Hair transplants in African American patients

virtual clinicIntroduction

The diversification of hair transplantation techniques makes it possible to provide a definitive aesthetic solution for most hair and hair strains in African-American patients. The indications take into account numerous parameters of thinning (etiology, localization, extent or evolution). and particularities of the patient (age, gender, ethnicity, personal motivation), mainly about the scalp, more rarely the beard, the mustache, the eyebrows, the pubic hair and the eyelashes.

The most common micrograft technique by segmentation of follicular units under a microscope (FUS) makes it possible, after shaving, to obtain a natural appearance thanks to a fine implantation of one to three hairs and the implantation of 1000 to 2000 hairs. in one session.The technique of micrografts or follicular units with long hair (FUL) or the hair have not been previously shaved, allows the immediate visualization of the result. It allows the practitioner to better perform the surgical procedure in the choice and orientation of micrograft and the patient to better imagine its future outcome.

The technique of follicular extraction sampling (FUE), where shaving is essential, has in African-American patients more limited indications because of the curvature of the roots. The simple operative follow-ups are followed by definitive regrowth of the hair. The combination of surgical correction and anti-fall medical treatments (minoxidil and finasteride) further improves the outcome and post-operative outcomes of hair micrograft transplants.

Keywords: hair micrografts, hair, FUE, follicular units with long hair (FUL), African Americans

Key words: Hair micrograft, vellus, FUE, Follicular Unit Long hair (FUL), Afro-americans

Hair transplantation provides African American patients with an aesthetic and definitive solution to most hair loss in African-American patients. The main reasons for treatment are androgenetic alopecia in men and women, definitive thinning secondary to traction alopecia (1, 2).

I- The hair transplant

Hair transplants use small fragments of scalp micrograft type (or follicular units) of 1 to 3 hairs per transplant. The implantation of 1,000 to 2,000 hairs per session, lasting from 2 to 5 hours, ensures the finishing of a hair line or the densification of a bald surface more or less extended (1).

It is necessary to perform a pre-operative medical check-up, premedication with tranquilizer and local anesthesia (anesthetic creams and truncal infiltration). The operation is painless and the operative follow-up, simple, allow the patient to leave 2 hours after the intervention and to resume his professional activity the next day.

II- Measurement of the capacities of the micrograft donor zone

At the present time a digitized automatic camera allows the analysis of hair growth parameters such as: density, size, growth rate, percentage between miniaturized hair and normal hair.

This technique makes it possible for each patient to follow the evolution of his fall, spontaneously or under treatment, to measure the capacities of the donor zone of micrografts, to note the quality of the regrowth of the transplanted hair (3).

III- The conventional graft technique: segmentation of follicular units (fus)

The hair, collected in a region spared by the alopeciant phenomenon (crown in men or mid-occipital region in women) retain their capacity for growth after implantation throughout the life of the individual.

This method (1), based on the implantation of grafts of 1 to 3 hairs, seeks to recreate the natural emergence of 2 to 3 hairs through each pilosebaceous orifice and avoids the unaesthetic appearance in “hair of doll” .

  • Donor-preparation area of transplants

After shaving beforehand, a strip of scalp is removed (its size, between 10 and 25 cm, depends directly on the number of micrografts desired), then the donor area is closed by sutures or staples.The scar will be very thin, linear, horizontal and almost inapparent thanks sometimes to the trichophytic closure which consists of desépidermiser the lower edge of occipital excision. A levy in the mid-occipital donor zone avoids a hypertrophic scar or keloid. The scalp strip is carefully cut into small fragments of 1 to 3 hairs (micrografts or follicular units) under stereomicroscope in order to respect the entirety of the hair taken.

  • Receiving area

Advances in implantation techniques aim to recreate a natural aesthetic appearance and involve.

-a rounded outline of the front line in African-American patients

-a more rectilinear drawing in the woman by associating a fronto-temporal reconstruction

  • a fine implantation on the bald area with microsurgical needles and forceps allowing the choice of the axes of emergence, orientations, obliquities;
  • a purposefully fine and irregular “hair by hair” achievement of the anterior frontal line;
  • implantation of 1,000 to 2,000 hairs per session
  • a homogeneous distribution of these multiple micrografts and follicular units;
  • simple after-effects with shampoo and professional recovery 1 to 2 days later. The implanted hair can fall towards the 15 thday and push definitively between the 5 th and the 6 th

IV- The technique of long-haired micrografts (technique of Dr. Bouhanna): Follicual units with long hair (FUL):

In recent years, we have described the technique of micrografts and follicular units with long hair. The hair of the micrografts has not been previously shaved and the technical procedure is the same as that described above.

Its advantages are:

For the patient:

The “wait and see” has been replaced by the “see and wait”.

  • He immediately sees the resultalthough all or part of this hair can fall within 2 to 3 weeks. Note the favorable effect in this case minoxidil lotion and / or finasteride tablets.
  • The donor zone of micrografts is not shaved.
  • Small crusts that persist 10 to 12 days are hiddenby long hair. As a result, the patient can resume his professional activity very quickly.
  • For the practitionerwhen implanting long-hair micrograft (FUL), allows
  • A better evaluationof the orientation and the angle of the hair
  • A better choice especially at the anterior frontal line, thin or thick hair, black or white
  • A large amount of hair can be implanted at each session.

