Cost of Hair Transplant Surgery: What's the Real Deal?

Author: The Hair Transplant Expert

Just like any other surgery, the cost of hair transplant surgery is also expectedly high. A normal surgical procedure falls between $4,000 and $20,000. The pricing specified by surgeons is per graft depending on the type of procedure you choose and how extensive the procedure is going to be.
There are two most common types of hair transplant surgery and one costs double the price of the other. Strip Harvesting was developed first but it is now less preferred by patients. Doing this procedure on you would require scalp tissues to be removed. That means surgical stitches, scars and a longer recovery period. It may be cheaper but you would have to bear with the side effects for a longer time. Plus, the scars would not necessarily be covered if you have short hair.

Follicular Unit Extraction or FUE may cost double of the price of Strip Harvesting but this is preferable because it does not leave scars. The scalp tissues would not be touched and just the hair follicles will be transferred. Hair follicles from the donor area or the part of the scalp with the healthiest hair will be planted on the part of the scalp with thinning hair. Since this is a more meticulous process, more manpower is required; therefore, the cost of hair transplant surgery is a lot higher. The procedure also takes longer time but simply because of the absence of scars, people still prefer this now over Strip harvesting.

In choosing a surgeon or a clinic where you are going to have your surgery done, you also have to consider the skills or at least the reputation of your surgeon. You should not just choose any random surgeon to do your hair transplant because safety should be your top priority. There are a lot of websites that will help you choose the perfect surgeon for you. Also, opinion from friends or acquaintances who have undergone the same procedure will benefit you greatly in knowing the real cost of hair transplant surgery. That way, you would have a clear idea on which deals you should choose for your hair.

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About the Author
Get permanent, natural looking hair through new surgical hair transplant techniques. Explore all your hair loss options and get all your questions answered. Visit  http://www.NewLookMd.com and schedule a free cost hair transplantation consultation.

Minoxidil Side Effects

By Robbie Dee

Let's start by saying that this article isn't about knocking Minoxidil as a medication. It is a highly effective method of regrowing your hair, but it's important that you have all the information before you make a decision that it is THE method for you.

Itchy Scalp

 One of the most common complaints about Minoxidil is an itchy or dry scalp. This is actually not caused by the Minoxidil at all but by the Alcohol carrier solution that it is normally mixed with. Where Minoxidil is mixed with laser therapy this effect is greatly reduced as the laser helps stimulate blood flow to the scalp and thus the healthier skin.

Hair Loss

 A hair regrowth product that actually leads to hair loss? Initial use of minoxidil can sometimes lead to shedding of hair. This can be alarming for some people, but is actually a positive effect. The shed hairs will grow back and the new hairs will be stronger and healthier.

More hair Loss

 If you use Minoxidil for an extended period and then stop using it, the scalp may not be able to support the new larger stronger hairs. Once again shedding can occur and over a period of several months you can find yourself back where you started with your hair.

Allergic Reactions

 As with all medical products there is a chance of allergy. Topical Rogaine contains propylene glycol as a non active ingredient which most commonly is the substance in a minoxidil mixture which is reacted too. It's also possible to over absorb mioxidil when petroleum jelly or tretinoin is used on the scalp, or the scalp has been sunburned. Absorbing too much Minoxidil can result in hypertension.

Other Side Effects

 There are a number of less common side effects noted which include chest pain, lowered libido, tingling in the extremities(hands and feet, sometimes the face), irregular heart beat, changes in blood pressure, lightheadedness and acne in the areas the solution is being applied too. If any of the side effects listed are experienced it is a good idea to reduce or stop using the minoxidil until you have had the chance to talk to a doctor.

Who Should Avoid Minoxidil?

 If you have any blood pressure issues whatsoever you should visit a doctor before taking minoxidil. Women who are sexually active and likely to fall pregnant, as well as anyone who is already pregnant should not take minoxidil. The drug can be transferred into the bloodstream of an unborn child, and can also be passed to a newborn baby via the mothers breast milk.

If minoxidil side effects, surgery and drugs cause you a little anxiety, but you'd still like to Regrow Hair  on your scalp, then be sure to visit the quick and easy tips website for the complete low down on the options open to you and the best way to Regrow Hair  Naturally.

