What is a Hair Transplant?

The principle behind hair transplantation is actually quite simple. In English, this process is referred to as hair transplantation, in short, it is a transfer process. What is transferred is the hair strand or graft. The area at the back of the head, especially between the two ears, tends to grow healthy and permanent most of the time. Even in cases of severe androgenetic hair loss, we see healthy, non-shedding hair in this area because the hair follicles in these areas are not exposed to the effects of the hormone dihydrotestosterone (DHT).

The resistance or susceptibility of individual hair follicles to DHT is a genetic characteristic of that follicle and remains in the follicle even when transplanted from one part of the scalp or even the body to another. Therefore, these hair follicles transplanted into a bald area will continue to grow in the new location. We call this "donor dominance", in short, the hair will bring its own DHT-resistant property to the area where it comes from.

Not all hair characteristics are controlled by the genetics of the hair follicle. For example, think of a wavy strand of hair, the fact that it is wavy has more to do with the surrounding scalp than its structure. In short, wavy hair taken from the back of the scalp and transplanted to the front may tend to grow straight depending on the condition of the scalp. The rate of hair growth and the final length of the hair are affected by both the hair follicle and the skin surrounding the transplanted hair. Therefore, leg hair transplanted into a slow-growing scalp will grow faster and longer on the scalp but will not reach the length or thickness of the original scalp. The length of the scalp hair transplanted to the eyebrow will decrease over time, but it will most likely always need to be cut.

It is important to understand that in hair transplantation, the permanent hair is distributed to cover the areas of the head where the hair is thinning or falling out. In hair transplantation, new hair follicles are not actually created, existing hair is simply replaced. Therefore, it would be pointless to expect a net increase in hair. Nevertheless, a skillfully performed hair transplant can make a person appear to have more hair.

The amount of permanent donor hair a person has is an important factor in determining which people are suitable candidates for hair transplantation. This affects every aspect of hair transplant planning and determines how complete the results can potentially be. Therefore, a careful assessment of a person's available donor area is extremely important in hair transplant planning.

On the basis of hair transplantation, it is both an artistic endeavor and a technical achievement.

Hair transplant results should create a natural-looking result that is consistent with the available hair supply, the individual's unique hair characteristics and the patient's goals. A hair transplant should not only look good today, but should be designed to suit the person as they age. But of course, art alone does not ensure a successful hair transplant. The movement of thousands of tiny grafts requires tremendous technical skill; therefore, highly trained, experienced, clinical support staff is crucial when performing these lengthy, organizationally complex procedures.

The hair transplant specialist must have in-depth knowledge of the anatomy and physiology of the human hair and scalp, and a thorough understanding of the medical conditions affecting the scalp. The hair transplant specialist should also be familiar with facial anatomy, have excellent artistic skills and have a thorough knowledge of different hair transplant procedures and repair techniques. The best hair transplant specialists should be committed to following new developments in the field or be directly involved in developing them. They should be committed to the clinical practice of hair transplantation. It is literally impossible for an ordinary hair transplant specialist to perform state-of-the-art hair transplantation.

Hair Transplant History

I have always been an eternal believer in the power of history, witnessing how it sheds light on the future. The first successful hair transplant was performed in Japan in the early 1930s to treat various types of hair loss in areas such as the scalp, eyebrows and moustache, as well as hair growth in the female pubic area. Japanese doctors made a number of important observations when developing hair transplantation. For example, they noted that small grafts give better results than larger grafts, that donor hair is best removed through a single, long incision, and that individual hair follicles should be transferred to the recipient sites, i.e. the canals where the grafts are placed. They also observed that these grafts survived best when stored in saline, which is similar to the salt concentration of normal serum. They even observed telogen effluvium, the most annoying form of hair loss even today. Most importantly, they showed that individual hair transplantation results in a growth that is almost indistinguishable from naturally growing hair.

Unfortunately, due to the poor communication of scientific knowledge between East and West, exacerbated by the Second World War, Western surgeons were unable to use this important discovery for their own hair transplants.

The first hair transplant was performed in 1952 by Dr. Norman Orentreich in the United States. At first, the results of his research were rejected by the editors of many prestigious medical journals because they did not believe that such a procedure was possible. Eventually, the research was published in 1959 in the Journal of the New York Academy of Sciences. In the article, he explained the concept of "donor sovereignty", the idea that grafts continue to show donor site characteristics after transplantation. This remains the fundamental concept underlying all hair transplant procedures.

In Dr. Orentreich's original work, and in most hair transplant procedures until the early 1980s, grafts were harvested using an instrument called a trephine or punch. This small, round-headed instrument was used to remove hair-bearing tissue from the back scalp. The same instrument was then used to make a channel in the bald scalp where the graft would be placed.

In the 1980s, the standard graft size was reduced to 3 to 3.5 mm, but still without a successful, natural result. We can say that the main feature of the hair transplantation results in this period was that there were large dot-to-dot holes like the hair follicles of Play-Doh dolls.

When we look at the old hair transplantation times, we see that 25 to 50 grafts were done in an average of one or two hours. In addition to the fact that the size of the canals was very large, patients used to experience severe bleeding and hair transplantation was almost not considered as a reasonable treatment.

Finally, realizing this, hair transplant specialists started to take the donor tissue in a long strip and transplant it into the balding area. The strip from the donor area was sutured closed and the FUT technique, which leaves a long thin incision scar, was born. Knowing that it is difficult and time-consuming to obtain grafts from a single donor tissue, hair transplant specialists have adopted the FUT technique and there are still hair transplant specialists who perform the FUT technique, especially abroad.

