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Which Method to Choose

New Methods in hair transplantation
Baldness can be treated with both medical and surgical treatments.

Presently, there are only two approved drugs for this purpose:
 a) Minoxidil lotions 2% and 5%-it has to be applied daily twice over the affected area
  b) Finasteride 1mg tablets (propecia)- one tablet daily for 3-4 years and is more effective over vortex
The disadvantages of these drugs are –they have to be taken for long duration, indefinitely. Also, they  may not be effective in established and extensive baldness. HOWEVER THEY ARE OF GREAT VALUE IN PREVENTING FUTURE BALDNESS AND THEREFORE IN ALL YOUNG PEOPLE WITH EARLY HAIRLOSS THEY ARE NEEDED TO BE TAKEN. THEY ARE ALL SAFE DRUGS EVEN WHEN TAKEN FOR LONG PERIODS OF TIME. Hence, even after transplantation, they need to be taken in most patients.


Thus hair transplantation is the only permanent method of hair transplantation. What this means is that grafted hairs are permanent. The hair in the back of the scalp is genetically programmed and is insensitive to the balding process –hence is the basis for transplantation as they usually will last a lifetime. The transplanted hair is removed from back of the scalp (donor site) and transferred to another (recipient site). The transferred tissue is not "rejected" as it is not a foreign tissue.  There have been several maor advances in the techniques of hair transplantation. This article provides some details on these new methods of hair transplantation.

1. Follicular unit Hair transplantation(FUT):

Over years, instruments and techniques have been developed that allow us to achieve truly natural results by transplanting small grafts containing 1-2-3 hairs, very close together. It has been found that hair grows from the scalp in groups of one, two, and three hair follicles called follicular units. Transplantation of these units results in denser and more natural results. This, the so called ‘follicular unit transplantation or FUT is the state of art technique for hair transplantation today, performed in over 90% of world’s transplants. In FUT, a strip of skin with hairs is removed, dissected under microscope to separate follicular units and then transplanted.The removed strip area, is sutured by a special method called trichophytic closure which heals with an imperceptible thin line which is hidden under the hairs.The other major advance in this field is the use of microscope to dissect hairs and avoid transaction of hairs. Improvements in technique have enabled us to transplant even  upwards of 3000 units( in patients with good donor hair) in one session. While the average density given in an usual session is up to 35 per sq cm, higher density of even up to 50 or 60 can also be given.

2.Sutureless transplantation or FUE:

More recently a new method called FUE or follicular unit extraction has been introduced. In FUE, each unit is pulled out  from the donor area individually, with tiny 0.8mm -1mm instrument called punch and then transplanted in to bald area, These tiny holes then heal with minute imperceptible scars, without stiching. For this reason, FUE is also called suture less transplantation.  It should be understood that there is no difference in the way these hairs are transplanted in to recipient area. The only difference is in the way they are taken out from the donor area.
 Its advantages are:
a) It is a less invasive procedure. It is less painful and healing time is faster.
b)There is no suture
c) there is not suture scar and so patient can at any time shave his head.

It has some disadvantages too:

1. It is less perfect than FUT as hairs are pulled out blindly. 5-10%  of hair units may be lost.

2. Donor scalp needs to be trimmed very short, almost shaven-1 mm

3. It is more time consuming as each unit has to be pulled out individually.So a 1500 graft session  may take about 5 hours;

4. There is much variation between different patients and in different areas. In some, it may be easy and quick; in others it may be slow, difficult and associated with more transection of hairs.

5. Because it is more time consuming, and more difficult, it is more expensive; as much as three times the cost of FUT.

6. There is a limitation to the total number of grafts transplanted in one session: maximum is usually around 1500-2000. This is because:

In FUE, one unit in 8 units is taken out to preserve normal appearance. A hair is always left around a hair which is taken out and no two hairs consecutically are taken out.If the back of the head has about 25000 units, leaving out the  border areas( which can not be taken out to preserve cosmetic appearance), and allowing for some loss due to transection, about 1500-2000 units can only be taken out.If more are taken out, it would mean that 1 out of 6 or 4 would be taken, two adjacent hairs would be taken leading to a moth eaten appearance . In other words, to offset the sutureline of FUT, FUE produces a different cosmetic problem

It is to be emphasized that FUE method has received exaggerated attention and publicity on internet. It has major advantages for the hair transplant team as it needs fewer assistants, does not need surgical skills to remove skin and stich it. Since it is more expensive and can be done with lesser assistants, it is financially more attractive to hair transplant teams , particularly those run on commercial basis. Such centres therefore give  exaggerated exposure to this technique. It has also been wrongly advertised as scarless transplantation on internet sites. Once there is some damage in skin there is always a scar, however  small and hence scarless transplantation is a wrong and unscientific terminology. What is needed, is to have a balanced view and keep a proper perspective. See below table for comparison of the two methods.



