Hair loss can be a distressing experience, affecting one’s self-confidence and overall well-being. While scalp hair transplantation has long been a popular option for restoring lost hair, advancements in the field have opened doors to a lesser-known but equally effective alternative: Body Hair Transplantation. Let’s delve into the intricacies of this innovative procedure and explore how it can help you achieve the luscious locks you’ve always dreamed of.

Understanding Body Hair Transplantation

Body Hair Transplantation (BHT) is a specialized procedure that involves harvesting hair follicles from various parts of the body and transplanting them to areas of the scalp or body experiencing hair loss. Unlike traditional hair transplantation methods that rely solely on scalp donor hair, BHT expands the donor pool to include hair from the chest, back, arms, and legs, offering a solution for individuals with limited scalp donor hair or specific hair loss patterns.

Types of Body Hair Transplantation

Follicular Unit Extraction (FUE)

FUE is a minimally invasive technique that involves extracting individual hair follicles from the donor area using a small punch tool. These follicles are then meticulously implanted into the recipient site on the scalp or body, ensuring natural-looking results and minimal scarring.

Direct Hair Implantation (DHI)

DHI is a more advanced variation of FUE, wherein hair follicles are extracted and implanted simultaneously using a specialized pen-like device. This technique offers greater precision and efficiency, resulting in faster healing times and improved graft survival rates.

Assessing Candidacy for Body Hair Transplantation

Before undergoing BHT, it’s essential to undergo a thorough evaluation to determine candidacy. Factors such as hair density, quality, and donor site availability will be assessed to ensure optimal results. Additionally, your medical history and aesthetic goals will be taken into consideration to tailor a treatment plan that meets your unique needs.

Evaluating Eligibility

During your consultation with a hair transplant specialist, various aspects of your hair loss will be examined. This includes assessing the suitability of body hair as donor hair, analyzing the recipient site, and discussing realistic expectations for the procedure.

Preparing for Surgery

In preparation for BHT surgery, you may be advised to avoid certain medications or supplements that can interfere with the healing process. Additionally, it’s essential to follow any preoperative instructions provided by your surgeon to ensure a smooth and successful procedure.

The BHT Procedure: What to Expect

On the day of your BHT surgery, you’ll be greeted by a team of skilled medical professionals dedicated to making your experience as comfortable and stress-free as possible. The procedure typically involves the following steps:

1. Anesthesia Administration: Local anesthesia will be administered to ensure you remain comfortable throughout the procedure.
2. Donor Hair Harvesting: Hair follicles will be carefully extracted from the donor area using either FUE or DHI techniques.
3. Recipient Site Preparation: The recipient site on the scalp or body will be meticulously prepared to receive the transplanted hair follicles.
4. Hair Follicle Implantation: Using precise techniques, the harvested hair follicles will be strategically implanted into the recipient site, mimicking natural hair growth patterns.

Postoperative Care and Recovery

Following BHT surgery, you’ll be provided with detailed instructions on how to care for your newly transplanted hair and minimize discomfort during the recovery process. This may include:

• Managing Discomfort: Over-the-counter pain medication can help alleviate any discomfort or swelling in the days following surgery.
• Postoperative Instructions: Your surgeon will provide specific guidelines on how to care for your scalp or body post-surgery, including when to resume normal activities and how to cleanse the treated area.
• Follow-up Appointments: Regular follow-up appointments will be scheduled to monitor your progress and address any concerns you may have.

Achieving Optimal Results with Body Hair Transplantation

While the initial results of BHT may be visible within a few months, it’s important to understand that achieving full results can take up to a year or more. During this time, it’s essential to be patient and diligent in following your surgeon’s recommendations for postoperative care and maintenance.

Timeline for Hair Growth

Hair growth following BHT typically occurs in phases, with initial shedding followed by gradual regrowth. By six to twelve months post-surgery, you can expect to see significant improvement in hair density and coverage, with final results continuing to improve over time.

Expected Results and Maintenance

With proper care and maintenance, the transplanted hair from BHT can be a permanent and natural-looking solution for hair loss. However, it’s important to continue practicing good hair care habits, including regular shampooing, conditioning, and protecting your hair from environmental damage.

Risks and Considerations

While BHT is generally considered safe and effective, like any surgical procedure, it carries certain risks and considerations. These may include:

• Infection: Proper hygiene and postoperative care are essential to reduce the risk of infection at the donor and recipient sites.
• Scarring: While FUE and DHI techniques minimize scarring, some degree of scarring may still occur, particularly in the donor area.
• Hair Growth Direction: Ensuring natural-looking results requires careful attention to the angle and direction of hair follicle implantation.

Conclusion: Embrace Your Journey to a Fuller, More Confident You

Body Hair Transplantation offers a promising solution for individuals seeking to restore lost hair and regain their confidence. With advancements in surgical techniques and personalized treatment plans, achieving the hair of your dreams is more attainable than ever before. If you’re ready to take the first step towards a fuller, more vibrant mane, consult with a qualified hair transplant specialist to explore your options and embark on this transformative journey today.

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In this article, we aim to raise awareness about the growing popularity of facial hair transplantation (FHT) among both patients and physicians by discussing its increasing demand and addressing the reasons that lie behind this demand, and combining these discussions with various attractive images. Hair has always been an important part of the body to everyone and formed the basis for many social, cultural, economic, spiritual, and metaphysical behaviors and beliefs. For this reason, hairlessness has found a place in human culture and thought. Among the factors that shape today’s hair trends are improvements in hair transplantation techniques, the invention of the internet, and the popular networking platform known as social media, together with the fashion, music, and film industries. Social media may lead to an increase in the incidence of “Mirror-Mania Syndrome” by causing individuals to capture their appearance using photogrammetric methods that were not readily available in the past, post their digital photographs on social media platforms, view photographs of others, take selfies and receive feedback from others posted to a social media platform.

In the latter half of the past decade, the availability of the latest generation of various digital imaging modalities – smartphone cameras, “selfie sticks”, and social media platforms – has led to a significant increase in the use of these images by patients to see themselves, determine their facial appearance and assess their physical features such as their hairline, hair density, and beard. Although the increase in the number of facial hair transplantation (FHT) procedures performed and scientific knowledge about the procedure has been reported, to date, no articles have been published in the international scientific literature on this subject. Inspired by our experience with giving lectures and providing hands-on training in advanced FHT techniques to participant physicians at international scientific meetings, the importance of this issue, and the increasing popularity of social media in physician publications in the scientific literature, we therefore aimed to contribute to the international scientific literature by publishing this article.

1.1 Understanding Facial Hair Transplantation

Facial hair transplantation is a minimally invasive procedure and like other similar interventions, this is also undertaken with the FUE method. FUE is one of the most innovative techniques of hair restoration surgery based on the extraction of hair follicles individually. There are no sutures, cuts, or pigmentation and is performed at the clinic through local anesthesia. The principle can be summarized in: an automated micropoint extracts the follicles from the donor area (the nape of the neck for the most part) and then transplanted into the zones that require it. Beyond the specific techniques used, as always, the success of an intervention depends (also) on the skill and expertise of the surgeon, as well as the art and taste he is able to express. In the face, in fact, several details must be taken into consideration, such as the implant defect, the growth direction, and the angle of the fibers.

Hair loss procedures used to include only hair on the scalp; however, over the years, they have evolved to encompass other body hairs, particularly areas that cause aesthetic unease for some people, such as the eyebrows, eyelashes, and facial hair. The purpose of the facial hair transplant is to help people who are unhappy with the appearance of their facial hair. This can be for a number of reasons and is common among men who suffer from facial hair loss. Candidates for this procedure can include people who want to cover a scar left by an injury or surgery, to add hair where none has ever grown, fixing parts of the beard or goatee that have little hair, or to turn sparse hair into denser hair. It is also possible to design a cosmetic beard with hair transplantation. This type of intervention can be performed both in those with a trichologic pathology and in those who have lost hair in the beard and mustache areas due to certain medications or hospital treatments.

2. Types of Facial Hair Transplantation

There are 2 types of basic facial hair transplantation procedures. One is the removal of hair through follicle extraction and removal without making a strip to stitch up. It involves picking out hair plugs with forceps or operating under the scars left in the back of the head using the Follicle Unit Extraction devices. Chosen grafts would then be installed and grafted onto a patient’s face. The second procedure is with the strip method. During this method of facial hair harvesting, a strip of jet from the back of a patient’s head, about 2 cm wide. Under the use of a microscope, plug units with an average determination of two to four hair follicles each were harvested from the strip. Units would then be inserted carefully into small 1 mm incisions on the face made with a surgical needle and magnifying glass.

Facial hair transplantation can usually be completed in one session, in about two to five hours. It is perfectly legal and done on an outpatient basis, without taking a patient’s bone marrow or stem cells. This is often a same-day procedure. The process for the surgeon is very much like an artist with a blank canvas. A surgeon extracts hair follicles from a donor site to replace on or within the face. The most expressive part of the expression of most men is the beard area. Fabulously dense beards have been historically associated with wisdom, strength, and virility. They have also been very hard to come by for some. But finally, men who struggle with patchy beards, facial scarring from childhood or acne, or even men with very little facial hair who want a beard because they feel it completes their image, have harvesting it available to them.

2.1 Follicular Unit Extraction (FUE)

Although the procedure is delicate, caution is necessary when treating skin that has lower hair density than that of the scalp. Another newer method of extraction which uses a 3-mm biopsy punch device avoids the removal of long segments of each follicle. A newer technique uses a robotic arm in the harvesting of hair follicles. The method utilizes a 1-mm pointed device to enhance a mechanical system for the delivery of the graft. Other newer devices for follicle extraction use a sharp inwardly beveled circular knife that cuts each graft as it is pulled into a cylindrical tube. The Sharp or Gigaselection system uses a disc that vibrates at extremely high speed. However, the speed alone will not suffice to cut the follicles. Here too, the hair follicles barely pass through the centrally opened shafts of two hollow needles that are parallel and concentric and encase the disc to separate the grafts from their insertion cords.

Safe techniques for extraction of hair from the scalp for transplantation to the face are the strip or FUT technique and FUE. FUE is the method used most frequently. The procedure is performed using local anesthesia with anesthetizing the hair follicle itself. In the method used, the hair is extracted using a 0.8 to 1.0-mm manually driven carbon steel cylindrical punch in a double isomorphic configuration with one center. Individual follicular units are extracted without violating the surrounding units. The graft is removed from the extraction site before making another, thus ensuring that the extracted-quality graft, which is best for re-implantation, is preserved. The instruments used in the procedure have been designed for the purpose of delivering the grafts efficiently and without damaging the grafts.

2.2 Follicular Unit Transplantation (FUT)

Natural hair transplantation has been procedurally enhanced and improved over time. FUT (follicular unit transplantation) utilizes the safe donor area in the occipital scalp. Each naturally occurring “follicular unit” naturally contains from one to four terminal hair follicles. Through the miracle of micro-follicular extraction and trichophytic closures, we now harvest consistent strips of this tissue with the potential of achieving the storage capacity of two to three hairs per individual follicular unit during the transplant procedure. Therefore, in a triple hair unit case, one would not want to create a high frontal hairline. Rather, it is aesthetically important to design a hairline that closely emerges from the supratarsal crease, 50-90 units down, so as to properly blend with the five hundred single hair fronto-temporal follicular unit, “softening” the blending and creating naturalness.

Follicular Unit Transplantation (FUT) is a hair restoration procedure that involves the transplantation of hair follicles from the safe donor area to the recipient area. A hair transplant involves basic steps like preparing the donor hair (usually by trimming and dissecting under a microscope), placement of the grafts into the transplant area, and post-procedure care. Dissecting hairs from a donor strip entails stereoscopic binocular microscopes. Careless graft handling and dissection can damage the naturally occurring open angles within the transplanted grafts, leading to increased pitting during the postoperative flattening of the grafts that occurs frequently in the recipient area initially to full graft root anchoring. Today, we can clearly demonstrate that incision sites in the recipient area must be custom-designed for those specific angles of the hair follicle units that lie within different regions of the scalp, and we have developed several devices that assist the technician in producing natural hair recessions.

3. Candidate Assessment

Specifically, when operating over previous hairline hair growth points, parallel incisions are pointed out to ensure that no vertical surgical lines are observed between the current and pre-transplantation hairs. Furthermore, it is explained to our patients that the transplanted hairs will be similar to the original hair in terms of characteristics and that the hairs need to be at a certain phase in the anagen cycle to minimize hair loss post-transplant. Feminine hairlines also resemble male hairlines in common aspects. Androgens contribute to the differentiation of scalp epithelial cells at the end of the telogen phase of the hair cycle into hair and sebaceous glands. In women who lack the necessary androgens or androgen receptors, the sebaceous glands atrophy after the third or fourth decade, leading to progression of the hairline. For this reason, women should be evaluated for the presence of hair loss pathology when they are assessed for facial hair restoration and a reversal of the hair loss should be ensured. Would-be candidate patients should be closely followed up to ensure that they are free of androgenic alopecia or minoxidil use.

Once the surgeon has determined that the patient is indeed a candidate for a facial hair transplant, the finer, more detailed aspect of the procedure is discussed. The patient’s hairline design is a key area of focus. Attention to the appropriate hairline design is of paramount importance in giving a natural appearance post-operatively, particularly in individuals desiring hairline restoration. Native hair growth pattern and the closeness of shaving are factors affecting the surgeon’s choices in the case of hairline restoration. Even before the surgery is performed, the surgeon should have a detailed conversation with the patient during which the surgical technique of choosing the correct angle for hair growth should be explained. The angle is determined according to the surgeon’s techniques and details of the donor and recipient area hair characteristics. The angle should observe the patient’s current natural hair growth direction to reflect a natural appearance. Particularly, the hairline should be anterior-most and oriented anteriorly, the hairs behind it should be fewer and mainly oriented horizontally (10-15° to skin) and the rest of the facial hair should be oriented more or less horizontally.

3.1 Evaluating Eligibility for Facial Hair Transplantation

Over one million hair follicles cover most of the human body from birth and unlike other epidermal (skin) tissues, stem cells of hair follicles are quite visible, reflecting their relative longevity, and humans shed or lose hair where a km of originally straight hair follicles exists. Hair replicates and diffuses to the surface and rearranges its in the growth phase (anagen), which generally takes between 3 and 6 years on the scalp, providing the length and easy to slice appearance. Although facial (and beard area as well) hair is a significant part of male secondary sexual characteristics, the normal adult beard area contains no more than 30,000 hair follicles. In addition, a scalp hair follicle produces considerably more hair. The requirement of utilizing head hair is the scarcity of alternative strong reliable donor areas.

