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Hair Transplantation Controversies
Marc R. Avram, MD,*† Robert Finney, MD,‡ and Nicole Rogers, MDxk
BACKGROUND Hair transplant surgery creates consistently natural appearing transplanted hair for men. It is
increasingly popular procedure to restore natural growing hair for men with hair loss.
To review some current controversies in hair transplant surgery.
plant surgery.
Review of the English PubMed literature and specialty literature in hair trans-
RESULTS Some of the controversies in hair transplant surgery include appropriate donor harvesting technique including elliptical donor harvesting versus follicular unit extraction whether manual versus robotic, the
role of platelet-rich plasma and low-level light surgery in hair transplant surgery.
CONCLUSION Hair transplant surgery creates consistently natural appearing hair. As with all techniques,
there are controversies regarding the optimal method for performing the procedure. Some of the current
controversies in hair transplant surgery include optimal donor harvesting techniques, elliptical donor harvesting versus follicular unit extraction, the role of low-level light therapy and the platelet-rich plasma therapy
in the procedure. Future studies will further clarify their role in the procedure.
The authors have indicated no significant interest with commercial supporters. M.R. Avram is an unpaid
consultant for Restoration Probotics.
ver the past 20 years, the cosmetic standard for
hair transplantation has been the ability to
consistently create natural appearing transplanted
hair for men (Figures 1 and 2). The procedure is
performed as an outpatient with local anesthesia with
a low rate of medical and surgical complications. As
with all surgical procedures, there has been a continual
evolution in technique with the goal of an ever more
efficient, safer, and even higher level of patient
satisfaction. This article will review several of the most
salient debates in the field of hair transplantations.
As with all procedures, the consult is vital to establish
candidate selection. Patients with increased donor
density, thick-caliber hair follicles, and areas of clear
thinning in the frontal scalp are ideal candidates for the
procedure. Those with limited donor density and fine
thin-caliber hair follicles will have less cosmetic impact
from a procedure. It is vital that patients understand
the ongoing nature of male-pattern hair loss and how
that will impact the perceived density and cosmetic
appearance of a transplant. Transplanting the frontal
half, the scalp is considered the cosmetically safe zone
where ongoing hair loss will impact the perceived
density of a transplant but not the natural appearance
of the procedure. Transplanting the vertex of the scalp
does have more long-term cosmetic risk with an
unnatural “doughnut” appearance of hair. Successful
medical therapy to stabilize male-pattern hair loss
should be discussed with all patients with existing
pigmented terminal hair considering a hair transplant
to create optimal long-term density. Age is not
a determining factor in candidate selection. Expectations, short- and long-term planning of where to
transplant and not transplant is the key. Younger
patients have greater risk of long-term widespread hair
*Private Practice, Dermatology, New York, New York; †Weill Cornell Medical Center, New York, New York; ‡Heights
Dermatology, Brooklyn, New York; xTulane Health Sciences Center, New Orleans, Louisiana; kPrivate Practice, Old
Metairie Dermatology, Metairie, Louisiana
© 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 1076-0512 Dermatol Surg 2017;43:S158–S162 DOI: 10.1097/DSS.0000000000001316
© 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Ellipse Versus Follicular Unit Extraction
Figure 1. Before hair transplantation.
loss and therefore must understand what can and
cannot be accomplished with a hair transplant. If
a patient has realistic short- and long-term expectations, they are potential candidates for the procedure.
Donor Harvesting
The day of the procedure, informed written consent
is obtained (consent given before the procedure for
the patient to review), and wound care instructions
and activities are reviewed. The area to be transplanted is marked off by the physician, and photographs are taken. Patients are encouraged to bring
food and drinks to the procedure and ask for breaks
to eat, drink, or check their emails during the procedure. The goal is to have a relaxed, comfortable
Currently, there are 2 techniques for removing donor
hair: elliptical donor harvesting and follicular unit
extraction (FUE). Elliptical donor harvesting has been
performed for over 20 years.1 It is performed under local
anesthesia. The length and width of the ellipse depends
on whether hundreds or thousands of follicular units
from the posterior scalp are needed to be transplanted in
the frontal scalp. The ellipse is separated by skilled surgical assistants into individual follicular units.
Follicular unit extraction is the direct removal of
individual follicular units using 0.8- to 1.2-mm manual punches, mechanically assisted devices, or robotically.2–5 With FUE surgery, the entire posterior scalp is
trimmed to 1 mm. This is mandatory to allow the
harvesting of individual follicular units using 0.8- to
1.1-mm punches (Figure 3).
