Hair Transplant

5/23/2018 Hair Transplant

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Hair Transplantation:

Principles and Practice

Presented by: Dr.Mir Laieeq

Moderator: Prof. Iffat Hassan.


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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 thebalding frontal scalp


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Introduction

In past,34 mm grafts containing 1530 hair follicleswere 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.


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Timeline

1939 Japanese dermatologist, Dr. Okuda, published a revolutionary method usingsmall grafts from donor area to correct lost hair from scalp, eyebrow, andmoustache areas. No impact in the Western Hemisphere due to the interruptionby World War II.

Late 50s Dr. Norman Orentreich, experimented with transplanting the hair on theback and sides of the head to the balding areas. Transplanted hair maintained theirbald resistant genetic character

60s and 70s involved the use of larger grafts that were removed by roundpunches and often contained many hairs

In 80s large punch grafts were gradually replaced with combination mini micrografting 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.


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90s introduction of follicular unit hair transplantation thecurrent "GoldStandard.

Transplants hairs in their naturally occurring one, two, three,and four hair follicular unit groupings in which they grownaturally.

1995,Dr. Robert Bernstein proposed creating hair restorationusing exclusively follicular units.

Dr. Limmer was first to use the binocular microscope toexamine the donor tissue to successfully isolate and trim thenaturally occurring follicular units into individual graft


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Indications

Androgenic alopecia(in men and women)

Male pattern alopecia

Cicatricial alopecia Traumatic alopecia

Traction alopecia.


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Contraindications

Diffuse female pattern baldness

Nondonor-dominant alopecia

Alopecia areata.Scarring alopecias are nondominant and, while

active, do not respond to hair transplantation.

Hair transplant is inappropriate in active phases ofLupus, infections and poor general health.

Vitiligo and psoriasis can be aggravated by hair

transplantation


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Candidate Selection

Selection of appropriate candidate needs to bedone from a medical and a psychologicalperspective.

Assessment of areas of greatest concern andWhether the patient has realistic expectations

A complete medical, surgical and hair loss history

Previous hair transplants and scalp surgeries aswell as scar formation.

The etiology of the hair loss is determined,primarily via physical examination of scalp


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Clinicopathologic correlation(occasionallyneeded)

The stage of patterned hair loss.

Medications review with regard to theireffects on hair growth and haemostasis.

Appraisal of the density and caliber of donor

hair in the occipital scalp as both have animpact on the perceived density of thetransplant


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FIVE BASIC CRITERIA FOR ASSESSING CANDIDATES FOR HAIR

TRANSPLANTATION

(1)AgePatients >25 years arepreferable.

Unpredictability of futurehair loss in individualsbetween 15 and 25 years of

age.This subgroup also tends to

desire a return to a full headof hair as opposed to amature pattern of restoration

done in older age groups(2)Hair shaft caliber

Those with large-caliber(>70microns) obtain much denser

coverage than those with

corn silk quality hair. (3)Donor hair density

Measuring a 0.25 cm sq.fieldand multiplying by four is thepreferred method.

Patients who have >80follicular units/cm sq.areexcellent candidates.

Those with donor hair

density


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FIVE BASIC CRITERIA FOR ASSESSING CANDIDATES FOR HAIR

TRANSPLANTATION

(4)Degree of baldness(most

important criterion) Those with complete

baldness of the frontal scalpas opposed to baldnesslimited to the vertex are

excellent candidates.When frontal baldness is

corrected, there is dramaticcosmetic appearance.

(5)Hair color Follicular unitgrafting has made hair colorless of an issue than whenpunch 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 orblonde hair are preferentialto those with jet-black hair.

Black-haired individuals arenot exempt as hair transplantcandidates, but shouldreceive only one-hair

follicular units in the frontalhairline for the most naturalresult.

Proper technique eliminatesmost problems with dark-

haired candidates


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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 forcamouflage post operatively.


