Other methods in hair transplantation

FUT

Follicular Unit Transplantation is a method in which a strip of the scalp is taken from the donor area - generally the back of the head. It then involves extracting from this strip individual hair follicles / follicular units under the microscope and preparing them for implantation. These Follicular Units, or FUs for short, grow in groups of 1 - 4 or sometimes even 5 follicles. The transplant material thus obtained is then implanted into a prepared recipient area. Hairs extracted this way retain their genetic information, growing again naturally in the recipient area after transplantation. To obtain the requisite number of hair follicles needed for the transplant to look natural, the patient's existing hair density in the donor area is determined as exactly as possible (density measurement). This is done by counting the number of FUs per square cm before FUT treatment and is the basis for determining the size of the strip of scalp to be removed. The strip of scalp (or any other area covered in hair) is then removed using a scalpel. This is done under local anaesthesia, meaning that no pain at all is felt.
FUT in 4 steps
FUT involves four main activities: 
- extracting the donor material 
- preparing the individual hair units / hair follicles 
- preparing the implantation area 
- implanting the donor hairs

 
Which patients are suited for FUT?
The biggest advantage associated with a strip extraction is the large number of FUs that can be made available during a single transplantation session. In contrast to Follicular Unit Extraction, many more hairs can be extracted within a much shorter period of time, thereby reducing effort. The FUT method is primarily suited to patients classified as Norwood III - VII, as these need many more hairs to be transplanted. Patients older than 30 - 35 are also deemed as being more suited, as the occurrence of the so-called stretch-back effect is less pronounced. FUT is also suitable for combined transplantations, for instance when scarring from a previous hair transplant needs to be corrected or at least decreased and when at the same time a hair transplant is to be performed.
 
The limitations of FUT
Type of scar and its development
The scar left by FUT at the back of a patient's head is very narrow, in most cases just 1 - 2 mm wide. The length differs. It is always a linear scar, and more or less visible. Its visibility is not just dependent on the hair surgeon's skill and experience and the technique he uses, but also on such individual factors as the patient's age, the type of skin, skin characteristics, skin tension and the healing process. How the scar develops is not foreseeable, even when past wounds have healed nicely. Also needing to be taken into account is the fact that a linear scar can change through the healing process and the tension of the scalp (the so-called stretch-back effect). This can occur directly after the transplantation or in the course of the six following months. The wound is sutured or stapled, meaning that there are stitches or staples needing to be removed. Dependent on the size of the FUT scar, hair can often not be worn shorter than 10 - 15 mm without the scar being seen.

The operation, healing process and possible post-operation complications
Ideally, the donor area should be shaved before the operation, in particular when a high density-FUT or mega-session is involved. Exceptions can be made and should be personally discussed with Dr. Feriduni. Where only small transplants are involved, in certain cases no shaving is needed at all. Though very seldom, complications can occur during or after the transplantation, as is the case with any operation. These include scar pain and wound infections. In the donor area a feeling of numbness can occur, or tension can be felt. Moreover the healing process can last quite a long time (up to 2 weeks) due to the size of the incision. After transplantation patients should desist from active sport (bodybuilding, martial sports) for a period of about 6 weeks. Light sport activity such as jogging, swimming, cycling can be started after about 2 weeks, though care needs to be taken. When extracting the donor hairs, hair follicles situated in the immediate vicinity of the cut may be damaged or injured. With the wound being sutured or stapled, this is another possible cause of damage to hair follicles. After the operation, swelling can take place. In some cases transplanted FUs may fall out.
Trichophytic Closure
This is a technique used to make the scars caused by the removal of the strip of skin practically invisible. Further advantages over previously used methods are that the scar becomes a lot finer and that the method can be used in all commonly used transplantation methods. Trichophytic closure (or tricho for short) involves overlapping the edges of the wound when suturing or stapling them. One side of the existing skin is cut at an oblique angle, after which the adjacent skin flaps are brought together to close the wound. Due to the angle of the cut, they overlap. One piece of scalp tissue now lies underneath another one - and in it also hair follicles, which then slowly grow through the tissue (i.e. through the ensuing scar), thereby concealing the scar and making the donor area look natural. When this closure method has been used after an FUT, it becomes quite possible for patients to wear their hair short - i.e. 6 - 8 mm long. This means that this technique is an alternative to Follicular Unit Extraction (FUE) for patients wanting to wear their hair short. Trichophytic closure can also be used on patients already having had an FUT to improve the donor scar. This technique is also used on an initial FUT operation and is very suited for reconstructive or corrective treatment.  
The success of trichophytic closure is not just dependent on the ability and experience of the hair surgeon, but also on the healing process and the characteristics of the patient's skin. Not every patient is suitable for Tricho-Closing. This applies especially to younger patients and it is therefore up to Dr. Feriduni to decide which closure technique to use.

