Micrograft techniques

Micrograft techniques

The techniques of scalp micrografts are directly related to the mode of sampling. The removal of a strip of scalp  without shaving allows cutting under microscope after obtaining follicular units longhaired (FUL), remember that the FUE (follicular unit extraction) requires prior shaving..

The causes and signs are basically male and female androgenetic alopecia  but also cicatricle alopecia, the traction alopecia alopecia of African-Americans, pubic balding, balding or thinning of the beardmustache and eyebrows.

FULL HAIR – Transplant by longhaired follicular unit

THE PRINCIPALE

Is to prepare micro-grafts or follicular units of 1 to 4 hairs per follicle segmentation from a strip of an unshaved scalp (FUL)

Essential fact: Hair taken from the hairy crown in men and the median occipital region in women ultimately retain their tracking capabilities and their growth once implanted on the bald or sparse area.

THE GOAL

This process seeks to recreate the natural emergence of one to four hair through each pilosebaceous orifice.

Aspect de émergence naturelle de 1, 2 ou 3 cheveux pour le même orifice folliculaire

Aspect of the natural emergence of 1, 2 or 3 hairs from the same follicular orifice

– For the final transplantation of bald areas of the scalp in men, women or transsexuals in order to give it an aesthetic and natural appearance,

– Or to blur some apparent scars: post-facelift, post-radiotherapy, after burns, pseudopelade etc., with prior test for post-menopausal frontal fibrosing alopecia

– Or for the densification of certain areas lacking in hair (eyebrows, eyelashes, beard, mustache, pubis).

PRE-OPERATIVE STEPS

– A minimum delay of 15 days between consultation and intervention is obligatory before any act of cosmetic surgery. A patient information sheet and an estimate for informed consents will be signed by the patient and the doctor.

– Medical photographs are always carried out: face – profile – aerial view and surface to be implanted.

– A preoperative blood balance and an electrocardiogram will be systematically prescribed according to the medical history and the patient’s age.

Drawing of anterior frontal line

repousse d'une région frontale après FUL

Regrowth of a frontal region after FUL

The preliminary drawing stage is one of the most important moments in the reconstruction of frontal male alopecia. It will have to consider multiple factors with aesthetic wish, age, and the ethnic characteristics of the patient on the one hand and the capacities of the donor area. A photo of the patient dating back a few years can also be useful.

Local anesthesia with an anesthetic cream beforehand makes this almost painless.

TECHNICAL UNITS BY LONG HAIR FOLLICULAR GRAFT (FUL)  (Bouhanna, hair and hair Micrografts: New New New Dermatol., 2010)

The hairs are neither cut nor shaved and are therefore used with their rod length of 3 to 4 cm. The FUL technique allows transplantation and transplantation of grafts with long hair.

Without prior shaving of the donor area, the strip taken is cut under a microscope in micrografts or follicular units with long hair.

Aspect des unités folliculaires à cheveux longs (FUL) après découpe sous microscope

Appearance of long hair follicular units (FUL) after cutting under a microscope
This FUL procedure allows the patient to immediately masks the scabs of the grafted region after the intervention and thus to attenuate the aesthetic postoperative state.
These long hairs will have two possible evolutions:

– Either a loss occurs at the third week and a regrowth occurs three months after the intervention

– Or all or part of these hair continue to grow, possibly stimulated by the lotion Minoxidil 2%.

Its advantages for the patient are:

–  The sampling area for micrografts is not shaved

– He immediately sees the result that some or all of that hair can fall in 2-3 weeks. The “wait and see” has been replaced by the “see and wait”.

– Small scabs that persist 10 to 12 days are hidden by long hair. As a result, the patient can resume his professional activity very quickly 24 to 48 hours later

Advantages for the practitioner:

– A better assessment of the orientation and the angle of the hair

– A better choice especially in the anterior frontal line, fine or thick hair, dark or light

– A large quantity of hair can be implanted at each session (4000 hairs per session).

The only disadvantage of the FUL technique would be to leave a thin scar line. To avoid this pitfall it is possible to realize the trichophytic technique. This consists of de-epidermising on 1 mm the lower edge of the excision of the strip. The hair will thus be able to cross the epidermis of the upper edge and thus attenuate the scar line.