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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 Ds are not good

candidates for hair

transplantation)


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Cl I t d l t j il h i li d i t


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Class Irepresents an adolescent or juvenile hairline and is notactually balding. The adolescent hairline generally rests on theupper brow crease.

Class IIindicates a progression to the adult or mature hairline thatsits a fingers breath (1.5cm) above the upper brow crease, withsome temporal recession. This also does not represent balding.

Class IIIis the earliest stage of male hair loss. It is characterized bya deepening temporal recession.

Class III Vertexrepresents early hair loss in the crown (vertex).

Class IVis characterized by further frontal hair loss andenlargement of vertex, but there is still a solid band of hair acrosstop separating front and vertex.

Class Vthe bald areas in the front and crown continue to enlargeand the break down of bridge of hair separating the two areas.

Class VIoccurs when the disappearance of connecting bridgeleaving 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 VIIpatients have extensive hair loss with only a wreath ofhair remaining in the back and sides of the scalp


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Norwood Class A(2A-5A)

The Norwood Class A patterns are characterized by a front to

back progression of hair loss. Norwood Class As 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 restorationearly

frontal bald area is not generally responsive to medication

dense donor area contrasts and accentuates the baldness ontop.

Fortunately, Class A patients are excellent candidates for hair

transplantation.

Diff P tt d d U tt d


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Diffuse Patterned and Unpatterned

Alopecia These types of genetic hair loss pose challenge both in

diagnosis and in patient management esp. in youngdiagnoses may be easily missed

Diffuse Patterned Alopecia (DPA) is an androgenetic alopeciamanifested as diffuse thinning in the front, top and crown,

with a stable permanent zone.Does not pass through thetypical Norwood stages.

Diffuse Unpatterned Alopecia (DUPA) is also androgenetic,but no stable permanent zone. DUPA tends to advance fasterthan 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 transplantcandidates, whereas DUPA patients almost never do, aseventually don't have a stable zone for harvesting.


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Diffuse Unpatterned

Alopecia (DUPA) in a 32

year-old male

The densitometry

reveals extensive

miniaturization.


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Key Concepts

Candidates should be made aware that AGA isprogressivedespite undergoing hair transplantation.

Medications (e.g. oral finasteride) can help to maximizehair 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 inanother 5 or 10 years.

The physician should emphasize how ongoing hair losswill affect the density and cosmetic appearance of

transplant.


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Key Concepts

The number of expected procedures to accomplishboth 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


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Key Concepts

Most female patients will not have sufficient donorareas of good density to adequately treat all affectedareas.

For most women the goal is limited to thetransplantation of primarily the cosmetically mostimportant areas like

Frontal area

Vertex whorl area and a

5- to 6-cmwide antero-posterior corridor throughwhich the patient's hair normally parts

The hair in these thickened areas is styled in such a

way as to camouflage the untreated area


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Four conceptual zones in MPB

Frontal Areabetween intended hair line and

intertragal line

Mid scalp area between frontal area and

vertex transition point.

Vertex areaincludes remainder of alopecic

areas

Evolving areas adjacent to 3 major zones.


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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.


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Some Mathematics!

No. of follicular units/cm2is

nearly constant in allindividuals, normal densitybeing 100 FU/cm2and no. ofhairs per unit is 1 to 4

Since the follicular unitdensity is relatively constant;the same number of follicularunits is needed to cover aspecific size of bald arearegardless of the hair densityof the patient.

A person can lose halfthenumber of his hairs before he

appears bald

Calculation of the number ofhair units required for therecipient area

Frontal area is triangular andthe area is calculated by the

formula x breadth x height

Vertex is circular and its areais calculated by the formula:A = pr2(A = area, p = 3.14, r =

radius). Usually halfthe calculated FU

are transplanted giving goodcosmetic results.


