A: We do not always harvest additional hair in repair procedures, but we do if possible because it can improve the aesthetic outcome by adding additional density and camouflage. This is called Combined Repair. As for whether we use FUT or FUE in repair procedures, the answer depends on the clinical situation. For example, a loose scalp favors FUT. If the person wants to wear their hair short, that favors FUE. If donor scars from the plugs need to be removed, that favors FUT. If scarring in the donor area needs to be camouflaged rather than removed, that favors FUE.Posted by
Q: I am having a facelift next month and also want to have a hair transplant soon after. How long should I wait between procedures? — S.H., Boston, M.A.
A: Although it would be possible to do a hair transplant as soon as a week after a face or brow lift, ideally one should wait at least three months between procedures for the following reasons: 1) there will be less tension in the donor area and, therefore, it will be possible to harvest more grafts, 2) if there is any shedding from the facelift it will make the planning of the hair transplant more difficult, 3) it will leave the option of adding hair, in or around, any problematic surgical scars, and 4) will provide the ability to add hair to any area of thinning that might result from the facelift.Posted by
Q: I have been reading about hair transplantation and I have a question concerning FUT (strip-harvesting). I understand, in this method, a strip is excised from the back of the scalp, the wound then closed. I wonder, then, is not the overall surface of the scalp reduced in this procedure? After two or three procedures, especially, (or even after one large session) will not a patient’s hairline also be shifted? That is, the front hairline would move back by the amount of scalp excised, or, more likely, the “rear hairline” (which ends at the back of the neck) must certainly be “moved upward.” At least, this is how I imagine it would be. Is my logic flawed? I’ve been trying to understand this in researching the procedure, but the point still evades me. — M.M., Great Falls, V.A.
A: The hair bearing area is much more distensible (stretchable) than the bald area and just stretches out after the procedure. As a result, the density of the hair in the donor area will decrease with each hair transplant session, but the position of the upper and lower margins of the donor area don’t move much – if at all. As a result, the major limitation of how much donor hair can be removed is the decreasing hair density, rather than a decrease in the size of the donor area.
With very low donor hair density the strip will yield so little hair that further sessions eventually become impractical. To say it another way, since a hair transplant decreases the donor density, in each succeeding hair transplant session, you need an increasingly larger donor strip to remove the same number of grafts.
This effect also explains why, in most instances, FUE will not allow the doctor to obtain any significant amount of additional hair, since the donor area is already too thin, and FUE would thin it further.Posted by
Q: Can the crown be transplanted first instead of frontal area? Why is the crown the last choice? Any reasons behind it? — H.H., Ladue, M.I.
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.”Posted by
Q: I have been told a number of different ways to massage my scalp. What do you suggest? — H.H., Pidemont, C.A.
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.Posted by
Q: Is it more important to do scalp exercises before the first procedure or the second? — P.P., Richmond, V.A.
A: When the scalp is tight, it can be useful for either the first or the second hair transplant.
Keep in mind, however, that the scalp will naturally stretch between hair transplant procedures, so that if exercises were not needed for the first procedure, they will generally not be needed for the second.
In our practice, we generally wait one year between hair restoration sessions so that we can see the full cosmetic impact of the first procedure and give the scalp laxity a chance to return to normal on its own.
In addition, there is a risk that active massage after the first procedure may widen the donor scar. Therefore, before considering massage before a second hair transplant, make sure that enough time has elapsed between procedures so that stretching of the scar will not be a be a problem.
In general, since the scalp will normally continue to relax for up to a year after a procedure, it makes sense that when there is a tight scalp, one should wait at least a year before considering the next hair transplant session. If massage is contemplated, it should be started one year after the prior procedure. This will give the scalp a chance to loosen naturally and will ensure that the massage will not stretch the donor scar.
In my opinion, it is a mistake to plan hair restoration sessions too close together in patients where scalp laxity is a constraint.Posted by
Q: How long should I do scalp exercises before the procedure? — O.D., Newport, R.I.
A: To get the most benefit from scalp exercises, one should stretch vigorously on a regular basis for at least eight weeks prior to your hair restoration procedure. However, this will vary based upon the individual and upon how much the laxity needs to be increased.
Please remember that for the majority of patients scalp exercises are not necessary.Posted by
Q: I am scheduled to have a hair transplant next month and wonder if I should do scalp exercises before the procedure? — G.F., Providence, R.I.