There are three types of hair follicles in the human body related to the length, shape, and the color of the hair produced, as well as the lifespan of the hair. The longest hair-producing follicles of the body are on the scalp and this has an elongated shape with a significantly long (anagen) growth phase. In the second group, the follicles are produced under the axilla, in the arm area, and these have a modified oval shape, which includes rather elongated tear-shaped cores. These do not grow as long as scalp hair and have a shorter growth phase. In the third group, short, thin hair follicles are located in the body’s hairy areas, such as the leg, and this type has an almost round core, and the growth phase is significantly shorter in duration and it grows slower towards the end of the anagen phase.

Traditionally, head hair has provided a plentiful source of donor material for hair transplantation procedures owing to its long anagen phase, the resistance to trauma, ability to grow to considerable lengths, and the natural scalp anatomical symmetry. Mapping potential donor hair characteristics and understanding the physiological differences between the hair follicle types of the body is crucial to obtaining satisfactory results, including for the facial area.

4. Preoperative Preparation

Facial hair transplantation should always be planned with precise shaping. Facial hair shape should be drawn in the morning at the beginning of the day, and the patient should agree with this design. Patients can dye their hair before the surgery with a color close to the color of the hair. The hair is not shaved before the procedure to maintain the sliding of the skin. The operation is performed in a hospital environment. When the patient comes to the hospital, beard design is done with the patient. Selection of hair follicles to be used is done after outlining the beard borderlines. A review is made on gratuitous places according to the patient’s wish. A written consent is obtained from the patient with a photograph, and the preoperative information form is signed. Photos are taken for clinical record. The recipient section is performed on the chairs in such a way that it allows maximum comfort for the patient and the team, and ergonomic planning is made. The following materials are prepared: 3/0 and 4/0 sterile suture materials with reverse cutting needle; Hair transplant graft-keeper solutions; Drills that are adjusted for the head of the hair follicles and that prevent them from getting damaged, punches or bevelled-tipped blades; Specially prepared plaques for the area to be transplanted and for the support of hair follicles; stainless steel forceps; A stain container prepared by providing the patient’s blood in a sterile environment, corks, a Bunsen burner; Petroleum jelly; Anastaltic, anesthetic solutions; Hairbrush; thermic drill preparation container; small and large scalpel; Blade and Scalpel handle; Small and large retractors; 3 ml, 20 ml, 60 ml pipettes; Tourniquet; Tweezers; Terist; Hexomedine; Fitil; Betadine; Paper and adhesive mastics; Steri strips; Stericloth; Surgical gloves; Dean scissors; The material list is: mucous-membrane tape, bipuvakain, histofix, minoxil, tigel, antibiotic eye drops, analgesics, and antibiotics, which the patient will get on an outpatient clinic basis one week before and after surgery.

4.1 Consultation with a Hair Transplant Specialist

Unlike topical or oral minoxidil or finasteride for facial hair enhancement, hair transplantation is usually permanent. The fact that the grafted hairs can be safely trimmed or shaved is an added advantage. However, given that plucking or shaving can lead to an ingrown hair, the ability to safely pluck or shave is less of a concern for the scalp where there is much more space between adjacent hairs. In summary, facial hair transplantation can be a reasonable solution for men who have not been able to grow a beard or mustache because of either an injury, a surgical or medical scar, or congenital absence. The idea that most young Caucasian men can grow a beard or mustache within a year may not hold true for those with certain medical conditions, trauma, or scars whereby their body has been incapable of producing hair within the past year. For instance, facial hair transplantation is a reasonable option for many men with polycystic ovarian syndrome, who have extra hair, or women who have facial hair deficiencies because of hormone, medical problems, or trauma.

Consultation with a hair transplant doctor is an important first step in determining whether or not facial hair transplantation is the right procedure for you. They will examine your facial hair and discuss factors affecting your beard or mustache growth. Whether or not you are considered a candidate for facial hair transplantation often comes down to your age, the medications you are taking, or the reason for your facial hair loss. For example, a young man without any facial hair is generally not considered a good candidate for facial hair transplantation. Some hair loss is normal. Androgens are a type of hormone that influences hair growth. Testosterone, which is found in the blood of both men and women, is converted into its more potent form, dihydrotestosterone (DHT). Several ethnic groups have higher levels of circulating testosterone than others. As a result, some ethnic groups tend to have facial hair that grows early and thick. For instance, some TDI or sympathomimetic drugs can increase DHT sensitivity of hair follicles.

4.2 Preparing for Facial Hair Transplantation Surgery

There is not an important preparation or skin or body care required before facial hair transplantation. The medications taken daily and surgeries performed previously are the majority of rules applied for the other hair transplantation procedures. There is no need for the patient to get a surgical domestic or overseas clinics. Facial hair transplantation can be performed in any clinic with a proper center and experienced personnel. Although hair transplantation is a surgical procedure, regaining a quality surgical result directly depends on the skill and experience of the doctors and team members. In addition, there are lots of individual factors affecting the success directly, such as the patient’s skin structure, ability of the donor area to be a source and density of the hair.

Facial hair restoration is not different from any hair transplantation procedures. It is a safe and comfortable procedure depending on the person and the relevant physician. Transplanted hair will maintain its characteristics permanently as the grafts are taken from the patient’s own hair. Thus, the main goal is to gather the most essential and strong donor hairs to be used in the case. The essential factors for patients who will undergo FHT are generally as follows. Patients should meet those criteria and the relevant contraindications will be assessed by the physician according to the patient.

5. Procedure Overview

The most important method that helps to minimize the loss of hair is this. The transplantation of each hair bundle should have no crimps on the hair root. As a result, every step should be begun after the landmarks are created, and the hairy skin is completely deadened. For extracting the plugs, small scalpel tips, extractors, and fine tips are chosen with the hair thickness. A faster and easier extraction will come out if the patient’s hair is straight and thick. If the patient’s hair is curly, extracting more hair for achieving the follicle is needed, but the chances of injury to the follicles increase. After collecting the grafts, the nurses count them up. In an ideal facial hair transplantation, collecting the grafts is completed after about 1-1.5 hours. During the facial hair transplantation, the grafts are usually held inside physiological serum at room temperature, but in experienced hands, a density of hair follicles will not result in damage if it is not forgotten to use the changed tip of the extractor.

The day of the surgery, several hours should have been planned. Prep parents if they attend to take something with them (audio books, DVDs, books) for it will be a day of waiting. They usually become impatient in the early hours of the surgery. Before starting facial hair transplantation, the scalp must be cleaned and then both the scalp and the facial areas should be anesthetized using the ring block technique. In this vasodilating structure of the ring block, the anesthetic has a fairly more effectiveness than the regional injections. According to the pillar block procedure, injecting deep to superficial at different places will numb the places where the hair grafts are released from the density of the hair vascular nerve bundles by blocking these places before the incision operation.

5.1 Anesthesia Options

The things to consider in the operation of mustache transplantation are: opposite to hair, the small gaps bear a finer and frizzier appearance; the individual gaps of the follicles are a bit close to one another; the follicular amount in the unit area is close to one another; the thickness of the root is thinner than the hair follicle and the exit angle from the cortical is often steeper than hair. The thing to consider in the operation of beard transplantation is dealing with large diameters and straight downward direction. The chest and abdomen are the most preferred capacity sources among the so-called donor units. The pointedness that arises at 5-10 weeks between the shed and the repeated growth of the beard hair occurs earlier with the hairs of the chest and abdomen. Among the secondary features of the beard, the signs of the hair which are emerging following a considerable brava are the helixes and the characteristic cross angles also may be observed in the abdominal and back hairs – to a limited extent – mostly. For this reason, the operation of chest hair grafting in beard transplantation is technologically easier when related to sperm hair and grafters can establish a broader and volumetric bending in this way. However, the sagittal angular ingression from the mist of the beard and the direction of the application, namely the growth which is vertical in some areas and descending in the others, the complex applies altogether. In order to avoid the artificial look, the surgeon needs to take one or more of the following methods at the same time, in addition to the advanced unit micrograft transplantation: retreatment, the use of the intermixing aliases, the use of hairs that are grown vertically in the thick areas, and the provisional act of hairs with horizontal penetration angle in the thin areas.

Facial hair transplantation is a complex procedure that requires experience, correct treatment planning, and detailed work for the best results. Although when performed with the FUE method, the hair follicles are taken from the nape or the body and transplanted as micro-grafts, difficulties arise in the direction changes of the grafts while implanting in the canals opened with the lateral slit methods. While each hair follicle would have been individually intervened in classical techniques if the canals hadn’t been opened in the form of slits with millimetric measures, because of the collective jamming of the follicles in the canals, new difficulties in the procedure would have to be overcome. This type of transplantation is not as easy as scalp hair transplantation operation and requires much more experience and dexterity. The direction, angle, and density of the hair have a significant effect in determining the natural look of a facial hair transplantation operation. The specialist must be very knowledgeable about the tissues that make up the mustache, beard, and eyebrow. Each of these hairs is an integral part of the face and completes its natural look. During replacement, if the specialist fails to pay enough attention to the following items, the outcome will most certainly look much artificial.

5.2 Harvesting Hair Follicles

FUE is an appealing surgical procedure for several reasons. One of these is that unlike the FUT surgery, there are no scalpels, sutures or staples, and consequently no linear scarring, which the FUT patients wish to avoid. After extraction, the treatment of the grafts is similar to that used for the strip method, where two methods of follicular unit mini-micrografts have been performed and refined, the follicular unit mini and the follicular unit micrografts. The follicular unit used is divided into two (bisection) by slivering the graft to remove the non-hair blade portion of the graft base by trimming with sharp microblade scissors, and contributor grafts can be selected for various scalp hair contributions by combining single-hair with multiple-hair follicular units.

In FUE harvesting, individual hair follicles are extracted directly from the donor area, usually the sides and back of the scalp, using a 0.9 mm to 1.2 mm punch, with no need to remove any strip of surgically excised scalp. After the patient is comfortably anesthetized using local anesthetic (lidocaine with epinephrine added), follicular units are harvested with the use of an oblique dissection. Also, the surgeon may shade the round incision of the skin surrounding the follicular-unit graft (excision). These grafts are removed by making a perpendicular cut around 0.4 to 0.5 mm away from the inferior or terminal part of the follicle-bulbar-cells and their base membranes. Then the graft is brought outwards by a gripper that isolates the units and facilitates the traction in a series of small parade-like movements. Because the excision is smaller than the graft itself, the resulting wound is elliptic similar to that obtained with “punches” but these are always larger than the graft. These operations do not result in deformation of the terminal hair follicular units similar to that found with the skin incisions, making the grafts more similar to those found with the strip method.

5.3 Recipient Site Preparation

The recipient site preparation is a critical aspect of achieving high graft survival, natural-appearing hairlines, and proper direction, angle, and hair groupings of the facial hair. Recipient sites should be small to overcome the lack of elasticity and pliability of the facial skin and resultant elevation and compression of the skin (i.e. “cratering”) with each incision made. Close attention should be focused on creating recipient sites that will allow for the selection of single donor groupings of hair for the majority of the hairline and sideburn regions. Changes in the direction of the recipient sites as related to the underlying cutaneous musculature are imperative to avoid force-feeding the recipient hair into a direction not naturally taken by the hair when placed into the skin. The limitations of using bevel-down grooving/slitting instruments to direct a graft in a specific direction for each incision made for the recipient sites are that (1) the width of the recipient sites created is equal to the diameter of the grooving instrument, (2) the depth of the recipient site can be difficult to control, and (3) changes in direction to avoid force-feeding the hair can result in the hair being placed too low in the recipient site.

Incisions for Dr. Epstein’s second generation of facial hair transplants are made using the smallest punch ever used for hair restoration surgery, the 0.75mm follicular unit extraction punch, which makes recipient sites that are barely 1mm in size. These ultra-tiny incisions result in the least amount of trauma to the skin, and therefore a reduction in the inherent risks of infection, scarring, and reduced growth after surgery. Dr. Epstein’s technique of creating recipient sites is called Unshaven Robotic Assisted Hair Transplants. The main advantages of the Unshaven technique of recipient site preparation are that the patient does not have to have their head or face shaved and is not left with an unsightly grid of skip lesions, which is so noticeable with other methods of recipient site preparation.

5.4 Hair Follicle Implantation

The room temperature is maintained at 25 and 27 °C. During this time, the medical nurse arranged the prepared hair bulbs, exposed to room air conditioning. Room air temperature should be around 24 °C to 26 °C. Factors such as bright lighting, and anything arbitrary or conditioned by doctors should not be performed. Room temperature should be suitable only for bulbs and patients. As time goes by, bulbs outside the refrigerator will get closer to room temperature. RequestContext tickets should be made with enough consideration. The medical nurse assesses the nurse’s contribution to the bald area at this time, and as time goes by, she brings the bulb into the operating room, and tells her how to quickly suction as much as possible and warn me to manage the site. Do not leave the prepared bulb in the room after the operation starts.

We have treated three issues in facial hair transplantation: FUT and FUE techniques, and postoperative considerations. Here, we submit full procedure cases which provide practical information to practitioners who are interested in facial hair transplantation. Facial hair transplantation is basically performed as the same method as scalp hair transplantation. Hair follicle implantation phase is a procedure that the nurse doctor must precede the doctor. In the case of facial hair transplantation, the direction of hair must be short and the angle must be small. Because it is difficult to carry out all these procedures if a large area is worked, almost all transactions are dealt with 1.5 to 3 hours, but the slower the nurse is, the more chance of accidental factors gradually decreases.

5.5 Duration of the Procedure

This number is determined before starting the operation, and the team will agree unanimously. One other issue is planning the transplantation to sift the grafts with double or multiple hairs and the oily and sweating ones and tissue material with blood inside and grafts that were cut into pieces. During the transplantation, grafts are initially sifted using the transmission light of a dim and transparent visible light which do not heat and cause any injury of the hair roots with a slit (also known as light dissecting microscopy transmitted from the graft bu lamp and/or a binocular) in order to verify the quality of the grafts. The ones deemed to be single, cool, and appropriate are selected. The others are on hold. This check is made quickly, but it is done definitely.

