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How To Avoid Post Operative Swelling In Hair Transplant Procedures

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Greetings,

In years past patients who underwent hair transplant procedures experienced a significant amount of facial swelling in the forehead and around the eyes post procedure. Typically the swelling occurred at around 3 days post operatively after the hair transplant and usually resolved by around 6 days post operatively. Oral steroids have been used in the past to combat this swelling and definitely helped to reduce the swelling in many instances, but taking oral steroids, even in small doses, can subject the patient to other possible complications. This led the hair transplant community to look for other options. In the context of any hair transplant procedure I use what is called “tumescence” to allow for easier graft placement. Tumescence is where saline fluid is injected into the scalp in the regions where the new hair is to be transplanted. This accomplishes a few different things. Firstly, it compresses the vasculature down below which then allows us to cause less vascular injury when placing the grafts. Also, it stretches the scalp which also causes less bleeding, thus allowing for better visualization. Finally the stretching of the scalp also “widens the playing field” of the area to receive the hair transplants, thus allowing us to place the grafts closer together. When the scalp shrinks back to it usual size this helps to create optimal density. What I now routinely do is mix in a small amount of injectable steroid solution, diluted in the saline that is to be used for tumescence. In addition, I no longer give any oral steroids. Since there is no downside to diluting such a small amount of steroid into the tumescence fluid, this make it much safer for the patient then taking oral steroids and the results have shown that greater than 90% of my patients experience no post operative swelling after a hair transplant procedure. In the rare case that swelling does occur, it is then possible to treat with oral strides if so desired. This truly has been a major advance in the field and one that greatly benefits the patients and decreases possible complications.

All the best,

Marc Dauer, M.D.

/by Los Angeles Hair Transplant Specialist

How Many Hair Transplant Procedures Will I Need?

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Greetings all,

Some of the most common questions I get from prospective patients are “can I only do one procedure?” and “how many procedures will I need?” These are excellent questions which I would like to address. To begin with, androgenic hair loss, otherwise known as male patterned hair loss, is a progressive condition and one which continues throughout your life. Is it true that as you age, the amount and degree of loss can slow down and even stabilize, but every patient must understand clearly that they will continue losing hair throughout their lives. Younger patients with more severe loss may lose their hair more quickly than older patients with mild to moderate loss but it can still vary from individual to individual. Usually in the course of a consultation I will discuss with the patient other family members (father, grandfathers, uncles, etc.) who experienced similar loss at their age and ask them how that person’s loss progressed. Sometimes that can offer some insight into how quickly and severely the individual’s hair loss will progress. There are other factors on examination, like miniaturization of existing follicles, that can provide some insight into how the individual’s hair loss will progress. Miniaturization is the process where a healthy hair follicle becomes a small, fine, almost “baby- hair”. This is typically the last step before the hair follicle falls out forever, and extensive miniaturization can be a precursor to extensive baldness. Medical treatments for androgenic alopecia include Rogaine and Propecia (Finasteride). Both of these medications can help not only to possibly regrow some hair, but to turn miniaturized follicles into healthy follicles again and to slow the progression of hair loss. Also, the studies have clearly shown that patients who use both Rogaine and Propecia together have a better result than patients who use either independently. Researchers are not sure why, but apparently there is some synergistic action between the 2 medications. Propecia is a pill which is taken once a day in a 1mg formulation and Rogaine comes as a foam or liquid is concentrations of 2% and 5%. I typically recommend the 5% foam formulation as it is easier to place on the scalp and is less greasy. Also, Rogaine has only shown results in helping hair loss in the crown region. Usually younger patients who are in line to experience much more hair loss are going to get the most benefit from using these medications. Another factor in determining the number of procedures is the severity of hair loss. Patients who have severe degrees of hair loss (Norwood 6 or 7) are usually confronted with a choice. Since I do not believe in transplanting many more than 3000  follicles in a single session (I will address my reasons for this in another blog), a severely bald patient will have the choice to either cover their entire head with a lower density of hair follicles, which may result in them wanting a secondary procedure for increased density throughout. Or to cover the entire hairline and mid scalp with higher density and leave the crown alone and then possibly cover the crown in a secondary procedure. Either way, in a severely bald individual, this is going to be a decision the patient will have to make. Finally, what I tell patients is that everyone who has the procedure, sees the difference, loves the difference, and wants more. The typical patient will undergo 2-4 procedures in a lifetime. I usually won’t consider performing a second procedure until around 8-9 months after the initial procedure. This allows me to see the new hair growth and also allows the donor area to relax, thus making it safer to harvest a strip from again. Every patient is different and must be individually evaluated in order to formulate a comprehensive plan tailored to them.

