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Poor growth after hair transplants: Why?

Poor growth after hair transplants:  

By 8 months, a hair transplant patient should have a fairly good idea of the growth. While it's true that it can take longer (.... even up to 18 months), the vast vast majority of patients experience some nice growth by 8 months. There is no harm in waiting a bit longer - but improvement is (statistically speaking) quickly unlikely.  


Fortunately, poor hair growth following hair transplantation is not something that happens all that often. But when it occurs the surgeon will need to explore many, many possibilities, including patient factors, physician factors and scalp factors. All in all, anyone with poor growth needs to sit down with their physician to review things in detail. 




PATIENT FACTORS


There are a few patient factors to consider - and many are centred around post op care of the grafts. The other patient factor that is important is smoking. Occasionally, smokers have poor growth for reasons that are not completely understood. Other factors one might think about under patient factors are medications that impair hair growth or cause excessive bleeding. There are a few other factors as well that a surgeon will review with a patient with poor growth. 




PHYSICIAN FACTORS


Physician factors also include the physician and his or her hair transplant team. These factors  include overly tight packing of the grafts (too tight, too packed can lead to poor growth) improper depth of grafts, rough handling of grafts by technicians, harvesting of grafts, temperature of grafts and poor hydration of the grafts. All these things are important. Sometimes the density is too high to begin with in certain areas. But these are the things to think about in the "Physician Factors"
 


SCALP FACTORS


This is also an important categories. Some scalps (because of excessive sun damage or other factors) may take up grafts less efficiently and this leads to poor growth. Some scalps bleed more than others are this can rarely impact growth due to post operative "popping" of grafts. Infection post surgery can impair growth as well. And finally some patients have scalp diseases that are either present before the surgery (but could not be detected) or some patients develop new scalp diseases after the surgery that impairs the growth of the grafts. This is rare. For example some individuals rarely develop alopecia areata or rarely develop scarring hair loss problems after their hair transplant. These scalp issues can impair growth partially or completely. A scalp biopsy is sometimes needed to diagnose these problems.

 

CONCLUSION
 

As you can see there are many, many possible reasons and only with a careful evaluation and a bit of "detective work" can a few possibilities be uncovered. That said, sometimes hair transplants don't generate the results that were expected and the next time they do. Any surgeon will tell you in a busy practice, there are occasionally patient's the have less than expected growth. Hair transplant is a fascinating science - but not an exact science.  Far from it. 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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HOW ARE HAIR FOLLICLES ARRANGED?

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Follicle arrangements

Hair follicles normally emerge from the scalp in groups of 1, 2 or 3 haired "bundles." They don't all emerge as single strands.

During the process of genetic hair loss as well as during the process of scarring alopecias, the bundles of 2 and 3 haired follicular units start disappearing from the scalp and what is left is 1 and 2 haired follicular units.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Can alopecia areata occur at the location of a hair transplant?

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).


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Hair transplantation in black men: Can we do FUE?

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.

 

 

 

 

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Follicular Unit Extraction in Black Men and Women

Follicular Unit Extraction in Black Men and Women

I few weeks ago I wrote a blog about considerations when performing follicular unit extraction (FUE) in black men and women.  Because hair in black men and women tends to be curlier than caucasian hair, there are several considerations that need to be carefully addressed before performing surgery.  Unless such care is taken, precious follicular units may be cut or 'transected.' Today, I read a great article in the journal Dermatologic Surgery by New York hair transplant surgeons Drs Singh and Avram. They outlined some practical points when performing FUE.

 

Key Aspects of Follicular Unit Extraction

The authors outlined four points, which I have summarized here:

 

1. Maximal sized punch. It's important to choose a big enough punch to accomodate hairs. 1.3 mm sized punch may be acceptable depending on the patient. 

 

2. Minimal depth. It's important not to go to deep to limit the chance of transection

 

3. Manual punches instead of motorized. The authors proposed that manual punches give better control for some patients. 

 

4. Meticulous attention to following the angle the hairs emerge from the scalp. This ensures that transection is limited. 

