Hair transplant

FUE (Follicular Unit Extraction) is a hair transplantation method by which individual hair follicles are transferred; it has been used since 2003. It is the most modern method of hair transplantation and tends to prevail worldwide thanks to its minimally invasive nature. The procedure of hair transplantation with FUE requires extensive and specialised training of the plastic surgeon, as it is a very precise and difficult technique that is considered extremely demanding. FUE sessions usually last several hours, as each hair follicle is extracted and implanted separately under magnification. Learning and mastering the FUE technique requires from the surgeon to monitor and perform hundreds of interventions in order to reach a satisfactory level of speed and quality both in the extraction and implantation of the hair follicles.

Very few doctors today are specialised in FUE. Plastic surgeon Dr. Anastasios Vekris can count himself among the most acknowledged experts, with experience of thousands of hair transplant surgeries in Greece and abroad. Dr. Anastasios Vekris has trained many Greek and foreign physicians and has established many hair restoration clinics in Greece, in Europe and in the Middle East.

The procedure that is being followed during an FUE hair transplant session is the following one: The physician first plans the donor area, the area from where the grafts will be extracted. For the application of local anesthesia is being used a lidocain-adrenalin solution. Hair follicle units are removed by a special automated device, easily, quickly and painlessly, and are maintained in a moist environment at 3-4 °C. The area of implantation is then determined and the doctor proceeds, under local anaesthesia, to the surgery. The implantation of the hairs is performed one by one, using a special device. The procedure doesn’t require the creation of holes at the receptor area (One-Step Implantation, FUE Direct). Thus, the trauma in the receptor site is minimised and the results are completely natural.

Hair growth reaches 95-98%. Most hairs are maintained from the very beginning, while some may fall out during the first two months and gradually grow back. A percentage of 70-80% of the final result is achieved after 4-6 months, and 95-100% after 12 months. Typically, the new hair growth is completed earlier in the region of the forehead, and may be delayed by several months on the crown. The new hair behaves and grows naturally and can be cut as it normally happens for regular hair.

At Advanced Hair Clinics, Dr. Anastasios Vekris after years of experience and research has developed the hair restoration technique One Step Implantation or Advanced FUE, by which the grafts are implanted directly in the affected area under the right angle, without creating holes or causing traumas to the skin.

Hair transplantation is currently the most popular cosmetic treatment amongst men, and is no longer reserved just for the few. Patients do not hesitate any longer to discuss their problem with dermatologists and plastic surgeons, who are the only specialist doctors to diagnose and treat hair loss. Hair transplantation has three main objectives:

Achieving uniform and complete coverage, without permanent injuries to the donor and recipient sites or the creation of permanent scars.

Offering natural-looking results with proper distribution of hair and a natural hairline. This is achieved by using thin, single-haired follicles in the hairline in a wavy or zig-zag arrangement.

Accomplishing maximal density, depending on the needs and particularities of each individual. In general, a density of 50-70 hairs/cm² is considered to be acceptable, but if a good donor site is available, the problem is limited, and high density of the new hair is desired, densities of more than 120 hairs/cm² can be achieved.

According to statistics, 2010 saw a doubling of hair implantation procedures in relation to the previous decade. Since then, the number of hair transplants worldwide increases by about 20% annually. Hair transplantation can be performed:

• In men and women who suffer from androgenetic alopecia
• In men and women with cicatricial forms of hair loss
• In cases of eyebrows’ thinning
• In cases of facial hair’s thinning
• For the coverage of scars caused by FUT (Strip) technique or scars due to injuries or burns
• In cases where the patient wishes to lower his/her hairline

Any man or woman aged 18 or older can undergo hair transplantation. Due to the minimally invasive nature of the modern FUE technique, which is performed under local anaesthesia, practically anyone can undergo the procedure, with the exception of patients with very serious health problems, such as a recent myocardial infarction or stroke, or under conditions of severe immunosuppression. Therefore, with the exception of patients who suffer from very serious pathological conditions (e.g. severe heart disease, severe immunosuppression, etc.), all adult men and women are suitable candidates for hair transplantation.

Special categories of patients, e.g. patients with cardiac or respiratory problems, diabetics, patients with clotting disorders, patients with thyroid diseases, etc., can safely undergo hair transplant, subject to prior discussion between the hair surgeon and their physician and subject to appropriate regulation of their medication. Ideal candidates are those with relatively restricted and well-defined alopecia of level I-IV on the Norwood scale, with a good donor site and relatively stabilised hair loss. Small scars that have been stable over time can be treated equally effectively.