All the best,

Marc Dauer, MD

/by Los Angeles Hair Transplant Specialist

Donor Scars in “Strip Harvesting”- How to Prevent and Treat

Greetings,

Today I would like to discuss donor scars in the “strip harvesting” technique in hair restoration surgery and how to approach them. The trend in many clinics is towards larger procedures which many patients request. Most people would like to get as much done as possible in one sitting, and for the clinic this can mean larger fees. However, this is not always in the best interest of the patient for many reasons. Firstly, there is a diminishing return in graft growth as the grafts are kept outside of the body for long periods of time. In “mega-sessions” of 3000+ follicles, this tends to become an issue. In addition, the only way to harvest 3000+ follicles in most people, is take a width of donor strip that exceeds 1.7 cm and in many cases even 2.0 cm. The studies have clearly shown that with donor strips this wide, even if all the other necessary precautions are taken in wound closure, there is a much higher incidence of scar widening, hair shock, and various other problems that can be encountered in the donor region. It is for this very reason that the largest case size I will perform is about 3000 follicles in a single session, and this is usually only on a first time patient with excellent donor density. More often, my large procedures are in the 2500-2800 graft range. I limit the width of my donor strip to 1.5 cm maximum, and try to keep it between 1.0-1.3cm whenever possible. The studies have shown that when the donor strip is kept below 1.2cm there is a very low risk of scar widening or any other complications. In patients with low scalp laxity, or even hyper-elastic scalp, it is sometimes necessary to place deep retention dissolvable sutures to decrease the tension on the skin edges. This can also decrease the incidence of scar widening. Typically on repeated procedures, the scalp tends to lose elasticity, which should make the physician think twice about how wide a donor strip to take in these cases. The typical donor scar should be between 1mm-3mm when everything goes as planned. Sometimes even though all the rules are followed the patient can still end up with a donor scar that is wider than we would like. In these cases the first step is usually to resect and revise the donor scar by just taking out the old scar and trying to limit the width to 10mm or less. If that is not possible, or the patient requests another option, a great way to treat this is by harvesting follicles by FUE (Follicular Unit Extraction), which involves using a special tool to harvest one follicle at a time, and then placing the grafts into the scar. Transplanted hair follicles grow very well through most scars and this treatment can be effective in minimizing the appearance of a wide donor scar. I hope this brief overview clearly explains how I approach “strip harvesting” in Hair Restoration Surgery.

