What is Follicular Unit Extraction and Transplant??

For contemporary hair transplants, there are two basic methods of harvesing donor hair. The conventional strip technique and follicular unit extraction. In Follicular Unit Extraction (FUE) technique donor hair are harvested one by one and is therefore more labour intensive. During this technique a small micropunch usually sized 1mm or smaller is used to isolate a group of hair from its skin attachments. These groups having one to four hair, called follicular units, are then gathered (pulled out) from the head. This leaves a pin point wound from the area of harvest.

In this way the hair are taken out one after another, until adequate number of hair required for that session have been harvested. This surgery is done at a "micro" level and requires 8X magnification and expert hand control. Since FUE procedure requires careful and delicate handling, it is possible to harvest only 1200-1500 follicular units per session. An average session may last 8 hours and may need to be repeated, if balding area or graft requirement is extensive. The donor wounds heal over the next of seven to ten days with barely visible scars. Stiches are not required

In contrast, in FUT (strip) technique all the required hair are removed in one long strip of hair bearing skin. These hair are then isolated from the strip and implanted. To close the gap after strip harvest, stiching is required.

After the grafts are harvested, micro slits are created in the bald area where these follicular units are implanted with help of fine instruments. Once they develop their blood supply they will grow into healthy growing hair. The angulation of hair, density in key areas and hair design remais different from surgeon to surgeon and depends upon his experience and expertise.

At the end of the day the difference is only in harvesting technique, but what a big difference is that.

I will try to post a video of FUE soon and may be a pictorial comparison of two techniques.

Follicular Dissection and Implantation : Video

Follicular unit Harvest as a Strip : Video

Hair Transplant Donor Harvesting & Graft Preparation Techniques Physicia...

Growth after Hair Transplant : What to Expect

What to Expect

Knowledge can prevent unnecessary distress, so it is a good idea to be familiar with natural post operative course of transplanted hair. I have given it in a table form for quick reference, followed by explanation of important points. Remember, everybody is unique and this timeline is just and indicator of average progress. If your experience is a little behind (or ahead) of this timeline, it is still alright.

POST OP DAY	TRANSPLANT AREA	SUTURED AREA (FUHT)	DONOR AREA (FUE)
DAY 1	Stubble like hair, blood and crusting. Decreased sensation	Pain and stretching sensation. Crusting.	Some discomfort. Crusting.
DAY 10	Scabs should be gone. Stubble like hair. Itching.	Some discomfort. Reduced sensation/ Numbness.	Near normal
DAY 15	No scabs. Effluvium begins. Area may feel hard to touch.	Suture removal. Area is hard to touch. May have reduced sensation and/or pain.	Near normal. May be hard to touch.
WEEK 8	All transplanted hair fall. Some redness may persist.	May have reduced sensation. Hard to touch.	Normal. Planning for second session may begin.
MONTH 2-4	Some hair fall from normal non transplant area. (Shock loss)	Near normal
MONTH 3-5	New hair growth begins. They are thin and fine at first.	Near Normal
MONTH 5-9	New hair keep coming out roughly 10-15% per month. Already sprouted hair begin to grow longer.	Near Normal
MONTH 9-10	80% of appearance. Transplant appears thin due to small caliber of new hair. Planning for second session may begin.	Planning for second session may begin. Scalp massage and scalp stretching exercises may commence.
YEAR 1	90% of appearence. Hair shaft continues to grow longer and thicker.
YEAR 2	Final appearence of transplant.

FAQs about Hair Transplant

What is Hair Transplant?

Word "Transplant" can be seen as  made of two  words, Transfer and Implant. So, hair transplant is simply transfer of living hair. These hair can be transplanted in any hairless area such as balding scalp or area of stable scar, eyebrow, moustache etc. Currently, this is the only technique that can give natural, permanent, growing hair in bald area.

Who Needs It?

Hair transplantation is used predominantly to treat the hereditary balding condition known as androgenetic alopecia ( Male pattern baldness). Patients with male pattern hair loss tend to loose hair from the front and top of their head. Since baldness is often ridiculed in society, it can undermine one's confidence and performance, especially if it comes at a young age.

Women with diffuse alopecia, selected patients with burn alopecia, eyebrow and facial hair loss patients are other candidates who can benefit from the procedure.

What Causes Hair Loss?

Although there are many causes of hair loss, the commonest cause is male pattern baldness. this is due to a combination of two factors. First, the hormonal byproduct Di Hydro Testosterone (DHT) and second your hair follicle's susceptibility to DHT, which is genetically determined. Both the factors should be present to cause hair loss.

