Lateral slit Follicular Hair Transplant

The Hair Restoration is a new concept that allows us to go beyond the expectations. It’s now possible to reproduce a natural hair aspect, through the use of these new surgical techniques. But how is it possible? The last decade was marked by important technical advances that have motivated the field’s most acclaimed doctors to exceed the limits achievable in a hair transplant procedure, making the good results reached in the past seem just modest. With the new, improved results more and more clinics around the world had to make the decision of leaving more profitable and simple techniques behind so to put themselves head to head with the best results available today..


Follicular Units (UFs) with 1 to 4 hairs.		Follicular Units (UFs) with 1 to 4 hairs, transplanted in the scalp.

This complete change of direction took place between 1996 and 1998, when a specialist started working with follicular units: 1 to 4 follicles, as seen in natural hair. Near the forehead we can find one-follicle units, while a four-follicle unit is encountered on the back of the head, and so on. But there was still a challenge to be overcome: High density!

It used to take up to two or three follicular implants to be able to achieve the ideal amount of hair in order to produce the natural hair aspect. Once again, individual efforts made it possible. By reducing the orifice size in 60%, it became possible to implant higher then 50 UF/cm2 densities, achieving “cosmetic density”.

Density barrier put down, the new expectation became to cover the bigger area possible in just one transplant. One more time, the efforts and dedication of a few specialists developed the high-density Super Mega-sessions. It was finally possible to cover a bald area up to 80 cm2 in just one session.

50 years down the history line, hair restoration is finally able to satisfy the most perfectionist patients and doctors. With the Lateral Slit Follicular Transplant is not that odd to find rigorous patients saying that the results were beyond their expectations!

Levels of baldness

Masculine androgenic alopecia can demand different treatment depending on the level of baldness: clinic treatment only, sometimes surgical, or both. Generally, baldness begins in the frontal hairline, with hair thinning to the progressive hair fall, till it gets to a very thin, soft hair (Norwood level II).
The lateral part of hair, near the frontal hairline area, is frequently affected too. Later on, the “frontal hairline” tend to fuse right behind the “forelock” leaving behind an “isle” of hair (Norwood III, IV and V). As the receding hairline advances, a “crown” rarefaction can be seen. Finally, there’s a fusion between the frontal hairline and the crown (Norwood IV and VII).

Some patients’ pattern of baldness, though, begins in the crown (Norwood III Vertex) later on affecting the frontal hairline. Some others, instead of the classic receding hairline, also present a total and uniform retreat of the frontline, giving the impression of a forehead progressive augmentation (Norwood IIa, IIIa, IVa and Va). Is just further on that the crown is affected. There are many patterns and degrees of baldness. One of them is a more diffuse start, affecting first the top of the head, saving the frontline as seen frequently in female baldness (Ludwig, I to III).

Norwood degree of baldness board.

The Lateral Slit Follicular transplant

Since the beginning, the transplant had a sagittal orientation. In 2003, however, the front page of Hair transplant Forum International was dedicated to comparing the classic sagittal technique with the revolutionary Lateral Slit one. A little on the subject:

Hair direction – The hair is formed by follicular units (UFs) naturally oriented in a coronal way, in other words, from ear to ear, horizontally; not vertically (from the forehead to the nape) as in the sagittal way.

Cover – On the lateral slit or coronal way, the hair works as a “sape grass roof” in which every UF grows to cover the one right below, blocking the view of the scalp. Besides following the natural hair direction, we can maximize the cover made possible by the follicular transplant, intensifying its volume and creating a higher density impression.

Angling - The Coronal technique allows us to put the UFs in a sharp angling, just like seen on natural hair that is, leaving the hair in a more laid down position, (10 º to 40 º). The natural hair presents a wide variety of angles, sharper on the lateral area (temporal region). To follow these hair angles is as hard as indispensable. There would be of no need to use follicular units but implanting them inadequately. The result would be a hard-to-brush artificial hair.

