THE HAIR TRANSPLANT PROCEDURE
Hair transplantation is simply the transferring of hair from a “permanent” area of the scalp to another area in which hair has fallen out due to heredity or some other more unusual cause. For most men and women who lose the hair on the top of their head, the hair on the back and sides of their head is relatively thick and destined to remain there for the rest of their lives. This “permanent” hair is harvested in the form of a narrow “strip” of hair, which is then meticulously cut up under microscopic magnification to produce hundreds of tiny follicular unit grafts of 1-3 hairs each.
In hair transplantation, these newly created tiny grafts of “permanent” hair are distributed artistically over the balding scalp according to a carefully planned pattern. They quickly take root and, after a short resting period of three to four months, grow – and keep on growing for the rest of your life.
To create great hair transplant results, a good amount of artistic ability is necessary on the part of the surgeon. He must have a “feel” for how to aesthetically create natural, feathered gradients of hair that are totally undetectable to those who will encounter that patient in the years to come.
After this new hair grows out, it can be washed, cut, colored, or styled in whatever way you like. There is nothing fragile about the transplanted hair. It behaves exactly the same as the rest of your native hair, except it is yours for a lifetime.
THE HAIR TRANSPLANT PROCEDURE
Follicular Unit Transplantation
State of the art Follicular Unit Transplantation is now the “gold standard” by which all hair transplant techniques are measured. It is the newest technique of permanent surgical hair restoration in which hair is transplanted from the permanent zone in the back of the scalp into areas affected by genetic balding, using only one’s own naturally occurring, individual follicular units. This procedure is unique in that is provides what we all want – hair that looks natural throughout, no matter which way the wind blows!
What Are Follicular Units?
Hair naturally grows in clusters of one, two, three, and some times four hairs. These naturally occurring groups of hair are called Follicular Units. The follicular unit is very small and can only be identified under magnification. Notice that they are scattered about in an irregular pattern. This is how hair grows … in follicular units and in an irregular pattern.
So given how hair naturally grows, an excellent hair transplant replicates nature by relocating these naturally occurring follicular units from the donor area to the recipient site (balding area) – one at a time.
Follicular Units – Magnified
Follicular Unit Extraction
F.U.E. otherwise known as Follicular Unit Extraction is a newer method of removing donor hair follicles. With FUE we use specialized instruments measuring .7mm- .95mm in size and remove each follicle individually. The main advantage of this method versus FUT is that in FUE there is individual extraction of hair follicles with a specialized tool versus the removal of a strip of skin with FUT. This means that FUE leaves no linear scar in the donor region. Just small dots that are not visible unless the hair is shaved down to the skin.
Dr. Dauer is an expert in performing F.U.E., and routinely teaches other physicians around the world the art of performing FUE. Dr. Dauer has multiple different state of the art FUE tools and can choose the one best suited for the individual patient’s hair type. If this is something you are interested in, he can explain this procedure in more depth on the day of your consultation.
How is Follicular Unit Transplantation Performed?
The real key to performing this procedure successfully is to transfer each follicular unit intact from the donor area to its destination. In order to remove Follicular Units from the back of the scalp without damaging them, the donor tissue must be removed in one piece. This technique is called “Single Strip Harvesting.”
The individual Follicular Units are then separated from the donor strip and trimmed under a microscope to create the ultimate micro graft. These micro grafts are then placed in very close proximity and in an irregular pattern that mimics how they naturally grow in the scalp. The end result is a hair transplant that looks natural because it applied the way hair actually grows.
Complete stereo-microscopic dissection has been shown to produce an increased yield of both the absolute number of follicular units, as well as the total amount of hair, in upward of 25% when compared to other techniques.
Also, the ability to do this successfully, and in a session of 1500 or more grafts (“a mega session”), has only come about in the past few years. The very small insertion sites permit many follicular unit grafts to be safely transplanted in a single procedure allowing the entire hair restoration process to be completed as quickly as possible. At this time only a small group of experienced hair transplant physicians perform this procedure with excellent results.
When performed by a skilled surgical team, Follicular Unit Transplantation can provide a totally natural looking result in as few as one or two sessions.
Why Aren’t All Transplant Physicians Using Follicular Units?
Basically the reason is that it takes time to change and adapt to these cutting edge advancements in technique. Follicular unit grafts require more time, skill, and expense to create compared to the mini/micro grafts.
Many hair transplant clinics, including the large commercial operations, find it more profitable to do the standard mini/micro graft procedure, because one doctor can do two or three patients a day using this older and less demanding hair transplant technique. This produces more revenue for the clinic but less than ideal results for the patient.
Follicular Unit Grafts
It is possible to achieve the appearance of naturalness and density on a consistent basis with natural follicular unit transplantation. This method requires greater numbers of grafts and technical skill in order to achieve the desired result. But once the technical skill to perform this technique is achieved the look is invariably natural. As stated earlier, Follicular Unit Transplantation is the “gold standard” by which all hair transplant techniques are measured.