Facial hair transplantation is longer than scalp hair transplantation, but well-organized teamwork makes it more efficient compared to historic procedures. Without any major complications, a good and experienced team is able to conduct the operation, fixing up to 3500-4000 transplant grafts without any problem. In our work experience, we have fixed 3000 to 3200 grafts in an operating session lasting 7-8 hours. However, these are the maximum limits, and 1500-2000 grafts, which correspond to 4000-5000 roots, is the most common number. The characteristics of the follicular units in naturally growing beard, hair, mustache of the host, the density of the host’s hair roots in the transplantation zone, the degree of the hair color – thick or thin and color, and the distance between the roots, the caliber, length, and other factors of the host’s hair follicles affect the maximum number of transplantation.

6. Postoperative Care

It is necessary to plan the sessions to provide effective results after the patient starts to lose his transplanted mustache and/or beard hair within 2 or 3 weeks postoperative. The best planning is to determine the size of the transplanted grafts, which are from the skin of different donor areas at 6th month postoperative, and to observe the number of grafts which grasp the anagen phase again. Having selected the patients more properly by listening to their expectations will also keep at a minimum the possible negative reflections of the postoperative period on the patients. All of the investigative methods can provide the chance for the clinician to provide effective results more quickly and more easily.

Despite the patient being able to return to his daily life after the surgery with the presence of edema, erythema, and scabbing (Figure 13), both the presence of these and the scars smoothed in the recipient area may cause many people to suspect aesthetic operations. Until these recoveries in the skin of the recipient and donor areas of the scalp are completed in four or five days after the intervention, care must be taken to hide the small scars and to inform the patient. The discomforts such as itching and irritation at the donor area are reduced through the recipient and the donor area are washed with the mix of the betadine and the physiological serum every 2 h and through the use of the antipruritic lotion on the 4th and the 5th day. The medicines to be used by the patient after the implantation must be told before the operation as it is necessary that the patient start to use the medicines including the corticosteroids such as Methylprednisolone and the antiedematous agents such as Diamox 2 d postoperative. The patient must be informed that the spreading of these medicines to the implant area must be prevented in order to avoid the reduction in yield and solutions are utilized in line with the needs such as emotion for the edema and the emollients for the drying of the skin surface (Figure 14).

6.1 Managing Discomfort and Swelling

The majority of individuals that undergo facial hair transplantation will have a degree of swelling of the face below the eyelids. This swelling can be quite significant and quite different from other hair restoration surgical procedures. Most of the swelling is typically gone within two weeks, although some patients may have swelling for approximately 90 days. The swelling is due to the fact that the beard area is the highest point on the head so that the fluids tend to drain downward. Wearing compression over the beard grafts does not prevent or reduce this swelling but simply helps make the grafted area lie a bit flatter and stay in place. Before shaving over this beard area, wait at least 72 hours. If an electric razor is used, the grafts can be freed of the crusts and shaved around. After a week, the face can be shaved and makeup can be applied.

There is no need for bandages, although you can use a paper tape to stabilize the implanted hair initially, for the first night. The hair should then be washed daily with a mild shampoo. If you are careful not to rub the small areas of scabbing when washing, they will not be torn off and you will not lose any implanted grafts. Some patients will be able to shave over the hair grafts beginning at about one week and others may have to wait a month. It all depends on how quickly the individual heals but, slower or faster, the end result will be the same length of hair growth and the quality of beard hair you have implanted. The recipient area may redden and the implanted hair continue to fall out over a period of weeks, after which the new hair shafts will emerge as new hair growth. This process might be hastened by minoxidil application hence additional treatment with minoxidil postoperatively is discussed further.

6.2 Postoperative Instructions for Optimal Results

Our doctors, trained staff, and postoperative regime are all elements of performance that are included in our strategic planning. This sharing of knowledge starts even before the patient arrives at our hair restoration clinic for the 1st consultation. This series includes multiple online educational videos accompanied by a detailed booklet that explains the preparation, orientation, consultation, the surgery itself, and the postoperative regime. Our educational program is in many ways a guide to establish the comfort that allows our patients to have confidence in the process and maintain peace of mind. Our patients’ comfort is very important to us and we believe that it is our responsibility to foresee problems, address them in advance, and to give our patients a precise system in order to demystify our methods.

The care of hair and restoration is a collaborative effort between the doctor, the team, and the patient. The care begins with an idea of what the hair will look like and involves the entire process of hair restoration. Drs. Cole and Mwamba use digital photography and computer morphing to plan every hair transplant. We include our patients in the decision-making process to ensure that the revised hairline and the overall number of hair they want reflects the full harmony in regard to the future or lost hair. The hair rejuvenation has to look good in the short term and in the long term or the short amount of time it takes to grow the hair and the density of the hair back. Below we will discuss the various components of the hair transplant process in order to understand the importance of all the factors that come into play.

6.3 Follow-up Appointments

The waiting period after the surgery is usually the most difficult time for the patients. It is normal to feel impatient, frustrated, and even anxious about the result. Following the surgery, some hair may fall out, and patients might notice an unusual shedding pattern during the first 1-2 months. However, by 3-4 months, new hair starts growing, and by 6 months post-op, plenty of new facial hair is visible. Dr. Asaria advises taking proper care of the transplanted hair to yield optimal results. Applying concentrated pressure with the fingertip on the transplanted hairs 2-3 times a day can help to secure the transplanted hair into the dermis and thus yield better results.

Patients will return 12-16 days after the surgery to have the sutures removed (if needed) and to have the transplanted hair washed. Subsequent follow-ups will continue every 2-3 months. After 6 months, the patient returns for a check-up and is able to shave and trim their facial hair as desired. Dr. Asaria suggests that patients send him an email with photos at 11 months and 1 year post-op to show the progress of the hair. It often takes about one year to see the maximum benefit of the hair transplantation, following the natural hair growth cycle.

7. Risks and Complications

Damaging the frontal branch of the facial nerve is a significant concern, and dissection in the subcutaneous plane in line with the hair shafts, constant eye and mouth protection, a clear knowledge of facial anatomy, and pinched forceps holding tissues during dissection are essential. Avoid excess tension or overpacking during tissue dissection and placement. Both endoscopic and retro-tragus incisions have been described for making recipient sites, and they are safe techniques if performed by an experienced surgeon according to anatomical landmarks. Langsdon and Voss.298 Sungjung et al. described the endoscopic technique for making recipient sites and found that it provides a safe, minimally invasive, easy, and reliable method for creating the hairline incisions. To diminish the injury of hair follicles while making small superficial incisions, Choi et al.299 described the use of needles in an irregular injection pattern that involves slipping and pulling back. Strand dissection in the perpendicular bevel to hair shafts is also recommended. Stringent postoperative care is important to reduce the risk of edema causing tissue expansion, and postoperative pain and edema (particularly around the eyes) are the commonest short-term complications of the procedure.

This procedure carries risks that are similar to other hair transplant procedures. Two concerns specific to women as well as men are mechanical and thermal injury to the periorbital region and facial nerve injury. Proper preparation, the exercise of caution, a team approach, and patient education will help to prevent the risk of complications. Although no cases of blindness have been reported following killer combo eyebrows and hair transplants, it is a well-recognized but rare complication. It may occur when bleeding enters the retrobulbar space of the orbit. High volume sprays of saline, vasopressors like adrenaline, small-bore hypodermic injections, hair punches, and carbon dioxide laser use close to the orbital rim should be strictly avoided. Special precautions include asking patients to close their eyes even for a few minutes during the injection of local anesthesia or hair extraction. The injection of local anesthesia can be administered via a retrobulbar block, but this should strictly and only be performed by an ophthalmologist who uses blunt-tipped needles. Bleeding can be controlled with a similar approach to the one used for a scalp hair transplant. This can involve head elevation or anti-g valves, arterial embolization, and systemic blood pressure control. Forced lip closure can help prevent retinal hemorrhage.

7.1 Potential Risks Associated with Facial Hair Transplantation

Poor or unnatural pluggy look (Pu) is a minor postoperative complication that could be avoided by practicing sound microsurgery. As a team, the initial insertion of follicles will be given, and this should enable the creation of both structures and skin areas (within the recipient sites) that are well-tuned. Compounded punch marks. Total loss or partial loss of grafts within the recipient regions may be related to insertion difficulties or poor tissue reaction. Techniques to minimize the markup of scabs while using any size receptor should be found, and subsequent target depth adjustment should be made. Failure to provide rich entombed (reliable) hair. Follicular units lacking aminoglycerol are likely to diminish the ability to develop cells. Follicular units (or even individual hairs) lacking appendages were often described as amorphous.

The risks of Facial Hair Transplantation (FHT) should always be discussed with the patient before performing any procedure. Due to the minimally invasive nature of the technique, most existing complications are of a minor degree, although severe ones can occur. Wound dehiscence is a minor complication within the recipient area and is more of a contributor to a genuinely poor result, as the number of wasted follicular units must be replaced by repeating entire processes on other regions of the face. Absent or slow growth might occur when existing follicles are heavily discriminated. Patients whose hair quality is poor and who insist on undergoing the procedure need to be warned that subsequent delay in hair gain can occur. Damaged follicles after poor production attempts can easily be inflicted by technicians who make inadequate statistics as to where proper hairlines and/or angles should be adhered to. Individual discretion is crucial for identifying a root with weak hooking capabilities, as well as for harvesting units of a length not longer than the recipient sites. Follicles are wasted if they are wounded and affected by the creation of microtraumas during typical recipient-region medication insertion.

7.2 Managing Complications

Infection is probably the most feared complication of any procedure. The signs of infection include excessive pain, tenderness, and redness of the involved area. The appearance of pustules or yellowish discoloration over suture lines or the operated area should raise an alarm. In hair transplantation, there is a possibility that hair-bearing skin becomes an easy medium for bacterial growth, but this is not necessarily post-operative infection. To avoid a true post-operative infection, proper care in the pre, intra, and post-operative period is necessary. The following steps help prevent infections. First, proper incisional cleaning with povidone-iodine solution followed by alcohol to dry the area. In theory, Rogaine use 10 days before hair transplantation may prevent post-operative infection. Secondly, antibiotics can be administered one hour before the procedure. Antibiotics may be prescribed in patients who are prone to recurrent infections. Irrigation of the area with normal saline to remove loose grafts as well as cleaning of areas absent of hair follicles is recommended on the first day post-op. Early infections usually occur within the first 24 hours. Post-operative mupirocin ointment may help prevent early infections. It is suggested that a combination of ciprofloxacin 0.3% with dexamethasone and ofloxacin 0.3% BP with dexamethasone are the kind of combined medications that prevent infections and obliterates acute inflammatory reactions to the transplanted hairs. Other suggestions are aceclofenac and paracetamol.

Management of complications is a fundamental cornerstone in the doctor’s armamentarium. Good management recognizes two critical points. Firstly, prevention is always preferable to cure. Secondly, when complications do occur, they are managed quickly and efficiently. There is a common denominator in managing complications in surgery, aesthetic or otherwise. The following steps should be remembered as the ‘Five A’. Regardless of whether surgical treatment is maximal, the five ‘A’ should be remembered if the complications are to be avoided or well-managed. They are: asepsis, which is infection; assemblage, which is the collection of blood or serum; accuracy, which is the correct performance of surgery; alertitude at the time of the surgery; and association, which signifies the involvement of other layers and anatomical structures during surgery. Despite the advances in surgery, complications are not rare. Thus, early detection of the problems leads to a better resolution of complications.

8. Recovery and Results

Small crusts at the base of hair follicles are a part of the normal process and these can be easily removed while the hair is gently washed with a soft touch under a shower. However, the initial hair washing should be done more carefully, keeping in mind the delicate, close graft placement. As hair shafts will be lost during the first month, only about 60-80% growth is expected in the first 9-10 months, with complete growth occurring in subsequent months. Using minoxidil for at least 3-6 months will further ensure good hair density in the transplanted area. The best part of a facial hair transplant is that it is your own beard and will grow naturally. Gradually, the transplanted hair will shed over the first 4-6 weeks, new roots will then push the resting hair shafts out. Any initial scabbing/pruritus and numbness will also disappear at this stage. Recovery can then be compared to the natural re-growing hair after shaving clear-beard due to cultural or religious customs.

After the transplant is completed, the area may be cleaned and marked. You will be informed of do’s and don’ts at this time. Instructions regarding the use of anti-fungal shampoo for the first few weeks and also antibiotics may be given. Special attention would be given to the careful cleansing of the grafts with the anti-fungal shampoos for the first few days. There is no need for heavy bandaging to the face. Cold face packs or local application of cold water or cold milk will reduce any temporary discomfort. Strictly avoid manipulating the graft, and do not pluck/tweeze-cut any hair in the bearded area. No shaving can be done until after 14 days, and a mustache cannot be grown for at least 3-4 weeks. The transplanted hairs will undergo changes as new hairs form and growth velocity increases on a gradual basis.

8.1 Timeline of Healing and Growth

General growth in facial hair restoration is generally observed in the following stages. Weeks 1 to 2: Hairs are very coarse and the existing natural hair is very fine. All eventually shed. Week 3 to 5: Hairs may start growing, legs may start to appear. Trimming is not necessary as new hair will eventually outgrow. Do not shave because tapering of hair is desired. Weeks 6-10: Shed hairs are generally completed and new hair will start maturing, become longer and coarser. At times, and for no specific explanation, the hair from all locations will grow back at various rates, and some areas will catch up even those areas from which they emerged faster than the others. Shaving and trimming are now healthier. Weeks 11-15: There should be no shedding. Hairs have been thickened and start taking on a denser hairstyle. By 6 months: As discussed earlier, this is the average start of a full follicle growth rate; however, don’t assume it would only happen gradually in those first six months. Depending on the person, maturation could surface on several occasions in small percentages.

One of the main differences between general scalp hair restoration and facial hair is the healing time. In scalp hair restoration, we tell clients that hair growth will be seen in 6 to 10 weeks. However, the transplant is not noticeable by any means yet, as these are the hairs that remain for the cycle. Compared to scalp hair, facial hair is very thick and becomes visible almost instantaneously after shedding, even after only a week. However, the speed to see sideburn hair thickening, it is refraining from trimming that hair until all the transplanted hair has gone through one shedding cycle, as the reshaping will need new full hair growth on all follicles to thicken.

8.2 Expected Results and Maintenance

The implanted hair will need a little bit of attention so that the hair you have transplanted grows in a natural way and to avoid going bald and falling out. As in the hair transplantation of the scalp in terms of growth and life quality in the facial area, the hair should be washed regularly after the hair has grown after one year. Also, other things such as hair style, image of the word, and your psychological happiness form the main factors influencing the care of the planted hair. Social and daily life before the beard and dart transplantation will be effective in the quality and care of the hair to be done after the operation. Aside from this, especially, manual or tool application should be avoided in the first six months following the beard dart transplantation. After the first year, it is aimed that the hair takes its full and natural look, and the hair is expected to grow in a natural way.

