Hair Restoration Surgeons Research Articles

Paradigm Shift from Linear Strip to Follicular Unit Excision in Hair Restoration Surgery.

Follicular unit excision (FUE) is a very effective and valuable modality for obtaining donor hair follicles using manual, motorized, or robotic devices to harvest individual donor follicular units in situ without a linear donor scar or visible scarring making it ideal for patients who wish to wear their hair short and hide signs of surgery. Over the past two decades, FUE has become increasingly popular, and the rising demand for FUE has driven the worldwide market size of hair restoration surgery (HRS) to an unprecedented height.FUE has revolutionized the HRS industry and offers excellent cosmesis and high patient satisfaction. Unfortunately, a large part of the favorable appeal of FUE is due to false claims that it is "minimally invasive," "scarless," or "not even surgery." Most patients opt-in for FUE due to these misconceptions, which are advertised by "black-market" clinics offering low-cost FUE surgery performed by amateur, nonprofessional technicians on unsuspected patients. The technique appears deceptively simple, and many neophyte surgeons falsely believe that the learning curve of FUE is short because the barrier of entry is low and no previous surgical skill is required. Nevertheless, injuries on grafts are extremely easy to occur since FUE is a blind technique and can be minimized only with excellent technique, which takes years to master.FUE actually presents unique challenges for the surgeon and carries potential long-term permanent side effects if not performed properly. The surgeon must have a thorough understanding of the nuances of the FUE surgical technique to ensure consistent graft quality and favorable cosmesis of both donor and recipient areas. Efficient FUE requires dexterity, training, dedication, devotion, enthusiasm, cognitive clarity, scientific knowledge, experience, and an extended learning curve.FUE is an invaluable addition to the armamentarium of a hair restoration surgeon but has to be judiciously performed.

Concepts, Terminology, and Innovations in Follicular Unit Excision Hair Restoration Surgery.

Follicular unit excision (FUE) has emerged as the preferred method for hair transplants. Standardized terms and definitions established by members of the International Society of Hair Restoration Surgery and prominent hair restoration surgeons have become the standard, enabling effective knowledge sharing. This chapter provides an overview of the terminology relating to the field.The historical evolution of FUE and its pivotal role in modern hair transplantation is summarized. Anatomical terminology and graft-related definitions follow, providing insights into the scalp's complex structures and graft characteristics. The subsequent sections detail the terminology associated with graft excision and extraction, shedding light on the precise techniques and procedures employed. An exploration of various FUE techniques and the evolving landscape of FUE devices underscores the continual refinement of hair restoration practices. The chapter proceeds to discuss the "safe'" scalp donor zones, donor assessment terminology, and elements in identifying the optimal donor area for a successful FUE procedure. Additionally, punch dynamics and technique characteristics are examined, emphasizing their pivotal role in achieving superior FUE outcomes. The chapter concludes by discussing the classification of punches and graft evaluation terms, offering insights into the tools, and criteria used to assess graft quality and viability.

Follicular Unit Excision Donor Area Management and Considerations of the Scalp.

Over the last several years, follicular unit excision (FUE) donor harvesting has become the predominant donor harvest method, surpassing the traditional method of linear strip excision donor harvesting. While this may offer advantages in specific clinical settings, the reality of ongoing losses with the natural evolution of male patterned hair loss places a premium on obtaining as much lifetime donor hair as possible to address this clinical reality. This lifetime demand requirement must be weighed against the possibility of a detrimental cosmetic appearance of the donor area with serial donor harvests utilizing FUE. This chapter will examine the important technical and artistic considerations critical for hair restoration surgeons to appreciate in order to maintain cosmetically high-quality donor area outcomes in patients choosing to undergo FUE harvesting for hair transplantation surgery.

Follicular Unit Excision-Linear Ellipse Donor Harvesting Technique: Combining Standard Follicular Unit Excision with Follicular Unit Excision inside a Linear Strip (Modified Linear Strip Excision) to Optimize Graft Yield.

