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Dr. Bertram Medical Hair Transplant
眉 髮 醫 學 移 植 中 心 ( 香 港 ) |
( 852 ) 3421-1138
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Graft Survival - How We Maximize the Growth
Transplanting a graft from one site to another does not guarantee good result. As damaged graft cannot re-grow, the surgeon must pay attention to every step and every details of the procedure.
On average 85-92% of grafts survive after transplant and grow new hair. There are 2 possible ways how a graft can be damaged or even killed. We call these the H-Killing Factor and the X-KillingFactor.
H Killing Factor
H stands for human, when poor growth is caused by a breach of protocol. H-factor may occur before, during, and after the procedure and is totally avoidable.
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Predisposing Factors That Compromise Result
- Poor Circulation of the Recipient Area
- Scar
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- Smoking
- Uncontrolled Diabetes
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Graft Injury During Procedure
Injury To Transplanted Follicles After Procedure
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X Killing Factors
X stands for unknown. This was first described by Dr Shield (Australia) in 1984, when the reduced hair growth was unexpected and unexplained. X-factor only accounts for a very small 0.5-1% of all no growth.
Dehydration
Dehydration causes serious graft damage. Deleterious changes in cell integrity when follicles are left to dry for more than 5 minutes (Gandelman). When grafts are exposed to air for more than 10 minutes, more than 6% will not re-grow. After 20 minutes survival markedly decreases (Kim).
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Duration of air exposure (min) |
% of no growth |
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0 |
4 |
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5 |
6 |
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10 |
6 |
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20 |
17 |
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30 |
37 |
Our Solutions
- We do not leave grafts on the gloved fingers
- All grafts are submerged in chilled saline solution or moistened gauze pads
Excessive Removal of Supporting Tissue
Removing too much tissue around the hair follicle is also a form of physical injury.
Stem cells responsible for follicular re- growth is located at the tissue surrounding the graft.
It has been known since 1997 that Chubby Graft survives better than Skinny Graft (Seager).The differences in survival is that the stem cells are retained in chubby grafts but trimmed away in the skinny grafts.
A recent study by Beehner (2010) compared their survival as follows.
| 2-hair follicular units |
Skinny Graft |
Chubby Graft |
% no growth after 19 months |
31.3 % |
12.0 % |
| 1-hair follicular units |
Skinny Graft |
Chubby Graft |
% no growth after 19 months |
52 % |
2 % |
 
1 & 3-hair FUs - Skinny by FUE ( left ) vs. Chubby by strip ( right )
Our Solutions
- Use microscopes to preserve stem cell containing tissues
- Try not to use FUE which always produce skinny grafts
Cold Injury
This is a form of physical injury. Study had shown that no frozen graft can survive. Yet many centers keeps the graft in a domestic-grade refrigerator for hours.
Our Solutions
We never keep grafts in the fridge. The inside temperature may drop below 0°C and kill all the grafts, without even our knowing. From studies there was no significant difference in survival within 6 hours whether the grafts were stored in room temperature or 4 °C (Kim). Consequently we try to complete implantation within 6 hours.
Transecting the Hair Follicles
Transection is the accidental damage to the hair follicle by sharp blade during harvesting and graft cutting. The mid-portion of the graft contains stem cells and must be preserved to survive. This is a form of physical injury.
The following pictures show the percentage of survival after the transected portion is implanted (Kim & Choi)
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Transected the follicle at upper 1/3
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The upper 1/3
- 100% will not grow |
The lower 2/3
- 17% will not grow |
Transected the follicle at middle
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The upper 1/2
- 60% will not grow |
The lower 1/2
- 73% will not grow |
Transected the follicle at lower 1/3
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The upper 2/3
- 35% will not grow |
The lower 1/3
- 100% will not grow |
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Our Solutions
- Use surgical loupes and microscopes to minimize transection
- Proper staff training for better graft handling
- Try not to use FUE which has higher transection.
Chemical Trauma To Grafts During Storage
When tissue is removed from the body, the cells will slowly run out of oxygen and eventually die.
Our Solutions
We successfully slow down the cellular activities by immersing the grafts into chilled saline solution. By switching from aerobic to anaerobic metabolism the energy requirement is reduced. Less than 10% are damaged if grafts are re-inserted within 4 hours (Dr Limmer 1992).
- Storage grafts in chilled saline
- Our large surgical shortens the graft preparation time. Implantation can be completed within 4 to 6 hours
- We avoid using FUE if more than 800 grafts is planned. FUE extraction usually take more than 5 hours
Duration after extraction (hour) |
% of no growth |
2 |
5 |
4 |
10 |
6 |
14 |
8 |
14 |
24 |
21 |
Ischaemic-Reperfusion Injury
After a period of low oxygen, when the grafts are implanted and suddenly re-exposed to oxygen, they may form free radicals which cause cell injury and suboptimal growth.
Our Solutions
We suppress tissue injury by the use of anti-inflammatory medication.
Source of picture: Stanford School of Medicine
Failure To Compile With Instruction After Procedure
After surgery the graft injury is usually caused by failure of the patient to compile with instruction.
Our Solution
- Detail written postop instruction is provided
- Free doctor follow-up. Same day appointment can be arranged for any immediate concern.
- A helpful team to answer any of your concern
Failure to Form New Circulation
Failure to form new circulation may starve the follicles and retard their growth.
Our Solution
- Request patient to reduce smoking
- Prescribe Minoxidil
Physical Trauma To Newly Transplanted Graft
The first week after transplant the grafts can be dislodged by direct impact.
Our Solution
- Provide detail postop instruction
- Protective dressing may to applied to selected cases
Infection
From experience infection if recognized and treated promptly will not affect grafts.
Our Solution
- Use of antibiotics for selected case
- Perform procedure in an aseptic envirnoment
- All staff has to follow protocol
- ALl follow-ups are conducted by our doctor to look for early sign of infection
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