High grades of baldness require a large number of grafts for coverage. The scalp donor area may not be sufficient. Non-scalp donor hair follicles from the beard, torso, and extremities can fulfill the deficiency in the supply. Improved technique and instrumentation of FUE have made harvesting body hair possible and successful The hair character varies by body region, with precise planning the combination of scalp and body hair can complement each other and look natural. The body hair along with scalp hair follicles can be used as in the primary procedure, and as a secondary procedure to previously transplanted scalp hair to augment the existing transplanted density. Never transplant beard hair follicles alone in one area as they stand out and look unnatural. Bear hair is thicker and curly in comparison to scalp hair, so their visual density looks more than that of scalp hair, while the body hair other than scalp hair is thinner. The body hair thickness after transplant remains unchanged but it becomes longer than that of their original length. #bodyhairtransplant #hairtransplantation

2. Overview
• Introduction
• Rationale of combination grafting
• History of combination grafting
• Advantages of body hair follicles
• Prerequisites for combination grafting
• Indications for scalp/body combination
grafting
• Contraindications of combination grafting
• Technique
• Conclusion

3. KEY POINTS
• High grades of baldness require a large number of grafts for coverage.
The scalp donor area may not be sufficient.
• Non-scalp donor hair follicles from the beard, torso, and extremities
can fulfil the deficiency in the supply.
• Improved technique and instrumentation of FUE have made
harvesting body hair possible and successful
• The hair character varies by body region, with precise planning the
combination of scalp and body hair can complement each other and
look natural.
• The body hair along with scalp hair follicles can be used as in primary
procedure, and as a secondary procedure to previously transplanted
scalp hair to augment the existing transplanted density.
• Never transplant beard hair follicles alone in one area as they stand
out and look unnatural.
• Bear hair are thicker and curly in comparison to scalp hair, so their
visual density looks more than that of scalp hair, while the body hair
other than of scalp hair are thinner.
• The body hair thickness after transplant remains unchanged but they
becomes longer than that of their original length .

4. INTRODUCTION
Hair transplant is becoming very popular in much demand.
Patients increasingly are seeking higher density and coverage with a natural
appearance. Higher numbers of donor hair follicles are needed.
The biggest limitation of hair transplant procedure is the discrepancy between the
demand and the supply of scalp donor hair.
Body hair is a good secondary source of donor hair follicles. 1,2

5. Objective of Hair transplant
Restore to Rejuvenate

9. The limitation of hair transplant procedure
is
the discrepancy between demand and supply.

10. Balding area 300 Sq. CM
1/3 scalp is roughly 100 Sq. Cm.
If we give min. density 25-30 G/Sq. cm. (Normal-
100G—still 1/3 of normal )
than we need 300 X 25/30 = 7500 to 9000 grafts
Usual scalp Donor can give 5500 to 6000 grafts.
Deficit around 1500 to 3000 grafts.
The body hair follicles can be used to cover the
deficit.
REQUIREMENT OF GRAFT
“Concept of Four Finger”

11. Scalp hair follicles are mixed with the body hair follicles
COMBINATION GRAFTING

13. HISTORY OF COMBINATION GRAFTING
The word “combination grafting”3,4 was used for a hair transplant procedure in which FUs along
with multi-follicular unit grafts (MUGs) are implanted to increase density and reduce implantation
and overall surgical timing.
But still, the need for higher density could not be overlooked. Recombinant grafting and high-
density grafting9,10 have their own advantages and disadvantages.
Higher-density grafting means graft implantation density more than 30 grafts per square centimetre
of the scalp area.

14. ADVANTAGES OF BODY HAIR FOLLICLES
Body hair follicles1,2 have the advantage of being a significant additional resource in both
numbers and character of the follicles.
Beard hair is thicker than scalp hair, giving a better illusion of density.
Chest hair is not as thick as beard and scalp hair but still, because of the wave and curl of
hair, it gives a reasonable visual density and certainly better than doing SMP.
Another good quality of hair is pubic hair, which patients are willing to undergo if
harvesting is done by FUE
As per the studies done by Kim11,12, Hwang11,12 and Lee13, when body hair is implanted on
the scalp the hair shaft thickness remains unchanged, but the length and rate of hair
growth change. Hairs become longer and grow faster. (It is not known if this remains true
over a long period of time).

15. PREREQUISITES FOR COMBINATION GRAFTING
• Patients must have enough body hair of the right type to be candidates.
• The most common and preferred areas for harvesting are the beard, chest,
abdomen.
• Patients with a history of keloid and or hypertrophic scars shall be subjected with
caution. A trial extraction of few grafts should be done in such cases.
• The patient needs to be informed about the risks of hypo or hyperpigmentation.
• Surgeon and his team must have expertise in body hair harvesting.

16. INDICATIONS FOR SCALPAND BODY HF
COMBNATION GRAFTING
• Young patients presenting with a higher grade of baldness (Norwood grade IV and above)
• Young patients with a strong family history of advanced degrees of baldness in first-degree relatives.
• Patients with a family history of baldness who are seeking high density for partial baldness at a younger age.
• Patients whose scalp donor density is relatively low with thinner diameter hair.
• Patients with higher-grade baldness and/or likelihood of developing higher grade baldness, who are not
willing or who cannot take medical treatment specially finasteride.