Article Source:  Minoxidil Side Effects - Learn the Side Effects of Minoxidil Before It's Too Late

Natural Hair Loss Treatment - Rogaine, Propecia, Minoxidil, And Other Organic Prevention Products

By Michael R Thomas

When dealing with hair loss, the best way is with a natural hair loss treatment. Natural hair loss products are always the best way to deal with any illness because it causes less trauma to the body. Of course there are lots of normal medication to choose from, but luckily you can now find many types of natural hair loss treatment on the market to choose from. Today I will discuss natural Propecia, natural Rogaine, natural minoxidil, along with a more natural hair transplant.

Natural hair loss products

When choosing a natural hair loss treatment you need to make sure that what you are taking is actually natural. Check on the box and see if it says organic hair loss treatment on it. If it does then you can be 100% sure that you are fighting your baldness with something that comes from the Earth and not from a factory. The reason for taking organic products is because you don't have to worry about poisoning your body with chemicals that it might reject. The reason why a lot of people had adverse side-effects to various types of medication is due to the fact that you are curing one illness and giving yourself another. That is never good to do to your body.

Natural hair loss shampoo

The first line of defense against baldness is by using a good natural hair loss shampoo. You need to make sure that the shampoo is healthy for your hair. No shampoo alone with cure you of your baldness because you use it for such a short period of time and then rinse it out of your hair. Of course, it can definitely help you in fighting baldness.

Natural hair loss prevention

If you use the shampoo that I mentioned above then you are already on your way to finding a good natural hair loss prevention method. Actually, the fact that you are reading this article shows that you care about your hair, so you are taking the right steps to getting your hair back and stopping more from falling out.

Natural Propecia

Natural Propecia can be found all over the Internet. These actually work pretty well, but a little slower than normal Propecia. Just make sure you buy it from a trusted place. If it's too cheap then it is probably not real, so expect to spend a bit of money on it. Also, it won't be covered by your insurance companies, unless you have some very nice coverage.

Natural Rogaine

With natural Rogaine you will be rubbing it on your scalp just like the real thing. One of the bad things is that it has a really bad smell, so you will want to do this at home. That's one of the reasons a lot of people don't use it because they don't want to stink.

Natural minoxidil

I don't recommend using natural minoxidil because it usually doesn't have the same effect that other baldness treatments have. You should probably consider taking the real thing if you insist on using minoxidil.

Natural hair transplant

I'll be honest with you and tell you that the natural hair transplant isn't all that it's cracked up to be. They simply use natural pain killers in the process, but it's still the most natural out of all the things you can do, in the fact that you don't take any medicine. Although, I'm not sure how natural cutting off a piece of your skin with hair attached and stitching it back on to another place on your body is. Anyone telling you that this is natural is crazy.

Of course you should always consult with a doctor before taking any drugs. Be safe, and remember, bald can be beautiful, but having hair is priceless. [http://www.hairlosscureblog.com/]Click Here to find out more about hair loss cures and prevention methods. For more information about a hair loss please visit us at [http://www.hairlosscureblog.com/]http://www.HairLossCureBlog.com.

Article Source:  Natural Hair Loss Treatment - Rogaine, Propecia, Minoxidil, And Other Organic Prevention Products

Facts About Minoxidil

By John Brian

Hair loss is one of the most annoying things that can happen to anyone, male or female of all ages. It isn't severe that it can kill anyone, it doesn't paralyze people and it isn't contagious. But it will suck the life out of anybody's confidence and self esteem. It is a natural occurring anti socializing phenomenon. Once you start experiencing hair loss, self esteem and attractiveness also goes down. You can either fight hair loss or accept that it is part of your life. I honestly believe that most people would be happier if they accept the fact that they are going to lose their hair. However if you are one of the few who wants to fight hair loss then read on. We now have FDA approve drugs that are meant to combat hair loss and regrow hair. I'm talking about Minoxidil products.

