A: Hair transplants, whether using the strip method to harvest the donor hair or by extracting individual follicular units one-by-one directly from the scalp, will leave some scarring. If the hair is long enough so that the underlying scalp is not visible, these scars will not be seen.

The quality and density of a person’s donor hair will affect this coverage and determine how short a person may keep his hair. In some cases the back and sides can be cut to a few millimeters, in others it would need to be kept longer. Since there is no scarring in the recipient area (the front and top of the scalp where the grafts are placed) the hair in these areas may be kept at any length.

In the past days, there might have been many physicians who did not care much about the importance of the follicular unit and they have only cut the grafts to size. Now, every hair transplant physician believes the importance of follicular unit, and there is no one who cut the grafts to size ignoring each follicular unit.

However, there are some physicians who shout that a hair transplant procedure can be called FUT only when people use all single FU exclusively, and the procedure cannot be called FUT, if mixture of single FU and double FU are used in a session.

I would like to ask you, if you could accept the usage of combination of single FU and double FU under the name of FUT, as long as the grafts were cut according to each FU and intact FU are used throughout the procedure. Could you accept easing of the very strict definition of FUT, which you published about 15 years ago? Could you agree to use mixture of single FU and double FU under the name of FUT?

A: Thank you for the kind words. In thinking about hair transplantation in general, it is important to consider that a hair restoration procedure spreads hair around and, as a result, the transplanted hair will be less dense than the person’s original hair. Therefore, one would never want grafts larger than the largest original follicular units or the results will not look natural. The artificially large grafts will stand out in relatively thin surroundings. If one were to try to fix this by transplanting the doubled FUs very close together (over one or more sessions) one risks running out of grafts for other areas of the scalp. In other words, you can’t fool mother nature.

For example, if a person has thin hair and has only 1-, 2- and 3-hair units occurring naturally in his scalp, then creating 4-hair grafts (by combining two 2’s or 1’s and 3’s) can result in an unnatural, tufted look. Doubling larger follicular units also necessitates larger wounds to receive the grafts which defeats one of the main advantages of FUT, namely to minimize recipient wounding.

That said, it is not unreasonable to place two 1-hair FUs in a single site (if there are extra 1s from the FU dissection) in order to increase density in an area and to eliminate an extra wound.) We do this for crown hair transplants when we are not doing a hairline and there is no need for 1-hair grafts. However, this is the exception.

Technically speaking, anything other than transplanting individual, naturally occurring follicular units is not FUT. However, a physician should make modifications to the procedure for the specific needs at hand. This is the art of medicine. By understanding and applying the underlying principles of Follicular Unit Transplantation, rather than being limited by its nomenclature, the physician will serve his patient best.

In addition to exploring the Hair Transplant Blog, to learn more about this topic, visit the Follicular Unit Hair Transplant section of our website and read detailed information about the hair transplant evaluation, the hair restoration procedure, follicular unit grafts, the donor area, and more.

A: The crown can be transplanted first in patients who have very good donor reserves (i.e., high density and good scalp laxity). Otherwise, after a hair restoration procedure to the crown you may not be left with enough hair to complete the front and top if those areas were to bald.

Cosmetically, the front and top are much more important to restore than the back. A careful examination by a trained hair restoration surgeon can tell how much donor hair there is available for a hair transplant.

For more information on this topic, see my publication on surgical planning of hair transplants, “Follicular Transplantation: Patient Evaluation and Surgical Planning.”

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: Fasting is not necessary for a comprehensive evaluation.

The comprehensive diagnosis may include hair pull tests, hair pluck, hair density measurements, anagen telogen ratios, scalp biopsies and laboratory (blood) tests but no pre-test fasting or other preparation is necessary.