Hair Transplant Procedures In Patients With Old Plugs

Hair Transplant Procedures In Patients With Old Plugs


It is not unusual for me to see patients presenting for consultation who have plugs from the old way of performing hair transplant surgery. The plugs were groupings of 5-15 hairs that were punched out of the back of the scalp, and subsequently punched into the areas of thinning. They were very unnatural and looked like “dolls hair” because hair does not naturally grow in clusters of 5-15 hairs. Natural hair follicles are typically 1-4 hairs per follicle, with only single hair follicles present in the hairline. These plugs were harvested using a primitive version of the harvesting procedure we now call follicular unit extraction or FUE. The major difference is that the punch tool used to harvest the plugs measured between 2mm-5mm in diameter, while the new tools I use to harvest my FUE follicles measure between .8mm-1mm in diameter. Besides the unnatural look that these plugs left in the recipient zone, they also caused a huge amount of scarring in the donor zone. Often times these patients donor density can be decreased up to 50-75% from their original density. For these patients wearing their hair very short is not an option as their donor density has been so depleted that they must wear their hair longer in order to cover up the thinness. In most cases the best way to treat these patients is to perform a strip harvest procedure and go right through the old plug zone. If there are areas that are unscathed (sometimes the sides are untouched) the patient will have more yield from these regions. Regardless, depending on the amount of scarring and door depletion, we can often harvest between 1500-2000 grafts from these individuals by taking a maximum safe sized donor strip. In some cases, this procedure may be performed more than once. We can then transplant single hair follicles into the hairline, camouflaging the plugs, and transplant follicular units into the pluggy areas throughout, creating a much more natural look. In some cases we can also perform FUE to plugs in the hairline to remove them completely or to reduce the number of hairs in the plug, and then recycle the follicles further back on the scalp.

The technology in hair transplant procedures has come a long way since the days of the old plugs. The good news is that using the latest technology at our disposal we can improve the look of the old hair transplant plug procedures.

All the best,

Marc Dauer, MD

FUT- Strip harvest hair transplant versus FUE- follicular unit extraction hair transplant


Sometimes when I meet a patient for the first time in consultation, they come to me with their mind made up as to which harvest procedure for the hair transplant they wish to undergo. Other times they come to me with no idea as to which harvest method for the hair transplant that they prefer. The Internet has been an amazing tool to educate patients regarding all aspects of hair transplant procedures, however there is a huge amount of misinformation in the Internet as well. Often it is difficult for the average consumer to differentiate between the truth and the fiction. To further complicate things, some Hair Transplant surgeons have their own agendas as well. These physicians may only be proficient in either FUT or FUE, and may then try to steer patients towards the procedure that they are more comfortable with. In other instances, the physician may have purchased an expensive piece of equipment that he needs to pay for, and then will steer patients towards the procedure which helps to pay off the equipment.

When I meet with patients the first thing I do is pay close attention to the hairstyle they wear when they come into my office. How short their hair is, how it is combed, product in the hair, hair color, etc. These are all clues that help me to understand the patient as an individual. In addition, between the family history of hair loss and the patients physical exam, I do my best to estimate how severe the patient’s hair loss will progress over time. I explain in depth the pros and cons of FUT hair transplant versus FUE hair transplant and tell the patient that I have no vested interest in which procedure the patient decides to have. I truly enjoy performing both FUT and FUE. My only interest is that the patient undergoes the procedure that suits them best. Not just in the short term but in the long term as well. That is part of my duty to my patients. I encourage my patients to take their time in deciding which procedure suits them best, so that they make the right decision. Not a quick decision that could prove to be wrong in the long term.

All the best,

Marc Dauer, MD

Hair Transplant Microscopic Dissection. All Microscopes Are Not Created Equal


Today I will discuss microscopic dissection in Hair Transplant procedures. Since the advent of Follicular Unit Hair Transplantation there are many different ways that physicians employ their staff to dissect the donor strip into individual follicular units in the process of hair transplant procedures, that is the groupings of hair that naturally occur on the scalp that we seek to move to the areas of thinning. There are many different types of microscopes that people use to dissect grafts and many different levels of magnification. Some physicians only have their staff use magnifying glasses on light boxes. I personally have my staff dissecting our grafts using brand new state of the art microscopes with 10x magnification and LED lighting. These microscopes are much more expensive than the typical microscopes but I believe they perform a superior job in dissecting the grafts. The 10x magnification is necessary to visualize the follicle in it’s entirety and allow for optimal dissection and the LED lighting provides excellent visualization while generating almost no heat (which typical lighting generates and can cause the grafts to dry out thus diminishing their chances of survival). Lessor magnification can result in the loss of intact follicles that cannot be visualized under lower magnification. This is turn can lead a lower survival of grafts in the hair transplant procedure.

