not represent balding.
• Class III is the earliest stage of male hair loss. It is characterized by
a deepening temporal recession.
• Class III Vertex represents early hair loss in the crown (vertex).
• Class IV is characterized by further frontal hair loss and
enlargement of vertex, but there is still a solid band of hair across
top separating front and vertex.
• Class V the bald areas in the front and crown continue to enlarge
and the break down of bridge of hair separating the two areas.
• Class VI occurs when the disappearance of connecting bridge
leaving a single large bald area on the front and top of the scalp.
The hair on the sides of the scalp remains relatively high.
• Class VII patients have extensive hair loss with only a wreath of
hair remaining in the back and sides of the scalp

Norwood Class A(2A-5A)

• The Norwood Class A patterns are characterized by a front to
back progression of hair loss.
• Norwood Class A’s lack the connecting bridge across the top
of the scalp
• Generally have more limited hair loss in the crown, even
when advanced.
• Since the hair loss is most dramatic in the front, the patients
look very bald even with minimal hair loss
• Men with Class A hair loss often seek surgical hair restoration
early
frontal bald area is not generally responsive to medication
dense donor area contrasts and accentuates the baldness on
top.
• Fortunately, Class A patients are excellent candidates for hair
transplantation.

Diffuse Patterned and Unpatterned
Alopecia

• These types of genetic hair loss pose challenge both in
diagnosis and in patient management esp. in young
diagnoses may be easily missed
• Diffuse Patterned Alopecia (DPA) is an androgenetic alopecia
manifested as diffuse thinning in the front, top and crown,
with a stable permanent zone. Does not pass through the
typical Norwood stages.
• Diffuse Unpatterned Alopecia (DUPA) is also androgenetic,
but no stable permanent zone. DUPA tends to advance faster
than DPA and end up in a horseshoe pattern resembling the
Norwood class VII.
• Differentiating between DPA and DUPA is very important
because DPA patients often make good transplant
candidates, whereas DUPA patients almost never do, as
eventually don't have a stable zone for harvesting.

• Diffuse Unpatterned
Alopecia (DUPA) in a 32
year-old male

• The densitometry
reveals extensive
miniaturization.
Key Concepts

Candidates should be made aware that AGA is
progressive despite undergoing hair transplantation.
Medications (e.g. oral finasteride) can help to maximize
hair density from a transplant by minimizing ongoing
hair loss.
 The surgeon should always assume that in the future
these medications may be discontinued
Additional hair transplants may be required, perhaps in
another 5 or 10 years.
 The physician should emphasize how ongoing hair loss
will affect the density and cosmetic appearance of
transplant.
Key Concepts

• The number of expected procedures to accomplish
both short- and long-term goals should be
reviewed, as well as the limits on available donor
hairs.
• Concentrating the transplants in the frontal scalp
will allow maximum long-term density with minimal
long-term cosmetic risk.
• Ideally a reserve should be left in the donor region
for any unanticipated areas of MPB as well as
thinning of the transplanted hair

Key Concepts
• Most female patients will not have sufficient donor
areas of good density to adequately treat all affected
areas.
• For most women the goal is limited to the
transplantation of primarily the cosmetically most
important areas like
 Frontal area
Vertex whorl area and a
 5- to 6-cmwide antero-posterior corridor through
which the patient's hair normally parts
• The hair in these thickened areas is styled in such a
way as to camouflage the untreated area
Four conceptual zones in MPB
• Frontal Area between intended hair line and
intertragal line
• Mid scalp area between frontal area and
vertex transition point.
• Vertex area includes remainder of alopecic
areas
• Evolving areas adjacent to 3 major zones.

• Ideally each of the major areas is treated at
the same time as adjacent evolving area of
MPB lateral to them.
• Typically only one major area is treated at
each session.
• It is only a general rule and variations are
there depending upon size of recipient area.
Some Mathematics!
• No. of follicular units/cm
2
is
nearly constant in all
individuals, normal density
being 100 FU/cm
2
and no. of
hairs per unit is 1 to 4
• Since the follicular unit
density is relatively constant;
the same number of follicular
units is needed to cover a
specific size of bald area
regardless of the hair density
of the patient.
• A person can lose half the
number of his hairs before he
appears bald


• Calculation of the number of
hair units required for the
recipient area
• Frontal area is triangular and
the area is calculated by the
formula ½ x breadth x height
• Vertex is circular and its area
is calculated by the formula:
A = pr
2
(A = area, p = 3.14, r =
radius).
• Usually half the calculated FU
are transplanted giving good
cosmetic results.