How is Hair Transplant done?

Patients having baldness still have good density of permanent hair on the sides and back of the head. These good quality hair that naturally last a lifetime, are used to fill up the bald region. The hair are taken out from the scalp one by one (as single units called FUE)  and are implanted individually in the bald area. This highly sophisticated procedure replicates the natural hair growing pattern.

Is There Pain?

Hardly if any at all. I customise local anesthesia solution to gently numbs the area of procedure. You will not feel anything at all. even in post operative phase when anaesthesia effect wears off, only mild painkillers may be required. Some people do not require any painkiller after FUE method.

How Long Will It Take?

Hair transplant is a one day  procedure in office setting. No admission is required. An average surgery of 1500-2000 grafts takes 5-6 hours. Megasessions of 3000 or more grafts may take 8-10 hours. You can go home the same day after procedure.

Are Results Permanent?

Yes. Since transplanted hair come from permanent hair zone (the back and side of scalp) that is unaffected by DHT, these hair do not fall after implantation. They will have same texture, colour, growth and quality as your back hair and the results will last you a lifetime.

Why Shouldn't I go for Artificial Hair?

Entirely too many reasons. The biggest reason that my patients tell me is that they feel artificial. There is always that fear of losing face in public if the hair piece comes off. Then, of course, there is price for maintenance, price for replacement and price for touch ups. After some time the cost of maintaining a good hair piece crosses that of transplant and you still have nothing to show. Last but not the least is health reasons. The glue can cause allergy, the clips can cause headache,even wounds if they are too tight, weaving may pull and damage your existing hair

Can I afford it?

The initial cost of a good hair transplant may be high but it does not require any maintenance. It is a kind of investment that will keep you giving good returns for times to come. An average a transplant session costs 5-7,000 US $ for FUT and 15-20,000 US $ for FUE hair transplants, but it is much cheaper in India.

Cause of Hair Loss

There are many myths in the society regarding hair loss. Reasons from diet to dandruff and change of water to  family stress have been cited as the cause for hair loss. There also have been a lot of research on the cause of baldness. In this post I would like to tell you about real cause of hair loss. It is always an advantage to know your enemy if you want to defeat him. I hope, with this working knowledge you would be able to plan your fight against hair loss in a better way.

 On the basis of cause hair loss or alopecia can be divided into three basic groups

1. Male Pattern or Androgenic alopecia, by far the common balding.
2. Diffuse pattern alopecia usually caused by disease
3. Scarring alopecia where injury to scalp causes hair loss.
   
   
   More than 95% of hair loss in men is due to androgenic alopecia. For androgenic alopecia to occur, three conditions must be met,
   
   
   1.Genetic predisposition to balding:This is not as simple as it sounds. You may have a father with full head and brothers with some baldness but you have a clean pate. The inheritance is usually polygenic, meaning multiple genes and their expressions play a role in development of baldness.
   However, if every man in your family loses hair by thirty, there is a stronger possibility that you will follow suit. Genetic factors are non modifiable. You must live with them.

2. Androgens or Male Hormones: All men and all women (YES!) produce male hormones. These hormones are generated in different quantities in men and women and typically the levels are much higher in males. This is also the reason why patterned baldness is much much more common in males than in females.
The male sex hormone, Testosterone is converted to another product called Di Hydro Testosterone (DHT) which is presently considered the main reason for hair fall. The conversion of Testosterone to DHT is mediated by an enzyme called 5 alpha reductase. DHT progressively destroys the hair root in genetically susceptible hair by a process called “miniaturisation” which leads to baldness.

         3.Time: Time or ageing is the third factor that plays arole in balding process. Nobody           loses hair before puberty (because DHT is not present in the body) but after that, everybody loses some hair. The pace of hair fall vary amongst individuals but it takes approximately 10 hair cycles for a strong anagen hair to become velus hair.

          Although much less important let me discuss other causes of baldness as well. Diffuse thinning of hair may be caused by anemia, thyroid or other hormonal disorder, severe physical stress etc. A rare type of diffuse thinning called diffuse unpatterned alopecia may even involve permanent hair zone.

On the other hand scarring alopecia could be due to injury, burn or skin conditions. Alopecia areata is a rare autoimmune disease in which hair are lost in bunches and body hair may also be involved.I hope it is now clear that change of water, tension and helmets are not the cause of your hair loss. And repeated shaving or oiling is not going to save them either.

Top 5 Hair Loss Myths

When you are suffering from hair loss, every one will offer you an advice or two. From office boy to neighborhood auntie, each can tell you cause and remedy of your hair loss. How they became so knowledgeable is anybody’s guess but here is a list to tell you when they are right and when they are not.