High density – Find out why the Lateral Slit Follicular Transplant is the only one capable of reestablishing an ideal hair volume creating a cosmetic density.

The hair transplant goal is to restore the natural volume one once had. The final result does not depend only on the number of hair units transplanted. The results are achievable not only according to the bald area size, and the number of UFs transplanted, but also by the density of single hairs from the donor area. The elasticity of it is another important aspect that is strictly linked to the final density result.

As said before, there was a time where we had to perform multiple transplants in order to get to build that dense aspect. for totally bald patients, the old, classic Mini-micro grafting transplant pattern demanded three sessions for each treated region. Even so, there was a chance to get that undesired “tuft” aspect, a characteristic of this obsolete technique. With the development of Lateral Slit Follicular transplant it’s now possible to overcome the baldness problem in just one session for each bald region with an impressive natural aspect. Of course that the probability of getting all done in just one session is smaller if the size of the bald area is too large.

It’s a matter of math: a normal hair has from 70 to 100 UF/cm2. Surprisingly so, with a little bit more than just half of this density it’s possible for us to create the illusion of a full hair. Another important worth considering is the hair caliber: The thicker it is, the lesser the density needed to create the desired volume. The thinner hair, in the other hand, demands a higher amount of UFs, once the volume generated by each hair is inferior. The volume is the mathematical reason length of one hair multiplied by transversal section area of each hair (pR2). So, when we double the caliber of each hair, we quadruplicate its volume. This shows the tremendous influence of the caliber. But, generally, we can say that 40-50UF/ cm2 can create the impression of a full hair. This full volume “illusion” is what we call “cosmetic density” which is different from real, original hair density.


Fine Hair.		Thick Hair.

Just to compare, all the Sagittal Follicular Transplant technique can do is to create a 20-25 UF/cm2 density, which means that a minimum of two sessions is required to get to a wanted volume. If the transplant area is partially bald, only one session is required, as soon as the original hair remains where it is.

In the Lateral Slit Follicular Transplant, once we can implant the UFs in smaller and more superficial orifices (0.55-0.70mm) it’s now viable to achieve a higher density of UFs per cm2 without compromising the blood circulation system.

Area X Density: Once the ideal is to get maximum density in each session, it would be illogical to spread hair through out the bald areas trying to solve the problem once and for all without the means available. If we were to do that the result would be a low-density-transparent hair and a frustrated patient. If we are aiming at building a high-density aspect we ought to concentrate our efforts to cover one specific area at a time. As we have something around 2.000 to 2.500 UFs per transplant, it’s viable to cover 50 or 60 cm2 in each intervention. Doing so, we will be always working on a virgin area with intact vascularization. There’s another advantage, it won’t be necessary to wait for the hair to grow in order to restart working on that same place. In this case, the intermission between sessions (when needed, usually in bigger baldness) can be reduced to a period of 6 to 9 months

Lateral Slit Follicular Technique Super Mega session

When the baldness area is greater than 60 cm2, bigger transplants will be necessary. Those who desire to restore a great bald area in only one session can go through a Super Mega Transplant. The number of follicular units transplanted exceeds a lot the usual 2,300. It varies from 2.800 to 4,000, in average 3.200. These bigger sessions allow covering areas of up to 90 cm2, a great advance. It is always good remembering that this number depends a lot on the elasticity and the density of each individual’s donor area.

The Basic technique of a Transplant

Donor and receiving areas

No hair transplant produces more hair, it only redistributes them. Consequently, we can only completely restore the hair of a patient whose baldness affects only 40% of the scalp. Bigger damage, in most cases, allows only partial restorations. How is it done? Each hair is taken from an area non-likable to get bald, the occipital region, called here as the donor area. After being properly prepared by the assistants, they are placed in the bald area, or the receiving area. This new hair shall grow naturally, later allowing to be cut, straightened or colored, just like any other hair. Those new reborn areas are risk-free of being once again bald, once they are now genetically protected. To better understand it, we can say that the problem with it, its not the land in each the hair is being planted but the seeds. Once we implant a good seed in a land which has always being fertile, the hair will grow naturally.

