Hair Transplant Strip Surgery

Hair transplant strip surgery has been the dominant form of surgical hair restoration since the early 1990’s. The early days of hair transplant strip surgery, while antiquated and primitive compared to today's techniques, represented a paradigm shift in how clinics operated and what patients could expect with regards to healing, pain management, scarring and final aesthetic results. “Mini-micro grafting” was the most common procedure performed during the 1990’s. Physicians were required to hire additional clinical technicians to assist with the overall procedure. These technicians were required to “sliver” and dissect the bundles of hair into manageable sized grafts that would be placed into the recipient zones where hair was needed. These “grafts” contained as few as one to two hairs or multiple follicular units with up to ten, twelve, and even fifteen hairs each, depending on the goals and aesthetic skills of the clinic overall. The grafts would be created based on the doctor’s needs. These grafts would be dissected using “jeweler’s loupes” or sometimes with the naked eye, which would result is transection rates that would not be acceptable in today’s market. In reality, mini-micro grafting is not a “bad” procedure in and of itself, as many excellent results were achieved with it’s use, modern advances have rendered the technique as obsolete.

Follicular Unit Transplantation

Follicular unit transplantation (FUT) was first described by Dr. Limmer of San Antonio, Texas in the mid 1990’s. This new development in the field of surgical hair restoration represented the first technological improvements that allowed for completely natural results to be achieved on a consistent basis. The procedure called for the introduction of stereoscopic dissecting microscopes to replace the clumsy and primitive jeweler’s loupes that had been the previous standard with mini-micro grafting. By incorporating microscopes to dissect the donor strip of hair bearing tissue the technicians could more easily identify and harvest individual follicular units as they occur naturally on the safe donor zone. Follicular units, by definition, are the natural bundles of hair that grow on the scalp (or anywhere on the body) that contain groupings of one to five hairs. This meant that the grafts prepared for the purpose of surgical hair transplantation would be smaller than typical mini-micro grafts. The challenge was that there was a steep learning curve for not only technicians but also for physicians as this new technique required ever smaller incisions during recipient site creation. With surgical hair restoration, smaller is usually better, so the smaller incisions required of this new technique allowed for increased naturalness, less scarring in the recipient zone due to said smaller incisions, and an increase in first surgery densities also due to the reduced recipient site incision sizes.

The manner in which FUT is performed is fairly uniform from one clinic to the next with multitudes of small varying details subject to personal physician operational preferences. The general outline for a typical FUT is shared below.

1. The doctor confirms the patient’s candidacy prior to surgery. This includes discussions regarding the patient’s expectations but also a physical characteristic assessment including an assessment of the donor zone. This requires that the doctor gauge the donor laxity by pulling the scalp up and down in a vertical plane to ensure that this laxity is sufficient for accommodating the width of the strip expected to be removed. The doctor will then gauge the density of the donor zone which is the second component to determining the total graft estimate for the surgery. With FUT, donor laxity + donor density = total number of grafts.

2. The patient is prepped for the procedure with various medications given, both orally and via injections. These include, but are not limited to, antibiotics to protect the patient from infectious organisms introduced into any open wounds as well as anesthetics for pain management.

3. The patient is then asked to either sit down in a chair resembling a barber’s chair or to lay prone on a table. The doctor will usually shave a narrow strip of hair from the donor scalp to allow for visibility. Usually, this area that is pre-shaved will be slightly wider than the intended donor strip size to allow for better maneuverability and visibility. The goal is to avoid as much donor hair transection as possible.

4. “Tumescence” will then be applied through additional injections. This is performed so that the donor zone inflates, similar to a balloon. This forces the follicular units to spread apart from each other thereby allowing the scalpel to be pushed or pulled in between the follicular units which limits follicular transection to a minimum.

5. Some clinics that wish to take wider donor strips will also use “undermining” to surgically separate the upper dermal layers in the donor zone from the underlying “galea”. The galea separates the dermal layers from the musculature of the scalp and allows for the donor wound to more easily be pulled together. This helps to reduce tension of the donor wound closure which helps to prevent undesirable donor scar stretching.

6. Upon closure of the donor wound the doctor will use surgical staples or sutures or a combination of the two with removal expected roughly two weeks post-surgery.

7. With the donor strip removed the technicians are able to begin the dissection process. In order to do this the strip is cross-sectioned with medical razor blades or scalpels into fine “slivers”. These slivers are narrow enough so that the bundles and more easily be seen and further dissected. They are then handed off to the rest of the technician team so they can further dissect the tissue down to the bare follicular units.

8. The doctor usually starts making the incisions into the recipient scalp at this time. Some clinics will require that the recipient zone be shaved so that the doctor can better see where to make the incisions as it is thought to help minimize transection of the native follicles. Most clinics however do not require such shaving as transection can be avoided with the use of magnification to aid the doctor.

9. Once the doctor has completed the incision making process technicians will start to place the grafts into the recipient sites. Some doctors will work alongside their technicians during the process but most doctors leave the placement completely to the technicians.

Recovery from FUT generally requires approximately one to two weeks off from work and in most cases no strenuous activities such as weightlifting and sports for six to twelve weeks minimum. The duration of the recovery is solely for the benefit of the donor zone due to the fairly invasive nature of strip removal. The recipient area typically heals within two weeks and is free from risk of physical trauma thereafter. Once the donor zone has completely healed a linear scar will remain for life. The length and width of the donor scar will vary due to the size of surgery and healing characteristics along with physician skill. When performed properly and the patient has average healing characteristics the donor scar is easily concealed with moderately short hair styles.