"Combination Grafting" of Scalp and Body Hair to Enhance the Visual Density of Hair Transplant and Coverage of Higher Grade of Baldness

Abstract

Hair transplant is becoming the most common cosmetic procedure across the world with demand for higher density and coverage of baldness. This needs more number of donor hair follicles. Scalp donor has limitations to fulfill the required number of follicles for Norwood Grade VI and VII baldness. The body hair follicles can be used to cover up the deficit.

The objective of this study was to observe the use of body hair follicles to increase the visual density and for better coverage for higher grades of baldness as an adjuvant to scalp hair follicles.

Materials and methods:
A total of 16 patients were evaluated for the availability of body donor hair, and consent for body hair harvesting was obtained from them. The beard was the first preference and then chest and abdomen hair follicles were used in combination with scalp hair follicles to cover bald area of Norwood grade IV and above baldness. Body hairs were harvested using follicular unit extraction (FUE) technique. Postoperative pictures were taken, and patient satisfaction, doctor's observation, and global photographic evaluation was carried out.

Observations:
The patient's photographs were taken after 4, 8, and 12 months of hair transplant. The results were analyzed on the basis of global photography. The use of body hair with scalp has enhanced the visual density, leaving to better coverage in even higher grades of baldness.

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DOI:
10.4103/JCAS.JCAS_89_18
163
Address for correspondence: Dr. Anil Kumar Garg MS, MCh Plastic surgeon,
Rejuvenate Plastic, Cosmetic and hair transplant centre,
Bhandari marg, Indore, Madhya Pradesh, India.
E-mail: anilgarg61@yahoo.com
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How to cite this article: Garg AK, Garg S.“Combination grafting” of
scalp and body hair to enhance the visual density of hair transplant
and coverage of higher grade of baldness. J Cutan Aesthet Surg
2020;13:163-9.
Innovations
“Combination Grafting” of Scalp and Body Hair to Enhance the
Visual Density of Hair Transplant and Coverage of Higher Grade
of Baldness
Anil K. Garg, Seema Garg
Rejuvenate Plastic, Cosmetic and Hair Transplant Centre, Bhandari Marg, Indore, Madhya Pradesh, India
Abstract
Hair transplant is becoming the most common cosmetic procedure across the world with demand for higher density and coverage of
baldness. This needs more number of donor hair follicles. Scalp donor has limitations to fulfill the required number of follicles for
Norwood Grade VI and VII baldness. The body hair follicles can be used to cover up the deficit. The objective of this study was to
observe the use of body hair follicles to increase the visual density and for better coverage for higher grades of baldness as an adjuvant
to scalp hair follicles. Materials and Methods: A total of 16 patients were evaluated for the availability of body donor hair, and consent
for body hair harvesting was obtained from them. The beard was the first preference and then chest and abdomen hair follicles were
used in combination with scalp hair follicles to cover bald area of Norwood grade IV and above baldness. Body hairs were harvested
using follicular unit extraction (FUE) technique. Postoperative pictures were taken, and patient satisfaction, doctor’s observation, and
global photographic evaluation was carried out. Observations: The patient’s photographs were taken after 4, 8, and 12months of hair
transplant. The results were analyzed on the basis of global photography. The use of body hair with scalp has enhanced the visual
density, leaving to better coverage in even higher grades of baldness.
Keywords: BHT, Body hair transplant, combination grafting, FUE, follicular unit extraction, NG, Norwood grade
IntroductIon
Hair transplant is becoming a very popular as well as a
much-demanded procedure. Now the demand for higher
density coverage with a normal look is increasing.
This needs more number of donor hair follicles. The
biggest limitation of the hair transplant procedure is
the big discrepancy between demand and supply. Body
hair is a good source of donor hair follicle.[1,2] We use
“combination grafting” in which scalp hair follicles are
implanted with body hair follicles. Combination grafting
is a similar procedure as mixed grafting[3] in which
multi-follicular units were implanted with follicular
units (FUs). This not only increases the total number
of donor hair follicles but also enhances results because
of the higher visual density of beard hair. Although
body hair other than the beard are thinner, but certainly
better than micropigmentation.