Comparison of FUT and FUE :Both have same technique over recipient area. ONLY DONOR IS DIFFERENT

FUT
FUE
Strip excision of donor skin with suturing (Stiching)
Extraction of individual units one by one through small punch holes; each alternate hair unit is removed. No Suturing.
Heals with a single linear scar which is 1-2 mms wide , hidden under hairs
Heals with multiple tiny scars  in between hairs
Healing over 1 weeks
Healing over 2-3 days
Donor area not shaved; suture completely hidden.
Donor area completely shaved; to remove 2000 grafts, at least 20*4 sq cm are is shaved
Quicker;4 hours for 2000 grafts
Slower 8 hours for 2000 grafts
More precise because of microscopic dissection
LESS precise as units are manually pulled blindly
Minimal damage to hair roots
Damage to hair roots possible in up to 5-10%
Operation in one day
Operation over 1-2 days
More comfortable as patient is mostly  sleeping face up watching TV
Patient in head down position for several hours- more uncomfortable
Operation site over  donor hidden completely even on the day of surgery
Operation site shaven and hence visible
Large sessions, up to 3000 grafts possible
Large sessions difficult-so suitable for smaller areas
Less expensive – Rs 44 per graft
more expensive because of the prolonged procedure Rs 85 per graft
90% of world’s transplants are done by this method
10% of transplants by this method- suitable for small areas, people who are afraid of stich and people who want to keep short hair

NOTE: FUE IS NOT POSSIBLE IN ALL- SOME PEOPLE HAVE VERY TIGHTLY PACKED HAIRS AND THESE GRAFTS DON’T COME OUT EASILY BY FUE, AND MAY BREAK-IN SUCH PATIENTS, A TEST CALLED FOX TEST IS DONE; BY EXTRACTING 50-100 UNITS TO ASSESS. IF THE TEST YEILDS POSITIVE RESULTS, ONLY THEN FUE IS PERFORMED.

3. Body Hair transplantation:

Body hair transplantation is generally done  only when scalp hair is exhausted. Again this is a technique receiving a lot of hype and exaggeration on internet sites, and many patients ask for it hoping not to disturb their scalp hair.
Body hair is not the preferred  source when scalp hair is visible for the following reasons:

1. Body hair has to be extracted singly and hence is slow- takes 2-4 days for a 2000 graft session.

2. Body hair occurs mostly as single hair units and hence gives less density.

3. Body hair diameter  is less and so gives less volume.

4. Long term behavior of body  hair is still not known as the technique is new.

5. Body hair may grow long when transplanted on to scalp, but not as long and as thick as scalp hair- so it is inferior to scalp hair

6. Lastly and most importantly, Body hair transplantation is possible only for patients who have good body hair on chest.

7. BHT is associated with tiny scars on chest.

Hence, BHT is performed only when scalp donor is exhausted.


4. Long hair transplantation: The normal length of grafted hair is 0.5 cm. Some patients (such as film actors) want long hairs after transplantation, to look natural- this is called long hair transplantation in which hairs are left long , 2-4 cms. However, it is technically more difficult to do and therefore costs more .Further, it should be remembered that whether hairs are transplanted long or short, they will fall off in the second week.


5. Transplantation in special situations:
i)Transplantation in between existing hairs: Many patients develop diffuse thinning , with out complete loss of hairs, with gaps in between hairs. Transplantation can be done for them also. The following special conditions apply:

a) Any graft needs minimum space to survive. So grafting can only be done in places where such gaps are available due to loss of hairs( loss of density)

b) Other gaps are due to decrease in diameter of hairs; here, transplantation is not possible and drugs are needed.If we transplant grafts too close to existing hairs there will be severe loss of hairs called SHOCK LOSS, WHICH SHOULD BE AVOIDED.

c) In other words, in all such patients , while transplantation can be done, it is only in combination with drugs.SO the final results not only depends on transplantation, but also how well drugs work.If drugs are stopped or they don’t work well( which happens in 15% of patients), then there are fresh areas of thinning.

d) Therefore in all such patients, it is always preferable to administer drugs for 4-6 months to decide how well drugs work before doing transplantation.