The hair that will grow following your beard transplantation will look natural because it is taken from the back of the head. Also, the hair planted in your facial area is expected to grow back and after a year, the transplanted hair will reach its desired full and natural look. Just as facial hair transplantation is expected to meet the need for a man who wants to feel more confident about himself by removing unwanted marks on his face by his beard, darts, and mustache, it is also expected to eliminate your psychological depression caused by the hair loss in your facial area and bring you and your relatives cum friends in closer relations and establish permanent happiness.

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Although some unique preparations have been described to help prepare the recipient areas not to shave, a successfully planned operation still requires experience to minimize the duration of the hair transplantation, which should impact around 4-5 hours. Comprehensive data and our own updated technique are presented in preserving hair integration created by the same person who shaves the head for the FUE procedure, continuing hair growth from the same originating punch sites, removing hair follicles from their original implantation regions as much as more rapid than 48 hours.

Non-shaven hair transplantation is a technique that is designed to create the illusion of not having had a hair transplant with reduced labor for the clinician. Creating a non-shaven appearance changes the dynamics of the hair transplant procedure by introducing a number of practical considerations that differ from the traditional shaven or partially shaved approaches. In response to these challenges, various approaches have been described to achieve the goal of an unshaven or minimally shaved recipient. For example, a transplantation technique can involve iterative punching if a simultaneous extraction of hair follicles followed by direct implantation is accomplished, temporal implantation in non-shaved regions, punching out of hair follicles from the neighboring hair to remove them from their original implanting regions, and hair by hair manual implantation to achieve an unshaven appearance without long-lasting potential to affect the hair growth look by producing any detectable scarring in the recipient areas.

2. Benefits of Non-shaven FUE

The FUE has been gaining contagious interest in the world of hair restoration because it leaves ample void space around intact follicles and does not insist on needling for their isolation that classical FUT strip excision is fraught with. In an ideal hair transplant practice, patients would value FUE with the donor unshaven for the obvious advantage of no more mental torture of discomflying look in the donor area. With self-esteem being the major burdening issue of cosmetic surgery patients, at least the young enthusiastic, proclaiming potential FUE candidates run off and disappear after FUT is offered to avoid the required donor shaving. In certain cases, non-shaven FUE is not just an obvious, but the only option for a hair transplant, but why not in the others, just for the sake of mental agony of the potential patients?

In a typical Follicular Unit Extraction (FUE), now widely practiced, hair on the donor area is trimmed. What comes as a discomfiting look for at least a week without a cap, these needles sneaked in between unshaved donors always pose a potential risk of trauma and resultant scarring of such a major visible organ. Next to neuro or endo-surgery, it might require the dexterity of the most skilled and imaginative surgeon to sneak in between those unshaven hairs without scarring them, but we master the physical laws of how to prevent a needle entry into a stationary but not a rapidly moving hair.

2.1. Reduced visibility of the procedure

If a patient requests a hair restoration that serves the principle of minimal visible changes, this requires a vast knowledge of the surgeon in planning and execution of the hair restoration. The information that in Non-shaven FUE only a limited number of grafts can be extracted can be a very important argument for accurate discussion with a patient who wishes to avoid the visible signs of interference in the implanted (recipient) area. If only a limited number of grafts can be harvested, the patient is warned of exaggerated expectations or of the fact that the physician would need to harvest an artificially low number of grafts just to accommodate the patient’s wish.

The reduced visibility of the hair transplantation process is one of the most pertinent factors in the increasing desire of patients to avoid any shaved areas post procedure. Patients have a very positive and confident feeling if they can go back to work or to social activities immediately after the surgery without anybody noticing that a hair restoration was performed. The patient perceives this discreet hair transplantation as a secret of his own that is reserved for him alone, while others observe the improvement but don’t associate it with a cosmetic intervention. It is a sensitive matter to respond to a patient’s personal desire for discretion. So a part of the physician’s art is to create minimal, barely visible changes; thereby respecting the patient’s request.

2.2. Minimal disruption to daily activities

The transplanted hair never grows back during this period of concomitant hair growth since the donor site is not shaved, and additionally, surgery traces from FUT are also hidden by hair, and minimal visual problems occur at this stage. In traditional FUT treatments, a large amount of tissue is removed from the donor area, which needs to be shaved; and it may take up to 14 days to reach a length suitable for social activities. With U-FUE or SAFER-FUE, areas with thinning and hair loss can be easily restored in one session without shaving; occasionally, with minor adaptations, the hair style can be done during the procedure. An alternative for patients who want to keep their hair short is “practically unshaven hair transplantation”; in some patients, hair is styled after opening the channels and necessary views become apparent. FUE-CRU is another new minimally shaved technique for which only minimal amounts of shaving are done on selected areas, and hair growth is different for every patient. Every kind of hair transplant method is performed progressively, as landing on the moon was, and it is also difficult to predict the possible developments.

With non-shaven hair transplantation, there is no waiting list for patients to grow hair, or for the hair to be a certain length, as the transplantation is done without shaving. It is possible to have customized hair restoration in areas where hair is lost, while continuing with daily life, with minimal disruption to the pace of daily activities. When the transplantation is done without shaving, it is not necessary to wait a long time to style the hair as desired. It is possible to grow it short over the weekend, and then get a haircut and continue social activities as usual. The advantage of this technique can be seen when looking at photos before and after transplantation. By inspecting the before and after photos, a successful FUE surgery can easily be appreciated; existing hair can be hidden but it may not be apparent that transplantation was performed.

3. Considerations for Non-shaven FUE

Regardless of the length, if hair loss is anticipated or expected up to 7 months after a non-shaven FUE, the hair extensions will absorb heat, as would the bulk of the hair with the longer cut. Hair extensions are used with Caucasian hair only. In general, a smaller number of 6 mm hair extension will be needed for a densely curly or wavy type of hair. One should remember the hair was long enough for hair extensions either at the time the FUEs were transplanted or cut prior to placement of the extensions. Women may want mutton chops/sideburns transplanted in conjunction with an FUE transplantation. It may be difficult to decide if keeping the sideburn on one side and removing the opposing sideburn.

Some considerations for non-shaven FUE are practical and involve both an understanding of the basic mechanism of this hair restoration surgery and personal factors such as the color and texture of the patient’s hair and amount of donor area. For example, lighter hair colors, especially blonde or light brown hair colors, or lighter red and browns, result in FUE openings being more noticeable than on patients with dark brown or black hair color. In addition, curly or wavy hair is less likely to cast shadows into the open FUE openings. The actual opening into the skin is short, only 1.2 – 1.2 mm deep. Because of the length of the hair shaft of Asian and African-American hair, the 6 mm length is preferred. In contrast, because of the length and bulk of scalp hair in patients of Middle Eastern and Mediterranean extraction and Caucasian race, the 1.2 mm length or less will usually be used; although any hair type can be used with any length cut above or below the scalp hair.

3.1. Hair length requirements

Contrary to a widely held belief, we are not doing a stricter form of FUE when performing these procedures, but simply doing it a lot more slowly. This is necessary because photography involves capturing motion capture sequences, and the faster we go, the more ‘errant’ follicular units emerge, and those scars would be easily appreciable on the magnified high-resolution photo screen. For this reason, we do not use a powered motorized tool but hand punch each follicular unit out, akin to the sudden widespread popularity of microsurgical dissection with handheld forceps in the late eighties till the mid to late nineties before mechanical dissectors were introduced.

We perform a large number of both FUE and non-shaven strip FUE transplants, and more are now done on a regular ‘non-shaven’ basis. Several patients wish to continue wearing their hair short and frequently visit the barber to trim their hair. Many of them are also in sales, marketing, or any profession where they have to travel frequently and cannot afford the 9-12 days needed for recovery with a shaved donor. For these situations, non-shaven (Fig. 1) and mostly hidden shaven (Figure 2) procedures are indeed helpful.

3.2. Potential limitations for certain hair types

The first of these limitations is that there are patients in which the ideal area for extraction is conical in shape, where straight hair is not present on the sides, so some hidden scars will remain. Or, with the use of hypotrichosis where there are many hidden scars, it is recommended to harvest the donor area in a conical shape immediately below the crown with perpendicular grafts so that, despite the presence of fibrous tissue, it is easy to camouflage. Although the option of education alone could be applied in certain areas, since the fibrous septae are sagittal with a perpendicular direction, the extraction of the grafts becomes long and, due to the excess time, the effectiveness of the non-shaven FUE is diminished.

Non-afro curly hair – Certain Asian or African patients have hair that behaves like curly hair on one part and straight hair on the other. To effectively achieve a high yield with this type of hair, the grafts are ideally extracted using FUE with the education option for the straight hair and the non-shaven FUE option for the curly hair, so the harvest can be entirely covered when the patient leaves the operating room. These yield results have been presented in a study. However, there are some limitations to the technique.

3.3. Longer procedure duration

By using 2 concurrently-operating motor-based punches, the surgeon is required to extract the top and bottom grafts within the time that it takes for the next neighboring grafts to fall into the extraction portion. The FUE procedure’s length extends in accordance with the number of participating health personnel present since each additional person requires their own respective punching set with mirror image stereo microscope and simultaneous extraction facility. The greatest number of punches in use at the same time can be observed with an 8-person FUE team (one surgeon and 7 additional staff). With 16 such concurrent operations, up to 3,000-4,000 grafts can be transplanted within a single day.

Since only the portion of the follicular unit extending up to a certain depth from the skin surface can be fully visible, grafts that exceed this depth during the extraction might emerge before the extraction is completed. Under normal conditions, these grafts would be excised during the graft collection phase. In contrast, the circumstance is somewhat different when using an extraction system that allows the visualization of excess tissue, as it prolongs the duration of the FUE procedure. However, if the surgeon can perform the procedure more rapidly, then grievances from the patient regarding the longer duration of the FUE procedure will be diminished. Thanks to our vast experience in performing standard hair transplantation procedures, we have been able to complete our FUE procedures very rapidly. Indeed, a simple FUE procedure necessitates a much shorter period to be completed as opposed to a more intricate hair transplantation procedure that involves more than 3,000 grafts, such as a surgery for baldness of the fifth or sixth degree.

4. Conclusion

The total number of follicular units with low transection counts at the hair zones 1-3 and 4-6 did not differ significantly, but the average number of follicular units with 0-3 hair per graft and the Transection Rate (TR) was significantly lower in FUSE compared to manual FUE at the 1-3 hair zones. Preservation of 0-3 hair per graft numbers is of particular interest, since maintenance of a natural appearance in comparison to FUE represents visual evidence of aesthetic improvements in the kitchen phase and represents the decisive intervening factor enabling optimal visual and quantified results. TR problems, and substandard and aesthetically poor results are continuously observed in FUE surgery but have not been visualized or analyzed here. This study will be followed by another manuscript in which the observed qualitative and quantitative visual improvements derivable from the low TR typical Endoscopic FUE are discussed.

Compared to FUE, FUSE demonstrates many technical advantages which, taken collectively, suggest that it is the method that will eventually predominate. It is argued that the present preference for FUE results mainly from habits, tradition, and commercial factors, rather than quality. By developing FUSE and taking the additional steps of proof, standardization, training, and popularization, the excitement, popularity, and problems of FUE will give way to the superior method already available that is correctly titled FUE.

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Right now, nothing beats this robotic system for reducing the duration of the hair transplantation procedures to the level of manual FUE. It delivers further benefits such as more successful hair transplant procedures by the physicians. However, potential complications and claims continue to be identified. Future developments of the system would be recommended for even more benefits. For example, side effects of hair bending and non-homogeneous distal hair unit (abnormal looking hair tips) like forming could be a concern in the Fuente system. A larger study involving many surgeons and patients from different ethnic backgrounds may be required since the current post-market reports only include nine patients. The post-market findings would be more interesting if a direct comparison between manual FUE and robotic FUE was presented by the eleven users from eight countries. It is possible that robotic speed may stand alone in reducing the duration when it comes to surgical performance. However, further gains via advances of the currently available motor systems will be valuable in order to achieve other benefits of the robot. A smaller handpiece capable of a wider range of articulation and reach, snake arm structure, and softer, lighter arm are some possible suggestions that could be considered in future systems.

There is an ongoing need to drastically reduce the duration of hair transplant procedures while still providing benefits for the patient and physician. While many are in favor of robotic technology, several false assumptions should be clarified. The rest of the paper describes two hair transplant robotic systems along with their post-market findings and evaluates the benefits of such robotic systems against the outlined objectives. Physicians are able to perform more successful hair transplant procedures in a reduced duration. However, caution should be exercised related to the learning curve and choice of patients. Developments are required to enhance the survival of extracted hair follicular units. Surgeon-designed robotic systems provide excellent benefits to the patients.

1.1 Benefits of Robotic Hair Transplantation

Therefore, the Martinez-Sanchez algorithm was recently proposed for optimal resource utilization in robotic FUE. Its specifications are able to counter these criticisms, making its use more accessible due to the several benefits it brings versus the manual technique. The Robotic Hair Transplantation (RHT) by ARTAS is currently the only robotic system for FUE available on the market. Developed by Restoration Robotics Inc., the ARTAS system is a semi-autonomous platform able to perform the FUE (Follicular Unit Extractor) technique for hair transplantation. The extraction process in the ARTAS device is mainly based on computer vision and a two-step needle holder approach, which allows for accurate and fast extraction. Despite the fact that the device is robotic, in its standard and fully automated configuration, the ARTAS system requires a human operator to oversee the protective system, to upload the punch tool base and the needle holders, and to supervise a part of the extraction.

Despite many innovations in the field of hair transplantation, the basic principles are the same: to harvest a follicular unit (FU) with various numbers of hair shafts and to place it at the recipient sites. The traditional extraction methods of hair transplant present certain limitations related to the need for a dedicated team of skilled technicians. The initial attempts at automation included rotation punches, but were replaced shortly after by core platforms, mainly requiring new staff training or the presence of hair technicians who were supposed to replace the tool functioning at the patients’ head, due to the frequent malfunction during the procedure. The newest approach is the robotic-assisted follicular unit extraction (FUE), which allows for a more predictable approach without affecting the primary outcomes. This new tool is able to use predefined extraction specifications to decrease human errors and also to be applied in the open mode (the patient’s head is not fixed) and in the presence of the physician. The critics of the use of this new device may argue that its high economic costs limit the possibility of its routine use, pushing surgical volumes for each center in order to justify the investment.

