Hair Transplant Terminology

Terminology

Term	Definition
Compression	Can occur when putting grafts into slits when the existing tissue 'compresses' the follicle, which can cause poor growth and/or improper direction of the hair.
Free Flap	A type of scalp flap surgery where one or more large flaps of hair-bearing scalp is detached and used to form a new hairline and replace hair loss where the scalp has been reduced.
Follicular Units	Follicular units are the natural bundles of hairs (from 1 to 5) that grow out of the scalp. Often, one or more hairs grow out of the same spot and share some of the same anatomy underneath the skin (such as sebaceous glands). Many doctors consider follicular units superior since they preserve the follicles as they are present in the scalp before transplantation.
Full Graft ("Plugs")	The first type of graft performed, these consist of 10-20 hairs in a circular 4-5mm graft. They are responsible for the 'cornrow' dollhead look of older transplants when finer grafts were not used to soften and fill in hairlines.
Line Graft	A large graft similar to a full graft but in a line rather than a circular graft. The line graft is used to provide density behind the hair line with a more natural look which is softened by other smaller grafts for a natural look.
Median Reduction	This is a type of scalp reduction in which the scalp is reduced in an oval shape at the center of the bald area of scalp.
Megasession	This term describes a transplant operation in which a large number of grafts (1000-3000, usually mini and micrografts) is performed in one operation. Proponents of the operation say it prevents multiple operations while still providing good results. Opponents say it may put too much stress on the blood supply and cause a low yield of hairs growing back.
Micrograft	One or two fine hairs used in transplants to 'soften' the front hairline to give it a natural appearance.
Minigraft	Two to Six thicker hairs used to 'soften' and fill in hairline transplants and provide density with a natural look.
PÂTÉ	Prolonged Acute Tissue Expansion. A scalp expansion procedure that is done during an operation rather than before or after by inflating and deflating a scalp extension balloon many times over several hours to stretch the available scalp.
Paramedian Reduction	An ovular scalp reduction away from the center of the balding scalp.
Random Flap	A flap which isn't tied to a particular blood supply. Typically used to correct remaining bald areas after remaining after procedures such as a scalp extensions.
Scalp Expansion	A scalp reduction surgery in which balloons implanted below the scalp expand hair-bearing areas which are used to cover the reduced scalp area.
Scalp Extension	A scalp reduction surgery in which a hooked medical device applies force to the scalp and stretch the hair-bearing areas to allow them to cover the reduced section of the scalp.
Scalp Flap	A scalp reduction surgery in which surgically removed flaps of hair bearing skin are used to cover reduced areas of the scalp and hair line. There are different methods of scalp flap surgery.
Scalp Lift	A scalp reduction surgery which allows a larger reduction (about twice as much reduced area) to be performed without flaps or extension.
Scalp Reduction	The simplest scalp reduction surgery is one in which small areas of balding scalp are removed in a succession of several small surgeries to reduce the area of balding scalp so that better results can be gained from transplantation.
Slot Correction	A random flap procedure developed by Patrick Frechet to correct remaining bald areas left over from procedures such as scalp extensions or median scalp reductions.
Slot Punch	The slot punch is a recent development which is supposed to allow results similar to lasers and prevent compression.
Slit Graft	A graft inserted into a slit in the scalp rather than a circular hole. Some doctors perform this more commonly for a variety of issues such as healing, appearance, etc.
Transsection	Occurs during harvesting of the donor hair or dissection of the grafts when follicles are accidentally cut by the blade, resulting in a loss of the hair, typically anywhere from 3-20% depending on technique. It is currently being debated how important this is since the latest cloning information shows most follicles should regenerate even if transsected.
Transpositional Flap	Commonly known as a flap rotation, this surgery takes strips of surgically removed hair bearing scalp and uses them to form a new hairline and/or cover reduced balding areas of the scalp.

Hair Transplant Information

Transplants are the most popular and common form of surgical hair restoration. Transplants have been around for many years and have advantages and disadvantages compared to other surgical options. Unlike some of the more radical surgical options, transplantation is a relatively minor procedure with few complications. It has been practiced for so many years that many doctors believe that the techniques involved have gone about as far as they are going to go in advancement. Due to increased competition, prices are generally decreasing as well.

What Are Hair Transplants

Hair transplants are really a very simple idea and process. It is simply the removal of hair at the back and sides of the head where hair is very dense and surgically implanting them into the balding area of the scalp.

A transplant is a permanent operation, so you should research your doctor well to assure you get good results and the best price! Here are some tips for finding a good transplant surgeon.