Follicular unit excision (FUE) graft dissection has become the dominant method of donor harvesting globally, however, only a percentage of donor hair can be excised inside the safe donor area before visible donor thinning occurs. Compared to linear strip excision (LSE) where all follicular units inside the harvested ellipse of hair are used, FUE poses substantial limitations for lifetime graft yield and, therefore, cosmetic coverage in patients with advanced pattern hair loss. This paper reviews how combining the donor harvesting methods of FUE and LSE has been shown to optimize graft yield while minimizing the risk of donor depletion from overharvesting. It then describes a surgical technique called FUE-Linear Ellipse (FUE-LE) where FUE dissection of grafts inside a demarcated linear ellipse eliminates the need for a large dissection team which has posed a barrier for many new practices that offer both the donor harvesting methods. For practices that currently offer only FUE, the addition of the LSE method by the modified FUE-LE technique is possible without specialized staff training or associated equipment costs. In this paper, surgery practices that have adopted this technique will report on their experiences. Hair restoration surgeons are encouraged to provide both methods of donor harvesting (FUE and LSE using FUE-LE) in order to optimize graft yield for patients and avoid long-term donor depletion. Based on limited experience, it appears the technique of FUE-LE will help achieve this goal.

Giant Congenital Melanocytic Nevus Correction: A Case Report

<h3>Abstract</h3> Giant congenital melanocytic nevi are usually an aesthetic challenge, especially in very exposed areas of the body. A multidisciplinary approach is suggested to achieve the best result for surgical management and long-term follow-up of these lesions. We present a patient with a frontoparietal giant melanocytic congenital nevus where reconstructive surgical treatment was thanks to the joint efforts between a plastic surgeon, who performed a partial excision W-plasty to re-create a hairline, and a hair restoration surgeon, who performed preview long hair FUE to achieve optimal scalp-nevus coverage.

Gender-affirming hair procedures

<h2>Abstract</h2> Hair transplantation can play a complementary role in the spectrum of gender affirming procedures. Amongst the hair restoration procedures sought by transgender patients, female hairline feminization, beard and eyebrow transplantation, surgical hairline lowering, and body hair transplantation are the most popular. Hairline lowering, hairline feminization, and eyebrow and pubic hair transplantation can play roles for the male to female (MTF) transitiong patient while beard and body hair transplantation can play integral roles for the female to male (FTM) transitioning patient to create a more feminine or masculine appearance and to help conceal prior surgical scarring. This chapter will delineate the role hair restoration plays for the transitioning patient. The various surgical approaches and treatment paradigms will be detailed for the hair restoration surgeon.

The “Punching-Out” Technique to Reduce the FUT Scar

<h3>Abstract</h3> A widened scar from a previous strip-removal procedure (follicular unit transplant) is a commonly encountered complaint from patients coming in for a second hair restoration surgery. Options for addressing widened scars have included surgical scar revision, transplanting the scar with follicular units, and scalp micropigmentation. The authors present a new approach, where the scar may be thinned with a punching-out technique followed by resuturing the area. Advantages of the technique include that the time spent on this procedure is usually less than 10-15 minutes, it utilizes skills and equipment that most hair restoration surgeons already have, and it also does not use additional precious follicular units. Our experience using this technique in 58 patients showed improved appearance of the scar.

Lichen Planopilaris Mimicking Androgenic Alopecia: The Importance of Using a Dermatoscope

Scarring alopecia (cicatricial alopecia) affects 7% of patients at hair loss specialty clinics. Clinical findings can be subtle and easily overlooked without a thorough physical examination of the scalp. Scarring alopecia can mimic pattern alopecia or coexist and contribute to thinning, so a high index of suspicion and utilization of a dermatoscope is critical to making the diagnosis. Hair restoration surgeons must be aware of the presentation and perform a thorough physical examination in order to avoid the costly mistake of performing surgery in patients who are potentially doomed to fail.