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Mega sessions

A session in which more than 1000 units aregrafted is called a mega-session. It has severaladvantages:

It avoids multiple surgeries and the resultingabsence from work

In multiple grafts, the first graft always yields

the best results

A large session economizes donor supply


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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)


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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


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Anaesthesia Ananesthetic field block is first created using 30-gauge

needles and 1-2 % lidocaine with 1:100,000 epinephrinealong the inferior edge of donor area.

Once anesthesia is obtained, 20 ml of normal saline or 50mlNS with 0.5ml of epinephrine can be injected to providefurther anesthesia, hemostasis and dermal turgor or

tumescence ; the latter helps to reduce the transection ofhair.

Local infiltration to create ring block of anaesthesia anteriorto anticipated recipient area is commonly used technique.

Lidocaine dose must be limited to 7 mg/kg withepinephrine(max 500 mg)or 4.5 mg/kg(max 300mg) withoutepinephrine.

After 2 hours LA should be reinforced by 0.25%-0.5%bupivacaine with 1:100,000 epinephrine(max 200mg).This

lasts 4 hours.


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Donor Region

The amount of available donor hair is the primarylimiting factor in hair transplantation

In general, there are 6585 follicular groupings/cm.sq.in the occipital donor scalp.

The mid occipital scalp between the two occipitalprotuberances is the recommended donor site

Density of hair

Ability to camouflage the donor scar(d/t lack ofinvolvement by AGA)

Donor density does not correlate with the extent of

current or future hair loss in the frontal scalp or vertex.


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Techniques for graft harvesting

2 techniques for harvesting of donor:

Elliptical donor harvesting

Follicular unit extraction


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Elliptical donor harvesting is performed in majority

owing toSafe and rapid removal of large numbers of hair

follicles

Minimal transection of hairs.

The width of the donor ellipse ranges from 7 mm to1.2 cm, while the length should be less than 30 cm.

The number of follicular groupings requireddetermines the dimensions of the donor ellipse.

Increasing the width of a donor ellipse creates morewound tension and may lead to a hypertrophic or

wide scar.


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Elliptical donor harvesting.

Initial scoring of the excisionmay be done with a single or

double #15 blade scalpel

Double blades should be

oriented parallel to theexiting 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.


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Elliptical donor harvesting.

Lateral retraction using fineskin hooks exerts tension

away from the excision and

creates good visibility.

The ellipse can be removedby 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)


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The donor ellipse can oftenbe primarily repaired with

no undermining if it is


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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 unitseither under a magnifying loupe or a microscope

Whether the grafts should be skinny (thin) or chubby (thickwith a little amount of dermis around them) is a matter ofdebate

After separation follicular unit grafts must be put intochilled saline or an equivalent medium until they are placedinto the recipient sites


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In 1984, Headington a paper demonstrating that hairs did notoccur singly, but as naturally occurring groups that were referredto 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 unittransplantation (FUT)

Follicular unit extraction (FUE) represents the removal ofindividual follicular units from the posterior scalp via 0.751.2 mmpunch 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 visiblescar

Extensive scarring from previous transplant procedures.


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But FUE isTime consuming

Obtains fewer follicular groupings from each

procedureHigher rate of transection of the follicular

groupings.

In the future, refined instruments and robotics willhopefully lead to more rapid and precise harvesting

of individual follicular groupings

ELLIPTICAL DONOR HARVESTING


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VERSUS

FOLLICULAR UNIT EXTRACTION

ELLIPTICAL DONORHARVESTING

FOLLICULAR UNITEXTRACTION

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


VERSUS

FOLLICULAR UNIT EXTRACTION


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FOX Test

It is important to note that the tightness with which follicular

units are held in dermis varies and hence FUE may not besuitable in all patients.

This test is to ascertain whether the patient is a suitablecandidate for FUE or not.

In FOX test, the surgeon takes out a few (about 100) graftsfrom the donor area and then evaluates how manycomplete/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 goahead with FUE

Fox grade 4-5 (it is almost impossible to predict the emergentangle), the yield is too low for the FUE procedure to besuccessful.


