Hair loss can be an emotional and stressful experience for both men and women. It can lead to increased levels of anxiety, and adversely affect an individual’s confidence and self-esteem. For many years there have been treatments designed to halt or restore hair loss but with varying degrees of success. However, recent developments in the techniques and technology used for these procedures have improved the quality of results dramatically and hair restoration procedures are now more popular than ever.
There are few people better qualified to talk to regarding hair restoration procedures than Bessam Farjo, a specialist in hair restoration surgery and Co-Founder of the British Association of Hair Restoration Surgeons. In 1993, he co-founded the Farjo Medical Centre with his wife, Dr Nilofer Farjo, exclusively practicing hair restoration surgery and medicine in Manchester and London. They currently perform over 300 hair restoration surgical procedures a year. He is also Past President and Fellow of the International Society of Hair Restoration Surgery (ISHRS). I was lucky enough to speak to him about how the techniques have changed over the 22 years he has been performing hair transplant surgery and the results that can now be achieved.
‘Before I started practice, the common technique was punch grafting. Where large cylindrical grafts of up to 20 hairs were transferred to the top of the head. While this did work, it resulted in the infamous ‘doll’s hair’ appearance,’ explains Bessam.
Along with leaving large grafts (or plugs as they were known) in the scalp, giving the ‘doll’s hair’ effect, punch grafts often left large scar areas on the back of the head. Hair transplant techniques were still in their infancy and not a great deal of thought was given on how further hair loss would look against the new grafts; this led to islands of grafted hair exposed as hair loss continued with age.
Follicular unit transplantation
‘When I started training over 20 years ago we were removing strips of skin from the back of the head of about 1 cm high and of variable lengths depending how many hairs you needed. We would then take it out and dissect it into grafts of between one to eight hairs each. That was the first stage. We then moved on to identifying that we want these pieces in their natural states — their follicular units. The only way to achieve this was use a microscope to divide the strip into these individual follicular units for transplantation back into the donor, and this is what is known as follicular unit transplantation.’
Follicular unit transplantation (FUT) was a giant leap forward from the earlier punch grafts as the follicular units consisted of fewer hairs than the grafts and could eliminate the ‘doll’s hair’ look associated with the earlier method. Owing to their smaller size, follicular units could be placed closer together to achieve more natural, denser looking hair. Surgeons were also able to obtain a larger number of grafts from the donor, which allowed them to expand the treatments they offered and the severity of hair loss they could treat.
Follicular unit extraction
‘The next step was FUE — follicular unit extraction. This began around 1999 and at the time transplants were becoming more popular thanks to the internet and the great results people could now share online. However, some surgeons began getting too adventurous and extracting too much skin from the back of patients’ heads. This led to good results but large noticeable scars. That is why we started using FUE, as it does not produce a scar. It uses the same principle as the original plug grafts but now we use smaller drill pieces — maybe 1 mm or smaller. We would scatter these extractions all around the scalp so you don’t get the strip scar but rather a much smaller dot scar. ‘
FUE uses the same techniques of insertion as FUT but by extracting follicular units individually rather than in a strip, it now became possible to perform hair transplants without leaving a visible scar. That is not to say there were no initial negative aspects to FUE, but Bessam explains they were overcome by the advances in technology.
‘It was a very labourous process, time consuming, and you could only move a small number at a time. The technique improved over the years and we have learnt how to do FUE more efficiently. We are at the stage now where we can remove up to 2000 grafts in one day. We can adjust the operation and technique according to the patient’s needs and can use the FUE in combination with FUT to further improve results.’
The ability to remove such a large number of grafts, for what was once a time-consuming exercise, is down to advances in technology and devices such as the Artas Robotic System. Bessam is proud to tell me that of only two Artas Robotic Systems in the UK, one is sat in his practice. The device uses high-resolution imaging to identify individual follicular units and guides a robotic arm to dissect the units at the appropriate angle of approach, producing healthy grafts and a low transection rate. Currently, the robotic system is only capable of dissecting the hair follicules from the scalp, but Restoration Robotics, who manufacture the system, are still producing further software and modules to increase the precision of the device and its applications.
While the insertion of the grafts back into the donor will still need to be performed by a surgeon, the robotic system greatly reduces the dissection time, ensures the quality of hairs extracted, and increases the number of units that can be extracted in one sitting.
The role of clinical research
The ability to achieve such great results in hair transplantation is not only down to the advances in device technology, it has a lot to do with years of clinical research into understanding the causes and science behind hair loss. This is something Bessam has always understood the importance of and he continues to be involved with research projects taking place around the world.
‘We think it’s important to find more answers and advise our patients on the best treatments, as well as ensure we are in a position to take advantage of any new developments for the benefit of our patients,’ he explains.
‘We were involved with a research project with the University of London, where we investigated the effects of environmental stress on the hair; we discovered that balding hair is more sensitive to pollution, oxidative stress, and smoke. While the research did not look for a cure, we now know that these environmental factors may speed up hair loss,’ he continued.
Bessam also tells me of the research he and his team conducted with Intercytex, a British biopharmaceutical company, in which they performed a 6-year clinical trial on volunteer patients on the subject of hair cloning.
‘It was the first human trial on cloning in the world. The general principle was taking hair off the patient’s head, multiplying the cells in the roots of the hair to millions of cells and then injecting the cells back into the patient. The main problem with hair transplantation is that you can only use what you have and you will eventually run out of hairs. The idea was to find out if we could grow hair from the cloned cells and, in theory, create an unlimited supply of hair. The results were positive in the animal studies but unfortunately in the human trial the hair was shown to not develop properly.’
His dedicated approach to research means he will never offer anything to the patient if he isn’t confident with the research or development invested into it the product or technique. It is for this reason he does not currently offer scalp micro-pigmentation, a superficial tattoo applied to the scalp to give the appearance of hair stubble, in his practice. He believes the results are not yet good enough and more work needs to be done in ensuring the ink used for the procedure does not change shape or colour. Only when he is satisfied with his own research into the technique and can guarantee quality results, will he offer it to his patients.
British Association of Hair Restoration Surgery
In 1996, Bessam co-founded the British Association of Hair Restoration Surgery, which was the first official member association of its kind. The inspiration behind the association was to give hair restoration surgeons a place to get together and discuss common issues.
‘There were around six surgeons members at the beginning and now we have around 50 or 60 hair surgeons in the UK today and around half are Association members. We meet twice a year and present on issues such as complications and difficulties, we discuss regulations or government recommendations, our relationship with international bodies, and share our experience with patients.’
With continued advances in the science and research, Bessam understands the importance of sharing expertise and knowledge with peers. Through this approach, this niche but growing market can continue to prosper and deliver excellent results across the board.