Beard hair, which is thicker and curlier, having higher
visual density, is used in the forelock and mid-scalp area.
Beard, chest, and other body areas are extra-scalp sources
of donor hair follicles, and their growth is androgen
dependent, which is an advantage in androgenetic
alopecia.
Aims and objective: The aims and objective of the study
was to observe the advantages of the use of body hair
follicles with scalp hair follicles to enhance the visual
density of hair transplant and provide better coverage for
higher grades of baldness.
Head1=Head2=Head1=Head2/Head1
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Garg and Garg: “Combination grafting” of scalp and body hair
164 164 Journal of Cutaneous and Aesthetic Surgery ¦ Volume 13 ¦ Issue 2 ¦ April-June 2020
MaterIals and Methods
Scalp hair follicles were mixed with body hair and
transplanted to cover the bald area. In all 16 cases, the
combination grafting was conducted. All cases of male
pattern alopecia of Norwood grade IV and above were
examined and evaluated for donor availability of scalp
and body hair. Total period of study was 18 months.
Adetailed discussion was conducted with the patient, and
consent was obtained for using the combination approach
of implantation. In all cases, scalp donor hair TricoScan
study at five places was carried out. Scalp hair can be
harvested either by follicular unit transplantation (FUT)
or follicular unit extraction (FUE). Selection of FUT or
FUE for scalp harvesting was left on patients’ choice. Body
donor hair follicles were harvested using FUE technique.
1. In Norwood grade IV baldness, we planned 2500/3000
grafts. We harvested 20%–30% of the total grafts/
follicles from the beard, (approximately 600–900) after
obtaining consent.
Two centimeters in front of the defined hairline zone,
including the transition zone, only scalp hair follicles
were used and implanted as per the standard guidelines
described by Shapiro.[4] Then in the three rows just
behind the defined zone, we mixed scalp to beard hair
in the ratio of 2:1 for more natural look, whereas in
forelock area, we mixed scalp to beard 1:1 for more
fullness. Similarly, in the mid-scalp area, we implanted
the remaining beard hair mixed with scalp hair follicles
roughly in the ratio of 3:1. We did not cover the crown
in the first stage of younger patients and advised them
to take medicines. Figure 1A presents after scalp hair
follicle implantation and Figure 1B presents the image
after beard hair follicle implantation showing the
planning of combination grafting. Figure 1C presents
actual planning on patient’s scalp.
2. In Norwood grade V baldness, 4000/5000 grafts were
planned. In single harvesting, either by FUT or FUE,
we harvested 2000–3000 grafts from scalp donor
area and the remaining from the beard and/or chest.
Planning of implantation of mixing of the scalp to
body ratio remained the same as explained in grade
IV baldness, only that the remaining body hairs were
implanted in the mid-scalp area. The aforementioned
procedure was carried out on 2 consecutive days. All
scalp hair follicles were implanted on day 1, leaving
space for beard/other body hair follicles for the next
day. On the next day, body hair follicles were harvested
and implanted in the gaps left in between the scalp
hair follicles [Figure 2].
3. In grade VI and VII baldness, detailed master planning
of recipient and donor area was carried out after
discussion with the patient. The total amounts of hair
follicles (HF) to be implanted were calculated, and the
number of follicles harvested from each area in multiple
stages was planned, which is explained as follows:
• As a routine, we implanted 6000–7000 grafts for
grade VI baldness depending on donor availability
and the patient’s desire for how many grafts he
wants. Of this total, we harvested 4500–5000 from
the scalp in multiple stages and the remaining from
the beard and other body parts.
• In the first sitting, 2 consecutive days were planned.
