Answer:
I would recommend that you do lots of research before you commit to having a Fleming Mayer flap procedure. The main positive feature associated with a flap is the high level of density which can be transferred during a single procedure. Unfortunately, the trade-off for this density is a very artificial look. I have never seen a patient with a flap who looked natural from every viewing angle.

During the Fleming Mayer flap procedure, a strip of tissue from the side of the head is dissected and then twisted around and relocated where the hairline is to be created. Your concerns about invasiveness with this surgery are well founded. Since this surgery takes a section of scalp from the side of the head, it is possible that the resulting scar will be noticeable after the surgery. Furthermore, if the blood flow to the section of flap is compromised, the flap could lose its hair or become necrotic. Even if the procedure goes as planned, the flap creates a wall of very dense hair which does not mesh well with the rest of the scalp hair. There is a very good reason why so few U.S. physicians perform flap procedures today. The explanation has nothing to do with technical difficulty or requisite expertise in the field. Rather, flap procedures simply do not look natural. The general feeling is why offer such an
inferior procedure when today’s hair transplant technology, in the hands of a competent physician, can yield a much more natural appearance?

Brandon Ross, MD
http://www.rmhri.com
IAHRS Recommended Hair Transplant Surgeon

Website: http://www.miamihair.com
Email: drnusbaum@miamihair.com

Dermatologist/ Board Certified by the American Board of Dermatology

Dr. Nusbaum has been widely published in the fields of dermatology and hair transplantation and has been extremely active in research and professional societies. He is in demand as a lecturer and has presented dozens of programs, research findings, and clinical reports at medical conferences.

He graduated from the University of Colorado in 1974, then received his doctor of medicine degree from he University of Miami School of Medicine in 1979.

Dr. Nusbaum interned in Internal Medicine at Mount Sinai Medical Center in Miami Beach from 1979 to 1980. He did his residency in dermatology at Mount Sinai from 1980 to 1983, serving as chief resident in dermatology from 1981 to 1983.

He has been a clinical assistant professor lecturing in dermatology in the Department of Family Medicine at the University of Miami School of Medicine and has also been a clinical instructor at the Department of Dermatology and Cutaneous Surgery at the University of Miami School of Medicine.

Dr. Nusbaum has been treating patients suffering with hair loss for 23 years. In 1980 he began experimenting with hair transplants and started performing Follicular Unit Transplantation in 1996, a technique he demonstrated on the Discovery Channel.

Dr. Nusbaum serves on the Ethics Committee of the International Society of Hair Restoration Surgery and is one of the first 30 physicians in the United States to be certified by the American Board of Hair Restoration Surgery. He has been chosen to be an examiner for the Board due to his outstanding performance on the certification examination.

Dr. Nusbaum is known not only for his artistic sense, but is recognized for his original research in developing techniques to reduce pain associated with the procedure. For this purpose, he utilizes all of the most advanced techniques and has been selected to write an article on “Techniques to Reduce Pain in Hair Transplantation” for The American Journal of Clinical Dermatology.

His published articles in medical journals include “Hair Transplantation in Black Patients” (Hair Transplant Forum, 1991); “The Recipient Area: An Organized Approach for Preventing Complications” (Journal of Cosmetic Dermatology, 2000) and “Reducing Pain During Hair Transplantation” (Journal of Dermatologic Surgery, 2001).

Hello,

I hope you answer my question. My 12 yrs. old daughter has been diagnosed with Androgenetic Alopecia. Her hair has been thinning in the front and at the temples. We have been using the 2% Rogaine for 3 weeks, as recommended by her dermatologist. The hair in the back of her head seems normal. This is starting to affect her emotionally.

Is it too soon to think about hair transplant? Should we wait until she is 18? Please let me know.

We live in the Bay Area, Any recommended hair transplant MD’s??

Thank you for your time,
Mariam

Answer:

Androgenic alopecia is quite uncommon in a 12 year old male or female. I am curious how the diagnosis was made. There are multiple reasons for hair loss in the front and temple areas besides androgenic alopecia. If it is androgenic alopecia, one would consider a full medical workup to determine why it is occurring at such a young age. Androgenic alopecia has some characteristic findings. These include miniaturization of the hair and lightening of the hair color in the affected areas. In addition, there are also some characteristic histological findings under a microscope. I would have her seen as quickly as possible. In the bay area, I recommend Sheldon Kabaker, who practices in Oakland or Peter Panagotacos, who practices in San Francisco. They can assist you with a diagnostic work up, as well as a treatment plan.

I really don’t think you should consider any surgical intervention until you are certain about the cause and any underlying medical conditions that might be treatable without the need for surgery. Certainly, it always best to delay any form of surgery as long as possible with androgenic alopecia. The reason for this is quite simple. Androgenic alopecia is a life long, unrelenting process. While there may be enough follicles to manage minor loss at a young age, the supply gradually declines as you beg from Peter to pay Paul. While someone may need enough bricks to build a 2000 square foot home, eventually they may need a 10,000 square foot home yet not possess enough bricks to build such a structure. Hair loss is much the same. It begins at minor levels, but gradually affects greater portions of the scalp. The donor area in the back and sides is finite and may even decline in quantity naturally itself due to senescence or old age of the follicles. Females are especially prone to loss of the donor hair especially on the sides.

It is certainly understandable that hair loss in a female at any age is psychologically troubling. You should have this evaluated as quickly as possible.

John P. Cole, MD
http://www.forhair.com
IAHRS Recommended Hair Transplant Surgeon

I am 57 and have had multiple hair transplants with great results. I suffer from male pattern baldness. Two years ago I began taking testosterone and HGH replacement therapy under the direction on an anti-aging physician. My concern is by increasing testosterone/DHT, am I at risk of loosing the grafted hair. What has been your experience with patients using hormone replacement therapy and hair loss. Could propecia mitigate the potential side effects of hormone replacement and hair loss?

Answer:

First of all, if you were going to experience any loss of hair, transplanted or otherwise, you would have noticed by now, having taken testosterone (T) and HGH for two years. The loss would be the greatest in non-transplanted hair.

Theoretically the transplanted hair originated from a zone of follicles free of DHT receptors so they should not be affected by DHT or T. In reality the transplants behave like the donor hair and there have been reports of thinning of transplants if the donor hair thins. Most often this thinning is seen with age (senile alopecia) but can also be associated with medications or systemic illness. Fortunately the incidence of this is low. By taking T, DHT will most likely increase. As a precaution finasteride could be taken to lower the concentration of DHT. Finasteride reduces the amount of DHT by 70%. If you are increasing T and therefore DHT, even with blockage of 70% of the production of DHT there will still be more DHT.

So the answer to your question is yes finasteride could potentially decrease hair loss from DHT produced by an increase in exogenous T. One has to be aware of the side effects of finasteride which are well documented.

Bradley Wolf, MD
http://www.wolfhair.com
IAHRS Recommended Hair Transplant Surgeon

- Accepted member of The International Alliance of Hair Restoration Surgeons

- One of less than 50 hair transplant surgeons throughout North America recommended by The American Hair Loss Association

Website: http://www.forhair.com
Email: info@forhair.com

John P. Cole, MD practices in Atlanta, Georgia, Chevy Chase, Maryland, Cleveland, Ohio, and Charlotte, North Carolina. Dr. Cole attended Mercer University on an academic scholarship from the United States Army and graduated summa cum laude with a degree in biology and chemistry in 1981. He continued on to the Medical College of Georgia, where he received his medical degree in 1985. Dr. Cole completed his postgraduate medical training at the University of Missouri in the field of internal medicine. He has dedicated his practice solely to the field of hair transplant surgery since 1990. He has maintained a private practice in hair restoration since that time. He is a member of the International Society of Hair Restoration Surgery, the American Society of Hair Restoration Surgery, and the American Academy of Cosmetic Surgery.

Dr. Cole was among the first thirty physicians to become a Diplomat of the American Board of Hair Restoration Surgery. He serves on the Board of Directors and examination committee for the American Board of Hair Restoration Surgery. In the interest of sharing his knowledge to improve the field of hair transplantation, Dr. Cole has written and presented many papers, both to hair transplantation societies and at educational seminars.

