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Hair Transplant Microscopic Dissection. All Microscopes Are Not Created Equal

Greetings,

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

/by Los Angeles Hair Transplant Specialist

One Week After FUE- Follicular Unit Extraction

Greetings,

Today I will show a patient of mine who received 1653 grafts via FUE using the SAFE system motorized manual punch with the .9mm hand piece. This patient was experiencing his hair loss primarily in the frontal scalp and this is where the majority of the grafts were placed. I believe the SAFE system which utilizes the blunt tip technology to extract the donor grafts in the best motorized piece of equipment for harvesting grafts via FUE. I also believe that the .9mm punch tip is ideal for extracting intact healthy grafts, while causing the least amount of scarring. Most punches for FUE are 1mm or larger, including the new ARTAS robot which only uses a 1mm punch at present. the difference between .9mm and 1mm may not seem like much, but when you multiply 1500 or 1600 times .1mm it adds up to a significant amount of increased scarring with the larger punch tip. In this patient I also used ACell which is an extracellular matrix (ECM) a natural biological material that can be implanted at the site of an injury or damaged tissue in order to stimulate healing. The graft stimulates the body’s own cells to form new tissue specific to that site (a process referred to as “Auto-cloning”). Therefore, instead of the body producing scar tissue, the body heals by remodeling with new tissue. I mixed the grafts to be implanted with ACell and saline and then at the end of the case I placed all the ACell and saline over the donor region and over the grafted region. The patient reported a minimal amount of crusting after the procedure both in the recipient and donor regions, and quick healing. The photos you will see show the patient immediately pre procedure and then then 7 days later. I will also be charting this patient’s progress throughout the next year with both photos and video. More to follow.

All the best,

Marc Dauer, M.D.

/by Los Angeles Hair Transplant Specialist

FUE (Follicular Unit Extraction) Harvest to Transplant Into Eyebrow Scar

Greetings,

Today I will demonstrate a case I recently performed utilizing FUE (Follicular Unit Extraction) to harvest the individual follicles and subsequently transplanted the follicles into and eyebrow scar. Traditionally I would not usually perform FUE in an eyebrow transplant case as it only requires a small incision in order to harvest the number of follicles necessary in order to restore typical eyebrows to normal appearing density. In patients who insist on shaving their hair extremely short (#2 buzz cut or shorter) FUE is a better option in order to make sure that the scar does not show through. In a small FUE case I do not have to shave the entire donor area, and can shave a small strip of hair to harvest the donor follicles and then the patient can cover the donor region by combing the hair above over the shaved area. As you can see from these results the transplanted follicles into the scar grey very nicely and the patient was very happy with the final outcome. I have also used FUE to harvest follicles from the neck in order to transplant into mustache scars (in patients with cleft palate deformities and others) and other beard scars with excellent results. Below I have shown the before and after photos of this patient with the eyebrow scar.

All the best,

Marc Dauer, M.D.

/1 Comment/by Los Angeles Hair Transplant Specialist

Post Hair Transplant Scabs- How to Minimize

Greetings,

Today I will discuss the scabs that form on the transplanted grafts immediately after the Hair Transplant procedure. Typically the crusts around the transplanted grafts form overnight. In my typical treatment I place a thin layer of antibiotic ointment on the grafts immediately post procedure. I also give all of my patients a copper peptide containing solution that I have formulated and call “Heal Spray”. I instruct my patients to spray on the grafts every 3-4 hours for the first 3-5 days. I have found that the copper peptide solution serves not only to keep the grafts moist, but it also loosens the crusts sooner and allows for quicker healing time and shedding of all the scabs. I also give my patients a special shampoo I have formulated called “Thicken” that contains a number of follicle thickening agents as well as coltar, which is used to treat a variety of different forms of inflammation and seems to calm the scalp down and reduce inflammatory properties that can cause scalp irritation. I encourage my patients to wash their hair with the Thicken shampoo beginning day 1 after their procedure by mixing a small amount of shampoo and water in a bowl and pouring it over the head. The Heal spray combined with the Thicken shampoo tends to get rid of most of the crusts around the transplanted follicles in 5-7 days which allows for a quicker return to normal appearance and a better growth potential of the grafts.

All the best,

Marc Dauer, M.D.

/by Los Angeles Hair Transplant Specialist

The Illusion Of Density

Greetings,

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

/by Los Angeles Hair Transplant Specialist

Hair Transplant From One Individual To Another

Greetings,

Today I would like to discuss a question that is often posed to me regarding transplanting hair from one individual to another. Unfortunately the bottom line is that is does not work, unless it is from one identical twin to another. I have discussed this concept with a number of prominent hair transplant surgeons, one of whom actually tried to transplant 100 grafts from one individual to another. In the test case it did not work, and I have not spoken to one individual who claims to have had success transplanting from one individual to another. I do have a colleague who recently transplanted hair from one identical twin to another in a rare case where one twin lost hair secondary to radiation exposure for treatment of cancer. The transplant was performed less than 6 months ago, so the final results are not yet in, but preliminary results show good growth of the transplanted hairs in this case.

The holy grail for the field of hair transplant surgery will be the advent of hair cloning where we will be able to send a small sample of any individual’s hair to a lab for multiplication. This will negate the supply and demand imbalance that often exists and will also negate the need to harvest donor follicles either via FUE or FUT. Unfortunately we are many years away from being able to perform this in actual practice, but I have hope that the day will come. Until then, we can continue to harvest donor follicles via FUE or FUT and create impressive natural results in suitable candidates.

All the best,

Marc Dauer, MD

/by Los Angeles Hair Transplant Specialist

Pain Associated With Hair Transplant Procedures

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

/by Los Angeles Hair Transplant Specialist

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

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

/by Los Angeles Hair Transplant Specialist

Non-Physicians Performing Hair Transplant Procedures

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.

/by Los Angeles Hair Transplant Specialist

FUE Into Previous Strip Scar From FUT

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Greetings,

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.

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All the best,

Marc Dauer, MD

/by Los Angeles Hair Transplant Specialist