Mega sessions
• A session in which more than 1000 units are
grafted is called a mega-session. It has several
advantages:

• It avoids multiple surgeries and the resulting
absence from work

• In multiple grafts, the first graft always yields
the best results

• A large session economizes donor supply
Preoperative evaluation
• Complete history and physical examination.
• Appropriate lab studies focussing on excluding
Bleeding dysesthesias (complete coagulogram)
Hypertension
 Coronary artery disease
 Hepatorenal disease
• In females rule out potentially treatable causes by
CBC,Iron profile,TFT
Total & free testosterone,DHEA(if irregular menses)




Patient positioning
• During the removal of the donor strip, the
patient is placed in a prone position with the
head in a special prone pillow that allows
comfortable breathing while face down
• During the creation of the recipient sites and
insertion of the grafts, patients are usually in a
semi-supine position

Anaesthesia
• Ananesthetic field block is first created using 30-gauge
needles and 1-2 % lidocaine with 1:100,000 epinephrine
along the inferior edge of donor area.
• Once anesthesia is obtained, 20 ml of normal saline or 50ml
NS with 0.5ml of epinephrine can be injected to provide
further anesthesia, hemostasis and dermal turgor or
tumescence ; the latter helps to reduce the transection of
hair.
• Local infiltration to create ring block of anaesthesia anterior
to anticipated recipient area is commonly used technique.
• Lidocaine dose must be limited to 7 mg/kg with
epinephrine(max 500 mg)or 4.5 mg/kg(max 300mg) without
epinephrine.
• After 2 hours LA should be reinforced by 0.25%-0.5%
bupivacaine with 1:100,000 epinephrine(max 200mg).This
lasts 4 hours.

Donor Region

• The amount of available donor hair is the primary
limiting factor in hair transplantation
• In general, there are 65–85 follicular groupings/cm.sq.
in the occipital donor scalp.
• The mid occipital scalp between the two occipital
protuberances is the recommended donor site
Density of hair
Ability to camouflage the donor scar(d/t lack of
involvement by AGA)
• Donor density does not correlate with the extent of
current or future hair loss in the frontal scalp or vertex.
Techniques for graft harvesting
• 2 techniques for harvesting of donor:
Elliptical donor harvesting
Follicular unit extraction

Elliptical donor harvesting

Elliptical donor harvesting is performed in majority
owing to
Safe and rapid removal of large numbers of hair
follicles
Minimal transection of hairs.
• The width of the donor ellipse ranges from 7 mm to
1.2 cm, while the length should be less than 30 cm.
• The number of follicular groupings required
determines the dimensions of the donor ellipse.
• Increasing the width of a donor ellipse creates more
wound tension and may lead to a hypertrophic or
wide scar.

Elliptical donor harvesting.
• Initial scoring of the excision
may be done with a single or
double #15 blade scalpel
• Double blades should be
oriented parallel to the
exiting follicles.(to avoid
transection)
• The incision should extend
into the subcutaneous fat but
not deeper (∼5 mm into the
scalp),to prevent damage to
occipital artery and nerves.
Elliptical donor harvesting.
• Lateral retraction using fine
skin hooks exerts tension
away from the excision and
creates good visibility.
• The ellipse can be removed
by scissors or a scalpel, being
careful to avoid damage to
any follicles in the
subcutaneous tissue.
• Ellipse can be removed
without the use of
electrocoagulation (if incision
is within Subcutaneous fat)
Elliptical donor harvesting
• The donor ellipse can often
be primarily repaired with
no undermining if it is <1
cm in width.
• Some surgeons utilize a
two-layer closure while
others perform a single-
layer closure.
• Staples or sutures (Vicryl or
3-0 silk) can placed and
then removed 7–10 days
later.

