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Hair Transplant FAQs: Can you get the appearance of a full head of hair from a transplant?

Hello Dr Bernstein, I have a few questions. I'll start by saying that I'm a 5A on the Norwood Hair Loss Classification chart, and I've looked into micrograph procedures and know that you can't get back totally a full head of hair like when you were young, but I've seen and heard that you can get, "the appearance of a full head of hair". Is this a common phrase used by hair restoration physician's and practitioner My 2nd question: Is it true that the average amount of hair per square inch on a full head of hair is about 700, and that people don't experience a loss of hair until they lose about 50% of that, or 350 hairs per sq inch, and that the replacement of that 50% would give the appearance of a full head of hair? My 3rd question: How many micrograph procedures would it take, at 1000 graphs per session, to give the appearance of a full head of hair, using 1 & 2 hair graphs in the hairline and progressing to 2 & 3 hair grafts on top and 3 & 4 hair graphs in the crown, given a 5A Norwood candidate? Approximately. My last question: Is this normally achieved producing only one scar in the donor area or more, as a end result. and is there a point at which it become unsafe to continue farming the donor area, in other words, what is the approximate maximum number of hairs or graphs that can be taken from a person with a 5A Norwood hair loss classification? I thank you in advance for your time and input, and apologize for so many questions.

The appearance of a full head is all a hair transplant does. That is why the term is used. 100 follicular units/cm2 with 2.1-2.3 hair per unit is average. Putting 50% back would give the appearance of a full head. This is impossible for most bald people except in select areas. We usually just achieve this towards the front. I don't perform micrografting. Our published data on follicular unit transplantation can be found at www.newhair.com/NHI medical publications/follicular unit transplantation: patient evaluation and surgical planning. The average person with good scalp laxity has 6,000 movable follicular units in their donor area. Even with multiple hair transplant procedures you should have just one scar. Dr. Bernstein

How painful are hair transplants, I am a great coward when it comes to pain?

Dr. Bernstein, how painful are hair transplants? I am a great coward when it comes to pain. Can one be put to sleep totally while the procedure is done? I have one value in my heart that is larger than the other, and I have had shots every twenty eight days since I was seven years old to avoid the possible throat infection that is related to it. Can I still get a hair transplant? I would like to wait for the cloning technology, but I also would like to benefit from a transplant right now. Is there some way that I could have a hair transplant done now, and still be able to make use of the cloning technology in the future, without "wasting" my donor reserves presently? Thanks so much for your help

Hair Transplants don't hurt but the injections can be uncomfortable. Usually they are just given at the very beginning of the procedure. You can not be put to sleep. It is a long procedure and that would create unnecessary risk. Your valve abnormality would not preclude surgery but we would coordinate the surgery with your internist. You certainly can have a hair transplant now and cloning later when it is available. We don't know when that will be , but it will be years. Sincerely, Dr. Bernstein www.newhair.com

Is laser better then the conventional hair transplant method? And if so, how come everyone's not using it?

Dr.Aaron Stone, I'm considering hair transplantation, and I came across a Dr.Riggs, of the Hair&Scalp Clinic in Florida, who uses the CO2 Nova Pulse Laser. The use of the laser sounds like there is much less trauma involved. Is laser better then the conventional hair transplant method? And if so, how come everyone's not using it? Thank You,

If it was so much better everyone would be using it! As a physician who performs laser surgery I can say there is a large misunderstanding by the general public as to what laser is & can do medically. Part of the problem has been unscrupulous physicians & laser manufacturers convincing the public via advertising & newsmagazine shows (also advertising) that laser is a godsend. Lasers are not some magical star trek device. How a laser works & its effect on tissue are dependent on the type of laser & there are more types or models available everyday. All have in common a collimated beam of light that is absorbed by different tissues with different effects. Some are only absorbed by blood vessels of the skin & leave the overlying skin intact. If the beam strength is too high the skin may later blister & can heal with scarring or pigmentation changes. Others such as the carbon dioxide (CO2) laser can cut through tissue by burning through it thereby creating "an open wound". The degree of skin injury prior to cutting or along the sides of the cut is dependent on more than one laser parameter. The greater the degree of skin injury the greater the risk of scarring or pigmentation changes (temporary or permanent). It has been proven at least in rat experiments that if you cut the skin with a laser (with little surrounding skin injury) vs. a scalpel you can't tell the difference between the two incision sites some months later. It has also been shown that laser incisions take longer to heal. Therefore, stitches have to be left in longer to prevent wound separation. As most plastic surgeons will tell you the sooner stitches can be removed the better the end scar result. The belief that there is less trauma with a laser is unfound. Would you rather have an incision that was burned into you with a laser that damages adjacent tissue or cut with sharp cold steel that has virtually no damage to tissue adjacent to the cut? The justification that cauterizing with a laser as you cut offers an advantage over scalpels is false. I have seen patients who had the same hematoma complications after laser eyelid surgery as those who had the procedure performed by sharp metal scalpel.

How can anyone dissect single follicular units without cutting through and transecting adjacent follicular units?

Dr Bernstein, I don't want to get you involved in a public slinging match with Dr Woods, but as one of the pioneers of follicular unit hair transplantation, what is your opinion on damage with the strip excision as Dr Woods states? The reasons why there is so much transection and damage with the strip excision are as follows; The act of pushing a scalpel blade through the dense hair bearing donor area causes transection and destruction of hundreds of follicles even if an angled blade is used. On average this cut takes 1 to 5 minutes. Look at the back of anyone's head. Follicular units are randomly scattered and overlapping. How can anyone dissect single follicular units without cutting through and transecting follicular units above, below and to either side. It is unfortunate for the technicians who chop up the strip that nature did not align the follicular units in perfectly straight geometric rows to aid in dissection. Slow dissection means the donor strip is exposed to air drying for prolonged periods and desiccation will destroy follicles in 2 to 5 minutes. The entire donor strip is chopped up and placed into the recipient area. That is the fat, dermis, skin etc. - Tissue which should have stayed in the back of your head is now competing with the follicles for circulation and nutrition and the follicle often loses. Sewing up the hole with a needle and thick nylon thread pushed into adjacent hair bearing skin means further follicles are transected and skewered and traction damage also occurs. Sewing up the donor site usually takes between 5 and 15 minutes.

Dear Gerard, Thank you. I will give a somewhat longer answer than I usually do in this informal chat because the issues you raise are important. I will answer all of your questions specifically, but first let me give you a little background. The importance of minimizing follicular transection was first scientifically addressed by Dr. Bobby Limmer in Texas, who began using a stereomicroscope in 1988. With the microscope, he was able to see significant amounts of dissection caused by punches and multi-bladed knives, damage that was unnoticed by gross visualization or with ordinary loop magnification. To solve this problem he developed the technique of single-strip harvesting, followed by stereo-microscopically controlled slivering, followed by stereo-microscopic controlled dissection of small mini-micrografts. When we published Follicular Transplantation in 1995, we were mainly concerned with keeping follicular units intact. The first thing we did was to greatly increasing the spacing of the blades on the multi bladed knife, the next was to use loop magnification for all aspects of the dissection, and the third was to build backlighting tables at all of our work stations to provide trans-illumination of the grafts, in order to increase visibility during dissection (This was the idea of Dr. Paul Rose). Unfortunately, none of these procedures were effective in keeping the units entirely intact. When we first heard of Dr. Limmer’s techniques (actually through the work of Dr. David Seager) it seemed obvious that this was the solution for both keeping follicular units intact, as well as avoiding follicular transection. We published a bilateral controlled study in Derm Surg the following year comparing the techniques and showed this indeed to be the case. The reason why single strip harvesting and stereo-microscopic dissection are more effective than other techniques in preventing follicular transection and keeping follicular units intact can best be understood if one divides all harvesting and dissection into two types of procedure, one that is performed “blind” and another performed under “direct visualization.” Blind harvesting and dissection would include situations where one is unable to see the entire length of the follicular structure during harvesting or dissection and/or when one is unable to surgically adjust for what is seen. Direct visualization would be defined as the situation in which the entire follicular structure can be seen and, equally important, when the technique allows the operator to adjust surgically to these visual cues to avoid follicular and follicular unit damage.

A goal of Follicular Unit Hair Tranplantation (FUT) is to minimize blind harvesting and perform as many parts of the harvesting and dissection under direct visualization. Whenever the initial incision into the donor area is made, it is a form of blind harvesting. Even when one removes a single ellipse, and the surgeon carefully (under magnification) observes the wound edge as he cuts, in order to follow the exact angle of the hair, there is some transection and splitting of follicular units. Fortunately it is extremely small. This has actually been measured by Dr. Limmer using stereo microscopy and is consistently around 1% (I think that this answers one of your questions). The idea behind single strip harvesting is that it keeps the area of tissue that is cut “blind” to an absolute minimum. To illustrate this point, lets take a typical 1,000-graft procedure. The strip would measure 1cm x 11cm. (The additional 1cm is to account for the fact that the ends are tapered into an ellipse). The 10cm2 would yield 1,000 follicular units, as there is 1 follicular unit per mm2 of donor tissue in the average Caucasian. The linear cut would thus be 22cm. There would be 1% damage in this “blind” part of the procedure, but then the strip is placed under a stereomicroscope and divided, via slivering, into large sections and placed in chilled Ringers Lactate. The “slivering” enables the dissector to go around follicular units with no transection. Once thin slivers are generated from the slivered sections, individual follicular unit dissection can proceed. With the donor tissue viewed under the stereomicroscope in vitro (out of the body), the strip literally becomes transparent and the structures of the unit stand out. With the microscope, a skilled dissector can readily avoid any follicular damage and keep follicular units intact. We have carefully studied (and published data on) the ability of our own staff to do this. To answer the concern about the donor strip drying. The donor strip is a large mass of tissue compared to an individual graft. Although a single graft may dry out in 2-5 minutes, the donor strip will not be impacted at all during this time period. Once the donor strip is removed, it is immediately placed in chilled Ringers lactate and only the section that is being dissected is kept out of the bath, not the whole strip. In addition, as we dissect, we have syringes of chilled Ringers that are used to keep the tissues constantly hydrated. The tissue is never allowed to dry. In our practice, donor wounds are sutured with Monocryl, a suture of low tissue reactivity that is absorbed by the hydrolysis (slowly broken down by the action of water). The sutures are placed within 1.5mm of the wound edge and spaced ½ cm apart so there is very minimal encroachment upon follicular units. We have recently published this technique. Contrast this to using a small 1.25mm punch (cylinder). For the same 1000 graft procedure, if one removed every other follicular unit, 20 sq cm of tissue would be involved (rather than the 10 cm with single strip harvesting). The length of the incision would be 1.25mm x 3.14 (pi) x 1000 grafts = 40 cm (rather than the 22cm with single strip harvesting). In addition, there would be 1000 wounds, albeit small, to heal by secondary intention (i.e. fill in with scar tissue) in contrast to almost none with the primary intention closure of single strip harvesting.

The issues regarding the use of small punches are not as simple as one would think. First, is the problem of blind harvesting that I mentioned. But, a much more important fact is that, although follicles are grouped in the upper portion of the skin (the dermis) into discrete follicular units, the bulbs of each follicle are random in the fat. This means that each follicle takes a curved, rather than straight, path through tissue. If one looks at this in three dimensions, the follicular unit looks much like a broom that is gathered at the top and splayed towards the end. Since the curves go in opposite directions, we (and others) have found it impossible to remove follicular units with small punches, and also capture all of the bulbs. (This is what I had alluded to in my first comments with the fiber optic technique we were using.) As a result, the transection rate with small punches exceeded 30% in our hands and we thus abandoned the technique. An additional problem is that the removal of one graft, and subsequent healing, distorts the adjacent grafts, making subsequent procedures more difficult. As a result, the person using a punch technique must extend well beyond the mid-portion of the donor zone for tissue. Even from the example I gave above, where every other follicular unit is removed, the donor width must be double what one needs with single strip harvesting. In repair cases with severe donor scarring, when a very tight scalp precludes a strip excision, small punch excisions have been used by a number of us to remove small amounts of donor hair. The risk of follicular transection is sometimes warranted in these cases, since the patient is left with few other surgical options. We all welcome solutions to the problems discussed above, but are not terribly impressed by unsubstantiated claims. The testimonials of patients, although very important, does not give real insight into a technique. Wasting of donor hair is rarely appreciated by the patient, especially early on, or when the balding is limited. The observation of doctors working under magnification gives little information about the ability to solve some of the problems I have mentioned. Speaking on behalf of Physicians in the ISHRS, and as a Contributing Editor of Dermatologic Surgery, I welcome any physician possessing special skills or techniques to share them with the scientific community at large, so every patient may benefit from this knowledge. Sincerely, Dr. Bernstein