Hair Transplantation Information – FAQs
1. What causes baldness?
The cause of male pattern baldness is no longer a mystery. Research has shown that when the male hormone – testosterone is exposed to 5-alpha-reductase, an enzyme in the hair follicle, it produces another hormone called dihydrotestosterone (DHT), which causes permanent hair loss. This hormone (DHT) causes the hair follicle to shrink and grow a finer hair that is lighter in color, shorter and less deeply rooted than its predecessor. Most often, the hair in the balding region will continue to grow at an increasingly slower rate until hair growth ceases completely.
The pattern of progression, and the extent and speed of male pattern baldness, is largely dictated by genetics, hormones and age. For men, this permanent type of baldness generally follows specific patterns. Even in the most extensive cases, a horseshoe shaped fringe of hair remains in the back and sides of the scalp. This donor fringe is insensitive to the balding process and will last a lifetime. This is because this hair is genetically programmed in the root, or hair follicle, to be resistant to the effects of DHT.
The hair in this donor area provides the basis for surgical hair restoration. These hairs, when transplanted into thinning or balding areas, will take root and grow, and continue to grow for the rest of a person’s life.
2. Are hair transplants permanent?
Since the hair used in hair restoration surgery comes from the donor area, which is not sensitive to the balding process, it will be permanent. This hair will retain its genetic characteristics even after relocation. It will grow and continue to grow for the rest of your life.
3. What is “follicular unit hair transplantation”?
This procedure has been called the logical end point of 30 years of evolution in hair transplantation beginning with traditional larger plugs and culminating in the move to one, two, and 3 hair follicular unit hair grafts, which mirror the way hair grows in nature. (Hair Transplant Forum Feb. 1997).
The key to follicular unit transplantation is to identify the patient’s “natural hair groupings” and use them intact to create from ” follicular unit hair grafts” that are composed of naturally occurring 1, 2, 3, and 4 hair grafts.
These follicular unit micrografts are much smaller than traditional untrimmed micrografts that contain equivalent amounts of hairs. Their size enables larger numbers of them to be placed in tinier, less traumatic incisions closer together.
Using this advanced technique a surgeon can move more hair in a totally natural way – creating a natural look at every stage of hair restoration.
4. Why are so few physicians performing all micro”follicular unit hair transplantation?
It’s known that using small follicular unit grafts of 1 to 4 hairs and sessions of 1500-3000 grafts are the ideal procedure for a patient who wants to achieve the most natural result with the least number of sessions.
Using smaller grafts results in the need for greater quantities, thus it is more labor intensive. It necessitates a larger staff and longer time commitment to achieve the desired result as well as a staff that is experienced in the art of dissecting “follicular units” and placing the grafts into tiny incisions.
5. How many sessions will I need?
How many sessions you will need depends on various factors – such as, how much hair loss you have now, the amount of hair loss you will have in time, and your goals and expectations – or how thick you want it to be.
6. What does Hair Transplantation Cost?
Generally hair transplantation has become a dramatically better value over the past several years. The cost of hair grafts have gone from a typical $25 per graft charge for the old large pluggy grafts, to prices ranging from $4 to $10 for today’s follicular unit grafts.
Dr. Dauer’s pricing is moderate by industry standards and financing through Care Credit is available.
7. Since Propecia is now available, will hair transplantation be a thing of the past?
While Propecia and Rogaine have been proven to regrow hair, they will not grow all your hair back. Both products have not been proven to grow any significant hair in the frontal region, which is the main area of concern for most people.
Their greatest benefit seems to be in slowing down hair loss. Propecia and Rogaine can be part of an effective hair restoration plan. We prescribe Propecia in order to help maintain some of the hair which may be lost over time.
8. What about “Scalp Reductions”?
Scalp reductions were first introduced in the mid-1970s as a way of treating an individual with a midline bald spot. Although several design approaches can be used, an elliptical approach is generally the most common. With this procedure, an ellipse of bald skin is removed centrally in the crown area and the hair-bearing scalp on the sides of the head is stretched toward the middle to obtain closure.
Because scalp reductions do not allow for an upward and forward advancement of the entire scalp, they are not effective in treating patients who possess or have the potential for more extensive baldness. Due to this inherent surgical limitation, as well as the aesthetic drawbacks, which include an excessive stretching back of the bald area and increased receding at the temples, the scalp reduction procedure is considered outdated for the treatment of moderate to extensive baldness. Newer procedures offer more predictable and better aesthetic results, and often require fewer surgical sessions.
9. Does removing hair from the donor area on the back of my head leave a gap?
The scalp is very elastic. When the donor strip of hair is removed, the scalp on both sides is just pulled together and sutured. The only evidence of surgery is a thin line hidden under the hair that grows vertically on the back of the head.
10. Are there risks involved?
Elective surgery to improve physical appearance is universally accepted and is being performed successfully everywhere there are qualified specialists. Hair restoration procedures differ from general surgery, however, in that they involve only the outer layers of the body. You should not worry excessively about risks or complications, because they are rare.
11. Is hair restoration surgery painful?
The discomfort associated with hair restoration surgery is usually comparable to that of dental surgery. Pain medication is always offered, though its use is limited generally to the first 24 hours after surgery.
12. Will my transplanted hair require special care?
Your newly restored hair will grow and require the same maintenance as your original head of hair. It’s your hair and can be colored, permanently waved or styled in a variety of ways suitable to your lifestyle.
