How a Modern Hair Transplant is Performed
Dr. Blake Bloxham Feller & Bloxham Medical, PC
What is a “Modern” Hair Transplant?
• Today’s hair transplant is very different from the “plug” procedures of yesteryears. A modern hair transplant is known as Follicular Unit Transplantation, because the procedure involves the removal and re-implantation of follicular unit groupings – the natural units follicles grow in.
• By removing only true follicular units and implanting these into the bald and thinning regions -- typically in large numbers and densely packed together when appropriate – a modern hair transplant can be extremely natural.
How is a Modern Hair Transplant Performed?
• A modern hair transplant can be broken down into several steps:
• 1) Surgical Planning
• 2) Donor tissue harvesting
• 3) Implantation of follicular unit grafts into the recipient area
Surgical Planning
• Surgical Planning refers to both defining the parameters of the safe area for harvesting in the donor region and demarcating and designing the areas where the new grafts will be placed – IE new hairline design.
• Donor Area Planning: It is imperative that only dihydrotestosterone (DHT) resistant follicles from the “safe zone” be used in hair transplant surgery. Follicles from outside this zone may thin and “fall out” over time. The donor harvesting area must be carefully demarcated to fall safely within this region.
• Although several models exist, most agree that the safe donor begins in the occipital region at the nuchal ridge/occipital protuberance and extends superiorly approximately 6cm; this area extends in the same fashion across the parietal/temporal scalp up to the pre-auricular area. During some Follicular Unit Excision (FUE) cases (to be discussed under “Donor Harvesting”), doctors will take from “safer” areas in the donor region in specific patients (older, less active androgenic alopecia, limited loss in general, limited family history of loss, etc) as long as these patients consent and understand that the grafts from these areas are still not as resistant to future loss as those taken from the true safe donor:
Surgical Planning
• Recipient Area Planning:
• Planning in the recipient plays a crucial role in the overall result. This planning includes: designing new hairlines, rebuilding temporal regions, reconstruction of the natural “whorl” pattern in the crown/vertex, etc.
• Education, experience, and a conservative, “longterm” approach is crucial for creating natural results which will age well and look appropriate at all times.
Donor Tissue Harvesting
• Modern Follicular Unit Transplantation can be performed via two different harvesting methods:
• Follicular Unit Strip Surgery – also known as “FUSS,” “FUT,” and “Strip Surgery”
• Follicular Unit Excision – also known as “FUE” or “Follicular Unit Extraction”
Follicular Unit Strip Surgery
• During an FUSS procedure, a small strip of hair-bearing skin is demarcated in the safe donor region. The area is trimmed, cleaned (chlorhexidine, iodine, alcohol, etc), and numbed with local anesthetic (typically 2% lidocaine with differing amounts of epinephrine). The strip is then excised with a scalpel, and then immediately closed with sutures or staples – which can be done in a variety of ways including multiple layer closures and even in a “trichophytic” manner where hair is encouraged to grow through the resulting scar itself.
• The “strip” is then handed to highly skilled and experienced surgical technicians who will carefully dissect the tissue down into individual follicular units under high-powered stereoscopic microscopes.
• The FUSS procedure leaves behind a linear incision line scar in the donor area.
• Strip harvesting must be performed by the physician.
Follicular Unit Excision
• During an FUE harvest, small dermal punch-like tools are used to carefully score around individual follicular units – after cleaning and trimming. These tools are very small; typically anywhere from 0.7mm to up 1.3mm (though tools this large are now less common). The tool may be a manual punch powered only by the doctor’s hand or may be attached to a motorized tool – wherein a motor provides the rotation or oscillation of the punch. There are various devices which partially automate the process, and even some robotic devices controlled via software. The punches themselves can also be sharp, dull, or a “hybrid” of a sharp and dull punch.
• Once the follicular unit is scored, forceps are used to grasp and apply traction to free the follicular unit from the surrounding tissue.
• Typically, these units are placed under the same stereoscopic microscopes and examined for quality. Some clinics also slightly trim the grafts to remove any excess tissue.
• Despite how the procedure is sometimes marketed online, FUE is a surgical procedure which does leave scars in the donor area. The resulting scars are small, punctuate, hypopigmented “dots,” which can be very subtle.
• FUE harvesting must be performed by the physician.
“FUT vs. FUE”
• There is much debate online today over which technique is “best.” The reality is that each technique has its benefits and limitations, and patients should be evaluated individually and appropriate recommendations made.
• There is much discussion about this topic online, and we encourage interested parties to research further.
• What the ISHRS agrees is not debatable, however, is that donor harvesting in both FUE and FUT is scalp surgery and should only be performed by experienced, licensed professionals – most typically physicians. Delegating this task is illegal in most US states.
Graft Implantation
• The final step of a modern hair transplant involves implanting the follicular unit grafts into the “recipient” area – IE the bald and thinning regions previously demarcated.
• Grafts are typically implanted one of two ways: into pre-made recipient “sites” or in conjunction with recipient site creation using implanter devices.
Graft Implantation
• During placement into pre-made recipient sites, the process starts by the physician numbing the recipient region. This is typically done via a ring block or a supraorbital/supratrochlear block (done with the same local anesthesia used for the donor region).
• After the area is numb, the physician will make recipient incisions or “sites” using either a blade (typically a small, custom-cut flat blade) or a needle. These sites are made in specific directions, angles, and densities in order to create a natural result.
• After the recipient sites are created, surgical technicians carefully “place” each follicular unit graft into each slit.
• Most commonly, the technicians will use jeweler’s forceps (typically “curved”) and needles to carefully and expertly place grafts. However, implanter devices can be used as well. These implanter devices are typically open bore sharp or dull needles attached to a loading port. The grafts will be loaded into the port, the needle will be inserted into the slit, and the graft will be slipped through the needle and into the slit. Some devices even have a spring-loaded action to push the graft. The device will then be removed – leaving the graft in place -- and will be reloaded for the next slit.
Graft Implantation
• Graft placement can also be done via simultaneous slit creation and graft placement using implanter devices.
• These devices are the “spring-loaded,” sharp needle type discussed in the previous slide.
• The implanted pen is “loaded” with graft and handed to the physician. The physician will determine where he/she wants the graft to be, and use the sharp needle to make the recipient incision. The doctor will then push the plunger, which slides the graft into the site that was just made. The device is then removed, the graft remains placed, and the implanter is re-loaded with another graft.
• Once all grafts are “placed,” the case is complete and the patient is discharged (usually with a brief course of antibiotics and pain medication) to rest, recover, and wait for the new hair to grow starting 3 months later.
How a Modern Hair Transplant is Performed
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Arguably one of the most important aspects of a modern hair transplant is that it is performed by an experienced, licensed physician. Procedures
