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Evolution of Hair Transplantation
Hair Transplantation has been around for a while, but many have dismissed it remembering the awful and stigmatic appearance of hair plugs.
Many advances have been made since then and we are excited to offer the latest technique – Follicular Unit Extraction (FUE) using NeoGraft technology.
Early Hair Transplantation
The premise behind hair plugs is valid – harvesting hair from the stable areas of hair and relocating to balding areas- the problem was that the grafts taken were too big, resulting in obvious gaps between implanted grafts and obvious scars at the donor site.
Reducing Graft size
The next step in the evolution of hair transplantation was to reduce the size of the grafts.
Instead of using large punches to extract hair grafts, one or multiple strips of hair bearing scalp was excised from the stable zone and the individual follicular units were then dissected by technical staff. This is still a very common method of hair transplantation used today and is know as Follicular Unit Tansfer (FUT) or The Strip Method.
The downside to this technique is that it leaves a long scar at the back of the head. Follicles either side of the excision area may be damaged upon incision or later with haemostasis and suture closure which can result in localised scar alopecia. The scalp skin is relatively rigid as it is adherent to the underlying galea- it doesn’t have as much elasticity as the skin elsewhere in the body and wounds will have more tension across them after closure.
Some scars heal well, but many don’t. Even the best scar may be visible and patients undergoing this method need to wear their hair a bit longer to hide the scar. A buzz cut, or shave will expose the scar. This is the biggest drawback to the technique, but sometimes the best choice for individuals with limited donor site area, such as Norwood 6 and 7.
Improving the donor site
Improving the donor site was the next logical step in the evolution of hair transplantation and the development of FUE.
Instead of excision a strip and dissecting the grafts, they are harvested directly as individual follicular units using a micro-punch with a diameter of 0.9 – 1.0mm. The resultant wounds are very small and contract further with rapid healing.
Together with regrowth of remaining hair in the donor site, the scars are undetectable within a week. Contrary to some reports, the scars of these wounds are not linearly additive and not at all comparable to a 20+cm incision.
The benefits of this is significantly less trauma, less pain and a quicker recovery.
FUE can be performed with manual or motorised hand punches, and with or without vacuum assistance.
Hand punches (without vacuum assistance)are usually used with 2-3 technicians working at the same time. After completing an area, the follicles are extracted with fine forceps and stored on cooled moist dressing pads.
The grafts can’t be checked for follicles until they are extracted which doesn’t allow for modification of technique if the punch is angled incorrectly and the graft is transected.
Vacuum assist devices
Vacuum assistance allows use of a punch-and-drag technique where the graft is punched and partially extracted with the integrated suction, then dragged against the skin allowing the follicle to be viewed and checked before it completely enters the suction tubing. If the follicle isn’t present, depth and angulation can be adjusted to ensure optimal follicular yield.
This allows for compression of 2 steps into one- punching and extraction- and thus saves time during the harvest, the most uncomfortable part of the procedure for patients, as you must lie prone (face down).
There are 2 suction assist devices currently on the market and they are similar in many ways.
We have chosen NeoGraft because it’s the newest and smartest technology available, with several important functional improvements that increase safety, reliability and graft viability.
Recipient sites are created according to the preplanned hairline design and the follicular units are implanted
The first step is a consultation to determine if you are a suitable candidate for FUE.
Your donor site is assessed and recipient sites discussed, as well as the likely number of procedures you need.
For practical reasons, a maximum of 2500 grafts (~5000 hairs) are implanted in each session, with second sessions from 4-12m later.
Hairline design is an art in itself and an essential component of a successful hair transplant procedure. In your consultation we will discuss the most effective placement of grafts and the implications of future hair loss and the impact it has on hairline design.
If you would like to know more, or determine if you are a good candidate please contact us for a consultation.
The average person has approximately 100 000 hair follicles on their scalp, grouped in follicular units with 1 – 4 hairs.
Hair cycles through 3 growth phases, but not all hairs are in the same phase at any one time. Disruption of this cycle will result in hair loss over time.
Anagen = the active growing phase. About 90% of your hairs are in this phase at a given time, usually for a period of 2-6 years.
Catagen = a transition phase between growing and resting, and usually occurs over a period of 2-3 weeks.
Telogen = the resting phase, with no active hair growth. About 10% of your hairs are in this phase at a given time. It is normal to lose up to 100 hairs a day in this phase. Normally these follicles will enter Anagen at the end of this cycle and a new hair will form.
The human eye can’t detect hair loss until at least 50% of the hair in an area has been lost. Thinning is better disguised in those with low colour contrast between their hair and scalp, and more obvious in those with a high contrast, such as black hair and a pale scalp.
Hair Loss in Women
Up to 40% of women will experience some form of hair loss by the time they are 50. As with men, the most common cause is Androgenetic Alopecia, aka Female Pattern Hair loss. This is usually later in onset than that in males and has a different distribution. The severity of hair loss is classified using the Ludwig scale.
The Ludwig Scale
The hair follicles are also susceptible to DHT, but as these levels are much lower in females it may be precipitated by the differing ratio of female hormones as menopause occurs, such that the relative rates of DHT increase. Decreasing DHT production with Finasteride is not effective in the treatment of Female Pattern hair loss and contraindicated because of its potential effect on male embryos in pregnancy. Minoxidil may be useful in some, but is less practical for daily use in women with long hair.