A TYPICAL HAIR TRANSPLANT PROCEDURE – A WALK THROUGH TOUR
About three weeks before the scheduled session, the patient is sent a list of “pre-op instructions”, and also a map and a brief description of what to expect during the first week after surgery. Our nurse-receptionist may assist the patient with any other arrangements they need help with, such as motel or travel arrangements.
The day of the hair transplant procedure, the patient is dropped off picked up. We do not allow our patient’s to drive themselves home after the procedure. The hair transplant patient is encouraged to take a shower and shampoo their hair the night before and morning of the procedure. The patient is also encouraged to eat a generous breakfast the morning of the procedure. When the patient arrives, he is greeted by our staff and is handed a consent form and “medical history questionnaire” to fill out.
What to Expect…
Reviewing Consent with the Hair Transplant Patient
After taking the time to review, discuss and sign consent forms, the hair transplant patient usually makes one last trip to the bathroom and then is ready to get started. We first stop briefly in our small, in-office “photo studio” to take an initial series of photos from 5 different views, which can be looked at later on to measure the progress from the transplant sessions. The patient is then escorted into the procedure room for his or her day’s adventure.
Entering the Hair Transplant Procedure
The patient enters our spacious and comfortable procedure room in Century City, Los Angeles, with background music playing and changes into a comfortable gown. Dr. Dauer then reviews the plan with the patient and draws the proposed hairline on the scalp, along with the zones behind it which will be filled in with the appropriate size grafts. The patient is given one last look at it with mirrors, to make sure he agrees with the plan. One final photo is then taken of the plan drawn on the patient’s scalp.
The patient is then turned over onto the stomach in the “prone” position, on the belly. With the patient in this position, Dr. Dauer then shaves a very narrow horizontal strip of hair down to about 1mm in length in the area where the donor hair will be harvested. This strip is located about 1/3rd of the way up from the bottom fringe border, around the bump known as the “nuchal ridge” in the back of the head.
The donor area is then anesthetized with a series of small local injections and the pain is minimized by a special vibrating device that Dr. Dauer uses. There is no general anesthesia used in this procedure. The donor region is then “tumesced” (filled by injection) with a saline solution which also has a weak concentration of adrenaline in it to control bleeding, and Lidocaine (anesthetic) to numb the region. Then, a single strip of donor hair is meticulously taken out by Dr. Dauer with a specialized scalpel technique. Dr. Dauer is careful to limit the depth of the incision to 3-4mm in order to minimize any damage to the surrounding or underlying tissue. The strips are then carefully removed and placed in chilled saline.
Dr. Dauer uses a very fine suture to close the donor region which results in a very fine donor scar and is much more comfortable to sleep on than staples, which other doctors commonly use. Dr. Dauer also performs a trichophytic closure on the donor region, which allows hairs to grow through the donor scar, making it even more undetectable.
One the donor harvest is completed, the patient then turns onto their back, and the angle of the surgical chair is adjusted to create maximum comfort for the patient.
Next Dr. Dauer “tumesces” the scalp in the recipient area. This means he injects saline into the area so that the skin is expanded and elevated. This serves to “widen the playing field” thus allowing Dr. Dauer to place the grafts even closer together, as well as elevate the skin away from the underlying blood vessels, thus protecting the vasculature in the scalp and allowing for more rapid recovery and greater growth of the transplanted follicles.
Dr. Dauer also has a machine that allows him to create custom cut blades for his receptor sites. The blades he uses range in size from .5mm to 1mm in increments of .05mm. This allows Dr. Dauer to use the smallest possible blade that works with the character of the patients hair, so that the greatest amount of density can be created with the least amount of scalp injury. Not all hair follicles are created the same and therefore it is imperative that the proper recipient blade is suited for the patient’s hair type. Dr. Dauer also has a specific blade handle which limits the depth of the blade so that it only goes as deep as the length of the patient’s hair follicle. This is also to protect the scalp from unnecessary injury in the course of the creation of the recipient sites.
All of these innovations allow Dr. Dauer to create the maximum amount of density in any particular area of the scalp, while minimizing the damage to the scalp.
In the next phase of the procedure Dr. Dauer meticulously creates all of the recipient sites for the transplanted hair follicles, into which the hair grafts will be placed. These are created following the pattern which Dr. Dauer drew at the beginning of the procedure, with special care taken that the direction of the hair is completely natural.
While Dr.Dauer is making these tiny incision sites for the recipient grafts, the assistants are busy dissecting the harvested donor hair into hundreds or thousands of small grafts. This process is done entirely under microscopic vision, which results in far superior grafts and better preservation of hair. There is ample communication between Dr. Dauer and the cutters, to insure that the exact number of recipient sites that are made matches the number of grafts that are cut. Oftentimes, Dr. Dauer will make only a few recipient sites for a certain type of graft and then do a “test placement”, to insure that the grafts and the sites match perfectly.
The final step in the hair transplant process is the placing of the grafts into the scalp recipient sites. There may be light-hearted back-and-forth conversation while the assistants carry out the all-important task of placing the grafts or the patient can watch tv or take a nap. When we are finished, Dr. Dauer carefully inspects the patient to be certain that the position and placement of the grafts are perfect.