 

On account of the greater curl, follicular unit extraction is black men and women presents several differences compared to caucasian or asian hair. However, with carefully attention to fundamental principles outstanding results can be acheived. 

 

Reference

Singh MK and Avram MR. Technical Considerations for Follicular Unit Extraction in African American Hair. Dermatol Surg 2013; May 13

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Follicular Unit Extraction (FUE) in Black Men and Women

Follicular Unit Extraction (FUE) in Black Men and Women

In a hair transplant, there are two main ways of removing hairs from the back of the scalp or 'donor area' :

1. Follicular unit extraction (FUE) 

2. Follicular unit strip harvesting (FUSS)

Both methods can give great results and there are advantages and disadvantages of each. Men who plan to shave their scalp in the future (or wear their hair very short) prefer the FUE method because the linear scar is not seen.  

 

FUE Techniques in Black Men and Women

There are several factors that influence whether someone is a candidate for FUE.  One of these is the shape and curl of the patient's hair follicles.  It is much easier to extract hairs by FUE in men and women with straight hair than men and women with curly hair.   The structure of hair in black men and women is such that it is curlier than caucasian and asian hair.  The curlier the hair, the more difficult it is to predict the path that the hair follows under the scalp and the more likley these hairs are to be damaged by FUE.  We call this damaged 'transection.' Curlier hair is much more likely to be transected during FUE. It's for this reason that a proportion of black men and women are not good candidates for FUE.  

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Compare the photos below of follicular units in a caucasian hair (above):

 with photos of follicular units from a black hair (below):

curved threes.png

You'll note the hairs are much curlier in black hair.

Conclusion 

I often recommend performing a short 'test session' prior to hair transplant surgery to ensure 100 % that hair follicles will be easy to harvest on the day of surgery and to ensure that the follicles will not be subjected to excessive damage.  Indeed a 30 minute test procedure for the patient in photo 2 peformed 4 weeks before a scheduled hair transplant confirmed that it was still possible to extract follicle by FUE with minimal damage (transection).  


This blog has been filed into the following folders:


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Follicular Units: The Building Blocks of Modern Hair Tranplantation

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Building Blocks of Modern Hair Tranplants

The figure on the right shows that hair follicles normally emerge from the scalp in groups of one, two or three hairs.  These groupings of hairs are called "follicular units".

 

Hair transplant surgery nowadays relies on the use of these "follicular units". 

In individuals with genetic hair loss, hairs from the back of the scalp can be removed and processed into "follicular units" and then inserted into the front or middle of the scalp.

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The second photos shows some freshly prepared "follicular units" from a patient undergoing a hair transplant. "Follicular units" containing single hairs are normally placed into the frontal hairline and "follicular units" containing two or three hairs are normally placed behind this area.  This strategy of placing follicular units mimics what we see in the normal scalp and when placed at precise angles and directions - allows a hair transplant to look natural.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Hair Transplantation Using Leg Hair

 

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

 

 

 



Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Robotics in Hair Transplantation: Coming Soon to a Clinic Near You?

ARTAS system.jpg

Robotic assisted devices and computers are now used in many different types of surgerical procedures. It is likely that the same trend may be seen in hair restoration over the next decade.

Restoration Robotics, a privately held medical device company in the United States, created a robotic device to assist hair transplant surgeons.  The so called ARTAS system consists of a chair where a patient having a hair transplant would sit and a robotic arm that a hair transplant surgeon would control using a computer interface.  The robotic arm would dissect hair follicles from the back and sides of the scalp. The hope is that the quality of hair follicle harvesting may be enhanced by the ARTAS system. The device received FDA clearance in April 2011 for men with brown or black straight hair.

The company announced last week that they have raised 41 million dollars in venture capitalist funding and will begin now to focus on how the technology can be marketed in the United States.



Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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