Donor area: Preparation of follicular units

Without shaving, the levy on the occipital donor region is made by excision of a strip, the size depends on the desired number of follicular units. The closing of the banks is done with a suture or with cutaneous staples. To avoid the linear scar, the trichophytic technique can be recommended. The segmentation is performed by cutting the fragments with the help of a stereomicroscope. On average, 500 to 1,500 grafts (1,500 to 4,500 hairs) will be cut.

Preparation of the receiving area

The operator prepares the anesthetized receiving area by performing perforations with a Nokor needle of 16 to 18 gauges. The implantation of the fragments is done with very fine tweezers. Currently, it is possible during a session to transplant up to 1500 follicular units (4,500 hairs).

 

POST OPERATIVE CARE AFTER FOLLICULAR GRAFTS

  • A dressing or bandage is sometimes applied for one night.
  • The first shampoo can be made the next day and long implanted hair can be dried with a warm dryer.
  • An edema on the forehead can sometimes appear within 24 to 48 hours after surgery, it will take 2 to 4 days to disappear. The application of ice cubes and the taking of arnica makes it possible to avoid or lessen this.
  • Small scabs and implanted hair will take about 7 to 10 days to fall away. Long implanted hair can persist.
  • The stems of the implanted hair can fall transiently with the scabs.
  • New hair regrowth will begin between the 3rd and 4th month following surgery.
  • We must insist on the extreme reliability of the follicular units.
  • 12 months are needed to judge the end result of the intervention.

INDICATIONS OF Micrografts (FUL)

The goal is to achieve a harmonious equalization between aesthetic desire, age, ethnic characteristics, sex, psyche, evaluation of the parameters of the various classifications, the evolutionary degree of alopecia and the donor area and the technical surgical possibilities on the other hand.

Androgenetic alopecia

The various parameters of multifactor classification (Bouhanna, dynamic classification androgenetic alopecia multifactorial of masculine and feminine. Nouv Dermatol, 2000)

Measurements such as the extent of the bald and hairy surfaces in relation to certain fixed markings of the face, the elasticity and thickness of the scalp, the covering power of the hair according to density, size, shape, growth rate and color.

 

The digitized phototrichogram (Bouhanna. The phototrichogram and a macrophotographic study of the scalp. Bioengineering and the Skin, 1985)

Bouhanna’s phototrichogram allows for an objective measurement, thanks to a camera, of hairy surfaces, of the donor and recipient areas of grafts: density, caliber, number of miniaturized hair, number of terminal hair and growth coefficient.

Male androgenetic alopecia

alopécie masculine stade 3 avec transplantation d'unités follciulaires à cheveux longs en 3 séances

Stage 3 male alopecia with transplantation of long hair follicular units in 3 sessions

According to one of the three schematic stages of classification, surgical correction involves transplantation of micrografts adapted to one of these stages:

– Stage 1 (accentuation of the frontal-temporal gulfs with possible appearance of a tonsure at the level of the vertex), Implantation of 1000 hairs in 1 session (the implantation of 2000 to 3000 hairs is sometimes necessary during the associated treatment of the tonsure)

– Stage 2 (recoil from the frontal line to the top of the skull, possibly associated with a tonsure). Implantation of 2,000 to 3,000 hairs in 1 to 2 sessions (up to 4,000 hairs during associated tonsure).

– Stage 3 (baldness called “Hippocratic” where the hair persists only on a crown at the temples and the neck). Up to 7,000 implanted hairs, in 2 to 3 sessions.

Female androgenetic alopecia

Alopécie féminine stade 3 avec transplantation d'unités folliculaires à cheveux longs en 1 séance

Female alopecia stage 3 with transplantation of long hair follicular units in 1 session

The degree of severity of female androgenetic alopecia can be defined, using the Ludwig classification, in three evolutionary stages:

– Stage 1 (moderate thinning or balding on the top of the head, respecting the frontal line) with the implantation of about 1000 hairs in one session

– Stage 2 (short alopecia with short hair, located 1 cm behind the forehead), with 1500 to 2000 hairs implanted in one to two sessions

– Stage 3 (almost complete alopecia with a thin line of hair at the forehead), with 3000 to 4000 hairs implanted in two to three sessions.