Hair transplant involves extracting hair follicles from the donor areas of the scalp that are resistant to balding, and transplanting them to bald areas. For a successful transplant, it is important to select appropriate candidates, ensure sufficient donor hair supply, manage patient expectations, and have a skilled surgical team. Factors like medical conditions, medications, psychological factors, and age can impact the results.

1. How hair transplant works
(basic logic)
– Hair follicles taken from an aesthetically suitable
area that will not be affected by hair loss (donor)
and is transplanted to another (recipient) area.

2. Donor Dominance
• The idea of donor dominance is the most
important constituent basis of hair
transplantation.
• Donor dominance refers to hair follicles
maintaining their original characteristics in the
transplanted area.

3. The ideal hair transplant
(1) Safety and comfort during the procedure
(2) Short surgery time
(3) Zero recovery time
(4) No scars
(5) 100% graft survival hence full hair re-growth of the
transplanted follicles.
(6) Cosmetically excellent results
(7) 100% preservation of the donor hair follicles hence
unlimited donor supply
(8)Cheap cost

4. Basis of hair transplant
• In male pattern hair loss, the occipital area is
not affected by balding; hairs in this region are
permanent
• Hairs from this region can be relocated to a
bald area and continue to grow normally.

5. Hair transplantation history
• The first recorded publication of hair
transplant for baldness treatment was in 1822
in Wurzburg, Germany.
• Diffenbach a medical student and his mentor
surgeon Professor Dom Unger performed an
experimental surgery in animals and humans.

6. Hair transplantation history
• Up until after the second world war, there was no
known advancement in hair transplant.
• However, the currently used technologies of
surgical hair transplantation were first developed
in Japan in 1930s and 1940s.
• In 1939 Dr. S. Okuda, a Japanese dermatologist
illustrated how hair was restored by transferring
fully thick grafts of hair-bearing skin to hairless
areas e.g. scalp, eyebrows and upper lip.

7. Hair transplantation history
• Treatment of Androgenentic Alopecia (AGA)
by hair transplantation kicked off in 1959 with
a paper written by Norman Orentreich, MD.
• Dr. Orentreich showed that donor dominance
was the most important factor in the success
of hair transplant for the treatment of AGA.

8. Hair Transplantation Today
• Today, surgeons can carry out safe, effective and
natural looking hair transplants thanks to the scientific
and technical advances in this field.
• In the last 5 years the Follicular Unit Extraction FUE
technique is becoming the more desirable choice of
graft extraction because;
– It eliminates the limitation of the linear scar associated
with the strip technique
– Grafts can be extracted from alternative donor areas
– Presents a larger donor area hence more grafts can be
harvested.
– Good results can be obtained .

9. Hair transplantation indications and
candidate selection
• Any one who has pattern hair loss, has good
donor hair, is in good health with realistic
expectations is eligible for hair transplant
surgery.

10. Hair transplantation indications and
candidate selection
• Male and Female AGA
• Selective patients with Cicatricial Alopecia
– Primary Cicatricial Alopecia – criteria not yet
established
– Secondary Cicatricial Alopecia – can be done with
or without primary surgical excision.
• Beard and mustache transplant
• Eyebrow and eyelash transplant
• Pubic hair transplantation

11. Limitations of hair transplantation
• The ability to bring out a fully satisfying
cosmetic result is dependent on:
– Proper patient selection
– Accurate assesment of the patients donor
– Appropriate hairline design
– Natural distribution of grafts

12. Limitations of hair transplantation
1. Insufficient donor
2. Age limits
3. Unrealistic expectations
4. Female patients
5. Scar alopecia
6. Medical problems
7. Psychological factors
8. Capability of the surgeon and his team

13. Donor
• Male pattern baldness is limited by the following important
factors:
– Donor area assessment and management
– Recipient area design and planning
– Long term planning of the solution
• To meet the increasing demand of hair transplant, hair
transplant surgeons are constantly increasing the
maximum-possible number of grafts transplanted in one
session to achieve maximum coverage of the recipient area.
• Surgeons are now disputing over a standard to define the
‘safe donor area’, because nowadays large number of grafts
can be obtained by FUE.

