Who said miniaturization only happens in AGA?

Miniaturization  

It is often said that miniaturization of hairs (progressive thinning of hairs) is a main feature specific to men and women with androgenetic alopecia. This is not entirely accurate.

Miniaturization can be seen in many conditions including traction alopecia (shown here), alopecia areata as well as androgenetic alopecia.

Miniaturized Hairs

Do they grow the same length as originial hairs?

In the early stages of androgenetic alopecia (first few years), miniaturized hairs grow almost the same length as original hairs (not quite but close). 

As time passes, and if androgenetic alopecia progresses, them miniaturized hairs grow in the scalp for shorter and shorter periods. In advanced cases, hairs affected by androgenetic alopecia grow for only a 2-3 months - and are very, very short and very, very thin. We call these "vellus-like" hairs rather than miniaturized hairs but they are a type of miniaturized hair.  Over time, vellus like hairs just don't grow any more.

Scalp Elasticity: The Mayer Paul Formula

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

Focal atrichia: A worrisome sign of AGA

Focal atrichia: What is it?

Focal trichina is a term which  refers to a specific observation seen on the scalp of patients with androgenetic alopecia. Those with focal atrichia have small circular areas devoid of hair.

This is a feature of advanced male balding (androgenetic alopecia) and also female pattern androgenetic alopecia. The finding is very important to recognize. Focal atrichia occurring in patients under 30 is worrisome for me as it is associated with a higher risk for progression to more extensive balding.

Androgenetic Alopecia and Teloqen Effluvium: Dual diagnoses Common

AGA and TE

Recognizing whether a patient has genetic hair loss or telogen effluvium ... or both .... often requires listening to the patient's story about their hair loss in addition to examining the scalp and looking at the blood test results.

Many women have both.

 

Differentiating between AGA & TE

AGA often shows hair loss in regions rather than all over although it can certainly be all over. AGA is fundamentally characterized by hair follicle "miniaturization." The hair follicles get skinnier - this is not a feature of TE. Telogen effluvium is characterized by diffuse loss and waves of regrowth. Empty tracts where a hair once was found and upright regrowing hairs characterize TE. Patients with TE often have a trigger such as low iron, thyroid problems, nutritional issues, crash diets, stress or medications that lead to the shedding. Shedding in TE is more pronounced than in AGA.

Dutasteride for Male Pattern Balding: New study point to low incidence of side effects

Dutasteride, a dual inhibitor or 5 alpha reductase type 1 and 2

Dutasteride is approved in Korea for the treatment of male pattern balding. It is used "off label" in many other countries. Whereas finasteride (Propecia) inhibits 5 alpha reductase type 2, dutasteride inhibits 5 alpha reductase types 1 and 2.

Finasteride has received press on account of its side effect profile (especially sexual side effects) and possibilities of long lasting, possibly permanent side effects in a low proportion of users.  

Dutasteride is known to have a similar array of overall side effects, and given the greater inhibition of 5 alpha reductase that dutasteride has, one might expect a similar if not greater number of side effects. Interestingly, this has not been the case in all studies to date. In fact, most studies support the efficacy and tolerability of dutasteride at 0.5 mg with relatively low incidence of side effects.

New study

A new study published by Choi et al looked at over 700 men ranging in age from 18-41. These men were using dutasteride at 0.5 mg. The frequency of side effects were low. 1.3 % of patients experienced decreased libido, impotence in 1 %, fatigue in 0.7 %, breast enlargement was seen in 0.3 %. Over 79 % of men reported improvement with their hair.

FINAL COMMENT

This study was not set up to compare dutasteride to placebo. This was simply an observational study as part of routine "post marketing" surveillance. Overall, the findings are encouraging and expected- pointing to a low risk of adverse events with this dual inhibitor of 5 alpha reductase.

 

REFERENCE

Choi GS et al. Ann Dermatol. 2016 Aug;28(4):444-5

Machine settings for Platelet rich plasma: A Look at Hematocrit

What is Platelet rich plasma?

Platelet rich plasma or "PRP" continues to be studied as to its precise role in the treatment algorithms for many types of hair loss.