Dr. Cole maintains a keen interest in development of instruments to refine hair transplantation procedures, creative research in follicular anatomy, and has developed mathematical formulas to accurately measure human performance in hair restoration surgery. In 1999 Dr. Cole was awarded a research grant from the International Society of Hair Restoration Surgery for his work on regional variation in hair diameter and hair density. He presented the current findings from this research at the 2000 meeting of the International Society of Hair Restoration Surgery. In December 2000, Dr. Cole orchestrated the Beginner’s Program at the International Society of Hair Restoration’s annual medical conference in Hawaii whereby he trained over 75 physicians in the processes and techniques of hair transplantation. Dr. Cole is an invited speaker to the first Korean Workshop on Hair Restoration, the 2001 European Society of Hair Restoration Surgery in Barcelona, and the 2001 Italian Society of Hair Restoration Surgery meeting in Sicily. Dr. Cole will function as Co-chair at the Aegean meeting of hair restoration surgery in Athens, Greece in 2002. At the 2000 International Society of Hair Restoration Surgery meeting Dr. Cole and Dr. Devroye were awarded First Place by the International Society of Hair Restoration for his poster presentation entitled, “Computer Applications in Hair Transplantation.” Dr. Cole was awarded the Archimedes Award in 2001 and the Michelangelo Award in 2002 by the Italian Society of Hair Transplant Surgery. He was named to the Research Committee of the International Society of Hair Restoration Surgery in 1999. Dr. Cole functioned as director of the Beginners Program at the International Society Meeting of Hair Restoration Surgery meeting in Puerto Vallarta, Mexico. He is in charge of the audio-visual committee of the ISHRS meeting in Puerto, Vallarta. His most recent scientific project is developing improved optics to the dissection and harvesting of white hairs using physics and lasers. Dr. Cole is chairman of the International Society of Hair Restoration Surgery meeting in Chicago, Illinois.

Dr. Cole has invented numerous instruments to improve the speed and efficiency of hair restoration surgery. These include instruments to harvest the donor region, instruments to prepare the recipient sites, and most recently a translucent slivering board to assist in the preparation of thin strips of donor tissue over 1 cm in length and 1 mm wide. This slivering board is transparent and allows for both top and bottom fiberoptic lighting. The combination of both improves visualization of the grafts and decreases trauma to the individual hairs. The production of thin slivers speeds the production of grafts, approaching a rate of 450 per hour, with minimal risk of damage to the hairs.

Teaching: ISHRS Beginners course 98, 99, 2000, 2001. Italy 1997 beginners course. European 2001 Beginners course. Korean Live surgery workshop 2001. Numerous physicians have visited Dr. Cole for advanced training in hair transplant surgery. Dr. Cole’s office is always open to those wishing to advance the field of hair transplant surgery. Dr. Cole Served on the faculty of the WHRS 1999 and 2002. Articles: Dr. Cole has published several articles in the Hair Transplant Forum on nomenclature, the use of trigonometry to accurately calculate the donor harvest, how to estimate the recipient area, how to estimate the size and number of follicular units, how to maximize donor yield, how to measure the distance between the grafts based on the density and the pattern of distribution, how to predict coverage, and predicted yield.. ;He co-authored the chapter on Donor Harvesting for Dr. Walter Unger’s new text entitled Hair Transplantation. Dr. Cole was interviewed by Cosmetic Surgery Times on Donor Harvesting in 1998, which resulted in a featured article.

Presentations: Maximizing Donor yield, donor harvesting, mathematics of follicular transplantation, microscope vs loops comparison, etiology of hair loss, mustache transplantation, the metamorphic changes to surgically excised hairs, biological switches, geometry of scalp reduction surgery, and the physics of light. Dr. Cole has held numerous seminars across the United States on the cause and treatment of androgenic alopecia to the lay public.

Dr. Cole’s other interests include computers, electronics, flying, snowboarding, water skiing, snow skiing, baseball, wake boarding, golf, dressage, and raising his children.

I am from Cyprus and I am a candidate for a transplant operation. I have found many answers to many of my questions in your site and I thank you for that. The reason I am getting in touch with you is that I have my doubts on the number of hair “roots” they can get per square centimeter for a hair transplant. Can you please inform me what is the MAXIMUM number of hair roots that can be taken from a square centimeter? I consider that important as the total cost of the operation depends completely on the number of hair the will transplant. For instance if the strip they will get is 28 square centimeters and with average density what would be a possible number ‘roots” to be transplanted

Thank you once again ! I look forward to hearing from you !

Answer:

When you say “roots,” I am assuming you are talking about hair “follicles,” as a follicle is the smallest unit which can be successfully transplanted. With that in mind, the average number of follicles per square centimeter donor tissue is roughly 100/cm. I have seen this number vary from between 40/cm to 160/cm. The higher the number, the more follicles the tissue provides. Someone with a density of 40/cm is unlikely to be a good candidate for surgery because of the low yield and because the donor region is so sparse that you would probably be able to see the donor scar.

Using your example of a 28 square cm donor section, the yield would be roughly 28 X 100 = 2,800 follicles. However, this doesn’t necessarily mean that the incision would be 28 cm in length. To calculate the surface area of donor tissue to be excised, you have to multiply the length of the incision by the average width. In my practice, I limit my donor incisions to 1.2 cm in width. Therefore, to obtain a 28 square cm section, my length of incision would be 28/1.2 = 23.3 cm.

Brandon Ross, MD
http://www.rmhri.com
IAHRS Recommended Hair Transplant Surgeon

- Accepted member of The International Alliance of Hair Restoration Surgeons

- One of less than 50 hair transplant surgeons throughout North America recommended by The American Hair Loss Association

Website: http://www.foundhair.com
Email: jsemd@foundhair.com

Facial Plastic Surgeon/ Board Certified by the American Board of Facial Plastic and Reconstructive Surgery; the American Board of Hair Restoration Surgery/ Fellow, American College of Surgeons

Dr. Epstein is considered one of the country’s leading experts in hair restoration surgery by the plastic surgery community. A board certified facial plastic surgeon, Dr. Epstein has been specializing in hair transplantation since 1993. Widely published in the plastic surgery, dermatology, and hair transplant fields, Dr. Epstein is also a Voluntary Professor at the University of Miami. In addition, not a month goes by that he is not quoted by the media or press for his expertise in this field. More importantly, amongst his peers he is considered an expert in follicular unit grafting, reparative hair transplants, and hair restoration for women.

Dr. Epstein was recently the featured surgeon in a three-part series on hair transplantation that ran in Popular Science magazine. This series focused on both his work in follicular unit grafting as well as his anesthesia technique through the use of The Wand®.

Most important to Dr. Epstein is the respect and recognition of his patients. He personally performs all consultations and procedures, while his highly experienced team of assistants performs all microscopic graft dissection and assists in the planting. Only one procedure is performed at a time, allowing the attention to detail that Dr. Epstein promises all his patients. His office procedure suite is accredited by the Florida Academy of Cosmetic Surgery, complying with the new State of Florida Office Surgery Regulations to assure safety. This accreditation allows for procedures to be performed under mild sedation, or if patients choose, twilight sedation.

Some of Dr. Epstein’s publications include “Hair Transplantation for Men with Advanced Degrees of Hair Loss” currently in press in Archives of Facial Plastic Surgery; “Hair Transplantation in Women: The Management of Female Pattern Hair Loss and the Repair of Scarring From Prior Plastic Surgery” currently in press in Plastic and Reconstructive Surgery; and, “Revision Hair Transplantation: The Repair of Prior Unsatisfactory Results” in Plastic and Reconstructive Surgery.

Dr. Epstein received his B.A. from Swarthmore College, then graduated from the University of Vermont College of Medicine in 1988. He then completed a 5 year residency in head and neck surgery at the University of Vermont, after which he was awarded a fellowship through the American Academy of Facial Plastic and Reconstructive Surgery, spending a year specializing in hair transplantation. Upon completion of his fellowship in 1994, Dr. Epstein received the highest score in the nation on the examination for the American Board of Facial Plastic and Reconstructive Surgery. In 1998, Dr. Epstein became certified by the American Board of Hair Restoration Surgery.