1.2 The Role of Robotics in Hair Restoration

Improvement has rested on the shoulders of technology. Robotic hair transplantation is the “new kid on the block” in hair restoration. It has been carefully designed to gently and efficiently remove permanent (donor) hair from areas often removed to reduce hair loss, to skillfully select the right hair as diagnosed by a physician, and then to stick to the patient’s scalp in the ideal places to mimic pre-existent hair. The robotic hair transplant can do this with incredible speed and accuracy, virtually eliminating the human fatigue factor and the time shadowing fears that other hair transplant procedures create. These fears can lead to self-imposed faster surgery and consequent inferior results. This robotics speed assures human surgeons that a first-year rotational resident will be able to do a consistently superior job with no more fake patient, resulting in virtually no patient or doctor anxiety over the last eight years.

For many years, hair transplantation was performed one follicle at a time using microscopes and two or more trained assistants until the development of the binocular microscope. This solution allowed the surgeon to see what was happening and perform the procedures more efficiently. Since then, however, the centrepiece of hair restoration has been to move through a surgical procedure as rapidly as possible to maximize the profits of the practice and create what is known as hair mills. The old analogy, “The faster the oil changes go, the more cars can be serviced in a day,” was gospel to continue the hair transplantation industry’s earning quest. Today, the single most important component in a successful hair restoration surgery is the speed of performing the hair. In addition, over-harvesting is the norm in these surgeries because there is no time to calmly and methodically make the correct number of donor extractions, thus reducing the quality and quantity of hair for more future procedures for the patient.

2. The Procedure

Wound healing is crucial. Trichophytic summer care is necessary. The wound closure must be intimate. While robotic hair transplantation technology continued to develop quickly, a study is offering more evidence for the current performance. The discussion started by emphasizing that the most important thing in hair transplantation remains the outcome. Within that scope, he expanded the discussion to treating hair follicles as a finite commodity. Robotic hair transplantation solves a number of technological difficulties that plagued early hair transplantation units. Although laser hair transplantation may have some advantages, this method has not yet been shown to deliver consistency with the ARTAS robot device. Scalp healing determines the final appearance of hair transplantation outcomes. The uneven, uncertain results typically observed in conventional hair transplantation surgery were definite characteristics that some men androgens could generate natural hair regrowth without the concerns of skin hair growth raised.

During the robotic hair transplant procedure, the patient is positioned on their stomach while the image of their scalp is projected onto a screen. The physician can then begin the process with the visual assistance of the fluoroscopic images. A small skin patch in the back of the patient’s head can deliver an almost unlimited number of hair follicle grafts. With robotic hair transplantation, individual recipients can receive hundreds or thousands of grafts from different donor areas. Hundreds or thousands of robotically harvested hair follicles are guaranteed to be implanted, simply because the complete process is guided by the smart technology that leaves the patient in the hands of the surgeon. After the removal of the grafts, the robot then harvests the hair follicle grafts for the recipient sites. The grafts will then consist of tiny tissue parcels, or “punches,” consisting of one to four hair follicles.

2.1 Preparing for Robotic Hair Transplantation

It is important to avoid unprotected sun exposure of the donor area for at least one week prior to your ARTAS Robotic Hair Transplantation procedure. While both the implant site and the ARTAS donor site will heal quite quickly, the extraction of follicular units can lead to healing patterns that require additional time to achieve the optimal aesthetic results (or otherwise be unsightly if not cared for hygienically post-Robotic FUE). For this reason, our patients are asked to closely follow specific post-robotic donor site healing instructions while we recommend only non-strenuous activity until the procedure takes place. This precautionary step can prevent hyperpigmentation in the donor region following the FUE procedure with the ARTAS Robotic Hair Transplant System and effectively inform the success of your robotic hair transplant. Additionally, avoiding sunburn or tanning before a Follicular Unit Excision session can help with our surgeon’s ability to provide high-quality FUE results, as the extraction and implantation of follicular units require an adequate contrast between the hair and the skin of your scalp.

Preparing for a minimally-invasive hair transplant is quite straightforward, starting with the hair cut. You will be provided with hair length and style instructions during a personal consultation and are requested to have a haircut within 24 hours of your robotic hair transplant. In this way, your hair will be short enough for the ARTAS Robotic Hair Transplant System to effectively achieve great graft quality and optimal visual healing. Moreover, your hair will be long enough to properly cover the extraction area post-procedure but also sufficiently short so that your recipient site healing is manageable and comfortable.

As you prepare for your ARTAS® Robotic Hair Transplant, there are certain things that we will ask you to do – or to refrain from doing – to ensure the best possible outcome. By following these guidelines and your personal preparation plan, you can be confident that you have done all you could for a smooth and comfortable procedure.

2.2 The Robotic Hair Transplantation Process

Day case surgical intervention – comprising administration of anesthesia, extraction of 500-750 microscopically prepared hair grafts, and the front hairline-opening incisions with dissection of 1300-1500 recipient sites – concludes in a medium to large hospital within one working day. Subsequent transplantation of these microscopically-milled grafts also falls within the schedule. This allows for a maximum of 8-hour robotic activity throughout an 8-hour on-site stay over a 24-hour day, providing an experience unchanged from standard hair transplantations. The surgical treatment ends with the optional massage, which nearly exhausts the 6-hour mobilization factor (the hospital stay factor to minimize any possible hair trauma, friction, or grit, and to prevent the used robot from becoming a contact infection source, demanding continuous sterilizations under intensive use). Subsequently, patients undergo the outpatient post-hydration and final cleaning by the nursing staff in the hotel in order to minimize the hospital stay count.

Patients arrive at the hospital in the morning and then either stand, sit, or lie down, depending on personal preference and the type of hair transplantation surgery. Approximately half an hour before the transplantation, the surgeon identifies the optimal hairline and draws a suitable line based on facial symmetry and personal preferences. Next, to rearrange hair and position it concentrically to the transplantation, the scalp is washed, and if necessary, some hair is cut. The incision size, angle, depth, and direction, as well as some important parameters, are adjusted depending on skin flexibility. In the meanwhile, the robot activates in the nearby room, receives position data from the external, infrared filters, and either starts taking the optional pre-scan images that help place these angles to the plucking location or waits for the patient to be ready for surgery.

Patients initially undergo an evaluation, where donor and recipient hair loss areas are observed and donor hair characteristics are considered (including hair density and graft quality). Post-evaluation, recipients are informed of the number of required grafts and whether their donor hair accounts for the number. In case of donor hair insufficiency, physicians may propose supportive treatments such as PRP, medications, or low-level light therapy.

2.3 Post-Transplantation Care

The scar drainage should last 4 days. It has a double objective: to avoid the formation of seromas postoperatively and to evacuate the residual local anesthetic. Most seromas usually occur 2 days after the procedure. Then, a visit with the doctor should be planned. The technique is simple and efficacious: the doctor apprehends the preserved hair on a comb and then uses the needle to make micro-punctures at a 2-3 mm level on both emergent sides according to the recommended spacing. The result is a small fuchsia-colored scar that does not alter the result of the procedure. Whether it is possible or not to predict the localized phenomenon of cutaneous necrosis, scar drainage may facilitate to avoid the formation of typical capillary crusts that are visually unpleasant to patients.

2.3.2.1. Scar drainage

Section 2.3 is related to the post-transplantation care of the patient. It also provides a description of the healing process taking place over the year following the hair transplantation. It presents the clinical follow-up on the donor site and displays the post-transplantation surgical intervention. This section focuses on the post-transplantation follow-up for the FUE. It is systematically followed on post-operative days 1, 20, and 3 months after the intervention with a patient suffering from severe androgenic alopecia, type VI.

3. Advancements in Robotic Hair Transplantation

Several studies have demonstrated the feasibility of using the Artas system, and a mean number of 962.82 grafts can be harvested with the donor harvesting device (DHD) for every hour of punch time compared to 1016 grafts with the manual technique in male patients, and approximately 1000 grafts with the Artas system in female patients. However, the Artas system has several limitations, including the inability to create recipient sites necessary to place the harvested grafts. This process is currently performed manually, limiting the advantages of automation and also potentially increasing variability when performed by different surgical teams. Recently, Artas received FDA clearance to commercialize an add-on device, in partnership with Restoration Robotics, with a price tag of $249,000. The restoration robotics implantation system was expected to be available for marketing by the second half of 2018, and the device applies a robotically controlled needle to place the harvested follicular units into the predetermined recipient sites.

Artas technology was introduced commercially in the United States in April 2011 and was initially available exclusively at the U.S. Hair Restoration physician practices. In August 2011, Restoration Robotics introduced an updated version: “Artas 9x,” which was made available to the U.S. Hair Restoration physician practices in 2012. In 2012, Restoration Robotics also received U.S. Food and Drug Administration (FDA) clearance to enhance the Artas system with one major operating software update known as “SergiRobotic System Software” version 6.2.2. In 2013, the Artas 9x system received a CE mark in the European Union and was available for sale in certain 17 countries in the European Economic Area (EEC), as well as in Australia and several other countries accepting a CE mark. This CE mark also included a larger graft harvesting area (15 x 15 cm instead of the 5 x 5 cm area of the previous system) and several new features. For marketing purposes, this new system with enlarged harvesting area was later branded “Artas 9x.”

3.1 Artificial Intelligence in Robotic Hair Transplantation

Recently, the number and availability of AI surgery-focused research and related publications has seen an exponential increase. The number of AI article titles in medical journal datasets with a study title hit 234 (0.10 unconference postings from submissions). Of these, x20 and x3.5 had a specific focus on surgical and medical robot applications in surgery. While medical and robotic AI articles saw a steady page rank decrease, surgical AI articles began with forward regression up to 2004. The ERC represented approximately 30% of surgical AI funded ($80 m/year) and 29% of the ERC in general medical AI articles. Journal title keywords: artificial intelligence, surgical robotics, human-robot interfacing. Highest hit subject areas included: computer science, computer application, and medicine. Within the highest hit AI keywords, intelligence is reflected by grooming, learning, positioning, recognition, microsteering, and modularization. Ongoing AI advances ensure streamlined voice, phonetic, image, and objective data gathering improvements.

The major disadvantage of hair restoration surgery is that hair takes anywhere from 6 months to a year to grow in fully. However, the newest technology aims to help people see the final results fully before embarking on the procedure. A team of researchers and funding partners have developed a plasma torch eyedropper kit that cuts out the steps of isolating and centrifuging the living fluid in preparation for injection. The use in major cosmetic surgeries such as FUE is in the proposed research. The first commercial application of plasma torch in hair transplantation allows hair to be grafted faster with greater color match. Intelligence is crucial in the automation of molecularly targeted surgeries to enhance medical model. The development of a fully autonomous treatment requires the integration of imaging and patient data, motion planning, and AI-based control software. Improvements are made based on defined criteria such as robotics, physics, hair coverage, incision and needle-less time, torque type, and drilling speed.

3.2 Future Possibilities and Innovations

Aside from robot-guided advanced tools, also adding visual servo-control or teleoperating techniques to have more advanced and safer abilities will be a promising development. The above discussions on further research in other diverse application areas, including microrobots, enhance potential robotic technologies that may exhibit futuristic opportunities in improving hair transplantation. The widely desired soft-tissue (face, hair restoration) procedures should be the main beneficiaries of future robotic developments. Biological studies, especially antimicrobial features or the physical architecture of skin or vital structures underneath the skin, would be very valuable to roboticists. Interaction with medical doctors, and especially robotic collaboration of surgeons and engineers in device design and system requirements, would create a good example for possible collaboration opportunities of different disciplines in healthcare.

New developments of emerging technologies allow for more capabilities to be available for future robotic hair restoration surgery. Microrobotics technology, which deals with constructing (micro-) robots that are little bigger than the millimeter scale, advances to medical devices in size-scale and novel robotic devices, suggesting various futuristic possibilities for hair transplant surgery. This innovative, minimally invasive medical procedure could start a breakthrough in hair restoration on humans. Application in neurosurgery is also often mentioned in the robotic community as one of the most complex and responsible operations in medical practices. Other fields where microrobots could be employed include plastic surgery, ophthalmic or laparoscopic surgeries though. Thus, one possibility would be integrating techniques already available.

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The hair transplant method has evolved over time and developed as the latest technology. Instruments in the hair transplantation process, which started to be applied as a cutting method in far eastern countries, have changed and evolved to be used in the form of some special instruments called micromotors today. From the formation of rudimentary tools to the present, hair transplantation has become a very comfortable method for doctors and patients. At the beginning and present, the hair transplant applied the same aim, by directing them to the direction and angle of growth of the original hair and no one to understand the hair without meeting the expectation. Even with the development of these techniques, sufficient attention is not paid to the channels opened in both the pre- and post-contested clinic environment; the fastest hair transplantation is materials in this area.

The DHI implantation technique is a robot-assisted procedure and has been developed to facilitate the surgeon’s work by performing the work by a robot. With the robot, the number of assistants needed in the operation can be reduced without entering any incisions, and since the control of the direction and angle of the channel will be achieved automatically, the number of surgical operations is reduced. In 1972, the first hair transplantation was carried out, parallel slits were opened in the scalp tissue with the help of tools such as Lister knives, and the hair grafts removed from the hair root were placed on the channels opened as the cut-off. Mini/micro graft and strip type surgeries were performed as intended.

1.1. Definition of Direct Hair Implantation

Hair follicular units are implanted here one by one. This is a slower technique than the other techniques but shortens the time by eliminating the waiting period on behalf of the hair follicular units to take the stage of integration in the skin after treatment. Another advantage is to minimize the dropping out of the hair outside the area where they are to be implanted. Because the method used in this Da Vinci hair transplantation operation is called the robust method due to the greater possibility of hair follicular units not rising in the case of irregularities occurring in the direction of the channel opening. Individuals give priority to their social lives, work, and financial planning during this time. Since FUT and FUE techniques do not provide this opportunity, the technique used in the hair transplantation operations performed is the Da Vinci hair transplantation method, which may also be expressed as the robust method. It may be preferred on behalf of the hair transplantation in case the planning is made after elimination of shortcomings regarding the time and the rate of success in the integration of the hair follicular units with the skin.

Before coming to this stage, hair follicular units shall be taken out from the back part of the head by local anesthesia. Then, these hair follicular units shall be treated in this area and some time is passed. After that, these hair follicular units are inserted in the area where hair is to be implanted. This period of time shall be planned based on the agreement between the patient and the clinic. Dropping out of the hair extracted from the back part of the head during divisions shall cause a major problem because this place shall not be preferred as the hair extraction area in a second operation to be performed later.