The PRP procedure involves taking 60-120 mL of a patient's blood, spinning it down in a dedicated centrifuge machine to obtain PRP and then injecting the PRP back into the patient's scalp. The procedure takes about 1 hour. 

All PRP is not equal

One common misconception is that all PRP is equal. The reality is that different machines produce different quality of PRP. Even the settings I type into the actual PRP machine affect the characteristics of the PRP I am able to produce for the patient.

A look at the "hematocrit"

A great example of this concept of differences in PRP is the "hematocrit". Hematocrit refers to the amount of red blood cells that are allowed to enter the final PRP.

If I set the PRP machine at a hematocrit setting of 7 % (high hematocrit), I produce a more red colored PRP (like shown on the left). This contains more platelets per liter and also contains more neutrophils (inflammatory cells). It also contains higher concentrations of growth factors like TGF beta and platelet derived growth factor (PDGF).

If I set the machine at a hematocrit of 2 % (low hematocrit), we produce a more yellow colored PRP (like shown on the right). This contains fewer platelets per mL and also contains fewer inflammatory cells, lower concentrations of growth factors like TGF beta and platelet derived growth factor (PDGF).

I generally like a higher hematocrit setting (7%) for treating genetic hair loss and a lower hematocrit setting (2%) for treating alopecia areata. Studies are ongoing to determine which is best and if these settings really make a difference.

REFERENCE

Sandman et al. Growth factor and catabolic cytokine concentrations are influenced by the cellular composition of platelet rich plasma. American Journal of Sports Medicine 2011.
 

What's new in male balding research?

NEW DRUGS MAY BE IN THE PIPELINE FOR MALE BALDING

According to a news release, Kythera Holdings has acquired licensing rights to setipiprant - potential drug for hair loss. Setipiprant is a selective oral antagonist to the prostaglandin D2 (PGD2) receptor.  

Why is blocking the PGD2 pathway important?

About three years ago, I shared a blog 

Breakthrough in Baldness? Blocking the Prostaglandin D2 Pathway May be the Answer 

In that blog, I described research showing that PGD2 levels were higher in bald areas of the scalp than non bald areas. Theoretically, blocking this pathway could have important roles for baldness. 

And so here we are three years later. Kythera Holdings, a subsidiary of Kythera Pharmaceuticals, announced that it has acquired  licensing rights to setipiprant, in the agreement with Actelion. Apparently, human studies are next for the company. What is so interesting about this drug is that it's already been studied for other uses. Setipiprant has previously been studied as a type of alley treatment, including a phase 3 study in patients with seasonal allergic rhinitis and a phase 2 study in patients with asthma. There were no serious side effects in these studies and treatment was well tolerated. According to the news release, Actelion suspended the development of setipiprant due to lack of efficacy seen in the allergy and asthma studies. So we haven't heard more about the drug. 

READ MORE  

Health, Obesity and Hair Loss:

Does unhealthy eating contribute to hair loss?

I'm often asked if healthy eating helps slow genetic hair loss. In other words, does an apple a day keep the hair doctor away? We don’t really  know how healthy eating slows hair low. However, what we do know is that unhealthy eating that leads to obesity does seem to accelerate hair loss.

Two studies support a relationship between obesity and hair loss

A 2011 study looked at the risk factors for male balding in policeman in Taiwan. Interestingly, young male policemen who were obese had much higher rates of male balding than thinner policemen.

In 2014, researchers from Taiwan explored whether there was a relationship between obesity the severity of male balding. They studied 142 men (average at 31 years) with male balding who were not using medicines for hair loss.   The study showed that men with more severe  hair loss tended to be more overweight than men with less severe hair loss.  In fact, men who were overweight or obese had an approximately 3.5 fold greater risk for severe hair loss than men with more normal weights. In addition, young overweight or obese men had a nearly 5 fold increased risk of severe hair loss.

 

Does an apple a day keep the hair doctor away?

We don't really know the role of healthy eating - does it slow hair loss? That's unknown. What we do know is that the flip side appears true - that extremes of unhealthy eating leading to obesity do seem to be associated with accelerated hair loss. Overall, these two studies mentioned above do support the notion that being overweight might contribute in a negative manner to balding in men. 

Further studies are needed to determine whether encouraging weight loss in obese patients could impact the rate of balding or the effectiveness of treatments for male balding.