• Absorbable sutures may
be used for those patients
who live a long distance
away from the physician’s
office.

Dissection of hair
• This is perhaps the most important step in the procedure.
• The elliptical strip is first dissected into small slivers of 1 or
2 follicular unit width (1-2 mm) under a stereomicroscope(
to avoid transection of hairs)
• The slivers are then dissected into units of 1-4 hair units
either under a magnifying loupe or a microscope
• Whether the grafts should be skinny (thin) or chubby (thick
with a little amount of dermis around them) is a matter of
debate
• After separation follicular unit grafts must be put into
chilled saline or an equivalent medium until they are placed
into the recipient sites



Follicular unit extraction
• In 1984, Headington a paper demonstrating that hairs did not
occur singly, but as naturally occurring groups that were referred
to as the follicular unit.
• Each unit consisted of 1 to 4 terminal follicles. This paved the way,
in 1990s, for the 'Rolls Royce of hair transplantation' follicular unit
transplantation (FUT)
• Follicular unit extraction (FUE) represents the removal of
individual follicular units from the posterior scalp via 0.75–1.2 mm
punch device.
• The incisions are so small that they leave no visible scar after they
heal.
• FUE is an excellent alternative technique for patients
 Who like to have closely cropped hair and do not want a visible
scar
 Extensive scarring from previous transplant procedures.

Follicular unit extraction

But FUE is
Time consuming
Obtains fewer follicular groupings from each
procedure
 Higher rate of transection of the follicular
groupings.
In the future, refined instruments and robotics will
hopefully lead to more rapid and precise harvesting
of individual follicular groupings
ELLIPTICAL DONOR HARVESTING
VERSUS
FOLLICULAR UNIT EXTRACTION
ELLIPTICAL DONOR
HARVESTING
FOLLICULAR UNIT
EXTRACTION
Visible scar if hair cut short Yes No
Transection of hair follicles Minimal Variable
Time required for harvest 10 to 20 mins 30 to 90 mins
Need to create grafts Yes No
Quality transplant Excellent Excellent
ELLIPTICAL DONOR HARVESTING
VERSUS
FOLLICULAR UNIT EXTRACTION
FOX Test
• It is important to note that the tightness with which follicular
units are held in dermis varies and hence FUE may not be
suitable in all patients.
• This test is to ascertain whether the patient is a suitable
candidate for FUE or not.
• In FOX test, the surgeon takes out a few (about 100) grafts
from the donor area and then evaluates how many
complete/incomplete follicular units are extracted.
• Bernstein and Rassman classified FOX test into five grades.
• If the patient is FOX-positive (grade 1-3), the surgeon can go
ahead with FUE
• Fox grade 4-5 (it is almost impossible to predict the emergent
angle), the yield is too low for the FUE procedure to be
successful.


Follicular Grafts

• Earlier punch grafts measured 3–4 mm in diameter
were often oriented in a perpendicular fashion and
contained multiple follicular units, leading to an
unnatural appearance.
• Nowadays, each graft contains just one follicular
grouping and is oriented at an acute, 30–45° angle
toward the front and slightly toward the midline
• Thus, these grafts mimic the natural grouping and
orientation of scalp hairs
Different sizes of hair
transplantation grafts.
A The newer technique
uses 1- to 4-hair follicular
unit grafts.

B The older technique
uses larger 10- to 15-hair
grafts
• Over several hours, surgical teams can
carefully separate 500–2000 follicular units
from the donor strip.
• Cutting instruments include #11 and #15
blades as well as #10 prep blades.
• Good lighting, comfortable chairs and well-
designed instruments are prerequisites for
producing follicular units with minimal
transection

Some surgeons believe
microscopic dissection or
magnification reduces
transection of follicles during
the separation process


However, the data are still
inconclusive
HAIR TRANSPLANTATION IS A MIX OF SKILL
AND IMAGINATION……
Hairline Design
• In men, the hairline defines the cosmetic
success of a hair transplant.
• Because women have stable frontal, temporal
and posterior hairlines, recreating a hairline in
them is usually not necessary.
• As with hair graft creation, hairline design
should mimic as closely as possible what
occurs in nature.