Myth No.1 : Shaving the Head will Prevent Hair Loss

NO! NO! NO! Shaving does not prevent hair fall. Probably the origin of this myth lies in the fact that short stubble feels coarser and is therefore considered made of better quality hair. In fact, it only feels harder because the hair is short and not because hair quality has improved overnight.  

Another contributing factor to the popularity of this myth may be that you stop “seeing” hair loss. After shaving your head, you don’t see hair in your hands or pillow like you used to. This is again because the hair is so short that you don’t notice its fall and not because hair loss has stopped.

Remember, the hair is falling due to hair root injury and shaving can not change this process. Hair fall will continue even if you shave your head hundred times.

Myth No.2 :  Dandruff causes Hair Loss

Again not true. The origin of this myth is the fact that every time you scratch your scalp you get one or two hair in your hands. These are just weak telogen hair that were about to fall any way. Dandruff on the other hand is a surface infection or colonization by a fungus. It happens in oily scalp and is medically treatable. It does not cause any damage to hair roots. Also remember that flaking of dry scalp is different from dandruff and only requires good hair conditioner.

Myth No.3 : Tension causes Hair Loss

False.  I  don’t know where this came from. Severe prolonged stress due to injury or disease can cause telogen effluvium, but day to day stress does not exacerbate hair loss.

Myth No.4 : Helmet or Hat causes Hair Loss

Wrong. Tight helmets or hats may contribute to hair fiber damage, but it does not cause root injury. On the other hand, pulling the hair too hard while wearing a turban or cornrows, can cause permanent hair loss. This is called traction alopecia and requires surgical treatment.

Myth No.5 : Oiling Prevents Hair Loss

Not true. Adequate oil is produced by your scalp to nourish hair roots. In fact, evey hair has its own oil producing gland. If you have very long hair, then putting hair oils may improve the texture, but short hairs do not require oiling. Head massage with oils can relax you but does little for hair growth.

So, what causes hair loss? I shall discuss this in my next blog.

Hair Fall and Stem Cells

There was a very interesting news item in field of hair transplant which I would like to share. This concerns cause of male pattern alopecia.
It is a known fact that in male pattern balding (Androgenetic alopecia), hair follicles don't disappear. They become so small by a process called “miniaturization” that they are not visible to naked eye. Although, we know that DHT is responsible for this process, how exactly it causes miniaturization of hair roots is still not known.

One theory of miniaturization says that DHT causes stem cell depletion in hair follicles of bald areas. A new study, published in the Journal of Clinical Investigation, tries to shed some light on this.  The research team led by Dr. Costarelis, MD collected cell samples from bald and non bald areas from the same persons and counted the number of stem cells present. They were surprised to find that bald areas had the same number of stem cells as hair bearing areas. When they looked further, they found that another cell type, which develops from stem cell, called progenitor cell was deficient in miniaturized follicle.

Dr Costarelis says that, "This implies that there is a problem in the activation of stem cells converting to progenitor cells in bald scalp." As of now, why or what causes the arrest in progression of stem cells to progenitor cells is not known. "However, the fact that there are normal numbers of stem cells in bald scalp gives us hope for reactivating those stem cells," notes Costarelis.
The logical next step would be to identify the factors that arrest this progression and to remove them. A locally applied agent or growth factors that can help stem cells to get converted to progenitor cells would also be very useful.
I have used growth factors injections in some of my patients. The results, especially when used with PRP are good but temporary. The repeated injections overcome the cost benefit. The big break will be an agent that can grow hair permanently. Till then we have hair transplants.

Advantage Follicular Unit Transplant

As I discussed in my last blog, the scalp hair is arranged in distinct anatomical and physiologic units called Follicular units. The knowledge of existence of follicular units have revolutionised the field of hair transplant, so that modern day transplant looks absolutely natural.

These are the advantages of Follicular architecture that we use in modern hair transplant;

Maximizing  growth

The follicular unit is a family. some have only one member while some have more. These members (hairs) of a follicular unit share vital support system. If we remove hair from them, then neither of them grow well. This results in sub optimal growth and inferior result.

 Natural Appearance


Since Follicular unit is a natural phenomenon, transplant done using follicular units looks natural and easily mixes with existing hair. The unnatural clumpy appearance of mini and micrografting is avoided. Since the follicular units are small in size an even density can be provided, mimicking the nature.

Dense Packing

Follicular units are generally prepared under the microscope and therefore it is possible to create trim grafts by removing excess of fat/skin tissue. This trimmed graft takes lesser space as compared to a traditional graft, and so, more grafts can be placed in same area.

