H-Factor and X-Factor

Damaged graft cannot re-grow

Transplanting a graft from one site to another does not guarantee good result. As damaged graft cannot re-grow, the surgeon must pay attention to every step and every details of the procedure. On average 85-92% of grafts survive after transplant and grow new hair. 2 possible ways a graft can be damaged or even killed - the X-Killing Factor and the H-Killing Factor.

"H" stands for human. Poor growth is caused by a breach of protocol. H-factor may occur before, during, and after the procedure. The result of a hair transplant procedure cannot therefore be guaranteed.

What Kills A Graft - X Factor

"X" stands for unknown. The term was first described by Dr Shield (Australia) in 1984, when the reduced hair growth was unexpected and unexplained. In early years this X-Factor only accounts for a very small 0.5-1% of all no growth. With the advance and standardization of surgicial techniques, X-Factors now accounts for the majority of unsatisfactory results.

Possible X Factors

It is of our opionion that such "unknown" factors are in fact biological damage to the grafts which takes plce during and after the procedure, including:

•   Denied or missed H-Factors
•   Reperfusion Ischaemic Injury
•   Auto-rejection of Grafts
•   Overheating and Dehydration of Grafts in the First Week
•   Improper haircare or activities

What Kills A Graft - H Factor

H-Factors Before Procedure

Predisposing Factors That Compromise Result include:

•   Poor Circulation of the Recipient Area
•   Scar on to-be-transplanted areas
•   Smoking
•   Uncontrolled Diabetes

H- Factors During Procedure

Grafts are injured During Procedure:

•   Dehydration
•   Excessive Removal of Supporting Tissue
•   Cold Injury
•   Transecting the Hair Follicles
•   Chemical Trauma To Grafts During Storage
•   Ischaemic-Reperfusion Injury

H-Factors After Procedure

Transplanted Follicles are injured after the procedure
•   Failure To Compile With Instruction
•   Failure to Form New Circulation
•   Physical Trauma To Transplanted Graft
•   Infection

How Surgeon Overcomes H-Factors

H Factor 1 - Dehydration

Dehydration causes serious graft damage. Deleterious changes in cell integrity when follicles are left to dry for more than 5 minutes (Gandelman). When grafts are exposed to air for more than 10 minutes, more than 6% will die. After 20 minutes survival markedly decreases (Kim)

Dehydration causes serious graft damage. Deleterious changes in cell integrity when follicles are left to dry for more than 5 minutes (Gandelman). When grafts are exposed to air for more than 10 minutes, more than 6% will die. After 20 minutes survival markedly decreases (Kim)

How Surgeon Overcomes Dehydration

•   Do not leave grafts on the gloved fingers
•   Avoid using FUE for more than 2,500 grafts ( 5,000 Hairs )
•   Avoid using implanters
•   All grafts are submerged in Hypothermosol solution or moistened gauze pads

H Factor 2 - Excessive Removal of Stem Cells

10X manification microscopes should be used to preserve stem-cells

Removing too much tissue around the hair follicle is also a form of physical injury. Stem cells responsible for follicular re-growth is located at the tissue surrounding the graft. Seager reported in 1997 that Chubby Graft (more fat) survives better than Skinny Graft (less fat) (Seager). In 2010 Beehner commented that the differences in survival is that the stem cells are retained in chubby grafts but trimmed away in the skinny grafts

How Surgeon Overcomes Excessive Stem Cells Removal

•   Use microscopes to preserve stem cell containing tissues
•   When using FUE for harvesting always use a larger punch to retain the fatty tissue

H Factor 3 - Graft Transection

Transected the follicle at upper 1/3
		Upper 1/3 - 0% will grow
		Lower 2/3 - 83% will grow
Transected the follicle at the middle
		Upper 1/2 - 40% will grow
		Lower 1/2 - 27% will grow
Transected the follicle at lower 1/3
		Upper 2/3 - 65% will grow
		Lower 1/3 - 0% will grow

Graft transection can be reduced to less than 2% overall rate by cutting the graft under direct and magnified vision.

How Surgeon Reduces Transection 1 : Open Technique

Blind harvesting technique is still commonly used in strip excision. Patient sits and leans forward. The surgeon stands behind and cut the strip without seeing the hair follicles. Those experienced adjust blade angles to follow the existing hair. This may work for Caucasian's short roots, but not for Asians' longer ones. Follicle are transected on the course of the blind blade. More blades are used, lesser grafts survive.

