AESTHETIC SURGERY
Microrefined Microfollicular Hair Transplant A New Modification in Hair Transplant Amit Gupta, MBBS, MS (Gen Surgery), DNB (Plastic Surgery) Abstract: Hair transplant is the most common cosmetic surgery procedure in men; at our center, we perform nearly 40 transplants a month, with nearly 450 procedures in a year. Current techniques of hair transplant are well established and several authors have had remarkable results using the current techniques of microfollicular hair transplant. Orentreich described hair transplant, Shiell has reviewed current techniques in his paper, whereas Rose reviews the latest innovations in hair transplant including Neograft and robotic procedures. We present our modifications to the process based on our experience of more than 1000 cases in the last 3 years. Microrefined microfollicular hair transplant is a procedure with innovations at each step of the standard microfollicular hair transplant procedure to improve results. The steps of the procedure are as follows:
1. beveled incisions on both ends of the strip to take the graft transection rate to less than 1%; 2. dissecting the strip in a way to leave a layer of fat on top of the galea; 3. slivering of the strip under magnification to ensure less than 1% hair wastage; 4. harvesting of 300 to 400 grafts with follicular unit extraction for the anterior hairline; 5. microzigzagging of all the slits; 6. graft preparation to ensure bare minimum fat at the level of the roots; 7. during implantation, handling of the grafts with the hair end and not the root end; and 8. fast processing and coordinated efforts to reduce operative time to approximately 4 to 4.5 hours for large cases (5000Y6000 follicles) and 2 to 2.5 hours for smaller ones. Key Words: hair transplant, MMFT, FUE (Ann Plast Surg 2014;73: 257Y265)
H
air transplant is the most common cosmetic surgery procedure in men. We have performed nearly 1200 transplants during the past 4 years, and so much has been the popularity of the procedure that we are now performing nearly 40 transplants a month, with nearly 450 procedures in a year. Current techniques of hair transplant such as follicular unit hair transplant (FUHT) and follicular unit extraction (FUE) are well established.1Y3 Orentreich described hair transplant.4 Shiell has reviewed current techniques in his paper.5 In more recent times, FUE procedures have been modified, and we hear of Neograft
Received March 26, 2012, and accepted for publication, after revision, September 10, 2012. From the Divine Cosmetic Surgery, Delhi, India. Conflicts of interest and sources of funding: none declared. Reprints: Amit Gupta, MBBS, MS (Gen Surgery), DNB (Plastic Surgery), Divine Cosmetic Surgery, Delhi, India. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7303-0257 DOI: 10.1097/SAP.0b013e3182741f66
Annals of Plastic Surgery
and robotic procedures.6 We believe FUE has major limitations if used alone as the main technique. Some of the problems that have been defined are graft wastage, additive nature of scars, and scar contraction6Y9 We will discuss these in detail subsequently. We are of the opinion that the follicular unit transplant (FUT) or the strip procedure is the best procedure particularly when megasessions are involved. During the last 3 years, we were very happy with our results, but we decided to modify certain steps in our constant endeavor to improve. We present our modifications to the process, which are based on our experience of more than 800 cases in the last 3 years and 400 odd cases with our modifications during the last 12 months. We have labeled our procedure as microrefined microfollicular hair transplant (MMFT).
MMFTVThe Technique Microrefined microfollicular hair transplant is the end result of a critical analysis of steps and results of the previous 800 procedures we had performed in the last 3 years. Most of the modifications have been the result of interactive discussions with surgeons, assistants, and patients. We have tried to modify each step to refine it so as to produce the perfect result. The steps are simple, have a small training curve, but make the process more logical. All magnifications are with Loupe (1Y1.5; we initially used 2, but no longer). With this magnification, we are able to reach a perfect combination of precision and speed. The steps of the procedure along with the modifications are as follows: 1. Strip harvestingVbeveled incisions on both ends of the strip to take the graft transection rate to nearly 0%. 2. Incising the strip off the galea in a way to leave a layer of fat on top of the galea. This precise step means leaving minimal tissue on the grafts. 3. SliveringVslivering of the strip under magnification to ensure less than 1% hair wastage. 4. Combination with FUEVharvesting of 300 to 400 grafts with FUE for the anterior hairline. 5. Preslits and the anterior hairlineVmicrozigzagging of all the slits. 6. Graft preparationVensure bare minimum fat at the level of the roots. 7. Graft placementVhandling of the grafts with the hair end and not the root end. This allows easy preservation of the roots, because the roots are not touched at any step of the process. 8. Coordinated team effortVfast processing and coordinated efforts to reduce operative time to approximately 4 to 4.5 hours for large cases (5000Y6000 follicles) and 2 to 2.5 hours for smaller ones (3000Y3500 follicles). A detailed discussion of each step is given to understand its importance and to provide obvious evidence to justify each step.
Strip Harvesting Beveled Incisions Strip harvesting is the first step in the FUT process. The process involves harvesting the strip after administration of local anesthesia (we used a combination of 2% xylocaine and 0.5% bupivacaine) and
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making the donor site tumescent with 10 to 15 mL of adrenaline saline solution (1:200,000). We have modified the step with beveling at both ends in the direction of the hair growth, in a way to preserve nearly each and every root, the incisions being made under magnification. This allows nearly a 0% transection of the roots both on the margins of the harvested strip and on the occipital site, allowing a larger number of grafts to be harvested; sometimes nearly 150 to 200 grafts more; as viable grafts all along the margin of the strip. The scar is extremely fine and hair growth occurs through the scar because viable grafts are present on either end of the incision. This is analogous to the trichophytic closure in MACS lift surgery (Tonnard and Verpaele) (Fig. 1).
