Factors Affecting Cosmetic Density In Hair Transplants

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Greetings,

Today I want to address the factors that affect cosmetic density in hair transplants. Firstly there are the anatomic factors. The single most important factor anatomically is the caliber of the hair. An increase in just .1mm of the diameter of the hair follicle can add up to 30% increased cosmetic density. The other anatomic factors that contribute are skin color to hair color contrast (the more contrast, the more you see through the hair), and curly versus straight hair (curly hair looks thicker than straight hair).

Then there is the follicles per cm squared, which is the amount of follicles transplanted in any given area. Normal non balding scalp can have a density of between 60-100 follicles per cm squared. The minimum density that should be transplanted into any bald area should be at least 30 follicles per cm squared. As we transplant more follicles per cm squared we achieve greater cosmetic density. It requires a much higher degree of skill to transplant a high number of follicles per cm squared.

In summary, there are both anatomic and surgical factors that contribute to cosmetic density. It is imperative that prospective patients looking at pre and post hair transplant photos take the anatomic characteristics into account when considering hair transplant results.

All the best,

Marc Dauer, M.D.

/by Los Angeles Hair Transplant Specialist

Female Hairline Lowering

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Greetings,

Here is a a female patient of mine who has a genetically high hairline and thinning of hair in the existing hairline. I slightly lowered the hairline and increased the density in the existing hairline. Female patients have a very different hairlines than male patients and it is imperative that this is taken into account when creating the recipient sites for the transplanted hairs. The photo below shows the patient pre operatively and then 2 weeks post procedure. Some of the transplanted grafts have already shed, which is normal. They will begin to grow back at about 12 weeks. From the “after” photo you can see the very specific angle and orientation of the transplanted grafts to match exactly the existing hair that that when the hairs grow out they are all flowing in the same directions as the native hair. The goal is that you should not be able to tell any difference between the transplanted hair and the native hair.

All the best,

Marc Dauer, M.D.

This is photos of a female patient who received a hair transplant to lower the hairline.

This is photos of a female patient who received a hair transplant to lower the hairline.

/by Los Angeles Hair Transplant Specialist

FUE (Follicular Unit Extraction) versus FUT (The Strip Harvest Procedure)