Over 50% of Dr. Epstein’s patients travel in for their procedures. Located in South Florida, the office is fully bilingual English/Spanish, and has a large Latin American patient base, in addition to patients from throughout the United States. Over 80% of patients are referred from other patients, fellow physicians, or hair stylists.

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Reader’s Digest took the opportunity to acknowledge The International Alliance of Hair Restoration Surgeons as the place to find a hair transplant surgeon.

Image Magazine Sept 2007 Issue
(click image for larger version)

Southern California’s premiere lifestyle magazine goes “Unplugged” to empower their readers with the truth about hair loss treatments including surgical hair restoration.

When Image Magazine’s Angela Fernandez was given the assignment to to provide her readers with cutting edge information about the 3.5 billion dollar hair loss industry, she decided to go straight to the source… Spencer Kobren and The American Hair Loss Association.

 Spencer discusses his own struggle with hair loss, as well as giving his advice on today’s cutting edge treatments. Dr. Paul Cotterill was also interviewed for the article providing his insight on low level laser light therapy and follicular unit hair transplantation.

 Both Spencer Kobren and Cotterill offer words of caution when selecting a hair transplant surgeon and discuss the importance of doing your research. The International Alliance of Hair Restoration Surgeons is recommended as as the only organization that independently screens surgeons “admitting only those physicians who meet the exacting medical, ethical and professional standards of the IAHRS board.”

Spencer Kobren explains how “hair transplantation is a team effort” and the important role that the hair transplant tech plays in the final outcome of the surgery.

Is numbness in the back/donor area permanent?

Answer:

The loss of feeling associated with the strip technique of donor hair harvesting should be temporary. The nerves in the back generally carry sensation vertically in an upward fashion. When the incision is made these nerves are severed, which causes a numb-type feeling directly above the incision line. The sensation in this region almost always returns to normal, but the length of time varies from person to person (usually anywhere from 2-3 weeks to a year). As the nerves gradually reconnect with one another, it is common for the patient to have a slight “pins-and-needles” feeling in a patchy distribution. Some things that could cause numbness to persist a bit longer are a history of prior scarring, keloids, and diabetes.-

Brandon Ross, MD
http://www.rmhri.com
IAHRS Recommended Hair Transplant Surgeon

What’s the difference between the Strip method and FUE (follicular unit extraction) for getting the donor hair?
Answer:

First and most importantly, I make sure my patients understand the greatest limit to any hair transplantation is that there is a fixed and limited amount of good genetic hair that we can transfer to the balding areas.

With that in mind, I explain that no matter how experienced the surgeon, when I remove the donor area with either method, I am removing it blindly (i.e. – I can not see under the skin until after the donor tissue is removed). The problem is that I can not see if the follicles have been damaged or transected until after it’s been removed. So it’s best to have as little tissue as possible exposed to any device removing the tissue.

With the strip method, we minimize the amount of donor area being exposed to the risk of damaging hair follicles while obtaining the donor hair. With F.U.E., the patient no longer runs the risk of having a linear scar on the back of their scalp, but there is a significant increase in the amount of surface area being blindly dissected and with that a significant increase in potential damage to the hair follicles.

While I use both methods to obtain donor hair, I make sure the patient understands the risks and implications of both and I help the patient make an educated decision.

Paul J. McAndrews, MD
http://www.hairgrowthdoctor.com
IAHRS Recommended Hair Transplant Surgeon

Why do I need to use Propecia and Rogaine? Why can’t I just have a hair transplant?

Answer:

The simplest way to answer these questions is to give you an analogy. A dentist does not prevent tooth decay, toothpaste prevents tooth decay. Just like tooth decay, hair loss is a progressive disease for men and women. You will continue to lose hair (usually about 4% density per year) if you do not use the “toothpaste” that prevents the hair loss – which is Propecia and Rogaine.

You can have a hair transplant, if you are a candidate. I can increase density by approximate 20% with one procedure. But that means after 5 years, you have essentially lost what you had gained. Then you need another transplant, and the cycle continues.

The greatest limitation to hair transplants is the fixed and limited amount of donor hair you have. The majority of patients don’t have enough to keep up with the progression of their hair loss. If I can help you prevent that hair loss with the medical therapies, then I can minimize the amount of restoration you will need and you will be a much happier and more satisfied patient.

Paul J. McAndrews, MD
http://www.hairgrowthdoctor.com
IAHRS Recommended Hair Transplant Surgeon

- Accepted member of The International Alliance of Hair Restoration Surgeons

- One of less than 50 hair transplant surgeons throughout North America recommended by The American Hair Loss Association

Website: http://www.hairgrowthdoctor.com
Email: doctor@hairgrowthdoctor.com

Clinical Instructor of Dermatology,
University of Southern California School of Medicine

•Board Certified in Dermatology

•Fellow of the American Academy of Dermatology

•Fellow of the American Academy of Cosmetic Surgery

Paul J. McAndrews, M.D. is a Clinical Instructor of Dermatology at the USC School of Medicine, teaching the residents the latest advances in hair loss and transplantations. Dr. McAndrews also lectures extensively to other physicians throughout the United States on the etiology and treatment of hair loss. Dr. McAndrews has a private practice located in both Pasadena and Beverly Hills, CA. Unlike most hair transplant surgeons, Dr. McAndrews was formally trained in a residency on hair transplants and the pathophysiology of hair loss.

Dr. McAndrews formally learned the art of hair restorations during his dermatology residency at the distinguished USC/LAC Medical Center. He was honored with the distinction of Chief Resident. He also received years of professional training under the mentorship of Dr. M.B. Corbett, who is known as one of the early “pioneers in the field of hair restorations”. In 1996, Dr. Corbett asked Dr. McAndrews to join him as a partner in his practice. Dr. McAndrews has since taken over Dr. Corbett’s practice that was limited to the field of hair restorations.

Dr. McAndrews does not believe automating the hair transplant process is in the best interest of the patients. He believes, as the surgeon, he should be involved in every step of the entire hair transplant process. Therefore, he insists on doing only one patient a day so that he can devote his undivided attention to his patient from start to finish. When a hair transplant clinic is performing 3-4 hair transplants at the same time, unfortunately the doctor is involved in very little of the procedure and much of the hair transplant is being performed by a technician unsupervised. He fails to see the quality in this approach.

The major limitation to hair transplants is there is a limited amount of good genetic hair that can be donated to the balding area. Dr. McAndrews believes in doing everything possible, even though it is less efficient and more demanding on him and his staff, to ensure the highest percent of grafts survive and grow.

Dr. McAndrews and his hair transplantation style have been featured on ABC News, CBS News, Fox News, KCOP News, Good Day LA and other News Channels.

Dr. McAndrews also served in the United States Air Force as a Flight Surgeon. He received his medical training at USC School of Medicine, where he achieved “Dean’s Scholar” every year and was elected to Alpha Omega Alpha (National Medical Honor Society for the top 15% medical students in the nation). He scored in the top 4 percentile in the nation on the National Board Medical Exam. He performed his undergraduate training at Cal Poly State U., San Luis Obispo, where he graduated Magna Cum Lauda.

Dr. McAndrews is a member of the International Society of Hair Restoration Surgery, the American Society of Hair Restoration Surgery, the American Academy of Dermatology, American Academy of Cosmetic Surgery, the American Medical Association, and the Los Angeles MetroDerm Society.

Located in Hasselt, Belgium Dr. Feriduni is offering some of the best state of the art hair transplant surgery in Europe. We were very pleased to receive his application and very fortunate to find him.

A little more about Dr. Bijan Feriduni:

The Practice of Dr. Feriduni is a professional clinic, specialized in aesthetic and reconstructive hair surgery. Years of experience of the medical team on the one hand, and the specialization of Dr. Feriduni within his field of expertise on the other hand, guarantee a high level of treatment certainty and a professional attitude. As a result of the compliance with the latest techniques and our disciplined internal co-operation, we can offer our patients an optimal and constant quality certainty. Visit Dr. Feriduni’s website

View Dr. Bijan Feriduni’s IAHRS Member page

I will be 30 years old in November and have been on Propecia for 21 months to prevent further hair loss. Fortunately it has significantly slowed the rate of loss, but did not regrow any hair. I am mostly stable now, although there is still some slight regression. Currently, I am a NW2.5V patient on the scale with more loss on the crown and less at the hairline.