All the best,

Marc Dauer, MD

/by Los Angeles Hair Transplant Specialist

New F.U.E. S.A.F.E System

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Greetings all,

For the past few months I have been using a new machine for my FUE procedures called the “New F.U.E. S.A.F.E System”. For those of you who are not familiar, FUE stands for “Follicular Unit Extraction”. It is the process where donor follicles are taken out one by one, instead of removing them via the “Strip Method”, where a strip of donor scalp is removed and dissected under the microscope into individual follicles. There are a number of advantages and disadvantages to FUE vs. Strip Harvesting but I will not get into this discussion here. FUE is typically described in marketing and promotional advertisements as a “scarless” procedure. This is not actually true. What is true is that FUE causes many “micro scars” in the areas where the follicles are removed. In most cases these micro scars heal well and only leave a small dot of hypo-pigmentation in each spot where a follicle is removed. This is usually cosmetically insignificant as the area where the donor hair is removed is usually covered by the remaining hair in that region. The other issue with FUE is that in the past there has been a high rate of transection with the removal of the follicles. This means that in the process of removing the follicle, the structural integrity of the follicle is compromised, thus giving the follicle a much lower percentage chance of growth. The goal is a system where there is a low rate of transection and where the follicle is exposed to the lowest amount of trauma possible. There are many new automated and manual systems available now for FUE and I did extensive research into all of them and decided that the SAFE system was the way to go. The thing I really like about this system is that the punch that is used to extract the donor follicle has a blunt tip as opposed to a sharp tip that most of the other systems use. What this means is that since the tip is not sharp there is a much lower incidence of transection. Since donor follicles are very finite in each individual (the average person has about 8000 donor follicles), a lower transection rate of even 10-20% can result in hundreds or possibly even thousands of saved follicles. In addition, because the tip is not sharp, I believe it causes less trauma to the underlying vasculature, which can protect the scalp for future procedures. Also, because this system is motorized, like a small drill, it allows you to “score” the follicles much quicker, thus allowing more follicles to be harvested in a session. With this system, you still have to manually extract the follicles, manually trim the follicles, and manually implant the follicles, but the automation in the drill definitely speeds up the process. FUE is good for some patients and has it’s advantages and disadvantages. We are now able to transplant up to 1200 follicles in a day with the new FUE system, as opposed to significantly lower numbers before this system. In addition, FUE allows us to harvest chest hair, back hair, and beard hair for donor follicles. What is most important, is that every patient throughly understands all the advantages and disadvantages of both harvesting techniques before deciding which route to take in their own hair restoration journey.

Marc Dauer, M.D.

/1 Comment/by Los Angeles Hair Transplant Specialist

The International Society Of Hair Transplant Surgeons Annual Meeting

Hello all, I have just returned from the International Society Of Hair Transplant Surgeons annual meeting in Boston Mass. As usual it was an amazing experience. It is always so great to gather with your peers and discuss all the different approaches to the conditions we treat. It inspires a constant re-evaulation of procedures and protocols that should always be evolving as technology and studies show new and improved ways of practicing our craft. It also serves as an excellent review of the fundamentals of the field of Hair Restoration, that though we may know and practice them regularly, they are always good to revisit. I also had the opportunity to catch up with many old friends, and students from my previous teaching lectures. I got to meet many great new people as well that I know I will keep in touch with for years to come. I feel so lucky to be able to work in a field that provides so much satisfaction to the people it touches, and yet provides so much satisfaction to me as their physician as well. Here is a photo from the entrance to the World Trade Center at the Seaport in Boston where the conference took place.
All the best,
Marc Dauer, M.D.

/by Los Angeles Hair Transplant Specialist

New Advancements In Hair Restoration

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The Latest Advancements In Hair Restoration

Eyebrow Hair Restoration and Concealment of Scarring with Hair Transplantation

By Marc Dauer, M.D., ABHRS

Hair Restoration has come a long way from the unsightly large “plugs” of yesteryear. Today we practice Follicular Unit Transplantation which allows us to relocate hair follicles in the same way they naturally occur. This technique has also allowed us to transplant hair to other areas of the body besides the scalp.

Follicular Unit Transplantation is the general term to describe transplantation of naturally occurring follicular units. Typically hair grows in clusters of 1,2,3, and 4 hair follicular units. There are two main techniques used to harvest these follicular units. The first and most commonly used method is called “The Strip Method”. This involves taking a narrow strip of hair (usually not to exceed 1.5 cm in width) from some region in the permanent hair zone (in men this is in the occipital and parietal regions of the scalp) and dissecting the strip under magnification into individual follicular units. The other technique used in harvesting is Follicular Unit Extraction. This involves using a biopsy punch tool, usually between .6mm-1.2mm, and extracting the individual follicular units from the permanent hair zone for transplantation into another area.

Eyebrows are one of the most important defining characteristics of the face. Often you don’t even realize the full impact that eyebrows make until you see a person without them. With the Follicular Unit Transplantation, it is now possible to restore natural looking eyebrows that will last a lifetime.

