This Isn’t Your Father’s Hair Transplant

This insightful article was written by  Dr. Shelly Friedman  of Scottsdale, Arizona who is one of our recommended hair restoration physicians.

To appreciate today’s hair transplant, one must realize how far we have travelled over the past 50 years:

When Dr. Norman Orentreich first introduced hair transplantation in the 1950s he was more interested in getting hair to grow in its new site rather than concerned with the cosmetic appearance.   The first hair transplants utilized a 4mm round punch which removed the hair and the surrounding tissue.   The “hair plugs” were removed with a cylindrical punch either manually or with an electric drill, and allowed to heal secondarily with a white scar.

This small piece of skin called a “plug” was then placed back into the scalp after a 3.5mm punch removed the bald skin.   The bald skin was discarded and the “plug” was inserted in the new recipient site.   The typical “hair plug” measured 4mm in diameter and had approximately 15-25 permanent or terminal hairs.   To accommodate the blood supply in the recipient region, the “plugs” needed to be spaced one “plug” apart.   This created the checkerboard effect which required 4 surgeries to fill in the entire transplanted area.

In 1984, Dr. Wayne Bradshaw, a hair transplant surgeon from Australia described a new approach to hair restoration whereby a 4mm “plug” is either bisected or quadrisected.   Instead of removing balding tissue in the recipient region, a blade is used to incise or create a paper cut within the tissue.   This new type of “plug” is called a minigraft.   The term “plug” was then abandoned in hair transplant circles.

Dr. Emanuel Marritt advanced Bradshaw’s technique by cutting one hair or two hairs from the minigraft and coined the term micrograft.   The micrograft was inserted into the skin after piercing the skin with a large bore needle (18 gauge needle).

As time went on, the harvesting of grafts with punches gave way to cutting an elliptical strip of skin which was closed by suturing the wound.  

In the 1990s Coalition member Dr. Bobby Limmer advanced the field of surgical hair replacement by acknowledging that hairs grow in discrete groupings of 1-4 hairs, and rarely 5 hairs.   The term follicular unit was used to describe one, two, three, four and occasionally five terminal or mature hairs in addition to a discrete nerve and blood vessel supply, a connective tissue sheath, sebaceous gland, and an erector pili muscle.   Dr. Limmer used a high powered binocular microscope to dissect the donor tissue into the natural hair grouping follicular units with the least follicular loss possible.   Dr. Limmer believed that a natural hair transplant could be achieved by duplicating nature’s follicular units, rather than separating the units or bundling the units into groups.   Follicular groups are composed of at least two or more follicular units.

Today, the donor hair is harvested by excising a narrow strip of tissue in the form of an ellipse from the back of the scalp where the follicles are resistant to hair loss.

The donor strip is then slivered or divided into very fine scalp sections measuring approximately 2mm in thickness utilizing stereoscopic dissecting microscopes.

A close look at these graft slivers demonstrate the natural grouping of follicular units.

The slivers are then dissected into individual follicular units using the stereoscopic microscope.

The microscope compared to magnifying loupes has been found to be more efficient in keeping the follicular units intact and resulting in less follicular transection.   This process yields a higher number of intact follicular unit grafts from the available limited donor hair.

Once the follicular unit grafts have been meticulously prepared, a micrometer is used to measure the width of the hair shaft’s diameter.   The length of the follicular unit graft is also measured in order to allow us to determine how deep the recipient site should be made to accommodate the graft.

After determining the width of the graft, custom made chisel blades are cut to perfectly match their size.

The length of the graft is then measured and carefully placed in a blade holder to match the length exactly.   Since every person’s grafts measure a different length, we are duplicating nature and assuring the best cosmetic outcome.

By making recipient sites with custom blades, we are able to place the grafts closer together and reduce the possibility of vascular injury or trauma.   In comparison to the 4mm “punch”, the typical chisel blade for a one hair follicular unit measures 0.7mm in diameter.   The two hair and three hair follicular unit grafts usually measure 0.9mm-1.1mm in diameter.

We choose to produce custom-made chisel blades rather than the alternative sharp or spear point blades.   The chisel blade produces a linear incision on the skin surface and a rectangular-shape beneath the skin surface.   This allows an incision at right angles to the direction of hair growth.   The spear point blades result in deeper incisions which could compromise or traumatize the vascular blood supply to the recipient region.   The chisel blade allows us to dense pack the follicular unit grafts and achieves more optical hair density.

Once the donor tissue has been removed, the skin is sutured closed using a technique called the Trichophytic Closure.   The trichophytic closure involves trimming the upper edge of the incision and then closing the wound so the hair near the edge that was trimmed can grow through the scar.   This technique has been found to reduce the visibility of the scar and better camouflage the donor region.