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Greetings,
I am often asked by prospective patients which harvesting procedure is preferable for hair transplantation. Follicular unit extraction or the strip harvest procedure? My answer is that it depends on the individual. If a person needs the option to cut his hair down to a number 1 or a number 2 buzz cut then follicular unit extraction is the needed procedure so as to avoid a visible linear scar. If the person is comfortable leaving their hair at a number 3 or preferably number 4 cut or longer,  then the strip harvest procedure is absolutely an option. Typical linear scars from strip harvest procedures should measure between 1 and 3 mm in width and the length is determined by the amount of hair follicles needed to be harvested. This is in contrast to tiny white dots that are left in the donor region after the follicles are harvested in follicular unit extraction. Neither procedure is scarless. There is no such thing as a scarless hair transplant procedure. In fact, the scarring from follicular unit extraction in the donor region is greater when measured in surface area then the scarring from the strip harvest procedure. The difference is that in the strip harvest procedure the scarring is concentrated in a linear scar which is more noticeable when the hair is very short as opposed to the diffuse pinpoint scarring which is the result of follicular unit extraction. Some patients who have been overharvested in follicular unit extraction still do not have the option to cut their hair very short as the confluence of many pinpoint scars can start to show as “moth eaten” scalp with a short haircut. Also, it is usually not advisable to cut the hair down to a number zero haircut after follicular unit extraction hair transplants as you will probably see the tiny white dots left from the extraction of the follicles. To be clear, when follicles are removed from the donor area in follicular unit extraction one by one, they do not grow back in the donor area. They are taken out and moved to another area where they then begin to grow.
In follicular unit extraction every third or every fourth hair follicle is randomly extracted so as not to create bald patches in the donor area. Because of this it is important to draw the hair follicles from the entire safe donor area. This means that the entire donor area is affected in the first hair transplant procedure. This is in contrast to the strip harvest procedure where only about a 1 to 1 1/2 cm wide area is extracted by a length that is determined by the amount of hair follicles needed to harvest, typically leaving behind a 1 to 3 mm linear scar with untouched robust donor area above and below the strip scar. When the patient returns for a second procedure the physician should harvest the second strip from the same area removing the original strip scar so as to leave the patient with only one strip scar even after multiple hair transplant procedures. If for some reason the strip scar widens and the physician is not able to extract the old scar, there is still untouched donor zone above and below the original strip scar allowing the physician to either take a new strip in a new area or begin follicular unit extraction in the surrounding areas around the original strip scar. What this means is that the ultimate donor zone in a patient will probably be contain more follicles if the patient begins with the strip harvest procedure versus follicular unit extraction. This also means that patients who are predicted to experience severe hair loss should strongly consider leaving their hair a little bit longer and undergoing the strip harvest procedure to begin with, in order to maximize the number of donor hair follicles from their permanent donor zone.
When harvesting follicles in follicular unit extraction, the patient must shave their head down to a number zero cut in order to extract the follicles, versus the strip harvest procedure which allows the patient to leave their hair longer and use the existing hair to cover up the strip scar.
In follicular unit extraction the physician can choose the larger follicular units i.e. the two, three, and four haired follicular units, while in the strip harvest procedure you only get what’s in the strip which may typically ends up being 2/3 one hair and two haired follicles. What this means is that the hair count can possibly be slightly higher in follicular unit extraction.
Follicular unit extraction can be much more variable than the strip harvest procedure because a high degree of skill and efficiency required to extract the follicles intact. This is in contrast to the strip harvest procedure which involves less handling of the hair follicles. Because of this we often see more variable rates of growth in the hands of inexperienced practitioners practicing follicular unit extraction. It is imperative that the prospective patient see multiple results of the physician you are considering with the follicular unit extraction procedure as well as the strip harvest procedure.
In summary there is no right or wrong when comparing follicular unit extraction and the strip harvest a procedure. Both are excellent procedures and both can provide excellent results in the hands of an experienced hair transplant surgeon. What’s most important is that the patient chooses the procedure that suits them the best both in the short term and the long run.
All the best,
Marc Dauer, M.D.
/by Los Angeles Hair Transplant Specialist

Botched Eyebrow Transplant Repair

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Greetings,

I recently saw a patient in consultation that had an eyebrow transplant procedure performed in the office of a very well known physician. The issue is that the physician did not perform the procedure. In fact, the physician is not trained in hair transplantation at all and does not even perform hair transplant or eyebrow transplant procedures himself. What he did was have a medical assistant perform the entire procedure, from beginning to end, and the physician did not perform any aspect of it. The medical assistant performed the harvest using the neograft automated FUE machine and then created the recipient sites and placed the grafts. The patient ended up having 2 procedures like this.

The entire procedure was an epic failure. Only about 20 hairs grew from both procedures on each eyebrow and the hairs that grew were growing straight out from the skin in unsightly directions. The donor area in the back of the head was also significantly scarred from the attempted extraction of many hundreds of hair follicles.

In addition, the patient also had an eyebrow tattoo performed in the same physicians office prior to the 2 eyebrow transplants which created even more scarring in the eyebrow.

To have a medical assistant perform the entire hair or eyebrow transplant procedure is not only unethical, it is against the law in many states including California.  Unfortunately this represent a growing trend in the field of hair and eyebrow transplantation. More and more companies are pitching “automated” devices to harvest hair follicles and selling physicians who have no experience in the field with a new device to increase their revenue growth. Their pitch is that you don’t need to know anything about hair and eyebrow transplants, just buy the machine and the company will supply per diems technicians to do the rest. This is the result of that.

I performed an eyebrow transplant procedure on the patient and placed approximately 300 follicles per eyebrow. The results are shown a week after the procedure. In a few months I will updated with follow up photos. Because of all the scarring from the previous eyebrow tattoo and botched eyebrow transplants, the patient will have less growth yield than someone with healthy tissue. She should still have an excellent result and I already told her she should expect to have a second procedure in 9-12 months to increase the density.

This should be a lesson to anyone considering hair or eyebrow transplants. Make sure you go to a physician who specializes EXCLUSIVELY in hair transplants or if you are going to have an eyebrow transplant someone who does many of these procedures, and that they have dozens if not hundreds of results to show you. Just because the physician is skilled in another field does not make them an excellent hair or eyebrow transplant surgeon.