Reference

Chao-Chun Y et al. Higher body mass index is associated with greater severity of alopecia in men with male-pattern androgenetic alopecia in Taiwan: A cross-sectional study.  J Am Acad Dermatol 2014; 70; 297-302.

Su LH et al. Androgenetic alopecia in policemen: higher prevalence and different risk factors relative to the general population (KCIS no. 23). Arch Dermatol Res. 2011 Dec;303(10):753-61

Capturing the very earliest changes of Genetic Hair Loss

Recognizing genetic hair loss in the earliest stages

Genetic hair loss is common. By age 50, about 60 % of men and 35 % of women will develop genetic hair loss.  Hair loss typically starts in certain areas of the scalp - such as the temples and crown in men and central scalp in women.

 

 

Alteration in follicular counts may precede miniaturization 

Miniaturization refers to the progressive reduction in hair follicle diameter during the course of genetic hair loss. In other words, hair follicles get skinnier and skinnier over time. This is a very typical feature of genetic hair loss. One other feature that is frequently seen is the alteration of hair follicle counts. Rather than hair follicles appearing in bundles of two hairs or three hairs, they are frequently seen as single isolated hairs. 

The photo above nicely illustrates this concept. Both photos were taken from the same patient. The photo on the left shows hair follicles grouped together in groups of two three and even four hairs. This area of the scalp is unaffected by genetic hair changes. The photo on the right shows very typical genetic hair loss. Hair follicles are still similar in size (thickness), but what is seen is mostly single hairs - the groupings of two and three hair bundles are no longer present. This is very typical of the earliest features of genetic hair loss. 

Dutasteride and Finasteride: New data suggests no Link with breast cancer in men

Dutasteride and Finasteride: Do they cause breast cancer?

Finasteride (Propecia) and dutasteride (Avodart) are prescribed for the treatment of male pattern baldness. Many of my male hair transplant patients receive finasteride or dutasteride in order to help reduce the progression of balding in existing hairs.  

Finasteride and dustasteride belong to a group of drugs called "5 alpha reductase inhibitors." They block the enzyme 5 alpha reductase and decrease the levels of the potent androgen hormone DHT (dihidrotestosterone). In addition to reducing DHT, the drugs increase the levels of estrogen slightly which has raised questions from physician and researchers around the world as to whether these drugs increase the risk of breast cancer in men.

US researchers set out to examine the relationship between the use of 5 alpha reductase inhibitors and male breast cancer. They studied men using the higher 5 mg dose of finasteride used in prostate enlargement (rather than the 1 mg dose used in hair loss) and the 0.5 mg dose of dutasteride.  They looked at the use of these drugs in 339 men with breast cancer and 6,780 men without breast cancer.

What were the findings and conclusions from the study?

The authors did not find an association between using 5 alpha reductase inhibitors and the development of breast cancer in men. Overall, the authors concluded that the "development of breast cancer should not influence the prescribing of 5 alpha reductase inhibitor therapy."

Reference

Bird ST et al. Male breast cancer and 5 alpha reductase inhibitors finasteride and dustasteride. J Urology; 190:1811-4

Is your hairline 'maturing' or a 'balding'?

Is your hairline 'maturing' or a 'balding'?

It’s a little known fact among many men that the frontal hairline actually changes shape between the ages of 17 and 27 – even if that man doesn’t proceed to develop genetic balding. We refer to this normal change as ‘maturation’ of the hairline and we say that the man noticing these changes has a ‘maturing’ hairline. Eventually the hairline stops ‘maturing’ and we say that the man has a ‘mature’ hairline.  Not all men’s hairlines proceed through this normal process of ‘maturation’ but most do.

The concept of a maturing hairline is extremely important to know about so that medical treatment or surgical treatment is not recommended to patients who don’t require it. For example, a 23 year old man who notices his hairline thinning out slightly in the area just above his eyebrows may not have genetic hair loss - but rather a ‘maturing’ hairline. He doesn’t need to begin any sort of treatment whatsoever. Several studies have shown that men with maturing hairlines don’t necessarily go on to develop balding. These are two completely separate processes!