Removing the hair to be implanted:

The hair is removed in a fast and simple way from the occipital region of the head, the donor area. Then, a thin band of the scalp is taken off. The boarders of it are placed side-by-side and sutured in two plans, being one of them deep and the other superficial, very delicately, in a way to leave only an imperceptible trace. The importance of producing a deep suture is to retain the tension, avoiding widening the stitches when they are taken off. These inner stitches are going to be absorbed after 6 weeks. The usual result is a undetectable 1mm-wide cicatricial line hidden by the hair. Even when the stitches are still there, they cannot be easily seen as the hair covers it.

Preparing the follicular grafts:

One of the most arduous, delicate and important steps of the process is the preparation of the follicular grafts, which is to divide and separate the follicular units containing 1, 2, 3 or 4 hairs each.

Being it pretty small and delicate, the task demands 3-D special-vision microscopes with back light system to separate, lapidate and classify each UF. After preparation, the follicular grafts are carefully conserved in a nutritional solution to 4°C. In order to produce 3.000 grafts, 8 assistants work for 4 to 6 hours.

01 - First, Follicular Units (UFs) of the donor area are removed;
02 - special Microscopes 3-D with vision are used to handle the UFs;
03 - The UFs removed is carefully separated;
04 - Now, the 4-hair UFs are classified in sets of 1;
05 - The follicular grafts are stored in nutritional solution 4° C;
06 - In the transplant, a clamp with a very delicate, fine diamond dust in the tip is used.

Placing the Follicular units:

As soon as the assistants finish separating the first UFs, the implantation begins. While the patient is under effect of local anesthesia, sleeping or just relax listening to some quiet music, Dr. Tykocinski and his assistant place the UFs, one-by-one. It’s a very delicate process, an arduous handcraft that can take up to 8 hours to be completed. In order to do the grafts, 0.55 to 0.70mm incisions are made with a very delicate clamp with fine dust powder in its tip, not to damage the follicular units. Important hair features as the way it stands when combed, for instance, is defined in this stage of the procedure.

The characteristics of Hairs:

Lateral slit transplant’s logical choice is to follow exactly the features of natural hair, like the angle and hair growth direction as to maintain the usual density and volume variety found in each region. The aspect of the implanted hair is almost like the natural one. It can be thicker, because differently from what occurred in the bald area, it has not being under the consequence of hormonal action. But the key-point of the lateral slit transplant is to maintain the hair’s natural distribution. Exemplifying: one-hair units in the frontline, near the forehead, follow by areas with two-hair units, implanting the denser units to some determined areas.

Team, anesthesia and duration of Lateral slit Transplant:

The full time taken in a lateral slit transplant varies between 5 to 8 hours. It is always done with local anesthesia plus a soft sedative. When done in a hospital ambience which means that during the major part of the procedure, the patient is asleep. Due to the high complexity of this technique, a team of 10 professionals is needed. Even though we might affirm that this is a simple procedure, we care a lot about security. For this reason we only operate in hospitals and clinics which dispose all necessary measures to maintain total control of the patient vital data. Generally, our transplants take place in our own clinic or at Albert Einstein Hospital in Sao Paulo (SP).

Right after the transplant: Next day cleaning and no bandages

The delicate characteristic of the technique makes possible that the UFs start fixing themselves just minutes after grafting. Even though it happens tenuously, it is enough to make the use of bandages, turbans or any kind of curative totally useless. The patient returns to the clinic on the next day after the transplant to have his or her hair washed and dried by our team as to receive a facial lymphatic drainage. All back-home procedures are once again explained to the patient so there’s no doubt about it. Basically, what we ask is for the patient to wash his hair in a daily basis with a soft bristle brush supplied by us and to use an anti-septic shampoo (also prescribed by us). New shampoos are going to be prescribed after the stitches are removed.