Hair transplant techniques enable natural-looking results

Key Points

La Jolla, Calif. - Advances in hair-transplantation techniques and instrumentation are allowing physicians to provide more comprehensive, natural-appearing results, sometimes in a single session.

Daniel E. Zelac, M.D., director, Hair Transplantation Unit, Scripps Clinic, La Jolla, Calif., says the methodology of follicular unit hair transplantation has virtually replaced earlier techniques that were commonly associated with poor long-term aesthetic outcomes.

"With a clearer understanding of the microanatomy of hair and what it takes to generate new hair growth, we have honed down the size of the graft to include individual or small groupings of naturally occurring hair shafts that emerge from a singlet or doublet follicular unit," Dr. Zelac says. "The resulting direction is termed follicular unit transplantation, and it is this advancement that has greatly improved the appearance and success of the hair restoration procedure."

Contributing to this natural outcome is the versatility of the follicular unit graft, Dr. Zelac says. "Use of smaller grafts has fostered the development of implantation techniques that maximize the achievable densities and perceived densities of the recipient region. Reduction in the visibility of implantation scars and the focus on the artistic placement and patterning of grafts have allowed for incredibly natural-appearing frontal hairlines and allowed the procedure to become a true art form."

Significant advances have been promoted in the field to tailor hairlines to genetic and cultural expectations and yield a much more satisfied patient, he says.

FUE advancement

Most recently, an approach called follicular unit extraction (FUE) has been popularized for the procurement of the follicular unit grafts. Traditionally, Dr. Zelac says, an approach called strip harvesting removed a linear strip of skin containing hair from an area of potential donor tissue. Through careful dissection, hair units would be identified and trimmed for implantation. The surgical scar resulting from a linear incision, as well as several other considerations with this approach, have helped shape an indication for the alternative, FUE, he says.

With FUE, "Units are extracted and harvested as individuals, thereby eliminating a linear donor scar," Dr. Zelac says. "Many short hairstyles demand an alternative due to the visibility of a linear scar when wearing a short haircut. In addition, for patients who have a very limited donor region due to previous procedures or scalp tightness, the FUE offers a viable method for obtaining donor tissue."

Before the advent of FUE, Dr. Zelac says, practitioners used punch techniques to extract units as large as 4 mm to 5 mm across and containing up to 10 to 15 hairs. Transplantation of these larger units tended to result in a "clumpy" appearance, which by today's standards would be viewed as unacceptable. Since the 1980s, however, "We have gone to minigrafting, then micrografting, and now we use the individual follicular graft approach either using traditional strip harvesting or FUE," he says.

Strip harvesting

Although FUE is gaining popularity, Dr. Zelac says strip harvesting remains the standard. Improvements in this area have included donor site choice, instrumentation and modified closures.

"An area that has been promoted for several years now is the utilization of a beveled closure skin edge termed the trichophytic closure," he says. "This modification camouflages donor-area scars by allowing hairs to grow through the scar, significantly improving the appearance of the donor site."

Earlier work in wound tension established parameters that assist in the prevention of widened scars due to tissue creep and challenged blood supply, Dr. Zelac says.

"Adoption of specific instrumentation, such as the Haber tissue spreader, has greatly reduced follicular unit transection during the strip harvesting. Transection is a major insult to the grafts and results in a reduced transplantation rate," he says.