Q: What can be done if I want to have a hair transplant and my scalp is very tight from prior surgeries? — R.R., Long Island, N.Y.
A: Follicular Unit Extraction is ideal in very tight scalps, provided that there is enough hair to extract without leaving the donor area too thin and provided that the follicles are not too distorted from the scarring.
With strip harvesting, undermining techniques may be helpful to close the wound edges once the strip is removed.
In undermining, the surgeon uses either a sharp instrument (scalpel) or blunt instrument (the dull edge of scissors) to separate the upper layers of the scalp (dermis and epidermis) from the lower part of the scalp (fascia). The hair transplant surgeon accomplishes this by spreading apart the fat layer of the skin or by cutting through scar tissue.
Undermining allows the upper layers of skin to literally slide over the lower layers and can significantly increase the ability to close a tight wound. However, if not done carefully, it may increase the risk of bleeding and injury to nerves and occasionally may damage hair follicles.
Undermining is usually used with a layered closure where the deeper tissues are brought together first with a layer of absorbable sutures before the surface of the skin is sutured closed with sutures that are removed.
Q: I am interested in an FUT hair transplant. How do you figure out how large a strip to use for the hair restoration when transplanting all follicular units? — P.K., New York City, N.Y.
A: The length of the donor strip incision is determined by the number of follicular unit grafts required for the hair restoration. There are slightly less than 100 follicular units/cm2, so if a 1cm wide strip is used, a hair restoration procedure requiring 1800 grafts would need a strip that measured slightly more than 18cm in length.
A 2800 graft procedure would measure slightly more that 24cm if the strip were 1.2cm wide.
The width of the strip is determined by scalp looseness or laxity. For more information, please see the page on the Donor Area.
Q: I have heard that the hair for a hair transplant is taken from the back and sides of the scalp. Where exactly is the best place to remove the hair from? — L.L., Rivington, C.T.
A: You are correct. The best place to put the donor incision is in the mid-part of the permanent zone located in the back of the scalp. As more hair is needed the incision is extended towards the sides.
The vertical position can be found by feeling for the bump in the mid-part of the back of the scalp, also called the occipital protuberance. The strip should lie over this point.
If hair is removed too low on the back of the scalp, there is a greater chance that the wound will heal with a stretched scar from the movement of the underlying muscles. If the incision is too high, the hair will be subject to the same genetic balding and may not be permanent.
Q: I am 22 and want to go for hair transplantation. I want hair restoration surgery now because I have a concern about my donor area that it might diminish if I postponed my transplantation. Could this be the case? — T.J., Westchester County, N.Y.
A: The logic is not correct. Having a hair transplant at an early age does not protect the donor supply.
If your donor area diminishes over time, then the transplanted grafts will fall out as well. Hair does not become permanent just because it’s moved in a hair transplant. It is never any better than the hair in the area where it came from.
The longer you wait – i.e. the older you are when a hair transplant is performed – the more information we will have about the stability of your donor area and this will allow for optimal planning of the hair restoration.
A: In general, FUT will give you more hair since, in FUT, the best hair from the mid-portion of the permanent zone of the scalp (also called the “sweet spot”) can be utilized in the hair transplant.
With FUE, since only the hair follicles are extracted and not the surrounding bald skin, if too much hair is removed, the donor area will begin to look thin as hair is removed. This will limit the amount of hair that can be harvested.
Although in FUE additional areas of the scalp can be utilized to some degree, this will generally not compensate for the inability to access all of the hair in the mid-permanent zone and the total amount available for the hair restoration will be less.
Q: I understand that even if you have multiple hair transplants you will only be left with one scar in the donor area. — T.J., Yonkers, N.Y.
A: If the closure is performed without tension, each procedure should result in the same fine scar.
The best-placed incision is in the mid-portion of the permanent donor area. Since there is only one mid-point, there is one best position for the scar. All incisions should lie on this plane leaving one scar.
