CONCEPT BEHIND HAIR TRANSPLANTS
If you look at any balding man you will notice that he never goes bald on the sides or the back of his scalp, we call this his “hair bank”. We can take this hair and transplant it anywhere and it will usually grow forever. This is what we call “Donor Dominance”. If you transplant hair from a certain part of the body it will always grow like it did from the original donor site. In a hair transplant, we just take hair from the patient’s “hair bank” and transfer it to the balding area. For a balding man seeking a transplant, his most precious commodity is his donable “hair bank.” We are now able to make smaller incisions, which enables us to pack the grafts closer together to give a denser, more natural look.
There are two innovations that have revolutionized hair transplants. The first is transplanting each individual natural grouping of hair as a unit and the second is the use of the stereoscopic microscope to dissect the hair to be transplanted into follicular units.
Hair does not just come out of the scalp individually, one by one, but actually grows naturally in groups of one to four hairs with a fibrous sheath surrounding the group. Since that is how God designed everyone’s scalp, that is how I perform a hair transplant. I transplant the single hair grafts on the hairline and the natural groups, with three and four hairs, farther behind for density. The benefit of transplanting individual, “natural hair groupings” is the completely natural look I achieve and the higher survival rate of the transplanted grafts.
To try to obtain a natural look, many doctors now perform transplants with what is called “single hair micro grafts.” They separate the “natural hair groupings” into single-unit hair grafts and transplant the hairs individually. By separating the natural groupings of hair, the transplant surgeon is going against nature. A study published in the Journal of Dermatologic Surgery showed that the survival and quality of these grafts markedly decreases.
The stereoscopic microscope is probably the most important innovation in hair transplants. The “natural hair groups” must be preserved intact during dissection to insure increased survival and growth. Many doctors dissect with the naked eye or with minimal magnification. That leads to increase transection and destruction of the hair. When dissecting the donor hair without the stereoscopic microscope it is nearly impossible to ensure that the “natural hair groupings” will remain intact.
For a balding man seeking a transplant, his most precious commodity is his donable “hair bank.” The use of the “stereoscopic microscope” to dissect the grafts enables me to visualize each and every individual “natural hair grouping.” By using the “stereoscopic microscope” the trauma to the surrounding hair is greatly reduced and our patients receive superior quality grafts with a much higher incidence of survival. I can now achieve survival rates of 95 to 100 percent, as compared to other techniques where the survival rate is much less. The “stereoscopic microscope” also enables us to trim excess tissue away from the hair follicle, therefore, smaller incisions can be made, which enables us to pack the grafts closer together to give a denser, more natural look.
STRIP VS. FUE
Comparing Strip Excision Follicular Unit Hair Transplants to FUE (Multiple Punch Excision) Hair Transplants
There are four main segments to the hair transplant process. The extraction of the donor hair via-
Punch Excision (i.e.-FUE [0.8-1.25mm punch excisions] and how hair transplant first started in the 1950’s with 4-5mm punch excision or strip excision
The dissection/trimming of the donor hair (No longer performed)
The making of the recipient incisions
The planting of the grafts into the recipient incisions
The only difference between strip excision hair transplant and FUE (more accurately described as Multiple Punch Excision [MPE]) hair transplant is how we extract the tissue out from the donor area. Steps 2 through 4 are the same. Both techniques have their strengths and weaknesses; therefore, it is very important to know this and use the appropriate technique depending on the patient and the circumstances.
The advent of FUE Hair Transplants has brought about a lot of very unethical marketers, doctors and non-doctors, and companies that have very little knowledge of the pathophysiology of hair loss and even less knowledge of the art of hair transplants. Unfortunately, they are making claims that are outright lies and mistruths!
Claim- “FUE hair transplants are scar-less”. This is a claim that is commonly made by doctors who have purchased the Neograft punch excision machine who commonly have had no prior experience in the field of hair transplants so they many times allow an unlicensed technician perform the surgery for them.
Truth- This is absolutely false. The punch excision tool used to perform FUE has been used by dermatologist for a century and we know it creates scars for the last century. A 1mm punch excision tool used in FUE creates approximately a 1.2 mm white circular scar. In the 1950’s, hair transplants got its origins in the United States from this 4-5mm punch excision tool.
Claim- “FUE Hair transplant is non-surgical and incision-less”.
Truth- This is absolutely false. Every form of hair transplants is surgical and involves incisions (i.e.- the cutting of tissue). In matter of fact FUE hair transplants creates over ten times the surface area of incised tissue as strip excision follicular unit hair transplants. There is much more cutting of tissue with the FUE technique.
Claim- “FUE Hair transplants are painless”.