There is an intense debate as to which technique is
superior. Advocates of elliptical donor harvesting
believe that there is a lower transection rate of follicular units resulting in greater growth of transplanted
hair. Advocates of FUE tout the minimally invasive
aspect of obtaining follicular units, absence of a long
linear scar, and no need for sutures results in better
wound healing. In addition, FUE mimics the trend in
medicine toward minimal invasive surgery.
The donor harvesting is performed using local anesthesia
such as lidocaine with epinephrine. Patients are in the
prone position for harvesting the grafts from the posterior scalp.
Currently, both techniques should be considered state of
the art in hair transplantation. Both techniques should be
discussed during a hair transplant consult. Each
Figure 2. After 1,100 grafts, 1 procedure.
Figure 3. Harvested follicular units measuring 0.9 mm in
© 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
technique has potential advantages for the individual
patient (Table 1). For example, a man who wears his hair
short or may want to wear his hair short in the future
would choose FUE as the preferred harvesting method.
The pinpoint scarring from FUE is less obvious to the eye
than a linear scar from an ellipse.6 Meanwhile, a woman
with shoulder length hair will never trim hair to 1 mm in
length necessary for FUE, which makes elliptical donor
harvesting the clear choice. The keys to a successful hair
transplant surgery remain to be appropriate candidate
selection, the skill of the physician and surgical team, and
choosing the appropriate procedure for the patient.
The recipient sites to place grafts in the frontal scalp
are made with #19–#21 gauge needles. The grafts are
placed with microvascular forceps.
After the procedure, patients go home with a pressure
dressing that remains on overnight. Patients are given
prednisone 40 mg daily for 3 days to minimize frontal
edema and 2 to 4 tablets of Tylenol #3 for pain relief.
Most patients use little to no pain medication after the
surgery. Patients apply petroleum jelly to the donor
region twice daily for 1 week postsurgery. They shower
each day by allowing the water to rinse off the scalp but
to avoid scrubbing or scratching at the scalp. The perifollicular crusting that forms around the grafts resolve in
5 to 8 days. After 1 week, patients resume full sports and
all physical activities. Transplanted hair takes 8 to 16
months to fully grow.
Holding Solutions
Another controversy in hair restoration is centered
around the ideal holding solution for the time the
grafts are out of the body. To date, there are no firm
data how long grafts can remain in a holding solution
and remain viable, but anecdotal evidence has shown
that graft survival tends to decrease consistently when
out of the body time is greater than 2 hours.7 There is
little debate that grafts must be kept well hydrated and
handled gently. Historically, normal saline has been
widely used as an effective and inexpensive fluid that
can be used at room temperature. However, there is
evidence that other aspects can and possibly should be
optimized, including the temperature, osmotic balance, pH, and electrolyte balance. For instance,
enzymatic activity decreases by 1.5- to 2-fold for each
10°C drop in temperature. Thus, chilling the grafts
may confer a survival advantage, as demonstrated by
Limmer’s study on graft survival in 1992. Likewise,
Plasma-Lyte is 1 solution that more closely mimics the
pH of human serum (both are 7.4 vs saline which is 5.0
and Lactated Ringers which is 6.5). HypoThermosol
FRS* (Biolife Solutions, Inc., Bothell, WA) is a proprietary holding solution that was developed for
optimal use at 2 to 8°C and contains the buffer HEPES.
It is designed for oncotic balance, with numerous
impermeant anions that will not cross the cell barriers
to allow cell swelling or rupture. Liposomal adenosine
triphosphate (ATP) (Energy Delivery Solutions, LLC,
Jeffersonville, IN) is another interesting product that
can be added to any holding solution or used as
a postoperative spray to increase graft survival. It is
also kept chilled but even in optimal conditions has
a 2-month shelf life. In 1 study, by Jerry Cooley, survival was shown to be significantly improved when
grafts were placed in hypothermosol alone or hypothermosol with ATP as compared to normal saline.8
TABLE 1. Ellipse Versus FUE
Transection rate
Variable depending on training of
surgical assistants <5% with trained staff
Variable depending on skill
of physician and
device of operation of robot <5%
with trained staff
Sutures needed
Yes; linear scar visible
with short hair
Yes; pinpoint white scars may be
visible with short hair
Extensive trimming of hair in
posterior scalp for donor region
FUE, follicular unit extraction.