On the other hand, less good candidates for hair transplantation are men with a high degree of thinning (level V-VII on the Norwood scale) with a small or thin donor site, and women with diffuse hair thinning, where either the distance between the hairs in the receptor site is not enough to securely install new hair follicles, or the donor site is equally thin and weak. Generally, it is considered that a donor area with a density of less than 90 hairs/cm² is unsuitable for transplantation.

Regarding the frequent question of what is the right age to proceed with hair transplantation, the answer is that it should be performed when the thinning is now evident and negatively affects the patient’s psychology. The clinical expression of androgenetic alopecia varies considerably from person to person, with the result that there are young men, even under the age of 20, with very extensive hair loss, at Norwood V level and above. In contrast, there are patients older than 60 years of age with very little thinning, at Norwood level II-III. The age of the first session is therefore determined by the clinical picture of each patient and, above all, by the psychological impact of hair loss on the individual patient. It is therefore preferable to start the first hair implantation session at an early age before losing all of one’s hair and to repeat it a few years later.

Since androgenetic alopecia is a gradually evolving condition largely related to the action of androgens in the body, hair loss and the gradual thinning it causes accompany the patient throughout his or her life after puberty. However, particularly between the ages of 20 and 40, the phenomenon of hair loss is quite pronounced. When the first hair transplantation session is carried out at a young age, it is almost certain that a second operation will probably be needed in the future because of the continuing hair loss.

The doctor who will perform the hair transplantation is one of the most decisive factors for the success or failure of the operation. International standards require specialised training in hair transplantation by plastic surgeons or dermatologists, who ideally should be members of the International Society of Hair Restoration Surgery (ISHRS). The training in hair restoration must be comprehensive and cover the fields of modern techniques and the FUT or Strip method, but also of the FUE technique, as well as restoration of failed cases and restoration of scars created by earlier transplantation techniques, such as FUT or Strip.

The training of a doctor who is considered experienced in hair transplantation should also include restoration of special cases such as female alopecia, transfer of hair from other areas besides the head (face, beard, chest, back, etc.), and restoration of special areas such as facial hair (moustache, beard, sideburns, eyebrows and eyelashes).

The skillfulness of the doctor is the primary factor for the success of the result; he plays a key role in the transplant team, performs the local anaesthesia required for the extraction and implantation of the hair follicles, and prepares the design of the hairline and the distribution of the hair follicles.

Every case is examined individually and the cost of each hair transplantation session with FUE varies. The price for a hair transplant depends on the extent of the problem, the number of grafts implanted, the possible difficulties during surgery, and the duration of the session. The duration of a long one-day session ranges from 7-8 hours. The cost will rise significantly if larger areas need to be covered, which typically require two-day sessions in order to achieve full coverage. In cases where a few dozen follicles are required, e.g. to cover a small scar, the cost is quite low. Therefore, the cost increases according to the duration of the session. Cases in which a prior treatment with strip technique (FUT) has caused considerable damage and scarring in the donor site are more difficult, but do not change the cost of the session.

Specialised interventions with an increased level of difficulty are the thickening of the eyebrows and facial hair, the use of body hair, and the so-called unshaven FUE sessions. Provided that the donor site is very good and the hair is cut short, one long daily session allows the transplantation of 2000-3000 or even more follicles, equivalent to more than 6.000-8.000 hairs, achieving excellent density and coverage, if distributed correctly.

At Advanced Hair Clinics, the calculation of the cost is based on the duration of the session that is required to cover the bald area to the fullest possible extent, with optimum density, with no upper limit to the number of hairs or hair follicles to be extracted and implanted, under the sole condition of safety and health of the donor and receptor sites. We find the approach of some hair transplant ‛clinics’ to charge their sessions according to the number of hairs or hair follicles highly spurious and misleading, since the patient is not in any way able to count the hairs or hair follicles implanted during a session.

Hair transplant surgery is the most effective treatment for hair loss. The two most widely used hair restoration procedures are FUT and FUE, but today FUE is the most popular and medically recommended method for the following reasons.

• It is a minimally invasive procedure with no incisions or stitches.
• It is not a painful procedure, unlike FUT.
• Faster recovery time, usually patients can go back to work two days after the procedure.
• The results show a perfectly natural appearance, they are permanent and the technique leaves no permanent linear scars and marks on the back of the head.
• At Advanced Hair Clinics we use the advanced FUE technique, with success rates approaching 100%.

Hair transplantation is a completely safe procedure. It is performed at the clinic, under local anaesthesia, while the patient is awake and can talk, listen to music or even watch TV. Any inconvenience that maybe caused to the transplantation area is negligible. Most patients feel a little pulling in the donor site for 1-2 days. Mild analgesics rarely need to be prescribed. The area should be kept hydrated during the first 3 days with regular sprays of saline.