Level of Strip Harvesting The strip is harvested in a plane just below the roots to ensure some fat is left on the galea. This process is very exacting and delicate because the plane is usually less than 1 mm from the level of the roots (Fig. 2). Advantages of this step are as follows: (a) Bleeding is virtually eliminated, and the tiny blood vessels at this level can easily be cauterized. A concern can be raised here regarding the possible injury to donor-site hair or marginal hair damage with the bovie process. However, this is not seen practically. We use microbipolar forceps because the vessels are very fine. Bipolar cauterization does not spray the current. Further, it is seen that the vessels are tortuous and as the strip is gently raised off the galea, the vessel stretches, allowing a clear zone for safe and precise cauterization of the vessels (Figs. 3 and 4). (b) No long-term paresthesia problems, which are seen when the galea is transected. This is a very difficult problem often seen in patients who have had transplants with inexperienced surgeons. This paresthesia is very irritating and often without a solution. A carefully conducted dissection goes a long way in preventing this complication.
FIGURE 2. Preservation of fat on top of the galea and on the strip. Also seen is a blood vessel on the deep surface. Note the length of the vessel.
transection. This means more number of hair follicles per graft, and thus translates into better result (Fig. 5).
FUE Grafts for the Hairline Layer We harvest 300 to 400 grafts with FUE procedure using 0.8- to 1-mm punches; we implant these grafts in the first 1 to 1.5 layers of the anterior hairline. Advantages of this step are as follows: (a) FUE grafts are thinner than strip grafts because there is virtually no dermis and fat. Thus, larger number of grafts can be placed per
Slivering of the Strip Horizontal slivering of the strip is done under magnification to make slivers of 1 to 2 follicular unit thicknesses. Advantages of this step are as follows: (a) brings down the hair wastage to less than 1%; (b) faster graft separation by the team; and (c) good preservation of the follicular units, ensuring higher density. Two assistants in the team are specially trained to sliver the strip to 1 or 2 rows of grafts only. It is obvious here that the work of the other assistants is considerably reduced, as they only now need to separate grafts that are clearly visible, without worrying about
FIGURE 1. Beveled incisions and preservation of grafts on the sides of the incision after harvesting the strip. 258
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FIGURE 3. A strip being raised and fine blood vessel on the deep surface at safe distance from the roots. * 2014 Lippincott Williams & Wilkins
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FIGURE 4. A picture showing fine blood vessels while raising the strip. Also note the length of these vessels, making it easy to cauterize them without damage to the roots. square centimeter. We implant 300 to 400 grafts in the first line itself. This allows extremely natural density in the first line. (b) Because the FUE grafts are thinner, we can place grafts with 2 follicles in spaces meant to hold single follicle grafts; thus, we are able to get higher number of follicles per graft in the first line. We place alternating layer of grafts containing 1 and 2 follicles, respectively. This maintains the naturalness of the hairline and also gives a very high density in the first line (Figs. 6 and 7).
follicles are at risk, but we are able to pretty easily harvest grafts of 1 to 3 follicles with nearly 95% to 96% preservation of grafts. For the hairline, we do not require grafts with 4 follicles because they look unnatural anyway. Our techniques have evolved to reduce the follicular transection rate and wastage to 4% to 5%, so effectively that if we take 350 to 400 grafts, we would, at the worst, waste 12 to 16 grafts (Fig. 8).
An alternative to this is to super-refined the grafts under highpower microscope to totally bare the dermis and fat. We agree with this; however, we do not do this step because this requires special trainings of the assistants; the step takes significantly longer than FUE to get the same number of grafts. Lastly, we are able to reduce the length of the strip and the FUE scars are virtually invisible because 0.8- to 1-mm punches are used. Addition of the FUE process adds approximately 45 to 60 minutes to the procedure. However, the results achieved by this step justify the extra time. Because we only require approximately 400 grafts, we do not need to shave off any segment larger than already done for the strip, making the FUE marks invisible to anybody. An additional concern could be regarding the potential wastage of hair with FUE. Transection in FUE is a controversial issue. Experts in FUE counterargue that strip causes more wastage, but in our view, a lot of this depends on the surgeon’s experience. It is absolutely without doubt that grafts with 4
Slits are preplaced in our technique. In the first 1 to 2 rows, we place 600 to 700 grafts and continue the zigzag placement all the way through. The sizes of the slits are different throughout. In the first 1.5 rows, they are smaller, approximately 1 to 1.2 mm, and as we go back it increases to 1.5 to 2 mm. Further back, it can increase to 2.5 mm. However, this depends from case to case. In patients with thick hair, the slits need to be larger, and patients with thin hair, the slits are finer.
FIGURE 5. Slivering of strip to single follicular unit layers. * 2014 Lippincott Williams & Wilkins
Anterior Hairline and PreslittingVMicrozigzagging of the Slits
FIGURE 6. Comparison of FUE and FUT grafts. The FUE grafts are thinner than strip grafts. Note that grafts have little or no fat below the roots, and microzigzag pattern in the front hairline and the zigzag pattern being carried further back in the center. Also note the difference in slit size in the anterior line and further back. www.annalsplasticsurgery.com
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FIGURE 7. Microzigzag pattern in the front hairline and the zigzag pattern being carried further back.
FIGURE 10. Showing 5 assistants carrying on the implantation process simultaneously.
FIGURE 8. Donor area showing strip and FUE scars. Note the limited area of the shaving required and reduction in the length of the scar.
FIGURE 9. Slits with the horizontal palisading method on the left side. Note the irregularity of the pattern toward the front and center done by the zigzag method. 260
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Advantages of the procedure are as follows: (a) A horizontal palisading effect is caused by the conventional slit process, where the slits are placed in single rows; this gives a relatively transplanted appearance due to gaps between contiguous rows. This is avoided by the zigzag design, where the grafts are seen to come out in continuity and not in rows, adding to the naturality of the results. (b) The zigzag process opens the slits out better because all natural tension lines in the scalp are released. In the horizontal slit process, the lines between the rows are not released and often the slits open inadequately or the slits need to be made larger. This is not to put this technique in negative view; all procedures (including ours before this innovation) have been done this way only and we got good results. The addition of this step increases the natural look of the result. Smaller slits can be as effective as the larger ones because they open out better, reducing the scar formation.
