Hair transplantation

Scarring alopecia (atrophic inflammation of the scalp, injuries, burns, permanent traction, radiation damage), male androgenetic alopecia (Norwood I-VII) and female alopecia androgenetica. Replacement of beard hair (e.g. harelip correction), reconstruction of eyebrows, eyelash transplantation after alopecia mechanica, replacement of pubic hair, alopecia triangularis congenita.

Prerequisite: sufficient own donor hair available

Two surgical methods are to be distinguished:

1. Pivot flap techniques (e.g. rotational flap according to Juri; rarely used).
2. Autologous full-thickness skin grafts
   :The grafts are introduced into the recipient region as so-called square grafts, strip grafts or punch grafts.
   • In punch grafts (method according to Okuda and Orentreich), so-called standard grafts of 3.0-4.5 mm in diameter are taken from the occipital hairline and inserted into equally sized, previously punched out recipient holes in the alopecic area. Aesthetic disadvantage: Tufted hair growth. Today, follicular unit transplantation is recommended.
   • Follicular unit transplantation - with transplantation of several thousand follicular units = follicular units FU a 1-4 hair follicles in high density. Currently, the transplants are significantly smaller (0.8-0.9 mm in diameter) due to optimized drilling systems (hexagonal hybrid punches, atraumatic rotating drilling systems). This results in good to very good cosmetic results. Procedure in LA.
   Patient sitting upright or in prone position. Removal of a narrow strip of skin in the hairline region. Prerequisite is to check sufficient quality of the occipital, if necessary also parietal donor region with regard to FU density and quality, signs of miniarization and elasticity. The collection should be performed only in safe zones for permanent hair growth. A strip of 20 x 1 cm is required to harvest 1400 FU grafts at a donor hair density of 70 FU/cm². From this, 3500-4000 hairs can be obtained. The wound is continuously closed atraumatically with monofilament suture material.
   • In the minigraft method (3-5 follicles) (according to Lucas), grafts of 1.6-1.8 mm diameter are used. Micrografts are implanted in the area of the hairline, minigrafts behind it. The implantation channels are created by motor-driven circular blades (Holes method). Alternatively: slit-shaped implantation channels with a fine lancet-shaped blade (slit method). Arrangement and spacing of the 0.8-1.5 mm diameter holes should be irregular, not too dense (risk of necrosis) and not too light (too little visual effect). The planting holes or slits can also be made with a_{CO2 laser} suitable for this purpose if the patient has the necessary experience. In any case, strict attention must be paid to the future direction of hair growth. The insertion of the grafts is done with micro tweezers. Adhesive forces and the effect of the body's own fibrin hold the grafts in position, so that no special fixation measures are required. With the slit technique, there is more of a risk of graft dislocation. Over 1000 mini- and micrografts can be transplanted per session. On average, 400-700 grafts are needed per operation. Optimal hair density can be calculated by trichodensitometry. Postoperative application of a sterile protective dressing (no pressure dressing!) for one night. Strict care must be taken to ensure that the grafts do not stick to the dressing, as they will then be torn out when the dressing is removed. Already after 3 days the patient can wash his hair by himself with a mild shampoo. The stitches in the donor area should be removed after about 2 weeks.
     The transplanted hairs fall out temporarily postoperatively (after about 3-4 weeks). After 3-4 months, the follicles continuously produce new hair.

Notice. In hair transplantation, preoperative planning and patient education are of particular importance. Hair transplantation is a redistribution of still existing hair. Too large removal strips and the simultaneous transplantation of too many FU's should be avoided: On the one hand because of unfavorable scarring in the donor area, on the other hand in order to be able to implant the FU's promptly and gently. The patient must know that even after several treatments only a hair density of 40-80% of the hair density in the donor area can be achieved. Thickening operations can be performed after 3 months at the earliest. The future hairline must not be placed too deep in any case, rather a little higher. Marking and discussion of the hairline is done together with the patient before local anesthesia. Care should be taken to ensure accurate photographic documentation. Information is available from the Association of German Hair Surgeons (VDHC: https://www.vdhc.de/downloads/VDHC-Leitlinie_HT.pdf) and the International Society of Hair Restoration Surgery (ISHRS. https://ishrs.org/).

• Bleeding
• Pain
• Swelling
• Itching

1. Finner AM (2022) Hair transplantation- sustainable medical planning and implementation. Dermatologist 73:358-368
2. https://www.haarerkrankungen.de/aktuelles/haarsinglenewsmeldung.php?newsid=20180222
3. Neidel FG (2019) Hair transplantation- what is current? Derm 25:177-182