There are several other causes of hair loss in men and women. Although less common, a thorough history and examination will reveal the underlying cause in most.
Hair transplantation is not recommended in patients if the health of their donor hairs or their uptake after transplantation is considered to be poor.
Hair Loss in Men
Approximately 50% of men will have noticeable hair loss by the time they are 50. In 95% of these, the cause is Androgenetic Alopecia, more commonly known as Male Pattern Hair loss. This is an inherited condition, but the exact genetics have not yet been determined. We do know that multiple genes are involved, that they may be from either parent and that there is a variable expression of their effect amongst family members, so one brother may be bald and another have a full head of hair.
These patterns are classified using the Norwood scale. The patterns are usually progressive, so knowing your family history may be useful in predicting what your eventual hair loss pattern might be. The younger your hair loss starts, the more severe it is likely to be. Stages 1 and 2 are mild to minimal loss, stage 3 is the beginning of clinically significant balding. There is a typical pattern, with progressive loss in both the anterior and vertex area. In some one of these areas is better preserved, theses are noted as types v (vertex) or a (anterior). The most severe types 6 and 7 have the smallest donor site, but the biggest graft demand.
The Norwood Scale
Hair follicles in these individuals are susceptible to the androgen Dihydrotestosterone (DHT) which causes the hairs to become finer (a process called miniaturisation), the growing phase (Anagen) to become shorter and increases the percentage of hairs in the resting phase (Telogen). Medications that decrease the amount of DHT, such as Finasteride can help to stop the progress of hair loss. Minoxidil can also help by increasing the percentage of hairs in the growing phase.
The good news is that there is a stable zone of hairs present at the back and sides of the head, in a U shape. These hairs are not susceptible to DHT and can be used as donors in hair transplantation. Their genetic makeup won’t change when transplanted so they will be permanent.
Establishing the cause of your hair loss is the first step towards treating it. If your hair loss does not fit the pattern of Androgenetic alopecia, further investigations may be recommended in addition to a consultation with other specialists, such as an endocrinologist or dermatologist.
This is an oral medication with a recommended dose of 1mg per day. This is a prescription medication, so you will need to discuss it with your doctor before commencing treatment.
It decreases the amount of circulating DHT by blocking 5aR (5 alpha Reductase, the hormone that converts Testosterone to DHT). This will help prevent future hair loss, but it won’t restore hairs that have already been lost. There are side effects to this medication, the most problematic being sexual dysfunction- the risks are very low, and often resolve after a few months of treatment. A lower dose may reduce side effects and only marginally reduce its effectiveness.
This is not an effective treatment for Female pattern hair loss and is contraindicated in premenopausal women as it may interfere in the development of male embryos.
This is a non-prescription medication approved for use in both men and women. It increases the percentage of hairs in the growing phase. Is is a topical product usually applied as a foam to the scalp once a day. It may cause scalp irritation. Formulations with an anti-inflammatory component have been shown to decrease this side effect.
Like Finasteride, it won’t bring back hairs that have been lost.
The effect of both of these medications is not permanent. If you stop treatment your hair will return to the state it was in before you started.
Oral contraceptives and Spironolactone may be prescribed for Female pattern hair loss if deemed appropriate. There are many health supplements specifically marketed for both hair loss and hair health.
PRP (Platelet Rich Plasma)
is a concentrated suspension of platelets in a small volume of plasma derived from your blood. Platelets store and synthesize Growth Factors that initiate and regulate wound healing and regeneration. Approximately 70% of stored growth factors are released within 10 minutes of injection and almost all by 1 hour. Platelets continue synthesizing growth factors for up to 1 week until they expire.
In regards to Hair restoration, PRP has been shown to stimulate hair growth by increasing the number of hairs in the growing phase (Anagen). The hairs stimulated into anagen are thicker than hairs that are becoming miniaturized as part of the progression of pattern baldness. Growth factors act on receptors around the hair bulb and its microenvironment, increasing blood supply and tissue vitality. It is very unlikely to bring hair follicles that have atrophied back to life, so this is best on thinning hair not the bald head.
The research has been equivocal so far, but there have been positive anecdotal reports and some positive studies. The biggest problem in obtaining consistent results has been the variability in preparation and consequent concentration and viability of platelets. It is generally agreed that PRP should have a minimum of 5 times the number of platelets compared to baseline whole blood for PRP to be considered “platelet rich”.
There is variability in the response between patients, but the science behind PRP is valid and exciting. PRP treatment is synergistic with other treatments, by boosting growth factors, it amplifies the effect of microneedling and transplantation.
Microneedling with SkinPen™
is performed in our clinic with SkinPen, the only FDA approved handheld microneedling device. Each cartridge tip contains 14 x 32G stainless steel needles which oscillate up to 7000 times a second causing thousands of micro-injuries in the top layers of the skin. This stimulates a natural healing response, inducing not only collagen production, but an increase in blood supply and other extracellular matrix components. It can stimulate hair growth as a result of this and may also have a role in stimulating the hair bulb directly. It can be used synergistically with PRP, as this will amplify the healing response and potentially quicken response times.