Direct Hair Implantation (DHI) is a technique applied by transferring hair follicular units to the area where hair is to be implanted using a pen device. In FUT and FUE techniques, hair follicular units are taken out from the back part of the head (the occipital region) where hair is genetically tougher, and they are divided into segments containing 1 to 3 hair follicles. Long, thin cuts are opened on the area where hair is to be implanted by needle or by some other medical tools, and then the follicular units are inserted in these cuts. The area is then covered with medical dressing.

2. Benefits of Direct Hair Implantation

DHI creates natural hair. What you aim for in a hair transplant is a natural-looking hair. After the DHI Chennai treatment, you can grow your hair, as per your will, because we use the hairs taken from you. After 3 months, the first results of the treatment start to be seen. However, like everything else in nature, hair grows over time. Your hair reaches the desired, natural appearance in a year. The part of the transplanted hair, namely its end and middle parts, will shed and be replaced by new hair. Due to its naturalness, the hair will continue to grow, without any contraindication, in its recipient area.

DHI is an advanced hair restoration method. Advanced methods provide your surgeon an aid to take better decisions that can give you the best result. In the case of hair transplant, the single most advanced method is DHI hair replacement. During the treatment, your healthy hair follicles are directly implanted in a direction-specific manner to the treatment area. Follicles surrounding the recipient area may stay. Given the sound health of the donor area, Direct Hair Implantation is the most efficient treatment type because it prevents traumatic practices, such as cutting and making needle injections, on the patient’s valuable scalp.

As I said, there are numerous methods for hair replacement, and while all methods come with their unique set of benefits and limitations, Direct Hair Implantation or DHI hair transplant method has emerged as a clear winner among the available ones. There are currently more than hundreds of reasons as to why a surgeon loves to recommend DHI hair transplant to their patient. In this treatise, however, we limit our discussion to five benefits of DHI treatment, although the benefits are anywhere more than hundreds.

2.1. Natural-looking results

A relatively new option is Direct Hair Implantation (DHI), which in just six years made more than one hundred thousand clients happy. This new procedure, developed by experts at the DHI Global Medical Group, is an improvement on the FUE technique. In DHI, hairs are transplanted one by one into the recipient area, fulfilling the expectations of an increasingly demanding public who want maximum efficiency with the least possible inconvenience. This method overcomes the handling challenges of other methods, like implanting the hairs soon after their extraction. The DHI devices are developed based on principles from the Asian auto industry, which leads the world in this area. The DHI devices picked up where other methods left off. Besides the device, implanting the grafts soon after their extraction is one of the reasons for the naturalness that the DHI technique can offer. As a result of this study, in just one hour, up to a 105% increase in the survival rate of the grafts was achieved.

Like health, youth, and wealth, hair is often taken for granted until it is gone. The psychological and physical health costs can have long-term effects. When one is missing something, it can be said that it was taken for granted. One of the most obvious changes that occur slowly is hair loss. The average person loses close to one hundred hairs per day, but an increase in this number can be an alarming sign. Those who think they may be experiencing unusual hair loss would be well advised to see a doctor. Medical treatments include new topical medications like Rogaine (minoxidil) and Propecia (finasteride), among others, which can help reverse hair loss. There is already a method of hair grafting that has gained a solid reputation because of its results and minimal invasiveness in every procedure.

2.2. Minimally invasive procedure

Because of the speed of our minimally invasive, innovative DHI procedure, we can assure maximum graft survival, and your hair will measure maximum hair density, no matter what area you need it for. Don’t worry about having the “largest area to cover”. DHI can assure you of providing you with the finest results available “today” in the hair transplantation industry. The enabling technologies of the Direct Hair Implantation Procedure were conceived by the DHI Medical Group, who have been innovating the newest, most minimally invasive and most sterile hair transplantation process for as long as it has existed. Our responsible approach to our innovative medical technology has been of key importance. The DHI process has been of crucial value to our patients’ comfort and successful hair growth. In these revolutionary developments, the DHI technique has stirred a major evolution in the global hair restoration market.

The procedure is very minimally invasive, therefore reducing any potential for scarring and any time-consuming or uncomfortable post-operation procedure, such as common graft recovery procedures of removing the donor’s scalp skin. Thanks to our innovative, minimally invasive procedure, we can ensure that the follicles that are transplanted soon start to recover their normal health, hence ensuring new hair growth happens sooner than ever before possible.

2.3. Reduced recovery time

The fact that this is a comfortable procedure is extremely important especially for the related groups. For instance, this level of comfort, and the short recovery times is of extraordinary benefit for women as they will not lose excessive time and comfort from their busy schedules.

Also, because of the lack of invasive cuts and incisions, especially ones that need to be closed up, but also due to the reduced trauma to the scalp, with no areas of cutoff circulation or severed nerve points, the lack of tangling blood vessels, bandaged wounds or injuries, the dangers involved are much, much more reduced. Because of this, much fewer pre-surgery or after-surgery medications are required, for different complications such as infections, or to ease the client’s discomfort. This in turn decreases or even completely removes side-effects of these medications, such as allergies, digestion complications, headache, nausea or uneasiness, etc., bringing several other health advantages to the patient, who is most probably already in stress due to his or her sufferings from the hair loss.

One of the major drawbacks in traditional hair implantation procedures was the recovery period and the surgery healing process. The new technique eliminates scarring and has reduced the recovery period from weeks and even months to days. However, patients are often advised to restrict physical activity for up to a month after the procedures, but in most cases, the recovery period is just a few days. This helps make it easier for people who have had the procedures to go back to their life much faster. Such reduction in recovery time is also a considerable benefit to the clients.

3. Procedure of Direct Hair Implantation

One of the most frequent consequences of repetitive hair plugs over 10 years or younger creates a strange and aesthetically unacceptable appearance. Early and extensive hair loss makes these “plugged” grafts more noticeable, and the difficulty and expense increases significantly as the patient ages. Repairing badly executed hair transplant processes is a challenge that confronts many men during their life. Our clinic is more experienced than anybody else in the repair procedure. We have improved that specifically through our expertise in Direct Hair Implantation. This can quite consistently restore the broken cosmetic image of “pluggy” – actually invasive appearance directly contributing to a normal-looking hairline or patient.

The procedure starts with a one-on-one consultation with a certified hair transplant surgeon who will help you finish your individual surgical plan, explain all details of the surgery, and answer all your inquiries. The licensed and certified doctor will also inform you about all the processes involved in Direct Hair Implantation. With full understanding and realistic expectations, you are ready to begin your transformation. Following photos are taken and the treatment location will finally prepare it. Important paperwork is completed to consent to the treatment, and you can have a medically related test, blood analysis, and vitals will be required.

3.1. Extraction of hair follicles

Storing the harvested hair follicles during the time of making of the channels and possible break times between, in a Physiological Serum offers the great advantage of lessening the cytokinins release by the deprived tissue that generates swelling and is particularly intense if a large area is harvested. This worsens the survival of hair follicles. This is particularly important because, before implanting the hair follicles at the manufacturing phase of the channels, there is a time rhythm which depends to a large extent on the thickness and strength of the skin of the desepithelized area of time.

Extraction of hair follicles: The titanized 0.85 mm and 0.9 mm or 1.0 mm diameter punches are used for the extraction of hair follicles. The punched hair follicle is retracted from the scalp with the tip of the punch and extracted manually. The hair follicles are extracted from the back side, lateral and upper side of the head by adjusting the angle and depth of application according to the spatial distribution of the tissues. The twist motion of the hands allows to forego any linear incision line. By using the angulation and rotation ability of the punch, it is possible to separate the tissue from the hair follicle from each other with minimum contact, thus preserving the integrity. This requires much skill and experience. The time standing in a medium to very high curvature diameter scalp with the hair follicle’s diameter limit is forming in the punching area. The extracted hair follicles are placed in a DHI implanter.

3.2. Preparation of recipient area

At the time of opening incisions using a traditional scalpel, the underlying hair first has to be shaved, and this may unnecessarily cause visible signs or cause possible scars that may even jeopardize the survival of grafts in the vicinity, while this disadvantage does not exist in the DHI method, where it is possible to open a proper incision within the area of the recipient’s existing hair. In general, the proper direction of recipient incisions in terms of natural growth plays the most necessary role in hair regrowth, and the proper level of incision heals the fastest way, ensuring the natural and rapid closure of the wound.

In DHI, the implantation sites are created with the help of an implanter pen called the Choi Implanter Pen, providing the possibility of direct implantation of hair with a controlled implantation angle, proper depth and direction, and which forms the key to minimal postoperative trauma, while also allowing recipient area preparation before the actual day of the procedure. When compared to the incisions made using metal scalpels and no implantation instruments, the incisions, as small as 0.5mm or 0.6mm in diameter, with the implanter pen guarantee the shortest wound closure period, rapid recovery of healing, and thus form the most efficient growth support through the prevention of unnecessary trauma and dehydration (the least exposure to extracorporeal environmental influences).

The teeth of the Choi Implanter Pen vary from 0.6mm-1mm, 0.7mm-1.1mm, and 0.8mm-1.2mm in width, while the shape of its blade is cylindrical, adding to the method that the curved sharp blades can support the safe implantation of narrow, wide, and ultra-narrow grafts, thereby minimizing trauma and damage with full control. The 9-position depth control of each implantation thickness can be adjusted up to the desired depth according to the topographic anatomy of the scalp, ensuring a firm grip on the graft and preventing misdirection or slippage inside the pen, as the implantation follows a consistent natural exit angle and rotation advancement.

Implantation is done during the preparation of the recipient area, after the extraction is completed. Specifically, while the recipient incisions are being performed, the extracted grafts are preserved outside of the scalp in a patented hypotonic storage solution containing ATP (Adenosine Triphosphate), Phosphocreatine, Dextrane, and antibiotics, at a temperature of 4°C-8°C (39°F-46°F). This continuously reinforces the tissues that are outside of the scalp with energy, guarantees strong hair regrowth, and maintains the tissues in a state of rest until the moment of implantation, again minimizing graft damage by protecting the delicate cells against mechanical damage, intra- or extra-vascular pressure variations, extreme temperatures, dehydration, and physical injuries.

3.3. Implantation of hair follicles

There are insufficient reports in the literature regarding the minimum time necessary between the two hair transplant procedures. The interval between two hair transplants performed using the FUT technique has been reported to be 6 or 12 months. However, with the development that we experienced since then between now and when the FUE technique was initiated globally, it became possible to perform 4 hair transplantations within two years. We used an interval of 3-5 months between the 3 hair transplant procedures. Considering previous reports in the literature, 3-5 months was a fairly good time for pigmentation problems to occur and resolve with the possible effect of the 2% topical minoxidil solution. So we maximum increased the interval time up to 4 months. Since the mustache area has the highest spontaneous hair regrowth in the donor region, by using collateral vascularity, we initiated the first two hair transplantation sessions from the scalp region to the mustache area.

3.3. (Implementation of Hair Follicles) As much as the first two stages are important in hair transplantation, it is equally vital to implement extracted hair follicles in the recipient area without damaging them and implanting them at the right angle. Graft technicians make the slits on the area to make DHI inscription possible. Through the use of implanter pens, the hair follicles are placed in the recipient area. Each hair follicle is meticulously handled to ensure that the natural pattern of hair growth is retained.

4. Conclusion

DHI-Effor starts to give satisfactory results from the first control that is made one year after the application. If the expected results do not appear in this time period, it is possible to re-implant grafts. In order not to experience deviation while the number of grafts increases, one or two backside hair transplantation operations can be performed with the same method. In this case, it is preferred to collect grafts using oscillated tips, which will open randomly shaped cuts in the region to be implanted. However, it is necessary to leave 6 months between each of the applications. If the application is performed meticulously and if the candidate obliges to use the lotions that are supplemented.

The safest and most effective, but at the same time, also the most ethical method of hair transplantation is Direct Hair Implantation. In this method, extraction and implantation functions are combined and performed by only one specialist who can apply the knowledge and skills gained through practice. An artistically natural hairline is not created only through correctly implanting the follicular units collected. Everything, from the design of the hairline to the implantation phases, including the way and direction of the incisions and the choice of the correct sizes, depths, and shapes of lancets, directly affects the final cosmetic result. In addition to these, the situations planned and developed during the pre-application phase guide the process in the exact way and prevent time and effort loss. All of these make DHI-Effor, which is the new name of DHI-AYGE, the most ideal hair transplantation method not only for the candidate but also for the medical expert.

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Until recently, the extraction technique has been thought to be impractical in the clinical setting. This view is a result of not being able to efficiently use non-grip separating tools or instruments that are large enough to fit in hand devices. When controlling for the caliber of the punch area of the donor area as a variable, control of the post-operative appearance of the donor area doesn’t greatly influence impressions of the overall density of the patient as a result of the long-existing technique of hair over punch scar implantation. Here we present imaging findings that demonstrate the continued contrast enhancement phenomenon despite the use of larger extraction incision punches, and photographic findings that these scars are not more visible than PI scarring in realistic clinical settings.

In controlled studies, it has been reported that the average texture value in an FUE graft significantly improves with implantation time. As a result of this wound remodeling, the skin’s textural irregularities are made less prominent by the ingrowth of epidermis over the upper grips of FUs (vs. being left indermal), accentuating the contrast from the overlying thinned epidermis (Figs. 1A and B). This contrast enhancement is additive to the contrast mechanism employed in standard implantation whereby casting shadowing is used to enhance endoplasmic chromatic color contrast by angling hairs and selectively shadowing bare scalp areas with longer hairs. Follicular unit extraction also improves hair transplant cosmesis by reducing visible scarring.

2. Advantages of FUE

The risk of sensory loss is minimal – compared to the linear scar which typically results in a permanently numbed area of sensation. Most patients report having the extraction sites as the fastest healing area. The FUE donor area – heals in just 4-7 days. Most patients are comfortable being seen in the public with the smaller punches in just a few days. When micro punches are properly used, the overall quality and density of the safe donor zone appears to be widely spared from the extraction. Our center has performed thousands of surgeries without experiencing any instance of permanently depleted donor area. Patients are encouraged to trim their hair so that the procedure is even easier – and berries in the resulting look. FUE also opens the doors to thousands of people who otherwise could not undergo traditional strip method where scalp size is a limiting factor as is the case of teens who desire for early intervention. Part of the cases for every surgeon are complicated by scarred safe donor area from previous surgeries, or having a large percentage of their hair in the safe zone. In these cases, some centers have developed BHT or body hair take, as well as lower hairy scalp wound out limitations such as healing in legs in people with balding foreheads. Follicular Unit Extraction has opened more doors to treat these patients who were otherwise turned away by older techniques.

