Hair restoration is a surgical procedure intended to permanently correct male pattern baldness. Hair surgeries should be performed by certified surgeons, who specialize in hair replacement.

The most popular hair restoration surgery technique is follicular unit transplantation, which involves the removal of donor follicles from the back of the head (where hair tends to be more permanent). Once removed, the "donor area" is then stitched back up with no visible scaring. Next, the donor follicles are transplanted into the "problem areas" of the patient’s balding scalp

Hair transplantation involves relocating (transplanting) bald resistant hair follicles from the back and sides of the head (the donor areas) to a person’s bald or thinning areas. The transplanted hair follicles will typically grow hair for a lifetime because they are genetically resistant to going bald. In recent years hair transplantation techniques have evolved from using large plugs and mini grafts to exclusively using large numbers of small grafts that contain from between 1 to 4 hairs.

Since hair naturally grows in follicles that contain groupings of 1 to 4 hairs, today’s most advanced techniques transplant these naturally occurring 1 – 4 hair "follicular units" in their natural groupings. Thus modern hair transplantation can achieve a natural appearance by mimicking nature hair for hair. This recent hair transplant procedure is called "Follicular Unit Transplantation." Given the improved naturalness of hair transplantation surgery hair loss sufferers are increasingly selecting this hair loss treatment

History

The use of both scalp flaps, in which a band of tissue with its original blood supply is shifted to the bald area, and free grafts dates back to the 19th century. Modern transplant techniques began in Japan in the 1930s, where surgeons used small grafts, and even "follicular unit grafts" to replace damaged areas of eyebrows or lashes. They did not attempt to treat baldness per se. Their efforts did not receive worldwide attention at the time, and the traumas of World War II kept their advances isolated for another two decades.

The modern era of hair transplantation in the western world was ushered in the late 1950s, when New York dermatologist Orentreich began to experiment with free donor grafts to balding areas in patients with male pattern baldness. Previously it had been thought that transplanted hair would thrive no more than the original hair at the "recipient" site. Orentreich demonstrated that such grafts were "donor dominant", as the new hairs grew and lasted just as they would have at their original home.

For the next twenty years, surgeons worked on transplanting smaller grafts, but results were only minimally successful, with 2-4 mm "plugs" leading to a doll's head-like appearance. In the 1980s, Uebel in Brazil popularized using large numbers of small grafts, while in the United States Rassman began using thousands of “micrografts” in a single session.

In the late 1980s, Limmer introduced the use of the stereo-microscope to dissect a single donor strip into small micrografts. In 1995, Bernstein and Rassman published the first paper on "Follicular Unit Transplantation." where hair is transplanted exclusively in naturally occurring groups of 1-4 hairs. With microscopic dissection of donor pieces from an excised portion of scalp, individual follicular units containing but 1-4 hairs could be prepared and individually relocated into needle punctures in the recipient areas. Since the transplanted hair mimics the way hair grows in nature, completely natural results were attainable.

The follicular unit hair transplant procedure has continued to evolve, becoming more refined and minimally invasive as the size of the graft incisions have become smaller. These smaller and less invasive incisions enable surgeons to place a larger number of follicular unit grafts into a given area. With current techniques, over 50 grafts can be placed per square centimeter, when appropriate for the patient.

Surgeons have also devoted more attention to the angle and orientation of the transplanted grafts. The adoption of the “lateral slit” technique in the early 2000s, enabled hair transplant surgeons to orient 2 to 4 hair follicular unit grafts so that they splay out across the scalp's surface . This enabled the transplanted hair to lie better on the scalp and provide better coverage to the bald areas.

The procedure

At an initial consultation, the surgeon analyzes the patient's scalp, discusses his preferences and expectations, and advises him/her on the best approach (e.g.,single vs. multiple sessions) and what results might reasonably be expected.

For several days prior to surgery the patient refrains from using any medicines, or alcohol, which might result in intraoperative bleeding and resultant poor "take" of the grafts. Pre-operative antibiotics are commonly prescribed to prevent wound or graft infections.

Surgery

Transplant operations are performed on an outpatient basis, with mild sedation (optional) and injected topical anesthesia, and typically last about four hours. The scalp is shampooed and then treated with an antibacterial chemical prior to the donor scalp being harvested.