All the best,

Marc Dauer, M.D.

This is a botched eyebrow transplant with pre existing eyebrow tattoo present.

This is a botched eyebrow transplant with pre existing eyebrow tattoo present.

This is a botched eyebrow transplant with pre existing eyebrow tattoo showing the hairs growing in different directions incorrectly.

This is a botched eyebrow transplant with pre existing eyebrow tattoo showing the hairs growing in different directions incorrectly.

 

This is a botched eyebrow transplant with pre existing eyebrow tattoo immediately post corrective eyebrow transplant procedure.

This is a botched eyebrow transplant with pre existing eyebrow tattoo immediately post corrective eyebrow transplant procedure.

 

This is one week after approximately 300 grafts were placed in each eyebrow to correct a botched eyebrow transplant procedure.

This is one week after approximately 300 grafts were placed in each eyebrow to correct a botched eyebrow transplant procedure.

 

This is one week after approximately 300 grafts were placed in each eyebrow to correct a botched eyebrow transplant procedure.

This is one week after approximately 300 grafts were placed in each eyebrow to correct a botched eyebrow transplant procedure.

 

 

/by Los Angeles Hair Transplant Specialist

Bad Hair Transplant

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Greetings,

Here is a patient who had a previous hair transplant strip procedure with a large chain Hair Transplant operation by a physician who had been performing hair transplants for over 30 years. The patient came to me requesting more density in the frontal scalp, but also complaining of a wide strip scar that was elevated with severe numbness. He also complained because the Physician who had performed his last procedure created a second strip scar deviating at one point from the first. He wanted me to take out the unsightly scar and consolidate the 2 scars into one.

When I started to dissect out the strip I noticed small blue thread and assumed it was a small retained suture that dipped below and was missed in the suture removed. To my amazement what I then discovered was that almost the entire length of the strip scar was closed below the skin with non absorbable nylon sutures. These are sutures that are only to be used on the skin surface and removed. They were placed into the subcutaneous layer below the skin and created a significant amount of scarring and was also giving the patient numbness. I removed the suture, which was caked in scarring at this point, and consolidated the 2 scars into one. The results are shown in the photos.

This should be a warning and reminder to prospective patients that when choosing your hair transplant surgeon make sure to do tremendous research into the person performing your procedure. Experience and focus on the singular discipline of hair restoration are imperative, but just as important is the fact that your surgeon should not have a cavalier attitude towards hair transplants, no matter how long they have been performing the procedure, and must convey and strong sense of sensitivity and respect for the art and science of the procedure, as well as keeping up to date on the latest developments in the field. The field of Hair Transplant surgery is the wild west and there are more unqualified individuals performing bad procedures than good. You only have one chance to do things right, so take the time to chose the proper physician who will give you the greatest chance of successfully achieving your goals.

Respectfully,

Marc Dauer, M.D.

Showing the strip scar before revision.

Showing the strip scar before revision.

This shows the nylon suture retained in the tissue below the skin and the scarring.

This shows the nylon suture retained in the tissue below the skin and the scarring.

Sutures found in the strip scar

Here is the strip scar immediately after revision and removal of the scarred tissue and retained suture material.

Here is the strip scar immediately after revision and removal of the scarred tissue and retained suture material.

/by Los Angeles Hair Transplant Specialist

Consumer Alert Warning Regarding Hair Transplants

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Greetings,

With the growing field of hair and eyebrow restoration procedures, and the abundance of new “automating” machines, companies are “pitching” doctors as not needing to know anything about hair transplantation, just buy the machine and we will provide some medical assistants to perform the entire procedure. This is taking place everywhere and I am seeing more and more cases of patients undergoing botched procedures in dermatology and plastic surgery practices that have no experience doing hair and eyebrow transplant procedures. I have posted some of these botched procedures and will continue to do so. It is imperative that the consumer stay vigilant and only go to an individual that specializes exclusively in hair and eyebrow restoration in order to increase the likelihood of an excellent result.

Now the International Society of Hair Restoration Surgery has also issued a warning to consumers regarding unqualified individuals performing hair and eyebrow restoration. Just because you are going to see a Physician does not mean that the individual is well versed in hair and eyebrow transplants. Make sure your treating physician can show you at least 100 before and after photos of their own patients that look good to you before considering the physician for your procedure.

