Hair Transplantation: Details Of Surgical Techniques. (Part II)
What is Follicular Unit Transplantation?
Follicular Unit Transplantation (FUT) is a procedure where hair is transplanted from the permanent zone, the area in the back and sides of the scalp where hair is more resistant to balding, to the bald or balding areas of the scalp. This is accomplished using naturally-occurring groups of 1, 2, 3, or 4 hairs, called follicular units. After the patient’s scalp is anesthetized, the doctor removes a strip of tissue from the donor area, an area within the permanent zone, and, once extracted, the donor strip is cut into many individual follicular units using microscopic dissection techniques. As these follicular unit grafts are being prepared, the doctor makes tiny holes.in the scalp, called recipient sites, where the grafts are placed.
STEPS OF THE PROCEDURE:
First and the most important step as in any surgery is obtaining a detailed Informed consent from the patient and relatives of the patient.
Anesthesia in Hair Transplantation
- FUT is done under local anaesthesia and tumescent fluid infiltration.
- Tumescent is prepared by adding little Triamcinolone and 1:1000 cc of adrenaline (1 ml) in 100 ml of normal saline.
- For the frontal recipient area, Nerve blocks are preferred (supraorbital and supratrochlear).
A major advance in the removal of the donor strip is the use of tumescent anesthesia. Tumescence simply means to expand by injecting fluid into
the tissues. In this technique, very dilute concentrations of anesthetic fluid are injected into the fat layer of the donor region of the scalp. This serves a number of purposes, the first is to decrease bleeding from the pressure of the fluid on small blood vessels (capillaries), the second is to firm the skin so that the incision can be more easily controlled and third, to increase the distance between the follicles and the deeper tissues of the scalp.
The technique for FUT
Average donor strip is approximately 1cm wide and of variable length, depending upon the number of follicular units that are needed for the hair restoration. In the average person’s scalp, there are approximately 90-100 follicular units per square cm of donor tissue, so a 2,000 graft hair transplant session would require a 1cm wide strip that is slightly over 20 cm in length.
Position of the Donor Incision
The ideal placement of the donor incision is in the mid-part of the permanent zone located in the back and sides of the scalp. This area lies in a band that starts above the occipital protuberance (the bump felt in the middle part of the back of the scalp) and extends to either side in a gentle, upward sloping curve that follows the contour of the scalp.
In a Trichophytic closure, the surgeons makes the initial incision parallel to the hair follicles and then trims away 1 to 3-mm of tissue of either the upper or lower wound edge (or both), so that the top of the hair follicles at that wound edge are removed. During the “Tricho” closure, the trimmed wound edge is pulled towards the opposite edge so that the bottom parts of the cut hairs are pointing slightly towards the incision (rather than parallel to each other). The goal is that these hairs will eventually grow through the incision and thus decrease the visibility of the scar.
The first step in stereo-microscopic dissection is a process called “slivering”. In slivering, the dissector divides the long donor strip into smaller sections of approximately 2-2.5mm in width. The sectioning is accomplished by passing a scalpel blade through the spaces around follicular units, rather than merely cutting directly through the block of tissue. This technique generates smaller pieces of hair bearing tissue without breaking up follicular units and without transecting (cutting) hair follicles.
The dissector then isolates the individual follicular units from these small sections by trimming away excess dermis and fat. The photo shows 1-, 2-, 3-, and 4-hair follicular units. Hundreds of these individual units are sorted according to the numbers of hairs they contain. They are then stored in Ringer’s lactate solution and refrigerated while waiting placement into the scalp.
Role of Magnification:
One of the most important aspects of Follicular Unit Hair Transplantation is stereo-microscopic dissection. This allows follicular units to be removed from the donor strip without being broken up or damaged. During the dissection, it is critical that the whole follicular unit is kept intact as this will maximize its growth. Intact follicular units will also give the most fullness to the hair restoration, as they contain the full, natural complement of 1-4 hairs. Skin city has the most advanced stereo microscopes named “mantis” which helps us to increase the yield of grafts as well as offers the best graft preparation for FUT.
Recipient site creation
The recipient sites in all of our hair transplant procedures are made using lateral slits (also called coronal or horizontal slits). Generally, there are three different types of incision:
- the small slits, or the more anterior, receive one-hair grafts ;
- the medium-sized slits receive two hair grafts ;
- The larger slits receive the three or four-hair grafts.
They give the hair transplant surgeon the highest degree of control over the direction and angle in which the transplanted hairs will ultimately grow. The density of recipient sites (the number of sites per area) determines how close together the follicular grafts are placed. Each graft is implanted manually. It is very important to handle the grafts very carefully in order to avoid damaging them. There are various methods which can be used to implant grafts,which includes stick and paste method,use of different type of implanters or implanting grafts in pre made slits.
Follicular Unit Extraction(FUE)
Follicular Unit Extraction (FUE) is a method of extracting, or “harvesting,” donor hair for transplantation in a follicular unit hair transplant. In an FUE procedure, an instrument is used to make a small, circular incision in the skin around a follicular unit, separating it from the surrounding tissue. The unit is then extracted (pulled) directly from the scalp, leaving a small open hole. This process is repeated until the hair transplant surgeon has harvested enough follicular units for the planned hair restoration. The donor wounds, approximately 1-mm in size, completely heal over the course of seven to ten days, leaving tiny white scars buried in the hair in the back and sides of the scalp. After the grafts are harvested, tiny “recipient sites” are made in the balding area of the scalp using a fine needle-point instrument. The follicular units are then placed into the recipient sites where they will grow into healthy hair-producing follicles. The creation of recipient sites and the placing of follicular unit grafts are essentially the same in both FUE and FUT procedures. The difference lies in the quality and quantity of grafts obtained with each technique.
Hair transplantation is a team effort. A team of assistants to cut the grafts and place the grafts in the recipient area is an absolute necessity to ensure large sessions. Most transplant sessions last up to 4-5 hours and team work is therefore essential. Skin city has the perfect team for done giga sessions; it includes well trained dermatologists, plastic surgeons, and an excellent cutting team in the state of art operating theatre.
Follicular unit transplantation ( FUT) is a well established method of Hair Transplantation. Magnification with advanced mantis stereoscopes is a hallmark of quality of graft preparation.