Eyebrow hair loss can occur for several reasons in women and men. Physical trauma (such as burns or lacerations), medical treatments (such as chemotherapy or radiation therapy), excessive plucking, and even menopause, can all contribute to eyebrow hair loss. In the past some people opted for eyebrow tattoos to recreate lost eyebrow hair. Eyebrow transplants can be implanted over eyebrow tattoos to recreate natural looking eyebrows.

The hair to be transplanted into the eyebrows is usually harvested from either the mid occipital region or the nape in the posterior auricular region. In both cases the hair in these areas is of finer quality, thus more accurately resembling natural eyebrow hair. With an artistic eye, and keen attention paid to the individuals facial characteristics, the boundaries of the new eyebrows are drawn in so that the patient can see the shape of their new eyebrows. Once the design is completed the area to be transplanted is anesthetized with local anesthetic containing epinephrine and then tumesced with saline solution. The tumescence allows the grafts to be placed closed together, while elevating the skin further away from the underlying vasculature, thus resulting in less vascular damage. Small recipient sites are made with a solid core 22 gauge needle, with care taken to limit the depth to the size of the follicle to be transplanted. Grafts placed too deeply may result in excessive bruising and/ or cyst formation or scarring. Only single hair follicular units are placed in the eyebrows.

/1 Comment/by Los Angeles Hair Transplant Specialist

Hair Restoration Conference in Dubai

Greetings, I have recently returned from leading a teaching conference on Hair Restoration in Dubai on behalf of the American Academy of Aesthetic Medicine. This conference was very well attended with 25 attendees in all. This was my second time in Dubai so I did not have to do all the required sightseeing again. There are many wonders to see in Dubai. The attendees came from the U.K., South Africa, India, U.A.E., Syria, Iran, and the U.S. I met many very interesting individuals, some of whom I am sure I will stay in contact with for years to come. It is always enjoyable to teach my techniques and approach to Hair Restoration to others. It also helps me to review and stay up to date on the latest innovations in the field. I will post a few photos from the conference.
All the best,
Marc Dauer, M.D.

/by Los Angeles Hair Transplant Specialist

Bangkok Hair Restoration Teaching Lecture

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Hello all, this sunday I am headed to Bangkok, Thailand to teach Doctors from Asia the latest techniques in Hair Restoration Surgery. The conference is sponsored by the American Academy of Aesthetic Medicine. There are physicians attending from Australia, China, and Thailand. It has been very enjoyable putting my lecture slides together. The process has allowed me to review my notes and texts on the processes of hair loss and the latest techniques in Hair Transplant Surgery. While I am in Bangkok I also plan on visiting some of the large Hair Transplant Clinics there to see how their practices are set up and observe their techniques. Dr. Viroj Vong of Bangkok has been kind enough to lend me some of his hair transplant nurses to assist me on the practical portion of the conference where I will be performing transplant procedures on about 12 patients over 3 days. Considering the fact that I typically only do one Hair Transplant procedure per day in my office, this should definitely be a challenge, but one that I am looking forward to. I hope to post pictures of Bangkok and the people I meet there during the conference.

All the best,

Marc Dauer, M.D.

/by Los Angeles Hair Transplant Specialist

Hair Transplantation / Hair Restoration in Younger Patients

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Hello all, over the past few years I have been performing an increasing number of Hair Transplant / Hair Restoration procedures on younger individuals, so I thought that I would outline my general approach to these patients.

As the new technologies in Hair Transplantation have improved, the numbers of individuals seeking out a permanent treatment to hair loss have increased. This has included younger individuals who are anxious to treat their hair loss. Many times hair loss in younger individuals can have even more devastating psychological consequences than in older patients. These psychological issues must be as carefully managed as the medical plan to treat these patients. It is very important to take a thorough medical and psychological history to assess the patient’s psychological well being as well as their hopes and expectations. In most cases, I will not consider transplanting a patient younger than 25, as often the full extent of their eventual hair loss cannot be fully determined at such a young age, and therefore it is in the patients best interest to wait until their late 20’s when a more complete picture of the patients eventual hair loss is better determined.

