Hair Transplantation

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Hair Transplantation

Hair transplantation is to transplant the hair follicles, which are extracted from the bald resistant donor areas of the body such as breast, leg-arm, genital area, especially the scalp into the bald area. Hair follicles in the nuchal area are more preferred as donor grafts in hair transplantation.

Due to being insensitive against the DHT hormone, there is less hair loss in the nuchal area of men. Hair follicles taken from other parts of the body have a possibility of hair loss and they can be fallen again after hair transplantation. However, women do not have an area like the ones without hair loss of men. Therefore, the result of hair transplantation in women is less successful than that of men and it should be known that the transplanted hair will also fall gradually since it will be affected by the hereditary structure.

Due to the increasing demand for hair transplantation in recent years, it has been advertised and popularized too much, therefore it has been considered an income channel. In hair transplantation, hair follicles which contain 1-4 stem cells should be transplanted by doctors. Today, the operation, in which natural hair follicles containing 1 to 4 hair cells are extracted from the donor site and transplanted as a group with advanced techniques, is called FUT “Follicular Unit Transplantation”, and this method is mostly preferred by people suffering from hair loss/baldness problem.

The history of hair transplantation

A method was used in the 19th century, which was applied by striping the scalp and grafting surgically into another area. The modern transplantation technique was used for the eyebrow and eyelash transplantation in Japan in the 1930s. However, they did not try this method in hair transplantation.

For decades, the world has not been informed about these operations in Japan which was isolated after World War II. The first hair transplantation news of the modern age was heard in the 1950s when New Yorker dermatologist Orentreich began to perform hair transplantation on males.

Before, it was believed that hair would not develop like the original hair after transplantation. However, Orentreich showed on his experimental subjects that the hair developed and was permanent. For 20 years, surgeons worked on hair follicle grafting, but they failed. In the 1980s, Brazilian Uebel began to use hair transplantation technique on a small scale, and the method began to be heard. In fact, it began to be popular when Rassman from the USA transplanted thousands of hair follicles with the micro-surgical method at once.

In the late 1980s, Limmer examined the scalp under a three-dimensional microscope. The FUE method, which was first introduced in Japan in 1988 by Masumi Inaba and began to be known gradually with 1mm punches in the medical world, took its place in the medical literature in 2002 thanks to William R. Rassman and Robert M. Bernstein. In 2007, robotic FUE hair transplantation method was developed by Dr. Miquen G. Canales and Dr. David Berman. Robotic hair transplantation is based on the FUE hair transplantation method.

Side effects of hair transplantation

The main complications experienced after hair transplantation operations are listed below.

  • Bleeding: Bleeding may occur in the areas where hair follicles are taken or transplanted. In order to prevent this complication, the patient’s bleeding profile should be examined before the procedure, the necessary laboratory test should be done, and the medications that may cause bleeding should be discontinued before the operation.
  • Infections: The occurrence of infections in an area where hair follicles are transplanted or extracted is a very rare complication because it has the natural resistance to infections due to the bleeding of the scalp. However, if an infection occurs, it should be treated with antibiotics which are systemically given.
  • Bad scar tissue formation on the area where hair follicular units are extracted: It is more common in hair transplantation applied with the FUT method. It is more likely to be seen in the patients who have sensitive skin or have received poor techniques.
  • Loss of sensation in the area where hair follicular units are extracted: It is rarely seen in the FUT technique and disappears usually with appropriate treatments.
  • Dermoid cysts: They appear after a few weeks following the procedure and are stemmed from the transplantation of hair follicle units into the depth. The specialist performing transplantation operation should compress on the donor area well enough before transplanting of the hair follicle units, and then transplant the hair follicles.
  • Cobblestone appearance: It occurs when the hair follicles are not transplanted deep enough into the recipient areas. This results in a bumpy appearance on the scalp.
  • Hairs growing in the wrong direction: growing of the transplanted hair follicles in the wrong direction are usually caused by a bad hair transplantation technique. If hair follicular grafts are not transplanted at an angle of 30-35 degrees towards the right direction during transplantation, hairs can grow in the wrong direction. It is the main reason of this complication.
  • Accelerated loss of native hair: It can be caused by being damaged of native hairs next to the recipient area while transplanting hair follicular grafts, or caused by overstressing of hair transplantation. Sharp tools must be used during the operation and blunt tools should be changed immediately.

In order to minimize the risks of the complications listed above, it should be performed by professional people.

Hair transplantation methods

Hair transplantation is a procedure that takes place in 2 stages, including extraction of hair follicular grafts and transplantation of these extracted hair follicles.

