The flexibility or "elasticity" of the scalp is an important consideration for hair transplant surgeons performing follicular unit strip surgery (FUSS also called FUT). In general terms, the more elastic an individual's scalp is, the greater the number of grafts that can be taken ... and the better the final hair density that can be created for the patient undergoing surgery.
A number of formulas and methods have been proposed to help surgeons calculate elasticity. There are even a number of commercial available instruments and tools that can also be bought to help calculate scalp elasticity.
The Mayer Paul Formula
The Mayer - Paul Formula is a well established method for calculating the elasticity of the scalp. To calculate elasticity on the scalp, two lines are initially drawn 5 cm (50 mm) apart. Then the two lines are compressed together (ideally with the two thumbs). Then, one records how far apart the two lines are after being squished together.
Scalp Elasticity is calculated as
[(50 mm - new position in mm)/50] multiplied by 100 %
VIDEO EXAMPLE: DEMONSTRATION FO THE MAYER PAUL
In this video example, the lines have been squeezed from 5 cm apart to 2.5 cm apart (X = 2.5 for the formula in this example). The elasticity is calculated as 50 %. According to the Mayer Paul formula elasticity of 30 % or more means that a strip of at least 2.2 cm can be taken (if needed) on a first FUT surgery. In contrast, 10 % elasticity means that the strip should be kept less that 1 cm in width
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Can alopecia areata develop at the site of a hair transplant?
Alopecia areata affects 2 % of the world. It is an autoimmune hair loss condition whereby the immune system targets the hair follicle causing it to fall out. Alopecia areata can develop anywhere on the scalp - and anywhere on the body where there is hair such as eyebrows, lashes, etc.
In previous published reports, alopecia has been documented to occur at the site of a hair transplant. However, proving there is a direct link between the two is challenging. Alopecia areata usually develops in most people without trauma or injury.
Is a link plausible for some?
It is certainly not impossible that some sort of a more direct link could exist between alopecia and injury. I have many patients with autoimmune type reactions in the donor area following hair transplantation - including alopecia areata and lichen planopilaris. It's just really difficult to prove a direct association.
This photo show "black dots" and vellus hairs that are typical of the scalp in patients with alopecia areata. The photo also shows the scar from a previous hair transplant done using follicular unit strip surgery (FUSS).
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Scalp micro pigmentation or "SMP" is a method of camouflaging hair loss. Dots are tattooed to mimic the appearance of hairs cut in cross section. In this photo, small black dots can be seen in between the hairs. For this particular patient, these dots camouflage scars from a previous hair transplant
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Choosing between FUE and FUSS in hair transplant surgery
There are two ways that a hair transplant can be done nowadays: FUSS and FUE. With FUSS (follicular unit strip surgery), a strip of skin is removed from the back of the scalp and then the area is stitched up. The result is a linear scar or line. With FUE, the back of the scalp is shaved and hairs are removed from the area "one by one." The results is small tiny circular 'microscars in the area where the hairs were taken. the advantage with FUE is patients can wear their hair short in the future without worrying about seeing the scar.
FUE in black men: What the are the main considerations?
Most of my male patients with afro-textured hair want to wear their hair very short. Having a linear scar is not practical. Therefore, the decision on having FUE rather than FUSS is very important.
Performing FUE on afro-textured hair requires much more skill than caucasian hair. The photo in the top panel on the right shows the typical curved hair follicles in afro textured hair and the photo on the bottom shows the relatively straight hair from a caucasian patient. It's easy to see why removing these hairs with a small punch would be more difficult in the top panel.
Ensuring healthy grafts: how do I perform FUE in afro-textured hair?
In performing FUE, I focus on being flexible in the instruments I use. I don't start the day thinking that I'm going to use one sized punch over another, or do the procedure one way instead of another. One must be flexible. I generally start with a 1.17 mm punch and then move to 1 mm and then 1.3 mm and see what produced the best grafts. I move from manual punches (that I direct myself) to 'motorized' punches that drill with the help of a motor. I go from minimal depth punches to deeper punches into the skin. All while looking at the grafts that are coming out to ensure they are healthy.
