Limitations of Hair Transplant

How hair transplant works (basic logic)

– Hair follicles taken from an aesthetically suitable area that will not be affected by hair loss (donor) and is transplanted to another (recipient) area.

Donor Dominance

• The idea of donor dominance is the most important constituent basis of hair transplantation.

• Donor dominance refers to hair follicles maintaining their original characteristics in the transplanted area.

The ideal hair transplant(1) Safety and comfort during the procedure(2) Short surgery time(3) Zero recovery time(4) No scars(5) 100% graft survival hence full hair re-growth of the

transplanted follicles. (6) Cosmetically excellent results(7) 100% preservation of the donor hair follicles hence unlimited donor supply(8)Cheap cost

Basis of hair transplant

• In male pattern hair loss, the occipital area is not affected by balding; hairs in this region are permanent

• Hairs from this region can be relocated to a bald area and continue to grow normally.

Hair transplantation history

• The first recorded publication of hair transplant for baldness treatment was in 1822 in Wurzburg, Germany.

• Diffenbach a medical student and his mentor surgeon Professor Dom Unger performed an experimental surgery in animals and humans.


• Up until after the second world war, there was no known advancement in hair transplant.

• However, the currently used technologies of surgical hair transplantation were first developed in Japan in 1930s and 1940s.

• In 1939 Dr. S. Okuda, a Japanese dermatologist illustrated how hair was restored by transferring fully thick grafts of hair-bearing skin to hairless areas e.g. scalp, eyebrows and upper lip.


• Treatment of Androgenentic Alopecia (AGA) by hair transplantation kicked off in 1959 with a paper written by Norman Orentreich, MD.

• Dr. Orentreich showed that donor dominance was the most important factor in the success of hair transplant for the treatment of AGA.

Hair Transplantation Today• Today, surgeons can carry out safe, effective and natural

looking hair transplants thanks to the scientific and technical advances in this field.

• In the last 5 years the Follicular Unit Extraction FUE technique is becoming the more desirable choice of graft extraction because;– It eliminates the limitation of the linear scar associated with the

strip technique– Grafts can be extracted from alternative donor areas– Presents a larger donor area hence more grafts can be harvested.– Good results can be obtained .

Hair transplantation indications and candidate selection

• Any one who has pattern hair loss, has good donor hair, is in good health with realistic expectations is eligible for hair transplant surgery.

Hair transplantation indications and candidate selection

• Male and Female AGA• Selective patients with Cicatricial Alopecia– Primary Cicatricial Alopecia – criteria not yet

established– Secondary Cicatricial Alopecia – can be done with or

without primary surgical excision.• Beard and mustache transplant• Eyebrow and eyelash transplant• Pubic hair transplantation

Limitations of hair transplantation

• The ability to bring out a fully satisfying cosmetic result is dependent on:– Proper patient selection– Accurate assesment of the patients donor– Appropriate hairline design– Natural distribution of grafts

Limitations of hair transplantation

1. Insufficient donor2. Age limits3. Unrealistic expectations4. Female patients5. Scar alopecia6. Medical problems7. Psychological factors8. Capability of the surgeon and his team

Donor• Male pattern baldness is limited by the following important

factors:– Donor area assessment and management– Recipient area design and planning– Long term planning of the solution

• To meet the increasing demand of hair transplant, hair transplant surgeons are constantly increasing the maximum-possible number of grafts transplanted in one session to achieve maximum coverage of the recipient area.

• Surgeons are now disputing over a standard to define the ‘safe donor area’, because nowadays large number of grafts can be obtained by FUE.

Donor limitations

• Sparse donor• Depleted donor• Insufficient donor in relation to the recipient area• DUPA (Diffuse Unpatterned Alopecia)• Presence of different levels of miniaturized hair in

the donor area (the future of stability of the donor supply)

• Age, family history, physical examination and Finasteride intake.

Donor

• Normal donor density 2.2 hairs/mm2

• Low donor density 1.3 hairs/mm2 and extensive miniaturization

Depleted donor

• Previous use of donor hair that resulted in poor results or insufficient coverage of the recipient area– FUE – FUT

Donor hair factors that affect the results

• Hair density• Hair diameter• Hair Color• Hair type - Curly hair

Age

• One of the most important limitations of hair transplant is doing a hair transplant surgery on young patients (under 20, 20-25). In fact, it is a mistake.

• Young patients have this wrong notion that a single hair transplant will solve their present and future balding.

Age related limitations

• Physicians cannot exactly determine the permanent zone for young patients.

• Physicians are not able to determine if the donor area of the young patient will be stable over time.

• Patients who have early hair loss are more likely to have extensive baldness in future (hence hair transplant may not be worth it).

• Most young patients have very high expectations in relation to desired density and lower hairline.

Age

• The most rational solution for patients younger than 25 years old is to:– delay having hair transplant until the real picture

of future hair loss is determined – preserve the existing hair using medical therapy or

finasteride/minoxidil until the hairline is mature

Expectations

• It is necessary for the surgeon to listen to the patients expectations, then in relation to the size of donor and the bald area, let the patient distinguish between the realistic and the unrealistic expectations.

• Often, the donor hair is not enough to cover the entire bald area on the scalp.

• Its important for the patients to know that they will never return back to their youthful hair (especially patients with high Norwood scale)

Hair transplant in women

• Female hair loss is different from male hair loss in terms of the shape of thinning of scalp hair.