I prefer to have the FUE procedure to fill in the existing frontal hairline (as this has not receded from its original location, but rather has become less dense), the mid scalp, and the crown. My goal is to restore adequate density to provide coverage over the affected area.

I am concerned about shock loss in the transplant area due to the relatively broad coverage of the existing hair, so please address this issue in your response. Please advise my options, including the estimated number of grafts to achieve the desired results and the associated costs of the procedure.

Answer:

At 30 even using Propecia, you could and probably will lose more hair. For this reason I’m not a big fan of grafting the crown in men less than 35. The only one exception to this rule is if FUE is used. If extensive loss ensues you could cut your hair short without seeing a linear scar. You do have noticeable loss in the hairline which is more amenable to transplants and where results would be noticed. You have diffuse loss behind the hairline to the crown, more loss in the crown. I’m not sure what you mean when you say “adequate density to provide coverage over the affected area.” Some would think the coverage you have now in the mid-scalp is adequate.

The density could be increased in the crown but the change wouldn’t be as noticeable as in the hairline. The mid-scalp looks pretty thick from the photos. There could be shock loss where the hair is the thickest. The more grafts one attempts to place between existing hairs the greater the chance of shock loss. The density you have in the crown and mid-scalp is difficult to work with, too thick to dense pack without significant shock loss which would limit a big visible increase in density.

It would help to clip your entire scalp with a clipper without a guard. This would need to be done in the donor area anyway. Clipping the recipient area reduces shock loss and allows me to see the spaces better. Plus if there is shock loss you won’t notice as the new hair grows in with the shocked hair to some extent. I do everything possible to avoid shock loss.

It’s difficult to say how many grafts without examining you. Roughly I would say I could get up to 2000 in the hairline and between existing hair back to the crown if the entire area where clipped short. It may be fewer. That’s the good thing about FUE; you can stop when you fill the spaces. With strip you have to use all you take, which generally isn’t a problem.

You can view fees on my website at: http://www.wolfhair.com/service/fees.shtml I hope I haven’t confused you. But the bottom line is from the photos, it would be difficult to get a lot of grafts between existing hairs behind the hairline due to existing density.

Bradley Wolf, MD
http://www.wolfhair.com
IAHRS Recommended Hair Transplant Surgeon

I am going on a vacation to Hawaii in a month. Do you recommend I have my hair transplant procedure done now, or should I wait until after I get back?

Answer:

This is a difficult question to answer, as there are pros and cons with both choices. Obviously, the sooner you get the hair transplant, the sooner your new hair will be growing. The main drawback to having your procedure performed prior to your vacation is that you need to make sure the top of your head does not get a sun burn. While it is never a good idea to get a sun burn on any part of your body, evidence suggests that a sun burn on the newly grafted scalp region can lead to diminished graft survival. I usually recommend taking extra precautions, such as hats and suntan lotion, for a minimum of 3 months after surgery to avoid a sun burn in the grafted area.

Waiting until after your vacation causes you to wait that much longer for your hair to grow. However, it’s not as if all of your hair loss happened over the last few months- you’ve waited this long, so you can probably wait a month or two more. If you are afraid you may have trouble avoiding sun exposure during your vacation, I would recommend delaying the procedure until after you return.

-Brandon Ross, MD
http://www.rmhri.com
IAHRS Recommended Hair Transplant Surgeon

I am 27 with roughly type II hair loss. I would like to evaluate my ability to get a hair transplant to restore the front hairline. It is difficult to clearly show the difference in growing ability between the front and back hair because I just got a haircut before buying my digital camera. Basically all hair directly above my forehead is
getting sparse and thin and won’t grow beyond a certain length, and when the full head of hair grows long, it doesn’t keep up.

Answer:

It would be ideal to see you in person to get a good look at your hair loss and discuss all your options. There are medications you can take, minoxidil (Rogaine) and Propecia (finasteride) which can prevent further loss and actually add some density to the miniaturized hairs still hanging on. You appear to have a receding hairline and generalized thinning at the hairline and front. A hair transplant would increase the density of the hairline and front and could be used to recreate the hairline at an appropriate level. The transplanted hairs remain there so we have to be careful where they are put so they look appropriate as you age. There are a lot of aspects to discuss, beyond the scope of this post. You can get more information at our website, wolfhair.com. Again the best next step would be to schedule a consultation, for which there is no charge. In summation, you appear to be a candidate for transplants. In addition I would highly recommend the use of medications to prevent further hair loss.

Bradley Wolf, MD
http://www.wolfhair.com
IAHRS Recommended Hair Transplant Surgeon

I am wondering if I can wear a hat after the surgery. Also, how long until I can wear my motorcycle helmet?

Answer:

You can wear a baseball cap right after the surgery, provided that it is loose and flexible. Many people bring a hat or a bandana with them to the procedure and then wear it home so nobody sees that they have had surgery. The one caveat about this is that the hat cannot come in contact with the newly grafted follicles. It is okay if the hat touches the donor area on the back of the head, but if the hat is too tight or pushed town to far, there is a chance that the grafts will stick to the hat and subsequently be pulled out when you take the hat off. This can usually be avoided by wearing something loose that can be tilted a little forward.

The motorcycle helmet, on the other hand, represents a problem. We recommend waiting about 2 weeks after all of the tiny scabs have fallen off before you begin to wear a helmet. Generally, helmets are fairly heavy, which means that they are likely to press down on the head. This, coupled with the helmet vibration inherent with riding a motorcycle, could lead to damage to the new grafts and a diminished survival rate.

-Brandon Ross, MD
http://www.rmhri.com
IAHRS Recommended Hair Transplant Surgeon

Hello, I had my surgery two weeks ago and I noticed that many, if not all, of the scabs on the top came off with the hair attached. What percentage of this hair will grow back?
Answer:

That is a completely normal occurrence during the immediate post-operative period. After the procedure, the transplanted hair shafts are expected to fall out at or around the same time as the scabs fall off. Occasionally a portion of the grafts (the percentage varies widely between patients) will retain the original hair shafts and begin growing new hair from day 1. The usual course is for the transplanted follicles to shed their hairs soon after they are grafted and then start growing a new hair anywhere from 3 months to 12 months thereafter. The survival should be near 100%, whether the hairs shed after the surgery or keep growing and all of the follicles should be generating hair within a year.

-Brandon Ross, MD
http://www.rmhri.com
IAHRS Recommended Hair Transplant Surgeon

Website: http://www.rmhri.com
Email: bmr@rosscmg.com

Dr. Brandon M. Ross is the president and cofounder of La Jolla’s Ross Medical Hair Restoration, Inc. He serves as the only physician in this practice, which ensures that his expertise will serve every patient who enters his door. Dr. Ross is a firm believer that great care and planning must go into every surgery he performs. Therefore, he performs only one procedure per day and he utilizes only the most innovative techniques the industry has to offer. Dr. Ross specializes exclusively in hair restoration for both males and females to ensure that his attention is undivided. It is with his tremendous focus and naturally gifted hands that Dr. Ross is recognized as one of the leading hair restoration physicians in the United States.

A native San Diegan, Dr. Ross graduated from La Jolla High School as Salutatorian. His ambitious nature propelled him towards the University of California at Davis, where he graduated Summa Cum Laude with a B.S. degree in genetics and multiple awards for outstanding research in his field. Next he ventured to Boston, where he attended Tufts University School of Medicine. While in Boston, Dr. Ross took advantage of the Tufts/Northeastern/Brandeis University combined degree program, as well as his merit scholarship, to attain both his Masters of Business Administration (MBA) and Masters of Public Health (MPH). Finally, he returned home to San Diego for his post-graduate training at Scripps/Mercy Hospital. He began specializing exclusively in hair restoration in 2001 and now receives roughly 2/3 of his new clientele from either physician or patient referral.

Because he is married and expecting his third child, Dr. Ross is not afraid to tell people that gardening is one of his passions. He also spends time reading 20th century history and weight training. Dr. Ross enjoys playing and watching most sports and is a Chargers and Padres fanatic. His greatest joy in life, however, is spending time with his family.