The procedure, which usually takes anywhere from 6-8 hours to complete (depending on the number of grafts the patient is to receive), is now over. A small bag of medications and a clean brand new baseball hat are then given to the patient. The post procedure instructions are carefully explained and reviewed.
The patient then returns to see Dr. Dauer approximately 12-14 days after the procedure to have their sutures removed. If the patient is from out of town, arrangements are made for the patient to have the suture taken out by a physician close to their home.
The hair transplant procedure is minimally invasive and while there may be some minor discomfort, there is rarely serious pain involved. Dr. Dauer provides every patient with pain medication for the post procedure period, though it is rarely needed after 24-48 hours.
How Will I Look After a Transplant Procedure?
The first day after the procedure there are tiny scabs around each transplanted follicle that look like little grains of sand. If the patient has native hair in the region they can usually cover up the work with a creative hair style. Within a week most of the scabs are gone and the patient is left with the transplanted tiny hair follicles.
During the days following the procedure, the patient can return to work and recreational activities. We recommend refraining from strenuous activities such as weight lifting, racquet ball or tennis for 12-14 days to avoid accidentally damaging the grafts or stretching out the donor region. With FUE patients they are able to resume normal activities after 1 week. The hair is washed gently for 8 days by pouring water over the scalp. The grafts are not touched during this time. After 8 days the patient may resume normal shampooing of the hair.
There is usually a little redness of the scalp in the transplanted regions that dissipates over a period of weeks after the procedure.
Activities After Hair Transplants
You may return to work the day following the procedure as long as your work does not require strenuous activities. Light exercise such as walking is permitted after 3 days, but it is best to wait 12-14 days before participating in strenuous activities, workouts, or sports.
Dr. Dauer also recommends that you wear a hat for prolonged periods in the sun, to protect your scalp from sunburn, for a period of 3-4 months after the procedure.
If you have any questions or concerns about anything at all please do not hesitate to call Dr. Dauer.
TO SCHEDULE YOUR CONSULTATION PLEASE CALL 310.748.2224.
STRIP METHOD HARVESTING VS F.U.E.
The increase in both marketing and internet-hype of motorized follicular unit extraction has potentially created some confusing facts for both consumers and physicians, especially for those less experienced in hair restoration surgery.
The International Society of Hair Restoration Surgery’s website has recently posted a position statement on scalp surgery and a paper that presents a fair and balanced view of the controversies of FUE versus donor strip harvesting.
The following is the official position of the ISHRS
August 2010 – Comparison between Strip Harvesting and Follicular Unit Extraction:
A Fair and Balanced View
ISHRS Position Statement on Qualifications for Scalp Surgery
Ten years ago the use of follicular unit extraction (FUE) was advocated as an alternative to traditional strip harvesting of the donor tissue. The use of the technique has been slow to be accepted as a new standard. Many physicians have, in fact, tried the technique but with markedly varying success. The recent promotion of mechanical devices and powered follicular extraction devices has sparked renewed interest and controversy regarding this method of harvesting. A great deal of discussion by physicians, ancillary personnel, and the general public has occurred on the Internet and multiple media sources about the value of FUE versus strip harvesting and vice versa. Sadly, many of the claims of “superiority” of the newer technique seem more related to marketing and self-promotion rather than a clear scientific evaluation.
This article discusses advantages and disadvantages of both techniques to provide a more accurate and balanced view of the two approaches.
The Donor Area and Scar Formation
Strip harvesting produces a linear scar. The appearance of the donor strip scar can be a significant concern for patients who wish to wear their hair very short. The vast majority of patients who undergo strip harvesting have minimal scars that are easily concealed by the hair above the scar. And in many instances the scar may not be evident at all except on careful inspection. There are, however, some patients who have scars that have widened, and there are also patients who have several scars from multiple procedures. In some instances the apparent widened appearance of a scar may actually be due to damage to follicles along the incision line during harvesting rather than true scarring.
Judicious planning on the part of the surgeon can largely diminish the problems associated with strip scars. By limiting the width of the strip to be taken and avoiding tension on the wound, the surgeon can minimize the donor scar. To avoid multiple scars many physicians who use strip harvesting employ a single scar technique even if multiple procedures are performed. By utilizing careful dissection along the incision line, damage to hair follicles can be diminished.
The use of the trichophytic method of closure for strip harvesting can also be extremely helpful in improving the appearance of the strip harvest scar. As noted above closing under minimal or no tension can help to avoid the widening of a scar. This allows hair to camouflage the scar and the hair growing through the scar can limit the stretching. Avoiding damage to the hair follicles along the incision lines is crucial in preventing the appearance of a prominent scar.
Some physicians advocate the use of a layered closure and undermining as techniques to minimize scars. Other surgeons feel that undermining and layered closures do not seem to alter the healing except in situations where tension is a problem.
There are patients such as those with Ehlers Danlos syndrome, who because of alterations in collagen deposition, are prone to widened scars and poor wound healing. There is little that can be done to prevent such scars in these patients. The circular scars produced by FUE may suffer the same fate and be stretched in these patients.