It soon became clear that even these small strips did not look natural at all, especially in the front hairline. At least for the front hairline part of the hair transplantation, individual hair transplantation had to be done. 1 and 2 hair grafts were called "micro grafts". The procedure in which 1 and 2 hair grafts are used in the hairline and 3-8 hair grafts are used in other parts of the scalp, that is, mini micrografting, started to be performed.

Despite the fact that mini micrografting techniques were a significant improvement over the old punch-graft techniques, there were many problems with the procedure. The most important of these was that the procedure still did not look completely natural. If the patient had thick hair or wanted to comb the hair backwards, exposing the hairline, it was very obvious that a hair transplant had been performed and it did not look natural. The second and biggest problem was that the probability of hair survival was very low due to the instruments used. Multiple blades cut the hair follicles, damaging the tissue and preventing growth. The result was less hair and an unnecessarily thinned appearance.

The historical process of hair transplantation has progressed quite slowly. The large grafts used in the sixties and seventies were eventually replaced by mini-grafts in the eighties and mini-micrografting in the early nineties. Follicular Unit Transplantation, or FUE, then came on the scene. First described by Bernstein and Rassman in 1995, this method soon emerged as the latest technology in hair transplantation, replacing mini micrografting in the treatment of androgenetic hair loss.

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Hair Graft

During hair transplantation, small grafts containing hair follicles are extracted from the permanent hair areas on the back and sides of the scalp and moved to areas with sparse or complete baldness. The grafts are loosened with a tool called punch and then collected with a tweezer-like tool called pen set. The collected grafts are kept waiting while micro channels are opened in the recipient area. Sharp blades called slit are used to open the channels. Especially in the channels opened using a sapphire tip, a special sapphire tip size is used in each area. This helps us to transplant hair to different areas at different frequencies and moreover, to give a very natural appearance. Both the size of the grafts and the size of the recipient areas have decreased in the last 40 years. This reduction in size has made hair transplantation dramatically more natural.

The grafts that are kept while the channels are opened can survive, depending on how they are harvested and stored. From the moment the hairy tissue is removed from the back scalp to the moment it is transplanted into balding areas, it must be kept in a cool, moist environment to ensure maximum survival. In large long-term hair transplant procedures, proper graft handling and storage is particularly important.

Grafts cannot be transferred from one person to another. They can only be replaced in the body of a single person, which we call "autograft" and as such, there is no possibility of rejection of one's own tissue. This has two important consequences; firstly, we do not need to test a person to see if the hair transplant will work and secondly, no medication is needed to make the transplanted hair grow. As such, there is no need to use strong immunosuppressive drugs to prevent rejection of the tissue after a hair transplant.


Graft Dimensions

Grafts are generally divided into five general categories: standard punch grafts, minigrafts, slit grafts, micrografts and follicular unit grafts. Standard punch grafts are 3-4 mm in diameter and can each contain up to 30 hairs and 10 or more intact or partial follicular units. Minigrafts are smaller, 1.2-2.5 mm in diameter and contain 4-12 hairs per graft. Slit grafts are similar to mini-grafts in terms of hair content but are rectangular rather than round because they are cut from long, thin strips. Micrografts are even smaller, 1.5-1.0 mm or less in diameter and contain 1-2 (or 3) hairs per graft. Follicular unit grafts consist of single follicular units. Each of these naturally occurring groups may contain 1 to 4 hairs.


The Importance of the Hairline

Large grafts placed in the frontal hairline are dotted and look unnatural when the hair is combed back or to the side. With older procedures, the hair transplant patient had to comb their hair forward to hide the hairline because of the use of large grafts. To create more natural-looking hairlines, hair transplant specialists began to reduce the size of the grafts and place these smaller grafts in front of the larger ones. The use of larger grafts in the front hairline also caused the patient to undergo hair transplantation again to correct this problem, as the patient's appearance after hair transplantation was spoiled and did not achieve reasonably good results. Large graft transplants often look unnatural because they are clumped in nature. When examined closely, it is unfortunately impossible for large graft transplants to look and feel natural.

The design and position of the hairline is perhaps the most critical aesthetic aspect of hair transplantation. Some hair transplant centers create the same standard hairline for every patient. In fact, if you look carefully, everyone's hairline is different from each other and this difference brings a natural appearance. The hair transplant specialist should normally be very aware of this spectrum of diversity and adjust each hairline according to the patient's specific facial features. He or she must also take into account that as the patient matures, facial features will change and balding will continue, but the position of the transplanted hairline will be permanent.

The frontal hairline is not symmetrical in most people, so one should not try to create a perfectly balanced hairline. If the hairline is placed too far below the forehead due to overly demanding patients, the result will not be really good. While it is important for the patient to play an active role in the decisions regarding the placement and design of the hairline, it is very important to guide the patient and explain the parameters to ensure that the procedure looks natural now and in the future.

I would like to leave a note of caution: Some hair transplant centers invent unusual terms for grafts in order to show that they have some special, unique knowledge or technique. Do not be confused by fancy terminology. In today's hair transplant technology, the FUE technique is the gold standard for hair transplantation.


Direction and Slope of the Hair to be Transplanted

Another important point in hair transplantation. Hair grows in different directions in different parts of the scalp. The hair on the front and top of the head grows predominantly forward; the hair on the back grows downwards; the hair on the sides of the head tends to grow in both directions. The place where the hair changes from forward to backward is called the vertex transition point and is more commonly known as the crown area. When designing a hair transplant, the hair transplant specialist should be familiar with these natural growth patterns, hairstyle preferences, and how you want your hair to look both groomed and un-groomed. A full understanding of all the nuances of the different hair characteristics and patterns that individuals may have is extremely important when performing a hair transplant. During hair transplantation, the angle of the channels opened before the hair is transplanted to the recipient area contains these elements of naturalness that I have just mentioned.

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