You can find the full text of the ISHRS press release below.

All the best,

Marc Dauer, M.D.

http://www.ishrs.org/content/consumer-alert

Seeking Hair Restoration Surgery?  

Be sure that a properly trained licensed physician or properly trained licensed allied health professional practicing within the scope of his or her license is responsible for your treatment.


The International Society of Hair Restoration Surgery (ISHRS) is concerned about the growing risk to patients of unlicensed technicians performing substantial aspects of hair restoration surgery.  The use of unlicensed technicians to perform aspects of hair restoration surgery which should only be performed by a properly trained and licensed physician or properly trained and licensed allied health professional (e.g., nurse, nurse practitioner, physician assistant) practicing within the scope of his or her license,  places patients at risk of: (i) misdiagnosis; (ii) failure to diagnose hair disorders and related systemic diseases; and (iii) can result in the performance of unnecessary or ill advised surgery all of which jeopardizes patient safety and outcomes.  There may also be a risk that unlicensed technicians may not be covered by malpractice insurance.

The ISHRS believes the following aspects of hair restoration surgery should only be performed by a licensed physician or licensed allied health professional practicing within the scope of his or her license:

  • Preoperative diagnostic evaluation and consultation
  • Surgery planning
  • Surgery execution including:
    • Donor hair harvesting
    • Hairline design
    • Recipient site creation
  • Management of other patient medical issues and possible adverse reactions

To help insure patients have information needed to make informed decisions about who performs their hair restoration surgery, the ISHRS urges potential patients to ask the following questions as well as questions regarding costs, risks, and short and long-term benefits and planning:
Patients Should Ask These Questions:

  1. Who will evaluate my hair loss and recommend a course of treatment?  What is their education, training, licensure, and experience in treating hair loss?
  2. Who will be involved in performing my surgery, what role will they play, and what is their education, training, licensure, and experience performing hair restoration surgery?
  3. Will anyone not licensed by the state be making incisions or harvesting grafts during my surgery?  If so, please identify this person, explain their specific role and why they are legally permitted to perform it.
  4. Is everyone involved in my surgery covered by malpractice insurance?

 

             

 

Be your own best advocate. Protect yourself.

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International Society of Hair Restoration Surgery
A non-profit medical association
303 West State Street, Geneva, IL 60134 USA
www.ISHRS.org

The International Society of Hair Restoration Surgery is a non-profit medical association exempt from federal income tax pursuant to Internal revenue Code Section 501(c)(3). The mission of the ISHRS is to achieve excellence in medical and surgical outcomes by promoting member education, international collegiality, research, ethics, and public awareness.

/by Los Angeles Hair Transplant Specialist

FUE Hair Transplant Results and Donor Zone After 6 Months

Greetings,

Here is a video of a patient of mine who had just under 1700 grafts harvested from his donor zone with a 0.9mm FUE punch tip. The harvesting was done by me personally with a serrated tip and a motorized hand held punch allowing for minute changes in angles to ensure the greatest quality grafts and graft survival. The patient’s donor zone is shown at 6 months in the video and even with a very short haircut there is no evidence of the FUE harvest that was performed in the area that you see in the video.

I have also included the patients recipient zone at 6 months to show the amazing result that this patient already sees at 6 months. The patient should see significantly more growth over the next 6-8 months and what we are seeing in these photos is about 50% – 60% of the final results, but the growth is already impressive and the patient is very happy.

I hope you enjoy watching.

All the best,

Marc Dauer, M.D.

FUE Hair Transplant Results

FUE Hair Transplant Results

FUE Hair Transplant Results

FUE Hair Transplant Results

FUE Hair Transplant Results

FUE Hair Transplant Results

FUE Hair Transplant Results

FUE Hair Transplant Results

/by Los Angeles Hair Transplant Specialist

Neck Hair Follicular Unit Extraction – FUE

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Greetings,

I am often asked when is it a good time to use beard / neck hair for a hair transplant. Firstly the only way to harvest beard hair is via FUE. Also, since beard hair is slightly courser than scalp hair it should not be used in the hairline but for filler throughout the rest of the scalp. It can also be used effectively for beard augmentation or to cover beard scars. Beard follicles are typically 1 or 2 hairs as opposed to scalp which has larger follicular units. It also requires a high degree of FUE proficiency in order to be successful at harvesting intact grafts from the beard via FUE. Also, I prefer to only harvest from below the jaw line as it does leave very slight white dots after the grafts has been harvested. These dots are very hard to see in most individuals, however I prefer to leave these dots below the jaw line which makes them even harder to  find. Neck hair is a good alternative when looking for this type of hair or when the scalp donor is exhausted. It needs to be harvested with a high degree of efficiency and placed properly for maximum results.