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Follicular Grafts

Earlier punch grafts measured 34 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, 3045 angle

toward the front and slightly toward the midline

Thus, these grafts mimic the natural grouping and

orientation of scalp hairs


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Different sizes of hair

transplantation grafts.

A The newer techniqueuses 1- to 4-hair follicular

unit grafts.

B The older techniqueuses larger 10- to 15-hair

grafts


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Over several hours, surgical teams cancarefully separate 5002000 follicular unitsfrom the donor strip.

Cutting instruments include #11 and #15blades as well as #10 prep blades.

Good lighting, comfortable chairs and well-designed instruments are prerequisites forproducing follicular units with minimaltransection


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Some surgeons believemicroscopic dissection or

magnification reduces

transection of follicles during

the separation process

However, the data are still

inconclusive


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H IR TR NSPL NT TION IS MIX OF SKILLND IM GIN TION


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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 whatoccurs in nature.


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Hairline Design

Trying to recreate the hairline a patient had before the hairloss 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 willremain balanced with the temporal and posterior hairlines.

This requires recreating a frontal hairline which is higher andmore receded than the one which was present before the

process began.

A common reason for cosmetic failure

HOW TO PREVENT IT?


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Hairline Design

Hairline should be considered a natural transition zonerather than a fixed zone .

This ill-defined feathering zone is re-created byrandomly placing, in an irregular pattern, follicular unit

grafts along the newly created hairline .

Dense packing of grafts should not be performedbecause this will lead to a hairline with an unnaturalappearance.

The level at which the hairline is placed varies fromindividual to individual and it is important to firstexamine each patient in a global, 360 manner.


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Hairline Design and Recipient Site Creation

While male pattern hair loss is progressive,

transplanted hair will have long-term growth.

The surgeon must assumethat 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


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Immediate postoperative appearance with graft placement

and hairline design.


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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 (placedinto the dermis and not the subcutaneous space)

creates excellent hemostasis.


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Anesthesia and Recipient Site Creation

Recipient sites should mimic the natural 3045 angleof hair growth on the scalp

Instruments such as NoKor needles, slits (for

combination grafts), rectangular punches, 18/19 sizeneedles (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 1030 FU/cm2,

depending on the density of existing hair on the scalp.


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Recreating the 3045 of hair growth on the frontal scalp.

(A) Correct versus incorrect technique (B). Grafts should not be oriented

perpendicular to the scalp surface


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Graft Placement

Two to three surgicalassistants place the graftswith microvascularforceps.

Follicular units are

grasped by theirperifollicular tissue,avoiding trauma to thehair follicles.

Regular surgical forcepsare not recommended.

Placement of the graftsinto is the most

challenging step.

Methods for insertion:a)Stick and place method'involves making arecipient site, followedimmediately by insertion

of hairs into the site by anassistant

b) Creating all the

required recipient sites atone time and then placingthe grafts one by one


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POSTOPERATIVE CARE

Day of the procedure Apply non-adherent dressing overnight

Oral paracetamol 300 mg/


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Oral paracetamol 300 mg/

codeine 30 mg every 46 hours SOS

Oral prednisone 40 mg OD for 3 days to reduce frontal scalp

edema

Resume regular activities, but no heavy lifting or strenuousexercise until staples/sutures removed

Sleep with head elevated

Postoperative days 13 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 47 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


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Complications

Complications are unusual.

The extensive vascular supply to the scalp results in rapidwound healing and a low risk of infection.

Temporary

Excessive swelling (5%),

Postoperative bleeding (


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Other potential complications.

Lidocaine toxicity. 20 mg diazepam may be injected to raise the minimal

convulsive dose.

Lidocaine should be injected superficially and

intermittentlyMax. Dose should not be exceeded.

SYNCOPE.

Keep patient supine or prone

Control pain and anxietyAdequate hydration

Blood glucose maintainence.