Extraction of Follicular Unit Grafts

  • FUE: Follicular unit grafts are extracted one by one from the donor area in the nuchal area. Before the hair grafts are extracted from the donor area, local anaesthesia is applied to the area in order to prevent the patient from feeling pain. Follicular unit grafts (hair follicles) extracted from the donor area are transplanted one by one into the recipient area. FUE hair transplantation has changed too much, compared to its earliest form. Today, p-FUE applied with micromotor has replaced the first described technique. Rarely, the FUE technique can be performed with a biopsy needle called a punch in appropriate cases. This technique does not leave a stitching scar on the nuchal area. At the end of 1 year, the transplanted hair will gain health and strength in the new area.
  • FUT: It is applied by removing a strip that contains many hairs from the donor area of the nuchal area and then excising the grafts individually under a microscope. It was used for the first time in the 1930s. A surgical scar like a strip at 5-10 cm wide can be left in the donor area where the strip is removed. As a result of using of micromotor in the FUE hair transplantation technique, the application rates of hair follicles transaction have decreased to 1%, and now it is about to be the gold standard. While it becomes increasingly widespread in the world, it requires technical skills. Due to the success rate and strong hair follicles extracted from the donor area, your hairs will not fall out after transplantation.

After local anaesthesia is applied to the patient, FUE hair transplantation is applied through the following steps:

First of all, the donor area having the follicular unit grafts to be used in the transplantation process is shaved in order to shorten the native hairs. Grafts (hair follicles) are extracted from the donor area by a manual punch or by millimetric surgical devices called micromotor.

The grafts extracted are put in a container with a nutrient liquid in order to be protected. Grafts are divided into groups with single, double or several follicles to make convenience during the transplantation procedure. In the recipient area where the hair transplantation will be performed, microscopic incisions will be made in order to transplant the hair follicles.

The number of incisions to be made in the donor area should be equal to the number of grafts to be transplanted. The accurate determination of the angle of this incision is very important in terms of the natural appearance of the hair. It is also important to create a natural hairline during the incision process. The next step is the transplantation of grafts.

It is important to know exactly how many grafts will be transplanted in the recipient area where transplantation will be applied. For example; For a natural appearance, it is ideal to transplant a single graft in the front hairline and multiple grafts on the back of the head.

The hair transplantation session applied with the FUE method can last for an average of 5-9 hours. The number of grafts to be transplanted within this period may vary between 3000-5000. According to the needs of the person, a single session may be sufficient, or two or three sessions can be required.

The recovery process after transplantation

In the first week following hair transplantation applied with the FUE method, it is very important to take protective measures for the skin since the scalp will become quite sensitive. During this period known as the hair retention process, the person having hair transplantation should avoid dusty and dirty environments; stop alcohol consumption and smoking, doing tiring activities and avoid applying any other substance on the scalp rather than the one that is recommended by the doctor.

In the first three days after hair transplantation, the hair should never be washed. After three days, the new hair is first washed in the centre of transplantation. Bruising and crusting can be seen on the hair roots, it is a normal condition so that patients should not worry about because it will disappear in a short time.

In case of long-lasting crusting, since it can prevent the growth of new hairs, the patient should consult the doctor. In the second process which has started a few weeks after the transplantation and lasted for six months, firstly the weak hairs fall out, and then new hairs begin to grow. During this process, there are some important points that patients should pay attention.

These are as follows; to avoid swimming in the sea and especially in the pool, to avoid using too much hot water when taking a shower and exposing the hair to high-pressurised water, to keep away from the products such as hair fixing gel and spray. A large part of the new hair begins to grow within 6 to 9 months after the operation. Completion of new hair growth takes for almost 1 year.

What should be taken into consideration after hair transplantation?

Within 48 hours following hair transplantation, the area transplanted should not contact with hands. A hat can be worn to camouflage the transplanted area after the operation. In this case, a stiff top cap/sports hat that fits on top of the head but does not touch the transplanted are should be preferred.

The hair transplantation area should not contact with any part of the hat. The most appropriate hat is the one that has a stiff top and does not collapse, which we see on African safari documentaries. If not available, it is advised to wear golf hats with a stiff top.

