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 haven’t 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.
History of Hair Transplant
Hair loss has always troubled people, urging them to seek methods to address the issue. Transplantation of course, using our own hair, was something impossible in the old ages.
OLD & 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.
Today, the methods used in hair restoration are two:
In recent years, many promising robotic hair transplant systems have appeared (Robotic Hair Transplatation or ARTAS® Robotic Hair Transplant). Due to lack of sufficient accuracy, these systems cannot replace an experienced FUE hair transplantation team at present, but improvement of this technology in the future may at some point allow their generalised use.
Other Techniques to cover baldness
Apart from hair transplantation, which up to date is the only scientific way to permanently restore hair growth in the bald part of the scalp, there are also various non-invasive and non-medical ways to cover bald spots that have been used at times or are still used today.
Who can have a Hair Transplant?
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. 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:
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.
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 proper discussion between the hair surgeon hair and their physician and appropriate regulation of their medication.
FUE Hair Transplant technique
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.
With this hair transplantation method, the physician first plans from which region the grafts will be taken. He will then locally anaesthetise the area with lidocain-adrenalin solution. Hair follicle units are removed by a special automated device, easily, quickly and painlessly, and maintained in a moist environment at 3-4 °C. The implant area for the grafts is then determined and doctor proceeds to the surgery, again under local anaesthesia. Implanting the hairs is done one by one, using a special device and that 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.
At Advanced Hair Clinics, Dr. Anastasios Vekris after years of experience and research has developed the scalp 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 growth after FUE is around 95-98%. Most hairs are maintained from the outset, 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.
FUE Hair Transplant Post-operatively
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 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 administered. 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, without it even being noticeable that he has underwent 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 placed between the existing hairs.
Hair Transplant using FUT technique
FUT or strip technique is an older hair transplantation method for the treatment of baldness. It started being used in the 1990s and quickly spread worldwide. In recent years the FUT technique finds itself in rapid decline, giving its place to the less invasive FUE method. The reason for this, is that the results of FUE are very impressive, without the difficult consequences of the FUT method.
Eyebrow restoration using FUE Hair Transplant
Eyebrow transplantation by a plastic surgeon is intended for people who suffer from congenital absence of the eyebrows, wish to cover scars from accidents or burns, or have excessively thinning eyebrows due to waxing, chemical peeling, or age. However, one may also wish to acquire more dense and youthful eyebrows for purely aesthetic reasons.
Restoration of scars from previous Hair Transplantation with the FUT/Strip method
FUT (Follicular Unit Transplantation) or strip technique is an older method of hair implantation. In recent years the FUT technique finds itself in rapid decline, giving its place to the less invasive FUE method which does not leave marks and scars.
Success rates of Hair Transplant
Many doctors perform hair transplantations, but only few achieve absolute success and natural results. The qualifications and experience of the plastic surgeon are the key factor to success. Cautious supervision of a detailed intraoperative and postoperative protocol is an essential factor for the successful completion of a hair transplant session. In the hands of an experienced transplantation team, the FUE method can offer results that exceed 95-98% after 12 months. There are cases in which the final growth even exceeds 100%, thanks to the fact that during the implantation of the hair follicles with the One-Step Implantation technique (Direct FUE), there is no handling of the hair follicles. As a result, follicles are transplanted that contain partially transected hairs. Research has shown that even partially transected hairs can develop at a rate ranging from 30-70%, depending on their length, due to the fact that they contain stem cells which may lead to the development of new hairs, thereby further enhancing the final result.
There is no less or more suitable age to undergo a first hair transplant session. As the clinical manifestation of androgenetic alopecia varies from one person to another, there are young men, even under the age of 20, with very extensive hair loss of level V or over on the Norwood scale. On the other hand, there are patients above 60 years of age with a very restricted thinning of Norwood level II-III. Therefore, the suitable age for the first session is determined by the clinical picture of each patient, and depends mainly on the psychological impact of hair loss on the patient. In other words, the proper age for hair transplantation is when the thinning has started to become apparent and adversely affects the patient’s psychology. It is advisable to undergo one’s first hair implantation session at a young age, before all hair is lost, and to repeat the procedure after a few years. The success of a hair transplantation always depends on the successful natural integration of the transplanted hairs among the existing hairs, and on the application of appropriate conservative treatment, usually with minoxidil 5% and PRP (Platelet Rich Plasma), in order to maintain the existing hair.
Given that androgenetic alopecia is a gradually progressing condition that is largely associated with the action of androgens in the body, the hair loss and thinning will accompany the patient throughout his entire life after puberty. Especially between the ages of 20 and 40, the phenomenon of hair loss is quite intense. If the first hair transplant session is performed at a young age, it is almost certain that the patient will need a second surgery in the future because of the continued hair loss. Therefore he should be informed accordingly.
