Follicular Unit Hair Transplant Method Treatment & Management

Minoxidil and finasteride are approved by the US Food and Drug Administration (FDA) to treat male-pattern hair loss. Minoxidil is the only medication approved for the treatment of female-pattern hair loss. Both medications are more effective for patients with earlier stages of hair loss and are excellent treatment options for patients who are losing hair but who are not candidates for surgery. The key to success with each medication is compliance. Six to 12 months can elapse before medications begin to work.

For patients who are candidates for surgery, continuing medical treatment often helps increase the density of transplanted hair by slowing down the rate of loss of existing hair and increasing the caliber of existing and transplanted hair. Medication usage should not alter candidate selection, the hairline design, or the distribution of transplanted hair. In all patients, the physician must assume the patient may stop taking the medications sometime in the future and must determine the cosmetic impact this would have on the transplanted hair.

Finally, a variety of over-the-counter products purport to treat male- and female-pattern hair loss. Few to no independent, peer-reviewed studies support their safety or efficacy.

Planning and design

The midpoint of the frontal hairline is designed to fall approximately 8-9 cm above a horizontal line drawn through the center of the patient's eyebrows. Then, the hairline is gently curved laterally and superiorly toward the temporal lateral fringe. This curvilinear portion of the hairline may rise gently above, but should not be designed below, the horizontal plane. Depending on the existent lateral fringe, the hairline may be connected to this temporal fringe.

Donor area

All patients should be aware before surgery that a permanent scar will result from removing the donor ellipse. For the vast majority of patients, the scar is of no practical concern. If a patient wears his or her hair at least 2 cm in length, the existing hair will camouflage the scar.

The donor region is the only limiting factor in hair transplantation. For the majority of transplants, the donor hair is harvested via a surgical ellipse. The length and width of the ellipse is a reflection of the number of grafts needed for the surgery and the patient’s donor density. The average donor density is 80-90 follicular groupings per cm². To increase the number of grafts, make the ellipse longer rather than wider. Ellipses wider than 1 cm have an increased risk of creating a wider or even hypertrophic scar. As an example, if 1000 grafts are needed and a patient has average donor density, an ellipse of 14 X 0.8 cm will provide approximately 1000 grafts.

The donor ellipse is removed with the patient under local anesthesia and in the prone position. Staples or sutures are left in place for 7-10 days.

Graft dissection

Once the donor tissue has been removed, it is kept in chilled saline over frozen packs to maintain a cool temperature while the tissue is dissected. To maintain graft viability, the grafts must not become dehydrated or heated. The grafts are dissected using a binocular microscope at a minimum magnification of 10X.^[10] Sterilized tongue blades placed over an autoclavable glass cutting plate create a cutting surface for the tissue. Assistants use jeweler's forceps to apply traction while cutting with a standard double-edged razor blade or knife. Donor tissue first is reduced to thin wafers or slivers containing only a few follicular units. Then, these slivers are cut into follicular units and trimmed of excess bald tissue.

See the image below.

The use of magnification and a polarized light allows minimal transection of follicles during the dissection process and dense packing in the recipient area. The ability to create greater density within the recipient zone as a result of the small size of the grafts is the key to follicular unit hair transplantation. The dissection process is undeniably the most labor-intensive portion of the process and requires 2-3 graft-dissection assistants for every one implanting assistant.

Graft implantation

During the implantation stage, the follicular unit grafts are placed into the anesthetized recipient sites created by 19- to 22-gauge needles by using microvascular forceps. A goal of 20-30 follicular unit grafts per cm² is reasonable and readily achieved by skilled assistants.

See the image below.

Once the implantation process has been completed, the recipient surface is cleaned using chilled saline spray. The use of a postoperative dressing helps protect the grafts as they heal overnight.

Patients are able to resume regular activities immediately but should avoid heavy exercise for at least 3-4 days after surgery. Patients can remove the dressing at home the morning after the procedure. Some perifollicular hemorrhagic crusting can be seen at this point, and it remains for 5-8 days. Patients are instructed to shower but should not try to pick off their scabs. The majority of patients with existing hair return to work after 2-3 days without any cosmetic problems. The staples or sutures are removed in 7-10 days. The transplanted hair should begin to grow 3-6 months after surgery and should be fully grown in 12 months.

See the images below.

Medical and surgical complications are rare and, if they occur, are seldom threatening. Postoperative bleeding and infections are unusually rare. Donor suture lines occasionally may spread and are more prone to do so if closure is performed under tension. Transient folliculitis or pruritus may occur.^[11]

The majority of complications arise from poor hairline design, poor technique, and, most commonly, unrealistic patient expectations.

The goal is to make the final product look so natural that it cannot be distinguished as a transplant. The tight packing of grafts provided by microscopic dissection generates a natural appearance acceptable to most patients. Although this method is time and labor intensive, the results justify the meticulous attention to detail.

Low-level light therapy has been advocated as a possible new therapy for male-pattern hair loss. In 2007, a device received 510k approval from the FDA to treat male-pattern hair loss. As of early 2009, the existence of large independent peer-reviewed studies has not yet been made public.

Cloning hair follicles has been a topic of intense interest among physicians and patients for many years. Several privately funded laboratories are working on cloning hair follicles. Early studies are promising, but the reality of having unlimited hair follicles to transplant remains years away.