This document discusses hair transplantation techniques and procedures. It provides information on hair anatomy, the hair loss cycle, patterns of hair loss, patient consultation and evaluation, pre-operative therapies and preparation, anesthesia techniques for donor and recipient sites, follicular unit extraction and transplantation methods, graft preparation and storage, recipient site implantation, and post-operative care. Potential complications of hair transplantation are also outlined.

1. HAIR
TRANSPLANTATION
Dr Mu jtu b a Per vez Kh an
Resid ent D UHS / CHK

2. 2
ANATOMY
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• Ectodermal (hair + pilosebaceous gland) and mesenchymal
(dermal papilla) origin
• Shaft and root
• Vellus hair (soft, hypopigmented), on frontal area of scalp
and over the body
• Terminal hairs (thick, long, pigmented) over the scalp,
eyebrows and pubic area
• With age, vellus hairs replace terminal hairs
• In bald areas, hair follicles are present but are atrohpic

3. 3
CYCLES
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active regressing resting

4. 4
PATTERN OF HAIR LOSS
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• Most common cause Androgenic
alopecia
• Scalp follicles responsiveness to
androgens leads to reduction in
growth rate, hair shaft diameter and
length of anagen phase
• In men, frontal and crown region are
affected
• In women, begins at vertex and
progresses anteriorly
• Traumatic hair loss, post burn
alopecia, comatose patients,
prolonged GA, aesthetic surgeries

5. 5
CONSULTATION
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• Paternal and maternal family history of
Androgenic Alopecia (AGA)
• Familiarity with pattern of baldness
• Donor site evaluation
• Density of FU’s/surface unit, number of
hairs per FU, anagen telogen ratio,
diversity of hair caliber, color contrast,
hair texture, scalp laxity, hair pull
• Modify their unrealistic expectations

6. 6
CONSULTATION
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• Photographs, Folliscope
• Inform about the risks of the
procedure
1. Postoperative edema (severe in 2%,
periorbital ecchymosis)
2. Scalp hypoesthesia
3. Temporary hair thinning
10-20% in males, 40-50% in females

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WHEN TO REJECT A PATIENT FOR TRANSPLANTATION
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• Inadequate donor reserves
• Norwood class VI or VII
• Donor scarring from previous surgery
• Unrealistic expectations

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PREOP THERAPY
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• Finasteride 1mg (5 alpha reductase inhibitor)
• 85% efficacy in slowing hair loss
• Most effective in posterior scalp region
• Risk of high grade prostate cancer, depression, male breast cancer,
permanant sexual adverse effects
• Topical minoxidil, increases anagen hair percentage, enhances local
vascular perfusion
• PRP, increase hair count, diameter. Microscopically, thickened
epithelium, proliferation of collagen fibers and fibroblasts, greater blood
vessel around follicles

9. 9
PREPARATION
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• Discontinuation of herbal medications, Acetylsalicyclic acid 3 weeks
before
• Abstaining from alcohol
• Minoxidil 2%-5% topical application 1 week prior
• Scalp massage from 4 weeks
• Photographs / HD video
• Donor site hair trim to 2-3mm
• Light sedation by oral diazepam/lorazepam with analgesic
acetaminophen/hydrocodone

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ANESTHESIA
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• Field block inferior to the donor
region
• Field block anterior to the
recipient area
• Regional.
Supraorbital/Supratrochlear
nerve block

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DONOR SITE
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Safe donor area

12. 12
TECHNIQUES
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• Follicular unit transplantation (strip
excision)
• Most common method
• Minimizes hair follicle transection
• Single scar regardless of the procedures
• Use magnification to see the angle and
direction of the hair shaft
• Tumescent solution -> increases inter FU
distance
• Skin hook or tissue spreader technique

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TECHNIQUES
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• Follicular unit transplantation (strip
excision)
• 0.8-1.2 cm width from the densest
SDA
• Single or two layer closure
• Wedge suture
• Trichophytic sutures
• Donor to recipient ratio 1:2 or 1:4
• Dissection of individual FU from the
long cuts

14. 14
TECHNIQUES
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• Follicular unit extraction
• Extracting individual FU
1. No linear scarring
2. Rapid, comfortable recovery
3. Patients can have a short haircut
• Manual / powered instruments
• 1mm punch -> 2.5 hairs/graft
• 0.75mm punch -> 2.1 hairs/graft

15. 15
TECHNIQUES
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• Follicular unit extraction
• Only every 3rd or 4th FU can be
removed from the SDA
• Overall density of the donor area
is reduced
• Donor site heals by secondary
intention
• Over harvesting can cause a moth
eaten appearance

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GRAFT PREPARATION AND STORAGE
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• An ideal graft is pear shaped, no excess epidermis, protective dermis, fat,
intact sebaceous gland and dermal papilla
• Main cause of graft failure is graft desiccation
• Survival of graft decreases by 1% per hour out of body
• Holding solutions
1. Ringer lactate
2. Culture media (DMEM etc)
3. Hypothermic tissue holding solutions
4. PRP

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RECIPIENT SITE
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• Do not place the hair line too low
• More severe MPB -> more superior
the hairline
• Gently arched line to two lateral
points
• Widows peak gives an illusion of a
low hairline
• Transition zone 0.5-1 cm, contains
micro and macro irregularities
• Angle and direction should mimic
the pre existing hairs of the scalp

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• Most common causes of inadequate hair density are
1. Injury to the blood supply
2. Insufficient number of grafts transplanted
3. Injury to the transplanted follicles during dissection, storage or
implantation
4. Selection of donor hair peripheral to the SDA

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• Multi unit grafting (MUG)
• 2 Fu’s that are close together are incorporated
• Illusion of increased recipient area density
• MUG is favored when
1. Low hair to scalp color contrast
2. Fine diameter, wavy or curly hair
3. Transplant in the forelock, mid scalp, anterior crown
4. Presence of surrounding hair so as not to expose MUGs over time

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• Dense packing
• More than 30 FU/cm square
• Adv: Most closely resemble a natural hair distribution
• Improves patient satisfaction
• Minimizes further procedures
• Disadv: Increased vascular compromise
• Challenging graft insertion
• Greater hair follicle transection
• Graft desiccation
• Traumatic graft insertion
• Stick and place method

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POST OP CARE
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• Overnight bandage
• Gentle shampooing after 48hrs
• Topical Minoxidil 5-12 weeks
• Icing or 10-15 minutes at the nape of neck, forehead and temples
• Supine for initial 72 hrs
• Suture removal 8-10 days, if tension present 10-14 day
• Avoid smoking
• Improvement after 9-12 months

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COMPLICATIONS
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• Periorbital edema
• Scalp hypoesthesia
• Temporary hair thinning
• Folliculitis
• Wound dehiscence
• Visible, hypertrophic scarring
• Keloid

23. THANK YOU
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