Greetings,

Today I will discuss discomfort associated with the Hair Transplant procedure. Many patients are anxious prior to the procedure that the pain will be extremely intense both during the procedure and after the procedure. I have also encountered patients who have been treated elsewhere who did experience significant discomfort either during their procedures or afterward. I can honestly say that the vast majority of my patients report very little discomfort both during the procedure and after the procedure. Typically the greatest discomfort is the first night post procedure and in most cases by the second day after the hair transplant, most of the pain has resolved.

The first thing I do when a patient arrives on the day of their procedure, after they have signed consent forms and all their questions have been answered, we give them a small amount of oral Valium in order to relax. To minimize the pain during the injections of the local anesthetic I use a massaging device that barrages the brain with vibratory sensation thus making the discomfort of the injections very minimal. I have used many different anesthetic devices in the past (The Wand, etc.) and without a doubt this is the most painless way to administer the local anesthetic. I extract the donor strip meticulously and close the donor area with a very fine suture. This also minimizes post procedure discomfort as compared to metal staples or thick sutures which can both be very uncomfortable.

There is never any post procedure pain in the transplanted region. Typically there is some discomfort the first evening after the procedure and the patient is given pain medication is order to alleviate this pain. Usually by the second day, most if not all of the pain is gone and the sutures have been described as “slightly annoying”. With FUE there is almost no discomfort starting day 1 after the procedure and there are no sutures.

I have met so many patients who were scared to undergo the procedure because of their fear of injections or their fear of the pain involved. Universally the feedback has been that the pain associated with the hair transplant procedure, whether by FUT (Strip Harvest Procedure) or FUE (Follicular Unit Extraction), is so much less than they were anticipating and would never again deter them from having a follow up procedure.

I hope this helps to alleviate some concern among prospective patients regarding discomfort during and after the hair transplant procedure.

All the best,

Marc Dauer, MD

Greetings,

Today I want to discuss the scarring that is created in FUE versus FUT. In FUE procedures a small tool measuring between .8-1.0mm is used to harvest each individual follicle. In FUT a linear strip is resected and the strip is dissected into individual follicles. In FUE because we cannot extract every follicle in any one area (or we would create bald patches in the donor zone) we must extract every third or fourth follicle. Because of this, if we are trying to obtain over 1200-1500 follicles for transplantation in an FUE procedure, we must extract these follicles over the entire donor zone, which can measure up to 30cm x 10-12cm. If we were doing a 1500 graft FUE case using the 1mm extraction tool and we wanted to measure the amount of scarring produced in the donor zone by the harvest, this would create approximately 1500 x 1mm = 1500mm= 150cm of pinpoint scarring over the entire donor region. By comparison, to harvest 1500 grafts via FUT and using a density of 80 follicles per cm2 this would require a strip of about 19cm x 1cm to be resected and after normal healing this should result in a linear scar that measures 1-3mm (lets say 2mm x 20 = 40mm or 4cm of linear scar). By looking at these numbers it is clear to see that there is significantly more scarring produced in FUE procedures versus FUT procedures. The main difference is that the FUE scars are pinpoint and spread over a much larger area, while the FUT scars are linear and over a much smaller area. Also, because FUE must be harvested over a much larger area, the number of donor follicles any individual will be able to donate over a lifetime will be significantly less with FUE versus FUT. There is a still a place for FUE in Hair Transplantation, specifically with people who insist on wearing their hair at a #1 or #2 buzz cut, when the linear scar may show through even under the best of circumstances. These are the people who I generally recommend FUE to. It is imperative  that every patient understand all the details related to both harvesting techniques prior to deciding which is best for them in the short term and the long term.

All the best,

Marc Dauer, MD

Greetings,

Today I want to discuss FUE otherwise known as follicular unit extraction. All Hair Transplant surgeons are not created equal and certainly all surgeons performing FUE are not created equal. There are many different devices on the market used to harvest FUE grafts ranging from the Artas Robot, to the Neograft, to motorized hand held punches to manual punches. After doing extensive research into all the different devices I opted to use the SAFE system which is a dull tip motorized punch to harvest my FUE grafts. Because FUE involves harvesting a follicle (with a typical diameter small than 1mm, and the base of the follicle below the skin which you cannot see when harvesting) it requires a tremendous amount of skill on behalf of the person performing the harvest. In my practice I harvest every follicle personally. I will post a photo of my FUE grafts that I harvested yesterday. What you can see in the photo is that each and every graft in completely intact with the entire follicle and a small amount of tissue surrounding the follicle as well. This is crucial to the graft survival and a key reason why so many patient’s do not get the results they hope for with FUE. Not all FUE surgeons are created equal and it is very important to do your proper research before deciding to have FUE with a specific surgeon. In experienced hands FUE can be an amazing procedure.