The primary rationale for the use of FUE is that a linear scar is avoided. Several proponents of FUE market the procedure as a technique that does not involve cutting, is less invasive and does not result in scars (i.e., “scarless”). While a linear scar is not created with FUE, circular scars are created. The length of incision is greater with FUE than with strip harvesting. This is apparent when one calculates the circumference of a 1mm punch (1mm x pi = 3.14) and then multiplies this by the number of grafts, for instance, 1000 grafts (1000×3.14 =3140mm which equals 31.4cm). In comparison, a strip harvest of 1000 grafts assuming an average density of 80 FUs per sq cm and a 1cm strip width the length of the scar created would be 12.5cm (1000/80 = 12.5).
“Cutting” is clearly involved when using a punch. Although a linear scar is not produced with FUE, scars are created and evidenced by virtue of the fact that hypopigmented or hyperpigmented “dots” may be visible when the hair is cut very short. These “dots” may be a scar reaction or actual post inflammatory pigment changes, particularly in darker skinned individuals. Also the human eye may pick up “spaces” where follicular units are missing in the normal pattern.
The depth of the incisions with FUE is usually shallower as compared to strip harvesting. The punch depth is to the level of the fat or at the fat-dermis junction. With strip harvesting the depth of incision is into the fat. Some physicians cut to the deeper fat or just above the fascia.
When using FUE it is important to recognize that as more and more grafts are harvested the area may appear moth eaten. If grafts are taken too close together there may be an appearance of a scar. In some patients as large numbers of grafts are removed there can be a clear demarcation between the areas that have been harvested and areas left alone. This is opposed to the strip technique where hair of similar density is brought back together at the suture line. Opponents of strip harvesting would note that if hair does not grow well in a strip scar and the scar widens, then the scar might be apparent if the hair above it is short or otherwise thin.
Some promoters of FUE have stated that nerves and veins are not cut. This claim is untrue. By entering the skin with the punch arteries, veins and nerves are cut. It is important to point out that with FUE the patient’s hair usually must be trimmed quite short for harvesting. This is the case especially when large numbers of grafts are required. A way to avoid trimming all of the donor hair is to set up rows of short hair between rows of long hair. The short hair grafts can be harvested within the existing long hair. But again, this is only suitable when relatively small numbers of grafts are needed.
Debate exists as to the rate of survival regarding FUE versus strip grafts. There is some concern that because the FUE grafts may have very little tissue surrounding them that they are less likely to survive. Such grafts are more prone to dehydration, which has been shown to be a major cause of diminished graft survival. The lack of perifollicular tissue is often a result of “pulling” on the graft to remove it. Because there is added manipulation in trying to remove a graft this may also contribute to diminished survival. Sometimes the ends of the bulbs are splayed or unusually far apart. This makes the bulbs more susceptible to trauma, as a result of increased graft manipulation during implantation. As of this time there are not adequate studies to compare survival rates. Clearly there are patients who have undergone the FUE procedure and have excellent results. Some physicians might argue that less successful results may be due to technical surgical skill rather than the nature of the more fragile graft created with FUE.
With FUE there is a greater chance of transection of hairs as compared to strip harvesting and this could result in poor growth or lack of growth depending on the level of transection. The rates of transection seem to vary widely with FUE. Conversely, with strip harvesting, grafts may be damaged in making the initial skin incisions and subsequent dissection of the tissue, but this is considered minimal. The use of the microscope for dissection of the donor strip should limit transection rates to 1-2%. Grafts created with strip harvesting generally have a greater amount of surrounding tissue and fat. This may decrease the chance of dehydration and allow for greater leeway in manipulation of the grafts during placing and hence, better graft survival.
Placing of Grafts
When manual placement of grafts is utilized there is no difference in regard to the technique of placement of strip harvested or FUE harvested grafts. There may be some concern about the fragility of the FUE grafts and the fact that they may be more susceptible to drying and over manipulation.
When a machine that uses pneumatic pressure is used it is the contention of the manufacturer/distributor that the machine places the graft with less manipulation. Some surgeons who have used the machine have indicated that the graft placing capability of the machine is limited at times and not always reliable.
Perfectly harvested grafts may be damaged during the placement phase and fail to grow. Trauma and graft drying are well known factors that may occur in inexperienced hands and will effect graft survival. Regardless of how grafts are harvested, there is a considerable amount of artistry and technical expertise necessary to place them to produce an excellent or even acceptable result. The surgeon must be able to create an aesthetic “blueprint” for graft placement, determining the distribution of 1, 2, and 3 hair grafts. Hairline design is obviously important, as is the grafting plan over the rest of the scalp. The experienced hair surgeon will create gradients of density to achieve natural looking results with adequate density. In addition, the incisions must be made at the proper angle and direction. Even single hair grafts will look unnatural if placed at the wrong angle.
A somewhat different skill set is required for FUE harvesting. The surgeon must be able to align the small punch correctly, find the right depth and adjust the punch to account for changes in direction of the hair. The primary concern with FUE is the rate of transection. That is, if the hairs in a follicular unit are transected they are less likely to grow. This is in part dependent on the level of transection. The reports from physicians performing FUE indicate that the rate of transection is higher than with strip harvesting.
As noted above, the physician must be able to adjust the punch to account for change in hair direction. Patients with curly or very wavy hair may be difficult to treat when FUE is used. In comparison, strip harvesting is suitable for all types of hair. The use of the blunt punch can be helpful in harvesting curly or wavy hair with the FUE technique.