FIGURE 11. A 24-year-old male patient, 1800 grafts for the front hairline and side temple region, 1 session. Result after 6 months. The picture on the left shows the area of baldness as well as the markings (1900 grafts). * 2014 Lippincott Williams & Wilkins
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FIGURE 14. Donor area of the same patient in Figure 13 showing the scars of the punches and the design of the strip. FIGURE 12. The same patient in Figure 11, front view. The picture on the left shows the preprocedure situation and the markings.
(c) Better densities are achieved, adding to a good dense hairline. (d) A practical consideration of this has been seen in some patients who have darker skins (some patients from the southern parts of India, and others) and have a firmer skin texture, necessitating a larger slit creation for placement of grafts. This process allows the tension lines to be broken, and thus, smaller slits are possible (Fig. 9).
Graft Preparation and Placement The assistants prepared the grafts in a way that bared as much fat and dermis as possible (it is not possible and inadvisable to remove 100% of the fat). This process allows grafts to survive on
minimal host supply and ensure virtually 100% graft survival. This is easily understood as we know the process of engraftment. The dermis and fat have far greater needs than the follicle; therefore, the lesser the tissue, the better is the engraftment. This is only important when we want to place more number of grafts in a small area like the anterior hairline. There is another reason for our attempt at reducing tissue at the lower end of the graft, we place grafts into the slits by holding it from the follicle end; a graft root is stiffer, if it has lesser fat around it and slides very easily into the slit. The conventional way of graft placement is to hold the graft from just below the roots with fat and place them into the slits. Because we bare the graft to leave almost no fat below the roots, we have modified the process of placement. As we are not handling the graft by the roots, we ensure nearly 100% graft survival. A combination of these steps allows us to ensure almost 99% graft harvest and nearly 100% graft survival. We assure our patients of at least 95% graft growth rate.
Team Coordination Hair transplant is a team approach, and a coordinated effort is essential to ensure a speedy procedure. Strip harvesting is done by 3 people, and 9 assistants are involved in graft separation. Simultaneous implantation is done by 2 assistants (3 when simultaneous front and crown areas are being treated), whereas 1 assistant works to keep the field clean and delivers grafts near the implantation site.
FIGURE 13. A 34-year-old male patient who earlier underwent punch grafting elsewhere with very poor result. Note the plugs of hair on the lateral aspect of hair in the frontline. * 2014 Lippincott Williams & Wilkins
FIGURE 15. The same patient in Figure 13 after 8 months of hair transplant procedure (2500 grafts). www.annalsplasticsurgery.com
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FIGURE 16. A 36-year-old male patient before and 9 months after a transplant procedure (2500 grafts).
This allows us to complete 6000 follicles (2600Y2800 grafts) in approximately 4 hours (Fig. 10).
RESULTS A few results using this technique are presented (Figs. 11Y30).
SUMMARY Hair transplant is a constant struggle between density and coverage. Even with the best techniques, results depend to a large extent on the hair quality, density, hair texture, and others, so a number of factors are actually beyond the surgeon’s control. We decided to work with factors that we can modify. With the current techniques of hair transplant like FUT, FUE, and Neograft procedures, there is a lot of confusion as to which technique should be used. This article does not aim at advocating a particular technique, but rather wants to combine the best of all available techniques in a unique amalgamation, which we have labeled MMFT. Certain facts are obvious and these are enumerated as follows: 1. The maximum number of grafts that can be extracted by the FUT procedure is limited by the scalp laxity and density. 2. Further, we know that hair cannot be stretched and only the hair that is transplanted grows; there is no stem cellYlike effect in increasing the number of hair follicles.
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FIGURE 18. A 44-year-old male patient before and 4 months after a transplant (1800 grafts). 1. Somehow increasing the number of hair follicles that can be extracted: Because scalp laxity and density are factors beyond a surgeon’s control, we suggest the first modification to preserve a larger number of grafts by using beveling, slivering, and magnification. 2. Improving graft survival: We suggest baring of the grafts to minimize tissue around the roots to allow better graft survival. We also suggest the technique of placing grafts by holding them from the shaft end and not the fat around the root. Implantation is further speeded up by the reduction of fat around the root because thinned grafts are stiffer and move into the slits faster. 3. Improving hairline design and density in the anterior hairline; and introduce randomness in the design of hair placement: We suggest harvesting of grafts for the anterior hairline with FUE to increase hairline density. A microzigzag design allows a very natural look with no evidence of being transplanted. This zigzag process is continued all the way back, allowing a very random and therefore natural hair growth appearance. As experience has taught us, we actually get better densities by these techniques.
Thus, any improvement in hair transplant results will depend on the following:
FIGURE 17. A 47-year-old male patient before and 9 months after a transplant. Note the gray hair pattern due to large number of white hair follicles (2600 grafts). 262
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FIGURE 19. A 32-year-old male patient. Top upper picture and left lower picture at 4 months, after the procedure, before the second session. Lower central and right picture 1 year after the second procedure (4700 grafts). * 2014 Lippincott Williams & Wilkins
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FIGURE 22. A 25-year-old male patient 8 months after a transplant (2000 grafts). FIGURE 20. A 39-year-old male patient 9 months after a transplant (2400 grafts). 4. Increasing the number of hair follicles that can be generated: By gene therapy and hair cloning, which are presently the best but cannot be relied on for results, at least not yet. Asakawa et al10 brought in some hope in this regard in their paper on bioengineered hair. Another exciting development could be the use of platelet-rich plasma (PRP) in hair transplant. Rose mentions the potential at increasing density with concurrent PRP use. We do not believe that PRP should be part of a routine practice until its role is clearly defined. McElwee and Shapiro11 discussed prostaglandins and stem cell base therapies as future directions.
Improvements in donor site results can be improved by the following: 1. Better scar appearance: We have modified the trichophytic closure technique by using a beveled cutting of tissues. This procedure actually allows hair growth through the scar due to viable grafts along the margin. Rose6 mentions trichophytic closure
FIGURE 23. A 42-year-old male patient after a transplant (2500 grafts). method after a perpendicular incision at the donor site. We feel that a parallel incision is more physiological. 2. Donor-site complications like hematoma and paresthesia are managed by removing the strip at a subcutaneous fat level: This step, which leaves fat on the galea, preserves nerves and eliminates bleeding.