Some of the new hairs may be shedded during the first 2-8 weeks, but this does not have to worry the patient, as the roots remain and will produce new hairs over the following months. This effect can be minimised by the use of minoxidil 5% immediately after the operation. The next day after the hair transplant, the patient visits the clinic where the donor and receptor area are checked and the hair is carefully washed for the first time. After 3-4 days the patient can return to work, as it is not noticeable that the patient has undergone a hair transplantation. Finally, it is recommended to avoid intense physical exercise and swimming for one week.

In the case of an unshaven FUE session, the patient can return to his professional or social activities within 24-48 hours, as there are no visible signs of hair transplantation because the new grafts are implanted between the existing hairs.

With modern techniques, we do not create holes with scalpel or scissor cuts for implantation of the grafts, nor do we use large amounts of saline. So the chances of the patient experiencing swelling after surgery are only 1% to 2%.

When low-quality techniques are applied, such as a large amount of injected saline or an excessive number and size of sockets are opened in the recipient area, the chances of swelling increase. Also particularly increased are the chances of severe swelling that descends into the eyes and looks like we have been punched when preventive treatment to avoid it has not been taken, usually with topical or injectable cortisone.

To avoid such complications, it is important to choose a Clinic with proven experience and expertise.

With FUE method, complications such as mild folliculitis or a small swelling of the forehead are few or none, occurring in percentages of under 1%, and subside immediately.

Folliculitis, which is a local inflammation in the new follicles that appears during the first or second week after the operation, will subside with the topical use of an antiseptic shampoo and antimicrobial lotion applied for a week.

Post-operative swelling in the region of the forehead or around the eyes rarely occurs; it may appear approximately 24-72 hours after the completion of the hair transplantation session, and can be minimised by taking cortisone orally for 3-4 days.

Another immediate complication is a small degree of local bleeding in the site from which the hair follicles were removed. This is a common complication after the FUT or Strip method, but is very rare in cases of transplantation with the FUE method.

One more delayed side effect of hair transplantation is the absence of hair growth due to technical issues, inexperience of the transplantation team or doctor, improper maintenance of the hair follicles, or incorrect implantation. An additional, delayed, side effect of hair restoration may be an unnatural effect, due to bad alignment of the hair follicles or wrong design of the hairline.

The possible side effects of hair transplantation, whether immediate or delayed, are usually preventable and can be avoided by proper selection of candidates or appropriate medication (in cases of immunodeficiencies such as diabetes, and in cases of people who cannot, safely, undergo local anaesthesia). For example, if a patient has recently suffered acute myocardial infarction, the procedure should be postponed to a later, safer time. Alternatively, in such cases the patient should have to be regulated with appropriate medication. In the case of diabetes mellitus, the patient should take broad spectrum antibiotics in order to avoid the aforementioned side effects.

On the contrary, FUT technique is often accompanied by complications such as chronic pain in the region of the scar, numbness in the skin above the scar, and the formation of a hypertrophic or unsightly scar. Aesthetic issues after a session with FUT or strip technique are frequent, as an unpleasant side effect is the formation of a permanent scar in the donor area which may become visible when the patient cuts his hair short. Actually, many patients who have undergone hair transplant with FUT technique avoid to cut their hair due to the obvious malformed scar. These side effects are avoided with the modern Advanced FUE method, as there are no permanent scars.

If performed correctly with the modern Advanced FUE method, hair transplantation does not have any serious side effects, either immediate or later. In Advanced Hair Clinics, Plastic Surgeon Dr Anastasios Vekris and his team apply special protocols before and after the session that minimize the probability of complications.

Failure of a hair transplantation may be due to factors that have to do with poor patient selection, inexperience of the transplantation team, inexperience and lack of knowledge by the doctor who performs the transplantation, or technical issues that affect the quality of the result. In particular, if the needs for coverage and density and the possibilities of the donor site are not determined first, i.e. no proper preoperative assessment has been carried out, chances are that the clinical outcome will fall short of the expectations of both the patient himself and the transplantation team. Another factor for failure may also lie in the choice of the wrong technique. It has been observed that patients who have previously undergone a scalp restoration surgery with FUT or Strip method and are left with extensive or deformed scars in the donor site, have significantly reduced the width of the donor site and the quality of the hair follicles, resulting in an insufficient donor site to achieve proper results.

