Procedure steps
Hair restoration and transplantation are conducted by harvesting tiny grafts from parts of the body that have a good growth of hair, or a larger portion of scalp from a donor area, which are then divided into tinier pieces for grafting. These grafts are then planted in the areas of the scalp that are balding or thinning.
Typically, several sessions are required for complete transplantation and each session needs a period of healing before the next session can be done. This means that the entire process can take up to two years before the final results are seen. Moreover, the amount of coverage depends on the patient's hair color and texture. Gray, coarse, or light-hued hair gives better coverage than dark, fine, or silky hair.
The most suitable candidates for this surgery are those who have considerable hair loss but still have healthy hair growth on the sides and back of the head to be used as donor areas.
Here is a general overview of the steps involved in a hair transplantation procedure:
Consultation
The first step is to meet with a hair transplant specialist to discuss the patient's hair loss and determine the best course of treatment.
Although age is no bar for hair transplant, patients between 20 and 30 years should have a stabilized rate of hair fall before they are considered suitable for hair transplantation. A detailed family history is also helpful in assessing hair loss and planning a new hairline.
Planning
Planning the hairline is one of the most critical steps in hair transplantation. The hairline is the most visible landmark, and the quality of the hairline often judges the quality of the work of a surgeon.
Preoperative preparation
Before the procedure, the patient will have to wash their hair with a special shampoo (Betadine surgical scrub) to prepare the scalp.
Anesthesia
Before the procedure begins, the patient will be given local anesthesia to numb the area where the hair will be transplanted.
Preparation of the donor area
The hair in the donor area (occipital region) is trimmed to 2–4 mm. After injecting anesthesia just below the donor area, a complete homeostatic effect is maintained after 10-20 minutes to minimize bleeding.
Harvesting
The next step is to remove hair follicles from the donor site. It can be done using either the Follicular Unit Transplantation (FUT) method or the Follicular Unit Extraction (FUE) method.
Harvesting donor hairs that are white or light-colored is challenging. Extra care has to be taken to preserve the hair follicles. These patients are instructed to dye their hair a few days before the procedure to enhance visibility. Extra care is also required in patients undergoing a second procedure because scars from previous surgery distort the direction of the hair in the donor area.
Graft preparation
As soon as the donor strips are harvested, they must be placed into icy normal saline. This is achieved by submerging the tray with the grafts in the saline solution and keeping it cool. It is essential to ensure that the donor grafts are hydrated with cold saline during the entire process of the surgery, as it affects the survival rate of the grafts.
It is also very important to provide sufficient lighting during the cutting of the grafts. They can be trimmed on wooden tongue depressors or a vinyl dissecting surface that is equipped with a backlighting system. It is imperative to make sure that no part of the wood stays attached to the grafts after they have been cut since these foreign particles can later lead to the formation of epidermal cysts.
Preparation of recipient area
Before any incisions or punctures are made in the recipient area, anesthesia is inserted and the area must be swollen to reduce bleeding and anguish. It is essential to stick to the path of the existing hair follicles in the vicinity when making slits or cuts. The hairline should appear to be jagged and uneven in an organic manner.
When undergoing secondary or tertiary treatments, a greater amount of bleeding is likely to occur in the recipient area. If a suitable level of swelling is maintained and a 10-15 minute gap is left before creating the holes, this may help to reduce the excessive oozing. It is also noted that due to fibrosis from past treatments, cuts in the recipient area can be difficult to make during secondary procedures.
Graft placement
The hair follicular units grafts (FUGs) are then placed very cautiously in the recipient area to guarantee the hair is growing in the accurate positioning and angle. Pressure is used to make sure that the grafts are even with the neighboring skin. It should be prevented from being buried too deep underneath the skin level as it can cause a pitted look and result in epidermal cysts. A cobblestone look appears when the grafts are too far away from the skin's surface. Two or three persons can simultaneously insert grafts to make the process more efficient and faster. Grafting treatments may take up to five or six hours and in this period, 2000-3000 FUGs may be transplanted.
Post operative care
The patient is discharged the same day, typically without any bandages. Some surgeons may prefer to bandage, but it must be done very carefully to avoid shearing. The bandage must be removed skillfully and carefully because grafts can stick to the undersurface and get removed unintentionally.
Some swelling is evident after a hair transplantation surgery, and the patient should be informed of this before the procedure. Oral steroids for 3–5 days can minimize edema (fluid retention).
A headband should be worn immediately after the operation, as it helps prevent the swelling from coming down onto the face and creating a puffy appearance.
The patient should wash their hair with a mild shampoo on the 2nd or 3rd postoperative day.
While combing the hair in the transplanted area for three weeks, the tooth of the comb should not scrape against the transplanted grafts.
Wearing clothes like T-shirts or pullovers that need to be removed over the head should also be avoided for three weeks.
Patients should also avoid hair oils or other stronger shampoos and helmets for the same period.
Results
The epidermis and dermis, along with the shaft of the transplanted hair outside the skin, fall off as scabs two to three weeks after the surgery. However, the follicles remain and go into a resting phase. New hairs start growing about three months after the procedure.
It usually takes six to nine months to enjoy the result of a hair transplant. If a second procedure is needed, it must be at least three to six months after the first sitting. Some patients may complain of hypoaesthesia (numbness) of the scalp in the donor area. It is usually temporary but may persist for as long as 18 months in some cases.
The thickness of transplanted hair is less especially in areas that are totally bald. The patient should be informed of this preoperatively and a second sitting can be scheduled to increase hair density.