17. CONTRAINDICATIONS OF COMBINATION GRAFTING
1. Patients are not willing to undergo body hair harvesting.
2. Patients with a strong tendency of keloids and pigmentation
problems.
3. Surgeons’ lack of competence in body hair harvesting.

18. TECHNIQUE
The combination grafting of scalp and body hair can be done in two
ways.
1. As an adjuvant-As secondary procedure
2. As a combination- As the primary procedure

19. As an adjuvant-(A secondary procedure)
Body hair follicles are implanted to an area of the scalp previously
transplanted with scalp hair to improve the visual density (commonly
called “Fullness”).

20. Indications of combination as an adjuvant
(Secondary procedure)
1. Patients who had a previous scalp hair transplant but wants more
fullness.
2. Patients with too much scalp showing through their hair.
3. The scalp donor is not sufficient to cover the required bald area.

21. Planning
• To augment the anterior hairline and temporal triangle-- it is preferable to use scalp hair with or
without chest hair, because of the similarity of hair shaft thickness and character. If the scalp
donor area is already exhausted, then donor hair follicles from the chest are best suited. Care has
to be taken during implantation to orient the curve of the hair in a uniform direction toward
rather than away from the scalp.
• For augmentation of the forelock and mid-scalp, beard hair follicles are the best choice and chest
hair the second.
• For the vertex area
• If the vertex was not covered in prior hair transplantation, then use a combination of scalp + Chest +
Beard but do not use beard alone because this will look unnatural.
• If the vertex was transplanted previously, then beard and or follicles from any other body donor area
can be used to augment density. It is important to distribute them evenly throughout the transplanted
scalp hairs.

22. Preoperative pictures
after implantation of grafts
showing postoperative results

23. This case who has already undergone one FUT procedure to cover his front area, and now
wanted to cover the rest of the bald area also. 2567grafts were taken from scalp donor on day
one and on the second day 2420 grafts were taken from beard, 1058 grafts from the chest. A
total of 6045 grafts were implanted.

24. Combination of scalp and body hair
(A primary procedure)
In this model, body hair follicles are used along with scalp hair follicles
during the primary procedure.

25. Advantages of using body hair in primary procedure
1. We can make a master plan to cover the entire bald and future balding
area.
2. Proper mixing of body hair with scalp hair follicles can be done to prevent an
unnatural look of body hair.
3. The scalp hair follicles are preserved for future use in aesthetically important
areas, such as to augment anterior hairline and temple areas.
4. Young Patient with positive genetic history-whatever stage they present but they are
likely to develop Norwood stage VII in future.
5. Body hair follicles growth is androgen-dependent and very often younger ones are
refusing to take finasteride and even medication, so higher chances of early miniaturization.
6. Beard hair are thick and curly so along with scalp hair increases the visual density and give a
bounce to the implanted hair.

26. Technical details for combination grafting
All cases of male pattern alopecia of Norwood stage IV
and above are examined and evaluated for donor
availability of scalp and body hair. A detailed
discussion is conducted with the patient and consent
is taken for using the combination approach of
implantation.
First, the scalp hair grafts are harvested either by FUT
or FUE depending on the patient’s and surgeon’s
choice.
The scalp donor hair follicles are implanted as per the
scheme shown in figure, leaving gaps in between scalp
grafts for body hair follicles.
The complete hairline, transition zone (macro and
micro irregularities), and the defined zone is
reconstructed only by scalp hair as per the standard
norms of aesthetic hairline creation14
In the forelock area few scalp hair follicles are
implanted leaving space for body hair follicles.
In this forelock area the scalp and body hair follicles
implantation combination ratio is kept 2:1.follicles.

27. -Master planning of combination implantation. This picture shows the complete planning of
combination in Norwood stage up to VII, BHF-body hair follicle, SHF-scalp hair follicle.

28. After implanting all scalp hair follicles, the body hair follicles are harvested
using the FUE technique.
Just behind the defined zone and forelock area the scalp and beard hair follicles
are implanted in the ratio of 2:1 , and in rest of front area in ratio of 1:1 (there
can be some alteration in ratio depending on number of beard hair follicles).
In the mid-scalp and crown area the scalp to beard hair follicle ratio is 1:1 to 1:2
depending on donor availability.
Never put only beard hair alone in one region as they will give stand out and
look unnatural.
In crown area author prefer to use scalp to beard HF in 1:2 ratio, and if beard is
not sufficient than chest/abdomen hair follicles are being used.

29. On the first day author usually implant all the scalp hair, and on the second day beard hair follicles are
harvested and implanted in between scalp hair follicles.
All the recipient sites are made on day one. As a safety precaution, author does not extract from more than
two body areas on a single day, as this may cross the safe limit of anaesthetic drug.
If chest hair follicles are excised, it is advisable not to harvest from another body donor area the same day, as
the chest itself is a large donor area needing higher dose of anaesthesia.
In Norwood stage IV, around 2500 to 3000 grafts are implanted ,and out of this 500 to 700 grafts are harvested
from beard and remaining from scalp donor area. The planning is shown in figure 31.3B. The entire procedure
is done in one day itself.