• This maybe because of hormonal differences; for this reason, very few female patients are suitable candidates for hair transplant.


• Female patients should undergo donor density testing using densitometer to ensure that the selected donor does not exhibit any signs of thinning.


• Another important factor to be considered is the cause of the hair loss.

• Pregnancy, hormonal disorders, vitamin deficiency are some of the causes of hair loss.

• Suitable female candidates are female patients with AGA that have sufficient donor hair.

Cicatricial Alopecia

• Well selected scar alopecia patients can exhibit exceptional results.

• In relation to hair transplant, cicatricial alopecia can be categorized as:– Stable (Secondary)– Unstable (Primary)

Stable Cicatricial Alopecia

• Scar quality is one of the major problems. • Hypertrophic scars and advanced atrophic

scars with poor circulation may not yield satisfactory results– Before the surgery, blood supply in the scar area

should be tested with the 19G needle under local anesthesia.

Stable Cicatricial Alopecia

• Full coverage of large scars may be limited by insufficient donor. – The most suitable alternative approach to such

cases is to reduce the scar area by primary excision.

Unstable Cicatricial Alopecia

• These diseases primarily target the hair follicles causing hair loss.– pseudopelade of Brocq – discoid lupus erythematosus – Lichen planopilaris– Folliculitis dekalvans

Skin diseases

• Some dermatologic diseases cause hair loss and hair transplant may not be appropriate.

• Examples – Alopecia Areata– Infections– Vitiligo – Psoriasis (must be evaluated since hair

transplantation can aggravate the disease)

Unstable Cicatricial Alopecia

• The major factors to consider are; – If the disease is currently active or not– If the disease will or will not activate later– If surgery may activate the disease

• Generally, a test hair transplant can be done after a 2 year stable period– If successful (no re-activation)then the full session

can be done.

Medical conditions and medication

• Even though hair transplant has no contraindication, situations that may bring complications in the procedure should be carefully considered.

• In such special cases, the surgeon should contact the patients physician or the appropriate specialist.

Medical conditions and medication

• The scalp tissue is a well-vascularized tissue, thus HIV, HepB and HepC patients may be a risk for hair transplantation team

• Immunodeficiency characterized with HIV-positive patients indicates high risk of developing infections

• Patients with hepatitis, dosage should be evaluated according to the liver functions.

Medical conditions and medications

• Diabetic patients also have high risk of developing infections and should be appropriately evaluated before surgery.

• Bleeding diathesis disorders can seriously affect the hair transplant procedure. It is a good idea to question the patients medical history before the procedure.

Medical Conditions and Medications

• Patients who use blood-thinners or anticoagulant medication should postpone or stop the medication before the surgery (with recommendation from the cardiologist)

• Drug interaction of Epipherine with non-selective beta-blockers used by arrhythmic patients can cause a hypertensive attack.

Medical Conditions and Medications

• Epipherine can trigger an epileptic attack on patients with epilepsy.

Psychological Factors

• Hair loss can cause significant emotional stress especially in young patients.

• Patients with psychiatric problems are more severely affected by this stress.

• These factors should be carefully evaluated before surgery and the surgeon should ensure that the patient fully understands the procedure and the results.

Psychological Factors

• Psychiatric conditions that should be considered in relation to the success of the hair transplant are;– Trichotillomania– Obsessive-Compulsive Disorder (OCD)– Body Dysmorphic Syndrome (BDS) – Depression.

Psychological Factors: Trichotillomania

• Active trichitollomania on any part of the body is an obvious contraindication to a hair transplant, but if a person has a history of this condition, the doctor should also be cautious and only consider surgery if the therapist is confident that the condition has little chance of recurring.

Psychological Factors: Obsessive-compulsive disorder

• OCD patients are extremely difficult to satisfy and even in a very successful hair transplant can focus on a minor imperfection seeming oblivious to the good overall result.

Psychological Factors: Body dysmorphic disorder

• Whilst there may be no actual physical defect, the patient is overly critical of their physical looks.

• Such patients will most likely not satisfied with the results of the surgery, or any other cosmetic procedure.

• This condition should be treated by a psychiatrist .

Psychological Factors: Depression

• The most commonly experienced psychiatric disorder among hair transplant patients is depression; it is also a common symptom in people experiencing hair loss.

• Hair transplant will not cure medical depression and unsatisfied expectations may even worsen the condition.

Surgical team capability

• The doctor and the technicians must be well experienced in hair transplantation.

• In addition, the doctor should have knowledge in areas such as hair loss diagnosis, medical treatment of hair loss e.t.c.

Surgical team capability

• Artistic aesthetic hair transplant design, anesthesia administration, graft extraction and implantation are complex procedures that should only be performed by expert and experienced capable teams.

• Since this procedure lasts 8-10 hours under local anesthesia, the doctor should be well trained in anesthesia related complications.

Surgical team requirements

• Since hair transplant is a technical procedure, the following are important– The doctor should have both dermatological and

surgical skills – The technicians should be well trained and skilled– Team work– Attention to detail and accuracy– Full concentration

Remarks

• With follicular unit transplantation technique a surgeon can create natural looking hair patterns and results.

• The success of the procedure depends greatly on – Proper patient selection– Accurate assessment of the patient’s donor – Natural distribution of the grafts; taking into

consideration age and future thinning possibilities.

Health & Medicine

Limitations of Hair Transplant