Robert,

Thank you for taking the time to write! I am not sure I can speak for the majority of hair transplant surgeons, but through my training and experience with many of the top surgeons out there, the short answer to your question is; it is a judgement call.

The chief concern, as you identified, is whether you will do more harm to the existing hair, than good! If the existing hair is close to complete loss, I believe many surgeons would choose to help that patient by restoring a conservative area of hair/hairline.

If the hair in the area seems to be salvageable, some surgeons would feel more comfortable trying medical therapy alone for 6-12 months, while others would simply exercise caution during the transplant. Too many grafts at once with the latter approach can exacerbate shock loss, especially if the patient has fine or miniaturized hair to begin with.

If you believe you are in this latter category, it is always best to go with the hair surgeon who levels with you about the risk of shock loss; you will be replacing the hair with permanent hair, so you will have a net benefit, but the risk of significant shedding with more limited re-growth does exist.

All of the above refers to hair on the top of the scalp no matter where it is thinning. I’d like to mention, however, that the crown is a unique area with its own set of problems. If the only thinning area you want to fill in is the crown, a patient should seriously consider going on Propecia or deferring surgery entirely until it is clear that the frontal area will not need the grafts more than the back!

The reason is that the grafts are in limited supply, and you want to be able to place them in the most cosmetically beneficial area possible - get the most bang for your grafts! - so to speak. The most cosmetically beneficial area is almost always the front, since it is a natural balding pattern to have some crown loss but still have your face framed conservatively. So, whether there is some hair remaining in the crown area or not, many hair physicians would think twice about treating this area aggressively.

I hope that answers your question! Remember that the best surgeons will not treat any area that still has hair in it without having a long discussion with the patient about expectations and alternative medical treatments first. Good luck and I wish you good hair!

Warm Regards,
Dr. Sara Wasserbauer
Member, International Alliance of Hair Restoration Surgeons
Member, American Hair Loss Association

Post from: Hair Transplant and Hair Loss Info Center | IAHRS

My question is: Would you recommend the FUE technique? Or maybe another technique that is know to have better lasting results? Also, how do I find an honest hair transplant doctor that I can trust and that does top notch work? - Shawn
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Shawn:

Thank you for submitting your question.  I will attempt to answer each component of your question individually.

First let me state that the “A”, (or anterior) pattern of hair loss only represents about three percent of patients with genetic hair loss.  “A” patterns are some of my favorite patterns to transplant because with strong mid-scalp and crown hair, the results can be dramatic and therefore very rewarding for the patient.  However with that said, as a young man you must assume that there will be progression in your pattern of genetic hair loss to a 4A, 5A, or even to a Norwood-Hamilton 6 classification.  Especially if you are not firmly committed to stopping ongoing hair loss by properly using either Rogaine, (minoxidil), Propecia, and/or Low Level Laser therapy for the long term.  As a young man experiencing genetic hair loss, your primary concern must be an all out effort to stop ongoing loss.  Stopping ongoing hair loss is the cornerstone of your successful result, not having a hair transplant procedure.  If you are committed to “locking in” your 3A pattern, then hair restoration surgery could lead to you enjoying a full head of hair for the rest of your life.

If Rogaine, (minoxidil) did not provide you with an acceptable result, for whatever reason, then it is not the right option for you.  Don’t look back, simply move ahead with one of the other two FDA approved options.  And you note that you have now chosen to use Propecia.  All things being equal, I believe that Propecia provides men with the most convenient option to stop the progression of genetic hair loss.  And convenience is critically important.  If you make something easy enough for someone to incorporate into their daily lives, their compliance is much greater over the long term.  And this coorelates directly with maintaining scalp hair counts over the long term.  Consider taking monthly pictures of your scalp to more objectively monitor your result on Propecia.  Remember that a “GOOD” result is NO CHANGE in the photos.  This represents a stabilization in the progression of your pattern.  Not every patient will improve the quality of their hair by using any or all of the three FDA approved options.  But that is OK.  If “regrowth”, (slight thickening of the shaft diameter of the genetically susceptible hair) occurs, so much the better.  But the goal is to stop your current pattern of hair loss from progressing.  And virtually all men will achieve this goal by using Propecia for the long term.