FUE can be a tedious process and both patient and physician may experience fatigue. This can limit the amount of grafts that can be harvested in a single session. Because of the time usually involved in harvesting and the possible strain on the surgeon performing the harvesting one has to wonder if less emphasis is placed on the recipient area.
The learning curve for FUE can be slow for physicians who are used to excisions with scalpels and unaccustomed to the use of punches for harvesting. The physician may need to use high power loupes 4x-6x. Working at a shorter focal distance can be tiresome and lead to neck problems. Some physicians have used ophthalmic microscopes to facilitate the surgery.
An important issue associated with a particular mechanized FUE is the marketing to physicians that unlicensed personnel may be able to perform the harvesting. This raises significant legal issues in many countries, including the U.S. There are states where it is clearly illegal to have a non-physician, non Physician Assistant (PA) or Nurse Practioner (NP) perform such surgery. The laws in other countries may present similar medico legal problems regarding who can harvest tissue. For example, in Austria, Israel, Italy, Korea, Georgia, Thailand, Turkey, and Japan, only physicians are allowed to make incisions, and regulations vary as to the role of assistants in graft insertions. In some countries including the US, entrepreneurial nurses and medical assistants are setting up hair transplant clinics, and hiring physicians as medical directors who may have limited or no hair transplant experience, but who “supervise” the procedure. Many U.S. states allow the physician to delegate responsibilities to staff under supervision, but both the degree of supervision, and the extent of staff responsibilities is not clearly defined.
To date, this issue has not been challenged or reviewed by any state medical board.
The following is the position of the International Society of Hair Restoration Surgery:
ISHRS Position Statement on Qualifications for Scalp Surgery
The position of the International Society of Hair Restoration Surgery is that any procedure that involves tissue removal from the scalp or body, by any means, must be performed by a licensed physician in the field of medicine. Physicians who perform hair restoration surgery must possess the education, training, and current competency in the field of hair restoration surgery. It is beyond the scope of practice for non-licensed personnel to perform surgery. Surgical removal of tissue by non-licensed medical personnel may be considered practicing medicine without a license by state, federal or local governing boards of medicine. The Society supports the scope of practice of medicine as defined by a physician’s state, country or local legally governing board of medicine.
Number of grafts per session
In general most physicians who perform FUE are not able to do as many grafts in a single session as can be done with strip harvesting. With strip harvesting, sessions of 2000-3000 grafts are very common and some physicians frequently perform sessions in excess of 4000 grafts. There are, however, exceptions and some physicians, routinely performing motorized FUE, report similar in excess of 2000 grafts. Unfortunately, the rates of graft transection in these larger FUE sessions has not been studied or reported.
The cost of FUE is usually significantly more than that for strip harvesting on a per graft basis. The costs may exceed double the price of strip harvesting.
FUE can be very useful for harvesting body hair. In such situations the majority of follicular units are single hairs. Evidence of the surgery is often visible as hypo or hyperpigmented “dots” in these non-scalp donor areas.
Small number of grafts
When small numbers of grafts are needed FUE may be an excellent choice of technique. Using the technique where narrow rows of trimmed hair are used it would be relatively easy to camouflage the work and avoid creating a linear scar. On the other hand using a 2.5 cm long and 1.2 cm wide strip a surgeon could easily obtain 240 or so grafts. (2.5 x 1.2 =3.0 sq cm) assuming a density of 80 FU per sq cm (80 x 3 = 240 grafts). Thus, evidence of removal of 240 FUE grafts would be a 2.5cm long scar.
FUE into scars
FUE can be used to try to camouflage linear donor scars. This is considered by many hair restoration surgeons to be another excellent use of the technique. Some surgeons have suggested that a combination of strip harvesting and FUE is the optimal use of the techniques.
The cost of instrumentation for strip harvesting and non-mechanized FUE is modest. With the advent of mechanization the cost for machines that can be used for FUE can be expensive. Powered or motorized devices can cost several thousand dollars and one system currently sells for approximately $80,000 (USD).
With the motorized systems there is debate as to the rate of transection. Some physicians who perform FUE but do not use the motorized systems feel that the rate of transection is higher with such devices. Other surgeons indicate that transection rates are the same or lower. This may depend on the training and skill of the physician performing the work.
Increased donor supply
Advocates of FUE have stated that FUE expands the donor area in the scalp. With FUE the surgeon can harvest in the nape of the neck more easily as well as the areas superior and more anterior to the ear. This apparent advantage is somewhat negated because the area can become moth eaten in appearance as more and more graft are obtained. In addition going into the nape of neck area or high onto the scalp can be a problem later in life for the patient as some men lose hair in this area as a result of male pattern hair loss.
Some of the surgeons who prefer FUE feel that patients experience less pain and there is a shorter recovery time. There is little data to support this view. One would need to compare the pain associated with comparable numbers of grafts harvested per session. For instance one would want to compare, for example, 1000 grafts harvested with strip vs. the same number harvested with the FUE technique. The fact that pain is very subjective complicates such studies.