In summary, state of the art high powered LED lit microscopes are more expensive, but superior in creating healthy follicular units for use in hair transplant procedures.

All the best,

Marc Dauer, MD

High Powered Microscope For Hair Transplant Dissection

The Illusion Of Density


Today I will discuss an important concept in Hair Transplant Procedures known as “the illusion of density”. The typical density of follicles in a non balding scalp or healthy donor region is anywhere between 60-100 follicles per cm2. Usually the number is in the 70-85 range. Keep in mind that when I state follicles, the follicles may be single hair, 2 hair, 3, hair, or even 4 hair follicular units. Every individual has a different amount of each, but the average is about 2.5 hairs per follicle, with some having a slightly higher number and some slightly lower. The general rule is that once thinning of hair is noticeable in any particular region, the individual has already lost 50% of the original amount of hair that was present in the region. That is why we can create the illusion of density by re-creating slightly more than 50% of the original hair that was present in any given region. The reason why this is so important is that in many individuals they will go on to lose a large amount of hair over a lifetime. This can lead many male patients to end up as norwood 6 or 7, which means they end up losing most of the hair on the top of their head. The only difference between Norwood 6 and 7 is whether the donor hair fringe on the sides stays high, or gradually lowers over time as well. So clearly there would never be enough hair in the donor region to re create the original amount of density over such a large area. By meticulously and artistically placing the follicles with discrete angles and orientations, and creating a hairline that allows for future hair loss and conservation of donor follicles for this future loss, we can re- create completely natural hairlines, with less hair than was originally present. Hair caliber and curl are major determining factors in the final cosmetic result with an increase in hair caliber by .1mm possibly adding up to 30% to the overall cosmetic density of the final result. Also, skin to hair contrast has a major effect on the final cosmetic density as well.

This is why it is so important to have a strong grasp on the artistic elements that allow us to create this natural hairline and placing the hairline in a location that conserves donor hair for future hair loss.

All the best,

Marc Dauer, MD

Pain Associated With Hair Transplant Procedures


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

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


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

FUE- Follicular Unit Extraction Grafts, Not All Created Equal


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

Vitamin D and Hair Follicles


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.

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


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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Testing, Testing…Can You Hear Better Now?

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

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

Non-Physicians Performing Hair Transplant Procedures


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.

FUE Into Previous Strip Scar From FUT


In this blog I will demonstrate a patient who came to me after he underwent the strip harvest procedure from another physician and his donor scar was wider than he expected and he could no longer wear his hair at the short length he wanted. In some cases these wide scars can be revised by excising them and closing them again under less tension than they were previously closed. In this case, the physician who performed the original procedure had already attempted to revise the donor scar and was unsuccessful in reducing it’s size. I recommended to the patient that I perform Follicular Unit Extraction (FUE) by harvesting follicles ones by one  with a special tool and then placing these harvested follicles into the strip scar to cover it with hair. Here are the results after 9 months. It made a significant difference to the donor scar and the patient is very happy as he can now wear his hair shorter and not be conscious of his wide donor scar. I have treated a large number of patients like this and it remains a good option for those with wide donor scars who wish to wear their hair shorter.

P1070449-274x300 P1050483-255x300

All the best,

Marc Dauer, MD




Los Angeles Hair Transplant Specialist

2080 Century Park East Suite 1802
Los Angeles, CA 90067
Phone: (310) 748-2224

Dr. Marc Dauer, MD is a board certified leader in hair restoration, hair transplants, eyebrow restoration for men and women, hair transplants for scars, and facial hair transplants.
Dr Dauer is experienced with successfully treating and restoring hair loss of the scalp, eyebrows, sideburns, male pattern baldness, female pattern baldness and from scarring. Dr. Dauer
is board certified by the American Board Of Hair Restoration Surgery and a member of the prestigious International Society of Hair Restoration Surgery. Dauer Hair Restoration provides
hair restoration, FUE and FUT, hair transplants. Los Angeles hair loss treatments, eyebrow transplants, sideburn transplant, treatment for male pattern baldness and female pattern baldness, and
transplantation for scarring. We serve patients from the Los Angeles area including, Santa Monica, West Hollywood, West Los Angeles, Culver City, Brentwood, Bel Air, Beverly Hills, Hollywood, Manhattan Beach,
Redondo Beach, Malibu and beyond. Consider Dr. Dauer for your hair restoration needs.

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