Truth- This is absolutely false. Any form of hair transplants has to have local anesthesia which involves a certain degree of discomfort. Many times, FUE hair transplant involve much larger area of donor area removal in order to spread out the scar tissue; therefore, the discomfort would be greater since a greater area would have to be anesthetized.
Claim- “Strip surgeries create spread scars”.
Truth- Strip excision follicular unit hair transplants typically create very thin linear scars that even short haircuts hide and are hard to find. The biggest risk of a spread scar is when a doctor takes out too wide of a strip and closes the wound under tension. This is typically caused by doctors performing “mega-sessions” since they typically need to take wide strips to meet the number of grafts. Stopping mega-sessions hair transplants will prevent most patients from getting spread scars.
Short term and long-term pros and cons of a patient with #2,000 graft FUE/Punch excision hair transplant versus a #2,000 graft follicular unit hair transplant via a strip excision.
Short Term Pros Short Term Cons
No need for sutures Scalp needs to be shaved completely resulting in having no hair to hide the healing process
Takes weeks sometimes months for the hair to regrow to hide the #2,000 healing punch holes
Much more surface area of donor scalp exposed to surgical cutting/excision—i.e.-more trauma to the donor area
FUE- #2,000 grafts of punch excisions
Short Term Pros Short Term Cons
No need to shave the scalp so the donor site and sutures is hidden the day you walk out of surgery The donor site needs sutures that are removed in 1 week.
Long Term Pros Long Term Cons
Patient will not have a linear scar The patient will have 2,000 1.2mm circular scars which equates into 2,400 mm² of scar tissue to the donor area. Strip excision for 2,000 grafts typically creates a 1mm x 200mm linear scar which equates to 200mm² of scar tissue. Therefore, there is approximately 12 times more scar tissue with FUE/punch excision technique
In order to spread out this increased amount of scar tissue, many doctors punch excise hair outside of the boundaries of where the good genetic hair is. Therefore, those grafts are only temporary and will eventually miniaturize and go away.
FUE/Punch excision technique exposes each graft to “blind dissection” which means the doctor cannot see through the tissue he is cutting with the punch. Therefore, he does not know if he has transected and destroyed the hair follicle until after it is already done. Transected hair follicles have much poorer survival.
With much more surface area of scar tissue it can lead to the donor area looking “moth eaten” if over-harvested.
FUE- thousands of punch excisions
Long Term Pros Long Term Cons
Much less surface area of scar tissue than FUE/Punch excision technique Will have a linear scar- however this should easily be hidden by even short haircuts and hard to find
Can dissect the strip tissue under the stereoscopic microscope in order to have full visualization while dissecting the hair follicles, as opposed to blind dissection. Being able to fully visualize the hair while dissection gives greater ability to decrease the transection rate of the grafts which increases the survival of the grafts. At an increased risk of a spread scar if the surgeon tries to take out too much tissue in order to do a mega-session. Solution – don’t let your surgeon perform a mega-session hair transplant. You can always do another hair transplant tomorrow, but if you deplete the donor area you won’t have enough in the “hair bank” to do so in the future.
Can remove the tissue from the area of the best genetic hair
HAIR TRANSPLANT LIMITATIONS
Male pattern baldness (androgenetic alopecia) is a progressive disease that worsens with aging. The cosmetic, medical, and surgical treatments have evolved greatly over the last several years. Unfortunately, there is still no perfect solution in the treatment of hair loss. Nonetheless, today’s hair transplantation procedures are far superior, and should ultimately be undetectable.
Unfortunately, there are limitations to today’s hair transplantation technology. The most significant limitation is that each patient only has a fixed amount of good genetic hair on the sides and the back of the scalp available for transfer to the balding areas.
With the limitations in mind, we as physicians need to focus on 3 very important areas when performing a hair transplant:
When performing hair transplants, we need to ensure the highest percent of grafts survive for continued growth after transplantation.
The worst thing a hair transplant surgeon can do is waste part of the very limited “hair bank” of a balding patient (i.e.- having the hair grafts not survive due to poor hair transplant technique, improper trained hair transplant physicians or technicians, or automating the hair transplant process).
Hair transplant surgeons should use only those techniques and technologies that ensure the highest percentage of survival of the grafts, and should avoid those techniques and technologies that damage or decrease the viable hair in the “hair bank”
We need to use the very limited donor hair wisely when performing hair transplants.
The utmost focus should be to “use up” as little of the “hair bank” as possible during the hair transplant. The focus should be about making the patient happy and not about how many hair grafts the doctor can transfer as quick as possible during a single session. (Haste makes waste!).
Aesthetically, the most important area to have hair is the frontal forelock because it frames the patient’s face and maintains a youthful appearance (Figure A).