The procedure is preceded by a series of anesthetic injections to the scalp to null any pain. This is actually the most painful part of the operation and depends on the individuals. Some people have found it pretty painful and said that doctors underplayed this. After the anesthetic sets in, there is no pain.

First, a small area of the scalp is selected as the donor area. The amount of hair you can transplant depends on how thickly this hair grows. This area is removed and the open area is stitched together so that it can heal. Scarring is generally minimal but depends on how easily you heal from scars and the skill of your surgeon. The hair near the scars overlaps the scar and therefore hides it. This flap of scalp containing the hairs to be transplanted is then taken and cut and divided into the hairs or groups of hairs to be transplanted.

The hairs are then grafted into position by the surgeon. This is the most critical part of the operation as far as results are concerned, since the hairs must be placed properly in order for the hair to have a natural appearance. This is why many doctors stress the need for your surgeon to have an artistic ability when creating hairlines and to see many examples of his work. A good surgeon can be the difference between a hairline that looks natural and one that makes it obvious you had a transplant. How you look afterward is obviously a concern. The above picture demonstrates how grafts often look after hairs have been transplanted before the slits for the graft have healed (source: Dr. Stephen Cotlar).

One problem with transplants is the matter of progression of hair loss after the transplant. For many, it is easy to get a good result for how your hair looks now. But how about later when your hair loss has progressed more? A good doctor will evaluate your eventual loss and plan for how to proceed should further loss occur. Don't think this is a concern? Check out these photos of a person who had micrografts and then later experienced loss behind the hairline. His initial grafts look great but check what happened later.

So you're thinking: "Great, I do this operation and then in a couple of weeks I'll have a full head of hair!" Hold on, partner. It'd be nice if it worked that way, but just as with medicinal treatments, hair growth takes time. Generally after a transplant operation, most of the hairs fall out and enter a resting phase before regrowing in their new location. For this reason it takes about three to six months for transplanted hairs to grow back in, and even up to a few more months to see the full results. One company called ProCyte that is working on a hair regrowth treatment is also using the same type of treatment to prevent transplanted hairs from going into resting phase. Their treatment, GraftCyte, has been approved by the FDA as a medical device for doing this. The treatment consists of many dressings soaked in the treatment that are placed on the newly transplanted area immediately after the surgery and for the next few days. The dressings are replaced every few hours and provide a moist, safe environment to heal the wounds in as well as the treatment which prevents hairs from falling out and going into their resting phase. The dressings themselves are only sold through transplant doctors, but the accesory treatments including a mist spray and soon shampoos are available from ProCyte directly or through a couple of other mail order stores.

When you consider transplants, you have to consider results. While most doctors are skilled and can perform natural looking mini and micrografts, there are still some quacks out there who just shouldn't be practicing. Look out for a doctor who wants to perform plugs and not micro or minigrafts. You don't want to end up looking like these patients did. Check out photos and if possible meet some of his previous patients. Be sure and check with your local better business bureau to see if this doctor has had problems in the past (or presently!)

After that, it's mostly a matter of waiting. Depending on the amount of hairs transplanted and how much hair was needed, followup transplants are often needed to achieve the desired density, although many doctors are performing "megasessions" that transplant large numbers of hairs in one session so that further operations are often unnecessary.

Want to relate your transplant experience? We will be adding a new section with peoples' experiences soon once we get a few. Please contact us using the link at the bottom of this page .

Hair Transplant Culturing / Cloning

Hair Culturing (also known as Cloning)
What Is It?	Hair culturing involves removing donor hairs from the back of the scalp, isolating the stem cells from which the follicle grows, and culturing (growing) them in a lab, and reimplanting the new stem cells into the balding area of scalp. Because many stem cells are being grown in the lab from a few hairs, you will be able to grow many times the number of hairs removed. This will end the limits of how much hair can be transplanted due to the limited amount of hair that can be extracted from the back of the scalp during normal hair transplants.
Status	Several doctors are developing this technique: A study is underway in Canada at the University of Toronto to develop hair culturing. A Dr. Gho in the Netherlands has been granted a European Patent as of 9/14/98 and is conducting a study on actual patients. They expect their study to be done in 8 months (early 2000), after which time they plan to license the technology if it proves successful. Dr. Colin Jahoda of the UK is researching the process. At least one doctor in the US is seeking to develop the technique privately as well.
Time to Availability	As soon as 2 years but could take 5-20 more depending on how far along the people working on it really are. At least 5 years is more likely.
Advantages	Unlimited or nearly unlimited hairs to implant/transplant. Less scarring where hair is removed since less needs to be taken. Stem cells may be implanted by syringe which may mean less trauma to the implant area than traditional transplants. Less invasive procedure may require less anesthetic and involve less pain to the patient. Recent research indicates it may be possible to take donor cells from other individuals.
Drawbacks	Costs may be dramatically higher than traditional transplants, especially when the technique first becomes available. Cultured cells often have shorter lifespans than normal cells and it is possible that the hairs will not last a lifetime (and since the procedure is so new there will be no way to tell until it has been available a while). Implanting stem cells in this fashion can carry a risk of tumor or cyst formation - it is unclear at this point whether this may be a stumbling block to development.

