FUE procedure

In the FUE procedure, the follicular units are extracted individually using a punch. The punch can be manually operated in an oscillating manner, can be attached to a rotating or oscillating drill — which is still manipulated by hand — or can be used in the most sophisticated method by a robot. Currently, the only robotic device commercially available is the Artas™ (Restoration Robotics, Inc., San Jose, CA), which takes over 50 images per second in order to determine the correct angle and depth to extract the hairs. Although the robot is still controlled by the operator, the element of human error and fatigue is eliminated. The advantage of FUE by any of these options is that instead of leaving a linear scar, each extraction site leaves a small round scar that can be hidden by short hair with greater ease than a linear scar. There is also less pain and faster healing; however, the donor area needs to be shaved completely for FUE harvesting and the resulting grafts are not as robust as those derived from the strip method. It is also not possible to harvest as many grafts in one sitting as can be achieved using the strip method, and there is a greater transection rate. Since this transection rate can be variable, the yield of grafts is less predictable compared to the strip technique.

FUE can be used to harvest hair from other parts of the body although, apart from beard hair being used for patients wishing to have a hair transplant to the beard or moustache area, it would always be advisable to use scalp donor as the first choice since growth rates from body hair can be very unpredictable and it is not likely that body hair will take up recipient site life-cycle patterns and hair length.

Technically, it would be expected that 90% or more of transplanted hairs should grow, but a patient’s perception of success is dependent on his/her preoperative expectations and how closely these were matched by the postoperative results. Acknowledgement of the density that can be realistically achieved, agreement on the design and distribution of the grafts, explanation of the 3–4 month delay before growth of the transplanted hairs, and 12–18 months before maturation of the transplant is achieved, will contribute to having a satisfied patient. This is particularly relevant for eyebrows because of the prominent position in the middle of the face and the variability in what fashion trends and individual patients deem preferable.

Figure 4 Female hair transplant (A) before, and (B) after

Figure 4 Female hair transplant (A) before, and (B) after

Planning for the future

In both male and female patients with genetically-determined patterned hair loss, it is important to plan for future progression of hair loss. While knowing that there is a positive family history of advanced FPHL or MPHL is useful, even those without immediate relatives who have extensive hair loss might be genetically destined to have significant alopecia. This is particularly hard to predict in younger patients, and it is in these patients that extreme caution should be exercised in recommending or performing hair transplants. In men, frontal hairlines should be designed to take into account what will look natural and appropriate when they are in their 60s and 70s. Transplants into the crown should take into consideration that hair loss around these grafts may leave a ‘doughnut’ appearance that would entail a commitment to further surgery, and similarly, transplants into fronto-temporal recessions may become isolated if hair loss progresses behind them, and might require further grafting to maintain a natural appearance.

In women, the available donor is often limited as thinning tends to be more generalised over a wider area of the head that includes the parietal scalp. Therefore, the transplant design needs to focus on where the aesthetic benefit will be maximised, such as hair-part lines and immediately behind the frontal hairline.

Scars

While graft survival is less guaranteed in scar tissue, and care needs to be taken not to de-vascularise scars by overly ambitious incision density, hair transplantation is often the only solution to scars in hair-bearing areas, especially when the options of serial excision or tissue expansion have been considered and ruled out or exhausted. Burn scars and skin graft scars on the scalp need some tissue between the scar and the cranium in which to insert the grafts. Large areas of scarring alopecia might not be possible to cover owing to a paucity of suitable donor hairs. Dermatological scarring alopecia can leave patchy areas of hair loss, which can be suitable for hair transplantation as long as the inflammatory condition is completely dormant or burnt out. Most surgeons would be unwilling to surgically revise areas of post-radiotherapy alopecia, but hair transplantation has been successful in these cases, providing adequate donor hair is available.

Figure 5 Hair transplant into a burn scar (A) before, (B) during, and (C) after

Figure 5 Hair transplant into a burn scar (A) before, (B) during, and (C) after

Future developments

Looking to the future, hair follicle stem cell culture has long been the elusive Holy Grail that would create an unlimited supply of donor hair for implantation, while current hair transplants rely on a finite number of hairs that are transferred from their donor location to the chosen recipient site. Unfortunately, despite small advances in the basic science research, this remains unlikely to be available for clinical use in the foreseeable future. Although it has been achieved in murine models for some time, there are significant differences in the way stem cells behave in mice and in humans, and some of the obstacles that present themselves in human follicle culture have yet to be overcome. As the follicles in non-scarring patterned alopecia remain present but dormant, a more likely therapeutic modality is a pharmacological agent delivered topically or systemically that awakens the dormant hair follicles and stimulates hair growth again. Despite large numbers of laboratories around the world working to find such an agent, none has been found to date.

Figure 6 (A) Before hair transplant and (B) rejuvenated appearance after hair transplant

Figure 6 (A) Before hair transplant and (B) rejuvenated appearance after hair transplant

Conclusions

It can be argued that, especially for men, there is no other aesthetic procedure that rejuvenates the appearance as much as a well-designed and executed hair restoration treatment. It can also be suggested that patterned hair loss is as much a disease process as the dermatological scarring alopecias. Not all individuals go bald as they age, while sooner or later we all show signs of facial ageing manifested by wrinkling and sagging skin. With more and more celebrities admitting to having had a hair transplant procedure, the stigma surrounding having hair restoration is diminishing and the day may come when having a hair transplant is as accepted as a trip to the dentist.