Hairline Design


Trying to recreate the hairline a patient had before the hair
loss began leads to cosmetic failure even if all the available
follicular units are utilized.
This is due to slow steady recession of the temporal and
posterior hairlines as well as the frontal hairline.

• The design of the frontal hairline should be such that it will
remain balanced with the temporal and posterior hairlines.
• This requires recreating a frontal hairline which is higher and
more receded than the one which was present before the
process began.
A common reason for cosmetic failure
HOW TO PREVENT IT?

Hairline Design

• Hairline should be considered a natural transition zone
rather than a fixed zone .
• This ill-defined “feathering zone” is re-created by
randomly placing, in an irregular pattern, follicular unit
grafts along the newly created hairline .
• Dense packing of grafts should not be performed
because this will lead to a hairline with an unnatural
appearance.
• The level at which the hairline is placed varies from
individual to individual and it is important to first
examine each patient in a global, 360° manner.
Hairline Design and Recipient Site Creation


• While male pattern hair loss is progressive,
transplanted hair will have long-term growth.
• The surgeon must assume that all patients will
progress to the highest grade of involvement with
only transplanted hair remaining.
• This assumption allows transplanted hair to look
equally natural 1 year and 20 years after surgery.
AN IMAGINATIVE ASSUMPTION
Immediate postoperative appearance with graft placement
and hairline design.

Anesthesia and Recipient Site Creation

• A combination of supraorbital/supratrochlear
nerve blocks, field blocks and local infiltration
with 1% lidocaine with epinephrine can be
performed.
• Hemostasis is essential for good visibility when
creating recipient sites and for graft placement.
• The epinephrine in the local anesthetic (placed
into the dermis and not the subcutaneous space)
creates excellent hemostasis.
Anesthesia and Recipient Site Creation
• Recipient sites should mimic the natural 30–45° angle
of hair growth on the scalp
• Instruments such as NoKor needles, slits (for
combination grafts), rectangular punches, 18/19 size
needles (for 1- to 2-hair units) and blades of different
sizes are used.
• When making recipient sites, surgeons must be careful
not to transect existing hair follicles.
• The key to success is to create recipient sites in a
random, highly irregular pattern with 10–30 FU/cm2,
depending on the density of existing hair on the scalp.

Recreating the 30–45° of hair growth on the frontal scalp.
(A) Correct versus incorrect technique (B). Grafts should not be oriented
perpendicular to the scalp surface
Graft Placement
• Two to three surgical
assistants place the grafts
with microvascular
forceps.
• Follicular units are
grasped by their
perifollicular tissue,
avoiding trauma to the
hair follicles.
• Regular surgical forceps
are not recommended.
• Placement of the grafts
into is the most
challenging step.
• Methods for insertion:
a)‘Stick and place method'
involves making a
recipient site, followed
immediately by insertion
of hairs into the site by an
assistant

b) Creating all the
required recipient sites at
one time and then placing
the grafts one by one

POSTOPERATIVE CARE
Day of the procedure
• Apply non-adherent dressing overnight
• Oral paracetamol 300 mg/
codeine 30 mg every 4–6 hours SOS
• Oral prednisone 40 mg OD for 3 days to reduce frontal scalp
edema
• Resume regular activities, but no heavy lifting or strenuous
exercise until staples/sutures removed
• Sleep with head elevated
Postoperative days 1–3 • Day 1 – remove dressing
• Shower each day and allow water to run over grafts
• Comb hair without allowing comb's teeth to hit
perifollicular crusts
• Do not pick or scratch at perifollicular crusts
• Apply emollient to the donor site(s) daily
• Days 1, 2 – continue prednisone
Postoperative days 4–7 •Resume light exercise
• Follow instructions outlined above for showering,
combing and emollient application
Postoperative days 7–
10
• Staples/sutures removed
• Resume regular exercise regimen
• Perifollicular crusts gradually disappear
Complications