30. Planning of scalp and beard hair follicles in
Norwood stage V
In Norwood stage V male pattern baldness, at
least 4000/5000 grafts are needed to cover the
bald area.
In single harvesting either by FUT or FUE, harvest
2000 to 3000 grafts from the scalp donor area,
and then the remaining grafts can from the beard
and/or chest are harvested.
During implantation of grafts of the mixing of the
scalp to the body, the ratio remains the same as
explained before.
The procedure is done on two consecutive days.
All scalp hair follicles are implanted on the first day
leaving space for beard/other body hair follicles
and next day, body hair follicles are harvested and
implanted in the spaces left.

31. NORWOOD STAGE VI
A detailed master plan of the recipient
and donor areas is done after discussion
with the patient.
The total number of hair follicles to be
implanted is calculated and the number of
follicles to be harvested from each area in
multiple stages is also calculated.
As a routine, 6000 to 7000 grafts are
needed for stage VI, depending on donor
availability and the patient’s desire for
how many grafts he can afford.
Out of this total, harvest 4000 to 5000
from the scalp in multiple stages and
obtain the remaining grafts from the
beard and other body parts.
Done in multiple sittings.

32. NORWOOD STAGE VI
THE FIRST SITTING-
• Two consecutive days are planned.
• A total of around 5000 grafts are harvested to cover the front and mid scalp bald area.
• Out of 5000 grafts, 2500 to 3000 grafts are harvested from the scalp on day one and
the next day remaining hair follicles are from the beard or other body parts on day two.
• Body hair follicles are implanted between the gaps of scalp hair follicles.
• The implantation plan in the front area remains the same as described for treating
Norwood stage V patients, the remainder of the scalp is implanted mixing with beard
hair.
According to the patient’s desire and need for more coverage and density, the further
stages can be planned.

33. Norwood stage VII planning
In Norwood stage VII the
bald area is nearly 280-300
cm² and to give a density of
25 to 30 grafts per cm², 7000
to 9000 grafts are needed to
cover the entire area.
Planning is the same as in
Norwood stage VI.

34. Guideline for combination method of hair
transplant in Norwood stage of male pattern
baldness.
N. STAGE GRAFTS SCALP HF BODY HF STAGES
IV 2500-3000 2000-2500 500-700 One days
V 4000-5000 2000-3000 1500-2000 Two days
VI 6000-7000 4000-5000 2000-2500 More than two days
VII 7000-9000 4500-6000 2500-3000 More than two days

35. CASE STUDIES
Here are few cases done by author using the combination method
showing how a combination method can be used to increase the converge
of higher grade of baldness with reasonable density in minimum stages.

36. Male pattern Norwood stage IV.
The patient shown here came with male pattern Norwood stage IV with family history of
baldness. Author planned for FUE method. He had good beard and scalp donor hair.
Author harvested 2493 grafts from scalp donor area and 524 grafts from beard shadow
area on the same day. The figure shows the results of hair transplant after 11 months.

37. Male patient having diffuse pattern hair loss. Results after 13 months of hair transplant
The patient shown is a 28 years male patient having diffuse pattern hair loss and took treatment for the hair loss also. He
wanted hair transplant and opted for FUE and gave consent for scalp and beard hair follicle harvesting. Total of 5119 grafts
were extracted in two days. On day one 3112 scalp grafts were extracted and implanted in front and mid-scalp area leaving
spaces for beard hair follicles. On day two the 2007 beard hair follicles were harvested and implanted. The figure also
shows post hair transplant results after 13 months of hair transplant.

38. Male patient having diffuse pattern hair loss. Results after 11 months of hair transplant.
The patient shown here, is 37yrs male and was on medical treatment and wanted to cover his entire scalp in
one stage. A total of 4900 FUE grafts were implanted in pre made slits. The 2996 FUE grafts from Scalp on
day one harvested and after implanted and on next day 1904 beard hair follicles were extracted and
implanted in between scalp hair grafts. The figure also shows the results after 11 months of hair transplant.

39. Norwood stage VII male pattern baldness
STAGE I— 2353 scalp grafts + 2004 BEARD
AFTER 4 MONTHS
STAGE- 930 chest hair follicles , On next day 1563 beard hair follicles

40. CONCLUSION
There is an increasing demand in treating high grades of baldness for greater
coverage and density.
The supply of scalp donor hair follicles is limited, and the available grafts are not
sufficient to cover higher grades of baldness.
Non-scalp donor area from different areas of the body such as beard, torso and
extremities provide the additional follicles needed.
Improved technique and instrumentation of FUE have made harvesting body hair
possible and successful.
The proper distribution and combination of scalp hair follicles with body hair
follicles will add to the final visual density of hair transplant and camouflaging the
individual characteristics of body hair follicles.