Our hair transplant program for afro-textured is consistently able to offer FUE as a good option for hair transplantation. In fact, for most of my black male patients we are nearly routinely doing FUE rather than FUSS - a big change from just 3-4 years ago.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
The number of hair follicles available to move from the back of the scalp (the 'donor area') to the front or top of the scalp (the 'recipient area') is limited. Someday, hair research may allow us to expand the number of hairs available, but for now there is a limited number. The number of grafts available to move depends on a number of factors, espeically how bald a person is destined to become. It is generally estimated that between 4,000-10,000 follicular units are available in men. Men who are destined to have advanced balding patterns have less hair available to move than men destined to have minimal balding.
New study from Mount Sinai
A new research study by Dr Walter Unger and colleagues from the Department of Dermatology at Mount Sinai School of Medicine set out to refine these estimates even further. A group of 39 hair transplant surgeons were asked to estimate the number of 'permanent' follicular units available for surgery in a hypothetical 30 year old man destined to develop advanced balding (i.e. Hamilton Norwood Scale V or VI)
What were the results of the survey?
Respondents indicated that men destined to have Hamilton Norwood Stage V balding had between 5,000 - 8,000 follicular units available for surgery and men destined to have Hamilton Norwood Stage VI balding had between 4,000 - 6,600 follicular units available for hair transplant surgery.Man with 4000 follicular units max in lifetime
Why are these results important?
This study reminds hair transplant surgeons (and patients) that there are a finite number of follicular units available for surgery. A middle aged man destined to have advanced balding in his lifetime has two (and maybe three) surgeries maximum in their lifetime. It is exteremely important to discuss with patients how grafts will be placed so that the appearance of bald areas of the scalp can be minimized throughout life.
Patients undergoing hair transplant surgery using the strip method not only want a natural looking transplant but also a maximally camouflaged scar.
The trichophytic closure is a technique for stitching up the donor area which helps to minimize the appearance of donor scars. It's use in hair tranpslant surgery is credited to three physicians: Dr Paul Rose (USA), Dr Patrick Frechet (France) and Dr Mario Marzola (Australia). Nowadays the technique is widely used by many hair transplant physicians, including myself.
How is the trichophytic closure done?
The trichophytic closure involves clipping hairs from the edges of the donor area so that they are more likely to grow back through the scar when it heals. When hairs grow back through the scar, the appearance of the scar is greatly minimized. A photograph of hairs growing through a scar in a patient who had a trichophytic closure is shown in the attached image.
In select individuals, (such as those with minimal tension in the donor area), the trichophytic closure is a great technique to minimize scar appearance.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Patients in my practice often ask me if I can take hair from the chest, back or legs and add it into thinning areas on the scalp. The concept of "body-to-scalp" hair transplantation is somewhat new but slowly catching on. Generally, most hair transplant specialists would reserve this technique for very special circumstances (i.e. poor donor hair density at the back of the scalp or poor donor quality, or excessive scarring in the donor area). Hair from other body sites isn’t quite the same as hair on the scalp – it looks and feels different. It grows at different rates too.
Dr. Sanusi Umar, a hair transplant specialist from California, wondered if he could use these differences to his advantage. Specifically, he wondered it he could take advantage of the fact that leg hairs are small, thin and soft and use these legs hairs to improve the appearance of the frontal hairline (which is normally chalked full of soft, thin hairs).
Can hairs from the leg really be transplanted into the hairline?
Dr. Umar studied two of patients, each of whom had 1000 leg hairs transplanted into their frontal hairlines. In both patients, Dr. Umar reported that about 75-80 % of the hairs survived. Interestingly, the transplant legs hairs were a bit longer than the original leg hairs and were less curly. Dr. Umar followed the first patient for a total of 4 years and followed the second patient for 3 years. The transplanted legs hairs remained and grew well in the frontal hairline. Moreover, the areas on the leg where the hairs were taken healed without visible scars.
Dr. Umar's study, which is published in the journal Archives of Dermatology is an interesting and unique study. It shows promise in the use of leg hairs to soften the hairline. As body-to-scalp hair transplants move forward, it seems that both chest hair and leg hair may be a possible source of transplantable hair for some patients.
Reference
Umar S. The Transplanted Hairline: Leg Room for Improvement. Archives of Dermatology 2012; 148: 239-242
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