• Complications are unusual.
The extensive vascular supply to the scalp results in rapid
wound healing and a low risk of infection.
Temporary
Excessive swelling (∼5%),
Postoperative bleeding (<0.5%),
Folliculitis,
 Headache, and
Pruritus or numbness of the scalp.
Persistent problems
Permanent numbness in the donor or recipient sites
Abnormal scarring around the grafts
Hypertrophic scarring of the donor site
Poor growth of hair grafts.
Other potential complications.
• Lidocaine toxicity.
20 mg diazepam may be injected to raise the minimal
convulsive dose.
 Lidocaine should be injected superficially and
intermittently
Max. Dose should not be exceeded.
• SYNCOPE.
Keep patient supine or prone
Control pain and anxiety
Adequate hydration
Blood glucose maintainence.
Occipital scalp scar secondary to elliptical donor
harvesting
Follow up
• Generally no follow-up is required.
• The grafted hairs may start falling at 2 weeks due to
postoperative telogen effluvium
• The hairs start growing by 3-4 months at the rate of
one cm every month, with full cosmetic results at
the ninth month.
• Minoxidil is started in the second week to promote
hair growth and prevent delayed results



CORRECTIVE HAIR TRANSPLANT
SURGERY
A Usual Scenario
“Patient present for corrective surgery because of
previous transplantation of 3–4 mm punch grafts
that have led to unnatural large “plugs”,i.e. a
“pluggy” transplant.”
3 options can be tried:
• (1) Add a large number of follicular unit grafts
containing one to four hairs between the larger
plugs to soften their appearance;
• (2) Surgically remove the large grafts; and/or
• (3) Perform laser-assisted hair removal.
(1)Adding follicular unit grafts

• Transplantation of a large number of follicular unit
grafts containing one to four hair follicles – in front
of, in between and behind large grafts will soften
the “pluggy” appearance .
• This option is appealing for many patients because
it allows for both cosmetic improvement and
increased density
• But it cant be done if depleted donor supply from
previous transplant procedures
• Some are reluctant to have another surgery
following the emotional trauma from the initial
transplant.











(A) Previous transplantation of 3–4
mm punch grafts can lead to
unnatural large “plugs” of hair.
(B, C) Addition of follicular unit grafts
between and in front of the larger
grafts softens the hairline and the
overall appearance
(2)Surgical removal of grafts

Done for cosmetically unacceptable hairlines &
Large grafts with perifollicular white scar tissue.
The grafts can be removed by either a 2–4 mm punch
instrument or an elliptical excision.
 Also follicular unit extractions from larger grafts via 1
mm punch instruments
• This reduces the “pluggy” appearance of the larger
grafts while allowing a more natural appearing graft to
remain.
• Cosmetically evident scars develop in a small minority
of cases.
Pulsed dye, ablative, non-ablative, or fractional ablative
laser treatments can be used to help improve the
cosmetic appearance.

3 Laser-assisted removal of large
grafts

• As with other parts of the body, lasers only remove
pigmented terminal hair follicles
• Typically 5–10 treatments are needed to permanently
remove the majority of follicles.
• It eliminates majority, but not all of the hairs leading to
substantial cosmetic improvement of the unnatural
plugs.
• Some of the transplanted hair is retained for a more
natural appearance.
• Laser therapy is an excellent option for patients who
want to improve their cosmetic appearance in a
safe,non-invasive manner.
Hypertrophic or broad scars in the
donor region
• No easy solution for repair.
 The best method for minimizing the risk of a wide scar
is to keep the width of the donor strip to ≤1 cm.
• Scar revision leads to variable improvement.
• Pulsed dye, non-ablative or fractional ablative lasers
may be used to help reduce the thickness and
erythema of hypertrophic scars.
• Another option is to transplant a large number of
follicular groupings into the scar in an attempt to
provide camouflage
Hair Transplantation in Scarring
Alopecias