Patients that have a more moderate degree of hair loss can still be candidates for Hair Transplantation in their mid 20’s, and in the right cases, by performing the Hair Transplant earlier, it allows the patient to “stay ahead” of the hair loss that they will be experiencing in the future. Barring any medical contraindications, I usually encourage all my young patients to begin on a regimen of Propecia and Rogaine. I also think there is some positive scientific evidence to support the benefits of Low Light Laser Therapy in these patients. Another issue I am commonly confronted with in regards to Hair Transplantation in younger patients, is hairline design. Many patients wish to have their hairlines restored to the hairlines they had as teenagers. I often encourage my patients of all ages to bring in photos of them in their youth to give me a complete picture of what the patient looked like before their hair loss set in. In designing a hairline in a younger individual, it is very important to explain to the patient that there is a very finite amount of donor hair in every patients “hair bank” (the permanent hair on the sides and in the back).

Sometimes the problem with bringing the patients hairline down too low is twofold. The first issue is that young patients with hair loss are set in motion to have a significant degree of hair loss as they get older. Medical therapies can help slow this progression, but rarely stop it all together. When the hairline is brought down too low, it then forces the Hair Transplant Surgeon in successive surgeries to spend large numbers of grafts to “fill in” the areas just behind these low hairlines, and sometimes this is at the expense of other balding areas that can no longer be addressed, because of the overall lack of donor hair. In addition, a hairline that may look natural on a 25 year old, will probably not look natural on a person in the 50’s or 60’s.

I tell all my younger patients to think as conservatively as possible on their first Hair Transplant. I tell them that they have a finite number of donor hairs in their “hair bank”, and that it is very important that every hair is used in the most effective manner, and placed in the exact appropriate location. Hairlines can always be brought down, but once they have been brought down too low, the patient is faced with either the prospect of permanently removing valuable transplanted hair in the hairline, or trying to fill in just behind the hairline, at the expense of balding areas on the top of the head. Just like hair loss is a progressive phenomenon, so too, the approach to Hair Transplantation is usually that a typical patient will undergo 2-4 Hair Transplant sessions over their lifetime. The transplanted hairs we put in will never fall out, but most patients will continue to have loss of their surrounding native hairs in the areas prone to genetic hair loss.

It is important to educate the patient that proceeding more conservatively on the first procedure can give the patient many more options as they get older, and as their hair loss progresses. I hope this clarifies some of my approach to Hair Transplantation / Hair Restoration in younger individuals. Please feel free to email me if you have any additional questions.

All the best,

Marc Dauer, M.D.

/by Los Angeles Hair Transplant Specialist

My first post

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Hello all, this is my first time posting a blog so I hope you’ll excuse my newbie status. I have been practicing Hair and Eyebrow Restoration for almost 5 years now and I must say it is one of the most gratifying fields to be involved in. I began my medical career in Head and Neck Surgery and subsequently transitioned into Emergency Room Medicine before finding my real calling in Hair and Eyebrow Transplantation. At the core of who I am, I am an artist. Whether I am drawing, playing guitar or piano, writing a song, or a short story, it is the expression of art that I truly enjoy. Hair and Eyebrow Transplantation affords me the opportunity to express myself artistically. Every patient is different and presents a new set of challenges. There is the constant management of expectations between what the patient wants, what’s best for the patient in the long run, and what is realistic for the patient. In the field of Hair and Eyebrow Restoration, managing all these together, while still maintaining the ultimate cosmetic result is a challenge, but one that I relish. I receive immense gratification in following up with my patients after their new hair has grown in. Seeing how the results can change peoples lives and better their self esteem is truly a gift.

I feel incredibly lucky to be in the field of Hair and Eyebrow Transplantation and I look forward to many posts in the upcoming days and years to discuss various cases and issues that I am presented with on a daily basis.

All the best, Marc Dauer, M.D.

/by Los Angeles Hair Transplant Specialist