All the best,

Marc Dauer, M.D.

/by Los Angeles Hair Transplant Specialist

Hair Restoration Surgery- Great Expectations

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Greetings,

Today I want to discuss how I as Hair Restoration surgeon manage my patient’s expectations to give them the most realistic idea of what to expect from their hair transplant procedure. Most patient’s today spent time online, from minutes to hundreds of hours, studying hair transplant photo results. This creates varying expectations amongst people.

My role as a Hair Restoration Surgeon is to understand the prospective patient’s expectations and give them feedback as to what they can expect realistically in terms of results from a hair transplant procedure.

The first thing I do is explain the procedure in depth and show them before and after photos of patient’s of mine who have had a similar hair type and balding pattern. This gives an idea of what to expect. I always encourage my prospective patients to spend time on my website looking at the more than 500 before and after patient photos and more than 100 videos of patient’s discussing their experience undergoing the procedure and their results shown on video. I feel that looking at both the photos and the videos give patients a realistic expectation as what to expect and the wide variety of results that are possible. The key factors are hair type, color, skin to hair color contrast, curly versus straight, and most importantly, how much hair will the person eventually lose over time.

Since it takes 6-7 months to see any appreciable results from the hair restoration procedure it is important to stress the growth timeline to the patient so that they understand exactly what to expect and are prepared for the time after the procedure before the new hair grows in. This can be a difficult time for some people and preparing properly is a very important thing to do before undergoing the procedure.

Finally, I tell every prospective patient that they will undergo this procedure more than once. This is for two reasons. Firstly, the transplanted hair will not fall out but the native hair will continue to fall and the person will want to keep up with continuing hair loss by transplanting more follicles. Secondly, almost every patient sees their results and wants to add to them by creating more density. Who wouldn’t want to add more density to their hair if they could?

All the best,

Marc Dauer, M.D.

/by Los Angeles Hair Transplant Specialist

When Is The Right Time To Have A Hair Transplant?

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Greetings,

Today I want to discuss a question I am commonly asked which is “when is the right time to have a hair transplant procedure?” The answer is different for every person. Each time I examine a prospective patient I try and estimate the full extent to which the hair loss will progress over the patient’s lifetime. This is imperative in order to understand how much donor hair the person will have available for the amount of balding area that will present over time. The individual needs to understand and internalize the amount of hair loss they will eventually have and try best as possible to see if they can be happy with a realistic result based on their supply to demand ratio. Young patients may not want to know their eventual hair loss amount or may want to proceed with a treatment plan that does not take this into account. This is not an option, as it is our job as hair restoration surgeons to educate the individual and only do what is right for the patient both in the short term and long term.

In general, I like to wait until the patient is at least 25 before performing the hair restoration procedure unless hair loss is taking a severe toll on the patient’s psychological health and I believe that the eventual loss of hair will not preclude the individual from being a good candidate for the procedure. In addition, that the prospective patient has a good grasp on what is a realistic result both in the short term and long term.

I always tell my patients when they ask me, “do I need to do the hair transplant now?”. No one needs to do this at any point. This is an elective procedure that people undergo in order to make them feel better about themselves. To reclaim a piece of the person that they once had. Something that was once part of their body and their appearance, that was taken away from them. When you get to the point that you don’t like looking in the mirror anymore at what you see on your scalp, then that is the right time to have a hair transplant procedure (assuming you are chosen as a good candidate and you have realistic expectations).

The psychological component of hair restoration surgery is one of the largest factors involved and it is our duty as hair restoration surgeons to educate our patients and allow them to make the best educated decision for themselves both in the short term and long run.

 

All the best,

 

Marc Dauer, M.D.

/by Los Angeles Hair Transplant Specialist