FIGURE 21. A 23-year-old male patient 7 months after a transplant (2400 grafts). * 2014 Lippincott Williams & Wilkins
FIGURE 24. A 27-year-old male patient a year after a transplant (1900 grafts). www.annalsplasticsurgery.com
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FIGURE 25. A 28-year-old male patient who had undergone transplant by punch technique 6 months back elsewhere, 9 months after a transplant (2200 grafts).
Our procedure amalgamates the best features of the 2 basic techniques, namely, FUE and FUT. The FUE procedure is gaining a lot of ground today but is limited by a number of grafts that can be extracted in 1 session, potential wastage rates of up to 10%,6 and lesser graft quality compared to FUHT, additive nature of scars, and length of the procedure. Rose compares the donor area in a large FUE session to seem almost as a ‘‘moth eaten ‘‘ appearance, and in fact when we do large sessions, there may be a clear demarcation of high-density and low-density areas at the occipital area. There is a report of donor-site necrosis and cicatricial alopecia after FUE also.12 This is a dreaded situation and needs to be avoided at all costs. Such a situation becomes difficult to manage. The additive nature of scars is another factor to take into consideration.13 This technique is still not
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FIGURE 27. A 21-year-old male patient 9 months after a transplant (1900 grafts).
universally accepted, and the ratio of FUHT to FUE at our center is 85:15. Gokrem et al7 in their paper on FUE clearly noted that FUE is not a scarless technique; it is in fact a scar spreading procedure. They further noted that FUE in fact heals with secondary scarring and their cumulative scarring is more than the linear scar of the FUE procedure. They have noted that there is a greater patient variability in determining the results in FUE due to hair characteristics, and the surgeons’ training is very important here. In their series, they take 10 hours to implant 2000 grafts when 2 operators are involved. Compare this with less than 4 hours taken by us for nearly 2500 grafts with the FUT process. Herein underlines the need for amalgamation of aspects of both procedures. Newer modifications of FUE, namely, robotic procedures, claim to reduce the problems. However, these are relatively recent procedures,
FIGURE 28. A 29-year-old patient; center picture 4 months and right picture 9 months after the operation (2400 grafts).
FIGURE 26. A 38-year-old male patient with result 1 year after a transplant. Upper right picture is a preprocedure with markings; center and lower right show the same patient in different pose (2500 grafts). 264
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FIGURE 29. A 43-year-old male patient 9 months after the operation (2600 grafts). * 2014 Lippincott Williams & Wilkins
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ACKNOWLEDGMENT Informed consent was received for publication of the figures in this article.
REFERENCES
FIGURE 30. A 42-year-old male patient 8 months after the operation (1600 grafts).
with no long-term series available to justify claims of significant advantage. The robotic and semirobotic (Neograft) are said to reduce the wastage rate significantly.14 Lin et al15 presented a very interesting article on emerging trends with robotic transplant. However, the number of grafts, time involved, and additive nature of scars are still major features to be considered. The current techniques of FUT have been perfected and presented by many surgeons; prominent among them are Dr Uebel and Dr Barrera. Microfollicular hair transplant remains the gold standard for hair transplant; FUE has not been able to replace FUHT as the preferred transplant technique. Our proposed technique, MMFT, initially takes longer to perform due to the exactness required, however, the learning curve is only about 100 cases, and reasonable speed and accuracy is easily achieved. A hair transplant unit must be dedicated to hair transplant, and as plastic surgeons, we must constantly endeavor to improve our results.
* 2014 Lippincott Williams & Wilkins
1. Barrera A. Advances in aesthetic hair restoration. Aesthet Surg J. 2003;23:259Y264. 2. Uebel CO. Refining hair restoration technique. Aesthet Surg J. 2002;22:181Y183. 3. Bernstein RM, Rassman WR. The aesthetic of follicular transplantation. Dermatol Surg. 1997;23:785Y799. 4. Orentreich N. Autografts in alopecia and other selected dermatological conditions. Ann N Y Acad Sci. 1959;83:463Y479. 5. Shiell RC. A review of modern surgical hair restoration techniques. J Cutan Aesthet Surg. 2008;1:12Y16. 6. Rose PT. The latest innovations in hair transplantation. Facial Plast Surg. 2011;27:366Y377. 7. Gokrem S, Baser NT, Asian G. Follicular unit extraction in hair transplantation: personal experience. Ann Plast Surg. 2008;60:127Y133. 8. Poswal A, Bhutia S, Mehta R. When fue goes wrong! Indian J Dermatol. 2011;56:517Y519. 9. Dua A, Dua K. Follicular unit extraction hair transplant. J Cutan Aesthet Surg. 2010;3:76Y81. 10. Asakawa K, Toyoshima KE, Ishibashi N, et al. Hair organ regeneration via the bioengineered hair follicular unit transplantation. Sci Rep. 2012;2:424. 11. McElwee KJ, Shapiro JS. Promising therapies for treating and/or preventing androgenic alopecia. Skin Therapy Lett. 2012;17:1Y4. 12. Karac¸al N, Uralo?lu M, Dindar T, et al. Necrosis of the donor site after hair restoration with follicular unit extraction (FUE): a case report. J Plast Reconstr Aesthet Surg. 2012;65:e87Ye89. 13. Pros & Cons of Follicular Unit Extraction (2005). Retrieved July 27, 2012 from http://www.bernsteinmedical.com. 14. NeoGraft Hair Transplant Machine for FUE (2005). Retrieved July 27, 2012 from http://www.bernsteinmedical.com. 15. Lin X, Nakazawa T, Yasuda R, et al. Robotic hair harvesting system: a new proposal. Med Image Comput Comput Assist Interv. 2011;14(pt 1):113Y120.