My Clinical Experience with Needle and Laser SMP Devices

The ever-changing inclinations of patients for non-surgical hair loss treatments and procedures is of great importance to the hair restoration surgeon.[1][1] Many non-surgical hair loss treatments garner attention, such as minoxidil, DHT inhibitors, laser light therapy, and regenerative procedures.

Preview long hair follicular unit excision: An up-and-coming technique.

Follicular unit excision (FUE) is a popular hair transplant technique, but requires shaving the donor area. This is a deterrent for some patients wishing to keep their hair transplant discreet. The new long hair FUE technique avoids shaving the donor area, which appeals to a wider patient population; however, it has a reputation of being technically challenging and slow. We review the tools and techniques developed for long hair FUE and present our experience using the Trivellini Long Hair System and Long Hair punch. With the new advances in tools and techniques for long hair FUE, this method is gaining momentum and has the potential to be the next trend in the hair transplant industry. There are a few different punch designs marketed specifically for long hair FUE (window/slotted, Trivellini Long Hair, and bi-pronged). Although this technique is slower to perform than shaven FUE, graft survival and final outcome are comparable. Innovations in technology have made the long hair FUE technique more accessible to hair transplant surgeons. It is important for hair restoration surgeons to keep knowledgeable about this technique in order to maintain a competitive business.

Changing trends in surgical hair restoration: Use of Google Trends and the ISHRS practice census survey.

Hair loss affects most people at some point in their lifetime, causing anxiety and decreased self-esteem. There are multiple surgical and nonsurgical treatments available, with the surgical options having greater and longer-lasting effects. Such treatments have evolved over time with advances in technology and research, with numerous patients researching these treatments on Google. Many surgeons who provide these treatments belong to the International Society of Hair Restoration Surgeons (ISHRS). To investigate trends in surgical hair restoration treatment from both the surgeon and patient perspectives. Patient epidemiological and surgical data from the ISHRS were combined with search trend data from Google to analyze changing trends in surgical hair restoration treatment. Worldwide Internet searches for "hair transplant" have increased from 2004 to the present. Follicular unit excision (FUE) has supplanted follicular unit transplant (FUT) as the most popular hair transplant performed. Since 2004, there has been an increase in both nonsurgical and surgical female patients. Beard and eyebrow transplants have increased in popularity. Google searches follow this trend. Nonsurgical treatments such as platelet-rich plasma (PRP) are being searched more frequently. Hair restoration clinics and Google searches were affected adversely by the COVID-19 pandemic. Technological advances in available therapies, improvement in delivery systems, changes in hair fashion, and global events have direct impact on hair restoration treatments offered by physicians and researched by patients. It is in the best interest of all hair restoration providers to keep abreast of changing technologies and treatment trends to stay at the forefront of their profession.

Reducing Surgical Time: An Innovative and Versatile Instrument for Creating Multiple Brick-Pattern Sagittal Recipient Sites in a Single Stroke

<b><i>Introduction:</i></b> Recipient-site creation is a very important step in the hair transplant procedure as it ultimately decides the density, direction, and exit angle of the implanted hair and the final result of the procedure. It can be done with knives or needles. The slits can be <i>sagittal</i> (parallel to hair direction) or <i>coronal</i> (perpendicular to hair direction). For better visual density and coverage, the majority of hair restoration surgeons use sagittal slits. <b><i>Methods:</i></b> Recipient-site creation takes up a significant amount of the surgeon9s time. A considerable reduction in surgical time for coronal slit creation has been described using a multi-slit knife.¹ A multi-slit knife for sagittal slits has not been described until this paper. Our technique reduces surgical time by the use of an innovative and versatile new instrument that enables the creation of single rows of equidistant “brick-pattern” sagittal slits of the same direction, angle, and depth in a single stroke. <b><i>Results:</i></b> The device that we have designed enables the surgeon to reduce the time needed for recipient-site creation while increasing precision. It is a versatile instrument that can be used with appropriate configurations in bald, thinning, and vertex regions. <b><i>Discussion:</i></b> The vast majority of hair restoration surgeons typically use cut-to-size knife blades to create recipient sites, which is repetitive and time-consuming. Brick-pattern slits are preferred to minimize the “see-through effect,” which adds time and challenges.³ Our instrument is easy to assemble and use, and can create slits at desired density, depth, and angle.

