Correct marking of direction and size of the incision is a standard hair restoration procedure

Hair restoration procedure Hair transplant recipient site preparation and implantation

Hair Transplant Recipient Site Preparation and Implantation

Below is an overview of the step by step procedure involved in hair restoration surgery. This applies primarily to procedures using follicular unit transplantation, but a similar approach will be used in other types of hair restoration surgery.

Implant site preparation

To prepare you, the hair transplant patient, for receiving the graft implants, you will be asked to sit in a surgical chair or in a semi supine position on a surgery table. There are arguments about which position is more comfortable and which leads to fewer complications with the procedure. So far no clear winner has emerged. The advantage of the semi supine position is that it reduces the chances of fainting or dizziness during the procedure. This can happen before the anesthesia is injected into the implant area, but rarely happens once the anesthesia takes effect. On the other hand, a sitting position reduces the amount of bleeding when the grafts are being implanted. The vertex (front and top of the scalp) has a high density of blood vessels in it. When the skin is cut on the scalp it can bleed quite a lot. A sitting position helps drain blood away from the scalp and in so doing reduces the amount of blood that bleeds from the implant wounds. Some surgeons may arrange for you to lie down for the initial anesthetic injection and then have you sit in a chair for the implant procedure to get the best of both approaches.

The hair line

The area of skin for implantation is sterilized by swabbing with an antimicrobial solution. Anesthetic is injected locally in the area of skin ready for implantation. Once the anesthetic has taken effect, the implantation procedure can begin. For those with classic androgenetic alopecia in a male pattern and recession of the frontal hair line, the hair line is the first problem to be addressed. The surgeon, rather than any assistants, should be the one to make the incisions for the graft implants that will form the hair line. In general the surgeon will also be the one that fills the hair line incisions with grafts, although sometimes a nurse will do it. The hair line is the most important part of any hair restoration procedure. This will determine whether the result looks natural or artificial. For the hair line to look as natural as possible, the surgeon must make the line reasonably bilaterally symmetrical although perfect bilateral symmetry of the implanted hair line is unlikely. The hair line needs to adjusted on each side depending on the shape of the face - particularly if your face is not very symmetrical! When the hair follicles are actually implanted, only the small one, and occasionally two, hair follicle unit grafts are implanted into the hair line. They may not be in an exact line as, if you look at a natural hair line, there are always a few odd follicles out of line. A very slight “wiggle” in the hair line makes it look just that much more natural.

Making the incisions and inserting the hair follicles

Different hair transplant doctors have different personal preferences for how they make the incisions into the skin ready to receive the hair follicle grafts. Some use needles of 16-18 gauge – which is pretty small. Others use small scalpels and make little slits in the skin into which the implants can be squeezed. A few hair transplant surgeons still use punch biopsies, although punch biopsies are only made as small as 2mm which is, for the most part, too large for the modern practice of follicular unit implantation. There are also some special implantation devices available that some surgeons use. Regardless, the objective is to make nice clean, small wounds ready to receive the hair follicle implants. The hair follicle units are then pushed into the small wounds using watchmaker’s forceps. Because the follicular units are so small and there are often many of them to implant, there are usually two nurses working on either side of the head to speed up the implantation process. Time is important, the longer the hair follicle grafts are lying in cold saline the longer they are away from nutrients in the blood that they need to grow. This is probably why it takes so long for transplanted hair follicles to grow after a procedure. The hair follicles have been starved and that usually sends them into a state of suspended animation (telogen). Once the grafts are healed in and they start receiving food via the blood again, so the hair follicles can repair themselves, rearrange themselves and start growing hair.

Pattern of implantation

The pattern of incisions and hair follicle implantation is very important for ensuring a natural looking result. Hair follicles grow at an angle over the scalp and the angle changes depending on what area of the scalp you look at. For most people, though not everyone, the hair on the top of the scalp grows in a clockwise whorl pattern with the center of the whorl at the vertex. For this reason, if there is a parting it is usually on the left hand side of the scalp. It is much harder to part hair on the right and have the hair lay flat. Because of this whorl pattern, the surgeon will similarly arrange the implanted hair to match this natural hair growth whorl. The hairs will be implanted into the skin at an angle consistent with any remaining hair and pointing in a direction that follows the whorl pattern. The parting is also an important consideration for the surgeon. He/she may implant hair follicle units at a slightly higher density around the natural parting than on the opposite side of the scalp. This will help give the parting a normal looking hair follicle density.

Whilst the ideal is to give you a normal hair density in a natural growth pattern over the entire bald area, the limitations on how many donor hair follicles you have and the size of the recipient area to cover will modify the nature of the implantation. If there aren’t enough hair follicles to transplant, then the surgeon may implant more towards the front of the head than the back so that the hair can be grown longer and combed back to cover the thinner areas behind. The surgeon must also modify the implantation when there is more than one surgical procedure in the complete hair restoration. If subsequent transplant sessions are expected, then the implanted follicles may be more spread out than would be expected with just one implantation procedure. The surgeon is leaving room for hair follicles to be implanted in the next session in between the grafts implanted in the current session. This means the total hair restoration is built up over multiple session, and until the final session is done, it is not possible to determine just how natural (or not) the transplant looks.

Eventually all the grafts should be implanted and the basic procedure is complete.