© 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Recently, platelet-rich plasma (PRP) has been suggested as an alternate holding solution. To date, there
are no published data to show whether PRP is able to
enhance graft survival.
Controversies in Medical Therapy
Currently, in hair transplant clinics, all patients are
counseled on medical therapy to help halt further hair
loss and thus maximize the impact of any transplant
long term. In the past, options were limited, with the
conversation focused mainly on minoxidil and finasteride; however in the past several years, both lowlevel laser light therapy and PRP have emerged as
adequate treatment options for both men and women.
Low-level laser light has many dermatological applications, but with respect to hair, it was originally discovered paradoxically. At high energy, devices
emitting red/near-infrared wavelengths cause hair
destruction; but at lower energy, it have been found to
actually stimulate hair growth. To date, many different devices exist, from laser caps to combs. A recent
evidence-based review of all the trials performed show
that the handful of randomized control trials provides
a moderate–high level of evidence in support of these
devices safety and efficacy. In the authors’ experience,
the results are more moderate than the other treatments already FDA approved for the treatment of
pattern hair loss, although they can be a helpful
adjunct. It is also important to note that these devices
require that the energy reaches the scalp and thus, if the
desired treatment area has moderate or better density
of overlying hair, a comb may provide more efficacy
than a cap.9–11
Platelet-rich plasma has been utilized for years in
wound healing and orthopedic conditions, but more
recently it has gained traction in aesthetic medicine,
especially with respect to hair loss. Several clinicians
have had some success in treating alopecia of various
etiologies (lichen planopilaris, alopecia areata, etc),
but most of the limited data have been focused on PRP
use for male- and female-pattern hair loss.12,13
Although not all is known regarding PRP’s mechanism
of action, it is known that once activated, platelets are
able to aggregate together and release alpha-granules
containing various growth factors, such as plateletderived growth factor, transforming growth factorbeta, vascular endothelial growth factor, epidermal
growth factor, fibroblast growth factor, and insulinlike growth factor-1 (IGF-1). Their release increases
angiogenesis and vascularization, providing resting
telogen hairs the signal that they need to enter the
anagen phase. This increased vascularization and mix
of growth factors also fosters the proliferation of
dermal papilla cells and inhibits apoptosis, helping to
prolong the anagen phase. More specific to androgenetic
alopecia, PRP may help to counteract certain effects
of dihydrotestosterone (DHT).14 In a mouse model
of androgenetic alopecia, DHT was shown to block
IGF-1 contributing to hair loss and PRP is a known
source of IGF-1.15
Although not all studies have shown positive results,
enough literature has shown that both are capable of
moderate success in treating androgenetic alopecia
and have the added benefit of being very well tolerated.16–24 Platelet-rich plasma is also autologous and
thus provides patients a more “natural” treatment,
with side effects limited to procedural discomfort and
bruising. There is no standard system, quantity, or
interval of treatment regarding PRP for hair loss. They
currently treat patients monthly 3 times and then judge
efficacy after 8 to 12 months. If a patient has
a response, then retreatment at follow-up may result in
continued efficacy if performed at a 6- to 12-month
basis, although no studies have been performed to
support this.
With respect to hair transplantation, PRP has been
discussed anecdotally in the treatment of the donor
area to promote the growth of hairs transected during
the procedure, use as a storage solution to keep grafts
viable, and treatment of the recipient sites to promote
earlier regrowth and an overall higher yield. If the
recipient area is treated, it also doubles as a medical
therapy for their ongoing pattern hair loss, rendering
the end result potentially more dense coverage than
could be achieved by transplantation alone. Only 1
study has been published to date, a single-blinded
study that treated the recipient area in patients
undergoing FUE with either PRP or placebo. All 20
© 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
patients in the PRP group had >75% regrowth at 6
months post-op, compared with only 4 of 20 patients
in the placebo group. The PRP group was also noted to
have significant regrowth at 8 weeks post-op, which is
much earlier than expected after receiving a hair
In the next few years, longer-term studies will help
better define the medical and surgical role of PRP and
hair loss.
Hair surgery has evolved significantly since its inception in the 1960’s and 70’s. Fortunately, the newer
techniques and increased knowledge has paved the
way for increased graft survival and optimal cosmetic
outcomes for patients. Where there is still debate and
controversy, the authors’ hope it is what keeps them
moving toward even better results in the future.
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Address correspondence and reprint requests to:
Marc R. Avram, MD, Private Practice, Dermatology,
905 Fifth Avenue, New York, NY 10021, or e-mail:
© 2017 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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