Procedures

Hair transplant strip surgery, has been the primary method of surgical hair restoration since the early 1990s. Though it might be deemed as antiquated by the internet and hair transplant marketers, it marked a significant advancement in clinics’ operations and patients’ expectations regarding healing, pain management, scarring, and final aesthetic results.

In the 1990s, “mini-micro grafting” was the prevalent procedure, involving the hiring of additional clinical technicians to assist with the surgery. These technicians would “sliver” and dissect hair bundles into grafts with varying hair counts, based on the clinic’s aesthetic approach. However, with technological advancements, modern techniques have now surpassed mini-micro grafting.

Follicular Unit Transplantation (FUT), introduced in the mid-1990s by Dr. Limmer of San Antonio, Texas, revolutionized surgical hair restoration. With FUT, stereoscopic dissecting microscopes replaced jeweler’s loupes, enabling the identification and harvesting of individual natural bundles of hair called follicular units. These units contain one to five hairs, resulting in smaller grafts for transplantation, offering increased naturalness and reduced scarring in the recipient zone.

The typical FUT procedure includes the following steps:

1. Patient Candidacy Confirmation: The doctor assesses the patient’s physical characteristics, including the donor zone’s laxity and density, to determine the total number of grafts needed.
2. Prepping the Patient: Various medications, including antibiotics and anesthetics, are administered to the patient for pain management and to prevent infections.
3. Donor Strip Removal: The patient either sits or lies down, and the doctor shaves a narrow strip of hair from the donor scalp for better visibility. Tumescence (inflation) of the donor zone is done to minimize follicular transection.
4. Dissection Process: The donor strip is cross-sectioned into fine slivers, which are handed off to technicians for further dissection into individual follicular units.
5. Recipient Site Incisions: The doctor makes incisions in the recipient scalp, either shaving the area or using magnification for precision.
6. Graft Placement: Technicians (in most cases) place the dissected grafts into the recipient sites, with some doctors overseeing the process while others leave it entirely to the technicians.

Despite the advent of newer techniques like Follicular Unit Extraction (FUE), FUT remains a great option for the right candidates, especially those destined to experience extensive baldness or those presenting with advanced baldness. For such patients, FUT can provide excellent results and should always be considered as a viable option in their hair restoration journey.

Follicular Unit Extraction, or FUE, has emerged as the latest hair transplant surgery, gaining popularity since the early 2000s. Unlike the traditional Follicular Unit Transplantation (FUT) that involves a linear strip harvest, FUE utilizes small-diameter surgical punches to extract individual follicular units, resulting in minimal scarring in the donor area.

How is FUE Performed?

1. Donor Area Evaluation: The first step in FUE is to evaluate the donor area’s characteristics. The surgeon assesses the donor zone’s density and evaluates the suitability for extracting individual follicular units.
2. Prepping for Surgery: Once the patient is deemed a suitable candidate for FUE, various medications, including antibiotics and anesthetics, are administered to prepare for the procedure.
3. Harvesting Donor Grafts: During the surgery, the surgeon uses small-diameter surgical punches, typically ranging from 7mm to 1mm, to score the skin and extract individual follicular units from the donor scalp tissue. Each graft contains one to four hairs, depending on the targeted follicular unit.
4. Separating Grafts: After extraction, the grafts are carefully separated based on the number of hairs in each bundle. Single hair grafts are placed along the frontal hairline and central crown, while multi-hair grafts are used to add volume and coverage behind the hairline and in the mid-scalp.
5. Recipient Site Creation: The surgeon starts making incisions in the recipient scalp, where hair is needed. Some clinics may require the recipient zone to be shaved for better visibility, while others use magnification to aid the incision process without shaving.
6. Graft Placement: Technicians then place the extracted and separated grafts into the recipient sites created by the surgeon. The placement process ensures the natural orientation and distribution of the hair, achieving a natural-looking result.

Over the years, FUE has significantly improved its graft yield, making it a competitive alternative to FUT. Donor limitations in FUE are based on pre-surgical donor density and extraction patterns. Efforts have been made to reduce “patterned” extraction, where reduced density in the donor area creates unnatural box-like patterns, affecting the aesthetic outcome.

Another limitation lies in the visual threshold of donor area management. While FUE can technically harvest more grafts than FUT, there’s a limit to maintain a visually appealing donor appearance. The concept of “donor homogenization” aims to balance density between the donor and recipient zones, allowing for higher graft numbers over multiple procedures.

Despite its early challenges in graft yield, FUE has gained significant market share with FUT and has become the dominant hair transplant procedure being promoted and performed today.

In conclusion, FUE represents a significant advancement in hair transplant surgery, offering patients the option to avoid a linear scsr. As FUE techniques continue to evolve, it is expected to maintain its popularity and play a crucial role in the field of surgical hair restoration.

Direct Hair Implantation (DHI) is a variation of the Follicular Unit Extraction (FUE) hair transplant surgery. DHI, also known as the “stick and place” technique, involves a unique approach where the surgeon uses an implanter pen to create recipient sites and simultaneously implant the grafts into these sites.

What is an Implanter Pen?

An implanter pen, also known as a DHI implanter, is a specialized medical device used in DHI for graft placement. It consists of a hollow needle-like tip designed to hold the extracted graft securely. Once the grafts are loaded into the implanter pen by technicians, the surgeon uses the pen to create tiny incisions in the recipient scalp (stick) and directly implant the grafts into these sites (place).

Steps of DHI – Stick and Place Technique:

1. Donor Area Evaluation: The DHI procedure begins with an evaluation of the donor area to determine the suitability for extracting individual follicular units.
2. Prepping for Surgery: The patient is prepared for surgery with necessary medications, including antibiotics and anesthetics, to ensure a comfortable and safe procedure.
3. Extraction of Follicular Units: The surgeon uses traditional FUE methods, such as manual or motorized punches, to carefully extract individual follicular units from the donor area. These grafts are then collected and prepared for implantation.
4. Loading Grafts into Implanter Pen: Skilled technicians load the extracted grafts into the hollow tip of the implanter pen, ready for the surgeon’s use during the stick and place procedure.
5. Stick and Place Technique with Implanter Pen: The surgeon takes the loaded implanter pen and skillfully uses it to create tiny incisions in the recipient scalp. Simultaneously, the grafts are implanted directly into these sites.
6. Post-Surgery Care: Once the graft placement is complete, the surgeon ensures that the recipient area is appropriately covered. The patient is given post-surgery instructions to promote healing and maximize graft survival.

In conclusion, Direct Hair Implantation (DHI) with the stick and place technique offers a distinctive approach within the FUE hair transplant method. By utilizing implanter pens, such as the Choi implanter, Lion implanter or other available devices, for both recipient site creation (stick) and graft placement (place), DHI presents an alternative method of graft placement that some surgeons have adopted and prefer.