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Hair transplant is a method that is constantly gaining ground in our days. Hair loss has been troubling many men and women ever since antiquity, and still is a source of psychological issues, especially in today’s challenging times. Nowadays hair transplantation is the most common cosmetic procedure in men in the Western world. This field of medicine is evolving day by day at fast pace and with impressive, natural results.

According to the ISHRS (International Society of Hair Restoration Surgery), the number of hair transplants performed worldwide is growing with approx. 18-20% per year, with the highest growth rates recorded in Asian countries (China , India) and the Middle East.At the same time, hair transplants that aim to restore eyebrows or facial hair are becoming more and more frequent. In recent years, the expansion of the modern FUE hair transplantation method, which allows hair restoration without causing permanent marks or scars in the donor site (as was the case with the older FUT or strip technique), in combination with the natural-looking results that can be achieved, has contributed to even greater popularity of hair transplantation and has caused the decline of older, non-medical techniques whose goal is to cover the scalp such as prostheses or wigs, the use of which is waning constantly.

Apart from conservative therapies, hair loss can be treated surgically with hair transplantation, which addresses patients who have not been able to halt their hair loss and wish a definitive solution to their problem. In order to achieve the best possible results, surgical restoration is best combined with simultaneous medication against hair loss, combining the growth of new hair with maintenance of the existing hairs. Modern treatments such as PRP (Platelet Rich Plasma) have contributed to even better address the phenomenon of hair loss; meanwhile, medical research continues intensively, so that in future it may be possible to use stem cells against hair loss or to clone hair in the laboratory (hair duplication).

Moreover, beyond the prevalence of the new FUE technique (Follicular Unit Extraction), some very interesting technological developments have made an appearance in the field of hair transplantation, such as robotic hair transplantation, which, although not yet perfected to a satisfactory degree, are promising if evolved further.

OLD and NEW Hair Transplant techniques

The first hair transplantation procedures that were introduced in the 1960s and continued to be applied for about 40 years, were characterized by their extremely invasive, painful and bloody nature and very poor cosmetic results.

Plastic surgeons were the first to use relocation of skin flaps from the scalp with intact blood supply (flap surgery) in order to cover skin defects or bald areas. In these operations, a portion of the bald part of the head was excised and covered by a flap of skin originating from adjacent areas of the scalp. These interventions were particularly painful and bloody, were usually performed under general anaesthesia, and the cosmetic result was usually very poor. In today’s plastic surgery, the application of skin flap transplants is still continued for specific indications, such as major detachment of the scalp skin due to injury, extended damages of the skin due to full depth burns, in cases of extensive skin cancer, etc. The use of skin flaps for surgical restoration of androgenetic alopecia, on the other hand, has practically been abandoned and is referred to here for historical reasons only.

One other plastic surgery technique for the treatment of male baldness that has seen widespread use in the past, was the so-called scalp reduction. In this procedure, a portion of the bald skin was excised, the adjacent skin was stretched with proper undercuts, and the wound was then sutured with the objective to reduce the extent of the bald part of the scalp. These operations were characterised by the existence of large and malformed postoperative scars and poor cosmetic results.

A modern, improved version of the scalp reduction technique that is used for cases of extensive skin absence or extensive scarring of the scalp due to burns or injuries, is the use of tissue expanders. In this procedure, which is typically performed under general anaesthesia, a tissue expander in introduced subcutaneously into the healthy portion of the scalp, and the wound is sutured. Next, over a period of 8-12 weeks, the tissue expander is gradually stretched with saline, which also results in a gradual stretching of the overlying skin of the scalp. When the dilatation is completed, a second surgery follows in order to remove the tissue expander and to excise part or all of the bald or scarred portion of the scalp; the gap in the skin then covered using the excess stretched skin of the scalp. This complex, lengthy and painful process has certain serious remedial indications, but is not used to cover male pattern baldness for aesthetic reasons, because of its highly invasive nature.

In the 1980s, the technique of punch grafting appeared, in response to the growing need for less invasive hair restoration techniques, as it began to be understood that head hair grows in groups. In punch grafting, a circular knife (punch) of a large diameter (typically 0.5 mm) is used to remove a total of 20 to 30 hairs, which are then placed into a hole with a smaller diameter (typically 0.4 mm) which has been drilled into the receptor area of the bald part of the head. Punch grafting was widely adopted during the decade of 1980-1990 but was gradually abandoned, as it was quite traumatic and bloody technique, characterised by unnatural cosmetic results, as large grafts of 20-30 hairs (plug grafts) can not be placed too close to each other and do not mimic the natural follicles that are much thinner, especially in the hairline. The unnatural appearance of these plug grafts became known as the ‛doll-like effect’. In recent years, punch grafting has practically been abandoned, but there are still numerous cases of patients who have undergone hair transplantation with the punch graft method, who now resort to plastic surgery in order to restore the scars and the unnatural hairline with FUE.

Today, the methods used in hair restoration are two: FUT (Follicular Unit Transplantation) or strip technique, and FUE (Follicular Unit Extraction), which is the most modern technique. FUT came into use in the early 1990s and is performed with surgical resection of a portion of skin and hairs from a donor site at the back of scalp. The excised hairy skin section is submitted to a special treatment under the microscope and separated into grafts which are then inserted in the bald area. Depending on the technical training and experience of the team performing the FUT session, the grafts that are obtained in this manner can either be minigrafts (with 4-8 hairs) or micrografts (with 1-3 hairs). The skin in the donor site is sutured, leaving a permanent scar, the diameter of which depends on the suturing technique and the width of the missing strip, while malformed postoperative strip scars that need cosmetic restoration are not uncommon. Better results in the final appearance of postoperative strip scar seems to be presented when the more modern technique of so-called trichophytic closure technique is being used. The production with FUT or strip technique of typically large diameter grafts with several hairs, which are not similar to the normal hair follicles of the scalp, often leads to unnatural aesthetic results, especially when multiple-hair follicles are implanted in the hairline.

The most modern technique in hair transplantation today is FUE (Follicular Unit Extraction), which is done by transferring individual hair follicles from the occipital region to the thinned area. FUE was originally described in 2002-2003, when it was still in an experimental stage, and has since evolved gradually. Initially it was possible to transfer only a few hundred hair follicles, but today, with the use of automatic extraction devices, it is possible to perform sessions with several thousands of hair follicles in one day. FUE has significant advantages over FUT, as the latter leaves huge, unsightly scars that remain permanently visible at the back of the head and possibly will remain painful for life. FUE, on the other hand, offers great aesthetic results without scars, pain or discomfort of the patient.

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