Follicular Unit Excision Punches and Devices.

Follicular unit excision (FUE) is used to harvest follicular units for hair transplantation using trephine punches. The characteristics of FUE punches can impact the success of this technique; thus, many innovative punch designs and devices have been developed. With many options available, it can be difficult for the hair restoration surgeon to know which punch best suits the needs of their patients. To provide a comprehensive review of punch shapes and devices available. Search of PubMed, reference mining of relevant publications, and hand searching trade publications. We examined FUE punches and devices and consolidated descriptive information for each to create textual and visual guides. No single punch shape or device may suit all cases; thus, it is important to know the best uses and limitations of each. The surgeon should have a comprehensive knowledge base of available punch shapes and devices and understand the advantages and disadvantages of each. It is also beneficial to have an in-depth knowledge of skin properties and follicular unit structure. Ultimately, understanding the dynamics behind punch excision will enhance the FUE technique.

The edge out punch: An advancement that reduces transections in follicular unit excision hair transplantation.

The follicular unit excision (FUE) technique has become the preferred method for hair transplants over the traditional strip harvest technique due to low scar visibility and shorter recovery time for the patient. However, a limitation of the FUE technique is the potential for graft trauma due to the small diameter, sharp punches used to harvest individual follicular units. Here, we introduce the novel edge out FUE punch that is designed with a thicker wall and has an internal bevel. We describe how the dynamics of this punch reduces the risk of follicle transection. A review of the available literature and information on the edge out punch in comparison with other punch shapes, as well as the authors' experience in this area, is provided. The edge out punch is designed with thick walls and an internal bevel, placing the sharp cutting edge on the outer diameter. The dynamics of this punch aid in directing the graft into the center of the punch lumen and keeps the sharp cutting edge away from the hair follicles deeper in the dermis, reducing the risk of follicle transection. The dynamics of the forces generated by the edge out punch aid in minimizing follicular transections during graft harvesting. By understanding the dynamics behind this novel punch, hair restoration surgeons (HRSs) can optimize their surgical technique to obtain consistently high-quality grafts during FUE.

Innovations hair restoration surgeons have made to adapt to the challenges of follicular unit excision.

Early use of follicular unit excision (FUE) as a method of hair transplantation was limited by high rates of hair follicle transection. This hurdle has been overcome by innovative methods, punch shapes, and devices. With the vast array of tools available, it can be difficult for hair transplant surgeons to choose the best option for their practices. To provide an in-depth review and comparison of currently available FUE methods, punch designs, and motorized devices, and discuss how these tools fit the unique skin and hair characteristics of patients. A review of the literature and available information on FUE methods, punches, and devices, as well as the authors' experience in this area, is provided. Innovative FUE methods, punch shapes, and motorized devices have successfully minimized the rate of hair follicle transection. Methods include the use of sharp punches with depth control, and blunt rotating punches. Punch shapes such as flared, hybrid, and edge out have successfully reduced transections by keeping the cutting edge away from the follicles under the skin. The development of motorized devices using features including rotation, roto-oscillation, oscillation, vibration, suction, and hydration has also aided in achieving more successful graft excision. Follicular unit excision is a widely used technique by hair restoration surgeons. Therefore, it is important for physicians to be aware of the array of punches and devices available and understand how these tools can be used to adapt to the unique skin and hair characteristics of individual patients to optimize successful graft harvesting.