Hairline maturation diagram

The following diagram helps to explain the process by which the hairline matures and how it differs from genetic hair loss. The hairline of a boy or early adolescent is relatively flat and we refer to this as a ‘juvenile” hairline.  Between age 17 and 27, many men (but not all) start to notice that the hairline directly above the middle section of the eyebrow starts to undergo thinning (maturing).   

In fact, if you wrinkle your forehead, you’ll see a series of lines that run side to side. The highest forehead wrinkle often marks a spot where the ‘juvenile’ hairline was once located. A ‘mature’ hairline is usually about 1-1.5 cm above this. In true genetic balding (male pattern hair loss), the hairline may recede beyond this 1.5 cm point and undergo even more significant recession in temple area. 

Why is this concept important?

Understanding the concept of hairline maturation is especially important when it comes to designing natural looking hairlines during a hair transplant.  Attempting to lower a ‘maturing’ hairline is a young man is usually not a good idea. Many young men want a more ‘juvenile’ hairline when they first meet for a hair transplant consultation.  However, by proceeding down that route,  the young man runs the risk of having his new hairline take on an unnatural looking appearance when compared to other males as he approaches his 30s, 40s and 50s.

Other References of Interest

Rassman WR, Pak JP and Kim J. Phenotype of normal hairline maturation. Facial Plast Surg Clin North Am 2013; 21: 317-23

This blog has been filed into the following folders: 

Minoxidil - Does it help with hair loss ... in the front ... or top .. or both?

Accumulating evidence suggests minoxidil helps with hair loss in the crown (top) but may help hair loss in the front and temples in men as well.

Minoxidil - Does it help with hair loss in the front?

Minoxidil is a topical medication that is FDA approved for treating genetic hair loss (sometimes referred to as androgenetic alopecia). If you pick up a bottle of minoxidil it will state that it is to be used for hair loss in the crown in men and may not benefit other areas of hair loss. The original studies of minoxidil focused on the crown and did not address the benefit in the front of the scalp.

So the question that remains is:  

Does minoxidil help men with hair loss in the front of the scalp or not?

Certainly, the answer is yes.   Many hair loss specialists around the world, including myself,  have witnessed benefit to minoxidil in the front of the scalp in balding men.  However, the companies which produce minoxidil are not setting out to formally prove the benefit in the front of the scalp and are not seeking approval from health regulatory authorities to be able to change the labelling on the bottles to indicate that it "works in the front and back."

New study shows 5 % minoxidil benefits men with hair loss in the temples

Back in the month of May 2013, I attended the World Congress of Hair Research in Edinburgh Scotland. A really nice study was presented by Dr. Blume Peytavi and colleagues from Berlin, Germany. They studied 70 men with moderate genetic hair loss and studied whether minoxidil 5 % foam could help hair loss in the crown and in the front.  The German group showed that men using minoxidil 5 % foam did obtain benefit from using the medication in the front and in the crown.  This was one of the very first studies showing the minoxidil foam benefits hair loss in the front.

Conclusion: 

Minoxidil has long been known to benefit men with hair loss in the crown. Accumulating evidence suggests it also benefits men with hair loss in the front (temples). More studies are needed to determine just 'how much' it helps men with hair loss in the front. In general, minoxidil seems to work better in the earliest stages of hair loss - as hairs are thinning and miniaturizing. 

Reference

Hillman K, Bartels GN, Stroux A, Canfield D, and Blume-Peytavi U. Investigator-initiated double blind, two-armed, placebo-controlled, randomized clinical trial with an open -label extension phase, to investigate efficacy of 5 % Minoxidil topical foam twice daily in men with androgenetic alopecia in the fronto-temporal and vertex region concerning hair volume over 24/52 weeks.  Poster at: World Congress of Hair Research, Edinburgh Scotland May 2013.

Benefits of Combining Minoxidil and Finasteride

Benefits of Combining Minoxidil and Finasteride

Minoxidil and Finasteride are two FDA approved treatments for hair loss. Minoxidil is a topical solution that is rubbed on the scalp and finasteride is an oral treatment (pills). Many men with genetic hair loss (androgenetic alopecia) consider the use of these medications and may consider hair restoration as a more permanent solution.

