Hair Transplant Procedure

What is the Best Hair Transplant Technique?

Dr. Nakatsui hair restoration surgery EdmontonWe are often asked what is the best hair transplant technique currently available as there are so many techniques out there. Although it might seem like there should be an easy answer, there are a number of variables that need to be considered, such as density and coarseness of the donor and recipient areas, age of the patient, type of hairstyle, curliness of the hair, and family history. At our centre in Edmonton, Dr. Nakatsui has done 1000s of hair restoration procedures on men and women for over 17 years and can give you a complete assessment of these variables. Once these variables have been assessed, he can make a decision as to which is the best hair transplant technique for you. The two most important things to decide are: (1) how the hair will be extracted from the scalp and (2) how the recipient sites will be made.

Step One: Two Methods of Extracting Healthy Hair Follicles

Although there are many techniques for harvesting donor hair, we believe it is important to use the ones that have the smallest chance of damaging hair follicles, as these are irreplaceable. At the Groot DermaSurgery Centre in Edmonton, Dr. Nakatsui uses two of the possible methods for harvesting hair follicles and which method is used depends on the needs and characteristics of the individual patient.  The two methods are known as Follicular Unit Transplantation (FUT) and Follicular Unit Excision (FUE).

Follicular Unit Hair Transplantation (FUT)

Hair transplant procedure flowsheetThe first extraction method Dr. Nakatsui uses to extract healthy hair is known as Follicular Unit Transplantation (FUT), which is regarded as current gold-standard technique. FUT is in fact a very imprecise term but it refers to the harvesting of follicular units using a single-bladed scalpel from the back and sides of the scalp in a single strip or ellipse.

Although Dr. Nakatsui first started using this technique over 17 years ago, there have been several refinements to the extraction method. One of them is a two step procedure whereby he first scores the skin with a hardened, ultra-sharp scalpel and then carefully and slowly dissects down between the hair follicles with the assistance of multiple skin hooks to spread the tissue apart. This makes the procedure longer but Dr. Nakatsui feels this is necessary to preserve as many hair follicles as possible. Once this hair has been carefully harvested, the donor area is closed in two layers with sutures and/or staples, often with a trichophytic closure. This is a type of closure where one edge of the donor is area is beveled to encourage hairs to grow through the scar.

FUT is a more time-consuming technique than those used by many other surgeons but the method is extremely efficient because over three to four thousand grafts can be obtained from a single ellipse.

This is currently the most commonly used method to harvest donor hair, although follicular unit excision (FUE) is rapidly gaining popularity. It is important to remember the method of extraction (FUT and FUE) is only the first step in the hair restoration procedure. Once the grafts have been harvested with either FUT or FUE, the grafts still need to be dissected and refined (Step 2). Following this, the recipient sites need to be created (Step 3) and then the follicular unit grafts need be transplanted into tiny incisions made in the bald or thinning areas of the scalp (Step 4) where they will resume their growth. The implementation of this simple idea requires artistry, careful attention to detail, and meticulous technique throughout each step of the procedure. Dr. Nakatsui incorporates all of these elements together and the technique he uses has been termed Ultra Refined Follicular Unit Grafting by others. Learn about the differences between standard follicular unit hair transplants and ultra refined follicular unit hair transplants here.

Follicular Unit Excision (FUE)

FUE Edmonton Dr. Nakatsui

The second extraction method Dr. Nakatsui uses is called Follicular Unit Excision (FUE), which is another technique for harvesting follicular units from the scalp and body for use in hair transplantation. This used to be referred to as Follicular Unit Extraction but we now refer to it as Follicular Unit Excision. With FUE, no scalpel is used and there are no stitches. Each individual follicular unit is incised using a very small punch, which can be manual, powered, or robotic (if you would like to learn about these different devices used to perform FUE, you can learn about them here). The follicles are then extracted from the skin leaving tiny spots <= 1 mm in diameter. The skin heals quickly in the space where the follicles were, with minimal or sometimes invisible scarring. One of the good things about FUE is that multi-follicular unit grafts (MFUGs) cannot be extracted using this method as this would produce unacceptable scarring and therefore all FUE procedures are by definition follicular unit procedures.