A: For the majority of patients, scalp exercises are not necessary.
The scalp in the donor area has a fair amount of redundancy. With a properly planned hair transplant, the donor area will close relatively easily.
If a patient’s scalp is particularly tight, or if a very large session is planned (even in the face of an average scalp), vigorous scalp exercises are useful in increasing laxity.
The advantage of stretching one’s scalp prior to surgery is that it allows the doctor to remove a slightly wider strip and it decreases tension on the closure so the person will heal with a potentially finer scar.Posted by
Q: How soon after the hair transplant procedure do I have to get them out? — T.J., Fort Lee, NJ
A: We remove every other staple at 10 days post-op. The remaining staples are generally removed at 20 days post-op. This varies based upon the patients scalp laxity and the width of the donor strip.Posted by
Q: Can you give me an idea of the average width of a donor strip, i.e. the actual width taken from the back of your scalp for a hair transplant? — A.E., Fort Lee, N.J.
A: The average donor strip is 1cm wide, although this will vary depending on the patient’s scalp laxity, density, and the number of grafts desired for the hair restoration.
The length also depends on the number of grafts needed. We average 90-100 follicular unit grafts per cm2 of donor tissue (that is the density of follicular units in an average person).
A 2,000 graft procedure, for example, would require a donor strip 22 cm long and 1cm wide. A 2,500 graft session would be 1.2 cm wide and 23 cm long.Posted by
Q: Dear Dr. Bernstein, a full head of hair averages ~100 FU/cm2. To achieve the appearance of fullness with a hair transplant 50% is required. In one of your articles you say that you recommend 25 FU / cm2 to your patients. Is that the density per one session or the final one? If that is final density, then it is far below the 50%. Please explain as I am profoundly confused. — W.N., Easton, C.T.
A: If a person is to become a Norwood Class 6, the hair that we have available for us to transplant is only about 12% of what was there originally. This, of course, will vary from patient to patient depending upon one’s donor density and scalp laxity and a host of other factors.
We make the hair restoration look good by restoring 25-50% in the front, and proportionately less in the back. Logically one cannot restore 1/2 of ones original density to an entire bald scalp with only a thin strip of donor hair – there is just not enough hair, even with multiple sessions.
I transplant 25-35 FU/mm2 in one session, but this is the density created in the front, not overall.
Due to follicular unit graft sorting (placing the larger follicular units in the forelock area) this provides even more density than the actual numbers suggest. If someone is relatively certain to have more limited hair loss, then the numbers can be increased, but it is risky if you underestimate the degree of eventual hair loss.
Please carefully read the article on Hair Transplant Aesthetics.
It will answer your excellent question in greater detail. The article is a bit old, but the principles are the same.Posted by
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: After a strip procedure, will the scalps laxity return to normal and how long after the hair transplant does it take? C.B. – Roanoke, Virginia
A: The scalp regains most of its laxity in the first eight months following the hair transplant, but it will continue to loosen slightly after that.
It is interesting that if the scalp is tight prior to surgery, the scalp is less likely to have its full laxity return than in patients who had loose scalps to begin with. With average or loose scalps, there is usually no difference. However, over time, the patient rarely, if ever, notices any permanent tightness unless aggressive procedures have been performed or procedures such as scalp reductions and lifts.Posted by
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.Posted by
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.Posted by
Q: I am 27 years old and have a Class 3 degree of hair loss. Should I do a hair transplant or consider non-surgical methods of hair restoration? — Y.B., Lake Forest Illinois
A: At age 27 with early hair loss, you should consider non-surgical options first.
Propecia is the most important medication, but you need to be on it for one year at the full dose of 1mg a day to assess its benefits.
If you have done this and other parameters are OK for a hair transplant, such as adequate donor hair density and scalp laxity and you have little evidence that you will become extensively bald (i.e. no donor miniaturization and no family history of extensive baldness), then hair transplantation can be considered.Posted by
Q: I have fine hair. Is that a problem for a hair transplant? — N.R., Boston, MA
A: Fine hair will give a thinner look than thicker hair, but will look completely natural. Thin hair doesn’t prevent one from having surgical hair restoration, providing your donor density and scalp laxity are adequate. These would need to be measured.
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