Telogen effluvium can occur in the donor area with FUE or strip harvesting, but this is uncommon. Infection is a very rare complication with hair restoration surgery. Dehiscence with strip harvesting can occur but this is quite rare and would be associated with surgical error. Similarly, necrosis of tissue should not occur unless the area harvested is too wide and/or closed under excessive tension. This could also occur if the arterial supply was already compromised.
Patients may complain of altered sensation but this can occur with strip harvesting or FUE as small nerves are cut in both procedures. Years ago some strip-harvested patients may have experienced significant dysesthesia as a result of damaging the occipital nerves. As dissection should be at the level of the fat or perhaps at the level of the fascia these nerves should not be damaged. Bleeding occurs with both techniques but more significant bleeding occurs with strip harvesting. That said, bleeding is not considered a problem with strip harvesting and in most cases bleeding is nominal.
A complication that is specific to FUE harvesting is the burying of grafts. This happens when the punch pushes the graft into the subcutaneous tissue. The grafts can be difficult to recover and can lead to a foreign body reaction and cyst formation.
Hypertrophic scars and keloids should also be rare with FUE or strip harvesting. If patients have a predilection for keloids making punch excision will not limit such scar formation.
In general hair must be cut short to be harvested with FUE. At times layers can be created allowing hair to cover the harvested areas but this places a limit on the amount of hair that can be removed at the session.
Strip harvesting requires a larger staff than FUE. For FUE the surgeon can get by with just one or two assistants but if the surgeon has to alter course and use a strip harvest having only one or two assistants could be problematic.
Strip harvesting and FUE are both acceptable techniques for harvesting donor grafts. Each technique has advantages and disadvantages. On a cost-benefit ratio strip harvesting would seem to provide the most cost effective procedure. FUE is well suited for patients who insist on not having a linear scar. It may be an excellent choice for young patients seeking small procedures. FUE may be the ideal choice for harvesting trunk, leg and arm hair, and it is an excellent way to camouflage strip scars.
It is important that objective data continue to be collected regarding graft survival with FUE. Similarly, it would be beneficial to obtain more information as to the degree of discomfort experienced with the two techniques and the healing times.
No matter the technique employed, the surgeon must be well versed in the technical and aesthetic components of performing the surgery in order to produce consistently good results. A single course or training session on one aspect of the hair restoration procedure such as harvesting is inadequate training for a physician to learn how to perform hair restoration procedures. The surgeon must acquire a sense of the aesthetic and technical components of the procedure. He or she must be able to develop a plan for patients with various clinical scenarios and know when to refer to a surgeon with more expertise.
The goal of hair restoration seems simple enough, namely to move hair from one part of the scalp to the other. However, any experienced physician will tell you how complex this seemingly simple task is. For example, one of the most important concepts the physician must appreciate is that hair loss is progressive and that any restoration plan must be made with this in mind. When a patient comes to the physician with a given stage of hair loss, the physician must be able to assess the donor area for hair density and quality, calculate the number of grafts needed, give the patient a reasonable expectation for what the result will be, and plan this result with the possibility of future hair loss in mind. The physician must be able to discuss the pros and cons of medical treatments designed to stop or slow future hair loss, such as oral finasteride and topical minoxidil. All of these elements require considerable training and expertise to implement for each patient.
Successful graft harvesting is only one small component of surgical hair restoration. Without attention to all of the other aspects, there is a very real possibility of a bad outcome. Finally, the incision of skin and tissue, whether using instruments that create a linear or circular incision, is legally considered surgery and should only be performed by a licensed physician with adequate training and expertise in hair restoration.
PRE and POST-OP FORMS
Propecia Consent Form (pdf)
AFTER MY HAIR TRANSPLANT… WHAT DO I DO NOW…?
After my hair transplant, I want to be careful not to lose any of my grafts. How do I accomplish this?
Care of Grafted Area
I should wear a paper medical cap or a clean hat anytime I venture outside during the first week after my hair transplant. Care should be taken so that the hat is not touching any of the grafts. I should apply a thin layer of antibiotic ointment to the stitches on the back of my head twice daily with my fingertip for 7 days. My stitches will be removed in 10-14 days.
The first day after your procedure you may place a soaked washcloth on your grafts for 10 minutes at a time up to 4 times per day. After 2 days I may begin gentle shampooing of the grafts twice a day. Gently means I do not allow the force of the shower to strike the grafts and I do not aggressively massage the grafts with my fingertips or fingernails. I may simple lean my head forward as I shampoo the back and sides of my scalp. This allows the suds and water to gently wash over the grafts, which is OK.
On the seventh day I may shampoo normally. I may normally massage the surface of the grafts with my fingertips and remove any crusts present.
Combing my hair- I may gently comb my hair (except in the grafted zone) from the first day after transplantation. I should not touch the grafts themselves with the comb. I may normally comb all my hair including any hair that may be present in the grafted zone beginning the seventh day as I did before the transplant.
Hairspray/Hairdressings- I may use hairsprays, conditioners, shampoos, and other hairdressings after 7 days. Since the grafts will be well healed, I will not harm them if sprays or other hair products come in touch with the grafts.
Pain- I have oral medication, Vicodin, to take as instructed for pain. I may also have Valium for relaxation and Ambien for sleep. It is important not to take these medications together, and only to take them as directed. Of course, there is no driving or operating machinery while under the effects of these medications.
