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Hair Replacement Surgery

Despite the advances in medical hair restoration, hair replacement surgery remains the only permanent solution to pattern hair loss, and appears by far to be the best hair replacement option.

Pattern hair loss, also known as androgenetic alopecia, is the hair loss that causes hair follicles to shrink and deteriorate over time. It affects the front, top, and vertex of the scalp but leaves the sides and rear of the head unaffected. The reason for this regional difference in hair loss is unknown, but it is something that is capitalized on by hair transplant surgeons. While there are various approaches that have been developed over the years, the basic idea behind all hair replacement surgery is that hair from the spared rear and sides of the scalp is moved to the front and top of the head.

The concept of hair replacement surgery has been around since before World War II. It was determined by Japanese doctors, even then, that the smaller that transplanted hair grafts were, the better the cosmetic results would be and the more grafts would survive. Unfortunately the scientific reason for clinical result was not understood. This knowledge did not survive the war and would not be rediscovered until the 1970s.

The next major breakthrough in hair replacement surgery would come in the 1980s, when the concept of the follicular unit was described. A follicular unit contains one to four terminal hair follicles, one vellus follicle, sebaceous glands, a blood supply, a nerve supply, and the supporting proteins that make up the follicular unit. The concept of a follicular unit gave surgeons two critical pieces of information. First, they now had an explanation for why sometimes individual grafts did not survive. If the follicular unit is disrupted and destroyed by the harvesting process—even if the visible hair was intact—the graft would not survive after it was transplanted. Second, they learned a way to harvest healthy follicular units from the donor area and maximize the cosmetic appeal and health of the transplanted hair.

After the complete description of the follicular unit, the evolution of hair replacement surgery was relatively rapid. The 1990s saw one main hair restoration procedure dominant all other. Follicular unit transplant emerged as the gold standard procedure for hair replacement surgery and is the primary procedure performed today.

Choosing patients for hair replacement surgery, and patient choices in surgical hair replacement

Follicular unit transplant is not for everyone. Patient eligibility, determination and selection is the first step to ensure a successful hair replacement surgery. Patients that are too young may not be ideal candidates. While they are very motivated to undergo the procedure, the degree and type of hair loss may not be apparent at that age. It is also the belief of many plastic surgeons that the expectations of this age group are unrealistic. Patients in their late 20s through 40s that do not have co-existing medical conditions make the best hair replacement surgery candidates.

Anyone considering hair replacement surgery should be counseled on the various options available to them, whether they are medical, surgical, or correction through hairpieces. Unfortunately most physicians are least competent to discuss the third option. As a result, many patients remain largely unaware of the benefits of hair replacement systems (like hairpieces).

If hair replacement surgery is the patient’s choice and he is a good candidate, the procedure should be explained in detail. Realistic outcomes should be discussed. For example, it may take nine months for the hair transplant to look “finished.” Patients should be warned that the transplanted hair may not (and likely will not) look like their natural hair. Hair replacement surgery is a cosmetic procedure and does not treat the underlying pattern baldness problem. In fact, many patients, especially younger patients, are strongly encouraged to use an oral or topical hair restoration product even if they are having hair replacement surgery. This will slow the rate of hair loss and greatly improve the overall cosmetic effect of the surgery.

Hair replacement surgery procedure

Hair replacement surgery: The Local anesthesia

Follicular unit transplant is performed under local anesthesia, which means the scalp if infused with a medication that numbs the nerves. The donor area is prepared using the tumescent technique. The tumescent technique involves the infusion of copious amounts of local anesthetic (like lidocaine or lignocaine) plus epinephrine (adrenalin) dissolved in sterile saline. This approach lifts the skin off of the donor area of the scalp making the dissection easier. Also the epinephrine squeezes closed small blood vessels, which keeps blood loss to a minimum. The recipient area, too, is numbed with local anesthetic and epinephrine prior to follicular unit placement.

Hair replacement surgery: Surgery at the donor (extraction) site

In general, there are two ways that the donor hair can be harvested in hair replacement surgery. In the older hair replacement surgery approach, a scalpel is used to cut a strip of hair about 15 cm by 1.2 cm out of the back of the scalp. The individual follicular units are then cut apart from one another by the surgeon using the scalpel and a surgical microscope. In the newer hair replacement surgery approach, individual follicular units are removed from the donor area. Thus in the older type hair replacement surgery, the donor site is closed with a single line of sutures while in the newer hair replacement surgery, the individual “holes” are small enough that they close and heal on their own.

The strip dissection technique tends to leave the hair replacement surgery patient with a rather unsightly scar in the back of the scalp. Also, the missing hair at the border of the scar can be quite noticeable. Because of this, most surgeons are moving toward the dissection of individual follicular extraction or FOX. The FOX technique, as described above, may leave the donor area with a Swiss cheese look in some cases, but is generally more cosmetically favorable than the strip.

