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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


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 common are musculoskeletal problems among hair transplant surgeons?

MSK Issues in Surgeon. 

Musculoskeletal concerns among hair transplant surgeons have not been the focus of significant study. Injuries are talked about among colleagues but numbers have not been collected. 

To explore the frequency, exact nature and extent of possible injuries,  a questionnaire which was e-mailed to 100 surgeons practicing in the hair transplant field more than 5 years. 38 surgeons completed the study, and most who did were males between 50-69 years of age. 50 % reported musculoskeletal issues during or after the procedure, including both pain and fatigue. The reported frequency of pain and fatigue was higher for FUE than FUT (strip) procedures and lasted longer during FUE than strip procedures.

Two thirds of surgeons indicated that they had moderate/severe pain during FUE procedures, compared to one third of surgeons during strip excision procedures. Seventy-five (75%) percent of surgeons indicated they had moderate/severe pain immediately after FUE procedures compared to 29% of surgeons immediately after strip excision procedures.  Moreover, one-third of hair restoration surgeons had pain, fatigue or discomfort lasting more than 12 hours after a procedure.  

Only 30 % of surgeons used any type of ergonomic support such as an ergonomic chair. 

 

REFERENCE

Williams K et al. Ergonomics in hair restoration surgeons. J Cosmet Dermatol 2016; 15: 66-


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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Minimizing the Appearance of Scars in Hair Transplant Surgery: The Trichophytic Closure

The Trichophytic Closure

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.

trichophytic scar.jpg

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.

 

 


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 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?

density crown.png

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.

Slide1.JPG

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.


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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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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.

1,2,3.png

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.

txp map.png

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:


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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To Dense Pack or Not to Dense Pack

What is dense packing?

fu densities.png

For patients having a hair transplant, dense packing refers to the placement of hair follicle grafts close together such that the final density is high (i.e. dense) - greater than 30-35 follicular units per square cm.  Dense packing may lead to densities as high as 50 follicular units per square cm in some cases. The diagram on the right illustrates these different densities.

Some surgeons have argued that dense packing is preferable in some cases because a better cosmetic result can be achieved. Other surgeons have argued that very good results can still be achieved wtih densities of 30 -35 FU/cm2 without risking the chance of getting poor survival of the grafts.   Poor survival is a theoretical possibility because grafts have to be trimmed thinner and thinner in order to be able to pack them close together.

Over the past 5-10 years, we have slowly gained more information about the survival of grafts and particularly how to improve the survival of densely packed grafts. But certainly more research needs to be done. A 2005 study showed that graft survival with dense packing at 50 FU/cm2 was 84 % (i.e. 16 % died) compared to 98 % (only 2 % died) at a density of 30 FU/cm2.   Compare this to a 2008 study by Drs Nakatsui, Wong and Groot which showed that survival was as high as 98.6 % in  a patient transplanted with a density of 72 FU per cm squared in on small test area. The technique used to tranpslant hairs in this study was slightly different than used in the 2005 study mentioned above.

To dense pack or not to dense pack?

The decision on packing density depends on many factors - including their age, the quality of their hair (i.e. hair color, curl, coarseness), the available donor hair and the likelihood of future balding.

Dense packing of 50 FU/cm2 in a 45 year old man with coarse curly salt and peppery colored hair probably won't give much of a cosmetically different result than a 30 FU/cm2 density. In fact, doing so runs the risk of using up more hair and possibly limiting the number of hairs that might be possible to transplant when the man is 55 or 65.

The decision on dense packing needs careful consideration. 

References 

Mayer M, Keen se S, Perez-Meza D. Graft Density Production Curve with Dense Packing. International Society of Hair Restoration Surgery Annual Meeting. Sydney Australia 2005

Nakatsui et al. Survival of Densely Packed Follicular Unit Grafts Using the Lateral Slit Technique. Dermatol Surger 2008; 34: 1016-25.

 


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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