All the best,

Marc Dauer, MD

Greetings,

I have recently begun to experiment using PRP, which is platelet rich plasma, in certain hair transplant procedures. PRP has been used in wound healing for a number of years. Recently some have begun to use it in conjunction with Hair Transplant procedures. The PRP is obtained from the patient prior to the procedure via a blood draw. The blood is then spun down to separate the red blood cells from the PRP. The PRP contains growth factors that aid in healing. We have been experimenting injecting the PRP into the donor region, bathing the grafts to be transplanted in the PRP, and then spraying the PRP onto the scalp for better post operative healing. So far the initial results have been promising. I still cannot definitively state that I see a superior result using the PRP compared with procedures performed without it, but I will continue to investigate and look forward to having more information moving forward. I also plan to offer it to my patients who are interested, though letting them know that we are still in the experimental phase. I look forward to discussing this further in the future.

All the best,

Marc Dauer, MD

Greetings,

I just returned from the International Society Of Hair Restoration Surgeon’s annual meeting in the Bahamas. This ISHRS Meeting 2012 is always such an amazing opportunity to compare notes with respected colleagues in the field and discuss the latest innovations and the new technologies on the horizon. I was a faculty speaker at the meeting and gave a lecture for the board review course on donor harvesting in the strip harvest procedure. I was very intrigued by many exciting new advances and plan to do further investigation to see how I can continue to improve my treatments for hair loss. My philosophy is that no matter how good you are there is always room for improvement, and if you are not moving forward you are moving backward. I plan to continue moving forward and along those lines I am excited to incorporate new advances into my practice. I look forward to discussing these new additions to my Hair Transplant practice in the very near future.

All the best,

Marc Dauer, M.D.

Greetings,

Yesterday the Wall Street Journal published an interesting article detailing new research that has shown some correlation between Vitamin D receptors in the skin and the ability to regrow hair follicles in the lab. While this technology is many years away from practical usage in the clinical setting I believe these new findings may help to develop new technologies that will lead to us eventually being able to clone hair follicles in the lab, or stimulate stem cells to create new hair follicles.
I was the expert Hair Restoration Surgeon on The Today Show today discussing this article today.
Here is a link to the show and a copy of the article below.

http://video.today.msnbc.msn.com/today/49001161

All the best,
Marc Dauer, M.D.

The Search for a Baldness Cure:

Researchers Target Vitamin D to Coax Dormant Follicles to Grow Hair; Early Promise, But Years to Go

By SHIRLEY S. WANG

Fresh clues to what makes hair follicles go dormant are pointing toward potential cures for baldness.

Vitamin D and its receptors appear to play a role in hair follicle health and now there’s new evidence that it could help treat common forms of baldness. Shirley Wang explains on Lunch Break. Photo: Getty Images.

Several research teams are working to figure out ways to spur existing follicles—the tiny organs in the skin that give birth to hair—back into action, or to make new, active follicles. New treatments based on this work likely are many years from the market, but these approaches could lead to the significant breakthrough of helping people who are already bald. By contrast, topical products available now, such as Rogaine, appear to be most effective in helping prevent further balding after it has started. And with current surgical procedures, healthy hairs can be moved into bald areas, but the operation has to be continually repeated.

Behind the Baldness

Crucial to the hair-growth and balding process, scientists have found, are vitamin D and the microscopic receptors that bind to it in skin. These elements have become the focus for several research teams. (Supplements might offer health benefits for people lacking enough vitamin D, but they won’t bring back lost hair, researchers say.)

Some researchers, including those from the San Francisco Veterans Affairs Medical Center and Harvard Medical School, have identified molecules besides vitamin D that appear to activate the receptor and hold potential for future treatments. In July, Japanese researchers demonstrated in animals that adding vitamin D helped the process of using stem cells to generate new follicles.

Vitamin D has long been known to be important for keeping bones and skin healthy. But research on its role in bone development has progressed much faster than has the research on skin and hair.

$2 Billion

Amount spent yearly world-wide on

surgical procedures

for hair loss.

Source: the International Society of Hair Restoration Surgery

35 million

Number of men affected by male-pattern baldness or androgenetic alopecia in the U.S.