In Support of Follicular Unit Transplantation

The Logic of Follicular Unit Transplantation

Follicular Unit Transplantation is a method of hair restoration surgery where hair is transplanted exclusively in its naturally occurring, individual follicular units. Specifically, single strip harvesting, stereo-microscopic dissection, and large transplant sessions will be reviewed.

A donor is better if it is as small as possible. The reason is that if a donor is big, hairs grow in … a very unnatural appearance. Hajime Tamura - 19431

Preservation of the Follicular Unit

The underlying premise of follicular unit transplantation is that the intact, individual follicular unit is sacred. Theoretically, they should neither be broken up into smaller units, nor combined into larger ones.^2,3,4

This simple idea may not seem like a radical approach to hair transplantation, but when viewed in the context of how the surgery has been performed over the past forty years (when the very existence of the follicular unit went generally unrecognized), it is radical indeed. At present, the majority of hair transplant surgeons will, at times, combine several follicular units or split them up, as they are not convinced that this has a significant impact on either the anesthetic outcome or upon growth. Practitioners of follicular unit transplantation, however, are certain that only this procedure achieves the best cosmetic results and their hair "bristles" when they witness surgical techniques that divide follicular units or transect follicles, techniques they feel preclude optimal growth and waste precious donor hair. In spit eof the heated debate, good scientific studies have not yet been performed to resolve these issues.

The follicular unit was first defined by Headington in his landmark 1984 paper "Transverse Microscopic Anatomy of the Human Scalp.⁵ The follicular unit includes:
1. 1 to 4 terminal follicles
2. 1, or rarely 2, vellus follicles
3. associated sebaceous lobules
4. insertions of the arrector pili muscles
5. perifollicular vascular plexus
6. perifollicular neural net
7. perifolliculum - cirumferential band of fine adventitial collagen that defines the unit

Photo: Follicular units at the level of the papillary dermis above the entry of the sebaceous duct. Each hexagonal follicular unit encloses sebaceous glands, sebaceous ducts, and several terminal and/or "vellus" hairs. Trichrome staining demonstrates pink keratin, smooth muscle, and blue collagen.
Photo courtesy of Dr. David Whiting

Transplanting Individual Follicular Units

That scalp hair grows in follicular units, rather than individually, is most easily observed by densitometry, a simple technique whereby scalp hair is clipped to approximately 1mm in length and then counted observed via magnification. What is strikingly obvious when one examines the scalp by this method, is that follicular units are relatively compact, and are surrounded by substantial amounts of non-hair bearing skin. The actual proportion of non-hair bearing skin is probably on the order of 50%, so that its inclusion in the dissection will have a substantial effect upon the outcome of the surgery. The great benefit of using individual follicular units is that the wound size can be kept to a minimum, while at the same time maximizing the amount of hair that can be transplaced.

Small Recipient Sites

The importance of minimizing the wound size in any surgical procedure can not be over emphasized and hair transplantation is no exception. The effects of recipient wounding are felt at many levels. Large wounds can lacerate blood vessels and although the blood supply of the scalp is extensively collateralized, any damage to these vessels will have an impact on local tissue perfusion. An equally important issue is to minimize the disruption of the microcirculation. This is especially important when transplanting grafts in large quantities. The compact follicular unit is, of course, the ideal way to permit the use of the smallest possible recipient site, and has made the transplantation of large numbers of grafts technically feasible.

Densities between 10 to 40 follicular units per centimeter are routinely reported. Densities greater than 40 follicular units per centimeter in a single session have been accomplished, but may result in a decrease yield in some patients. It is important to note that a follicular unit density of 40 units/mm² can create a hair density of over 120 hairs/mm² (if all 3- and 4-hair units are used in select areas), and this is a density that many hair transplant surgeons feel is not necessary, or even desirable, to exceed.

Transplanting Follicular Units in Large Sessions

Putting aside anatomic, physiologic and technical issues for the moment, it is important to emphasize the practical reasons to strive toward large sessions. The specific events that bring a balding patient to the doctor for hair loss will vary, but the common denominator of those seeking hair restoration is to improve their appearance, and to improve the quality of their life, be it personal, professional, or social.