Advantages of FUE Hair Transplants

This technique is particularly useful in patients who would like to avoid stitches or would like to keep their hair very short as it can leave almost invisible scars in most patients. In addition, there are some patients with extremely tight scalps, who cannot have sufficient hair removed using traditional methods. FUE can be invaluable for these patients. In addition, hair implants or grafts are sometimes harvested from the beard and body. Hair implants from the beard grow very well, although body hair transplants can be unreliable. Sometimes body hair transplants grow well but the percentage of viable grafts is definitely lower as compared to grafts taken from the scalp or beard area. Hopefully, the percentage of viable body hair grafts will one day be better once we master the intricacies of this technique.

Disadvantages of FUE Hair Transplants

FUE definitely has some advantages; however, there are disadvantages. One of the disadvantages is that FUE grafts often have very little surrounding protective tissue. These grafts are therefore more susceptible to trauma and dessication as compared to FUT grafts. Another disadvantage is that some patients have hair follicles that are very adherent to the underlying tissue and in these patients, FUE grafts can be very difficult to extract. Lastly, the main disadvantages of FUE hair transplants are time and cost. In the time it takes to move 1200-1500 grafts using FUE, 2500-3000 grafts could be moved using FUT. Consequently, this raises the costs involved when compared to strip harvesting. On the other hand, this technique may be the optimal choice, depending upon the patient’s needs. Which is the best hair transplant extraction technique for you? The answer is: it depends. For example, it you want to be able to cut your hair really short, FUE really is the only option. If you intend to keep your hair a little longer and want to transplant a large area, then FUT may make the most sense.

Video: Dr. Nakatsui demonstrating an FUE Procedure

Other Harvesting Techniques

Other harvesting techniques such as multi-bladed scalpels can be used to generate larger multi follicular unit grafts, as can be found in the mini-micrografting technique. Some surgeons will claim that transplanting larger multi-follicular unit grafts (MFUG) is the same thing as transplanting only follicular unit grafts because the number of hairs is the same, but this is not the case. Although it is much faster and easier to transplant MFUGs, the price you pay is a decrease in naturalness and an increase in detectability. Our patients tell us that naturalness and undetectability are very important to them and frankly, it is just as important to us. Consequently, we no longer use larger grafts such as slot grafts, minigrafts, and multi-follicular-unit grafts and are committed to using 100% follicular units.

Although there are additional methods of harvesting hair such as multi-strip harvesting using a multi-bladed scalpel, FUT and FUE are the only two methods used by Dr. Nakatsui. Choosing the extraction technique is the first step in any hair transplant procedure and once we have made the decision on FUE  or FUT, we are well on the way to deciding what is the best hair restoration technique for you. However, there are 3 more important steps to any hair transplant: graft dissection, recipient site creation, and graft insertion.


Contact Us For A Free Hair Transplant Evaluation
Dr. Thomas Nakatsui MD FRCPC FAAD
Edmonton, Alberta, Canada
Hair Transplant Questions? Contact us at:
780-482-7063


Step 2: Graft Dissection (FUE and FUT)

graft dissection for hair restoration edmonton

No matter which hair extraction technique is used–either FUE or FUT–the extracted grafts need to be dissected so that excess bald tissue can be safely removed. Using high-powered stereomicroscopes, the hair is separated into their naturally occurring bundles of one to three hairs without being damaged. Depending on the hair restoration surgeon, the grafts can be dissected out in different ways. One of the major differences is whether grafts are “skinny” or “chubby”. In other words, is the excess bald tissue around each follicular unit dissected away tightly to the hair follicles or is there a large amount of residual tissue left over? Chubby grafts have the benefit of increased resistance to trauma and dessication, but with an experienced implanter, these are of minimal concern. On the other hand, tightly dissected grafts can be placed closer together to yield higher density and heal incredibly well without pitting or protrusion. If excess tissue is left around the superficial part of the graft, there is a higher chance of surface aberrations around the grafts.

Although time-consuming, microscopic dissection is more accurate and produces grafts that require smaller recipient sites that can be placed closer together (i.e. denser), with faster and better healing. With FUE, very little extra dissection is needed because the extracted grafts already have very little tissue surrounding them when they are extracted. In fact, one of the downsides of FUE is that the extracted grafts may sometimes have very little surrounding protective tissue (even less than what a tightly dissected FUT graft would have), making them more prone to trauma and dehydration as compared to FUT grafts. As a result, even greater care must be taken to protect them and insert them as carefully as possible.

