Hair Restoration Surgery: Follicular Unit Grafting

Abstract

For adults, a full head of hair, at any age, confers a picture of health, vigor, and vitality. Therefore, alopecia in both men and women may have profound effects on self-esteem and overall well-being. Male pattern androgenic alopecia (MAGA) as well as female pattern hair loss (FPHL) is polygenic. While the latter is less understood, the former is usually the result of testosterone-dependent structural miniaturization of the hair follicle secondary to a reduction in the volume of dermal papillae (J Invest Dermatol 116:452–455, 2001; N Engl J Med 341:491–497, 1999). This is the end result of prolongation of the telogen-anagen phase ratio of the hair growth cycle.

The male scalp consists of several sections: frontal, mid-scalp, vertex, and temporal. Medical treatment with minoxidil (Rogaine; McNeil-PPC, Inc., Morris Plains, New Jersey) and 5-α-reductase type 2 inhibitors such as finasteride (Propecia; Merck & Co., Inc., Whitehouse Station, New Jersey) is far more commonly used by younger men in the early stages of hair loss (Arch Dermatol 146:1141–1150, 2010; J Invest Dermatol 109:296–300, 1997). For older men and those with more profound hair loss as characterized by Norwood, follicular unit hair transplantation (FUT) offers very good results. Female pattern hair loss, normally characterized by maintenance of the frontal hairline with central thinning, is characterized by Ludwig (Br J Dermatol 97:247–254, 1977). Exceptions to these patterns exist for both men and women.

Recent advances in microvascular surgical instrumentation have resulted in greatly improved outcomes in the treatment of MAGA and FPHL. The ability to extract single follicular units (FUs), containing between one and four hairs, either via follicular unit extraction (FUE) or strip excision (SE), has allowed for more seamless transition points between areas of hair loss and unaffected areas. While FUE is gaining in popularity, many surgeons are still utilizing SE which will be discussed in more detail in this chapter (2011 practice census results, Geneva, 2011).

The art of hair restoration is dependent on several other variables that include recipient site creation, graft size, packing density, and medical hair loss treatment. The future of hair restoration surgery is ever evolving and is moving toward minimal incision surgery and cell-based therapies. Discussion of these developments however is beyond the scope of this chapter.