BHT

Hair from the head area is generally used for transplantation purposes. However, patients sometimes do not have enough hair on the head to achieve the desired result. In such cases it is possible to transplant body hair, as such hair is very similar to head hair in structure and quality. At Dr. Feriduni Hair Clinic we only perform Body Hair Transplantation with donor hair taken from the chest.
Which patients are suited for BHT?

For certain patients, body hair can become the source of several thousand grafts additional donor material, especially when patients have a high amount of body hair at their disposal. This extended donor area is especially indicated to increase the overall hair density or to fill in a crown area – treatment options that would not otherwise be possible for patients with limited scalp donor hair. Body Hair Transplantation is however not really indicated in case of a full hair reconstruction or to restore the patient’s hairline.

BHT v1

Body hairs are removed using the FUE technique, leaving no linear scar. Body hair grafts are then implanted in the same way as grafts of head hair.

Generally speaking, donor hairs are taken from the tonsure, i.e. from the back or side of the head. Patients with insufficient hair in the donor area are unsuitable for a normal transplant. The reasons for not having enough hair include normal hair loss or result from previous hair transplants making any further extraction of donor hairs from the head impossible.
The results of a hair transplant with unsuitable donor hair are generally unsatisfactory, as these can only compensate hair loss to a minor extent. Moreover any resulting scars will be visible.

 
Criteria for assessing BHT suitability

Dr. True uses a special technique to determine the feasibility of a BHT - the Torso Donor Index, or TDI for short. Used for assessing the donor area for a body hair transplant, the TDI takes five criteria into account:

  • Hair density must be above 40 FUs per cm²
  • Similarity between the body and head hair
  • The number of FUs with 2 - 3 hair follicles
  • The size of the donor area
  • The length of the body hair

Where the Torso Donor Index is less than 4, the patient is deemed unsuitable for a body hair transplant. Patients with a TDI score of 5 - 7 may be suitable under certain circumstances. Patients with a score of 8 or more have more body hair than head hair suitable as donor material and are therefore suitable candidates for a body hair transplant.

Differences between a BHT-FUE and an FUE

The technique for transplanting body hair is derived from the FUE technique, and basically involves extending the donor area to the whole body. BHT is used primarily in cases where the donor area on the head is no longer suitable for the extraction of donor material or is not dense enough.
In such cases, and provided the physical requirements are met, follicular units can be extracted directly from different area of the body - torso, arms or legs - and transplanted to the scalp. The BHT-FUE method opens up new possibilities especially for patients whose donor areas have been badly used or even destroyed through the use of outdated methods.

Candidates for a BHT must meet certain physiological requirements, e.g. the body hair must be suitable for use as head hair. Body hairs are subject to different growth cycles. Whether these change over the course of time has not yet been scientifically proved, though our own experience points to this being the case.
FUs taken from the body are anatomically different to hairs taken from the head. Whereas FUs taken from the head generally consist of 1, 2 or 3 hairs, in most cases FUs from the body only have one hair.