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Microrefined Microfollicular Hair Transplant A New Modification in Hair Transplant Amit Gupta, MBBS, MS (Gen Surgery), DNB (Plastic Surgery) Abstract: Hair transplant is the most common cosmetic surgery procedure in men; at our center, we perform nearly 40 transplants a month, with nearly 450 procedures in a year. Current techniques of hair transplant are well established and several authors have had remarkable results using the current techniques of microfollicular hair transplant. Orentreich described hair transplant, Shiell has reviewed current techniques in his paper, whereas Rose reviews the latest innovations in hair transplant including Neograft and robotic procedures. We present our modifications to the process based on our experience of more than 1000 cases in the last 3 years. Microrefined microfollicular hair transplant is a procedure with innovations at each step of the standard microfollicular hair transplant procedure to improve results. The steps of the procedure are as follows:
1. beveled incisions on both ends of the strip to take the graft transection rate to less than 1%; 2. dissecting the strip in a way to leave a layer of fat on top of the galea; 3. slivering of the strip under magnification to ensure less than 1% hair wastage; 4. harvesting of 300 to 400 grafts with follicular unit extraction for the anterior hairline; 5. microzigzagging of all the slits; 6. graft preparation to ensure bare minimum fat at the level of the roots; 7. during implantation, handling of the grafts with the hair end and not the root end; and 8. fast processing and coordinated efforts to reduce operative time to approximately 4 to 4.5 hours for large cases (5000Y6000 follicles) and 2 to 2.5 hours for smaller ones. Key Words: hair transplant, MMFT, FUE (Ann Plast Surg 2014;73: 257Y265)
H
air transplant is the most common cosmetic surgery procedure in men. We have performed nearly 1200 transplants during the past 4 years, and so much has been the popularity of the procedure that we are now performing nearly 40 transplants a month, with nearly 450 procedures in a year. Current techniques of hair transplant such as follicular unit hair transplant (FUHT) and follicular unit extraction (FUE) are well established.1Y3 Orentreich described hair transplant.4 Shiell has reviewed current techniques in his paper.5 In more recent times, FUE procedures have been modified, and we hear of Neograft
Received March 26, 2012, and accepted for publication, after revision, September 10, 2012. From the Divine Cosmetic Surgery, Delhi, India. Conflicts of interest and sources of funding: none declared. Reprints: Amit Gupta, MBBS, MS (Gen Surgery), DNB (Plastic Surgery), Divine Cosmetic Surgery, Delhi, India. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7303-0257 DOI: 10.1097/SAP.0b013e3182741f66
Annals of Plastic Surgery
and robotic procedures.6 We believe FUE has major limitations if used alone as the main technique. Some of the problems that have been defined are graft wastage, additive nature of scars, and scar contraction6Y9 We will discuss these in detail subsequently. We are of the opinion that the follicular unit transplant (FUT) or the strip procedure is the best procedure particularly when megasessions are involved. During the last 3 years, we were very happy with our results, but we decided to modify certain steps in our constant endeavor to improve. We present our modifications to the process, which are based on our experience of more than 800 cases in the last 3 years and 400 odd cases with our modifications during the last 12 months. We have labeled our procedure as microrefined microfollicular hair transplant (MMFT).
MMFTVThe Technique Microrefined microfollicular hair transplant is the end result of a critical analysis of steps and results of the previous 800 procedures we had performed in the last 3 years. Most of the modifications have been the result of interactive discussions with surgeons, assistants, and patients. We have tried to modify each step to refine it so as to produce the perfect result. The steps are simple, have a small training curve, but make the process more logical. All magnifications are with Loupe (1Y1.5; we initially used 2, but no longer). With this magnification, we are able to reach a perfect combination of precision and speed. The steps of the procedure along with the modifications are as follows: 1. Strip harvestingVbeveled incisions on both ends of the strip to take the graft transection rate to nearly 0%. 2. Incising the strip off the galea in a way to leave a layer of fat on top of the galea. This precise step means leaving minimal tissue on the grafts. 3. SliveringVslivering of the strip under magnification to ensure less than 1% hair wastage. 4. Combination with FUEVharvesting of 300 to 400 grafts with FUE for the anterior hairline. 5. Preslits and the anterior hairlineVmicrozigzagging of all the slits. 6. Graft preparationVensure bare minimum fat at the level of the roots. 7. Graft placementVhandling of the grafts with the hair end and not the root end. This allows easy preservation of the roots, because the roots are not touched at any step of the process. 8. Coordinated team effortVfast processing and coordinated efforts to reduce operative time to approximately 4 to 4.5 hours for large cases (5000Y6000 follicles) and 2 to 2.5 hours for smaller ones (3000Y3500 follicles). A detailed discussion of each step is given to understand its importance and to provide obvious evidence to justify each step.
Strip Harvesting Beveled Incisions Strip harvesting is the first step in the FUT process. The process involves harvesting the strip after administration of local anesthesia (we used a combination of 2% xylocaine and 0.5% bupivacaine) and
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making the donor site tumescent with 10 to 15 mL of adrenaline saline solution (1:200,000). We have modified the step with beveling at both ends in the direction of the hair growth, in a way to preserve nearly each and every root, the incisions being made under magnification. This allows nearly a 0% transection of the roots both on the margins of the harvested strip and on the occipital site, allowing a larger number of grafts to be harvested; sometimes nearly 150 to 200 grafts more; as viable grafts all along the margin of the strip. The scar is extremely fine and hair growth occurs through the scar because viable grafts are present on either end of the incision. This is analogous to the trichophytic closure in MACS lift surgery (Tonnard and Verpaele) (Fig. 1).