Step 3: Recipient Site Creation Using the Lateral Slit Technique

Chisel blades Edmonton for recipient site creationThere are many devices that are currently used to create recipient sites for hair implantation, and deciding on which one completely depends on the comfort and ability of your surgeon: flat chisel micro blades, angled blades, needles, punches, and slots can all be used to create recipient sites.

With all of these devices, space must be left between grafts to ensure proper blood flow, providing the essential supply of blood for grafts to grow. However, the larger the grafts, the greater the spaces that have to be left between them, and consequently the less natural these will appear. As a result, Dr. Nakatsui does not like to use any device that will produce a larger recipient site and therefore prefers to only use flat chisel micro blades and needles as these give the smallest recipient sites. Dr. Nakatsui makes extremely tiny incisions (as small as 0.6 mm wide) that are spaced in close proximity (as close as 0.2 mm apart) to achieve greater density than was possible in the past for both FUE and FUT procedures (also known as dense packing).

Dense packing

Both FUE and FUT hair transplant procedures can be dense-packed as dense packing has nothing to do with the method of extraction. Dense packing is a term that can be defined as a density of 30 grafts/cm² or higher. In our clinic, we will typically use about double that (i.e. 60 grafts/cm²) at the hairline and 50-55 grafts/cm² for about 3-4 cm posterior to the hairline. Posterior to that, we will decrease the density of grafts to about 35-40 grafts/cm². The advantage to this technique is that sufficient density can often be achieved in one procedure (the “one-pass technique”), which benefits patients as they can get great results and do not have to go through the procedure more than necessary. The main disadvantage to this technique is that it is more difficult and time-consuming. As a result, many practices do not dense pack at all or to this degree.

Lateral Slit Technique

In addition, the incisions for both FUE and FUT are usually placed in what is referred to as a “lateral slit” (also know as coronal orientation or perpendicular slits), a technique that has been perfected over the last decade and yields exceptional results.


“[The lateral slit technique] may be the most important breakthrough in follicular unit transplantation….”

-Dow Stough, past President of the International Society of Hair Restoration Surgeons


The lateral slit technique is an advanced method for optimizing hair angle that makes the end result more natural than ever before. Dr. Nakatsui was trained in this technique by its originator, Dr. Jerry Wong, and is proud to have been among the very first surgeons in the world to use this technique, which has been adopted by many of the top hair transplant surgeons in the world.

The lateral slit technique for hair transplant surgery offers several advantages over previous methods, including:

  1. More precise control over hair angulation than ever before
  2. Optimal orientation of each follicular unit, leading to better scalp coverage
  3. The ability to pack grafts at higher density than with most previous methods (dense packing)
  4. Shallower incisions, thereby reducing trauma to the critical blood vessels deeper in the scalp (subdermal vascular plexus)

Imagine a stack of cards, with each card representing one hair within a three-haired follicular unit. One way to orient these cards is one in front of the other; another way is one card beside the others. Clearly, the best way to provide the most coverage is to orient these cards beside each other. In most transplants, hairs are oriented one in front of the other, or at best in a random orientation. With lateral slits, the orientation can be controlled, and this feature, coupled with dense packing, yields better results than ever before.

Deciding on the method of hair extraction (i.e. FUE or FUT) is probably the most important decision to make when pursuing a hair transplant but deciding on the method of recipient site creation is just about as important. In Dr. Nakatsui’s opinion, using flat chisel micro-blades and the lateral slit technique offer numerous advantages, although he will very occasionally use sagittal slits (e.g. in areas that don’t require as much density).


Contact Us For A Free Hair Transplant Evaluation
Dr. Thomas Nakatsui MD FRCPC FAAD
Edmonton, Alberta, Canada
Hair Transplant Questions? Contact us at:
780-482-7063


Step 4: Graft Insertion

graft insertion for hair transplantation

Once the recipient sites have all been created for your FUE or FUT procedure, the grafts are carefully inserted by our technicians using fine forceps or implanters.  At this point, all of the recipient sites have been created and the angle and direction have already been determined. Consequently, the grafts can only be inserted in one direction and at a precise angle. With dense packing, it can take a little longer to insert as it is technically more difficult but the results are worth it. One important thing to consider during this phase is that excessive force can damage the grafts so it is important to use a team that is very experienced.