Wound Healing and Recovery

Again, since graft size is small we need to make smaller cuts in scalp (to place them). These heal faster than the bigger cuts required for traditional grafting. It also means less pain and lesser chances of nerve damage.

Correction Hair Transplant

This method can be used to correct and improve the hairline and pluggy appearance of a punch or mini/micrograft transplant.

What is a Follicular Unit?

Follicular unit is a natural grouping of one or more hairs in the scalp. Follicular units also contain sebaceous (oil) glands, arrector pili muscle, and nerves and blood vessels. This can be likened to a family of hair. If you separate a person from his/her family, he may survive but will not be happy. These Follicular units terminal (and occasionally a velus) hair are so close together that it is not feasible to separate them, without compromising the growth.

This is how a follicular unit looks like.

On the left is a two hair unit and on the right is a single hair unit.

So, what is advantage of this follicular architecture?? How does this affect your hair transplant?
I shall discuss this in my next blog.

FUE or Strip: Which is Better?

The two most commonly performed procedures for hair transplant currently are Strip method (FUT - Follicular unit transplant) and FUE (Follicular unit extraction). Although FUT is currently most performed procedure, world over, FUE is fast emerging as a method of 1st choice especially when cost is not a constraint. I offer both procedures to almost all my patients who have good donor area and even now, most patients opt for strip method since it is cheaper.

The only difference between FUT & FUE is in harvesting the hair from the donor areas. The method of placement and the final outcome is similar in both methods..

Why FUE?

1. STITCH:

Strip method will always use stitch / staples in the donor area.

Some patients, in spite of the best techniques and educated judgment by the surgeons across the world will encounter problems due to stitches such as foreign body reaction, delayed absorption, suture spitting, stitch abscess etc solely due to presence of stitches. Such complication can then give rise to wide scars. Non Absorbable stitches and staples both need to be removed by 7 to 14 days and patient needs to visit the doctor for that that may add to their expenses and time out of work

FUE does not have stitches and therefore avoids all stitch related complications

2. SCAR:

Strip method will always leave a permanent linear scar in the donor area. This scar, how so ever fine is always visible in a short hair cut and therefore does not allow patient to wear a short hairstyle. Even trichophytic closure can have its own set of problems such as misdirected and ingrown hair.  After multiple sessions, patient will usually have “tram line” scars, tightness of scalp and low hair density leading to “show” of the unsightly scar.

FUE: Although it is known that FUE does leave marks and cumulative scarring is more than that of strip scar for equal number of follicles, it is the position of scar(s) that makes all the difference. I like to call it the stars and the Moon phenomenon. If you combine the brightness of all the stars in the sky the total brightness will be more than a full Moon. But still, you will more often notice a full moon in the sky first. The multiple pin point scars when combined are more than strip but they are so scattered as to be less visible to the eye.

3. PAIN:
 Strip method is painful and patient usually require pain killers for 3-5 days. Some patients cal develop long duration pain or painful scars. . Painful scarring, long term parasthesia or reduced sensation above the linear mark is always more in strip method.

 FUE patients usually have pain free recovery. Some patients may occasionally require painkillers for a day or two. Very rarely, some FUE patient may have hypersensitivity of the donor area but it always involves smaller area as compared to strip method and lasts for a shorter duration.

4. PREVIOUS SURGERIES

Strip method is not suitable for patients having tight scalp due to previous strip procedures or scalp reductions. In such cases, there is always some difficulty in closing the wound after strip removal and there is a high chance that the scar may widen with time.

 FUE does not require donor site closure and is therefore eminently suitable for such cases. In fact, many surgeons including me prefer to do second and third sessions with FUE, especially if the first one was FUT.

 5. SHOCK LOSS
Difficult to assess at this stage. Evidence is missing. FUT is more invasive so, it may cause more shock loss. FUE involves larger area so it may cause more shock loss.

6. SHAVING

Strip method is almost always done without shaving of the entire donor area. The existing hair in the donor area can usually hide the stitch line well.

 FUE requires shaving of the donor area. Theoretically, if small no. of hair are required, one may shave a strip of hair, harvest from it and use existing hair to cover the donor area. This is usually not the case. Shaving is the price, I feel, one should be ready to pay for all other donor site advantages.

7. BODY HAIR TRANSPLANT:

Strip method can not be used for BHT. Total hair supply is restricted to 5000 to 7000 grafts. In patients with advanced stages of baldness (Norwood VI/ VII) where more hair is required, it actually delivers less.

