Strategies for Higher Quality Grafts

Jun 25 / Skillmed Institute

Hair loss represents a distressing issue affecting a large portion of the population, including up to 85% of males and 40% of females, and its incidence increases with age for both sexes. (1) Hair transplantation has become a popular solution for people looking to address hair loss and restore their hairline. To ensure successful and satisfying results, it is important to focus on strategies that produce superior grafts. The quality of these grafts plays a crucial role in achieving a natural-looking hairline and increased hair density.

By employing techniques that yield high-quality grafts, the transplantation procedure can create a seamless and authentic appearance that closely resembles the patient's original hair pattern. Well-prepared grafts with undamaged follicles and proper alignment blend harmoniously with existing hair, ultimately enhancing the overall aesthetic outcome. Furthermore, grafts of higher quality have a higher chance of survival due to the presence of healthy follicles, intact blood supply, and reduced trauma during the transplantation process.

1. Preoperative Considerations

Before we dive into the latest operative procedures and weigh their benefits, there are some important preoperative considerations to be made in order to obtain the best results possible. (2)

Patient Selection  
Thoroughly evaluate patient candidacy based on factors such as age, donor area availability, and expectations. Potential exclusionary criteria (1) for HT would include:

  • Unrealistic expectations
  • Mental illness     
  • Donor site miniaturization      
  • Unusual hair loss pattern 
  • Many broken hairs           
  • Excessive shedding          
  • Scalp inflammation          
  • Unexplained scarring       
  • Scalp or skin pain, burning, pruritus 

Assess the patient's overall health and rule out any contraindications for surgery.

Educating the Patients   
  • Provide comprehensive information about the procedure, expected outcomes, and potential risks.
  • Set realistic expectations regarding hair density, coverage, and the number of sessions required.
  • Discuss postoperative care instructions and the importance of adherence.  

2. Harvesting the Graft

To achieve the best results in hair transplantation, it is essential to ensure optimum graft viability before the operative procedure. This involves careful consideration of various factors. One important factor is choosing the appropriate donor site.

The Donor Site

The donor site plays a crucial role in hair transplantation, regardless of the chosen technique, and serves as a limiting factor in the procedure. The donor site refers to the areas of the scalp from where healthy terminal hairs are harvested for transplantation. The safe donor site is typically located in the mid-occipital region between the upper and lower occipital protuberances. (3)

Harvesting Technique

Another important factor is the selection of an appropriate harvesting technique. There are two main techniques that are commonly used in hair transplantation: follicular unit transplantation (FUT) and follicular unit extraction (FUE). Currently, FUE has become the more prevalent choice due to its perceived advantages when compared to FUT. (4)

Follicular Unit Extraction (FUE)

FUE (5) is a minimally invasive hair transplantation technique that involves the individual removal of follicular units from the donor area. Here's how the process typically unfolds:

  1. Donor Area Preparation: The donor area is trimmed to a short length to facilitate the extraction process. Local anesthesia is administered to ensure patient comfort during the procedure.
  2. Individual Extraction: Using specialized microsurgical tools such as punches or robotic devices, individual follicular units are carefully extracted from the donor area. Each follicular unit typically contains one to four hairs.
  3. Graft Extraction Variations: FUE can be performed using different extraction methods, such as manual extraction with handheld punches or automated extraction using robotic devices. The choice of method depends on the surgeon's preference, expertise, and the specific needs of the patient.
  4. Donor Area Healing: After extraction, small, circular wounds are left in the donor area. These wounds heal naturally over time, leaving tiny, almost invisible scars. The healing process in the donor area is generally faster compared to strip harvesting.
  5. Graft Preparation: Once the grafts are extracted, they undergo thorough dissection and trimming to prepare them for transplantation. The grafts are sorted based on the number of hairs they contain to improve the transplantation process.
  6. Graft Placement: The prepared grafts are then transplanted into the recipient area using precise techniques, ensuring proper angulation, direction, and density to achieve natural-looking results.