Important fact:

The removal from the back of the scalp of a strip usually leaves a thin scar , almost invisible. Nevertheless, if the patient wants to shave his scalp, this thin scar can completely disappear thanks to the implantation of some FUE.

V- Follicular Unit Extraction (FUE)

The scalp of the occipital area is shaved beforehand. Follicular Unit Extraction (FUE) is a technique of collecting and extracting intact follicular units directly into the donor area using 1 mm micropunches inserted at 4-5 mm depth; this unit held by the epidermis is then “extracted” very slowly from the surrounding tissue.

This technique allows the implantation of about 500 to 1000 hairs per session.

However, FUE can be recommended in patients:

– who want to correct any pre-existing scar,
– which have little or no flexibility of the scalp,
– who shave the scalp,
– who wish a little meeting,
– or who are not likely to develop into a major baldness
– in African-American patients because of the curvature of the roots, the sampling is more random and therefore justifies a preliminary test of FUE.

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VI- Additional techniques

– Cylindrical grafts of 2 mm taken by an electric motor in the occipital region. This ancient technique may be recommended in rare indications.
– The Markmann or Rassmann automatic implementers are currently abandoned.
– The automatic machines (calvitron, omnigraft, neograft) developed about fifteen years ago remain nevertheless of limited diffusion.
– The stimulation of the growth of “miniaturized” hair present in male and female androgenetic alopecia could be obtained with a certain type of laser (He-Ne). It is the same for a new molecule based on hyaluronic acid injected in a painless system by mesotherapy. Both processes are currently under study.

VII- Indications of transplants in men

– Male Androgenetic Alopecia (AAGM)

The stripping is done according to a topography and a particular evolution. The measurements will be made according to the multifactorial dynamic classification of Bouhanna (3) which takes into account multiple parameters such as the extent of the bald and hairy surfaces compared to certain fixed landmarks of the face, the elasticity and the thickness of the scalp , the hair’s covering power according to density, size, shape, length, shoot speed and color. Various stages are thus defined:

stage I (accentuation of fronto-temporal glands with possible vertebral tonsure), stage II (retraction of the frontal line to the top of the skull, possibly associated with a tonsure) and stage III ( baldness called “Hippocratic” where the hair only persists on a crown at the temples and neck)

Surgical correction of AAGM involves micrograft transplantation, adapted to the stages described above:

for stage I , implantation of 1,000 hairs in 1 to 2 sessions (the implantation of 2,000 hairs is sometimes necessary during the associated treatment of tonsure).

for stage II , implantation of 2,000 hairs in 1 to 2 sessions (up to 4,000 hairs during associated tonsure).

-for stage III , up to 5,000 implanted hair, in 2 to 3 sessions

Micrograft implantation may be associated with local anti-hair loss treatment (5% minoxidil) and / or general (finasteride 1 mg, oral ), aimed at reducing residual hair loss. persistent between grafts, reduce the transient drop of grafted hair and accelerate the regrowth of grafted and ungrafted hair.

VIII- Indications of transplants in women

Female Androgenetic Alopecia (AAGF): The degree of relaxation of an AAGF can be estimated using a static classification of Ludwig or evaluated more precisely thanks to the multifactorial dynamic classification of Bouhanna. Ludwig’s classification defines three progressive stages: stage I (moderate loss of head on the head, respecting the frontal line), stage II (alopecia with short hair, located 1 cm behind the forehead) and stage III (alopecia almost total, with preservation of a thin band of hair at the forehead).

  • In young women, as early as 18 years of age, thinning of the medial frontal and vertex areas may justify micrograft transplantation associated with possible estrogen-progestin use and local application of 2% minoxidil.
  • During AAGF in postmenopausal women, implantation of micrografts associated with the application of minoxidil at 2% and the possible taking of hormone replacement therapy in the absence of contraindication (1 session sufficient more often, 2 to 3 sessions may be required during stage III) (8).
  • In transsexuals, it is necessary to fill the frontal gulfs and to give a fine hairline and feminine type.
  • Permanent alopecia traction: repeated pulls (blow-dry, straightening, braids, hairpieces etc), in patients of African-American origin can induce definitive alopecia of the fronto-temporal region. Before considering a transplant, it is necessary to check the absence of regrowth despite the application of minoxidil 2%, the stop of the tractions for at least 6 months and the application of products grinding stems (shea butter, phytospecific, etc.). )
  • The alopecia of the heating comb(syndrome of follicular degeneration) is caused by the association of hot oil and a heating comb or a curling iron. Its preferential location is the vertex.Hair transplant can be a good indication.


The transplantation of capillary grafts according to various new processes (FUS), FUE, FUL) is a useful supplement in African-American patients the favorable effect of the stop of the traction, the effectiveness of certain drugs (minoxidil) and greasy products. capillary stems. It is thus possible to definitively correct most alopecia.

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