Level of Strip Harvesting The strip is harvested in a plane just below the roots to ensure some fat is left on the galea. This process is very exacting and delicate because the plane is usually less than 1 mm from the level of the roots (Fig. 2). Advantages of this step are as follows: (a) Bleeding is virtually eliminated, and the tiny blood vessels at this level can easily be cauterized. A concern can be raised here regarding the possible injury to donor-site hair or marginal hair damage with the bovie process. However, this is not seen practically. We use microbipolar forceps because the vessels are very fine. Bipolar cauterization does not spray the current. Further, it is seen that the vessels are tortuous and as the strip is gently raised off the galea, the vessel stretches, allowing a clear zone for safe and precise cauterization of the vessels (Figs. 3 and 4). (b) No long-term paresthesia problems, which are seen when the galea is transected. This is a very difficult problem often seen in patients who have had transplants with inexperienced surgeons. This paresthesia is very irritating and often without a solution. A carefully conducted dissection goes a long way in preventing this complication.
FIGURE 2. Preservation of fat on top of the galea and on the strip. Also seen is a blood vessel on the deep surface. Note the length of the vessel.
transection. This means more number of hair follicles per graft, and thus translates into better result (Fig. 5).
FUE Grafts for the Hairline Layer We harvest 300 to 400 grafts with FUE procedure using 0.8- to 1-mm punches; we implant these grafts in the first 1 to 1.5 layers of the anterior hairline. Advantages of this step are as follows: (a) FUE grafts are thinner than strip grafts because there is virtually no dermis and fat. Thus, larger number of grafts can be placed per
Slivering of the Strip Horizontal slivering of the strip is done under magnification to make slivers of 1 to 2 follicular unit thicknesses. Advantages of this step are as follows: (a) brings down the hair wastage to less than 1%; (b) faster graft separation by the team; and (c) good preservation of the follicular units, ensuring higher density. Two assistants in the team are specially trained to sliver the strip to 1 or 2 rows of grafts only. It is obvious here that the work of the other assistants is considerably reduced, as they only now need to separate grafts that are clearly visible, without worrying about
FIGURE 1. Beveled incisions and preservation of grafts on the sides of the incision after harvesting the strip. 258
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FIGURE 3. A strip being raised and fine blood vessel on the deep surface at safe distance from the roots. * 2014 Lippincott Williams & Wilkins
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FIGURE 4. A picture showing fine blood vessels while raising the strip. Also note the length of these vessels, making it easy to cauterize them without damage to the roots. square centimeter. We implant 300 to 400 grafts in the first line itself. This allows extremely natural density in the first line. (b) Because the FUE grafts are thinner, we can place grafts with 2 follicles in spaces meant to hold single follicle grafts; thus, we are able to get higher number of follicles per graft in the first line. We place alternating layer of grafts containing 1 and 2 follicles, respectively. This maintains the naturalness of the hairline and also gives a very high density in the first line (Figs. 6 and 7).
follicles are at risk, but we are able to pretty easily harvest grafts of 1 to 3 follicles with nearly 95% to 96% preservation of grafts. For the hairline, we do not require grafts with 4 follicles because they look unnatural anyway. Our techniques have evolved to reduce the follicular transection rate and wastage to 4% to 5%, so effectively that if we take 350 to 400 grafts, we would, at the worst, waste 12 to 16 grafts (Fig. 8).
An alternative to this is to super-refined the grafts under highpower microscope to totally bare the dermis and fat. We agree with this; however, we do not do this step because this requires special trainings of the assistants; the step takes significantly longer than FUE to get the same number of grafts. Lastly, we are able to reduce the length of the strip and the FUE scars are virtually invisible because 0.8- to 1-mm punches are used. Addition of the FUE process adds approximately 45 to 60 minutes to the procedure. However, the results achieved by this step justify the extra time. Because we only require approximately 400 grafts, we do not need to shave off any segment larger than already done for the strip, making the FUE marks invisible to anybody. An additional concern could be regarding the potential wastage of hair with FUE. Transection in FUE is a controversial issue. Experts in FUE counterargue that strip causes more wastage, but in our view, a lot of this depends on the surgeon’s experience. It is absolutely without doubt that grafts with 4
Slits are preplaced in our technique. In the first 1 to 2 rows, we place 600 to 700 grafts and continue the zigzag placement all the way through. The sizes of the slits are different throughout. In the first 1.5 rows, they are smaller, approximately 1 to 1.2 mm, and as we go back it increases to 1.5 to 2 mm. Further back, it can increase to 2.5 mm. However, this depends from case to case. In patients with thick hair, the slits need to be larger, and patients with thin hair, the slits are finer.
FIGURE 5. Slivering of strip to single follicular unit layers. * 2014 Lippincott Williams & Wilkins
Anterior Hairline and PreslittingVMicrozigzagging of the Slits
FIGURE 6. Comparison of FUE and FUT grafts. The FUE grafts are thinner than strip grafts. Note that grafts have little or no fat below the roots, and microzigzag pattern in the front hairline and the zigzag pattern being carried further back in the center. Also note the difference in slit size in the anterior line and further back. www.annalsplasticsurgery.com
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FIGURE 7. Microzigzag pattern in the front hairline and the zigzag pattern being carried further back.
FIGURE 10. Showing 5 assistants carrying on the implantation process simultaneously.
FIGURE 8. Donor area showing strip and FUE scars. Note the limited area of the shaving required and reduction in the length of the scar.
FIGURE 9. Slits with the horizontal palisading method on the left side. Note the irregularity of the pattern toward the front and center done by the zigzag method. 260
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Advantages of the procedure are as follows: (a) A horizontal palisading effect is caused by the conventional slit process, where the slits are placed in single rows; this gives a relatively transplanted appearance due to gaps between contiguous rows. This is avoided by the zigzag design, where the grafts are seen to come out in continuity and not in rows, adding to the naturality of the results. (b) The zigzag process opens the slits out better because all natural tension lines in the scalp are released. In the horizontal slit process, the lines between the rows are not released and often the slits open inadequately or the slits need to be made larger. This is not to put this technique in negative view; all procedures (including ours before this innovation) have been done this way only and we got good results. The addition of this step increases the natural look of the result. Smaller slits can be as effective as the larger ones because they open out better, reducing the scar formation.
