6. Advances in hair restoration surgery: where are we now?
6.1. Follicular unit extraction
This technique involves the use of a punch instrument to cut into the dermis just below the arrector pili muscle, followed by extraction of the graft. It requires a dermal depth analysis to judge the depth of the arrector pili muscle which varies among patients. The incision should be shallow enough to avoid transection of the hair follicles but deep enough so that the intact graft is extracted easily. The advantages of this technique include a low rate of follicle injury; however, it may take longer to perform (Dua and Dua, 2010).
6.2. Robotics in hair transplantation
The use of robotics to aid FUE hair transplantation was introduced in 2011 as a mean of reducing the length of the procedure. The current robot available in the market is the ARTAS® robot, which uses cameras to continuously scan video images of the donor area and collects information about the angle, density and orientation of the FU. Once this information is obtained, a robotic arm can deliver punches to perform FU dissection.
One advantage is that the quality of the grafts is not confounded by fatigue of the physician: the graft implantation procedure remains the same throughout. The use of robots is more expensive than the traditional method and, as hair transplantation with other forms of FUE or strip surgery is already an expensive procedure, may not be as attractive to patients (Rose and Nusbaum, 2014).
6.3. Automated FUE hair transplantation
Automated machines are manually operated drills. They use sharp or dull punch dissection to assist with FUE transplantation and may give faster extraction rates (Dua and Dua, 2010). There are a number of devices available on the market, including some that utilise suction to simultaneously extract the grafts.
6.4. Stem cell therapy and cloning
Research around cloning hair follicles has largely been disappointing because the effective number of viable hairs following transplantation has been poor. However, one group recently reported a study with data to support the idea that hair cloning may become possible. Dermal papillae from seven human donors were harvested and the cells were cloned in tissue culture. The cells were then transplanted into the layer between the dermis and epidermis of human skin and grafted onto seven mice. Five of these mice had new hair growth which lasted at least 6 weeks post-implantation and was shown to be human in origin via DNA analysis.
However, some hairs grew with abnormalities such as an absence of pigmentation. Studies are, of course, ongoing and need to be continued for longer periods to ensure that reprogrammed cells continue to reproduce hair even after it naturally falls out (Higgins et al., 2013).
Although there are many medical therapies for different forms of hair loss, the results are often temporary; for these patients, hair transplantation can offer significant relief. Hair transplant surgery has evolved into a highly skilled subspecialty of cosmetic surgery. It has the potential to transform the lives of people with hair loss, who can suffer immense psychological and social problems.
FUT is performed by excising a donor strip of hair followed by careful dissection of the FUs. This procedure, however, leaves patients with a linear scar which is not acceptable to those who wish to keep short hair. FUE involves the use of an instrument to ‘punch’ the desired area for removing FUs. This technique avoids a scar; however, it requires more precision and takes much longer. Advances in hair transplantation include the use of automated and robotic devices for FUE. The future of hair transplantation includes developing techniques for minimal access surgery, cell-based therapies and the possibility of hair cloning.