In the usual follicular unit procedure, the surgeon harvests a strip of skin from the posterior scalp, in an area of good hair growth. The excised strip is about 1-1.5 x 15-30 cm in size. While he is closing the resulting wound, assistants begin to dissect individual follicular unit grafts from the strip. Working with binocular microscopes, they take great care to remove excess fibrous and fatty tissue without damaging the vital follicular cells that will produce the patients' first crop of new hair.

The surgeon then uses a fine needle to puncture the sites for receiving the grafts, placing them in a predetermined density and pattern, and angling the wounds in a consistent fashion to promote a realistic hair pattern. The assistants generally do the final part of the procedure, inserting the individual grafts in place.

The finest surgeons can place more than 70 grafts per square centimeter in order to get a good density and appearance. In a "megasession", they may perform more prolonged surgeries, placing more than 2500-3000 grafts, reportedly even 6000 grafts, in one sitting. There is a recently reported case of 7761 follicular units transplanted in a patient, performed by Dr. Victor Hasson in one 18 hour megasession.

New technology

Newer procedures today allow for far less invasive surgery with optimal results. FUE (Follicular Unit Extraction), invented by Dr. Ray Woods of Sydney Australia, allows the surgeon to select individual follicular units from a donor region and transplant them to the recipient region. This method uses a small needle (0,50-0,75 mm diameter)to pluck out the follicular units, eliminating the need for the surgeon to excise skin from the back of the head. Benefits of FUE are quicker healing time, far less trauma, no strip scar, and the surgeon's ability to individually select follicular units. Drawbacks are that the procedure is far more time intensive than traditional STRIP methods and thus is much more costly. A top STRIP doctor can transplant more than 5000 grafts in a day, while a top FUE surgeon is limited to 1000-2500 in a day. An FUE procedure can continue over consecutive days, allowing to harvest over 3000 grafts if required for larger sessions. If too many grafts are harvested, a patient may get a "moth eaten" appearance in the back of his head. Transplants using FUE, however, still have the same drawbacks as the strip method when it comes to the recipient site often leaving patients with poor density, pitted skin and unappealing results when done incorrectly.

An extension of the FUE procedure is BHT, body hair transplantation (BHT). A select group of surgeons are now successfully transplanting body hair to the head. In some cases, the body hair can take on many characteristics of head hair. However, the procedure is still in its infancy, and while there have been successful cases, more completed results are needed to give a better assessment. At this stage the hair transplant community sees body hair as a good "filler" between scalp hairs, and as an additional donor source when patients have run out of scalp hair to transplant.

Lately some of the initial results of mega session BHT have started coming in. Basically it seems that yield is directly related to the quality of the extracted hair and the trauma it has received. Initial results seem to show that the time frame of removing a body hair and re implanting it to the scalp is critical. The less the graft is out of the body the better the results. Thus it seems that the new extraction protocols should be modified to minimize this critical time frame. While scalp grafts can survive out of the body for many hours the time frame for Body Hair is dramatically less. BH grafts that are thin and fragile (eg. arm and thighs) have dramatically less yield than robust hairs (eg. chest). Another thing to note about BH is that if DHT inhibiting drugs are used (eg. Finasteride or Dutraside) these drugs could work against the success of BHT. The same drugs that are very successful in stopping or reversing MPB have a negative effect on body hair.

Post-operative care

Advances in wound care allow for semi-permeable dressings, which allow seepage of blood and tissue fluid, to be applied and changed at least daily. The vulnerable recipient area must be shielded from the sun, and is not shampooed for about a week.

During the first ten days, virtually all of the transplanted hairs, inevitably traumatized by their relocation, will fall out ("shock loss"). After two to three months new hair will begin to erupt from the moved follicles. The patient's hair will grow normally, and continue to thicken through the next six to nine months. Any subsequent hair loss is likely to be only from untreated areas. Some patients elect to use medications to retard such loss, while others plan a subsequent transplant procedure to deal with this eventuality.

Side Effects

There are possible side effects that may be encountered after a hair loss treatment. Hair thinning, known as "shock loss", is a common side effect that is usually temporary. Bald patches are also common, as fifty to a hundred hairs can be lost each day.

Other side effects include swelling of several possible areas such as the scalp and forehead. If this becomes uncomfortable, medication may be sought from a doctor to ease the swelling. Additionally, the patient must be careful if his scalp starts itching, scratching it will only make it worse and cause scabs to form. A moisturizer or massage shampoo may be used in order to relieve the itching.

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