Dr. Ross is recognized and/or holds memberships with the following organizations: International Alliance of Hair Restoration Surgeons, American Medical Association, International Society of Hair Restoration Surgeons, American Hair Loss Association, AMA Political Action Committee, Massachusetts Medical Society, Society for Education in Anesthesia, and American College of Healthcare Executives.

I had hair restoration surgery performed by Dr. Wolf in June 2006 (about 1 year ago). I am satisifed with the results, but I am wondering if there is any continuing maintenance I should know about.

I have been using regular shampoo, going in the sun, etc. Are there ways to maximize the results going forward, or things that I might do at this point which could damage the hair?

Also, my procedure concentrated on the frontal hairline. Some of the new hairs are wavy/frizzy. Is there a good way to deal with this?

Answer:

The best was to prevent hair loss of un-transplanted hair is to use minoxidil and Propecia. Minoxidil (Rogaine) now comes in a foam preparation which is much easier to use than the liquid. Propecia is available from us if you aren’t already on it. Sun, dyeing, straightening, all damage the hair after it exits the skin. The best way to treat this type of damage is to avoid the conditions. You can go out in the sun, just use a conditioner to treat sun damage. A conditioner will help with the post transplant kinkiness also. This should be getting better and will continue to improve to a point. Sometimes when it is really humid my transplants are kinky.

-Bradley Wolf, MD
http://www.wolfhair.com
IAHRS Recommended Hair Transplant Surgeon

•Specializes in Follicular Unit Transplantation

•Specializes in Hair Transplant Repair and Reconstruction

•Accepted member of The International Alliance of Hair Restoration Surgeons

•One of less than 50 hair transplant surgeons throughout North America recommended by The American Hair Loss Association

Website: http://www.wolfhair.com
Email: wolf@wolfhair.com

Dr. Wolf has practiced exclusively as a hair transplant surgeon since 1990. He received his Doctor of Medicine degree from Indiana University School of Medicine in 1980, and did his internship in General Surgery at Eastern Virginia Graduate School of Medicine in Norfolk, Virginia, from 1980-1981. He then did his residency in General Surgery there from 1981-1982.

Dr. Wolf is an active member of a number of professional associations, and has lectured extensively on hair transplantation surgery at medical conferences in the U.S., Europe and Russia. He has also trained physicians from Russia, the Czech Republic, Belgium, Ireland, as well as from the United States and has also presented live surgery workshops at medical conferences in the U.S., Europe, and Russia.

Dr. Wolf, who performs microscopically dissected Follicular Unit transplantation surgery, has earned a reputation of being honest, ethical, and dedicated to creating the best results possible for his patients. He is regarded as an expert in, among other topics, the aesthetic aspects of hair restoration surgery. In his lectures he has compared hair transplantation to Impressionistic Painting and Architecture.

Dr. Wolf personally performs all consultations and personally answers all email inquiries. He performs only one surgery per day taking the time to provide custom results based on the patient’s age, hair loss pattern, and expectations. He is one of the few physicians who places most of the grafts himself which allows him to create the best results possible. His surgeries take all day to perform due to his attention to detail and complete involvement in all aspects of the surgery. Up to one third of his practice involves updating and repairing patients who have had outdated procedures performed. He also has extensive experience in transplants of the moustache, eyebrows, and beard.

He is a member of the International Society of Hair Restoration Surgery and the European Society of Hair Restoration Surgery and regularly lectures and the annual meetings of both societies. Dr. Wolf was one of the first surgeons worldwide to become Board Certified by the American Board of Hair Restoration Surgery. He publishes in the Journal of the European Society of Hair Restoration and Hair Transplant Forum International. He was honored as “Surgeon of the Month” and recently featured in “Life Outside of Medicine” in Hair Transplant Forum International. Dr. Wolf’s articles are available on his website at www.wolfhair.com. Dr. Wolf recently authored the chapter “Anesthesia” in the definitive text of hair transplantation surgery.

Dr. Wolf performs surgery in Cincinnati, Ohio and Aspen, Colorado where he is associated with the Aspen Institute of Plastic and Reconstructive Surgery.

Hair repairs are not always necessary. Sometimes patients can learn to use a variety of camouflaging agents, such as makeup to color their scalp the same color as their hair so that the color contrast is minimized, or spray micro-fibers to temporarily fill in the spaces between the plugs. Another trick is perming the hair to give it curl so that the plugs underneath the curls are less evident. Sometimes coloring or actually not coloring the hair can help. By decreasing the color contrast between the hair and the scalp, the plugs will be less noticeable. Jet-black hair on a white scalp shows the worst. By bleaching the hair blonde, there will be much less color contrast against a white scalp. In the opposite manner, letting hair go gray rather than coloring it greatly decreases the contrast. Some patients simply give up and go to hairpieces. Recently, some have tried removing the hair permanently with laser hair removal. Unfortunately, it usually requires numerous treatments, is not necessarily permanent, and it leaves small, round, punch scars behind.

Exposed old-fashioned plugs are the primary reason patients present for repairs. These are my favorite cases. These patients all tell me the same thing. They are tired of watching acquaintances’ eyes dart back and forth between looking them in the eyes and at their hair. It is almost impossible to speak face to face with someone who has had a bad hair transplant without glancing up repeatedly to look at it. Jokes are made in private. For them it is embarrassing. For me it is bad advertising. Nobody notices a good hair transplant, only the bad ones. After seeing a few bad ones, people mistakenly believe that must just be the way hair transplants look. Hollywood certainly capitalizes on bad hair transplants frequently using them as comic relief. My happiest patients, without question, are my hair repair patients.

Hair repairs are not always necessary. Sometimes patients can learn to use a variety of camouflaging agents, such as makeup to color their scalp the same color as their hair so that the color contrast is minimized, or spray micro-fibers to
temporarily fill in the spaces between the plugs. Another trick is perming the hair to give it curl so that the plugs underneath the curls are less evident. Sometimes coloring or actually not coloring the hair can help. By decreasing the color contrast between the hair and the scalp, the plugs will be less noticeable. Jet-black hair on a white scalp shows the worst. By bleaching the hair blonde, there will be much less color contrast against a white scalp. In the opposite manner, letting hair go gray rather than coloring it greatly decreases the contrast. Some patients simply give up and go to hairpieces. Recently, some have tried removing the hair permanently with laser hair removal. Unfortunately, it usually requires numerous treatments, is not necessarily permanent, and it leaves small, round, punch scars behind.

For those patients willing to undergo hair repair surgery, the results can be dramatic. If the “plugginess” is not too great and good donor hair remains, the simplest maneuver is to pack follicular units tightly between the old plugs so that when the when the new transplant grows, the plugs will be less noticeable. Depending on the case and the quality of the hair, this could take one to three sessions to fully hide the old plugs.

If this is not an option, things become a little trickier. In these situations, the plugs must be entirely or at least partially removed and then recycled into new follicular units. In this way, I am simultaneously decreasing “plugginess” and creating new follicular units. To remove the hair from the plugs, various sized small, circular, cookie-cutter type instruments called punches are used. The original plugs were probably implanted in punch holes. These punches range in size from 1 to 4 mm in diameter and can be used to remove a core of the plug. The entire plug can be removed, but often I just remove the majority of the plug. By removing the majority but leaving behind small strands of hair, one can recreate the look of normal follicular units at the margins of the punch removal. After the punch is removed from the plug, the resulting small hole may be closed with suture. This does change the scar from the previous small circle to a small line, but after healing this is hardly noticeable.

In most cases, after the new transplant grows in, the small scars are not evident at all. The hole left from the punch does not have to be sutured shut, however. In tight scalps, there is not enough laxity to close many small punch holes simultaneously. If these are left open to heal, it takes approximately a month for the hole to fill in, but the results are usually good this way also. The final scar will be a small, whitish circle the same size as the punch used to create it. If the plan is to punch remove the unattractive plugs , the patient must be warned that, over the short term, his scalp will look worse than before surgery since I am removing hair that will not regrow for three to five months and leaving behind sutured or open punch holes which take time to heal. Patients must think about the long term payoff. Having said this, actually a fair number of patients think they look better immediately after surgery because the “plugginess” is gone. Each hair repair case is different and patients are warned that it may take multiple sessions to obtain a natural appearance. In some particularly bad cases, completenaturalness may not be obtainable, but significant improvement should be.