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Occipital scalp scar secondary to elliptical donorharvesting


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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 ofone cm every month, with full cosmetic results at

the ninth month.

Minoxidil is started in the second week to promotehair growth and prevent delayed results


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CORRECTIVE HAIR TRANSPLANT

SURGERY


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A Usual Scenario

Patient present for corrective surgery because ofprevious transplantation of 34 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 largerplugs to soften their appearance;

(2) Surgically remove the large grafts; and/or

(3) Perform laser-assisted hair removal.

(1)Adding follicular unit grafts


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( ) g f g f

Transplantation of a large number of follicular unit

grafts containing one to four hair folliclesin frontof, in between and behind large grafts will softenthe pluggy appearance .

This option is appealing for many patients because

it allows for both cosmetic improvement andincreased 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 initialtransplant.


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(A) Previous transplantation of 34

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


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g f g f

Done for cosmetically unacceptable hairlines &

Large grafts with perifollicular white scar tissue.

The grafts can be removed by either a 24 mm punchinstrument or an elliptical excision.

Also follicular unit extractions from larger grafts via 1mm punch instruments

This reduces the pluggy appearance of the largergrafts while allowing a more natural appearing graft toremain.

Cosmetically evident scars develop in a small minorityof cases.

Pulsed dye, ablative, non-ablative, or fractional ablativelaser treatments can be used to help improve thecosmetic appearance.

3 Laser-assisted removal of large


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3 Laser-assisted removal of large

grafts

As with other parts of the body, lasers only removepigmented terminal hair follicles

Typically 510 treatments are needed to permanentlyremove the majority of follicles.

It eliminates majority, but not all of the hairs leading tosubstantial cosmetic improvement of the unnaturalplugs.

Some of the transplanted hair is retained for a morenatural appearance.

Laser therapy is an excellent option for patients whowant to improve their cosmetic appearance in a

safe,non-invasive manner.

Hypertrophic or broad scars in the


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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


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Alopecias

Hair transplantation can be successfully performed in scarred skineven 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 shouldhave 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 scalpinflammation will likely affect the growth of the transplanted hair.


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Robotic Hair Restoration

The FUE robot (ARTAS)is an image-guided systemcomposed 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 thatminimizes injury to the grafts.

The image-guided system allows this step to be

accomplished with great precision.


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Advantages

Increased accuracy of

harvesting grafts tominimize damage to

follicles

Ability to use FUE in a

wider variety of patients

Reduced harvesting time

Increased graft survival

Debunking some myths!


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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 thedonor area cannot be determined.

Myth #2 Most women can benefit from hair transplantationjust likemen.

Fact:In spite of the great advances doctors are still limited by a personsfinite donor supply. In many women donor area is thinning as well as otherparts of the scalp, making hair transplantation ineffective.

. Myth #3 When large numbers of grafts are transplanted they do not getenough blood supply.

Fact:The blood supply of the scalp is so great and it is so collateralized thatit 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 theblood supply can be overwhelmed resulting in poor growth. Also, bloodflow 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


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Myth #5 Laser hair transplants are state-of-the-art.

Fact: Not used by the most experienced hair transplantsurgeons.

In fact, laser hair transplants are really a misnomer,

lasers have only been used for is to make the recipientsites .

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 thedonor area and poor graft growth.


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FUTURE TRENDS


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Cloning

Regeneration and cloning of hair follicles

represents the next step in revolutionizing hair

transplantation.

With an unlimited supply of hairs, there willno longer be constraints based upon the

density of hairs in the donor region.

Keratinocyte tubulogenesis has beeninduced by cultured dermal papilla cells.

Chermnykh ES, Vorotelyak EA, Gnedeva KY, et al.Dermal papilla cells induce keratinocyte tubulogenesisin culture. Histochem Cell Biol. 2010;133:56776


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;

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;60:7483

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 afterwounding.Nature. 2007;447:31620.

Erythropoietinhas 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;59:8690.

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;151:237380.


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