Having hair in the frontal forelock with a balding vertex is a natural balding pattern. In an extensively balding young male, the limited amount of good genetic hair should be reserved for transplant to the frontal forelock and the mid-forelock. The hair in the frontal forelock is typically the last hair to miniaturize during the balding process. This can present a dilemma in a young patient experiencing androgenetic alopecia because many times he desires to use his limited amount of good genetic hair to solve his acute problem (i.e. – his vertex or the fronto-temporal triangle).
Transplanting into the vertex will solve the immediate problem for this balding male. For the next several years, this patient will be happy with his newly acquired hair in the vertex. However, when his existing hair in his frontal forelock and mid-forelock miniaturizes, (leaving him with a very unaesthetic result), he might regret the decision to transplant his limited good genetic hair to his vertex. Unfortunately, at this point the patient will not have enough good genetic hair to create a natural balding pattern in the more important frontal and mid forelock areas. The original procedure solved an acute problem in the vertex, but in the long term it limited the patient’s ability to have further transplants. (Figures B, C, D)
Transplanting hair in the vertex of a young male is not a wise use of the very limited good genetic hair and it is prudent to refrain from such transplants. Patients with such issues should be placed on the medical therapies, Propecia (finasteride) or Minoxidil.
Before puberty many men do not have fronto-temporal triangles (Figure E), but by the age of 25 the overwhelming majority of men have developed these triangles (Figure F). It is a very natural balding pattern as men age. However, it can be very disconcerting for the young male, because it is usually the first sign of balding.
Hair transplant surgeons should also refrain from transplanting hair into the fronto-temporal triangles because it will eventually create a very unaesthetic and unnatural balding pattern. An immature hairline will not naturally frame the face of on aging and balding man. As shown in Figure G, the patient began to lose hair in the fronto-temporal triangles. Figure H shows that hair has been replaced through hair transplants. Figure I shows how those grafts will not look natural as the patient ages and the hair loss continues to progress.
The donor area (i.e. – the hair bank) along the sides and back of the scalp has a very limited amount of good genetic hair. It has been reported in the literature that there is 125cm² of good donor area in the average male. If half the donor area can be removed without it being noticeable, this would yield approximately 6,250 follicular unit grafts if the density in the donor area is 100 follicular units/cm². However, for many men, this number is awfully optimistic since other reports in the literature state there are approximately 80 follicular units per cm² in the donor area.
In my practice, the average male has 200cm² to (many times over) 300cm² of balding scalp. In order to cover this area at 50% density (i.e. – 50 follicular units/cm²) with all follicular unit grafts, it would take 10,000 to (over) 15,000 follicular unit grafts to achieve this goal. This would decimate the “Hair Bank” 2-3 times over. These numbers exemplify the striking limitation the hair transplant field has and stresses the importance of the medical of therapy.
We need the help from medical forms of therapy
The below scenario exemplifies the need of assistance from the medical therapies for hair loss. If a patient with 30% density of hair came to a hair transplant surgeon with the desire to create a look like he had a full head of hair, the hair transplant surgeon would need to add approximately 20% density. (Studies have shown that the human eye cannot tell a person is balding until the person has lost over 50% of his density. Therefore, we only need to achieve approximately 50% to achieve a full head of hair.)
The patient’s goal could probably be attained; however, with the progressive nature of male pattern baldness, the patient’s goal eventually could not be maintained. The average male experiencing male pattern baldness loses approximately 4% density a year. After 5 years his 30% existing density will now be at 10% and the transplanted 20% density will probably still be there— therefore he is back to where we started 5 years ago at 30% density.
The hair transplant surgeons’ biggest nemesis is the progressive nature of male pattern baldness and for many men we cannot keep up with nature.
GOALS OF A HAIR TRANSPLANT
There are many goals that a Hair Transplant procedure can achieve, the four most important goals are:
When performing hair transplants, we need to ensure the highest percent of grafts survive and continue to grow after the transplant.
To ensure that the highest percent of the transplanted hair survive and grow.
To ensure that today’s hair transplant will look just as good tomorrow as it does today.
Lastly, and most importantly, to be conservative when performing the hair transplant.
THE ULTIMATE HAIR TRANSPLANT TECHNIQUE
The ultimate hair transplant technique has to respect the only remaining limitation to the surgical treatment for hair loss, each patient has a fixed amount of good genetic hair from the sides and back of their scalp that can be used to transplant in the balding area.
It is of paramount importance that the hair transplant surgeon is entirely focused on ensuring every transplanted graft survives and grows. Any technique or procedure that ultimately increases the percentage of survival of the transplanted hair should be used. Conversely, any technique or procedure that decreases survival must not be used.
