FROM HEAD TO TOE
Fig 2a. Donor strip prior to excision.
Fig. 2b. Immediately after suture.
thorough physical examination to confirm that genetic hair loss is
the only pathology present since other types of hair loss may re-
quire medical therapy. During the consultation, it is very import-
ant to determine what is concerning the patient and what their
goals are for their final results. The average male patient may have
6,000-8,000 donor follicles available, whereas women typically
have less. It is important to discuss with each patient what their
donor hair will allow today while keeping in mind what future
hair loss issues may occur. This concept is especially important
in younger patients in their early 20s as they may have extensive
long-term loss that would not be served by an immediate surgi-
cal procedure. Unfortunately, these are often the most desperate
patients, so a conservative approach is crucial, while explaining
to them that an unnatural result can look worse and be more det-
rimental than being bald. In older patients, hair loss should start
to stabilize and certain areas such as the crown or temple are safer
to transplant.
There are two methods for harvesting donor hair: Strip Harvest
(FUT) or Follicular Unit Extraction (FUE). When done properly,
both techniques can have excellent results. The most important
factor in choosing which method to use is how short the patient
wants to keep their hair after the procedure. Patients who want to
keep their hair very short, may have a visible linear scar from FUT
and therefore, FUE is probably more appropriate.
Strip harvest is performed by removing an elliptical strip from
the back and sides in the Safe Donor Zone. This is typically a 5
cm wide strip in the occipital and parietal scalp that is genetically
resistant to hair loss over time. The ellipse is then sutured and a
linear scar is covered up by the remaining hair (Fig. 2). Using the
stereomicroscope, the strip is then cut into smaller slivers of five
to 10 follicular units. The slivers are then dissected into naturally
occurring individual follicular units.
FUE is a surgical technique where the physician uses a small
punch of 0.6-1.0 mm to excise each individual hair follicle. Each
graft is also prepared using the stereomicroscope to remove ex-
cess tissue. In this procedure, the grafts are also removed from
Fig 2c. Donor scar one year out. Scar width
can vary with each patient.
the same donor area as the strip (Fig. 3). This technique results
in small round scars that are spread over the donor area making
it difficult for the eye to pick up these scars. FUE can also be used
if a patient does not have enough laxity in the donor area after a
number of strip removals have been done. FUE allows for a greater
number of donor grafts to be obtained when compared to the strip
procedure alone.
Regardless of the harvesting technique, the most important
stage in surgical hair restoration is the physician’s ability to create
a hair line following natural boundaries and design. The soft, nat-
ural hair line was difficult to obtain with older “plug” type grafts in
the past. The advent of small naturally occurring follicular units,
allows the hair transplant surgeon to create natural appearing hair
lines which have become standard.
The number of grafts needed to correct a balding area can
range from 500 up to 5,000 or more grafts (Fig. 4, 5). The aver-
age number of grafts transplanted in one day depends on numer-
ous variables: balding area, donor density, patient age and patient
expectations. It is typical that a patient can have up 2,500-3,000
grafts transplanted in one day.
The International Society of Hair Restoration Surgeons
(ISHRS) is the world’s leading society for hair restoration. Key
components that should be completed by the hair restoration
surgeon include the evaluation of the patient prior to transplant,
creation of the hair line that includes areas to be transplanted, cre-
ating the sites in the recipient area and harvesting of the grafts to
be transplanted.
In recent years, there have been a number of practices in the
US and worldwide that have used unlicensed technicians to per-
form the entire procedure. The ISHRS has termed this the “Black
Market” of hair restoration. Patients have often ended up with
poor growth, unnatural results and depletion of their donor sup-
ply due to poor technique. In the state of Kentucky, only licensed
practitioners are allowed to perform surgical procedures.
According to the ISHRS, patients should ask the following
(continued on page 24)
APRIL 2020
23