Atotal of 5000 grafts were harvested to cover up
Figure 1: (A) After scalp HF implantation in Norwood grade IV. (B) After beard HF implantation. (C) Planning of combination grafting. AHL = anterior
hair line, TZ = transition zone, DZ = defined zone, AH = anterior hair
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Garg and Garg: “Combination grafting” of scalp and body hair
Journal of Cutaneous and Aesthetic Surgery ¦ Volume 13 ¦ Issue 2 ¦ April-June 2020 165
the area up to the vertex transition point. Of 5000
grafts, 2500–3000 grafts were harvested from the
scalp and the remaining from the beard or other
body parts. Planning of implantation in the front
area remained the same as described in grade IV
and V baldness, the remaining area of the scalp was
implanted mixing with beard hair.
• If a patient wanted further stages then a minimum
4-month gap was given. It may be a 1- or 2-day
harvesting session. On any given day, we did not
harvest from more than two body areas, and all
precautions were taken so that the dose of anesthetic
agent remained within safe limits [Figure 3].
4. In grade VII baldness, we implanted 7000–8000 grafts
in multiple sessions. Planning remained the same as in
Norwood grade VI baldness [Figure 4].
results
Here pictures of few cases are shown. Figures 5 is a case
of Norwood grade IV, Figure 6, is of diffuse pattern hair
loss, Figure 7 is of Norwood grade III, Figure 8 and
Figure 9 are case of Norwood grade VII. All these cases
the use of scalp, and body hair follicles in combination
has been done as per detail planning explained in method.
dIscussIon
Total scalp hair-bearing area is approximately 520 cm2
(Bernstein et al.[5] and Jimenez and Ruifernández[6]),
and of this, around 200 cm2 is safe donor area (Jimenez
and Ruifernández,[6] Cole and Devroye,[7] and Unger[8]),
the remaining area is approximately 300 cm2, which is
androgen dependent and vulnerable to baldness. To give
the visual effect of reasonable density, we need to implant
30–40 grafts/cm2 in this 300 cm2 area. For this, we need
around 9000 grafts. As per standard calculation, the total
number of grafts in the safe scalp donor area is 12,500,
and of this, we can safely harvest 6,000 grafts. So there
is a deficit of approximately 3000 grafts to cover a total
bald area of grade VII. This deficit can only be covered by
using extra-scalp hair follicles, that is, body hair follicles.
By presuming that any patient presented with grade IV
baldness or above has all the chances to go for grade VII,
we might need approximately 9000 grafts in total to cover
the baldness in the future. But certainly this calculation
demands the search for extra-scalp donor area. Body hairs
around 3000 and above can be harvested from beard, chest,
and extremities as per the requirement and availability. We
have not used donor hair from extremities.
The word “combination grafting[3]” was used for a hair
transplant procedure in which FUs along with multi-
follicular multi unit grafts (MUGs) were implanted to
increase density and to reduce implantation and overall
surgical timing. The main advantage was better density,
but if not carried out properly, there could be cosmetic
compromise as proper planning of placement of MUGs with
FUs was very important. This was used in the era of MUGs.
But then the era of micrografting came in and cosmetic
appearance superseded so MUGs almost disappeared. But
still the need for higher density could not be overlooked.
The recombinant grafting[9] and high-density grafting[10,11]
have their own advantages and disadvantages. High-density
grafting adversely affects graft survival, and recombinant
grafting needs more number of donor hair follicles.
The advantages of body hair follicles[1,2] is that this
provides extra-scalp donor hair follicles. Beard hair is
thicker, giving better illusion of density. Hair from other
body areas decreases the scalp show.