As far as the experience of the doctor and the transplantation team is concerned, international standards state that only properly trained hair surgeons who are specialised in plastic surgery or dermatology should be involved in hair transplantation. Nevertheless, it still happens that non-specialist doctors or doctors from other fields of expertise (e.g. ophthalmologists, gynaecologists, general physicians, etc.) present themselves as experienced hair transplantation doctors when in fact they lack both the technical expertise and the required experience. In such cases, many technical errors can occur that lead to failure of the procedure. Failure of transplantation may often be due to technical errors during the procedure, either during the extraction or the implantation of the hair follicles, but usually in the implantation phase. These errors are related to damages to the hair follicles during extraction or during cross sectioning (destruction and reduction of growth potential).

Errors may be associated to a large extent with poor maintenance of the hair follicles after they have been extracted from the head. The main factors for better survival of the hair follicles are humidification and storage at low temperature. If the follicle dries out or is maintained at high temperatures, damages occur on a cellular level that may affect its viability. This is also a factor that may lead to the failure of a transplant. Finally, during the placement of the follicles there are several factors that can lead to failure of the procedure, in particular with respect to the depth of implantation of hair follicles. If the follicle is planted too deep, it may be encapsulated in the skin during healing, and lead to formation of a cyst. On the other hand, if positioned too superficially it can lead to dehydration, drying and eventually loss. Technical errors during installation of the hair follicle are considered the most common factors that lead to failure of hair transplantation.

The results of hair transplantation with the FUE method are stable and permanent. They start to appear as early as one week after implantation. The hairs will develop gradually and there may occur a phase of hair loss between the second and eighth postoperative week. Regrowth of the lost hairs will start towards the end of the second month after transplantation and will gradually be completed within twelve months. There is research that shows that in 5% of patients, the results of a scalp restoration can still be enhancing even eighteen months after the surgery. The results gradually appear over a period of twelve months, but there are also known cases where the results of implantation are still enhancing even 18 months after transplantation.

The percentage of follicles that regrow after transplantation with the Advanced FUE method exceeds 95% and often reaches 100%. The results of hair implantation after a session with transfer of hair follicles from the beard have similar success rates. In scalp restorations with transplantation of hair follicles derived from the chest or other body parts, the regrowth rates may be slightly lower, i.e. 60-70%; also, the regrowth development of the hair follicles may be slower. In cases of restoration of scars caused by injury or pathological reasons, the regrowth rates of the transplanted hair follicles can vary between 60-90%. The growth rate depends on the quality of the scar (soft or hard), its blood supply, and other factors.

Regarding whether the results look natural, that depends on the experience of the surgical team and the doctor who performs the procedure. Ideally, the hairline needs to be planned correctly – where needed – in order to harmonise with the facial features of the patient. The first step is to determine how the hair follicles will be distributed over the scalp and at what density, taking into account the natural features of each head.

The natural look of hair transplantation is influenced by factors such as the growth angle of the existing hairs. The implanted hairs need to be aligned with the existing hairs in such a manner that they grow in the same direction, while the natural distribution of the various follicles should also be taken into account. This means that the front of a normal hairline should consist only of single-hair follicles, behind which a transitional zone is created with both single and double-hair follicles. More dense follicles should be placed behind the front line, primarily in the central region of the head in order to achieve a higher density. The results of the hair transplantation depend to a great extent on the experience of the surgical team and the technique used. In terms of percentage of growth, the results of hair implantation with either FUE or strip technique may be comparable.

Usually the FUE method gives better results in terms of naturalness, because it can produce single-haired follicles with a smaller diameter, while the FUT or Strip method in most cases renders thicker grafts (which don’t look natural if placed in the front line) instead of individual follicles. Another important issue, is whether or not holes (slots) are created in which the hair follicles are placed. With Advanced FUE, where the follicles are implanted with a special implanter in one step without creating slots (One Step Implantation), we notice that due to the restricted damage to the skin and the smaller amount of bleeding, regrowth is faster and in higher rates compared to the classical FUE or Strip techniques.

Hair transplantation today is an important field of research. In a few years:

• We will know exactly which genes are responsible for androgenetic alopecia, enabling us to predict who will present a problem and to intervene genetically. Even today, it is already possible to map and survey the genetic profile in the DNA of each person for at least 60-70 different genes that are involved in the process of androgenetic alopecia. With a simple blood test, the Alopecia DNA Test, the genetician and the doctor can predict the probability that a person will suffer from androgenetic alopecia and the speed of the anticipated hair loss. It is also possible to screen for the genes that control the greying of hair and thereby to determine, with sufficient accuracy, the natural tendency of each individual for early or late greying, from hereditary causes.
• To use new, more effective drugs to prevent hair loss.
• To clone hair follicles and to use large numbers of grafts (hair cloning, hair duplication)
• To produce hair from pluripotent progenitor cells in the laboratory, providing more hair implantation possibilities without the limitations associated with the donor site.