The principal differences between a body hair FUE and a conventional FUE:

  • The growth direction of the follicular units
  • The type of skin and its characteristics
  • The depth of the hair follicle under the skin
  • The thickness and structure of the hairs (straight, curly, wavy)

It is absolutely necessary for the hair surgeon doing such a transplant to have adequate knowledge and experience of both transplantation techniques - FUT and FUE - and to take certain basic principles into account, for such a transplant to be successful. These include:

  • The correct extraction of donor hairs
  • The right preparation of the follicular units
  • The error free storage and hydration of the extracted grafts
  • Optimal implantation, taking into account growth direction and the arrangement of the grafts
  • Obtaining a natural hairline
  • A careful approach and the use of the right technique, damaging as few grafts as possible.

There are 3 key success factors for any BHT:

1. The extraction of the hair follicles 
2. The growth cycle of the body hairs 
3. The compatibility of head and body hairs

The limitations of BHT
As a technique, body hair transplantation has not yet been the subject of as much research as has been done into the FUE and FUT methods. Due to the lack of experience and know-how, BHT should be seen as the last-resort method for improving an existing situation.

The experience we have gained up to now points to a 70 - 80% survival rate. Though this might seem low, for many patients it is the only option. Patients wishing to have a BHT should be aware of the fact that no guarantee can be given for a high percentage of implants actually taking root.
Body hairs can change their structure after being transplanted - in most cases they become longer and straighter, interestingly adapting somewhat to head hair structure.
Patients wanting to undergo BHT treatment should be aware of the fact that this form of treatment is a last-resort attempt, with success chances not foreseeable. This means that patients considering a body hair transplant must fulfil certain criteria, including the TDI mentioned above. Under certain circumstances, the treatment may also be suitable for patients who have already undergone transplantation and where the results look completely unnatural, meaning that living a normal life seems impossible.

This all means that any patient wishing to undergo BHT treatment needs to discuss this in depth with his hair surgeon. Similarly the operation must be performed by a fully competent hair surgeon, as the success of a body hair transplant is dependent on the experience, know-how and abilities of the surgeon performing the operation.
In the Dr. Feriduni Hair Clinic, hairs from the back, the chest and the thighs are used as donor hairs in any such transplantation. Due to the very high risk of scarring, Dr. Feriduni does not transplant beard hairs. 

Expander / Extender

A transplantation of follicular units using FUE or FUT is not always possible - in certain special cases a normal hair transplant is not the best choice or even contra-indicated. In such cases - after a very strict indication - the use of extenders or expanders, or their combination with a hair transplant, is often the right way to achieve satisfactory results.
The Frechet extender method

Frechet Extender method

This technique can be used to reduce the size of large bald patches or - in the field of reconstructive hair surgery - as a way of reducing the size of scars resulting from burns, accidents, previous transplants or infections.
To do this, an elastic band and 2 rows of small metal hooks are implanted into the bald scalp. The extender works like a rubber band, gradually pulling the scalp together and making it smaller. Through this pulling together, a fold of skin is created which needs to be removed by surgery. The result is that the previously bald patch is now covered by the parts of the scalp with hair. This operation can be repeated many times, enabling baldness to be completely eliminated.
The Frechet extender consists of an elastic band made of silicone and hooks made of titanium. After implantation it is invisible.

Frechet Extender method

The expander technique

The expander technique is another method used to reduce hair loss and remove scarring. A balloon made of silicone, the so-called expander, is inserted under the part of the scalp covered by hair. The latter is then stretched by gradually inflating the balloon. An operation is then performed to remove the bald patches / scars, with the hair-covered scalp formed by the expander then being used to cover the former bald patches.

Both techniques - expander and extender - are carried out under local anaesthesia and enable scars to be corrected so well that they are hardly visible any longer. Both use implants inserted under the scalp for a short period, and both methods require a lot of patience, as the results are often - as with a hair transplant - only visible after a number of months.

The Triple-Flap technique

This method is suitable for correcting problems often occurring after extender treatment. One such common problem is an unnatural hair growth direction.

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