Strip Harvesting (FUT)

Strip Harvesting (6), also known as Follicular Unit Transplantation (FUT), involves the removal of a strip of scalp tissue from the donor area, which is then dissected into individual follicular units. Here's an overview of the FUT procedure:

  1. Donor Area Preparation: Similar to FUE, the donor area is trimmed, and local anesthesia is administered to numb the area.
  2. Strip Excision: A strip of scalp tissue, typically from the back or sides of the scalp, is surgically excised. The length and width of the strip depend on the patient's specific needs and the surgeon's judgment.
  3. Wound Closure: The wound created by the strip excision is closed using sutures or staples. The closure technique aims to minimize tension on the wound and ensure optimal healing.
  4. Graft Dissection: The excised strip is carefully dissected into individual follicular units under a microscope. This process involves separating the individual follicular units from the surrounding tissue.
  5. Graft Preparation: After dissection, the grafts undergo further trimming and sorting based on the number of hairs they contain, similar to the FUE method.
  6. Graft Placement: The prepared grafts are then transplanted into the recipient area using meticulous techniques, ensuring proper angulation, direction, and density for natural-looking results.
  7. Both FUE and FUT have their advantages and considerations. FUE offers the advantage of no linear scar, allows for greater flexibility in hairstyle choices, and is suitable for individuals who prefer shorter haircuts. FUT, on the other hand, can yield a larger number of grafts in a single session and may be more appropriate for individuals requiring a high number of grafts.

  • Utilize advanced harvesting methods like follicular unit extraction (FUE) or strip harvesting (FUT) depending on patient characteristics and surgeon expertise.
  • Minimize transection rates by employing meticulous techniques during graft extraction.
  • Preserve the integrity of the donor area by avoiding excessive harvesting and maintaining appropriate spacing between grafts.

Graft Preservation

  • Handle grafts with utmost care to prevent damage and dehydration.
  • Maintain a controlled environment, utilizing appropriate storage solutions or media during graft dissection and implantation.

3. Graft Preparation

Graft preparation involves the meticulous dissection and trimming of grafts before transplantation. This stage is essential for optimizing graft quality, ensuring the survival of follicles, and achieving natural-looking results. Here are key considerations in graft preparation

Microscopic Dissection

  • Utilize high-powered microscopes and skilled technicians to ensure precise graft dissection.
  • Trim excess tissue, removing unnecessary bulk while maintaining graft integrity.
  • Sort grafts based on the number of hairs to facilitate optimal placement during transplantation.

Graft Hydration

  • Soak grafts in a balanced electrolyte solution or saline to prevent desiccation and enhance graft survival.
  • Maintain a moist environment during the transplantation procedure to minimize graft trauma.

4. Transplantation Techniques

Transplantation techniques encompass the precise and careful placement of grafts into the recipient area. These techniques focus on achieving natural hairline design, accurate angulation, proper depth, and consistent spacing. (7)

Graft Placement

  • Utilize appropriate instruments (e.g., implanter pens, forceps) for accurate and gentle graft insertion.
  • The administration of antibiotics covering skin flora should is necessary pre-operatively.
  • Adhere to correct angulation, direction, and depth to mimic natural hair growth.
  • Maintain consistent spacing and density to achieve natural-looking results.

Adequate Vascularization

  • Ensure proper blood supply to the recipient area by creating small and precise incisions.
  • Minimize trauma to surrounding tissues during graft placement to preserve vascularity.
  • Avoid excessive manipulation of grafts to prevent compromise of blood flow.

5. Postoperative Care

Postoperative care plays a vital role in ensuring the survival, healing, and growth of transplanted hair grafts. It involves providing patients with proper instructions, support, and monitoring during the recovery period.

Patient Compliance

  • Educate patients about postoperative care, including medication usage, shampooing techniques, and avoiding strenuous activities.
  • Encourage adherence to follow-up visits for monitoring and evaluation.
  • Provide guidance on managing potential complications or side effects.

Follow-up and Maintenance

  • Monitor patient progress and address any concerns or questions promptly.
  • Discuss the potential need for additional sessions or adjunct therapies to achieve desired results.
  • Provide guidance on long-term hair care, including a healthy lifestyle, nutrition, and potential hair loss prevention strategies.


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7. Joshi R, Shokri T, Baker A, Kohlert S, Sokoya M, Kadakia S, et al. Alopecia and techniques in hair restoration: an overview for the cosmetic surgeon. Oral Maxillofac Surg [Internet]. 2019 Jun 1 [cited 2023 Jun 25];23(2):123–31. Available from:

8. Avram MR, Watkins SA. Robotic follicular unit extraction in hair transplantation. Dermatol Surg [Internet]. 2014 Dec 11 [cited 2023 Jun 25];40(12):1319–27. Available from: