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Introduction

 People of different ethnicities have a lot of variation in their scalp and hair characteristics which need to be taken into consideration while taking up a case of hair transplant. We describe the salient features of the hair characteristics along with modification of the technique of  hair transplant in a Chinese patient.

Before Surgery

Case Report

A 56 year old patient of Chinese ethnicity presented to us with the complaint of baldness in his crown area. He had a positive family history of male pattern baldness in his first degree relative. There was no significant history of any drug intake or any other prior treatment for the same. No other significant medical history was present.

On examination, the shape of the skull from top was round in shape.Scalp examination revealed a grade 3 (vertex) male pattern baldness. The hair texture wasfine and the hair were predominantly straight and black in color with few gray hairs in between. Follicular density in the mid-occiput region as measured by a scalp densitometer was 85 / cm2. The patient was planned for hair transplantation of the crown area via Bio-FUE method using 1500 grafts from the scalp donor area.

Pre Op

The grafts mainly consisted of two hairs per follicular unit with the average follicle-graft ratio being 2.25:1. The average length of the follicles was 5.2 mm. The punch tip used for the extraction was a semi-sharp 0.9mm in length with a diameter of 3mm. the speed of the motor was kept between between 500-700 rpm. The grafts were extracted by advancing the entire length of the punch. Thus the authors were able to keep the FTR(0-2) and PTR (0-3) at minimum. The surgery went uneventful.

Discussion

 Asians have a typically round shaped skull (brachycephalic) as compared to their Caucasian counterparts which are dolicocephalic (oblong shaped). The straight and dark colored hair of Chinese provides a stark contrast against their light colored scalp which causes difficulty in giving a good scalp coverage via transplantation.

In our patient the average follicle-graft ratio was 2.25. Asian scalp hair has been shown to have a hair: Follicular Unit ratio between 1.7-2.0 which is less than that found in Caucasians (2.25). The donor area follicular density has been reported to be higher in Asians (80-90/cm2) as compared to Caucasians (55-70/cm2). The density in our patient was in accordance with the above findings.

Smaller punch size is used for Asians (0.8mm or 0.9mm inner diameter) because of relatively less number of hairs per follicular unit as compared to 0.9-1.0mm in Caucasians. The smaller punch has the additional benefit of reducing the wound size. As the average hair per follicular units is less than 2, 0.8 mm punch would be the best one to use but the authors prefer the 0.9mm punch as it not only facilitates the increase in the number of hair per grafts but also leads to the increase in the perifollicular tissue which comes in handy while delivering a good result in FUE surgery.

The average length of the follicle in Asians is described to be between 5-6mm as opposed to 4.0-5.0 mm in Caucasians. The current patient had a average follicle length of 5.2 mm (5.1-5.5 mm). the risk of transection increases with more follicle length in the Asians. Hence to achieve a low FTR, we used a semi-sharp punch and advanced it to its complete length for the extraction.

Post Op

Conclusion

 Hair transplantation in various ethnicities is a different and complex entity. A modification of the technique by the surgeons, keeping in mind the above-mentioned differences of the scalp and hair can give cosmetically pleasing results.


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