14. Donor limitations
• Sparse donor
• Depleted donor
• Insufficient donor in relation to the recipient area
• DUPA (Diffuse Unpatterned Alopecia)
• Presence of different levels of miniaturized hair in
the donor area (the future of stability of the
donor supply)
• Age, family history, physical examination and
Finasteride intake.

16. Donor
• Normal donor density
2.2 hairs/mm2
• Low donor density 1.3
hairs/mm2 and
extensive
miniaturization

17. Depleted donor
• Previous use of donor hair that resulted in
poor results or insufficient coverage of the
recipient area
– FUE
– FUT

18. Donor hair factors that affect the
results
• Hair density
• Hair diameter
• Hair Color
• Hair type - Curly hair

19. Age
• One of the most important limitations of hair
transplant is doing a hair transplant surgery on
young patients (under 20, 20-25). In fact, it is
a mistake.
• Young patients have this wrong notion that a
single hair transplant will solve their present
and future balding.

20. Age related limitations
• Physicians cannot exactly determine the
permanent zone for young patients.
• Physicians are not able to determine if the donor
area of the young patient will be stable over time.
• Patients who have early hair loss are more likely
to have extensive baldness in future (hence hair
transplant may not be worth it).
• Most young patients have very high expectations
in relation to desired density and lower hairline.

21. Age
• The most rational solution for patients
younger than 25 years old is to:
– delay having hair transplant until the real picture
of future hair loss is determined
– preserve the existing hair using medical therapy or
finasteride/minoxidil until the hairline is mature

22. Expectations
• It is necessary for the surgeon to listen to the
patients expectations, then in relation to the size
of donor and the bald area, let the patient
distinguish between the realistic and the
unrealistic expectations.
• Often, the donor hair is not enough to cover the
entire bald area on the scalp.
• Its important for the patients to know that they
will never return back to their youthful hair
(especially patients with high Norwood scale)

23. Hair transplant in women
• Female hair loss is different from male hair
loss in terms of the shape of thinning of scalp
hair.
• This maybe because of hormonal differences;
for this reason, very few female patients are
suitable candidates for hair transplant.

24. Hair transplant in women
• Female patients should undergo donor density
testing using densitometer to ensure that the
selected donor does not exhibit any signs of
thinning.

25. Hair transplant in women
• Another important factor to be considered is
the cause of the hair loss.
• Pregnancy, hormonal disorders, vitamin
deficiency are some of the causes of hair loss.
• Suitable female candidates are female
patients with AGA that have sufficient donor
hair.

26. Cicatricial Alopecia
• Well selected scar alopecia patients can
exhibit exceptional results.
• In relation to hair transplant, cicatricial
alopecia can be categorized as:
– Stable (Secondary)
– Unstable (Primary)

27. Stable Cicatricial Alopecia
• Scar quality is one of the major problems.
• Hypertrophic scars and advanced atrophic
scars with poor circulation may not yield
satisfactory results
– Before the surgery, blood supply in the scar area
should be tested with the 19G needle under local
anesthesia.

28. Stable Cicatricial Alopecia
• Full coverage of large scars may be limited by
insufficient donor.
– The most suitable alternative approach to such
cases is to reduce the scar area by primary
excision.

29. Unstable Cicatricial Alopecia
• These diseases primarily target the hair
follicles causing hair loss.
– pseudopelade of Brocq
– discoid lupus erythematosus
– Lichen planopilaris
– Folliculitis dekalvans

30. Skin diseases
• Some dermatologic diseases cause hair loss
and hair transplant may not be appropriate.
• Examples
– Alopecia Areata
– Infections
– Vitiligo
– Psoriasis (must be evaluated since hair
transplantation can aggravate the disease)

31. Unstable Cicatricial Alopecia
• The major factors to consider are;
– If the disease is currently active or not
– If the disease will or will not activate later
– If surgery may activate the disease
• Generally, a test hair transplant can be done
after a 2 year stable period
– If successful (no re-activation)then the full session
can be done.

