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Follicular unit graft is the gold standard for androgenetic alopecia

Article-Follicular unit graft is the gold standard for androgenetic alopecia

Hair restoration surgery (HRS) has come a long way from the unnatural-looking hair plugs of past decades, with refined procedures making it possible to achieve excellent cosmetic results and give much hope to balding men. But these advances have made natural-looking results even more dependent on the aesthetic abilities of the surgeon to mimic the natural hairline, transitions in density and angle of growth. Cosmetic Surgery Times recently sat down with three leading HRS specialists to learn how to master the "perfect" hair restoration procedure.

NATURAL-LOOKING HAIRLINE IS KEY The challenge of hairline design is to make the hairline undetectable. Hair transplant surgeons have come to realize that hairlines are anything but straight; instead they are asymmetrical and irregular. "Upon studying hairlines in more detail, we learned that they were a transition or 'zone' of hair that starts from the very thin and gradually gets thicker as you reach the thicker part of the scalp," explains E. Antonio Mangubat, M.D., of Southcenter Cosmetic Surgery and Hair Restoration in Tukwila, Wash. "Therefore, gradation of density is critical as it makes the hair look much more natural." Dr. Mangubat utilizes follicular unit transplantation, a technique in which the natural hair bundles are harvested and then individually repositioned on the scalp. He performs an average of 1,500 grafts per transplant session, which may take five to six hours to complete. The grafts are taken from the back of the head just below the nuchal promontory, also known as the permanent donor fringe. These hairs are resistant to androgenetic alopecia (AGA), making them the perfect "donor." Dr. Mangubat says that about 20 percent of his patients are very happy with just one transplant and the other 80 percent want at least two and sometimes three transplant sessions.

Dr. Mangubat
"It's crucial to discuss and be crystal clear on the expectations of the patients before performing HRS," says David Perez-Meza, M.D., a plastic surgeon and hair transplant specialist in Mexico City, Mexico. "That will assist in the choice of treatment, as well as a well-planned approach to therapy." Dr. Perez-Meza concurs that, currently, state-of-the-art technique in HRS is single- or multi-follicular unit transplantation in which either single hair grafts or several grafts are transplanted. In his experience, patients who undergo follicular unit transplantation invariably have excellent and natural results. However, to achieve ideal hair density, the patient may require more than one surgery.

29-year-old patient (left) before and (right) one year after one follicular unit transplantation procedure totaling 1,438 grafts. Photo credit: Marco N. Barusco, M.D.
"This procedure would be my first choice in those male or female patients with androgenetic hair loss," he says. "Those patients who have hair loss as a result of trauma, cancer, or post-radiation therapy could receive this procedure or more invasive HRS using tissue expanders, extenders or rotation flaps. When sculpting the hair zone, I like to make smaller incisions to accommodate more delicate grafts and more follicular units. The idea is to create a natural, denser hairline and this is better achieved by getting more unit grafts into a smaller surface area."

To create a more natural-looking hairline, it's not only important to make it irregular, but also crucial at what angle the surgeon places the hairs," explains Marco N. Barusco, M.D., of Medical Hair Restoration in Maitland, Fla. In order to achieve this cosmetic result, Dr. Barusco uses flat instead of round blades as he's found that a smaller slit site allows him to have more precise control over the incision angle, resulting in better three-dimensional positioning of the grafts.

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