Swelling is uncommon, but I may have some swelling around the area of my forehead and maybe around my eyes. Swelling if it occurs, peaks between the third and fifth day, and will be gone by the seventh day. Rarely does blood work its way down into the eyelids producing a black eye, but this can happen.
If my grafted area or the stitches in my donor area bleed, I can usually control the problem by applying pressure to the area with a cold pack. Applying a cold pack to the donor area can also help with pain control in the region. I can use a soft cloth saturated with ice-cold water or I can use an ice cube wrapped in a wet cotton cloth. If the bleeding does not stop with firm pressure applied for 15 minutes I will call Dr. Dauer or my personal physician. NEVER put a cold pack on the grafted area.
Numbness may occur for a short period of time after transplantation. It will resolve on its own, in most cases, within 3-12 months.
My stitches could be somewhat uncomfortable and this is normal. If my grafts or donor area become hot, inflamed or very uncomfortable, I should call Dr. Dauer. If he is not available, I should call my personal physician.
I may experience some dandruff-like scaling, redness, or itch during the first month after transplantation. I can use over-the-counter hydrocortisone cream or lotion to the area 2-4 times each day to clear this up. Small crusts may form at the micrograft sites. These will come off with shampooing at 7 days or later. The small spicules of hair that come off with the crust are normal and do not represent loss of grafts. The hair will still begin growing as expected 3 months after the transplant. Some “ingrown hair” type of pimples may occur during the regrowth phase, 45-90 days after the procedure. I can use over-the-counter benzoyl peroxide preparation to the area 2 times each day for 3-5 days to help clear these up quickly.
Swelling – I may have been given an oral medication, Prednisone, to take as instructed to help prevent swelling after the transplant.
I will contact Dr. Dauer or my personal physician if any of these uncommon complication occur:
- Vascular growths at surgical areas
- Tender scar formation
- Any sign of infection
- Any other problems I believe out of the ordinary
Many of these problems will be resolved on their own. Some will need the attention of Dr. Dauer or my personal physician.
A Note from Dr. Dauer….
Over many years of hair transplantation experience, we have found the procedure to be very safe and complicated by few difficulties. The vast majority of patients who have undergone the procedure have done so without problems. They have enjoyed the rewards of lifelong improvement in their appearance. Recent advances, especially with naturally occurring follicular unit micrografting, have dramatically improved the patient’s appearance creating a much more natural result.
Proper aftercare is important in assuring the best results, so be sure to follow the instructions given. Always remember, we have your very best interest at heart. We want you to be pleased with your results. Be assured we will do everything reasonably within our power to perform the procedure in a proper and professional fashion. Also, we will follow up on any problems you may develop in the routine course of healing after your transplant.
We expect you to inform us if any problems arise so that we can handle them in the proper manner. You are very special to us; you health and happiness are our purpose in life.
Things to Remember After Your Hair Transplant
- Follow instructions carefully to avoid loss of grafts.
- Growth will not be as thick as you or I would want. The top of your head originally had between 30,000-50,000 hair before it began to lose hair. Typically, even with multiple procedures, we only move 12,000-18,000 hair.
- Growth will not occur as fast as you would like, in fact, you will probably see no growth before 4 months. Be patient. It takes most people at least 4-6 months to begin seeing the positive change and 12 months to see the full benefit.
- In some cases, you may actually look a little thinner after the transplant. This is more likely to occur when pre-existent hair are present in the transplanted zone. These hair may thin out in the 3 months after transplantation, but will usually grow back about the same time and rate that the grafts grow in. Do not worry if you look thinner at 3 months after transplantation- your rewards come at 6-12 months.
- You will not get the maximum benefit from your transplant until 9-12 months after the procedure because the hair must have this amount of time to regrow length and thickness of shaft. You will see improvement at 4-6 months in the form of fine hair but results peak out at 9-12 months.
- Hair loss is a relentlessly progressive process, therefore you likely will want additional replacement procedures in the future to thicken or cover new areas of loss. This is also the reason we strongly recommend the use of Propecia and Rogaine to help prevent this progression.
- We are always available to discuss any questions or concerns you may have. Don’t be hesitant to cal usl. To us, you are the most important person in the world; you are our patient.
FINANCING FOR HAIR TRANSPLANTS
We accept Care Credit financing for our procedures.
If you wish to finance your procedure with Care Credit it is best to establish an account with them by calling 866-247-3049 or going to their website www.CareCredit.com. In some cases we can provide short term no interest financing through Care Credit.
About our Hair Transplants Practice
In our hair restoration practice we deal exclusively with Hair and Eyebrow Transplants. For each patient that presents to us for hair transplants, our goal is to achieve complete naturalness with as much density as possible. We feel these two goals are best achieved when the treatment plan is individualized for each hair loss patient. There are a host of factors that must be taken into account with each hair restoration patient before formulating the best treatment plan. Some of the more important factors are: the patient’s age, the hair-to-skin color contrast, the caliber of the hair, the character of the hair, the patient’s goals for styling, and, perhaps most important, the ratio of available donor hair in relation to the transplant recipient area in need of coverage. The most important thing is to always do what’s best for the patient.G+