32. Medical conditions and medication
• Even though hair transplant has no
contraindication, situations that may bring
complications in the procedure should be
carefully considered.
• In such special cases, the surgeon should
contact the patients physician or the
appropriate specialist.

33. Medical conditions and medication
• The scalp tissue is a well-vascularized tissue,
thus HIV, HepB and HepC patients may be a
risk for hair transplantation team
• Immunodeficiency characterized with HIV-
positive patients indicates high risk of
developing infections
• Patients with hepatitis, dosage should be
evaluated according to the liver functions.

34. Medical conditions and medications
• Diabetic patients also have high risk of
developing infections and should be
appropriately evaluated before surgery.
• Bleeding diathesis disorders can seriously
affect the hair transplant procedure. It is a
good idea to question the patients medical
history before the procedure.

35. Medical Conditions and Medications
• Patients who use blood-thinners or
anticoagulant medication should postpone or
stop the medication before the surgery (with
recommendation from the cardiologist)
• Drug interaction of Epipherine with non-
selective beta-blockers used by arrhythmic
patients can cause a hypertensive attack.

36. Medical Conditions and Medications
• Epipherine can trigger an epileptic attack on
patients with epilepsy.

37. Psychological Factors
• Hair loss can cause significant emotional stress
especially in young patients.
• Patients with psychiatric problems are more
severely affected by this stress.
• These factors should be carefully evaluated
before surgery and the surgeon should ensure
that the patient fully understands the
procedure and the results.

38. Psychological Factors
• Psychiatric conditions that should be
considered in relation to the success of the
hair transplant are;
– Trichotillomania
– Obsessive-Compulsive Disorder (OCD)
– Body Dysmorphic Syndrome (BDS)
– Depression.

39. Psychological Factors: Trichotillomania
• Active trichitollomania on any part of the
body is an obvious contraindication to a hair
transplant, but if a person has a history of this
condition, the doctor should also be cautious
and only consider surgery if the therapist is
confident that the condition has little chance
of recurring.

40. Psychological Factors: Obsessive-
compulsive disorder
• OCD patients are extremely difficult to satisfy
and even in a very successful hair transplant
can focus on a minor imperfection seeming
oblivious to the good overall result.

41. Psychological Factors: Body
dysmorphic disorder
• Whilst there may be no actual physical defect,
the patient is overly critical of their physical
looks.
• Such patients will most likely not satisfied with
the results of the surgery, or any other
cosmetic procedure.
• This condition should be treated by a
psychiatrist .

42. Psychological Factors: Depression
• The most commonly experienced psychiatric
disorder among hair transplant patients is
depression; it is also a common symptom in
people experiencing hair loss.
• Hair transplant will not cure medical
depression and unsatisfied expectations may
even worsen the condition.

43. Surgical team capability
• The doctor and the technicians must be well
experienced in hair transplantation.
• In addition, the doctor should have knowledge
in areas such as hair loss diagnosis, medical
treatment of hair loss e.t.c.

44. Surgical team capability
• Artistic aesthetic hair transplant design,
anesthesia administration, graft extraction
and implantation are complex procedures that
should only be performed by expert and
experienced capable teams.
• Since this procedure lasts 8-10 hours under
local anesthesia, the doctor should be well
trained in anesthesia related complications.

45. Surgical team requirements
• Since hair transplant is a technical procedure,
the following are important
– The doctor should have both dermatological and
surgical skills
– The technicians should be well trained and skilled
– Team work
– Attention to detail and accuracy
– Full concentration

46. Remarks
• With follicular unit transplantation technique
a surgeon can create natural looking hair
patterns and results.
• The success of the procedure depends greatly
on
– Proper patient selection
– Accurate assessment of the patient’s donor
– Natural distribution of the grafts; taking into
consideration age and future thinning possibilities.