Enhancing density in hair transplant surgery: the role of tumescent injection in the recipient area in implanter technique – A randomized study
Keywords:
Density, FUE + Implanter technique, 1 inch square boxAbstract
Background: Hair transplant surgery has undergone significant evolution - from FUT to FUE for follicular extraction, and from needles, slits, and implanter techniques to the sapphire technique for implantation. Despite these advances, achieving optimal density remains a challenge. In recent years, patients’ expectations for higher density have increased substantially, prompting surgeons to adopt techniques that are more effective and consistently deliver superior results.
Objectives: To achieve density in hair transplant surgery mainly in FUE (Follicular Unit Extraction) + Implanter technique using Tumescent which has a composition of 100ml NS plus one ampule of Adrenaline at the recipient area using a spinal needle to increase the surface area. The author’s technique differs from the conventional needle-based approach and offers a distinct method for optimizing density.
Materials & method: Patients willing to under Hair Transplant surgery by FUE + Implanter Technique where selected. The sample size was 100. Male patients with no associated medical co-morbidities where selected. A long 26-gauge spinal needle was used to inject the same tumescent solution in the recipient area. Implantation was performed using 1.2 or 1.0mm Inrut Implanters. A standard 1cm x 1cm box was placed over the image at the anterior region, where higher density is required, to assess density.
Results: The hair density appreciated from 221 grafts per square inch in the non-tumescent group to 282 grafts per square inch in the tumescent group while the graft survival rate increased from 70.8% to 90.3%. Thus, increasing the patient satisfaction levels.
Conclusion: Achieving optimal density in FUE combined with the implanter technique in hair transplant surgery remains a challenge. By increasing the surface area with tumescent solution, the popping effect during implantation is minimized. As the number of grafts per unit area increases, the resulting density also increases, serving as an indirect marker of success. This study presents a promising alternative for enhancing density; however, further comparative studies are needed to establish more precise treatment outcomes. The author has applied this method specifically to the implanter technique, rather than the conventional approach.
References
1. Tamashunas NL, Bergfeld WF. Male and female pattern hair loss: treatable and worth treating. Cleve Clin J Med. 2021; 88(3):173-182.
2. Jimenez F, Alam M, Vogel JE, Avram M. Hair transplantation: basic overview. J Am Acad Dermatol. 2021; 85(4):803-814.
3. Dua A, Dua K. Follicular unit extraction hair transplant. J Cutan Aesthet Surg. 2010; 3(2):76-81.
4. Avram MR, Finney R, Rogers N. Hair transplantation controversies. Dermatol Surg. 2017; 43 Suppl 2:S158-S162.
5. Lozinski A, Huq NS. Tumescent liposuction. Clin Plast Surg. 2013 Oct;40(4):593-613.
6. Conroy PH, O'Rourke J. Tumescent anaesthesia. Surgeon. 2013; 11(4):210-221.
7. Nusbaum BP. Techniques to reduce pain associated with hair transplantation: optimizing anesthesia and analgesia. Am J Clin Dermatol. 2004; 5(1):9-15.
8. Perez-Meza D, Niedbalski R. Complications in hair restoration surgery. Oral Maxillofac Surg Clin North Am. 2009; 21(1):119-148.
9. Field LM, Namias A. Bilevel tumescent anesthetic infiltration for hair transplantation. Dermatol Surg. 1997; 23(4):289-290.
10. Field LM. Bilevel anesthesia and blunt dissection: rapid and safe surgery. Dermatol Surg. 2001; 27(11):989-991.
11. Kumar MK, Inamadar AC, Palit A. A randomized controlled, single-observer blinded study to determine the efficacy of topical minoxidil plus microneedling versus topical minoxidil alone in the treatment of androgenetic alopecia. J Cutan Aesthet Surg. 2018; 11(4):211-216.
12. Savin RC. Use of topical minoxidil in the treatment of male pattern baldness. J Am Acad Dermatol. 1987; 16(3 Pt 2):696-704.
13. Wirya CT, Wu W, Wu K. Classification of male-pattern hair loss. Int J Trichology. 2017; 9(3):95-100.
14. Mubki T, Rudnicka L, Olszewska M, Shapiro J. Evaluation and diagnosis of the hair loss patient: part I. History and clinical examination. J Am Acad Dermatol. 2014; 71(3):415.e1-415.e15.
