Hair Transplantation

Hair Transplantation

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FUE Hair Transplant

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FUT Method

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Vertex transplant

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Vertex area is the most difficult area to treat and nearly always the least important area to transplant.

Vertex transplant is indicated in following cases

  1. Above 40 years
  2. Abundant donor reserves
  3. No family history of Norwood V,VI,VII baldness

I personally delay treatment of vertex as long as possible. Initially first I start with medical treatment

Norwood classification of baldness

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This classification mainly helps in a simple way to define accurate
treatment for hair loss.
Grade I – No Treatment Required.
Grade II – Mostly dealt with medical treatment.
Grade III, IV, V– Requires Hair Transplant with medical treatment.

Grade VI – Relative contraindication for hair transplant.
Grade VII – Absolute contraindication for hair transplant.




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There are numerous varieties of punches available in the market today. All punches vary from the size, shape and edges. Every FUE surgeons get into comfort zone by selecting a particular type of punches based on his/her skills. The trumpet punches will be the one of latest development under punch category. Its size varies from 0.70mm to 1.1mm and these punches can be classified into

  1. Standard hybrid trumpet punch (inner smooth outer sharp) and

      2. External serrated trumpet punch (inner smooth outer serrated)




Hybrid Trumpet punch has almost 90° outer edge that allows you to penetrate the skin easily in acute angle. The smooth funnel shaped inner edge treats the graft carefully when working in a vertical motion.


Because of smooth inner edge no need to increase diameter of the punches to avoid transaction and in serrated edges there is even less tissue contact so less tissue damage so therefore faster wound healing and there are reduced scars.


These high quality grafts make extraction process faster and easier resulting in overall time consumption.


Most of the time dull punches tend to bury the grafts and sharp punches tend to transect then but with hybrid trumpet punches with moderate pressure along with the sucking effect of the funnel shaped inside will reduce the missing grafts rate significantly and therefore more follicular units and follicles can be harvested.


  1. More Chances of surrounding hair root damage and decreased grafts obtained because of the conical shape of the punch.
  2. The diameter of the punches has to be kept as minimum as possible (0.8 to 1mm) to avoid neighboring hair root damage.


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Approximately 80% to 90% of Hair Restoration Surgery patients are males

Most important goals of surgical hair transplant is to re-establish the aesthetic balance that was lost in balding process.Its also important to replace those lost hair in a pattern that looks age appropriate as men grows older.

From aesthetic point of view ,restoring the hair-bearing frame constitute the most important goal and objective.

There are 2 underlying psychological research that motivate men to look into Hair Transplant

  1. To look younger view to restore the self-image.
  2. To feel youger view and increase one’s self confidence.

Key background factors in initial planning

  1. First is to decide whether or not the patient is suitable candidate for Hair Restoration Surgery.
  2. Choosing the plan that is most appropriate for his treatment given,his age and his expectation long term donar-receipient area ratio.
  3. Hair characteristics(calibes,color,curl)
  4. Scalp(Thickness,laxity and elasticity)
  5. Scalp condition(Diffuse Unpattern Alopecia-DUPA/Critical alopecia)
  6. Patient medical health
  7. Family history of Male Pattern Baldness.
  8. Patient psychological state.

Hair transplant to the scalp mainly covers four areas.

  1. Frontal scalp/Temporal scalp
  2. Mid scalp
  3. Evolving areas of Male Pattern Baldness
  4. Vertex

Frontal Scalp


Fig 1

Fig 2

Fig 3

  1. Frontal scalp mainly covers hairline zone also called transistion zone consists of only single follicular units in a zig zag pattern with macro and micro irregularities. This area  usually covers 0.5cms from hairline.
  2. Behind this zone is called defined zone, usually consists of 1 and 2 follicular units and covers 1 to 2cm behind hairline zone.
  3. Frontal tuff/egg shaped area (Fig no-4), behind the defined zone located in the central part of frontal region, mainly consists of 2 to 3 follicular units to achieve maximum density.

Position of temporal hair:

It should be always remembered that temporal hair aesthetically serves the purpose of supporting hair line zone.

Usually hairline starts from 8 to 9cm from glabeller in young adults, but as age progresses, the temporal points lend to fade posterior and leaves the lateral end of hairline without  temporal hair inferior  to it and gives unnatural appearance

So it’s wise to place a conservative hair line 2to 3cm anterior to the existing temporal point and this gives more aesthetic look for that particular age

To provide more aesthetic look it always depends on

  1. Placement of fronto temporal triangle.
  2. Frontal forelock and temporal fringe creation
  3. Supra temporal hump creation
  4. Parital fringe creation

MID SCALP(Refer fig -1)

Second most important area to be transplanted, if not patient may look good from frontal viewing, a lateral viewing will be cosmetically not satisfactory if there is a relatively large area of alopecia posterior to it.

Midscalp is relatively horizontal in its orientation and follicular units containing 3 to 4 hairs should be placed which permits the smallest degree  and detect ability.

Sometimes its advantages to treat midscalp first  before the frontal or vertex area, reason is that

1 .It avoids sudden appearance of hair that was not there before in frontal area.

  1. Transplanted hair in midscalp may be combed anteriorly and camouflaged
  2. Can be combed posteriorly to cover vertex also.


Fig 4

It’s the third most important area to be transplanted and these areas are

  1. Right and left Supra temporal fringe/hump
  2. Right and left Parital fringe/hump
  3. Occipital fringe

If these area are not transplanted, in the long term balding will develop between the fringe hair and transplanted areas.Its always necessary to march into these areas during initial transplant in the frontal and midscalp transplant.This gives a good camouflag and decent aesthetic look.

VERTEX AREA (Refer Fig-1)

Vertex area is the most difficult area to treat and nearly always the least important area to transplant.

Vertex transplant usually not indicated in young adults

  1. Less than 40 year
  2. Strong family history of Norwood baldness V,VI,VII baldness
  3. Less donor and recipient area ratio

Vertex transplant is indicated

  1. Above 40 years
  2. Abundant donor reserves
  3. No family history of Norwood V,VI,VII baldness

I personally delay treatment of vertex as long as possible. Initially first I start with

Minimum 1year of medical treatment followed by surgical treatment, even if surgical (vertex)transplant is planned, depends upon  donor reserve, its better to transplant midscalp and anterior vertex first, followed by peripheral /evolving areas of vertex ,second then go ahead with entire vertex transplant

And its better to place 1 follicular unit in the centre more of acute angle according to the direction of the whorl. 2 and 3 follicular units are placed at the periphery

Appearance of decreased density in the vertex of course should be expected, because of usual whorl pattern minimizes the overlapping /shingling effect that is necessary in creating the illusion of hair density transplanting.