FIGURE 11. A 24-year-old male patient, 1800 grafts for the front hairline and side temple region, 1 session. Result after 6 months. The picture on the left shows the area of baldness as well as the markings (1900 grafts). * 2014 Lippincott Williams & Wilkins
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FIGURE 14. Donor area of the same patient in Figure 13 showing the scars of the punches and the design of the strip. FIGURE 12. The same patient in Figure 11, front view. The picture on the left shows the preprocedure situation and the markings.
(c) Better densities are achieved, adding to a good dense hairline. (d) A practical consideration of this has been seen in some patients who have darker skins (some patients from the southern parts of India, and others) and have a firmer skin texture, necessitating a larger slit creation for placement of grafts. This process allows the tension lines to be broken, and thus, smaller slits are possible (Fig. 9).
Graft Preparation and Placement The assistants prepared the grafts in a way that bared as much fat and dermis as possible (it is not possible and inadvisable to remove 100% of the fat). This process allows grafts to survive on
minimal host supply and ensure virtually 100% graft survival. This is easily understood as we know the process of engraftment. The dermis and fat have far greater needs than the follicle; therefore, the lesser the tissue, the better is the engraftment. This is only important when we want to place more number of grafts in a small area like the anterior hairline. There is another reason for our attempt at reducing tissue at the lower end of the graft, we place grafts into the slits by holding it from the follicle end; a graft root is stiffer, if it has lesser fat around it and slides very easily into the slit. The conventional way of graft placement is to hold the graft from just below the roots with fat and place them into the slits. Because we bare the graft to leave almost no fat below the roots, we have modified the process of placement. As we are not handling the graft by the roots, we ensure nearly 100% graft survival. A combination of these steps allows us to ensure almost 99% graft harvest and nearly 100% graft survival. We assure our patients of at least 95% graft growth rate.
Team Coordination Hair transplant is a team approach, and a coordinated effort is essential to ensure a speedy procedure. Strip harvesting is done by 3 people, and 9 assistants are involved in graft separation. Simultaneous implantation is done by 2 assistants (3 when simultaneous front and crown areas are being treated), whereas 1 assistant works to keep the field clean and delivers grafts near the implantation site.
FIGURE 13. A 34-year-old male patient who earlier underwent punch grafting elsewhere with very poor result. Note the plugs of hair on the lateral aspect of hair in the frontline. * 2014 Lippincott Williams & Wilkins
FIGURE 15. The same patient in Figure 13 after 8 months of hair transplant procedure (2500 grafts). www.annalsplasticsurgery.com
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FIGURE 16. A 36-year-old male patient before and 9 months after a transplant procedure (2500 grafts).
This allows us to complete 6000 follicles (2600Y2800 grafts) in approximately 4 hours (Fig. 10).
RESULTS A few results using this technique are presented (Figs. 11Y30).
SUMMARY Hair transplant is a constant struggle between density and coverage. Even with the best techniques, results depend to a large extent on the hair quality, density, hair texture, and others, so a number of factors are actually beyond the surgeon’s control. We decided to work with factors that we can modify. With the current techniques of hair transplant like FUT, FUE, and Neograft procedures, there is a lot of confusion as to which technique should be used. This article does not aim at advocating a particular technique, but rather wants to combine the best of all available techniques in a unique amalgamation, which we have labeled MMFT. Certain facts are obvious and these are enumerated as follows: 1. The maximum number of grafts that can be extracted by the FUT procedure is limited by the scalp laxity and density. 2. Further, we know that hair cannot be stretched and only the hair that is transplanted grows; there is no stem cellYlike effect in increasing the number of hair follicles.
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FIGURE 18. A 44-year-old male patient before and 4 months after a transplant (1800 grafts). 1. Somehow increasing the number of hair follicles that can be extracted: Because scalp laxity and density are factors beyond a surgeon’s control, we suggest the first modification to preserve a larger number of grafts by using beveling, slivering, and magnification. 2. Improving graft survival: We suggest baring of the grafts to minimize tissue around the roots to allow better graft survival. We also suggest the technique of placing grafts by holding them from the shaft end and not the fat around the root. Implantation is further speeded up by the reduction of fat around the root because thinned grafts are stiffer and move into the slits faster. 3. Improving hairline design and density in the anterior hairline; and introduce randomness in the design of hair placement: We suggest harvesting of grafts for the anterior hairline with FUE to increase hairline density. A microzigzag design allows a very natural look with no evidence of being transplanted. This zigzag process is continued all the way back, allowing a very random and therefore natural hair growth appearance. As experience has taught us, we actually get better densities by these techniques.
Thus, any improvement in hair transplant results will depend on the following:
FIGURE 17. A 47-year-old male patient before and 9 months after a transplant. Note the gray hair pattern due to large number of white hair follicles (2600 grafts). 262
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FIGURE 19. A 32-year-old male patient. Top upper picture and left lower picture at 4 months, after the procedure, before the second session. Lower central and right picture 1 year after the second procedure (4700 grafts). * 2014 Lippincott Williams & Wilkins
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FIGURE 22. A 25-year-old male patient 8 months after a transplant (2000 grafts). FIGURE 20. A 39-year-old male patient 9 months after a transplant (2400 grafts). 4. Increasing the number of hair follicles that can be generated: By gene therapy and hair cloning, which are presently the best but cannot be relied on for results, at least not yet. Asakawa et al10 brought in some hope in this regard in their paper on bioengineered hair. Another exciting development could be the use of platelet-rich plasma (PRP) in hair transplant. Rose mentions the potential at increasing density with concurrent PRP use. We do not believe that PRP should be part of a routine practice until its role is clearly defined. McElwee and Shapiro11 discussed prostaglandins and stem cell base therapies as future directions.
Improvements in donor site results can be improved by the following: 1. Better scar appearance: We have modified the trichophytic closure technique by using a beveled cutting of tissues. This procedure actually allows hair growth through the scar due to viable grafts along the margin. Rose6 mentions trichophytic closure
FIGURE 23. A 42-year-old male patient after a transplant (2500 grafts). method after a perpendicular incision at the donor site. We feel that a parallel incision is more physiological. 2. Donor-site complications like hematoma and paresthesia are managed by removing the strip at a subcutaneous fat level: This step, which leaves fat on the galea, preserves nerves and eliminates bleeding.