FUE can extend the donor area to body hair. In doing so, a large pool of DHT resistant beard, chest and other hairs become accessible and therefore practically inexhaustible hair supply is available.

8. FOLLICULAR TRANSECTION RATE

Strip method probably has lower transection rate compared to FUE since it is done under vision. However, slivering and cutting which involves major part of procedure is done by trained technicians of different skills and it is not possible for surgeon to inspect and assess each graft prepared by the staff.

FUE harvest is almost always done by surgeon (hence the cost). He can maintain control on the quality of graft. In strip surgery 80% job is done by assistants and 20% by surgeon whereas in case of FUE it is vice versa.

9. HAIR QUALITY:

Strip method has no control over the quality of harvested hair. At a given time 5-15% of hairs on the head are in telogen /  exogen phase. In strip technique, what ever is harvested is grafted, whether it is a good anagen follicle or a poor telogen graft. Moreover, the exact no. of hair harvested is difficult to tell beforehand, and sometimes the surgeon may harvest more or less than the requisite number.

In FUE only good anagen hair are harvested, because every hair is chosen by transplant surgeon. These hair have more chance of robust growth in post operative phase as compared to poor telogen/ exogen hair. Also, the number of hair harvested is exactly the same as no. of hair required.

10. COST AND TIME:

Strip method is relatively faster and cheaper.

FUE usually requires more time. An average surgeon will do 1000-1500 FUEs per day depending upont the expertise of the team. However a single session can go on for 2-3 days or more, depending upon patient requirement.

The cost is usually 2-3 times more than strip method because 1.disposable items ie; FUE punches are costlier, 2. Majority of work is done by highly skilled cosmetic surgeon, 3. Only a limited no. of grafts can be transplanted in a day so operation theatre charges & maintenance cost goes up.

Hair Transplant Basics: Who is the Right Candidate?

Did you know that by the time you start noticing hair loss, approximately 50% of the hair are already gone. So, as soon as you notice hair loss, you should consult a doctor. Remember that consulting a doctor is not same as going for transplant. In early stages of baldness, medicines can help you retain your hair and may postpone the need of transplant. However, medicines can not bring back the lost hair and to grow new hair in a bald area, transplant is the only option..

You should plan a transplant if,

      You have Androgenetic alopecia stage III to stage VII.

      Your hairline is not appropriate for age or you wish to achieve younger looking hair line

      You have burn alopecia or traction alopecia.

      You have eyebrow, eyelash or facial hair loss.

You should wait if,

You are in your teens or early twenties with unstable hair line.

If you have rare genetic conditions like DUPA, extensive alopecia areata etc.

If you are medically unfit for surgery (uncontrolled blood pressure, uncontrolled diabetes, heart failure etc)

Even in these conditions, it is best to consult a qualified plastic and cosmetic surgeon; because he can help you chalk out a plan for future and may offer you alternative therapies. An honest expert advice can save you lot of grief and money.

Hair Transplant Basics: What is Follicular Unit hair transplant?

Baldness and thinning of scalp hair are conditions that affect almost one-third of all men in their thirties and, fifty percent by their fifties.  Infrequently, some women also experience noticeable hair loss. There are many causes for temporary hair loss including systemic diseases, severe infection, anemia, thyroid disease, protein, vitamin and mineral deficiency, certain drugs, cancer treatments, childbirth and birth control pills. In this type of hair fall the root of hair is not destroyed. Therefore hair loss is temporary and corrects after the offending agent is withdrawn.

However, when hair root is destroyed, the loss of hair is permanent. The causes include direct trauma such as accidents, burns, operations and inflammatory or infectious diseases of the scalp. But, the most common type of permanent hair loss is Androgenetic alopecia, the exact cause of which is not known. However a hormonal byproduct called DHT has a significant role to play. It is postulated that people who have hair roots with increased genetic susceptibility to DHT suffer more severe hair loss. Since DHT is present in very small quantities in women, they do not generally suffer this type of hair loss.In Androgenetic alopecia, hair loss occurs typically from front and top portions of head, while sides and back hair are retained. 

Artificial coverage of bald area can be done with hairpieces and fibers, but many people find them unnatural looking or difficult to maintain. There are some medicines and oils in the market that claim to restore hair growth with limited success. Although medicines like Finasteride (Propecia) and Minoxidil (Rogaine) may stop hairfall to an extent, no amount of medicines can bring lost hair back. Follicular unit hair transplant is the only predictable, natural and permanent solution for those who are bald or have thinning hair. Hair transplants or grafting is a procedure which produces natural growing hair in bald areas.