15. Konior RJ, Simmons C. Patient selection, candidacy, and treatment planning for hair restoration surgery. Facial Plast Surg Clin North Am. 2013; 21(3):343-350.
16. Rossi A, Muscianese M, Piraccini BM et al. Italian Guidelines in diagnosis and treatment of alopecia areata. G Ital Dermatol Venereol. 2019; 154(6):609-623.
17. Tosi A, Misciali C, Piraccini BM, Peluso AM, Bardazzi F. Drug-induced hair loss and hair growth. Incidence, management and avoidance. Drug Saf. 1994; 10(4):310-317.
18. Marwah MK, Mysore V. Recipient area. J Cutan Aesthet Surg. 2018; 11(4):202-210.
19. Sirinturk S, Bagheri H, Govsa F, Pinar Y, Ozer MA. Study of frontal hairline patterns for natural design and restoration. Surg Radiol Anat. 2017; 39(6):679-684.
20. Uttamani RR, Venkataram A, Venkataram J, Mysore V. Tumescent anesthesia for dermatosurgical procedures other than liposuction. J Cutan Aesthet Surg. 2020; 13(4):275-282.
21. Unger WP. Recipient area hair direction and angle in hair transplanting. Dermatol Surg. 2004; 30(6):829-836.
22. Shapiro R, Shapiro P. Hairline design and frontal hairline restoration. Facial Plast Surg Clin North Am. 2013; 21(3):351-362.
23. Strazar AR, Leynes PG, Lalonde DH. Minimizing the pain of local anesthesia injection. Plast Reconstr Surg. 2013; 132(3):675-684.
24. Seager DJ, Simmons C. Local anesthesia in hair transplantation. Dermatol Surg. 2002; 28(4):320-328.
25. Harris JA. Follicular unit extraction. Facial Plast Surg Clin North Am. 2013; 21(3):375-384.
26. Rassman WR, Bernstein RM, McClellan R, Jones R, Worton E, Uyttendaele H. Follicular unit extraction: minimally invasive surgery for hair transplantation. Dermatol Surg. 2002; 28(8):720-728.
27. Harris JA. Follicular unit transplantation: dissecting and planting techniques. Facial Plast Surg Clin North Am. 2004; 12(2):225-232.
28. Mysore V, Kumaresan M, Garg A et al. Hair transplant practice guidelines. J Cutan Aesthet Surg. 2021; 14(3):265-284.
29. Khanna M. Hair transplantation surgery. Indian J Plast Surg. 2008; 41(Suppl):S56-63.
30. Dias MFRG, Loures AF, Ekelem C. Hair cosmetics for the hair loss patient. Indian J Plast Surg. 2021; 27;54(4):507-513.
31. Shichang L, Jufang Z, Xiangying Y, Yali W, Li N. Self-management in the post-hair transplantation recovery period among patients with androgenetic alopecia: a qualitative study. Int J Nurs Stud Adv. 2024; 19;7:100234.
32. Ghimire RB. Clinical outcome and safety profile of patients underwent hair transplantation surgery by follicular unit extraction. JNMA J Nepal Med Assoc. 2018; 56(209):540-543.
33. Ahmad M. The first hair transplant assessment scale: parameters for good hair transplantation. J Cosmet Med. 2020; 4(1):1-6.
34. Dhurat R, Saraogi P. Hair evaluation methods: merits and demerits. Int J Trichology. 2009; 1(2):108-119.
35. Ahmad M.. Patient satisfaction in hair transplant surgery. Ann Pak Inst Med Sci. 2008; 4(4):220-222.
36. Ahmad M. Patient satisfaction in hair transplant surgery. J Pak Assoc Dermatol. 2009; 19(1):9-12.
37. Gupta J, Chouhan K, Kumar A, Chandrasegaran A. A comparative study on the rate of anagen effluvium and survival rates of scalp, beard, and chest hair in hair restoration procedure of scalp. J Cutan Aesthet Surg. 2019; 12(2):118-123.
38. Hunstad JP. The tumescent technique facilitates hair micrografting. Aesthetic Plast Surg. 1996; 20(1):43-48.
39. F Jiménez-Acosta, I Ponce-Rodríguez. Follicular unit extraction for hair transplantation: an update. Actas Dermosifiliogr. 2017; 108(6):532-537.