Until the transplant is cosmetically acceptable, the disruptions from the scheduling of multiple surgeries, the limitations in activity, and the concern about their discovery, can place a patient's life "on hold." It should therefore be incumbent upon the physician to accomplish their objectives as quickly as possible. Some patients prefer smaller sessions for economic reasons.

Microscopic Dissection

There is probably no other aspect of follicular unit transplantation that has generated more controversy than the use of the microscope. Stereo-microscopic dissection was introduced into the field of hair transplantation by Dr. Bobby Limmer⁶ in 1987.

The following statements summarize the use of magnification:

• In order to dissect intact individual follicular units, you must be able to see them clearly.
• Only magnification allows their clear visualization in both normal and scarred skin, independent of the specific hair characteristics of color, hair shaft diameter, and curl.

Follicular dissection can logically be divided into two parts; the subdivision of the initial donor strip into smaller pieces and the further dissection of these pieces into individual follicular units. The first part of the procedure, the handling of the intact strip, has always been the most problematic. The intact strip however, is difficult to stabilize and is too opaque for transillumination to be useful.

The dissecting microscope and other magnification methods allow the strip to be divided into sections (or "slivers") by actually going around follicular units leaving them intact. The dissecting stereo-microscope is able to accomplish this because of its high resolution (usually 5x more powerful than magnifying loops) and its intense halogen top-lighting that provides continuous illumination, as one dissects through the strip. Back light illumination has also proven beneficial. Stability can easily be achieved by applying slight traction to the free end of the strip. The thin slivers are then laid on their sides and the microscopic dissection of the individual units is completed. With stereo-microscopic dissection, except for the outer edges of the ellipse, every aspect of the procedure is performed under direct visualization, so that follicular transection can be minimized and the follicular units maintained.

Conclusion

The entire field of hair restoration surgery has moved toward the use of follicular unit transplantation. While the exclusive use of follicular units is not employed by the majority of transplant surgeons,. The impact of this approach has been significant. Hair restoration surgeons are becoming more scientific and precise in their approach to this field. The vague terminology of the past, i.e., round grafts, many grafts, micro grafts, has been replaced with more precise terms. We now converse in a language which details the number of follicular units per square centimeter, hair shaft diameter in microns, and incisional density of the recipient site for any given session. Perhaps the modern era of transplantation did not begin with the micrografting of the '80's, but its is only truly being realized with follicular Unit transplantation of the '90's.

References

1. Tamura: Hair grafting procedure, JPN J Dermatol Venereol [Japanese] 52(2):1943.
2. Bernstein RM, Rassman WR, Szaniawski W, Halperin A: Follicular Transplantation.
   International Journal of Aesthetic an Restorative Surgery 3:119-132, 1995.
3. Bernstein RM, Rassman WR: Follicular Transplantation: Patient Evaluation and Surgical Planning.
   Dermatologic Surgery 23:771-784, 1997.
4. Bernstein RM, Rassman WR: The Aesthetics of Follicular Transplantation. Dermatologic Surgery 23:785-799, 1997.
5. Headington JT: Transverse Microscopic of the Human Scalp. Archives of Dermatology 120:449-456, 1984.
6. Limmer BL: Elliptical Donor Stereoscopically Assisted Micrografting as an Approach to Further Refinement in Hair Transplantation. Dermatologic Surgery 20:789-793, 1994.

Copyright 1997 New Hair Institute, Inc.
All Rights Reserved

Tips on Finding a Good Transplant Doctor

The tips below are taken from Dr. Carlos Puig's transplant site:

Ask about and see the surgeon's credentials. Look for information from

• AACS: American Academy of Cosmetic Surgery
• ISHRS: International Society for Hair Restoration Surgeons
• AHLC: American Hair Loss Council
• ABHRS: American Board of Hair Restoration Surgery

or other reputable organizations.

Fees should never be quoted on the phone...every person's needs and expectations are different.

Take your time, have all your questions answered, and make sure you feel comfortable with the approach, results you'll get, and the people who will be working with you.

Understand the limitations - length of time it will take, density that can be accomplished and the costs.

Make sure you see numerous "before and after photos" of all types of hair and styles.

Ask about evaluations from previous patients on post-operative reactions...it should be documented.

The Hairline - The Hairline - The Hairline - Single hairs are the ultimate in artistry for great results.

Fees should include all follow-up visits.

The priorities of a physician's staff reflect those of the physician. If the office staff is patient-motivated, the physician is most likely patient-motivated. In other words, their service is primarily designed to meet your needs, not those of the doctor.

Complication rates: although the complications in this surgical procedure are few and rarely serious, an honest, conscientious medical group will track their complications and explain all the risks. A medical group that just "pushes it aside" is not educating you properly.