Q: Is it possible to do a hair transplant using follicular unit extraction without shaving the donor area? — V.S., Syracuse, N.Y.
A: In follicular unit extraction, the area that is extracted is clipped to about 1-mm in length. However, if the session is not too large, then the clipped area can be long and thin so that the patient’s existing hair will cover it. The person’s hair should be left long for the procedure.
Q: Is it possible to tell me roughly how many grafts would be left from donor area if one had a hair transplant of 2,500 grafts and had a density of around 2.0? G.H. – New York, NY
A: How much hair can be harvested in total depends upon a number of factors besides donor density. These include: scalp laxity, hair characteristics (such as hair shaft diameter, color and wave), and the actual dimensions of the permanent zone.
Every person is different, so all of these factors would need to be taken into account to determine the total number of grafts that would be available for the hair restoration.
Q: I am 19 years old and seem to be thinning all over, including the sides. My father has all of his hair but my grandfather is totally bald. Should I have a hair transplant now or wait until I am older? — T.K., Garden City, NY
A: Most likely you have a type of androgenetic alopecia called Diffuse Unpatterned Alopecia (DUPA). In this hereditary condition, hair thins all over rather than just on the front, top and back as in the more common male pattern baldness. The fact that the back and sides of your scalp are thinning (the donor area) precludes you from being a candidate for surgery. The diagnosis can be made by observing a high degree of miniaturization (fine hair) in the donor area under a magnifier. This instrument is called a densitometer.
Q: I have had 4 hair transplants with strips taken out for a total of 2600 grafts over 15 years. The last one was 1,650 grafts. My doc says my donor site is good for a few more but I think it has been probably stretched to its max. Is it believable that the skin can be stretched to such extremes safely? – Murray Hill, N.Y.
A: The scalp is very resilient to stretching, particularly in those with a loose scalp to begin with. After removing a strip, the laxity often returns to normal or very close to it within 6 months to a year.
The problem with multiple hair transplant procedures is not only that scalp laxity may decrease, but that the donor density decreases as well. If too much hair is harvested, the donor area may eventually appear too thin. This may happen with either Follicular Unit Transplantation (FUT) or Follicular Unit Extraction (FUE).
Therefore, it is important the doctor not only assess the scalp laxity, but the residual donor density.
Q: When harvesting donor hair, how does the surgeon know when to stop? – D.D., Pleasantville, N.Y.
A: The patient must first decide the shortest length he/she is comfortable wearing his/her hair.
Donor hair can be removed — whether through Follicular Unit Transplantation (FUT) or Follicular Unit Extraction (FUE) — as long as, at this length, the back and sides do not look too thin (i.e. do not have a transparent look) and the donor scars are not visible. The surgeon needs to use his judgment when harvesting, so that this endpoint is not crossed.
Additionally, the surgeon must anticipate that the caliber of hair in the donor area will decrease slightly over time as a normal course of events. The actual number of grafts that can be harvested varies greatly from person to person. It depends on the patient’s donor density, scalp laxity, hair characteristics and size of the donor area.
Q: I have developed a rather large, hard lump beneath the skin at the base of my scalp in the donor area that I first noticed this about two or three weeks after my hair transplant. What is this? — A.R. Bronx, N.Y.
A: You are describing an enlarged lymph node, a condition commonly seen as a normal part of the post-op course following hair transplants.
This is a normal part of healing in response to the surgery. It will resolve on its own in about 3-6 months. It doesn’t require any treatment and it should not be a cause for concern.
Q: Can you get your original density back with a hair transplant? — C.C. Scarsdale, New York
A: Although the cosmetic benefit can be dramatic, a hair transplant only “moves” rather than creates new hair. In surgical hair restoration, a limited amount of hair from the donor area is transplanted to a much larger area in the front and top of the scalp, so that we can never reach the original density.