Regarding your concerns about donor scarring with a transplant procedure, I will state the following.  Every surgical procedure has potential advantages and disadvantages.  With the advent of the “trichophytic” closure technique, scarring in the donor zone with “strip” harvesting has
greatly improved.  It has improved to the point that I find that my patients can wear very short hairstyles without any concern.  In my practice I find that I am limiting performing the follicular unit extraction, (FUE) technique to patients who require very small transplant procedures, (less than 1,000 follicles), or to transplant into wide donor scars initially created by another physician.

My biggest concerns with the FUE technique are as follows;

1) With the FUE technique the follicles are harvested from a much greater area of the donor zone, therefore, the harvested follicles may not be truly “permanent”.  Remember, what appears to be strong “permanent” hair today, may not appear this way in twenty or thirty years.  You would then have invested in a procedure that was to provide you with “permanent” hair, only to experience loss of that hair if it is susceptible to your genetics at a later timeframe of your life.  This is an example of why it is so critical for you to commit to stopping ongoing hair loss.

2) There are many reports of slightly “kinky” hair growth and unacceptably high follicle transection rates obtained with the FUE technique.  I can only surmise that the extracted follicles are somehow “manhandled” by those who may not be experienced in the technique.

3) At the International Society of Hair Restoration Surgery meetings there have been case study reports of long term donor zone anagen effluvium, (noticeable long term thinning in the donor zone where hair is shed by the follicles in the near vicinity of the extracted follicles) associated with the FUE technique.  If you saw what the donor zone looked like in these case studies, you might not be so interested in the FUE technique.

The bottom line is that there is no “one size fit’s all” procedure.  Each surgical technique, and every patient has potential advantages and disadvantages that need to be considered in creating the most appropriate surgical plan.  If a hair transplant surgeon only performs a single technique, I would seek a second opinion.

The Physician members of the International Alliance of Hair Restoration Surgeons, (IAHRS) have been carefully screened for ethics, and consistent quality results.  These physicians are considered among the “best of class” in the hair restoration profession.  I recommend that you consider scheduling a consultation with one or more of the members of the IAHRS.  You won’t be disappointed.

With Best Regards,

Robert J. Reese, DO
Member, International Alliance of Hair Restoration Surgeons
Member, American Hair Loss Association

Post from: Hair Transplant and Hair Loss Info Center | IAHRS

Thank you for your help in this matter.
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Thank you for your question regarding your dilemma of whether to have hair restoration utilizing strip surgery or FUE to obtain the grafts. Unfortunately, you may have heard conflicting information on this topic from either patients or physicians, due to either a lack of knowledge about either procedure, or due to a commercial bias. I am going to try and give you some information that may help you sort the facts and make a decision that is right for you.

You are not alone in your fear about ending up as one of those people you have read about with bad strip scars. But, lets take a step back, ignore the hype and look at the two procedures. First, I would like to tell you that about 60% of my patients opt for strip surgery and the remainder opt for FUE. I am hopeful that the reason my patients select one procedure over another is because they understood the risks, benefits and costs and then made a decision based on the merits of each procedure.

Strip surgery, if performed by a competent physician, rarely results in a a scar that is wide or disfiguring unless there was a gross error in estimating the skin laxity or mobility, or the patient had an abnormal tendency to heal with a wide scar. Both are pretty rare. The average scar width is probably between 1 and 3 millimeters. Pretty much undetectable unless someone is combing through the hair looking for it, however, if you cut your hair short maybe less than a 1/2inch or 1/4inch it may be somewhat visible. [...]

View Dr. James Harris’ Full Response:

James A. Harris, MD, FACS
Member, International Alliance of Hair Restoration Surgeons
Member, American Hair Loss Association

Post from: Hair Transplant and Hair Loss Info Center | IAHRS

This is a great question. I have a lot of patients between 18 – 26 that ask the same question. I really feel there is no specific age to make someone an appropriate candidate for hair transplantation. I think it depends on many different factors, including your age, the amount of hair loss you have, the pattern of hair loss, your maturity level, and your expectations. Maturity level is important because you have to be realistic and understand that whatever we do, or whatever any hair transplant doctor does at this age is permanent. Whatever results you are going to have, has to look good now, at age 25 or 26 and has to still look good when you are 40 and 50 years old.

You also have to understand that if you do the strip procedure, which most patients are doing at this time, you are going to have a little thin, fine scar in your donor area and you may have a slight limitation as to how short you can cut your hair in the back.

View Dr. Charles’ Full Video Response:

Glenn Charles, DO
Member, International Alliance of Hair Restoration Surgeons
Member, American Hair Loss Association

Post from: Hair Transplant and Hair Loss Info Center | IAHRS

Is there anything that can be done to get rid of them?  Do I have any legal recourse?

Thanks for your help.
Fred
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Hi Fred

Thank you for your question.
In order to find a solution to this problem, it’s important to arrive at a diagnosis.

(1) Are you noticing bumps in the skin which fill up with whitish or yellowish material and then “pop?”
(2) Are these bumps small like pimples or large like cysts?
(3) After they pop, does a hair appear where the bump used to be?
(4) Do they always appear in the same place or can they appear all over your scalp?
(5) Do they only occur in the transplanted areas or do they also appear in the non-transplanted areas?
(6) Were you told by your doctor that they are ingrown hairs or are you assuming that this must be the cause?
(7) Do you have straight or curly hair?
(8) Do you shave your hair?

I would visit the doctor who performed your original procedure & tell him or her about your concerns. If that is not possible, I would arrange to see a dermatologist who is familiar with hair transplantation in order to arrive at a diagnosis.

If the problem is indeed ingrown hairs, they could be removed surgically or sometimes simply expressed using a needle.  Some patients suffer from recurrent pimples called “folliculitis” which can cause painful bumps in the skin. This can be treated with antibiotics. Another possibility is that the raised bumps are due to “cobblestoning” if large grafts were used for your transplants.

Fred I hope these suggestions help you in your quest to resolve this issue.

Regards,

W.G. Mark McKenzie M.D.
Diplomate, American Board of Hair Restoration
Medical Director
Seager Hair Transplant Centre.
Member, International Alliance of Hair Restoration Surgeons
Member, American Hair Loss Association

Post from: Hair Transplant and Hair Loss Info Center | IAHRS

Dear Scott:

Thank you for your letter. The good news is that it is likely that you will continue to get more hair as the transplanted grafts continue grow over the next 2-4 months.

There have been sporadic reports of Propecia causing some mood alterations but the problem is that they occur so infrequently that it is unclear if the medication is in fact the cause. If by discontinuing the medication your problems resolve it in fact may have been the Propecia. The other possibility is that it may just be slight changes in the expression of your underlying mood disorder.

To answer your question, you should probably be using 5% minoxidil or Rogaine in the frontal area as well as crown. It may be your best bet at slowing the process. You can also consider adding 2% Nizoral shampoo and low level laser light therapy. The possibility of success with these latter suggestions are not well worked out but there are some reports of these treatments providing positive results in some patients.

If you do continue to recede additional transplants can be used to fill in the gaps and allow for a continued natural result. You should talk to your surgeon as it is likely that he/she has thought of this eventuality and has planned accordingly. It is important for you to understand what options you have. If the surgeon did not discuss the possible need for additional surgery or if you feel that there is a lack of communication you can address this directly with your doctor or search one out that is willing to discuss your situation.

Sincerely,
James A. Harris, MD, FACS
Member, International Alliance of Hair Restoration Surgeons
Member, American Hair Loss Association

Post from: Hair Transplant and Hair Loss Info Center | IAHRS

First of all Patrick, you bring up a very good case in point as to why young men (those under the age of 25 or so) should not be readily treated for their hair loss with a transplant procedure. Certainly, anyone at that age, I am going to recommend the most conservative approach, most likely Propecia, possible laser light therapy, and conservative follow up. For those men under the age of 26 or so, FUE is essentially the only procedure I would consider, for it does not leave the problem of a visible donor site scar.

With your donor site scar, I have found that the first step should usually be the excision of the scar with plastic surgery closure. While there is no guarantee that this will improve the appearance of the scar, it makes sense to try this first, for it does have a reasonable chance of scar narrowing, and perhaps if there is enough laxity, for the allowance of hair growth through the scar using the HITS (trichophytic) technique. A variety of techniques can be used for scar revision- most commonly it involves the use of deep sutures to help hold the tissue together, with superficially placed skin sutures as well. While results of this scar repair depend upon the scalp elasticity (sometimes very elastic scalps can actually have greater scar widening than non-elastic scalps), the location of the scar (the lower down in the back of the head the more likely to result in widening), and the technique used by the surgeon. With this scar excision, some donor hairs will be removed with the strip, which can be dissected out then planted into any part of the scar that is not excised.

The next approach to the scar is to plant into it. I will wait a minimum of 4 months- 6 to 8 months is preferable- before transplanting into the scar. The donor grafts can be obtained by the FUE technique, but for some patients it is preferable to make another donor site incision (obviously not in someone who plans to cut his hair very short) from which the grafts can be obtained. These grafts are transplanted into the donor site incision, using careful techniques to maximize the percentage of take, making deeper incisions typically that generate blood flow to assure graft survivability.

With these scar repair techniques, success as defined by meeting patients’ expectations is assured by two steps- using the very best techniques, and providing realistic goals of the procedure. Do not minimize the challenge in obtaining good results with these procedures- there are sometimes variables that result in less than ideal healing. However, by doing your homework and seeking out the most experienced and confident surgeon, the patient can help himself get the best results.

Jeffrey S. Epstein, M.D. FACS
Member, International Alliance of Hair Restoration Surgeons
Member, American Hair Loss Association

Post from: Hair Transplant and Hair Loss Info Center | IAHRS

Dear Hafeez,

The ideal season depends mostly on you and the procedure you choose.

Hair loss has a tendency to accelerate in the winter months. We usually see an increase in surgery patients in the fall and winter. As you know, some animals tend to retain more hair in the winter months and have more shedding in the warmer months. With humans, we tend to see more shedding in colder months.

Perhaps this is why we perform more surgical solutions in the winter than in the summer. Perhaps it is because people want a more active life style in the summer.

This leads me toward my recommendations. You are the one who will determine when to have a hair transplant. It will depend on your lifestyle. If you can wear a hat and can get out of public scrutiny in the winter, the winter will be better for you. If the summer is better for a more secluded life style, then have the procedure in the summer.

Then there is the question of when you want to see hair growth. Suppose you want significant growth 8 months after your procedure. In this instance you will want to plan your procedure 8 months before your “coming out” party.

Hence, there is no ideal season. Most patients prefer fall or winter months. Ultimately the decision is up to you. I think that if you are planning to shave your head for FUE or CIT, you will want to plan your schedule more cautiously. If you are having a strip, you will find that 7 to 10 days should be enough provided you use products to help get rid of scabs such as Graftcyte or Haircycle.

John P. Cole, MD
Member, International Alliance of Hair Restoration Surgeons
Member, American Hair Loss Association

Post from: Hair Transplant and Hair Loss Info Center | IAHRS

There is always hope that a less than ideal donor scar can be improved. The best method for correcting an unsightly scar in the donor region will depend on several factors including: 1) the width of the scar; 2) the location of the scar with respect to how high or low it was placed in the donor region; 3) the elasticity of the surrounding scalp; and 4) the baseline follicular-unit density in the region immediately adjacent to the scar.

There are two basic modalities available for correcting the scar. One can undergo a scar revision at which time the scar is excised and the remaining incision is meticulously repaired. An open scar revision like this will depend on the width of the scar and the elasticity of the surrounding scalp. A tight scalp may preclude this option since there needs to be some redundant scalp available to stretch into the defect which is left following removal of the scar. Tension is one of the single greatest contributors to the creation of a wide scar following a strip harvest procedure. You will have a high risk for developing another wide scar if the revised incision is closed under tension. A scar revision of this type is usually performed in conjunction with a trichophytic closure. This particular modification of the closure technique is designed to bury follicles in the incision line so as to promote hair growth through the subsequently healed scar. Your surgeon may recommend a few months of aggressive scalp massage prior to any attempt at scar revision if you have a tight scalp. Scalp massages have been shown to produce significant relaxation of the surrounding skin which may permit wound closure under less tension. Less tension at the time of wound closure would lessen your risk of recurrent stretching.

Follicular-unit extraction (FUE) is the other method that can be used to help camouflage an objectionable donor scar. This method is useful when tension prevents correction of the offensive scar with a traditional excision-based scar revision. Using the FUE method individual follicular units are harvested with a fine punch that measures 1 mm or less in diameter. The grafts are then strategically placed into the scar so as to provide direct camouflage from the hair growing out of the scar. The number of grafts needed will depend on many factors such as the length and width of the scar, the texture and caliber of the hair, the contrast between the hair and the skin, and the preferred length that you wear your hair. Fortunately, grafts seem to grow well when carefully placed into scar tissue.

In general I prefer to correct a wide scar whenever possible with a traditional scar revision repair. Any reduction in width with this method is beneficial and it minimizes the need for harvesting grafts via FUE. Many times the best result is obtained by using a combination of the two methods – first excising the scar to achieve the narrowest residual scar possible followed by using a smaller number of FUE grafts to finesse the final camouflage of the remaining scar line. With time and meticulous performed surgery you should be able to achieve a significant improvement in the appearance of your current scar.

Raymond J. Konior, M.D.
Member, International Alliance of Hair Restoration Surgeons
Member, American Hair Loss Association

Scar Revision By Dr. Raymond Konior

That patient underwent a single procedure by an inexperienced surgeon who used a multiblade for the strip harvest. He developed significant stretching and cross-hatching in the donor scar as well as pitting and ridging in the recipient site. I performed a donor scar revision with a multilayered closure. He healed with a relatively fine scar which was further softened with placement of individual follicular-units directly into the scar about a year later. The grafts were taken from the original transplant zone which was also revised by the direct excision of more than 90% of cosmetically objectionable hairline grafts. He is able to wear his hair short again without evidence of the original scar.

Post from: Hair Transplant and Hair Loss Info Center | IAHRS

Thanks in advance,
Terry
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Mr. Terry,

As you might expect, meeting a patients expectations depend on many factors with regards to their current state and end goals. Many men depending on age could be very happy with as little as 3000 grafts (esp is you are more of a stage 3 than 4), but I would not be surprised if you came back in at a later date and add another 1500 grafts.

In addition to your pattern hair color, quality and curl can have significant benefits or detractions with regards to your overall happiness. So many factors go into achieving ones desired goal that it can be hard to say what you might spend. But I suspect it would cost somewhere between 10K-15K to produce and nice end result.

If I could see detailed photos and get a little additional input, I suspect I could be more exact. The more conservative you are in design, limiting the areas to be covered, the less grafts you will use. Younger patients who want to cover larger areas with greater densities will obviously use more grafts.

Please let me know how I can assist.

Sincerely,

Brad Limmer, MD
Member, International Alliance of Hair Restoration Surgeons
Member, American Hair Loss Association

Post from: Hair Transplant and Hair Loss Info Center | IAHRS