Over 3500 grafts are routinely transplanted in a single session if there is adequate hair from the donor site. Thanks to new techniques, one surgical session is usually sufficient to provide good density. However, some individuals may require more than one session to produce the desired density, particularly if the donor hair is very fine.

 

 

FAQs on Hair Transplant Surgery

 How long will it be obvious I have had a hair transplant?
After the procedure, you will have some crusts in the recipient area that last about 7-10 days. Following this, the crusts can be removed without any fear of losing hair follicles. Once the crusts have been removed, there is minimal evidence a procedure has been done except for some redness of the transplanted areas that looks like a sunburn. The donor site will have staples or stitches for about 7-10 days following the procedure. If you have an FUE procedure, the extraction sites start to heal very quickly. After a week or so, the sites will not be very noticeable.
 Will I need a large bandage on my head following the procedure?
Years ago, we routinely bandaged the head with a large bandage that made the patient look like he had major brain surgery, but with new technology and procedures, it is absolutely unnecessary to do this and you leave with only a loose fitting ballcap. Consequently, when you leave our office, no one will suspect a thing.
 Can areas such as the temples and lateral sides of the scalp be filled in with hair?
These areas can definitely be filled in and we will always use a lateral slit technique in this area. If one follows the hair angle correctly, these areas can be filled in and often require a smaller amount of hair follicles because of a shingling effect. However, in patients whom we suspect will develop extreme hair loss, it can be dangerous to fill in the temples because the hair can recede behind it.
 What is follicular unit transplantation?
This is a technique that enables us to dissect away bald skin and produce 1-3 hair grafts, while maintaining the natural grouping of these hairs. These grafts are virtually undetectable and natural in appearance. With this hair replacement technique, we can harvest thousands of grafts from the donor site and place them into tiny, barely visible slits. This technique minimizes the disruption to blood flow promoting faster, better healing. Moreover, advances such as the lateral slit technique have enabled us to “dense pack” and place the grafts extremely close together. The result is a denser look than was possible in the past. See our photo gallery for some of our results
 Is the hair transplant surgery painful?
Hair transplantation (FUE and FUT) is considered to be a minor day surgery and is very safe. The procedure is done under local anesthetic without any sedation, and patients talk, listen to music, watch a movie on one of our iPads, and in many cases, nap during the procedure. After the procedure, only a small number or patients feel any discomfort. Less than 25% of patients elect to take pain-relieving medication.
 How long does it take the transplanted hair to grow out enough to fill in the balding area?
Usually it takes three to four months for the hair to begin growing, and after that it will grow about one cm per month. Initial hair quality is usually very fine, but this becomes coarser over time. Sometimes the initial hair is curlier or darker in color than the pre-existing hair.
 How long will the transplanted hair continue to grow?
The implanted hair will grow for as long the hair from the back of the head is destined to grow. In other words, if the hair at the back of the head is going to last until you are 150 years of age, then the transplanted hair will last just as long.
 Is there a scar at the donor area?
With FUT, the scar left in the donor area is typically extremely fine and is very difficult to see unless looking for it specifically. WIth FUE, the extraction sites are usually very difficult to see and in some cases, invisible. Some patients with darker skin colour may have tiny hypopigmented spots in the donor area after a FUE hair transplant procedure.
 How much is a procedure?
The cost of a hair transplant depends upon the number of grafts being transplanted. Whereas some surgeons charge a fixed fee for a given area, we charge based upon the number of grafts actually transplanted. Consequently, you only pay for what you get. We believe this is more fair as one person could get 500 grafts in a given area and another could get 1000 grafts in the same area with a noticeable difference in density. With respect to the number of grafts implanted, this will vary based upon patient desires, coarseness of the hair, and also the donor density. Consequently, costs can range from as little as $1500 to more than $12,000. For a more thorough explanation of the costs, click here.
 How many sessions of surgery will I need to achieve my desired density?
This depends upon the extent of hair loss and upon the desired density. The vast majority of patients are satisfied with one hair transplant session, but others require a second or third session to fill in balding areas to the desired density. See our photo gallery for some examples of our results.

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