FUE has evolved as a more patient-friendly option for hair transplantation for the following reasons: The procedure is completed by punching out follicular unit grafts from the safe donor zone – rather than removing a large strip of scalp. Hence, no sutures are required – and the patient is spared of an unsightly linear scar. Hence, patients can keep their hair short – a luxury not available after traditional strip method.

2.1. Minimally Invasive Procedure

FUE requires either a “shaved donor area” or a “sharp FUE” device. The shaved donor area, when the head is completely shaved, makes the procedure much easier. Unfortunately, for those patients who have great difficulty with the concept of shaving their heads, this requirement serves as a significant barrier. A newer device that allows for “sharp FUE” has improved the quality of unshaven (sharpened, rather) extractions, but this device requires “perfect” listening to a long list of conditions that we find to be neither practical nor useful. Outcome is the primary measure of success, not the minutia demanded by a complicated device. Taken together, FUE for hair restoration is minimally invasive, efficient, and productive. For the right patient and procedure size, FUE may be the procedure that is chosen to meet the patient’s needs.

2.1. Minimally invasive procedure. FUE is performed as an outpatient procedure under local anesthesia. Patients are given a mild sedative, such as Valium, to minimize discomfort during the procedure. Our patients generally watch television, read, sleep, or listen to music during the procedure… and some even take a nap! There is no discomfort during the hours-long procedure – most patients are pleasantly surprised by this fact. The procedure is performed using an XY rotation device that removes follicular units using a circular, 0.8 to 1 mm diameter punch. This device is the key to removing large numbers of grafts in a single session without strip scarring. Ironically, the struggle to develop this device has been a double-edged sword (cheek?), both helping and hindering the field. Several devices, derived from the initial work of the inventor, are now marketed to physicians worldwide. The pioneering work of Woods, Harris, Tyson, and Rassman, among others, has made FUE an efficient and effective means to extract large numbers of grafts.

2.2. Natural and Undetectable Results

Another instance was discussed earlier when the author’s patient, with a shaven nape of the neck, displayed his post-surgical scarring to warm weather acquaintances. Whether or not all of our patients will report satisfactory outcomes after FUE depends on the skill and experience of us hair surgeons. The learning curve for proficiently removing FUE grafts is considered to be in the neighborhood of 3000-4000 cases. In a report on 1750 patients from 2003, the Follicular Unit Extraction Study Group estimated that the failure (quality-related) rate that confronted physicians during their initiation period constituted nearly 20% of their practice. Supposedly, the measurements of these failures, which the study group based on follicular unit averages (2 cm), were not easily discernible. We need to more rigorously define and discuss how these measurements mandate (and/or alleviate) the work-market’s learning restrictions.

Several studies have documented highly acceptable cosmetic outcomes and patient satisfaction using FUE. In a 2008 study of 74 patients, although the rate of FUE device assessment declined from 89.1% to 83.5% after the surgery, it had no bearing on the overall patient satisfaction rate of 83.8%. Similarly, a 2008 case report featuring three patients revealed acceptable cosmetic outcomes with FUE with patients reporting “excellent” results. A 2008 pilot study conducted on 16 male patients by the author examining scarring for traditionally removed FUE grafts documented scarring that was consistently “not visible at the casual conversational distance.” Half the patients with cropped-short coiffures, despite the examination of donor scars within 1cm of the donor area edge, had no perceivable FUE scarring. “No patient, and no observer, knew that the study was based on a small series of narrow-contrast images from within the donor site,” the author stated. Worthy of explication is that in all of the previously discussed pilot study cases, follicular groupings are diffused (no vertical lines). Such cases, as well as those in which hair grafts are removed from outside of the donor area, are helpful in camouflage worries that FUE scars can be hidden within the donor region, spanning the sides of the head, till the scalp on either the left or right side is uncovered.

2.3. Faster Recovery Time

The smallness of the micro-incisions allows for greater ease of donor and recipient harvesting. The smaller extraction incisions result in less noticeable scarring and allow for both males and females greater freedom to style their hair in approximately half the time of the conventional linear method. There is no worry of the surrounding hair being impaired since the FUE procedure can avoid the “strip” areas where the hair is extracted. Large FUE graft sessions can be performed over consecutive days if a great amount of hair should be the goal. However, with FUE, the patient has one day instead of several spotting the recipient area after the grafts are made. Occupancy within the average procedure is only a few hours with minimal bruising.

After the FUE (Follicular Unit Extraction) hair transplant procedure, it only takes a few days for the scabs to fall off and the skin to heal. After five days, the donor area is barely noticeable unless the head is shaved. These micro-incisions typically heal within three to seven days and are completely undetectable once healed. Most of the time, the patient is back to work within a couple of days, and many times the very next day. The recipient area has almost no scabbing after the procedure when the micro-incisions are small, and the extraction is performed without disturbing the surrounding hair. This rapid healing encourages individuals who might not have considered a hair transplant to pursue the procedure for almost any special occasion.

3. Considerations for FUE

More popular harvested for extraction are so-called “stand-alone” FUE specialties and “FUE only” practices who tend to have little incentive to turn patients away when a better result could potentially be achieved by a different technique because the FUE providers do not actually do any hair transplant surgery treatments other than FUE. This is the way of the world of professional practice where it is human nature to try to find opportunity when it presents itself. Though attractive, FUE has distinct disadvantages and in many patients traditional hair transplants are still our best recommendation because traditional FUT gives a far better overall result to patients suited to that procedure since FUE has a higher transection rate (thus resulting in fewer hairs successfully harvested for transplant or a lower per graft yield) in addition to being less efficient and having some well-known and well-accepted shortcomings. These are facts about FUE and while FUE is a great option for some patients, it is less impressive in others.

There is no question that possible hair transplant patients are particularly interested in FUE and that this interest is generally a good thing. However, just as not every person benefits from other techniques in hair transplantation, not every patient is a good candidate for FUE. Today, in the right patients, hair transplantation without a linear scar is not only possible, but can even be preferred. However, like any hair transplant technique, consideration should be given to what will give the patient the best result.

At The Griffin Center in Atlanta, Drs. Edmond Griffin and Ashley Curtis have been performing hair transplantation for over forty years on patients from all over the world. Follicular unit extraction (FUE) is the newest technique to be offered in the field of hair restoration surgery, but as with any hot new thing, it is important to remember that FUE is not for everyone. The excitement surrounding the procedure is not only from the public, who are drawn to the thought of the “no scar” that it offers, but from members of the surgical hair restoration community that see this as an opportunity to expand their market.

3.1. Suitable Candidates for FUE

Scarring in FUE hair transplant cases is of less concern to the younger follicular unit extraction candidate, as insertion of long hair to disguise thinning and to make short, medium, and select longer hairstyles possible will be key to providing naturalness when seeking an undetectable hair transplant result over a lifetime. Postoperatively, there will be thousands of in-situ hairs from the patient’s original hairline, and this will provide the camouflage that will allow scarring to be hidden during the subsequent periods of hair loss and gain (the early phase where shedding occurs, followed by later regrowth). In many cases, appreciation of the visible results will mask concern regarding slim scars outside the donor areas – assuming these are not numerous and/or wide.

As the extraction (FUE) and implantation (plantation) processes have improved, the range of candidates for FUE transplants has broadened, and this has meant that younger men with less advanced hair loss are now scheduling surgery.

Hair transplantation is the ideal method for restoring hair in individuals with severe hair loss and minimal amounts of available donor hair. Many individuals are potential candidates for hair transplantation, but their options may be limited by the amount or non-uniformity of the hair density found in the safe donor area at the back and sides of the head. Creating the natural, undetectable, and long-term appearing hair transplant comes down to optimizing the distribution of the healthy hair follicles from the back and side of the head, and the FUE method is now preferred by more than 60% of surgeons.

3.2. Potential Risks and Complications

Time – While FUE takes significantly less time and should not interfere with your daily routine as much as Follicular Unit Transplantation (FUT), the length of the time depends on the duration of the procedure and number of grafts being moved. While FUE can take place on the same day, most patients choose not to because of the scalp needing to be shaved, which will make the new grafts more noticeable. However, it should not take as long to recover as shingles should not scab as much or stick to clothing and cause pain in that way. The possibility of other things becoming an obstacle is low. More than likely, the patient will be sore on the first day. The only activity the surgeon will restrict is heavy lifting. Nothing else will have to be stopped in your regular routine. This method is also best for people who regularly wear their hair short or shaved but is recommended for all affected with a hairline that is advancing more and do not want to be more affected by their physical appearance mentally or emotionally. Emotionally, this procedure pays the price you will pay during recovery much quicker than FUT. Because FUT takes months to heal and for the scars to cover up and blend with the patient’s normal hair, the suture can be infected while growing in, last much longer and through more of an innovative healing longer than it actually takes. FUT often goes wrong more than likely than FUE as HT with FUE is less invasive and HT with FUE is less invasive mean, safer, easier to recover from, and while easier in mind face of bigger (yet shorter: process) FUT procedures.

The potential risks, complications, and considerations involved in follicular unit extraction (FUE) include time, cost, and the potential that the patient may not be a good candidate for the procedure. Here’s a breakdown of its dangers and complications.

3.3. Cost and Financing Options

Patients are better off establishing relationships with American surgeons and asking about specific financing options at the time of consultation. Often, the best financing comes from the clinic themselves. The surgeon is free to negotiate with patients directly and may trade discounts in exchange for large, upfront cash payments. Such financial arrangements might explain why the father of Paul LePage, governor of Maine, decided to refer all American FUE patients to a specific Turkish network. In general, medical tourism in Turkey is a very controversial topic, especially with media sources even referring it as dark. Although medical tourism does provide some excellent results at very reasonable prices, it also carries significant promise of hidden drawbacks (as mentioned about the added intrigue of taking a trip to Las Vegas and experiencing hair transplantation; beer and chips included). For many patients, the benefits of hair restoration surgery are injecting improved self-confidence, appearance, and a significant return-on-investment for professional and personal life.

The cost of follicular unit extraction can be a make-it-or-break-it type of factor for many patients, especially those requiring a larger number of grafts (that is, more than 1,000). With quality FUE procedures often operating in eight dollar intervals per graft, the costs in these instances can scale rapidly. The surgeon may also require a down payment or offer 0% financing in order to lock in the order and charge a sizable credit card deposit. Some VIP patients choose to taper their payments while they experience the benefits of their growing hair in the 1-2 years following their procedure. There are also many American start-up companies disguising themselves as larger network operations, asking many patients to wire transfer tens of thousands of dollars to Turkey, using this business model to essentially hide themselves.

4. Conclusion

When choosing the place of greatest consequence to begin a restoration procedure, the hairline, precise placement of folliculars is key. Traditional transplant involves separating the units from multiple hair groups, which is a less precise method of transplant, as it requires heavier handling of each graft and allows for increased trauma to the folliculars. Using 1-2’s through the hairline can give a good-looking result, but it would not compare to the result one could achieve by using 1’s. You can be proficient in splitting up grafts, etc., but with FUE and similar techniques, you are starting with a precision graft. Hair transplantation has resulted in the creation of a great product. Giving the surgeons the option of starting with the finest elements available can only improve the results.

Single donor hair transplant procedures, such as Follicular Unit Extraction (FUE), are superior to traditional single hair or bulk hair strip harvesting. These types of transplants are not only better for the patient but also for the donor and the team that conducts the procedure. Harvesting and implanting single hair units result in a more natural-looking final product. Single hair harvesting ensures a natural hairline, in addition to full density throughout the entire area of restoration. This is also achieved in traditional procedures, but typically through cobbling together groups of 1’s, 2’s, and 3 hair grafts, which takes away from immediate density and is not as elegant or natural a choice as individual follicular units transplanted.

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The follicular unit represents the hair pattern of the balding scalp. Great strides have been made in the total number of hairs which are transferred per session since the original punch of Limemer. In his original presentation on this technique at a Medical Society Meeting in November 1988, only single hairs were taken from the donor strip using a series of punch tools. Larger 3mm punch tools were also used to separate 1-2 and 3-4 hair follicular units, the resulting entirely “split” single-hair grafts were placed in the frontal hairline and were thought to provide the most cosmetic satisfactory transplant patterns.

In 1995, a crucial refinement in follicular unit transplantation (FUT) led to much improved results in the procedure and its name was changed to follicular unit transplantation. The procedure has evolved over time since being first described by and has been used to treat over 2,000 patients at the Yale University Dermatology Clinic. A follicular unit is described as the structures of groups of 1-4 hair follicles, collectively responsible for the hairs in the normal scalp. The total number of follicular units in a standard size scalp is in the vicinity of 100,000. Each follicular unit contains, on average, 2.2 hair shafts viewed upon physical punch without magnification.

2. Procedure

Downtime following an FUT procedure is about the same as with any other surgical grafts. In other words, there is substantial discomfort of the scar, which tabs are placed. Also, this is strictly a hair transplant technique. This approach was pioneered for hair transplantation and does not provide a faster healing donor site and outstrip the FUT in terms of recovery time. Depending on the number of grafts being transplanted, the patient can usually resume exertion, weightlifting, or swimming no later than one week after surgery. At our centers, we try to use Follicular Unit Transplantation whenever possible because it provides better yield, which in turn provides us with the ability to obtain better density in fewer procedures and a less detectable scar in the long term.

Using the latest techniques designed to minimize downtime and the discomfort associated with hair transplants, at our centers we harvest the hair from the donor area using the advanced FUT technique. FUT is a donor harvesting technique whereby a long, narrow, elliptical strip of hair-bearing skin is harvested. This strip is then dissected into individual follicular unit grafts using a top-quality stereoscopic microscope. This technique has several advantages over traditional hair transplant techniques. It allows for better preservation of the follicular units and traditional strip grafts during graft dissection. Additionally, the process of sectioning allows for viability and preservation over a longer period without desiccation. Of course, these follicular units are transformed into individual follicular units for transplantation. The grafts are then implanted in the recipient region.