A key factor in the success of hair transplantation and the quality of the final result, is the extent of the problem and the degree of thinning. Localised alopecia in the forehead or crown can be treated satisfactorily even in one meeting, with excellent density. On the other hand, cases of extensive baldness of Norwood level V-VII usually take 2-3 sessions in order to achieve good coverage, provided that there is a sufficiently rich donor site. In some cases, an insufficient donor site in combination with a large extent of baldness may lead to the forced choice to either cover only a specific area (e.g. the forehead), or to perform a more sparse implantation over the whole bald area, which leads to poorer aesthetic results.
Realistic expectations of the patient who is interested in hair transplantation are an important factor in achieving the desired result. It must be explained by the physician and understood by the patient, that hair transplantation is a medical method for the restoration of alopecia, and in no case can substitute nature or reverse the process of hair loss, restoring the patient to the situation before puberty. Also, in cases of very extensive alopecia, the patient must understand that it is impossible to fully restore the scalp. Furthermore, in specific cases such as eyebrow transplantation, it should be made clear that the new hairs tend to grow and will have to be clipped regularly. Proper information on the doctor’s part ensures the selection of suitable candidates for hair transplantation and the understanding, from the patient’s end, that hair transplantation is a medical method with indications and limitations.
Ideal candidates for Hair Transplantation
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. 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.
The objectives of Hair Transplant
Hair transplantation has three main objectives.
Complications of Hair Transplant
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, if any, 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.
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 the scar can be unsightly and visible. Many patients who have undergone hair transplant with FUT technique avoid to cut their hair due to the obvious malformed scar.
At Advanced Hair Clinics, Dr. Anastasios Vekris and his team implement special protocols before and after the session, that minimise the risk of complications. We recommend using minoxidil 5% both before and after the hair transplantation, and PRP (Platelet Rich Plasma) sessions to maximise the results.
Hair Transplant in the future – DNA test for ALOPECIA
Hair transplantation today is an important field of research. In a few years:
Body hair & Facial Hair as alternative FUE donors
If the donor site is insufficient, hairs can also be obtained from the beard or the body and transferred to the affected area. Facial hair develop fast and grow back at remarkably high rates, exceeding 95%. Due to the specific texture of these hairs (they are more wild and more curly compared to scalp hair) and the fact that the shafts on average are twice as thick as that of scalp hair, they are unsuitable for placement in the front hairline. However, if the donor site of the scalp itself is insufficient, they are extremely useful for the densification of the middle zone or the crown, and to cover postoperative strip scars.
Body hair is another alternative resource of hair follicles for transplantation, especially in men who have a rich body hair but insufficient donor site on the scalp. All regions of the body can be used as donor sites for body hair, such as the chest, the back, the arms and legs, the pubic region, etc., but it has been observed that the most reliable and potentially usable area for harvesting body hair grafts are the chest and the sternum. The final regrowth rate of body hair is highly unpredictable and usually ranges from 70 to 80%. Due to the very different life cycle of body hair, which usually progresses more slowly than the life cycle of scalp hair, the regrowth of body hair is extremely slow and may even take two years to complete.
Facial hair and body hair can only be used in hair transplantation with the FUE method, which permits extraction of individual follicular units without incisions and permanent scarring. The FUT or strip technique has been used in these areas only to a minimal degree, because of the aesthetically unacceptable visible scar it would leave on the face or the chest, just for the purpose of obtaining facial hair or body follicles hair for transplantation.
Hair transplantation by transferring individual hair follicles (FUE) is currently the most ideal method for male and female hair loss. This hair transplant method is also used for the restoration of eyebrows or facial hair, as well as to cover scars left by STRIP of FUT technique.
Cost of Hair Transplantation
Every case is examined individually and the cost of each hair transplantation session with FUE may vary. 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.
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.
In cases where a few dozen follicles are required, e.g. to cover a small scar, the cost is quite low. The cost increases according to the duration of the session. 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 6000-8000 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.
Why choose ADVANCED HAIR CLINICS for Hair Transplant?
Results after 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 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 hair transplantations for the 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.
NATURAL Hair Transplantation results
As far as a natural look is concerned, the results of hair transplantation depend 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 transplanted 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 depends 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.
Failure rates in Hair Transplantation
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 are 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 loss. Technical errors during installation of the hair follicle are considered the most common factors that lead to failure of hair transplantation.
Choice of doctor for Hair Transplantation
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 skilfulness 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.
Side effects after Hair Transplantation
If performed correctly with the modern Advanced FUE method, hair transplantation does not have any serious side effects, either immediate or later. The most common side effects or complications after the process are immediate complications such as swelling of the forehead and eyelids, which may appear between the second or third day and usually lasts 24 hours. This can be avoided by administration of appropriate cortisone medication during recovery and a few days after. 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.
Another side effect of hair transplantation, which according to the observations of our clinic is very rare (less than 0.2% of the patients), may include a local inflammation in the new follicles during the first or second week after the operation. This inflammation is called folliculitis.
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.
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. Another side effect, seen primarily with the FUT or strip method, is a permanent scar in the donor area which may become visible when the patient cuts his hair short or may cause pain or numbness in the region. These side effects are avoided with the modern Advanced FUE method, as there are no permanent scars. One more 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.