This technique was first introduced by Dr Pathomvanich in 1998, Open Donor Harvesting has not enjoyed popularity. It's time-consuming taking an extra 30 minutes, thus used mainly by surgeons who care about scar and final result.

How Surgeon Reduces Transection 2 : Microscopic Dissection

In FUT the smallest follicular unit is used for grafting. Important parts of the follicle can easily be transected during cutting. Such grafts will yield suboptimal growth even if survived. The only way to preserve integrity of the follicles is to dissect under magnification.

The use of microscope was first introduced by Dr Limmer (USA) in 1991. However it took 10 years to become the gold standard. We are convinced that the result well worth the investment in equipment and training. We routinely use 10X stereoscopic microscopes with back lighting for better visualization. Cool LED light is used for illumination to avoid over-heat. Grafts are kept moist all the time to prevent dehydration. We have seven assistants for graft cutting grafts to shorten preparation time. Stem-cell containing tissue preserved for better survival.

H Factor 4 - Delay Re-implantation

From the table you can see that graft survival to 90% after 4 hours. So after 4 hours 10% of the extracted grafts will not grow hair. This is a wastage as the donor hair is limited in a life time.

How Surgeon shortens the Delay

•   Limited FUE Extraction time to 2-3 hours
•   Well planned procedure to shorten the operating time
•   A large surgical team to share the work load
•   Only perform one case a day so that all attention will be given

H Factor 5 - Cold Injury

This is a form of physical injury. Study had shown that all frozen graft will die. Domestic-grade refrigerator may have temperature fluctuation. If the fridge temperature is set too low it may drop below 0°C and kill grafts without knowing. From studies there was no significant difference in survival within 6 hours, whether the grafts were stored in room temperature or 4 °C (Kim)

How Surgeon Overcomes cold Injury

•   Store graft at room temperature if procedure can be complated within 4 6 hours
•   Use a special storage solution ( Hypothermosol ) to store grafts in the fridge
•   Try to complete implantation within 6 hours

H Factor 6 - Damage To Grafts During Storage

When tissue is removed from the body, the cells will slowly run out of oxygen and eventually die

Recommended Protocol

•   Use ATP as Storgae Solution
•   Shorten Surgical time

H Factor 7 - Ischaemic-Reperfusion Injury

After a period of low oxygen, when the grafts are implanted and suddenly re-exposed to oxygen, they may form free radicals. These free radicals may cause cell injury and suboptimal growth, and is known as "Ischaemic Reperfusion Injury or IRI" on Re-implanted Graft.

How Surgeon Overcomes IRI

•   Suppress tissue injury by the use of anti-inflammatory medication
•   ATP is added to the storage solution to protect the grafts

H Factor 8 - Infection

Infection if recognized and treated promptly should not affect the final result.

Recommended Infection Control Protocol

•   Use of antibiotics for selected case
•   Perform procedure in an aseptic envirnoment
•   All staff has to follow protocol
•   Follow-ups should be conducted by experienced staff to look for early sign of infection

H Factor 9 - Physical Trauma Transplanted Graft

The first week after transplant the grafts can be dislodged by direct impact, especially when the patient fails to compile with instruction

Recommended Aftercare Protocol

•   Provide detail postop instruction
•   Free doctor follow-up. Arrange same day appointment for any immediate concern.
•   A helpful team to answer any of your concern
•   A specially designed cap is provided to protect the transplanted areas

H Factor 10 - Failure to Form New Circulation

Failure to form new circulation may starve the follicles and retard their growth

Recommended Protocol to improve circulation

•   Request patient to reduce smoking
•   Immediately use Low Laser Level Therapy and ATP Spray after the procedure

Message from the Doctor

Welcome to “Doctor's Talk,” where I’ll talk about everything related to hair loss and hair transplants. This series is here to help you understand more about how hair treatments work and what you can expect from them. The information provided is based on my 18 years of experience in dealing with hair loss.

Disclaimer - Please note that this series is purely educational. Reading these posts does not guarantee my services, nor are they intended for business promotion. Information provided is not guaranteed to be up-to-date and should not be considered a substitute for professional medical advice.

Any opinions discussed may not be universally accepted or applicable to all individuals. Always consult a healthcare professional before making any decisions related to your health.

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