Achieving a cosmetically appropriate density in the front part of the scalp (which is around 1/3 to 1/2 of the original) generally takes two sessions and is the goal of most hair restoration surgery. Lower densities are used towards the back of the scalp.
“Hair Transplantation” is one in a series of medical textbooks published by Elsevier Saunders. The textbook — part of a series entitled Procedures in Cosmetic Dermatology — is written by Robert S Haber and Dowling B. Stough and edited by Jeffrey S. Dover. “Hair Transplantation” offers a step-by-step, practical guide to performing cutaneous surgical procedures.
The book’s editors selected Robert M. Bernstein as a major contributor, writing in two chapters. As pioneer of the advanced surgical hair restoration procedure known as Follicular Unit Transplantation (FUT), and as Associate Clinical Professor of Dermatology at Columbia University, Dr. Bernstein was uniquely qualified to provide medical professionals with insight and training on the state-of-the-art in hair transplant surgery.
Dr. Bernstein is lead author of the chapter entitled “Follicular Unit Transplantation” and co-author of “Follicular Unit Extraction”. The text details how to best achieve natural results, donor area diagnosis, aesthetic principles, tumescent technique, and more.
The purpose of this volume in the Dover series is to cover the tenets of hair transplant surgery by considering the philosophy, basic science, and techniques in a practical clinical text.
Succinctly written and lavishly illustrated, “Hair Transplantation” presents current, to-the-point guidance with a focus on procedural how-to’s and offers step-by-step advice on proper techniques, pitfalls, and tricks of the trade.
“Hair Transplantation” is shipped with a comprehensive DVD, containing video clips of techniques and procedures, as well as the hints and tips for surgical hair restoration. It features a wealth of color illustrations and photographs that depict cases as they appear in a hair restoration practice.
Q: If someone doesn’t have enough donor hair, do you ever perform an FUE hair transplant using donor hair from outside the permanent hair zone? — M.V., Nashville, TN
A: No. If hair was taken from outside the permanent zone as the surrounding hair continued to bald, the scars from FUE, although small, would become visible.
In addition, the transplanted hair would not be permanent, and over time would eventually fall out.
Cosmetic Surgery Times features Dr. Bernstein’s presentation to the 55th annual meeting of the American Academy of Dermatology in their April 1997 issue.
The article entitled, “Follicular Transplants Mimic Natural Hair Growth Patterns,” describes Dr. Bernstein’s introduction of his new procedure, Follicular Unit Transplantation, to the academy as well as the keys to making the technique successful. Find the complete article below:
Form Follows Function: Follicular Transplants Mimic Natural Hair Growth Patterns
By Neil Osterweil
Contributing Editor
SAN FRANCISCO – In recent years, many hair replacement surgeons have adopted the modem architecture philosophy that “less is more,” moving from the use of hair plugs, to split grafts, to minigrafts and, finally, micrografts. But at least one hair transplant specialist contends that a more appropriate architectural dictum is “form follows function.”
In other words, the surgeon should let the technique fit the head, and not the other way around, suggested Robert M. Bernstein, MD, at the 55th annual meeting of the American Academy of Dermatology.
Dr. Bernstein is an assistant clinical professor of dermatology at the College of Physicians and Surgeons, Columbia University in New York. He described his “follicular transplantation” technique in a meeting presentation and in an interview with COSMETIC SURGERY TIMES.
Natural Hair Groups Used
“Hair doesn’t grow singly it grows in naturally occurring groups of from one to four hairs. In follicular transplantation, we use these naturally occurring groups as the unit of the transplant,” he told CST.
The typical follicular unit consists of one to four terminal hairs, one or two vellus hairs, sebaceous glands, subcutaneous fat and a band of collagen which circumscribes and defines the unit. In the follicular transplant technique, the follicular unit is carefully dissected and removed, and then the intervening skin is discarded. This enables the donor site to be small, allowing implantation through a small needle poke. Because trauma to the recipient sites is minimal, the entire procedure can be performed at one time. Dr. Bernstein and colleagues have implanted as many as 3,900 follicular units in a single, 1 day session.