The Lateral Slit or Coronal Angled Grafting:

Since the advent of minigrafts, hair transplant surgeons have made recipient slit sites parallel to the direction of hair growth.

Demonstrating perpendicular versus parallel direction of hair growth

Hairs in the donor region are naturally arranged next to each other in a plane perpendicular to the direction of hair growth.   Placing the follicular unit grafts in a parallel or sagittal position creates unnaturalness and reduces optical density.   By duplicating nature, making the recipient slits perpendicular to the direction of hair growth, we are returning the hair to the same distribution and alignment as in the donor region.   This process is called the Lateral Slit Technique.  

Advantages to the Lateral Slit Technique include:

• More precise angulation of the slits especially over the sideburns, posterior scalp and the lateral fringes.
• Reduced injury to the scalp blood vessels due to a shallower recipient site.
• Less graft popping since the force of incision is downward and upward, allowing free transmission of pressure to the outer surface of the scalp.   This results in no pressure being applied to adjacent grafts.
• More optical density since the follicles lie side by side, rather than lined up behind one another. This results in the hair giving a thicker more natural appearance.   The same number of grafts placed in a lateral or coronal angled slit visually makes the transplanted hair appear more dense and thicker than the parallel or sagittal angled slits.

Dense Packing:

The same number of follicular unit grafts or hairs placed over the same recipient area can appear totally different.   The appearance of hair density is not only dependent on the number of grafts, but also dependent on the color of the hair, quality of the hair, and texture of the hair.   The color of the hair is important in contrast to the color of the scalp.   The more contrast, the more hair is required to achieve optical density.   Dark hair on a Caucasian scalp is going to appear thinner or sparser than lighter color hair such as blonde, gray or white.   This is opposite to lighter color hair on an African-American or darker pigmented scalp.

The quality of the hair is also important for determining density.   Hair that is curly or wavy appears to achieve more optical density since it camouflages the skin to a greater extent than straight hair.   In the 1970s men would perm their thinning hair to reduce the visual contrast between hair and scalp.  

The texture of the hair is one of the most important factors influencing the number of grafts required for a specified area of the scalp.   Hair shafts can either be very fine, fine, medium, medium coarse, or coarse.   The difference depends on the width of the hair; the wider or thicker the hair; the more optical surface density will be visualized.

Since each individual has a unique texture width, we can customize a recipient site blade to perfectly match the width of the follicular unit graft.   In the past, recipient sites were made with pre-cut manufactured blades which were “one size fits all” mentality.   With custom cut blades, we can place the grafts closer together to attain more density per square centimeter.     These custom-made blades have allowed hair transplant surgeons to dense pack fine hair without compromising blood supply.   We can transplant 50-60 follicular unit grafts per square centimeter in the hairline and approximately 40 follicular units per square centimeter over the frontal, midscalp, and vertex.

An example of dense packing approximately 50 follicular units/cm2 over the frontal region of the scalp

Hair Transplant Megasessions:

The term megasession varies from office to office and from surgeon to surgeon.   There is no defined number of grafts transplanted per surgery which is widely accepted among the hair transplant community.   Some offices may arbitrarily state that 2,000 or more grafts transplanted in one surgery as a megasession, whereas other offices may classify a megasession as 3,000 or more grafts placed in one surgery.  

The important thing to remember is why we perform megasessions:

• The more grafts transplanted per surgery allows provides more surface coverage and ultimately the less number of surgeries required to fill in the recipient region.
• The less number of surgeries results in less downtime or surgical visibility.
• The more grafts transplanted per surgery translates to more hair being transplanted per surgery.   This results in faster cosmetic coverage of the balding areas.   Since the purpose of undergoing hair transplantation is to move hair, the more hair moved, the better the aesthetic result.
• Patients who have deferred or postponed undergoing hair transplantation due to the thought of multiple surgeries required to achieve their goals, can now achieve cosmetically acceptable coverage and density in one or two surgeries.

Not all offices can perform megasessions due to a lack of qualified, experienced hair technicians.   Our average surgery is approximately 3,000 follicular unit grafts per surgery, but we have transplanted as many as 5,800 grafts in one surgery.   Keep in mind the number of grafts being transplanted in one surgery depends on donor region density, scalp elasticity, and the degree of baldness.

Today, we can transplant up to 6,000 follicular unit grafts in one surgery depending on the donor region density, scalp elasticity, and the degree of baldness.     Many hair loss patients can achieve the density and coverage they desire in one surgery, not the multiple surgeries required in the past.  

No, this isn’t your father’s hair transplant,   Today we can achieve a totally undetectable, natural appearance your father won’t even believe.

Dr. Shelly Friedman

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Bill Seemiller
Associate Publisher/Editor

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