Source: NIH

The vitamin D receptor is “crucial for the regeneration of hair,” wrote Mark Haussler, a professor in physiology, chemistry and biochemistry at Arizona State University in Phoenix, in a recent paper. He discovered the receptor in 1969.

Hair growth follows a cycle, with follicles typically producing hair for two to six years before the hair falls out and the follicle lies dormant for a period thought to vary from a few weeks to a few months. A replacement hair then emerges. At any point in time, some 15% of our follicles are sleeping, say researchers.

But for some people, this sleeping phase is permanent, and if enough follicles hibernate in the same skin area, baldness results. The message to grow hair appears to be guided by partner cells called dermal papilla cells. Stem cells in the skin that haven’t matured yet can become regular skin cells or differentiate into hair follicles. Without the right chemical communication, existing follicles go dormant and stem cells that have yet to differentiate themselves may become skin cells instead of follicles.

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Many scientists and several companies have tried to expand the number of follicles and normal dermal papilla cells while maintaining their functioning, but have failed.

The demand for better hair-loss treatments is great. Nearly $2 billion a year is spent world-wide in surgical procedures for hair loss, according to the International Society of Hair Restoration Surgery. One of the most common forms of baldness, called androgenetic alopecia—widely known as male-pattern baldness—affects 35 million men in the U.S., according to government data, and is related to the amount of certain hormones in the body. Estimates suggest 20 million to 30 million women also have alopecia, but they generally don’t lose hair in a pattern like men do.

Chemotherapy-induced hair loss in cancer patients is also common, and in some cases, the follicles may die. Several other factors such as childbirth, crash diets and some medications can also lead to hair loss, though the exact reasons why follicles are lulled to sleep isn’t well understood.

Current treatment options include topical products, such as Rogaine and Propecia, which work best for prevention, says Rashid Rashid, a dermatologist at the Mosaic Hair Transplant Center in Houston. Hair transplants—when hairs are moved from one area of the scalp to a bald area—are the other main option. This can be done more quickly than ever now, says Dr. Rashid, but the new hairs don’t regenerate and fall out after a couple of months.

Follicles don’t grow hair well outside the body, so although they can be grown in a lab, they don’t tend to produce hair.

Hair-regeneration research poses several challenges, researchers say. Follicles don’t grow hair very well outside the body, so even though the cells can be grown in dishes in a lab, they don’t tend to produce hair.

Much of the research in the field is focused on vitamin D. The receptor—the lock to which the vitamin D key binds—activates hair growth, rather than the vitamin itself, says Marie Demay, a professor of medicine at Harvard Medical School, who pioneered much of this work.

Biochemist Yuko Oda and a team at the VA Medical Center San Francisco and the University of California, San Francisco, recently found a molecule, called MED, that appears to suppress the actions of the receptor. In a study published in December in the Journal of Investigative Dermatology, they found that mice generated more hair after the gene that codes for MED in their skin was knocked out, suggesting a target for gene therapy.

Dr. Demay and colleagues last year found another molecule called LEF1 that also activates the vitamin D receptor, and can do so without the presence of vitamin D. The next step will be to demonstrate that activating the receptor in this way would actually produce hair, says Dr. Demay. If these molecules activate the vitamin D receptor, they change the “fate” of the cells into hair cells, Dr. Oda says. The work was published in the Journal of Biological Chemistry.

Researchers at the University of Tokyo recently added vitamin D supplements to the medium in which they were growing dermal papilla cells, hoping to spur more uncommitted stem cells to become active follicles.

In rats, the scientists found more stem cells were coaxed into becoming follicles when vitamin D was used in the final phase of growing the cells than those not treated, says Kotaro Yoshimura, a professor in the department of plastic surgery who was the senior author on the paper. In addition, more of those follicles matured to produce hair, raising the hope that this might lead to improved hair transplants in the future. The study appeared in the journal Stem Cells Translational Medicine.

Currently, hair transplants can only get single hair from one follicle “but we want to make 1,000 hairs from one follicle,” one after the next, says Dr. Yoshimura. They are now teaming up with two other sets of researchers and planning a clinical trial.

A challenge for researchers is that vitamin D has many functions in the body, such as improving bone growth. Taking too much vitamin D can have negative side effects such as calcium accumulation in the blood causing weakness or kidney problems, according to the Mayo Clinic. So it is important that any potential treatment be finely targeted. “We’re really aiming to manipulate vitamin D or vitamin D receptors only in the skin,” Dr. Oda says.

