Hair Transplant Areas
Hair transplants is one of the most effective treatment options for baldness. The scalp is the most common site of hair loss for which a hair transplant is indicated but it is not the only one.
Beard and mustache transplants are getting popular as well and so are eyebrow implants. Less commonly, hair restoration surgery is done at other hair-bearing parts of the body.
According to a census report by the International Society of Hair Restoration Surgery (ISHRS), the global market size for hair restoration surgery stood at USD 4.6 billion in the year 2019, a 10% rise compared to 2016 1. Follicle unit extraction (FUE) and follicle unit transplant (FUT) are the current standard surgical techniques for the most common areas of transplant.
Where on the body can a hair transplant be done?
The scalp is the most common area transplanted to, but with the wider availability of FUE and FUT, there is an increasing demand for hair restoration procedures on other areas of the body, particularly facial hair. A brief rundown of hair loss and its surgical treatment at various body parts is presented here. More details are available in separate articles for each section.
Scalp hair transplant
The most common cause of scalp hair loss is androgenetic alopecia or pattern baldness. In men, the frontal and temporal hairlines are the first areas affected, followed by the crown. Hair at the back of the head is relatively preserved. Hair loss is graded as per the Norwood scale, which gives an estimate of the number of grafts required. A transplant may be done on the forehead, the temples, the crown/vertex, the whole head, or isolated bald spots.
Facial Hair transplant
The appearance of hair on the face as beard and mustache are indicators of puberty in men and an important cosmetic and social factor for a positive body image. Increasingly, men with thin beard hair—due to hair loss, bald spots, or failure to grow a full beard or mustache with age—are resorting to hair transplant, with the ISHRS reporting a more than 120% rise in facial implants such as Beard transplants and mustache transplants between the years 2014 and 2020 .
Eyebrows Hair transplant
Eyebrows are an important part of the face, delineating the boundaries of the forehead. Alopecia areata, an immune condition, can lead to bald spots at hair-bearing areas of the body, including the eyebrows. Eyebrow hair transplant is an option for people with thin eyebrows or with eyebrows hair loss. Recently, the American model Chrissy Teigen made headlines for undergoing an eyebrows hair transplant.
Other body areas
People with sparse eyelashes or those with permanent eyelash hair loss can consider an eyelash transplant. Similarly, some people with no chest hair may decide to undergo a chest hair transplant, where hair from the back of the head is transplanted onto the chest.
The Donor Area
The process of hair transplant involves harvesting hair follicles from a donor area and implanting them into the recipient site. The donor site is selected on the basis of follicle density. Commonly selected donor sites, in order of preference, are:
- The back of the head: Hair at the back of the head (occipital region) is resistant to the effects of DHT, the hormone responsible for male-pattern baldness and, therefore, in most men with baldness this area is spared. It is often referred to as the permanent donor area and is the most common source of follicles for hair transplantation. On average, there are about 50,000 follicular units on the scalp of an adult man, of which 12500 are located in the permanent donor area. As a general rule, no more than 50% of the available follicular units are harvested from the donor site to avoid noticeable thinning. So, a maximum of 6000-6500 follicular units can be harvested from this donor site. This theoretical potential is not always utilizable, however, as the hair density is rarely uniform and the post-harvest donor site density must not be less than 1/mm2. Hair from the back of the head can be transplanted to the frontal scalp, the crown, and the temples as well as to non-scalp sites like the beard, eyebrows, and even the eyelashes.
- Body hair: Using body hair for transplantation to the scalp or other body parts is an established albeit less commonly used practice. It requires more expertise than scalp to scalp transplantation and the results may not be as convincing. Body hair from the beard or other hair-bearing areas like the chest, back, or thighs can be harvested. These sources are utilized when the primary donor area has insufficient follicle density.
Recovery at the donor site is usually without hiccups. With FUE, individual follicles are harvested from the donor area while in FUT a strip of scalp skin containing hair follicles is dissected. The recovery process at the donor site can be complicated by:
- Overharvesting: The final hair density at the donor site should not be lower than 1/mm2 to avoid looking thin, as the harvested follicle cannot, obviously, regrow. In rare circumstances, overharvesting can make the donor area noticeably thin.