FIGURE 21. A 23-year-old male patient 7 months after a transplant (2400 grafts). * 2014 Lippincott Williams & Wilkins
FIGURE 24. A 27-year-old male patient a year after a transplant (1900 grafts). www.annalsplasticsurgery.com
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FIGURE 25. A 28-year-old male patient who had undergone transplant by punch technique 6 months back elsewhere, 9 months after a transplant (2200 grafts).
Our procedure amalgamates the best features of the 2 basic techniques, namely, FUE and FUT. The FUE procedure is gaining a lot of ground today but is limited by a number of grafts that can be extracted in 1 session, potential wastage rates of up to 10%,6 and lesser graft quality compared to FUHT, additive nature of scars, and length of the procedure. Rose compares the donor area in a large FUE session to seem almost as a ‘‘moth eaten ‘‘ appearance, and in fact when we do large sessions, there may be a clear demarcation of high-density and low-density areas at the occipital area. There is a report of donor-site necrosis and cicatricial alopecia after FUE also.12 This is a dreaded situation and needs to be avoided at all costs. Such a situation becomes difficult to manage. The additive nature of scars is another factor to take into consideration.13 This technique is still not
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FIGURE 27. A 21-year-old male patient 9 months after a transplant (1900 grafts).
universally accepted, and the ratio of FUHT to FUE at our center is 85:15. Gokrem et al7 in their paper on FUE clearly noted that FUE is not a scarless technique; it is in fact a scar spreading procedure. They further noted that FUE in fact heals with secondary scarring and their cumulative scarring is more than the linear scar of the FUE procedure. They have noted that there is a greater patient variability in determining the results in FUE due to hair characteristics, and the surgeons’ training is very important here. In their series, they take 10 hours to implant 2000 grafts when 2 operators are involved. Compare this with less than 4 hours taken by us for nearly 2500 grafts with the FUT process. Herein underlines the need for amalgamation of aspects of both procedures. Newer modifications of FUE, namely, robotic procedures, claim to reduce the problems. However, these are relatively recent procedures,
FIGURE 28. A 29-year-old patient; center picture 4 months and right picture 9 months after the operation (2400 grafts).
FIGURE 26. A 38-year-old male patient with result 1 year after a transplant. Upper right picture is a preprocedure with markings; center and lower right show the same patient in different pose (2500 grafts). 264
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FIGURE 29. A 43-year-old male patient 9 months after the operation (2600 grafts). * 2014 Lippincott Williams & Wilkins
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Microrefined Microfollicular Hair Transplant
ACKNOWLEDGMENT Informed consent was received for publication of the figures in this article.
REFERENCES
FIGURE 30. A 42-year-old male patient 8 months after the operation (1600 grafts).
with no long-term series available to justify claims of significant advantage. The robotic and semirobotic (Neograft) are said to reduce the wastage rate significantly.14 Lin et al15 presented a very interesting article on emerging trends with robotic transplant. However, the number of grafts, time involved, and additive nature of scars are still major features to be considered. The current techniques of FUT have been perfected and presented by many surgeons; prominent among them are Dr Uebel and Dr Barrera. Microfollicular hair transplant remains the gold standard for hair transplant; FUE has not been able to replace FUHT as the preferred transplant technique. Our proposed technique, MMFT, initially takes longer to perform due to the exactness required, however, the learning curve is only about 100 cases, and reasonable speed and accuracy is easily achieved. A hair transplant unit must be dedicated to hair transplant, and as plastic surgeons, we must constantly endeavor to improve our results.
* 2014 Lippincott Williams & Wilkins
1. Barrera A. Advances in aesthetic hair restoration. Aesthet Surg J. 2003;23:259Y264. 2. Uebel CO. Refining hair restoration technique. Aesthet Surg J. 2002;22:181Y183. 3. Bernstein RM, Rassman WR. The aesthetic of follicular transplantation. Dermatol Surg. 1997;23:785Y799. 4. Orentreich N. Autografts in alopecia and other selected dermatological conditions. Ann N Y Acad Sci. 1959;83:463Y479. 5. Shiell RC. A review of modern surgical hair restoration techniques. J Cutan Aesthet Surg. 2008;1:12Y16. 6. Rose PT. The latest innovations in hair transplantation. Facial Plast Surg. 2011;27:366Y377. 7. Gokrem S, Baser NT, Asian G. Follicular unit extraction in hair transplantation: personal experience. Ann Plast Surg. 2008;60:127Y133. 8. Poswal A, Bhutia S, Mehta R. When fue goes wrong! Indian J Dermatol. 2011;56:517Y519. 9. Dua A, Dua K. Follicular unit extraction hair transplant. J Cutan Aesthet Surg. 2010;3:76Y81. 10. Asakawa K, Toyoshima KE, Ishibashi N, et al. Hair organ regeneration via the bioengineered hair follicular unit transplantation. Sci Rep. 2012;2:424. 11. McElwee KJ, Shapiro JS. Promising therapies for treating and/or preventing androgenic alopecia. Skin Therapy Lett. 2012;17:1Y4. 12. Karac¸al N, Uralo?lu M, Dindar T, et al. Necrosis of the donor site after hair restoration with follicular unit extraction (FUE): a case report. J Plast Reconstr Aesthet Surg. 2012;65:e87Ye89. 13. Pros & Cons of Follicular Unit Extraction (2005). Retrieved July 27, 2012 from http://www.bernsteinmedical.com. 14. NeoGraft Hair Transplant Machine for FUE (2005). Retrieved July 27, 2012 from http://www.bernsteinmedical.com. 15. Lin X, Nakazawa T, Yasuda R, et al. Robotic hair harvesting system: a new proposal. Med Image Comput Comput Assist Interv. 2011;14(pt 1):113Y120.
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