However, the majority of Americans don’t get the recommended daily dose of the vitamin. For some, getting their full amount—from foods such as fatty fish or from being in the sun—may generally improve health and aid hair growth, Dr Haussler says.

Write to Shirley S. Wang at shirley.wang@wsj.com

Copyright 2012 Dow Jones & Company, Inc. All Rights Reserved

Greetings, I just saw one of my patient’s in follow up. He is just under 6 months post his first procedure. His hair is already growing in nicely and he should see significant more growth in the next 6-7 months. The patient was so pleased with the results that he asked to narrate a video testimonial detailing his experience. This is the first in a series of video testimonials from the patient and we hope to chronicle his progress over the next few years detailing the progress from the initial procedure and any additional procedures. I think this video can help anyone who is considering hair transplantation.

All the best, Marc Dauer, M.D.

Greetings,

With the advent of the NeoGraft machine and it’s accompanying marketing that includes ideas for the prospective “NeoGrafter” that an attending physician is only necessary in order to “lend” his license to the practice so that they be allowed to perform hair transplant procedures, it has opened up a new chapter in the discussion of what is acceptable to delegate in Hair Transplantation. Physicians performing Hair Transplants have delegated certain tasks for years including dissection of the grafts and placement of the grafts. In some practice they even practice the “stick and place” method where the nurse create the incision site and places the hair graft in the incision. In my practice I create each and every insertion site for the placement of the hair grafts. My thought is that the exact design is based on the creation of the receptor sites. The hairline design, as well as the angle and orientation of the hair growth are all affected by the creation of the receptor site. I believe that the surgeon should have the complete control of this step as it is the surgeon who will take full responsibility for the outcome of the procedure. For patients exploring the idea of having a Hair Transplant procedure it is important that they ask important questions such as, “what are the steps in the procedure that the physician will be performing, if any, and what are the steps that the physicians assistants will be performing?” Knowing as much information about the physician and the medical group that is performing your procedure will assist in making an informed decision, and hopefully one that will lead to positive results.

All the best,

Marc Dauer, M.D.

Greetings,

I recently read an interesting article written by Dr. Yagyu from Japan that discusses guidelines for patients who are on antithrombotic therapy and interested in having a hair restoration procedure.

The procedures we perform as Hair Transplant Surgeons are typically completely elective and as such do not warrant putting the individual in any sort of medical danger. Along these lines, we are often approached by patients who may be taking antithrombotic medications including aspirin, coumadin, and plavix for a variety of medical conditions. In the past, the thinking has been that since we are usually transplanting into the scalp or face, and since the areas are so vascular (which is part of the reason why there is such good growth of follicular grafts and such a low incidence of infection) that it would not be a good idea to transplant someone who is on one of these antithrombotic medications, as it would be difficult to control the bleeding and thus difficult to create sites for the transplanted hair and place the grafts as well. This study by Dr. Yagyu included 25 patients with cardiovascular disease who underwent 46 hair transplant procedures. Risk factors in these patients included coronary artery stents, prosthetic heart valves, and atrial fibrillation. The conclusions based on the results showed that in these patients low dose aspirin “does not cause hemorrhagic tendency and it can be continued before hair transplantation”. The study also determined that low dose coumadin also does not interfere with surgery and can be continued before a hair transplant procedure. My own experience with a patient taking Plavix prior to undergoing an eyebrow transplant procedure, was that in this specific case, there were no complications associated with the patient taking an antithrombotic medication.

It is always imperative to weigh the risks against the rewards associated with any patient undergoing a surgical procedure, but the results of this study are very positive in regards to patients who require antithrombotic therapy and wish to undergo a hair transplant procedure.

All the best,

Marc Dauer, M.D.

Greetings,

Recently there has been a lot of discussion in regards to an article in CBS news (see below) that discusses researchers growing hair on mice. My thoughts on this are that this is one of the first in a series of studies that hopefully down the line will lead us to the ability to clone our own hair in a laboratory setting. I still believe we are at least 20 years away from being able to do this in a practical and economical way, but this is definitely the future of Hair Transplantation. The ability to clone one’s own hair will negate the need to harvest the hair from the individual either via FUE or FUT and will also give us unlimited supply for any demand. Again I believe we are at least 20 years away from this, but this is definitely the future of Hair Transplantation and I look forward to being a part of this exciting future. Here is a link to the article.

http://www.cbsnews.com/8301-504763_162-57416401-10391704/researchers-successfully-grow-hair-on-bald-mouse-humans-next/

All the best,

Marc Dauer, MD