  • The transplanted hair follicles should not touch the bed, quilt or pillow and should not be damaged when sleeping at night. It is recommended that you should use a stiff and small pillow. You can lie on the back, on the side of the donor area. Small-sized clothing and your face-down lying position are not recommended for two weeks, because they increase the risk of contacting of the recipient area with the pillow or bed. Furthermore, it should be preferred to wear clothing such as shirts, cardigans, zippered sweaters taken off easily for 2 weeks; t-shirts, turtleneck sweaters, and undershirts that have to be taken off overhead should not be worn in order not to damage the recipient area. In other words, for 2 weeks, the recipient area should not be contacted with anything, every possible contact can damage the hair follicles and they can fall out.
  • For 2 weeks, sports activities, Turkish bath, sauna, swimming, solarium and all kinds of hairdressing services are prohibited. They can damage the hair follicles and increase the risk of infection.
  • Hair can be cut with scissors after 15 days without a buzz cut. After 45 days, all kinds of hairdressing services are allowed (such as shaving, dyeing, buzz cut, perm, etc.).
  • For two days, the recipient area should not be washed and contacted with water. The first wash should be done on the 2nd day, in other words, 48 hours after the operation. This wash will be done by your doctor or health care team. The important thing is to wash thoroughly without damaging the hair follicles and the hair.
  • After washing, no towels and hair dryers should be used for the recipient area.
  • If you are doing sports that can damage your head (football, basketball, taekwondo, kickbox, boxing, wrestling, etc.), you should start these activities after 45 days following the operation.
  • If you are going on a journey immediately after hair transplantation, travelling with a simple inflatable pillow for the back of the head will prevent your head from leaning the glass or any other place and damaging your hair follicles.
  • You should not use aspirin in the first week after the operation. It is also not recommended to take anticoagulant medications and herbal supplements such as ginseng, ginkgo biloba and vitamin E. Growing of your hair may take a period of 2,5 to 4 months after hair transplantation. Antibiotics, painkillers, and medications to be used after hair transplantation operation should be given by the operating doctor.

Diagnosis and analysis of hair loss

Before making a decision on hair transplantation, the hair restoration surgeon should examine the scalp and investigate the causes of hair loss. If the surgeon suspects that hair loss is caused by another factor than female or male genetic factors, he/she should be able to reveal the underlying cause by performing other diagnostic examinations. Hair transplantation should be applied to the hair loss area after this cause of hair loss is treated.

Hair Pull Test: almost 25-50 hairs are grabbed and gently pulled upwards by fingertips to see how many strands are removed in each pull. Normally, several strands are removed, however, if a tuft of hair or more than the normal amount is removed, this indicates there is an abnormal condition; in this case, the hair body and hair root/bottom should be investigated by examining hair follicles under the microscope.

During the hair pull test, if the number of hairs in each pull is 5 and above, increasing of hair loss is caused by “telogen effluvium”. Hair losses caused by telogen effluvium are reversed; because its reasons can be pregnancy, stress, medication use. Such hair losses are seen after 3 months following stress and affect 30% – 50% of the total hair amount. In such case, the daily amount of the loss (normally 50-100 strands) can be 300 strands or more.

Phototrichogram: After clipping strands or cutting hair in a certain area, close-up photos are shot at 3-5 day intervals and growth patterns are examined.

Hair glass: Hair growth is observed within 3-30 days by clipping or by cutting hair in a certain area.

Hair loss caused by an abnormality in the hair growth cycle is less but can be seen at any age. Thyroid diseases, nutritional deficiency, side effects of some medications, anaemia, some systemic diseases and psychological stress are among the factors that may cause hair loss by affecting the hair growth cycle.

Skin biopsy: Although it is rarely required, it may be necessary to define some cicatricial alopecia (hair loss disorders caused by the damaged hair follicles on the scalp) and to diagnose infiltrative skin diseases that may cause hair loss.

Hair evaluation: If an abnormality or infection is suspected in the hair body, the hair will be removed from the scalp and examined under a microscope. Fungal, bacterial or viral infections can cause hair losses which can appear as breakage/disperse in strands.

Hair analysis: It is a laboratory test. Biochemical analysis of hair is carried out to understand the underlying cause of hair body anomalies. It is a reliable test to determine if hair loss is caused by a genetically altered hair-protein structure and/or medications used or heavy metal poisoning. It is not performed to diagnose systemic diseases or to find out nutritional problems.

What are the medications that cause hair loss in women?

  • Anticoagulant medications such as warfarin and heparin
  • Epilepsy medications, especially dilantin
  • Gout medications, allopurinol, and colchicine
  • Antihypertensive medications, diuretics, beta blockers
  • Anti-inflammatory drugs, especially prednisone
  • Cholesterol and lipid-lowering agents
  • Antidepressants such as prozac, lithium, tricyclic antidepressants
  • Chemotherapy
  • Thyroid medications
  • Oral contraceptives, especially those with excess progestin.
  • Diet pills, street drugs like cocaine, take vitamin A in high doses.
Author: Doç. Dr. Erdem Güven
We're writing about our patients.

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