Effect of COVID-19 outbreak on hair transplant field of India

World Health Organization declared the novel coronavirus (COVID-19) infection a global pandemic. All cosmetic, aesthetic, and hair transplant (HT) surgeries are stopped as elective surgeries may become the reason for infection spread. Most of the HT clinics have stopped surgeries or postponed till lockdown date limit. This pandemic situation has caused financial implications for these setups. India is still working to flatten the curve of the pandemic. Once the peak of the pandemic is over, virus may become endemic, and the risk of transmission of the disease to the HT team is also a possibility. HT field of India is thus in an extremely challenging position. We did a survey among the members of Association of Hair Restoration Surgeons of India (AHRS) to know the current status of the HT field of India and surgeon’s perspective toward the situation.

Rapid and Accurate Digital Measurement of the Recipient Area in Hair Transplantation Using a Tablet Application

<b><i>Background:</i></b> The recipient area measurement using grid counting is still a standard practiced by the majority of hair restoration surgeons. However, it is time-consuming and not quite accurate when the area is in different shapes such as a triangle, long and narrow shape, or circle. <b><i>Objective:</i></b> We propose a digital recipient area measurement using a tablet application¹ instead of visual counting of the grids manually drawn by the refined Chang9s method. <b><i>Method:</i></b> Once the recipient area was drawn using the refined Chang9s method,² we used an irregular area calculator application (SketchAndCalc). We then compared it with the refined Chang9s method counted by two physicians and one nurse in 20 patients who visited the clinic for a consultation or pre-operative assessment. <b><i>Results:</i></b> The analysis of both methods by Intraclass Correlation Coefficient (ICC) showed that the SketchAndCalc application has excellent reliability (ICC=1) equal to the refined Chang9s method (ICC=0.99). However, when the measured area is long and narrow, the SketchAndCalc is more accurate and precise since it can record in decimal points. <b><i>Conclusion:</i></b> The SketchAndCalc application is an easy, rapid, accurate method on a portable device for recipient area measurement.

Scalp Micropigmentation: Semantics, Terminology, and Standards

Scalp Micropigmentation (SMP) is a procedure that is used to create the illusion of shaved hair, stubble, or greater density in hair-bearing areas that have lost hair or require augmentation. It is becoming more popular around the world, and its value to hair restoration surgeons is demonstrated by

Assessing patient satisfaction among ABHRS surgeons: Opportunities to improve.

Online physician-rating websites are being increasingly used by patients to gauge physicians' quality of service. The objective of this study is to assess the impact of residency training background of hair restoration surgeons and to identify themes of patient reviews using online physician-rating portals. From July 1, 2018 to July 18, 2018, a list of American Board of Hair Restoration Surgery (ABHRS) physicians was compiled. Each member's name was searched on Healthgrades.com and Yelp.com websites, and profile reviews were analyzed for themes of patient satisfaction and dissatisfaction. Eighty-six ABHRS-certified surgeons were identified on the ABHRS physician directory practicing in the United States. Eleven different residency training backgrounds are represented. Surgeons were given significantly higher ratings on Healthgrades (4.63 vs 3.77, P<0.001), and nonsurgeons were given significantly higher ratings on Yelp (4.31 vs 4.11, P=0.036). A total of 567 five-star reviews and 59 one-star reviews were analyzed for content across both physician review portals. The most commonly cited topics included results, office staff, physician's bedside manner, comfort during procedure, patient-perceived physician's honesty, patient-perceived physician's knowledge, cost/financing options, recovery time, and wait time/scheduling. Significant, yet inconsistent differences in ratings were found between surgical and nonsurgical residency backgrounds across online physician-rating portals. Understanding drivers of positive and negative reviews may help surgeons improve patient satisfaction.

FUE as First Intention for Hair Reconstructive Surgery on Skin Grafts

1. Felix M. Popescu, MD (felix{at}drfelix.ro) 1. Bucharest, Romania “As a hair restoration surgeon, you sometimes feel the frustration of not saving lives. I am here to tell you that hair transplant surgery can save lives. To get this, I need to bring you directly into the firing line