e) Lastly, grafting amidst long existing hairs is more difficult and time  consuming .It is therefore helpful to trim the hairs short for better visualization of gaps. If this is not acceptable to patients, then transplantation can be done by using special techniques, which however costs more.

ii)Vortex transplantation: Vortex ( back of head) is generally a difficult area-this area is large,  circular in shape, and therefore hairs emerge in a radiating pattern, like spokes of a wheel. It also has whorls.Therefore it needs a large no. of grafts and these have to be arranged in different directions.This takes more time, and is time consuming. More importantly, because the baldness is circular, in future, it could expand in a centrefugal pattern- hair transplantation in the central circular area could result in a situation in future wherein, grafted hairs remain in the centre and new area of bald ness is seen all around it.This will look odd.

For these reasons, it is always the policy worldwide not to operate vortex area early, always try drugs first in this area, and operate in the front of the head first.

iii)Transplantation in young people: Young people below 23 years pf age present a special situation. Hairloss in them is still evolving, and in early stages, but they are very upset about it, and often find it difficult to accept it. They need drugs to prevent loss of existing hairs for atleast 10 years- which is difficult to do and  they generally can not be relied upon to take drugs for such prolonged years. However, if transplantation is done at this stage, while it will make them happy temporarily, but they will very soon lose hairs over rest of the scalp and come back for a second transplant with in 2-3 years.


iv)Hair transplantation in other areas-eye brow, moustache,beard, eye  lashes: Hair transplantation can be done, not only for baldness over scalp, but also over other areas such as eyebrows, eyelashes, moustache, beard, etc. These need special considerations as they are mobile areas. They are also more expensive.


v)Transplantation in women:It can also be done in women, which is however is more challenging. This should be discussed in person with the doctor.
1. In women, there are multiple causes for hairloss. These should be investigated treated before transplantation.
2. In women, hairloss is more diffuse and widespread, so a proper discussion about which area should be transplanted is necessary.
3. Women have long hairs and do not accept trimming of hairs. Hence transplantation should be done amidst these hairs. This is more time consuming.
4. Since women, wants hairs to be long, results take almost 1 ½ years, to grow to required length.
5. Finally, women have exaggerated expectations about their appearance. For these reasons a detailed discussion with the doctor is necessary.


Summary:

1. In our opinion , for Indian situation , for patients with limited budget, FUT is the best method as it is cheaper, more convenient and gives outstanding results .

2. Despite this, FUE holds attraction to many patients who are apprehensive of the FUT method because  of “ skin being removed” . In such patients, and for those who wish to have short hair, those with adequate financial resources, and limited bald area, FUE can be done, up to about 2000 grafts.Beyond 2000 grafts, FUT is better- if patient still wishes to have FUE, FUE will have to be combined with body hair.

3. Body hair in our opinion is inferior to scalp hair and is therefore recommended  only when scalp  hair is not available.

4. In our opinion, the real value of these new techniques is that they give more options for  the transplant team: The techniques  give options for those who have poor donor and for those who wish to have 3-4-5 sessions.They help us to transplant more grafts ; for eg. By combining FUT,FUE, BHT , it is possible to transplant even beyond 4500 grafts in one session: 2500 by FUT, 1000-1500 by FUE and another 500-750 by BHT, over a period of 3-4 days. This is particularly applicable for those with large areas of baldness, who wish to complete surgery in one session , such as those coming from foreign countries. Of course this  would mean a heavy cost, above Rs 3 lakhs.

It should be emphasized that despite all the hype in internet sites, 90% of all hair transplants in the world are done by FUT only. FUE accounts for only 10% of all transplants because of its high cost. This is the case with us also- we have many patients who seek FUE after reading on internet, and then change their minds to have FUT after knowing full details.

Great things are done by a series of small things brought together

Author:
Dr Venkataram Mysore MD. DipRCPath(Lond), dermatopathologist, 3437,Subbanna Garden, next to BTS garage,Vijay Nagar, Bangalore 40.ph:3392788

Branch:M104, Chicago avenue, Cunningham road, opp.standard chartered bank, Bangalore Ph:5114 8848


The author is qualified from Royal College, UK in dermatopathology and is the first Indian dermatologist to obtain this qualification. He is also a member of international society for hair restoration surgery and a fellow of American academy of dermatology. With over 75 research papers, he is also the author of a textbook this subject, called “Fundamentals in dermatopathology”.


He is the Past editor in chief of Journal of Cutaneous and Aesthetic Surgery.

© Copyright 2009. Venkat Charmalaya
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