Q: What is the most common cause of necrosis (death of tissue) in the recipient area? — A.Q., Los Altos Hills, C.A.
A:Recipient site necrosis is one of the worst complications of a hair transplant and results in skin ulceration and scarring. Usually it is caused by a combination of a few or many of the factors listed below. Each by itself should not present a risk.
Pre-existing conditions in the patient such as:
smoking (the big one)
diabetes (juvenile more than adult onset)
photo-damage (alters the collagen and vasculature)
long-standing baldness (less blood supply when there are no follicles)
Poor surgical techniques:
recipient sites that are too large
recipient sites that are placed too closely (too dense)
too many grafts placed at one time
too much epinephrine used in the procedure
multiple procedures in one session — i.e. FUE and FUE in same session, or large FUT and Graft excision, scalp reduction, etc.
Dr. Eric S. Schweiger, board-certified dermatologist, is quoted in a few recent articles on the effects of chemotherapy on hair, genetic testing for hair loss, and protecting a balding scalp from the sun.
“Coping with Chemo-Induced Hair Loss” was published in a recent issue of Energy Times, a publication focused on wellness and nutrition. Dr. Schweiger commented on the way hair follicles can react to chemotherapy treatment for cancer patients:
Expect changes like “chemo curl.” Eric Schweiger, MD, explains that chemo shocks rapidly dividing cells like hair follicles in the scalp, causing the hair loss. “When the follicles grow again, the shock sometimes changes how they grow, temporarily resulting in a different hair texture and color, which eventually normalizes,” explains Schweiger.
In the article, “Genetic Testing to Predict Hair Loss,” published on HairLoss.com, Dr. Schweiger and Dr. Bernstein discussed the efficacy of genetic tests for hair loss:
[Dr. Schweiger] explains, “I think the test has probably identified a predictor of hair loss but not the only predictor. There is science behind the test and some published research studies; however, the longitudinal, larger studies have not been done, because this testing procedure is just too new.” Dr. Robert Bernstein, M.D., director at Bernstein Medical Center, agrees and adds, “These tests focus on one particular dominant gene, but what is becoming apparent is that hair loss is a complex genetic condition most likely involving several different genes.” He further notes that age, stress, hormone levels, disease and many other factors also are at play in determining factors for hair loss. “Just because a person has the genes for baldness, it doesn’t mean the trait will manifest itself. The truth is the cause and effect have not been proven and differ from person to person, and the association is not anywhere near 100 percent.”
[…]
“Right now, we predict future hair loss based on follicle miniaturization, using advanced microscopic equipment,” says Dr. Schweiger, “and I advise a man to do this at around age 25. If someone presents with more than 25 percent miniaturization, then it’s time to start a hair loss prevention regimen.”
Lastly, Dr. Schweiger contributed featured commentary to an article on HairLoss.com on a topic of importance to those suffering from hair loss, namely, protecting your scalp from the dangerous radiation given off by the sun. In “When You Lose Your Hair, Protect Your Scalp,” Dr. Schweiger encourages bald or balding individuals to take important steps to protect their scalps:
…if you notice your hair thinning or you have baldness of any kind for any reason, it’s important to protect your scalp from sun damage, precancer and skin cancer,” says Dr. Eric Schweiger, M.D., a board-certified dermatologist and hair transplant surgeon at Bernstein Medical — Center for Hair Restoration in New York City. That’s because 100 percent of the surface area on top of your head directly faces the sun’s burning rays when the sun is strongest, between 10 a.m. and 2 p.m. “In general, a mild sunburn on your scalp won’t harm your hair follicles. But any exposure that causes blistering can cause scarring and pre-cancer cells, which will harm hair follicles permanently, so you need to take special care of your scalp when exposed to the sun, even for only a few minutes,” explains Schweiger.
Q: If a person is graying on the top and sides and you do a hair transplant from the back, will the top look darker after the hair restoration? — W.C., Houston, TX
A: The hair is taken from the back and sides of the scalp and the follicular units, once dissected from the donor strip, are randomly inserted into the recipient area. That way, the color of the harvested hair will be mixed and will match perfectly.
Usually, people’s hair is lighter on the top because of the sun, so when you move the hair from the back and sides to the top, it will actually lighten to match the surrounding hair, if it didn’t match already.
Q: It is my understanding that as a person loses his or her hair, the skin of the scalp undergoes a number of changes, namely there is a loss of fat, an increase in cellular atrophy, and of course the dreaded perifollicular fibrosis (now that’s a mouthful). It seems to me that these changes, in particular the fibrotic scarring, are the main obstacles in the way of regrowth, and the reason Propecia does not work for extensively bald men. What can be done about this demon we call fibrosis? Can it be slowed, stopped, prevented, reversed? If we could somehow counteract collagen formation, wouldn’t our baldness problems be solved for good? If a bald scalp is atrophic, how does it have the capacity to hold a whole new head of transplanted hair? Is there a limitation to the number of hairs we can transplant (outside of donor limitations)? — R.L., Rivington, C.T.
A: The findings that you are describing are well documented; however, it is not clear if these changes are the cause of the hair loss or are the result of having lost one’s hair. Most likely, the DHT causes the hair follicles to miniaturize and eventually disappear. This, in turn, causes the scalp to thin and lose its abundant blood supply (whose purpose is to nourish the follicles). The changes in the scalp are also affected by normal aging, which causes alterations in connective tissue including the breakdown of collagen and other components of the skin. The changes seen with aging are greatly accelerated by chronic sun exposure.
Fortunately, even with long-standing baldness there is still enough blood supply to support a hair transplant, although there are some limitations. One should perform a hair transplant with a lower density of grafts when patients have thin, bald fibrotic scalps since the blood supply is diminished.
The most important factor, however, is photo change. The sun dramatically alters the connective tissue making the grafts less secure in their sites and alters the vasculature, (blood vessels) decreasing tissue perfusion (blood flow to the tissues). When there is bald atrophic, sun damaged scalp, I generally perform two hair transplant sessions of lower density (in place of one) spaced at least a year apart to give time for the scalp to heal and blood flow to increase in the area.
I often have the patient treated with topical 5-flurouracil before the surgery to improve the quality of the skin and to treat or prevent pre-cancerous growths from the sun.
Q: Do you ever see poor growth from a hair transplant? What causes this to happen? — R.L., Edison, NJ
A: The situations where I have encountered poor growth are:
1) When hair is transplanted to areas of skin that has been thickened due to the prior placement of larger grafts or plugs (this is called “hyperfibrotic thickening”). Removal of the larger grafts can somewhat ameliorate this problem.
2) When hair is transplanted into a thickened scar.
3) When a hair transplant is performed into an area of severe chronic sun damage. In this case, a very modest number of grafts should be used in the first session and if these grow well, additional grafts can be added in a subsequent session.
Hair loss has a variety of causes. Diagnosis and treatment is best determined by a board-certified dermatologist. We offer both in-person and online photo consults.
Dr. Eric S. Schweiger, board-certified dermatologist, is quoted in a few recent articles on the effects of chemotherapy on hair, genetic testing for hair loss, and protecting a balding scalp from the sun.