Both minoxidil and finasteride have their own set of side effects. Finasteride, however, is much more effective. GIven that these two agents are clinically proven to help with hair loss, I'm often asked - "Is it better to use both of these products or should I just pick one?"

Combination Minoxidil and Finasteride better than single treatment

The answer is - 'yes.' There is clinical evidence that men using finasteride for hair loss who add minoxidil to their treatment plan have a slightly better result than men who only use finasteride. The benefits, however, are small. It makes sense that the two medications act synergisticially in treating hair loss given that they act differently. Minoxidil helps hair growth by directly stimulating the hair follicle. In contrast, finasteride works by blocking the action of the potent male hormone dihydrotestosterone or "DHT". 

Conclusion

Both minoxidil and finasteride should be considered. For men with early hair loss, the use of both might help and may be considered prior to a hair transplant. Minoxidil and finasteride have less benefit for men with advanced hair loss. In these cases, a hair transplant is the primary treatment.

This blog has been filed into the following folders:

The Hair Whorl: Importance in Transplanting the Crown

Transplanting the Crown

In the top of the scalp or crown, there is usually one or two areas where the hair changes direction from forward pointing to backward pointing. We call this area the “hair whorl.”

When I perform a hair transplant, I view the reconstruction of the hair whorl as being incredibly important in order to create a natural look.  For most individuals, the hair whorl is positioned in a clockwise direction.   About 2-5 % of the world has a double whorl.

Hair Whorl Research

Interestingly, recent research has focused on whether there is a relationship between the direction of the hair whorl and an individual’s tendency to be left handed or right handed.  There is some thought that genes controlling handedness also might control our hair whorl.  Research by Dr Klar showed that right-handed individuals are more likely to have a clockwise whorl pattern; for left- handed individuals there is a similar proportion of clockwise and counter-clockwise patterns.  Specifically, 8.4 % of right-handed individuals have a counterclockwise whorl compared to 45 % of left handed people.  Despite these interesting findings, the exact science of the relationship between hair whorl direction and ‘handedness’ remains a subject of controversy.

All in all, the hair whorl is something I pay particular attention to when transplanting the crown.  The rotations and directions of the hair need to be followed carefully in order for a hair transplant to look natural.

REFERENCES OF INTEREST

Beaton AA and Mellor G. Direction of hair whole and handedness.Laterality 2007; 12: 295-301

Klar, A.J.S., 2003. Human handedness and scalp hair-whorl direction develop from a common genetic mechanism. Genetics 165, 269–276

 

This blog has been filed into the following folders:

How many hair transplants can a patient have?

Hair transplants: how many can a patient have?

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.

Source

Unger WP, Unger RH, Wesley CK. Estimating the number of lifetime follicular units: A survey and comments of experienced hair tranpslant surgeons. Dermatol Surg 2013;

This blog has been filed into the following folders:

INCREASED RISK OF HEART DISEASE IN MEN WITH HAIR LOSS

Do balding men have an increased risk for heart disease?

Several studies in the past have examined the relationship between balding and heart disease.   In a study published in this month's British Medical Journal, researchers from Japan carefully examined all of the research studies to date focusing on the relationship between hair loss and heart disease.

Balding and heart disease: what did the new research find?

The researchers looked at studies involving 36,690 balding men and found that men with hair loss in the top of the scalp or ‘vertex’, had an increased risk of heart disease.  Interestingly, men with more severe balding had a greater risk of heart disease compared to men with lesser degrees of balding in the vertex.  Men with hair loss in the front of the scalp did not demonstrate an increased risk of heart disease.  

The exact reasons why balding men have increased heart disease risk is not clear but may be related to common mechanisms that lead to heart disease and hair loss including high blood pressure, smoking, high cholesterol, insulin resistance and increased inflammation in blood vessels.

These findings are important for the approximately 4 million Canadian men and 40 million American men affected with male balding.

SOURCE:   Yamada et al. Male pattern baldness and its association with coronary heart disease: a meta-analysis. BMJ Open; 2013; e002537.

 

Hair Transplantation for Early Hair Thinning: Things to Think About

Hair Transplantation for Early Hair Thinning:

It comes as a surprise to some patients who come to see me that they are not candidates for hair transplant surgery. Some patients are too young, some have hair loss diseases for which a transplant won't ever 'work,' some have too little hair (or are destined to be too bald to make a transplant a good idea).  Finally, some individuals have too much hair.