2.1. Harvesting the donor strip

It is advisable to perform an additional 1:1 care inspection prior to each tissue crunch, i.e. to check the tissue for concealed suture punctures or other, not immediately visible problems. The main trunk line is marked with the aforementioned marking technique. The assistant placed the fabric greasy. Not exceeding 15 mm wide, parallel pins are used to raise the edges of the wound so that they form congruent parallel wound flaps during the incision. The fabric is infiltrated with 0.9% NaCl supplemented with 1:1,000,000 epinephrine. For a 1.3-cm fabric width, do not use more than 12.5 ml of the liquid infiltrated in a 1.3-cm wide fabric, since the calculated maximum tolerable tissue expansion in the end-harvested furthest region would not be exceeded. It was said at one time: “The fabric will get wet in order to reduce oil tuberose friction from the instruments in the future so that graft loss is reduced, but you must be careful that (despite the epinephrine additive to the medium) the hair already stops, the follicles remain inactive and do not fall out!”

The two fundamental principles that guide the successful harvesting of a donor strip are the requirement for minimal injury to the hair follicles and the need for a wound that can be closed without tension. Both principles rely on a number of factors, the most important of which is the removal of excess subcutaneous fatty tissue, although also the type, cutting angle, and ratchet structure of the instruments used are equally important. Excessive mechanical loading of the hair can contribute to crush injury in follicular clusters. Excessive heating, especially by friction between the hair shafts, surface injuries such as desiccation of the epidermis or char-like carbonizations, or intracellular atypia of the vascular and perifollicular connective tissue can also sabotage the expected growth. Both principles can be fulfilled with different success depending on whether the donor area is in the occipital scalp or around the ears. Specific aspects of donor harvest from different body areas than the scalp, and the particular needs for body hair and neoplasia are beyond the scope of this chapter.

2.2. Dissection of follicular units

Assisted by two experienced technicians, the physician operates two microscopes. The donor strip is carefully trimmed of surrounding fatty tissue, and intact follicular units are meticulously dissected, trimmed, and placed under minimal mechanical trauma. The dissected grafts are carefully placed into chilled Ringer’s lactate solution for transfer into position. To avoid dehydration, grafts should not be kept outside a specialized holding solution for longer than 6-8 hours. Graft placement is done using the stick-and-place method with no-touch transfer technique to avoid trauma associated with grafting processes. In our experience, a workforce of three people per graft or two technicians and one surgeon in the case of a really trained team produces the best quality graft yield. The maximum length of time a donor graft should stay out of a good medium is 6-8 hours.

The dissection of the follicular units into individual follicular grafts is a critical step in follicular unit transplantation. Graft dissection is performed stereomicroscopically, using sharp, blunt dissecting blades specifically designed for this purpose. The most common graft dissection methods include stereomicroscopic dissection, which is performed on a large table under the microscope, and the “fingers and forceps” method, in which the graft is held with forceps and sectioned between the fingers. Stereomicroscopic dissection is the more widely used method, as it subjects follicular units to less trauma by allowing the operator to separate the blunt fibrous tissue surrounding the follicles rather than cutting through it. The use of cutaway palm leaf forceps with pointed tips has also been recommended for rapid graft dissection with minimal follicular trauma.

2.3. Creating recipient sites

The clinical approach in creating recipient sites has remained similar. That is, the surgeon creates the recipient sites using the same elliptical knife or blade used to harvest the follicular unit grafts. The overall difference between Elliptical Recipient Site Making and Stick-and-Place Technique or Slit Grafting is the creation of the recipient sites with the same instrument to harvest the patient’s follicular units. This method requires a surgeon to utilize and rely on his clinical skills to envision the natural hair alignment of the patient and orient his blade exactly to the hair follicles and not slice the follicular units, shear or lacerate the hair, and make the recipient incisions parallel to the hair shafts iced in the tissue to avoid damage to the roots.

The creation of recipient sites is the step in the hair transplant process that follows anesthesia and nerve block. The step of creating recipient sites is the most invasive step of hair transplantation located on the patient’s skin, as well as the step that is the most important determinant of how the patient’s results will look. Recipient site creation is completely resident with the technical and artistic skills of the hair transplant surgeon. It is absolutely essential to the successful outcome of a hair transplant that the recipient sites are created as close to the patient’s natural hair-bearing skin as possible, completely parallel to the surface of the patient’s scalp, and no larger than the size of the needing skin graft, follicular unit, or follicular unit graft that is to be placed in the recipient site.

3. Recovery and Aftercare

If there is some puffing up of the scalp after more than a week or two, this swelling will generally be caused by the muscle tissue inside the grafts and can be suppressed with a mild steroid. Patients experiencing follicular swelling can easily be treated at the offices of most hair transplant surgeons. Although most patients will respond well to post-operative follow-ups, about 12 days or two weeks after surgery, an antimycotic solution can be applied to the incision sites. Aside from careful surgical technique and the use of minigraft repair on a regular basis, infection is generally very rare. The external part of the scalp, however, often has a bloody appearance for several days after surgery. Moreover, patients will often see hair beam through their incision points relatively soon after surgery. When the hair has a sparser appearance, a T-shirt can easily be pulled over the head.

In general, a patient may return to normal activity about five days after surgery, even though the donor site takes a few days longer to appear and heal. Over a period of weeks or even months, the surface of the scalp can have a scabbed appearance. Scabs usually do not appear over any of the recipient grafts, but any swelling that may arise at the graft site will likely disappear a few days after the procedure. For about a week or two after surgery, the recipient area and donor area will be somewhat pinkish in color. The pinkish color of the scalp is usually caused by the healing of the graft incision points beneath the skin. These incisions are generally made using the smallest possible blades for surgery. The amount of the color that becomes visible often depends on the patient’s complexion.

3.1. Post-operative care instructions

There are no restrictions on physical activities, such as jogging, that will dislodge the grafts. Toe-curling type exercises should be avoided for at least a week, however. There is a significant difference in the comfort level between patients who adhere to this recommendation and those who do not. A comfortable recovery is important for good results. The overall physical health of an individual is also a factor in determining how rapidly the tiny post-operative micro-incisions (microscopic hair transplant sites) “heal” or close down. The only restriction patients are given after their hair transplant is to avoid absolutely all caffeine.

Care of the suture line is the most important part of achieving a good cosmetic result after hair transplantation. If the suture line is kept in pristine condition, the majority of patients should achieve a completely unnoticeable suture line. Upon discharge, the suture line will be cleaned and ointment applied to it. The ointment should be continued for at least the first two days after the procedure, but in many individuals – particularly after the initial few days – the ointment is counterproductive and its use should be discontinued. At that point, after the initial two days or so, the body tends to adapt to the suture line better if it is exposed to the air.

3.2. Managing discomfort and swelling

In most cases, the scalp is the primary complaint for the hair transplant patient with postoperative pain being classified as mild. Post-scalp pain, being Gonzo-Fut or the Mutant-Vibrate method and extremely unlikely to lead to grape-sized scabs or red-edged alopecic areas, does not bother our patients; in fact, they often report being surprised at the lack of postoperative discomfort. The quantity of Medrol is given in a high dose for four days and then tapers down in a stair-step fashion along with the oral prednisone. A small six-day Medrol jar is sent for this 6-day course. The key to a comfortable recovery with as little edema as possible is to ensure the patient completes the pre- and postoperative steroids. There are individual exceptions and predisposing factors that require addressing patient conditions before surgery. For example, a single patient experienced considerable postoperative scalp swelling and pain one month after a septoplasty but at 7 months he still had not regained his old appearance. FUT treatment was applied to the healing surgery to resolve his altered appearance.

While discomfort and swelling are generally minimal following FUT, some patients experience bruising and swelling more than others. Using a protocol that emphasizes refined, atraumatic surgical technique and the combined use of both prednisone tapers and Medrol dose packs for six consecutive days has made pain and bruising an extremely rare event in our practice, so most of our hair transplant patients do not require conventional analgesics. Prednisone does the heavy lifting. Prednisone is a highly effective anti-inflammatory drug. It is more effective than over-the-counter anti-inflammatories like ibuprofen, and less likely to cause bleeding problems during surgery. An oral prednisone taper is given to our hair transplant patients postoperatively, with or without accompanying lenin. Additionally, while postoperative patients have come to feel that hydrocodone is a good postoperative analgesic to control pain, it is also an effective cough suppressant and people really love it after their FUT procedure because steroids give people a hacking cough.

3.3. Hair care tips after FUT

Therefore, in this part we will focus on the care of hair after a follicular unit transplantation procedure. This information can be especially helpful to patients who have or are ready to have a hair transplant, even if this article can be of importance also to other patients who are worried or was made shaved in another way. However, the same applies as to some less common hair problems like scalp diseases (such as lichen planopilari) and more gradual hair loss like female or male pattern baldness. In any case, in relation to hair problems or treatments, nothing is a substitute for the opinion of professionals who can physically look at the scalp and hair, measure the density and diameter of the hair, and take a piece of the scalp to look under the microscope. Also, hair grows and changes from year to year, and it is not always easy to compare the appearance or hair count from a photo taken at different times. Let us also be honest about the fact that treatments often have their limitations.

It may be that the hair growing from your scalp is still growing at its usual speed and rate, but something has changed. You suddenly notice your hair in the mirror looks thinner and that you have no control over it anymore. Additionally, you may have noticed more hair than usual in your brush or comb, on your pillow, and even in the shower drain. What is going on and what can be done about it?

4. Results and Considerations

The determination of an average graft can be read for each separate area of the scalp, e.g., frontal, crown, and mid-scalp highlights. If more than one meeting may be desired for full aesthetic appearance, treatment planning and transition must be discussed. Good communication between the patient and the physician is crucial in determining the final aspect of transplantation. As for the actual numbers, to ensure that his/her density after transplantation is strong because the physician relies on large graft counts, the patients must appreciate that they may need multiple treatments to achieve the desired density if they have minimal previous characteristics, e.g., anisotropy, grey hair. If the final density desired is quite great, long-term planning for crowd movement is all the more critical since it is all too easy to leave the donor and patient in a situation where coverage of the necessary bald will never be achieved.

The final density will usually be less than when a single hair graft is placed, but a great deal of fullness can be obtained with proper design, follicle trimming, and a relatively even clinical graft count. As a rule, hair grows just like most of it placed only 1/2 or more inches (12 cm) away. As the first example mentions, coverage obtained with 35-55% of normal 2 1/2-inch-long hair density is also achieved as more than thin or medium length. The angles, direction, and non-use of few-berry grafts are all important considerations. The growing hair is cut from and fills in the thin areas.

4.1. Expected outcomes and timeline

The transplanted hairs generally start to grow at a rate of about ½ inch per month but this rate can slow down later on and the hair is generally at the full length. The hairs continue to grow and thicken for a noticeably longer period of time starting at 6 to 9 months post-surgery than all of the timeline charts you find in hair transplant brochures and websites. The idea resolution of the hair restoration surgery in terms of density and other cosmetic improvement starts to become apparent several months post surgery and the full results start to show at around 18 months post-surgery in moderately balding individuals. Out of the 100% donor hair that are included in the transplanted follicular unit grafts, about 80% to 90% will grow back along with the other pre-existing hair growing back at the same rate.

After the transplantation, the hairs of the grafted follicular units are gone within the first few weeks. After the first trimester, the hair starts to grow back as thin, weak, short hairs that get better and stronger over time. All of the follicular unit grafts from the FUT transplant initially produce the hair follicle and it takes about 6 to 12 months to fully regrow with the non-transplanted hair also starting to grow at this time. It generally takes about 12 to 16 months for the hair follicle to develop. The transplanted hair in the first few months will shed and many people experience much anxiety about this along with skepticism that the hair regrowth will be fully completed.

4.2. Potential risks and complications

The scalp is rather poor in nervous endings so the patient will himself realize the occurrence of this damage usually is when he finds difficulties to smile (zygomatic), to close his eyes (ciliary) or feels the cutaneous loss of sensitivity behind his ear. Generally, sensitivity will recover 1 year after surgery ends. Before that, it will be sometimes painful like an “electric shot”. Often, especially sensitive patients will even sometimes mind synchronous causes of momentary pain walking. Scalp thinning occurring in the strip area in the temporal region is possible, but really rare and only significant in face lift before this period. Patients who have had several transplants sometimes present a wide but very thin flabby strip that doesn’t want to close again because this zone was already strip harvested with several centimeters distance. Generally, it may be tissue depleted by too large multiple procedures inadequate prior.

The risk of major complications following FUT, namely scalp infection, hematoma or nerve damage, is generally 0.15 to 0.3%. Infection outcome depends on center organization. It may happen in the first postoperative week but currently these infection rates are extremely low. Even if there are unpredictable factors (hygiene of the head skin, scalp lesions occurrence mainly on the recipient site due to the postoperative edema…), overall, a rigorous asepsis during the procedure and the antibiotic prescription will minimize this infection risk. Hematoma is an inconvenience not truly life-threatening but it’s painful for the patient and a few large hematomas still experience a raucity difficult corrective surgery. This is due to a partial compression dressing that can be used in less experienced teams. However, a tissularized closure will reduce spontaneously its risk. Peripheral nerve damage is mostly transient in the donor area or behind an ear; its incidence is at 0.2%.

4.3. Factors to consider before undergoing FUT

It is important that physicians understand the current state of hair restoration and also be prepared to embrace future techniques. It is also important that patients are given the utmost attention, care, and medical oversight before, during, and after their surgery. A patient’s concerns also require due consideration. It is also important for the physician to continue to improve the field and to contribute to the field whenever he or she can.

Doctors with great skill will continue to perfect new techniques, and newer techniques will be performed mostly by leading physicians. I still believe that experience is the most important aspect in the hair transplant procedure. “As time goes on, the good doctors will continue to get better, and the inept physician will be lost”. Experience in the FUT procedure as well as in the new and future procedures will always be important.

In my opinion, I think that hair restoration surgery should be only performed by surgeons who are very experienced and talented. The future of hair restoration surgery casts doubt upon the young hair transplant surgeon who has meager experience. As the advances in the hair transplant field manifest, the mediocre young transplant surgeon will soon become inept and will have to adapt to the new requirements. In the immediate future, as techniques improve, experience and skill will matter even more. “The transplant surgeons of tomorrow will be divided into the ‘have not much’ and the ‘have a lot'”.

Then, it is a matter of determining if the patient has an adequate supply of donor hair. One should have an adequate amount of donor hair, which is not miniaturized and is not in the process of miniaturization. This can be determined by a detailed physical examination and scalp examination.

There are many factors and issues that need to be taken into consideration before a prospective patient should decide to undergo hair transplant surgery. First, the patient should be in good health. Good health can be determined through a physical examination prior to surgery. Hypertension, seizure disorders, and blood thinning agents may complicate the surgical procedure. These important issues should be discussed with the hair restoration surgeon.

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