Keys to the follicular transplant technique are:
• Identify the patient’s natural hair groupings and isolate the individual follicular units – Hair groupings are assessed with an instrument called a densitometer, and the average size of a person’s groups can be easily calculated. This information is critical in the planning of the transplant. The density of hairs in an individual measured as the number of hairs per square millimeter of skin is quite variable, but the density of follicular units is relatively constant within individual races.
Most people of Caucasian ancestry have a density of approximately one group per millimeter; people of Asian and African descent tend to have slightly less dense growth patterns, although the characteristics of the person’s hair (such as wavy or wiry hair), can give a full appearance even with low density.
If a patient has an average hair density of two, he will receive mostly two hair implants, with some one-hair and three hair implants mixed in. “If you try to make the groups larger than they occur naturally, they will look pluggy. If you try to make them smaller than they naturally occur, they’re not going to grow as well, because each group is actually a little biologic machine that makes the hair — it’s an anatomic unit. If you break it up it just doesn’t grow as well,” Dr. Bernstein observed.
A 38-year old man with a Norwood Class 5A/6 hair loss pattern undergoes a single procedure of 2,500 follicular implants. The result 11 months later. (Photos courtesy of Robert M. Bernstein, MD)
• Harvest meticulously – The acquisition and preparation of grafts must be carefully performed to ensure success for this demanding technique. Highly trained, skilled assistants are essential to the success of the procedure. Dr. Bernstein noted that he uses a highly trained team of up to 10 assistants to produce the implants for a single case. “The assistants, who range from medical technicians to registered nurses, are such an integral part of the procedure that they must become expert in their specific tasks for the surgery to be successful.” The physician must be able to skillfully harvest the donor strip and must be able to make accurate judgments about the size of grafts intra-operatively and adjust the technique accordingly. Dissection and placing of the follicular units is the most labor intensive part of the procedure.
• Design the recipient area well – The recipient sites are carefully distributed so that a natural looking pattern is maintained throughout the recipient area. An important consideration for this stage of the procedure is to “frame the face and spare the crown” so those facial features are kept in correct proportion. A common mistake in hair replacement, said Dr. Bernstein, is to create a hairline that is too high thereby elongating the forehead and accentuating, rather than minimizing, the patient’s baldness. It is also important to avoid or eliminate contrast between the implants and surrounding skin by creating a soft transition zone of single hairs and to have the hair emerge from the scalp at natural angles.
Procedure Lowers Cost
Although the procedure is highly labor intensive, it can actually be less expensive than conventional hair replacement surgery, because it can be performed in a single, but lengthy, session.
“It is also much more efficient and conserves donor hair much better than conventional hair transplants. Every time you make an incision in the person’s scalp you waste some hair and make the remaining hair more difficult to remove. Accessing the donor area just once or twice will increase the total amount of hair that is available for the transplant,” Dr. Bernstein told CST.
“In the very near future, the procedure will be improved and made more affordable with automated instruments that will enable the surgeon to make sites and implant the hair in a single motion. This will also decrease the possibility of injury to the implants by reducing handling and keeping the grafts uniformly cool and moist. It is possible that someday hair follicles may be cloned to provide a virtually unlimited supply of custom follicular units, but until then the finite nature of a person’s donor supply must be respected,” concluded the doctor.
“Hair Transplantation” is one in a series of medical textbooks published by Elsevier Saunders. The textbook — part of a series entitled Procedures in Cosmetic Dermatology — is written by Robert S Haber and Dowling B. Stough and edited by Jeffrey S. Dover. “Hair Transplantation” offers a step-by-step, practical guide to performing cutaneous surgical procedures.
“Hair doesn’t grow singly it grows in naturally occurring groups of from one to four hairs. In follicular transplantation, we use these naturally occurring groups as the unit of the transplant,” he told CST.