- Scarring: Occasionally, there may remain a linear scar at the donor area with a FUT hair transplant. Modern surgical techniques have minimized the risk of scarring.
Short term effects after surgery
Generally, a hair transplant is a relatively safe procedure, with an uncomplicated recovery of the donor area. In the first couple of weeks, one can expect the following short-lived complications:
- Pain: The procedure itself is almost painless as it is performed under a nerve block or local anesthesia. Mild to moderate pain may be experienced in the first 3-4 days after surgery which usually settles with over-the-counter pain medications.
- Swelling: The area can appear swollen and edematous for a few days after surgery. Some surgeons inject a dose of steroids during the surgery to reduce inflammation. Generally, over-the-counter anti-inflammatory medications are all that is required.
- Infections: Like any invasive procedure, the risk of infections remains. Fever, pain, or pus formation are signs of a bacterial infection.Good surgical hygiene and post-operative care are important to reduce infection risk. Some surgeons prefer to use prophylactic antibiotics to reduce the risk further. Once an infection sets in, a course of oral and/or topical antibiotics is usually required.
- Other risks: Rarely, there may be bleeding, or shock loss of the remaining hair at the donor site. The risks of hair thinning and scarring have already been mentioned in the preceding section.
The Recipient area
The hair follicles harvested from the donor area are implanted onto the recipient area. This is often an area on the frontotemporal scalp and vertex but can be any other part, like the beard, mustache, or eyebrows, where hair restoration is desired. Surgeons would initially mark the boundaries of the recipient area carefully, the frontal hairline in particular, before proceeding to the actual transplant process. The area to be covered and the desired follicle density depends on the patient’s preference and the number of grafts in the donor area at disposal. In general, the density achieved in the recipient area is 30-40 units/cm2.
The implantation process at the recipient area broadly involves the following steps:
- Assessment of the recipient area: This involves an investigation into the cause of hair loss and the condition of the scalp in the recipient area. Active infection or an ongoing inflammatory process may make the area unsuitable for hair transplantation.
- Calculation of the number of grafts: The extent of hair loss is graded according to the Norwood scale in men. There are 7 stages of progressive baldness in the Norwood scale with type I denoting minimal hair loss and type VII complete baldness. For a mild to moderate hair loss 1000 to 1500 grafts may be sufficient, while complete baldness usually requires north of 5000 follicle grafts.
- Implantation of hair follicles: The process of harvesting from the donor site and implantation into the recipient area differs somewhat according to the surgical technique. In FUT, follicles are extracted from the cut strip of hair and implanted one by one. In FUE, individual follicles are harvested, stored in a liquid medium to avoid desiccation and then implanted onto the recipient area. Direct hair implantation (DHI) is a newer technique, where the harvested follicles are implanted simultaneously to the recipient area, obviating the need for a storage medium.
Recovery after surgery is usually smooth in the recipient area. In the short term, the healing process takes a couple of weeks. Long term considerations include successful hair restoration, changes to the scalp, and quality of the transplanted hair:
- Hair restoration: Complete growth of the transplanted hair takes 9 months to 1 year. Generally, more than 80% of the implanted follicles survive in good clinics.
- Scalp complications that may develop include cobble-stoning at the recipient site and chronic folliculitis.
- Careful mapping of the hairline, adequate graft density, and proper adjustment of the implanted hair direction is important for a quality hair transplant.
Short term effects after surgery
The recipient area undergoes quite a few changes during the initial postoperative days. Some of the common ones are:
- Allergic and inflammatory changes: Scalp swelling, edema, itching, and pain are relatively common in the first few days. They usually settle with pain medications. Scab formation is another common feature at this stage. Avoid picking the scabs and excessive scratching. The scabs will fall off spontaneously.
- Infections: Like at the donor site, bacterial infections can complicate the recovery process at the recipient area too. Good post-operative hygiene is important. The hair can be washed gently after the first few days using baby shampoo and avoiding direct application of the shower stream. Antibiotics may be required for serious infections.
- Hair fall: The implanted hair will fall off by 3-4 weeks. It is part of the recovery process and not a cause for concern.Regrowth can be noticed by the 3rd month.