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Kayiran et al. Plast Aesthet Res 2018;5:9 I http://dx.doi.org/10.20517/2347-9264.2017.86 Page 5 of 8

The permanent solution for hair loss can be achieved with hair transplantation. The grafts harvested from the
donor area are transplanted to the recipient area in qualified, well-trained hands and at optimum conditions.
Nevertheless, graft viability depends on several factors determined by the hair type, delicate technique, physical
trauma, vascular factors, biochemical injury, infection, patient disruption, and idiopathic reasons .
[17]
Hair transplantation is comprised of consecutive steps: planning, preparation, anesthesia, graft harvesting,
secure of the harvested grafts, graft transplantation, and dressing. Each step may be individualized in
practice. Planning of the patient consists of some blood tests, a thorough history of medical situation, and
marking. After shortening of the hair if needed and preparation with antiseptic solutions, anesthesia is
carried out. Mostly, local anesthesia is preferred; however, regional anesthesia or local anesthesia with
sedation can be chosen. When an entire anesthesia is established, a tumescent solution is injected both to
the donor and recipient area. This enables an expansion to harvest the follicles in donor area and graft them
[18]
easily. The survival of the harvested graft is dependable on temperature, hydration, infection, and trauma .
The surgeon and staff shall not transect or crush and dehydrate the follicles during the procedure. This
meticulous technique will ensure the best outcome. It is also advised to maintain the follicles that are to be
transferred in a cold solution in order to reduce the ischemia and reperfusion injury. Some holding solutions
exist such as intravenous holding solutions (e.g. normal saline, lactated Ringer), cell culture media (e.g.
Dulbecco’s Modified Eagle Medium, Williams E) and hypothermic holding solutions (e.g. HypoThermosol,
BioLife Solutions, Bothell, WA) . Nevertheless, stored grafts are mostly kept cold in ice blocks or cold
[17]
solutions with the temperature rate between 4 °C and 10 °C. Harvesting of the follicles can be done via
manually or motorized systems. The practitioner can choose sharp or dull tipped punches with a wide
variety of diameter and bevel type. Eventually, the follicles are transplanted delicately into the recipient area
with appropriate angle to establish similar grow pattern with the normal hair. Nests for the grafts that are
to be implanted can be created via a sharp-punch and needles or scalpels in selected sizes [6,19-21] . On the front
line, we prefer to make the transplantations in a zig-zag fashion to achieve a natural-looking frontal hairline
design . The number of hair units required for the recipient size can be calculated by the formulas defined
[19]
for both frontal and vertex regions [22,23] . The normal hair density is around 100 units/cm 2[24] . In general, the
density achieved with hair transplantation is approximately 30-40 units/cm . Higher density called as dense
2
packing (up to 60 units/cm ) can be achieved with high viability rates [21,25] .
2
Follicular unit transplantation (FUT) is a widely accepted technique in hair transplantation . In
[26]
this method, the donor area is shaved and an elliptical excision is made for hair follicle harvesting. The
dimensions of the ellipse are calculated up to the recipient area that is to be grafted. The donor area is closed
meticulously to reduce the scar formation. The collected hair-bearing skin is dissected under magnification
and the extra tissues of the hair root as well as the epithelium around are removed as much as possible. The
grafts containing clusters of one, two and three follicles are put into Petri dishes containing cooled saline.
Later on, the grafts are inserted appropriately to the recipient area.

In contrast to FUT, FUE is a technique with the extraction of follicular units with one or two roots using
circular punches. Okuda was the first that used self-made sharp circular punches in various diameters
(1-4 mm) . He proposed to use 2-4 mm punches with regard to 1 mm because, according to him, the
[27]
transection rate was interestingly high in 1 mm harvests. In the market, there are several FUE donor
harvesting devices available; of which some are hand-held punches, some are motorized and some are single
user-directed robotic system which is also known as Surgically Advanced Follicular Extraction and ARTAS
robotic systems [28-32] . Success with FUE depends on being able to predictably dissect excellent-quality grafts
with minimum transection rates from the donor region [5,29,33,34] .

Ominigraft (Mecicamat S.A., Malakoff, France) has been introduced to optimize mini and micrograft
[29]
transplantation . This device consists of three major parts: hairtome; a hand-held pneumatic graft