Depending on a number of deciding factors, a hair transplant can either be one of the best decisions you will ever make, or one of the worst. Today we are going to discuss the pros and cons of surgical hair restoration, euphemistically referred to as a hair plug or transplant. In fact, the more accurate term is “autologous hair-bearing skin graft”. trapianto di capelli turchia This is because the actual procedure consists in removing sections of skin from a hairy area of the scalp (donor) and transferring it to a bald area (recipient) of the same person. Skin grafting between twins other than genetically identical will not work.
Dr Norman Orentreich
The technique of moving hair-bearing skin tissue grafts from one part of the scalp to another dates back at least 50 years. In the 1950s, a pioneering surgeon named Dr. Norman Orentreich to experiment with the idea on willing patients. Orentreich’s groundbreaking work demonstrated a concept that came to be known as donor dependency or donor identity, meaning that hair-bearing skin grafts taken from the zone of the scalp outside of the loss pattern continued to produce viable hair even though the grafts had been relocated to areas that were previously had gone bald.
Over the next two decades, hair transplantation gradually evolved from a curiosity to a popular cosmetic procedure, especially among balding men in their late middle years. In the 1960s and 1970s, practitioners such as Dr. Emanuel Marritt in Colorado, Dr. Otar Norwood and Dr. Walter Unger that hair restoration could be feasible and inexpensive. A standard of care has been developed which, in experienced hands, allows for reasonably consistent results.
Donor site by round punches
At that time, the most common technique was the use of relatively large grafts (4mm – 5mm diameter) that were individually removed from the donor site by round punching. This tended to make the occipital scalp resemble a Swiss cheese field and severely limited the yield of motion available for movement to the balding zones on and in front of the patient’s scalp.
Over the course of several surgical sessions, grafts were placed into defects created in the recipient zone (bald area) using slightly smaller punch tools. After healing, the patient returned to follow-up sessions where grafts were placed in and between the previous grafts. Due to the relative crudeness of this technique, the results were often quite obvious and the patient had to walk around with a doll’s hair-like appearance, particularly noticeable at the front hairline and especially on windy days. Such patients were usually quite limited in the ways they could style their hair and, due to the wasteful donor extraction process, many individuals ran out of donor hair long before the process could be completed.
Approximate A Natural
In the 1980s, hair restoration surgery gradually began to evolve from using larger punch grafts to smaller and smaller mini and micrografts. Minigrafts were used behind the hairline, while one and two hair micrografts were used to approximate a natural transition from forehead to hair. Donor site management also evolved from round punch extraction to strip harvesting—a far more efficient technique. Pioneers in this field were experienced surgeons such as Dr. Dan Didocha, Dr. Martin Tessler, Dr. Robert Bernstein and others. The concept of creating a more natural look evolved in the 1990s with the advent of Follicular Unit Extraction (FUE), first pioneered by the highly gifted Dr. Robert Bernstein and described in Bernstein and Rassman’s 1995 publication “Follicular Transplantation” goes even further.
The 1990s also brought new tools into play, such as the introduction of binocular or “stereoscopic” microdissection. The stereoscopic microdissection allowed the surgeon to see clearly where one hair follicle begins and another ends. During the 1990s, many transplant surgeons abandoned the use of larger grafts in favor of one, two, and three hair follicular units.
While very useful in the hairline, such “micrografts” have not always been optimal for restoring density behind the hairline. Even after multiple sessions, the end result of scalp transplanted with only micrografts tended to look thin and quite thin. Perhaps even more worrisome, dissecting a donor strip entirely into micrografts risked a significantly reduced conversion yield. Here’s why.
Suppose we start with two donor strips of hairy tissue from two similar patients. Two surgeons each dissect a single donor strip, but the first surgeon attempts to dissect into only one and two micrografts, while the second surgeon dissects only enough micrografts to place in the hairline, making larger three, four, five, and six Hair left grafts available for placement behind the hairline. Initially, each donor strip contains 1,000 hairs. Both surgeons should theoretically have 1,000 viable hairs available for transplantation, regardless of how the tissue was prepared. Unfortunately, the reality is not quite like that.
Each time the donor tissue is cut, there is a risk of severing a follicle. Severed hair follicles are colloquially known in the industry as Christmas trees – because they are hair that lacks viable roots. Basically, they produce either thin fine hairs or none at all from a previously robust final structure.
This is a problem for several reasons, but primarily it is a problem because hair transplantation does not “create” new hair. The process simply shifts viable hairs from the back of the scalp to the front.
And since there is a fixed supply of permanent donor hair that may not be sufficient to meet the area of need, it is inherently counterproductive to reduce this limited supply through a technique that is known to produce relatively low yield. The problem is solved by the careful use of FUE/micrografts in the replicated hairline and slightly larger grafts behind the hairline. In this way, a refinement at the hairline with the appropriate density behind the hairline zone is achieved. hair transplant turkey When any of these factors are missing from the equation, the result is dysesthetic hair restoration. Either the result looks thin and fuzzy (micrografts only) or it looks like doll hair (large grafts only). So now we can begin to understand why the size and strategic placement of each graft is becoming an extremely important consideration in hair transplant surgery.