Figure 2: Planning of scalp and beard hair follicles in Norwood grade
V. AHL = anterior hair line, TZ = transition Zone, DZ = defined zone,
AH = anterior hair
Figure 3: Grade VI planning. AHL = anterior hair line, TZ = transition
Zone, DZ = defined zone, AH = anterior hair
Figure 4: Grade VII planning. AHL = anterior hair line, TZ = transition
zone, DZ = defined zone, AH = anterior hair
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Garg and Garg: “Combination grafting” of scalp and body hair
166 166 Journal of Cutaneous and Aesthetic Surgery ¦ Volume 13 ¦ Issue 2 ¦ April-June 2020
Author plans for body hair implantation even at the first
hair transplant procedure so a proper scalp and body hair
combination grafting is planned. In Norwood grade IV
cases, as narrated, we implanted a total of 2500/3000 grafts
and of this, we harvested 2000 follicles from the scalp and
remaining from the beard and implanted them just behind
the hairline, forelock, and mid-scalp. The reason of using
beard hair even in grade IV cases is that it saves scalp
donor follicles for future use (for future anterior hairline
corrections and temporal area reconstruction) and also
the results are very encouraging in terms of visual density.
Similarly, the use of chest hair is good for the mid-scalp
and crown along with the beard and scalp. The thickness
of chest hair is not good as compared to the beard hair
and scalp hair, but still because of curl of the hair, the
visual density given is reasonable and certainly better than
Figure 5: Case I, grade IV
Figure 6: Case II, diffuse pattern hair loss
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Garg and Garg: “Combination grafting” of scalp and body hair
Journal of Cutaneous and Aesthetic Surgery ¦ Volume 13 ¦ Issue 2 ¦ April-June 2020 167
doing scalp micro pigmentation (SMP). Another good
quality of hair is pubic hair, for which patients will be
willing if harvesting is carried out byFUE.
As per the studies conducted by Hwang etal,[12] Hwang
et al,[13] and Lee,[14] when body hair is implanted on the
scalp, the thickness remains unchanged, but the length
and hair growth change. They become longer, and the
growth rate also increases.
We have been harvesting body hair for more than 3years
and have been using Cole 0.75- and 0.8-mm sharp
serrounded punch for beard, chest, and abdomen, but
have no experience with extremities hair. In last two cases
where chest and abdomen hair were very curly and long, we
used 0.9-mm flared punch, and this reduced transection.
We evaluated beard and chest donor hair for density and
thickness. Patients’ satisfaction with body hair is very
Figure 8: Case IV, grade VII
Figure 7: Case III, grade VI
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Garg and Garg: “Combination grafting” of scalp and body hair
168 168 Journal of Cutaneous and Aesthetic Surgery ¦ Volume 13 ¦ Issue 2 ¦ April-June 2020
high. In almost all cases, body hair after implantation
did not go into anagen effluvium (no comparative study
was conducted), but they were frizzy and dry initially
and became better over the 2years. In our experience,
chest hair growth was slower (no comparative study was
conducted, just an observation).
There are few limitations of body hair follicle harvesting
and complications. Body hair follicles harvesting has
a long learning curve because of reasons such as acute
exit angle of hair, more superficially sitting follicles in
collagenous dermis unlike scalp hair, which floats in fat,
absent bony support, and bulky soft tissue. Hence, do not
have a strong shaft to facilitate easy extraction greatly
variable direction, and pattern of body hair in beard
and chest, difficult positions, anesthesia, and there are
more telogen hair. Surgeon should be very careful about
the overdose of an anesthesia. Few complications such
as ingrown hairs or cysts, hypo-, or hyperpigmentation
in donor area are observed, which can sometime be
embarrassing for patients, specially in beard area.
Accidental injury to facial nerve during beard hair follicle
harvesting may give rise to facial nerve paralysis, which
may be temporary or permanent.
conclusIon
Combination grafting is a good answer to cover higher
grades of baldness as well as to enhance the result of hair
transplant.
With experience, one can improve technical challenges of
body hair harvesting such as anesthesia, harvesting speed,
and transection, so that every hair transplant surgeon
keeps body hair harvesting as a good adjuvant to hair
transplantation.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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