-Content Provided By Blaine Lehr, MD
Web: http://www.norwood-lehr.com
Email: lehr@norwood-lehr.com
IAHRS Recommended Hair Transplant Surgeon

Another factor to consider when contemplating a transplant is the final thickness of the transplant. Despite some advertising, a single transplant does not give full
thickness. Only someone with coarse, curly hair may look like they have close to full thickness after a single transplant. For someone with average hair, and, in fact, even for many with coarse, curly hair, higher densities will only be reached by re-implanting this same area at a later time. I prefer to wait a minimum of six months before re-transplanting this same area for several reasons. First, I like to be able to be sure we are implanting the second series of follicular units between the first set and not on top of them. Second, the sutured donor site will be well healed at this time and, hopefully, the surrounding scalp will be relaxed so that I can harvest a strip with good width on the second excision. If they are willing, I encourage my patients to wait a full twelve months before deciding about a second transplant. Many patients who give it this extra time realize that by letting the transplant get some length to it and by styling it in certain ways, they actually do not need another transplant. Although it is not full thickness, it looks good. They realize they just needed some, not all, of their hair replaced.

Depending on the nature of the hair and on how closely the follicular units are spaced during planting, the patient probably will require two to three transplants, at least, to take a balding area and give it the impression of full thickness. I say “impression” because it has been shown that we do not require our original density of hair to look like we have full thickness. If I took a scalp that had no previous hair loss and started plucking individual hairs, I would have to remove approximately 50% of the hairs before it would start to look like it was thinning.

Sometimes, looking at the density issue mathematically is helpful. In my experience, the majority of men have approximately 70 to 80 follicular units per square centimeter in the donor area. These are dissected down to individual follicular units and then re-implanted into the recipient area of the scalp. The average number of follicular units per square centimeter in the recipient area after transplantation is usually around 20, although at times we will make it much denser. The density in the transplanted area after regrowth then is approximately 25% full density (20 being 25% of 80). However, as noted above, if the patient can get
approximately 50% of the original number of hairs transplanted, then he may begin to look like he has full density. All of this is a gross generalization. Many factors influence how closely the follicular units can be packed during transplantation, and the packing density of 20 follicular units per square centimeter is not necessarily used throughout the entire transplanted area or in every scalp.

A look at the math is also helpful in dealing with the distribution of the transplanted hair. Many patients hear me refer to thousands of follicular units and mistakenly assume that more of the scalp can be covered then is realistic. Before the average person begins to lose hair, he has approximately 100,000 hairs on his scalp. Using an easy number to work with, if I move 2000 follicular units during a transplant, this means that I am actually moving about 5000 hairs on average. I get 5000 by multiplying the 2000 follicular units by the average number of hairs in a single follicular unit, which is approximately 2.5. Thus, if a very large transplant is performed with 2000 follicular units, in reality I am only moving 5% of that patient’s original volume of hair (5000 being 5% of 100,000). In most cases, the balding area in advanced stages of male pattern baldness will exceed 50% of the scalp. Thus it becomes obvious that moving 5% of a patient’s original volume of hair, even three separate times, will not yield enough to give full coverage. That is just another reason why I stress to the patient that I need to make sure that the front looks good first.

-Content Provided By Blaine Lehr, MD
Web: http://www.norwood-lehr.com
Email: lehr@norwood-lehr.com
IAHRS Recommended Hair Transplant Surgeon

These days, many balding men choose to go to the other extreme and shave their scalps. I caution patients not to have a transplant if they are considering this because the transplant will leave a fine, linear scar in the back where the donor strip was repaired. Similarly, if the patient wants to keep his hair so short (burr-type cuts) that someone could see through the hair to the scalp, then I warn him that he should expect that the donor scar will likely show through in the back. This is an especially common problem for those in the military. On the other hand, if the patient wears his hair long enough that someone cannot see through to the scalp, the donor scar should not be apparent unless someone is picking through his hair.

With previous forms of transplants, such as minigrafts, repeat procedures were often necessary to hide the resultant “pluggy” appearance. With follicular units, this does not tend to be the case. However, depending on the area of the scalp the follicular units are moved to, additional procedures may be necessary for continued balding (a strong argument for the anti-balding medications) or for additional thickness. I will discuss more on the thickness available with transplants momentarily.

Right now I want to concentrate on the distribution in the recipient area. The patient must be cognizant of how his transplant might look in the distant future as he continues to bald. The transplanted hair is permanent hair, which should not be susceptible to the hair loss associated with normal male pattern baldness. If someone reaches seventy to eighty years of age, he may notice a generalized thinning of all of his hair. This is termed senile alopecia and is unrelated to male pattern baldness. Otherwise, the patient should expect to keep the transplanted hair permanently. This means that when designing a transplant, the surgeon must plan a mature hairline, one that looks normal no matter the patient’s age. Many men, especially the younger ones who see their friends’ low hairlines, will complain that these mature hairlines are too high for their liking. Unless they can find a medicine that stops their hair loss, they cannot forget about the inevitable progression of male pattern baldness.

Even if someone does find a medicine that works, there is no guarantee that it will always work or that the patient will not later develop side effects necessitating the discontinuation of that medicine. The more conservative the patient is willing to be with his hairline, the better. The hairline can always be brought further down at a later time, but the reverse is not true. If the transplant is performed throughout the front and top of the scalp behind a mature hairline, future procedures may not be necessary even as the patients continues to bald. It is very normal in nature to have somewhat of an isolated frontal forelock. If, however, the transplant is performed in isolated areas such as the sides of a receding hairline, one could imagine that it would be very necessary to have additional procedures performed behind the original transplant if the preexisting hair continues to disappear.

In my opinion, it is much, much, cosmetically more beneficial to concentrate initial procedures on the front and top of the scalp rather than the back (vertex). There are some sizeable, potential pitfalls associated with working in the vertex area. From a purely aesthetic standpoint, making the front and the hairline look good is much more helpful then filling in the vertex. There are plenty of men who hate their bald spots in back, but the greatest benefit from a transplant comes with the framing of the face by the hairline and the hair immediately behind it. What we see when we talk face to face with someone is many times more important then what we see when we are sitting behind him. I am repeating this one more time for emphasis—the patient should not even worry about the back before he has the front and top looking good!

Perhaps the greatest risk with performing transplants in the vertex area is the possibility of continued hair loss if medicines are ineffective or not used. If the bald spot in back is filled in, as the patient continues to bald, he will develop a doughnut or halo-shaped area of bald skin around the transplant. This never looks normal. It must be remembered that as the halo enlarges, the donor area is simultaneously diminishing. The patient will naturally feel compelled to return for transplants to fill in the bare area around the transplanted vertex, but he will eventually run out of hair to move. In addition, the more he moves to the back, the less he will have available to move to the front or top if he wants to later (and believe me, he will want to move it there if the hair in front and on top disappears).

There are several ways around this problem in the back if the patient is realistic. One is to diminish the size of the bald spot by transplanting in a crescent shape. If the patient does bald around this, it is much easier to keep up with the bare areas since the surgeon would just be replacing hair lost on the sides. Another option is to only transplant the vertex in a thinning rather than a thick fashion. This way, if the halo develops, it is a not as noticeable and it would take less hair to keep any new areas of hair loss filled in a similar thinning manner. The best option is for the patient to just not worry about the vertex. Instead, he could style his hair so as to comb it back over the bald spot. A few hairs can easily be placed into the bald spot to simply act as anchors for the hair combed back into it.

-Content Provided By Blaine Lehr, MD
Web: http://www.norwood-lehr.com
Email: lehr@norwood-lehr.com
IAHRS Recommended Hair Transplant Surgeon

First and foremost, the person considering a transplant must determine whether his expectations are realistic. Most men assume they will be able to have their baldness filled in entirely. If someone has a few small areas to repair, that is possible, but if someone’s balding is advanced, he probably will not have enough hair to donate to fill in all of the areas. It must be remembered that we are rearranging hair, not creating new hair. On occasion, I suggest to patients in consultation that with their high levels of expectation regarding the amount of hair they will need to be happy, that they should probably purchase a hairpiece instead of a transplant.

How much coverage someone can expect is dependent on several factors. Not surprisingly, the greatest is the degree of hair loss. A person with advanced balding (Norwood type V-VII) should probably not expect to have all of the areas of hair loss transplanted. Also of paramount of importance is the quality of the donor hair. The greater the caliber of the hair shaft and the greater the curl, the better the results will be.

A patient with large caliber, wavy hair may appear to get double or triple the coverage compared with someone with very fine, straight hair if the same number of follicular units are moved in each patient. Obviously, the number of follicular units moved and the number of sessions will play a role in the amount of coverage. Single transplant sessions of 2000 to 3000 follicular units are now the norm in many clinics. Other variables include the density of the donor hair (the greater, the better, of course) and the laxity of the scalp. After each session, the area where the donor strip is removed is sutured shut. In most men after a transplant, the skin in the donor area of the scalp gradually relaxes. If that patient still has adequate donor hair, additional strips can be removed and again sutured. Unfortunately, after transplants in some men, the back of the scalp starts to become tighter, making subsequent excisions and repairs limited or impossible. Finally, the patient’s age must be taken into consideration.

-Content Provided By Blaine Lehr, MD
Web: http://www.norwood-lehr.com
Email: lehr@norwood-lehr.com
IAHRS Recommended Hair Transplant Surgeon

Minigrafts consist of 3 to 10 hairs while micrografts consist of 1 to 2 hairs. These grafts are cut without regard to maintaining the integrity of the follicular units. Follicular units are routinely broken apart during the naked eye dissection. Graft sizes are determined strictly by the size of the recipient holes being placed in the scalp. Generally, a small plug is removed leaving a hole behind or a stab incision is made with a scalpel blade. The grafts are then sized to match the size of the hole in the scalp.

Mini and micrografting is a much better method of transplantation than the large plugs that proceeded them, but it still has the same problem of giving a “pluggy” or “corn row” appearance. Additionally, an occasional patient will not have good growth after such a transplant. Most transplant surgeons still utilize this technique, although they may call it by a different name. It is a much quicker and simpler procedure from the transplant surgeon’s perspective.

Fortunately, more and more hair transplant clinics are beginning to convert to the follicular unit transplantation method exclusively. This may, in part, be due to better educated patients. There is no question that it is a long, tedious, and labor intensive procedure, but the results are so good that once the surgeon has made the difficult transition from mini and micrografts to follicular units, he will not go back. It is only common sense to move the hair in the same units as it started. And it only makes sense to microscopically enhance the dissection process to make sure that it is done with minimal damage to the roots.
With follicular unit transplantation, the single hair units are sprinkled in the front of the hairline followed successively by the 2, 3, and possibly 4 hair units. This recreates the natural density gradient found in balding men without creating “plugginess”. Additionally, using this technique, it is extremely rare for the patient to experience anything but great growth. When patients are adequately educated, it is difficult for them to ever consider mini and micrografts again. It is also telling that the vast majority of transplant surgeons who now have transplants done on themselves have it done with follicular units. No matter how the hair is combed, styled, or cut, and no matter from what angle it is viewed, even if it is wet or windy, there should not be a “pluggy” appearance. It is hard to imagine someone settling for anything less.

Several arguments have been brought to bear on follicular units by surgeons not performing them. One is the claim that minigrafts give more density. The fallacy of this argument can be approached from two directions. First, if they believe that minigrafts give more density than follicular units simply because each graft has more hair, then why are they not utilizing the old-fashioned 4 mm plugs? These 4 mm plugs could have 20 to 25 hairs in a single graft as opposed to the 3 to 10 hairs in a minigraft. It is because they know that if they transplant 3 or 4 minigrafts, they are actually transplanting the same amount of hair as a single 4 mm plug, but with less “plugginess”. The logic of using 2 or 3 follicular units instead of a single minigraft is no different.

Second, if a strip of hair was removed from a scalp and half of it was dissected into minigrafts and half was dissected
into follicular units, the same amount of hair would be removed and dissected with each method. The only difference (excluding the fact that the minigrafts were not dissected with a microscope) would be the size of the grafts and thus the potential for “plugginess”. The same number of hairs would be transplanted either way.

The only instance their argument has any merit is if only a small area is being transplanted. If the same number of minigrafts and follicular units were transplanted into a small area side by side, the minigrafts side would likely grow with more density (in addition to more “plugginess”). But if the patient is only interested in density or if the caliber of his hair is very fine, there is nothing in the follicular unit “rule book” that says that follicular units must be cut as single units. It is even easier for the technicians to dissect them into 2 or 3 follicular unit grafts rather than single follicular units. That produces the same size graft as the minigraft without the potential disruption of the individual follicular units.

The other common argument made against follicular units is that the great number of follicular units implanted in large cases may overwhelm the scalp’s ability to heal and result in poor growth. The scalp is an extremely vascular area as we all know after watching scalp wounds bleed. It is more than capable of accepting large numbers of transplanted grafts in a single setting. Follicular units are planted in holes made with needles smaller than needles used to draw blood with. Thus, there appears to be less damage to the scalp compared with the damage caused by the holes formed for the minigrafts.

When larger grafts are transplanted, it is not unusual to find a doughnut-pattern of growth where the central hairs have died because they were not adequately oxygenated by the surrounding tissue. Common sense dictates that the smaller the size of the graft, the less of a problem this would be. I have never seen a scalp’s ability to heal be overwhelmed by a large session of follicular units. I always hesitate when I use the word “never”. I am sure it could happen with poor technique, poor judgment, or with scalps with significant scar tissue. But it has not been my experience.

Another advantage to follicular unit transplantation is that noticeable scarring in the recipient area is extremely rare. The smaller recipient sites made with needles for follicular units are much less likely to show visible scarring when compared to the sites made with punches and scalpel blades for minigrafts. There are frequent problems known as “cobblestoning” and “dimpling” associated with minigrafts. As the names imply, “cobblestoning” is scar formation protruding above the skin and “dimpling” is the reverse. The shadowing created by these scars can be very difficult, if not impossible, to hide. The only way to correct it is to keep adding grafts around the scars in subsequent sessions.

The risk of “plugginess” with minigrafts cannot be over emphasized. It is very common for men to get locked into a slow cycle of repeat procedures to try and hide the resultant “plugginess” of previous procedures. This may continue until the patient runs out of donor hair. On the other hand, repeat procedures are not necessary to hide “plugginess” with follicular units since there should be none evident.

Content Provided By Blaine Lehr, MD
The Dermatology Clinic Inc.

Web: http://www.norwood-lehr.com
Email: lehr@norwood-lehr.com
IAHRS Recommended Hair Transplant Surgeon

A scalp may be divided roughly into two separate areas. One is the area susceptible to balding and the other, of course, is the area not. The horseshoe fringe of hair left behind on a bald man’s scalp is the area from which hair can be safely donated. Hair transplanted from this area of the scalp will not be susceptible to balding even when it is placed right in the middle of the bald scalp. This new hair maintains the same characteristics of the hair left behind in the donor area no matter where it is transplanted to the scalp. This is what is meant by donor dominance.

Multiple methods may be used to harvest this donor hair. In the early days of hair transplantation, the hair was removed in 4 mm plugs about the size of a pencil eraser. Multiple plugs were removed simultaneously and the area was allowed to heal in by itself. Although the healing areas were messy the first week because of the weeping from the open wound, the areas tended to heal well. The primary problem was the cobblestone scar pattern left behind. Eventually the plugs were taken out in rows so that the edges could be sewn together.

This led to the idea of excising strips of tissue rather than plugs. The open area left by the strip was more easilysutured together. As the grafts that were transplanted became smaller, physicians began to use multi-bladed scalpels. With a single pass of a multi-bladed knife, they could produce multiple, thin strips facilitating the quick dissection of grafts. Now, since the advent of follicular unit transplantation, many physicians will excise the strip with a single scalpel blade in order to minimize the transection of the follicular units. Most follicular unit proponents feel that the transection rate with a multi- bladed knife is unacceptably high and could lead to reduced growth of the transplanted hair.

In regards to the recipient area, during the early days of hair transplantation, the 4 mm plug removed from the back of the scalp was then simply implanted intact into the balding area in the front of the scalp. This certainly gave volume to the thinning hair but at the unacceptable price of extreme “plugginess” as the remainder of the preexisting hair eventually disappeared. Grafts were gradually down-sized to quartered 4 mm plugs and then to minigrafts. Minigrafts are small plugs of hair containing 3 to 10 hairs each. They are produced by cutting the excised strip or strips down to smaller sizes without magnification and without regard to follicular units. This certainly reduces the harshness of the “plugginess”, but by no means does it remove the problem entirely. Instead of fewer, big plugs, there are numerous small plugs. Micrografts were developed to hide this “plugginess” in the hairline. Micrografts consist of 1 to 2 hairs dissected without magnification and without regard to the follicular units. These are a tremendous aid in helping to disguise the artificiality of minigraft hairlines.

Follicular unit transplantation was the next major milestone in hair transplantation. A follicular unit is the natural unit hair grows in on the scalp. If the scalp is shaved and magnified, the follicular units are evident as the 1 to 4 hair groupings exiting the scalp from single points. Each individual follicular unit has a single root system. Follicular unit transplantation is defined as the dissection underneath a microscope of the individual follicular units followed by the implantation of these single units into the balding area. Emphasis is placed on not disturbing the root systems while dissecting the 1 to 4 hair grafts. A microscope is required for the adequate visualization necessary to avoid transection of the follicular unit root system. Since these 1 to 4 hair grafts are transferred individually, there should be no “plugginess”.

The recipient site in the front or top of the scalp must be prepared to accept the various forms of grafts. The recipient site for the 4 mm plugs was simply a similar-sized hole created with a punch. A punch is a small, circular, cookie-cutter type knife that creates tiny, circular holes in the skin. The recipient sites for minigrafts are made with either scalpel blade incisions or small 1.5 to 2.0 mm punches. Lasers have been utilized to create recipient sites for minigrafts to no great advantage, but certainly at greater costs. The recipient sites for follicular units are made by inserting small needles into the scalp to create tiny holes.

The implanting of the grafts is considered the most technically difficult portion of the procedure. As the grafts have become smaller, the skill required to gently insert them with a fine pair of forceps (tweezer-like instruments) has greatly increased. These grafts must be grasped and inserted without traumatizing the tissue, or poor growth is risked. This gentleness combined with the close-spacing of the grafts makes a planter with good hands, patience, and a sense of perfectionism, critical.

But does it hurt? The skin of the donor and recipient areas is anesthetized with local numbing shots. Most surgeons will either have their patients take pills to help them relax, such as Valium or Xanax, or inject medicines intravenously to put them to sleep before beginning the numbing shots. Although the intravenous medicines sound appealing since the patient is asleep, the patient and the surgeon must assume an increased level of risk. It is possible for the patient to stop breathing for himself, and monitoring equipment is required to check the patient’s status. The risk of severe complications seems to be quite small, but from a personal standpoint, that risk is not justified in my patients. In no way am I suggesting that the use of I.V. medicines is inappropriate. It is, simply, my experience that a patient who has taken something orally to help him relax and who is treated with gentleness and care does just as well, without the increased risk.

Various agents can be applied to the skin prior to the injections to reduce the sensation of the needle stick. Injection techniques such as tumescent anesthesia and nerve blocks further facilitate patient comfort. Tumescent anesthesia involves the injection of dilute anesthetics into the deeper, fatty tissue first. The fatty tissue is far less sensitive to injection pain than the skin. After it has been numbed, the skin injections are much less tender. Nerve blocks involve the injection of anesthetic around the bases of the nerves that supply the front of the scalp. These are located right above each eyebrow. Once the bases of these nerves are numbed, work in the central-frontal scalp is painless. The primary reason injections anywhere on the body hurt is due to the anesthetic being pushed into the skin too rapidly because either the person performing the injection is impatient or uncompassionate.

But, again, does it hurt? My answer is that if the procedure is performed by an experienced, gentle, and caring surgeon, it will hurt very little. After almost every procedure, I hear the same thing, “If I would have known how easy this was, I would have done it a long time ago”. On the other hand, if the surgeon lacks these qualities, (whether done under I.V. sedation or not) yes, it can hurt.

Very few hair transplants are performed by the physician alone. With the advent of minigrafts, and then, especially, follicular units, the amount of work required to prepare and implant the grafts has increased logarithmically. Surgeons working alone would only be able to perform small follicular unit transplantation sessions. Most surgeons plan the procedure, perform the excision and repair, and then oversee a team of technicians who dissect the grafts and then implant them. In my office, a typical follicular unit transplantation session will take six to ten hours and require four technicians, two dissecting and two planting. During the majority of the procedure, the patient relaxes in a reclined position. He may pass the time by watching television or movies, listening to music, chatting with the staff, or simply napping.

After the transplant is completed, bandaging of the head is usually unnecessary. On occasion, if a patient is oozing a little from the donor area, a bandage will be applied like a headband for several hours. Patients leave wearing a baseball cap to hide what has been done. Sutures or staples are removed in about ten days from the donor area. There are no sutures in the recipient area.

The transplanted hair shaft typically falls out during the first month after surgery. The root system is still present just as if the hair had been plucked. The new hair starts to grow in three to five months. This transplanted hair is now permanent hair not susceptible to the progressive nature of male pattern baldness. This hair may thin out when the patient reaches seventy to eighty years of age, but this is a general thinning known as senile alopecia which causes hair over the entire scalp to begin to disappear. Otherwise, the new hair is permanent. The transplanted hair occasionally grows in a little kinky and coarse during the first year, but it will ultimately appear just like the hair in the donor area. It will grow and need to be cut probably more frequently then any surrounding miniaturized preexisting hair. It can be colored and styled any way the patient likes. If another transplant is desired, usually I will ask my patients to wait a minimum of six months so that I will know where the new growth is and I can transplant between the previous grafts.

-Content Provided By Blaine Lehr, MD
Web: http://www.norwood-lehr.com
Email: lehr@norwood-lehr.com
IAHRS Recommended Hair Transplant Surgeon

- Accepted member of The International Alliance of Hair Restoration Surgeons

- One of less than 50 hair transplant surgeons throughout North America recommended by The American Hair Loss Association

Website:http://www.norwood-lehr.com
Email: lehr@norwood-lehr.com

Perhaps the greatest compliment and best introduction to Blaine Lehr, M.D. is a statement from O’Tar Norwood, M.D., one of the true pioneers in the field of hair transplantation (creator of the Norwood Baldness Scale, author of 1st two textbooks of hair transplantation, cofounder of the International Society of Hair Restoration Surgery, founder of the Hair Transplant FORUM International, and recipient of two of the highest awards—Golden Follicle Award and Manfred Lucus Award).

Before he retired, Dr. Norwood stated, “Over the last 30 years, I have been associated with, worked with, and in fact trained many of the other leading hair transplant surgeons in the world. As the demand for my services increased , I knew I needed an associate, and I knew because of my reputation, I could choose anyone. I did not want to sell out to one of the large nationwide franchises. You have no control over their integrity or the quality of their work. I first began working with Blaine in 1993. I recognized his natural ability immediately. Just as importantly, I found him to be honest in all circumstances. He is a hair transplant surgeon of the highest quality”.

Dr. Lehr now runs the Norwood and Lehr Hair Transplant Clinic in Oklahoma City where they utilize 100% microscopically dissected follicular units. At the N & L Clinic the patient is never sold to or pressured. Dr. Lehr stresses thorough education and understanding for his patients. He is completely up front about the positives and negatives of hair transplants in general, and an individual patients characteristics (degree of balding, caliber of hair, goals, and finances) in particular. Dr. Lehr believes in keeping prices very reasonable so that almost all interested patients can afford the opportunity to look better.

He has authored a book “Understanding Hair Transplants-A Simple Guide to Help You Learn What You Need to Know” which is available on Amazon.com and BarnesandNoble.com or free to prospective patients. Spencer Kobren’s review states, “Understanding Hair Transplants empowers the prospective patient with the knowledge to make an educated decision when considering surgical hair restoration. Dr. Blaine Lehr provides us with the tools to navigate through this confusing, and sometimes misleading field of medicine. This book is essential reading for anyone seriously considering hair transplantation.”