• Hair transplantation can be successfully performed in scarred skin
even though yield is lesser than non-scarred areas.
• More sessions are required.
• But patient satisfaction is high.
Guidelines
• Any inflammation should be resolved completely before hair is
transplanted.
• In the case of inflammatory scalp dermatoses, patients should
have no evidence of inflammation for 6 months off therapy before
the transplant procedure is performed.
• Biopsy specimen should be obtained if doubt about persistent
inflammation
• All patients should be told that any future flare of scalp
inflammation will likely affect the growth of the transplanted hair.
Robotic Hair Restoration
• The FUE robot (ARTAS)is an image-guided system
composed of a robotic arm, dual-needle punch
mechanism, video imaging system, and a user
interface.
• Inner punch has cutting capabilities to score the
upper most part of the skin
• Outer punch has a blunt edge used for dissection of
the follicular units from the surrounding tissue that
minimizes injury to the grafts.
• The image-guided system allows this step to be
accomplished with great precision.



Advantages
• Increased accuracy of
harvesting grafts to
minimize damage to
follicles
• Ability to use FUE in a
wider variety of patients
• Reduced harvesting time
• Increased graft survival


Debunking some myths!
• Myth #1 It is better to have a hair transplant when you are young.
• Fact: at an early age, the pattern of loss is unpredictable and the hair loss
has a greater chance of being extensive in the future. Permanency of the
donor area cannot be determined.
• Myth #2 Most women can benefit from hair transplantation – just like
men.
• Fact: In spite of the great advances doctors are still limited by a person’s
finite donor supply. In many women donor area is thinning as well as other
parts of the scalp, making hair transplantation ineffective.
. Myth #3 When large numbers of grafts are transplanted they do not get
enough blood supply.
• Fact: The blood supply of the scalp is so great and it is so collateralized that
it is able to sustain the growth of thousands of newly transplant grafts. But
If the grafts are too, large or if the sites are placed too close together the
blood supply can be overwhelmed resulting in poor growth. Also, blood
flow is significantly compromised by chronic sun exposure and smoking.
• Myth #4 Large grafts produce more density than smaller grafts.
• Fact: Density depends upon the total amount of hair transplanted to a
particular area, not the size of the grafts


• Myth #5 Laser hair transplants are state-of-the-art.
• Fact: Not used by the most experienced hair transplant
surgeons.
• In fact, laser hair transplants are really a misnomer,
lasers have only been used for is to make the recipient
sites .
• Even for this limited purpose, lasers are a problem.
• Lasers always produce more injury to the skin than a
small slit made with an instrument
• Grafts placed into laser made sites will be less secure
and there will be a greater chance of scarring in the
donor area and poor graft growth.

FUTURE TRENDS

Cloning

• Regeneration and cloning of hair follicles
represents the next step in revolutionizing hair
transplantation.
• With an unlimited supply of hairs, there will
no longer be constraints based upon the
density of hairs in the donor region.
Keratinocyte tubulogenesis has been
induced by cultured dermal papilla cells.

Chermnykh ES, Vorotelyak EA, Gnedeva KY, et al.
Dermal papilla cells induce keratinocyte tubulogenesis
in culture. Histochem Cell Biol. 2010;133:567–76
Stem cells derived from Bone marrow- and
umbilical cord were shown to be a reservoir for
follicle regeneration

Yoo BY, Shin YH, Yoon HH, et al. Application of
mesenchymal stem cells derived from bone marrow
and umbilical cord in human hair transplantation. J
Dermatol Sci. 2010;60:74–83
Epidermal wounding, with upregulation of
Wnt proteins, led to hair follicle regeneration
in adult mouse skin

Ito M, Yang Z, Andl T, et al. Wnt-dependent de novo
hair follicle regeneration in adult mouse skin after
wounding.Nature. 2007;447:316–20.
Erythropoietin has been found to promote the
growth of dermal papilla cells as well as to
prolong the anagen phase of cultured human
hair follicles

Kang BM, Shin SH, Kwack MH, et al. Erythropoietin
promotes hair shaft growth in cultured human hair
follicles and modulates hair growth in mice. J Dermatol
Sci. 2010;59:86–90.
Mouse model for androgenetic alopecia
should provide insights into mechanisms of
disease and therapies

Crabtree JS, Kilbourne EJ, Peano BJ, et al. A mouse
model of androgenetic alopecia. Endocrinology.
2010;151:2373–80.
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