The techniques that maximize survival of the grafts during the hair transplant are as follows:
Having a doctor (not an unlicensed technician), who is highly trained, perform the hair transplant. Any physician can legally perform hair transplants, even if they have little or no training. It is of utmost importance that any doctor performing hair transplants should have formal training under the strict guidance of a residency or fellowship program. Taking a weekend course on hair transplants or “on the job” hair transplant training at one of the big hair transplant clinics is inadequate.Over the past ten years there are many doctors and unethical FUE companies that have tried to automate the hair transplant process (in order to perform two or three hair transplants a day). I fail to see the quality in performing the hair transplant in this style and believe the doctor should be doing the hair transplant surgery.
Being meticulous and not rushing the hair transplant procedure.Typically, a hair transplant lasts four to seven hours, therefore, if the hair transplant physician is going to be involved in every step of the hair transplant process he can perform only one hair transplant procedure a day.
Natural Hair Grouping Transplants.Hair does not just come out of the scalp individually, one by one, but actually grows naturally in groups of one to four hairs with a fibrous sheath surrounding them. Since that is how God designed everyone’s scalp, that is how we do a hair transplant. We perform hair transplants with the single hair groups on the hairline and the natural groups of three and four hairs farther behind for density. The benefit of performing the hair transplant with the individual “natural hair groupings” is the completely natural look we achieve and a higher survival rate of the transplanted grafts.To try to obtain a natural look, many doctors now perform transplants with what is called “single hair micro grafts” or ultrafine micrografts. They separate the “natural hair groupings” into single-unit hair grafts and transplant the hairs individually. By separating the natural groupings of hair, the transplant surgeon is going against nature. A study published in the Journal of Dermatologic Surgery showed that the survival and quality of these grafts markedly decreases. (Follow this link for photos and results of this study). The best alternative is to mimic the pattern as God designed it, instead of trying to change it.
The stereoscopic microscope is probably the most important innovation in hair transplants. The “natural hair groups” must be preserved intact during dissection to insure increased survival and growth. Many doctors dissect with the naked eye or with minimal magnification. That leads to increase transection and destruction of the hair. When dissecting the donor hair without the stereoscopic microscope it is nearly impossible to ensure that the “natural hair groupings” will remain intact.Using the Stereoscopic Microscope in order to dissect out the grafts.
For a balding man seeking a transplant, his most precious commodity is his “hair bank,” (hair that is available as a source for transplants). The use of the “stereoscopic microscope” to dissect the grafts enables me to visualize each and every individual “natural hair grouping.” By using the “stereoscopic microscope” the trauma to the surrounding hair is greatly reduced and our patients receive superior quality grafts with a much higher incidence of survival. I can now achieve survival rates of 95 to 100 percent, as compared to other techniques where the survival rate is much less. The “stereoscopic microscope” also enables us to trim excess tissue away from the hair follicle, therefore, smaller incisions can be made, which enables us to pack the grafts closer together to give a denser look.
HAIRLINE DESIGN AND GRAFT PLACEMENT TECHNIQUES
The design of the hairline is crucial to the overall look of naturalness. A physician could use all the latest techniques and technology but still create an unnatural looking hair transplant because they do not understand the aesthetics of a natural human hairline. There are five important areas of concern when creating an aesthetically natural hairline and frontal forelock:
The anterior (or central) starting point of the frontal hairline:
Many hair transplant surgeons (or their technicians) place the hairline too low on the forehead, which will never look natural as the patient ages. Particularly with younger hair transplant patients who have more extensive baldness. The hair transplant surgeon needs to create a more conservative pattern that will look natural now and twenty years from now.
The lateral frontal hairline:
Many hair transplant surgeons (or their technicians) design too wide of a frontal hairline can create the look of an unnatural comb-over or hairpiece.
The angle of the hair exiting the scalp:
The angle of the hair gets more acute at the more anterior (frontal) part of the hairline. Many hair transplant surgeons (or their technicians) create the incision so the hair comes out perpendicular to the scalp, which is not aesthetically pleasing and does not cover the scalp as well. This also looks unnatural since your hair would not normally grow in this direction.
The irregularity of the frontal hairline:
The human hairline is naturally very irregular.
It is a common mistake of hair transplant surgeons to make the hairline too symmetrical and too linear. The human eye is naturally drawn to lines, which will draw unnecessary attention to the hairline and make the patient self-conscious. An irregular hairline is natural and does not draw attention to it.
Direction of the incision:
The hairs in a follicular unit typically sit side by side when looking at hair from front to back. This is a cosmetic benefit because the hairs are in a row instead of lined up behind one another, which gives a thicker cosmetic result. Therefore, the incision with the needle should be placed with the long axis going from ear to ear (coronal incision) versus from front to back (sagittal incision).
Since hairline design is so important to the overall result, it is vitally important that your hair transplant surgeon has been properly and formally trained in the art of hair restorations. Never let an untrained plastic or facial plastic surgeon or an licensed technician design your hairline.