It's this last issue that I'd like to discuss today - transplanting in areas of hair loss which are undergoing thinning but not yet significantly thin. Is it a good idea to transplant hairs in this area to prevent it from ever looking thin?

Is some cases the answer is yes, in other cases - no.  Even with the most delicate and meticulous surgery, exisiting hairs on the scalp can be damaged if the density is too high. There is a critical density below which a cosmetic improvement can be achieved.

Consider the young man (photo on the right) who came to see me for advice on getting a hair transplant. Is he a good candidate for hair transplant surgery? 

Not ideal.  A hair transplant in this man is unlikely to significantly improve density. This man would be much better off considering medical treatment with minoxidil and/or finasteride before considering hair restoration. Othe treatments could also be considered, including low light laser therapy. If these (and other) medical treatments didn't help, we could certainly discuss a hair transplant. 

At slightly reduced densities, it's possible to achieve a great cosmetic change. New hairs can be placed "between" the existing hairs in order to build a new density - without damaging any of the existing hairs.

I'm a big believer in transplanting in the early stages of hair loss in order to prevent the appearance of hair loss. But there is a fine line between when this is a good idea, and when it's not likely to provide the patient any benefit.

This blog has been filed into the following folders:

Is there a Link Between Sun Exposure and Hair Loss?

Sun Exposure and Hair Loss: Is there a Link?

This new video highlights the current evidence of the relationship between sun exposure and hair loss.

I hope you enjoy it!

- Dr Jeff Donovan

 References of Interest

Gatherwright J et al. The contribution of endogenous and exogenous factors to female alopecia: a study of identical twins. Plast Reconstr Surg 2012 130; 1219-26.

Su LH and Chen.  Androgenetic alopecia in policemen: higher prevalence and different risk factors relative to the general population. Arch Dermatol Res. 2011 Dec;303: 753-61

This blog has been filed into the following folders:

The Surgical Map: How hairs "go in" matters more than how they "come out" !

Follicular unit strip surgery (FUSS) or follicular unit extraction (FUE)

There is a lot of attention nowadays about what's a better technique for hair transplantation - follicular unit strip surgery (FUSS) or follicular unit extraction (FUE).  I perform both and both have distinct advantages and disadvantages.

But one aspect of surgery that is all too forgotten about in amongst the discussions of how to remove hairs from the back of the scalp - is how to put them back into balding or thinning areas so the result is natural.

The end result of either strip harvesting or FUE is the same - the production of "follicular units" - either one haired grafts, two haired grafts or three haired (or more) grafts. These are shown in the photo to the right.  Every patient has a different proportion of these grafts in the back of their scalps and so the planning of how they go into the balding areas must be given very careful considered. I refer to the exact plan of how hairs go into balding areas as the 'surgical map'

The surgical map in hair transplantation

If a patient is undergoing a transplant in the frontal area of the scalp, the typical surgical map would follow a pattern something like this: The one haired grafts are placed in the frontal area and placed in an irregular manner so as to create a soft and natural look. Anywhere from 100-400 one haired grafts might be placed in the front depending on the number of grafts they have and the density we are trying to achieve.  The two haired grafts are placed behind the one haired grafts the three haired grafts follow this.

A transplant session of 2000 grafts might contain:

200-400 one haired grafts

800-1500 two haired grafts

300-800 three haired grafts

One haired grafts vs two and three haired grafts

I view the one haired grafts differently from grafts that contain two and three hairs. One haired grafts are fantastic to help create a soft and natural look in areas. The three haired grafts (and too a lesser extent the two haired grafts) are importance for one main reason - building density!  The decision on where to put three haired grafts is very important. They are placed in areas where getting high density is important. 

Final comment

The way hairs are removed from the back of the scalp (i.e. FUSS or FUE) is important - but the way they go back in is more important. Ensuring the hairs are packed with the appropriate density, ensuring the sites are made at the correct angle and direction and ensuring the the one-haired, two-haired and three-haired grafts are put into the best possible locations are some of the most important factors to help ensure a natural result for patients.

This blog has been filed into the following folders: