A: It is a bit too early to tell. My sense is that it will not have any practical long-term benefits for the treatment of hair loss (MPB), since it doesn’t get to the cause of androgenetic hair loss, i.e. DHT. Treatments such as copper-peptide, saw-palmetto, laser therapy, have all been promoted for male pattern hair loss, but have not really turned out to have any significant long-term benefits. Further studies need to be done on PRP to get a better sense of its value in combating hair loss.

On the other hand, PRP can have a significant impact on wound healing and it is possible that it may be useful in promoting healing after a hair transplant in both the donor and recipient areas of the scalp.

For further reading, see the Bernstein Medical – Center for Hair Restoration web page on Platelet Rich Plasma (PRP).

A: Widened scars can be improved in two ways: they can be re-excised to make the scar finer, or hair can be placed into the scar to make it less visible.

Excising a scar works best when the original incision was closed with poor surgical techniques. In this case, using better closure methods can improve the scar. When the scar is the result of a person being a naturally “poor healer,” a wide scar will be the result – regardless of how the incision was closed.

I often approach the problem by excising a small area first, to see if I can decrease the width of the scar. If so, I would then proceed to excise the rest of the scar. If not, I would obtain hair using follicular unit extraction (FUE) — extracting hair in follicular units directly form the scalp — and place this hair into the scar. The hair placed in the scar can also be obtained from the edges of a partially excised scar.

If a wide scar that is thickened (called a hypertrophic scar) is also excised, it will usually reoccur and may result in an even worse scar. Because of this, thick scars should be flattened with injections of cortisone prior to removing. This will decrease the chance of a recurrence.

Flattening the scar is also important to permit the growth of newly transplanted follicular unit grafts.

For more on this topic, please see the Bernstein Medical – Center for Hair Restoration web page on fixing scars.

These people getting these miraculous jobs from Canada – it is a trick, right? They can’t honestly expect to be able to get away with what they’ve done over the course of their entire lives, can they?

A: I think you have better insights into hair loss than many hair transplant surgeons. ABI was the “rare” patient who seems to be a stable Class 3. I made that judgment due to: almost no miniaturization at the border of his Class 3 recession, no crown miniaturization, and his unusual family history. He had several older family members who stayed at Class 3 their whole lives.

Since we only have about 6,000 movable follicular units on average in our donor area, placing 3,000 at the hairline is obviously a joke and/or the doctor is playing “Russian Roulette” with the patient’s future.

As you point out, in most patients the hair loss will progress and the person will be out of luck. It is similar to the way flap patients were stuck without additional donor hair as their hair loss progressed. An additional problem was that the flaps were low on the forehead and very dense. The situation is analogous to placing 100 grafts per sq cm2 to create a low, broad hairline in a young person.

If you do the math you can see how ridiculous this tactic is. A person’s original density is only 90-100 follicular units cm2. Patient with Class 6 hair loss lose hair over an area of about 300 cm2.

This consists of:

• 50cm2 in the front (including a 15cm2 hairline)
• 150 cm2 for the mid-scalp
• 100 cm2 for the crown

Therefore, 6000 FUs transplanted to this area = 6000/300 = 20 FU per cm2. This is the number we often work with. We put up to 50cm2 at the very most in the mid-frontal forelock area and then proportionately less in other areas.

However, if you put 3,000 FUs at the hairline, in a density of 100/cm2, then you have covered only 30cm. This leaves only 3,000 FUs for the remaining 270cm2 of balding scalp for a density of a little over 11 FU/cm2.

Now, transplanting 11FU cm2 over the back part of the scalp is not a disaster EXCEPT if the front was transplanted at 100 per cm2. In this situation (as you have accurately pointed out) the patient will look very, very front heavy, with an aggressively placed, dense, broad, hairline and little hair to support it towards the back.

The gamble is that the patient’s baldness doesn’t progress, that finasteride or dutasteride can halt the process if it does progress, or that hair cloning methods will be available to save the day.

In my opinion, elective surgery should not be performed when its success depends upon these uncertainties – and particularly since a cosmetically disfiguring hair transplant can be so debilitating (and avoidable).

The reality is that doctors who claim to perform these procedures may not even be performing follicular unit transplantation. In FUT, the surgeon transplants naturally occurring intact FUs of 1-4 hairs. The extreme dense packing techniques preclude the use of 4- and sometimes even 3-hair grafts. What happens is that the larger FU are spit up. This doubles the graft counts (and the cost to the patient) without giving the patient any more hair. It also increases the risk of follicular damage and poor growth.

Patients in whom 10,000 follicular units are available to transplant are very rare and when they are shown on the internet, should be viewed as the exception rather than the rule.

A: I perform FOX tests on all patients when I am considering a FUE hair transplant. I do not routinely perform FOX tests before repairs (or on eyebrow transplants) where the number of grafts is relatively small.

The purpose of FUE is to identify those patients in whom FUE is inefficient — i.e. there is a greater than average risk of damage during the harvest. If this is the case, I would not perform the hair transplant since even slight inefficiencies create a significant problem when thousands of grafts are transplanted.

Remember, compared to Follicular Unit Transplant (FUT), FUE is a relatively inefficient procedure. Even when a small FUE hair transplant is performed (i.e., in a Norwood Class 3) we have to anticipate that eventually the person will need a large amount of grafts, so a FOX test is still important.

However, when the total number of grafts is small, such as in scar revisions or eyebrow restoration, small inefficiencies are not as important.

In addition, with repairs, the donor area is altered so that extraction in different areas may be very be different, rendering a FOX test in scar revisions far less useful.

Finally, if a FUE hair transplant is started, but then aborted due to extraction difficulties, the patient must either be reverted to a strip (which was not the preferred means of harvesting or a FUT would have been planned to begin with) or the patient will be left with a partial procedure – both less than ideal situations. However, if a FUE repair has to be aborted due to the inability to efficiently harvest hair, no harm was done; we just won’t be able to achieve our goal.

A: We have found that the most successful technique is to perform the exercises: once a day, for at least 15 minutes, and using three different hand positions.

For more information on this topic, please see the “scalp laxity exercises” section about half-way down the Donor Area in Follicular Unit Hair Transplantation page of the Bernstein Medical – Center for Hair Restoration website.