The FOX hair replacement surgery approach, while more cosmetically favorable, has run into problems with the health of the donor follicular units. The standard FOX technique destroys as many as 30 percent of grafts (though some surgeons report numbers as low as 5 percent). Since many patients prefer to have the FOX hair replacement surgery procedure, several enhancements have been proposed to minimize graft loss. One approach called surgically advanced follicular extraction or SAFE uses sharp punch to cut around the follicle but then a blunt scoop to remove the follicular unit. The pioneer of the SAFE procedure reports a damaged graft rate of about two percent.

Another surgeon has advocated a tool and technique called the powered punch. This approach is essentially the same as the FOX technique but no saline is infused in the donor site. A punch tool is used to harvest the follicular units individually. Apparently this leads to less follicular unit damage than traditional FOX.

Most hair replacement surgery is now performed during a single mega-session. A mega-session involves the transplant of more than 1,000 follicular units in a single setting. The reason that mega-sessions are used is because the patient needs only one surgery and one recovery period, the donor site usually does not respond well to multiple dissections and, from clinical experience, surgeons have noticed that the first time a patient has hair replacement surgery it is the best session.

Hair replacement surgery: The recipient site (where the hair is relocated in the scalp)

The recipient site for hair replacement surgery requires a bit of an artistic hand. Essentially a new hairline must be created on the front of the scalp. Cosmetic surgeons have developed a rule of thumb for the location and shape of the new hairline, but some variability exists between patients such that the final hairline is individualized.

The primary technique that surgeons use to place the grafts is to simply make small incisions in the scalp. The incisions are just large enough that the follicular units can be squeezed into them. The incisions, or slits, hold the grafted follicular units without the need for sutures—a friction fit or “snug” fit.

One hair replacement surgical technique that has been tried is the use of a cutting laser (such as a CO2 or erbium YAG laser) to prepare the recipient scalp. Instead of using a scalpel, the focused light energy is used to make small incisions in the recipient area. As it cuts, the laser cauterizes the surgical wound, which minimizes bleeding and bruising at the recipient site. Unfortunately the grafted follicular units require a robust blood supply in order to survive, especially in the days after hair replacement surgery. While the laser is great at stopping bleeding, it also seems to prevent an adequate blood supply. Therefore laser hair replacement surgery, as it is called, remains controversial.

Hair replacement surgery recovery

The scalp is fitted with a dressing, similar to a snug fitting cap, which keeps the area covered until initial healing can begin. Because the follicular unit grafts are squeezed into the recipient sites, the bleeding is fairly minor and the first stages of healing occur quickly—the cap dressing can be removed in a day or two. Gentle shampooing can begin within a day or two as well.

People are generally prescribed an antibiotic to reduce the risk of infected grafts. This antibiotic may be taken a few days before, during, and after the hair replacement surgery. Pain control is accomplished with NSAIDS and, rarely, morphine-like drugs. In general the recovery process is only mildly painful, unlike many other cosmetic surgeries.

Hair replacement surgery cost

The cost of hair replacement surgery can vary quite a bit, but the average cost of hair replacement surgery is around $5,000. Some surgeons have moved to a “price per graft” fee when charging for hair replacement surgery. The cost per graft can range $3 to $9 per graft, but the average is usually around $5 per graft (follicular unit). Since most patients will require between 1,000 to 1,500 follicular units or more, the costs can approach $10,000 in some cases.

Keep in mind that the cost of antibiotics, pain medications, bandages, and facility fees may or may not be covered in this price. Since the hair replacement surgery is done in the office as a same day procedure (even though it may take the entire day!) the facility fees should be part of the surgeon’s fee. Also, compared to the cost of the surgeon’s fees, the cost of generic pain killers and antibiotics should be nominal, an additional $100, at most. You should discuss all fees and costs with several plastic surgeons to get a specific idea of what you will be required to pay.

Hair replacement surgery reference list

(1) Bernstein RM, Rassman WR. Follicular unit transplantation: 2005. Dermatol Clin 2005;23:393-414, v.

(2) Headington JT. Transverse microscopic anatomy of the human scalp. A basis for a morphometric approach to disorders of the hair follicle. Arch Dermatol 1984;120:449-456.

(3) Jimenez F, Ruifernandez JM. Distribution of human hair in follicular units. A mathematical model for estimating the donor size in follicular unit transplantation. Dermatol Surg 1999;25:294-298.

(4) Venkataram M. Changing trends in hair restoration surgery. Indian J Dermatol Venereol Leprol 2006;72:103-111.

ABOUT THE AUTHOR: Michael T. Spako is an M.D. who chose to pursue a medical writing career instead of a doctors practice. I am pleased to have him as the principal writer for this hair replacement / hair restoration site, and look forward to his further contributions. Donald Urquhart, Psychologist, Editor.

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