40. Gawande MJ, Bansal S, Daga A, Latke S, Josph S, Agrawal R. Hair transplant: challenges, solutions and guideline for beginners. J Pharm Res Int. 2021; 33(49B):185-194.
41. Epstein GK, Epstein J, Nikolic J. Follicular unit excision current practice and future developments. 2020; 28(2):169-176.
42. von Albertini C, von Albertini MA. Does the use of implanters affect the quality of FUE grafts? Hair Transplant Forum International. 2017; 27(3):96-99.
43. Stough D, Whitworth JM. Methodology of follicular unit hair transplantation. Dermatol Clin. 1999; 17(2):297-306.
44. Josephitis D, Shapiro R. FUT vs. FUE graft survival: a side-by-side study of 3 patients undergoing a routine 2,000+ graft hair transplantation. Hair Transplant Forum International. 2018; 28(5):179-182.
45. Finney RL, Avram MR. Hair transplant. In: Evidence-Based Procedural Dermatology. Alam, M. Cham. Springer. 2019; 24:379-388.
46. Othman S, Glat P. Surgical management for hair restoration: a review of contemporary techniques. Aesthetic Plast Surg. 2023; 47(6):2415-2424.
47. Bernstein RM, Rassman WR. Follicular transplantation. Patient evaluation and surgical planning. Dermatol Surg. 1997; 23(9):771-784.
48. Bater KL, Ishii M, Joseph A, Su P, Nellis J, Ishii LE. Perception of hair transplant for androgenetic alopecia. Facial Plast Surg. 2016; 18(6):413-418.
49. Fang Liu, Yong Miao, Xingdong Li, et al. The relationship between self esteem and hair transplantation satisfaction in male androgenetic alopecia patients. J Cosmet Dermatol. 2019; 18(5):1441-1447.
50. Adil A, Godwin M. The effectiveness of treatments for androgenetic alopecia: a systematic review and meta-analysis. J Am Acad Dermatol. 2017; 77(1):136-141.
51. Humayun Mohmand M, Ahmad M. Effect of follicular unit extraction on the donor area. World J Plast Surg. 2018; 7(2):193-197.
52. Bicknell LM, Kash N, Kavouspour C, Rashid RM. Follicular unit extraction hair transplant harvest: a review of current recommendations and future considerations. Dermatol Online J. 2014; 20(3):doj_21754.
53. Ortega-Castillejos DKA, Pathomvanich D. Retrospective assessment of follicular unit density in asian men with androgenetic alopecia. Dermatol Surg. 2017; 43(5):672-683.
54. Ors S, Ozkose M, Ors S. Follicular unit extraction hair transplantation with micromotor: eight years experience. Aesth Plast Surg. 2015; 39(4):589-596.
55. Akhyar G, Jaya A. Hair transplant follicular unit extraction technique as a current treatment option for androgenetic alopecia. J Biomedicine Translational Res. 2024; 8(4):4216-4222.
56. ElSakka DM, Ahmed HT, Aly MS. Evaluation of clinical outcome of hair restoration by the follicular unit extraction (FUE) technique with versus without adding (PRP). Egypt J Plast Reconstr Surg. 2024; 48(3):171-182.
57. Wall D, Meah N, Fagan N, York K, Sinclair R. Advances in hair growth. Fac Rev. 2022; 11:1.
58. Klein JA, Jeske DR. Estimated maximal safe dosages of tumescent lidocaine. Anesth Analg. 2016; 122(5):1350-1359.
59. Moharana P, Bhaskaran R. Implanter technique in hair transplant surgery always a surgical challenge for the operating surgeon - A prospective randomized study assessment. Aesthet Med. 2024;10(4):e2024024.
Downloads
Published
Issue
Section
License
Copyright (c) 2025 Manan Gupta, Rajprakash Bhaskaran, Murugesan Krishnan
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Transfer of Copyright and Permission to Reproduce Parts of Published Papers.
Authors retain the copyright for their published work. No formal permission will be required to reproduce parts (tables or illustrations) of published papers, provided the source is quoted appropriately and reproduction has no commercial intent. Reproductions with commercial intent will require written permission and payment of royalties.
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
How to Cite