Minoxidil is a drug that has been found to be able to treat male pattern baldness. Minoxidil was first being developed as an oral drug for high blood pressure, but patients using Minoxidil were experiencing a side effect. Patients and health care providers like doctors and nurses notice that hair growth is being experienced by the patients as a side effect of the drug. The company developing Minoxidil saw this as a great way to make money so they decided to create a topical solution. This topical solution is applied to the scalp to treat male pattern baldness. The mechanism or how Minoxidil regrows hair is very much unknown. However it is known that Minoxidil stops hair loss by preventing or halting DHT from going to the scalp and hair follicles.

Minoxidil is suggested by the health care providers to be applied twice a day. It should be applied once in the morning and another at night. Each application should use approximately 1ml solution of Minoxidil. Minoxidil should not be swallowed so it is suggested that we wash our hands if it ever got in contact with Minoxidil. It should be applied twice a day for about four to six months to see some results. It is recommended that people use this product when we are younger. As we grow older, the effects of this drug aren't as effective. It is also recommended to apply this topical solution on the scalp for about four hours and the scalp should be dry so that it can absorb most of the products active ingredients. One of the bad things about Minoxidil is that it isn't permanent. Hair growth that comes with this product will disappear if the use is discontinued. It is a lifetime commitment so think about that first before buying it.

Minoxidil also has a lot of adverse reactions. Not everyone that uses minoxidil got the hair that they wanted. Some of the most severe adverse reaction of this product is irritation of the skin. Itching of the scalp, dryness and redness are often the most common cases of adverse reactions of this product. So if you have very sensitive skin, using this drug or product may not be right for you.

For some of the best hair loss treatment please go to my site. You can also find more information on thin hair treatments on my site.

Article Source:  Facts About Minoxidil

After Hair Transplant Care

Author: Parsa Mohebi

After hair transplant care is something that patients who undergo a hair transplant procedure need to know and follow closely.

Here is the post-op instruction of the patients at US Hair Restoration. Different hair restoration clinics may have different post-op care and instructions due to their different surgical methods.

Patients who had a hair transplant surgery using a strip technique usually leave our hair transplant center with a bandage around their head. The bandage is used only to support the newly closed donor wound on the back of scalp. Patients are given prescription for pain and anti-inflammatory medications for first few days after surgery. The first night after hair transplant surgery, patient needs to be cautious not to rub or scratch the transplanted area. It is recommend that all patients take it easy for the first days and avoid heavy physical exercises.

All patients need to come back for physician evaluation and hair wash the day after surgery. During this first visit, the bandage is removed and donor wound and the transplanted hair is assessed. The donor and recipient areas need to be washed very carefully while teaching the patient how to wash it at home during day two to four after hair transplantation. Hair wash after hair transplant surgery needs to be done twice a day with a special method to minimize the probability of dislodging the grafts. Patients ask if they can skip washing hair within the first few days to avoid damaging the grafts. The answer is 'No'. Hair wash is a key step in hair transplant care that guaranties the normal growth of the transplanted hair follicular grafts. Follow up in ten days should also be part of after hair transplant care for patient who have FUE (follicular unit extraction) hair transplant, eyebrow hair transplant, hair transplant repair or body hair transplants.

There are some restrictions in patient\'s physical activities after hair transplants. Some clinics recommend very strict rules for physical activities. It is preferred that patient keeps his normal daily activities with some minor limitations. The activities that add to the tension of the wound edges at donor area should be avoided for the first four weeks after surgery. Those activities are: extreme bending of neck and heavy weight lifting.

Patients need to go back to hair transplant clinic at day ten after hair transplant surgery to remove the staples (for patients who had strip surgery and donor is closed with metal staples) and to reevaluate the donor and recipient area. For the patients who have their donor closed with absorbable sutures, it is recommended to be seen in ten days to assess the healthiness of recipient and donor area, which includes patient\'s who had FUE (follicular unit extraction) hair transplant, eyebrow hair transplant, hair transplant repair or body hair transplants. All follow up visits are included in the initial cost of hair transplant surgery and patients won\'t be charged for any follow up visits.

Patient should avoid direct sun exposure to the recipient area for about six months after follicular unit transplant surgery. Extreme and direct sun exposure may harm the growing grafts. Sun contact may also cause skin changing the skin color.

And finally the last follow up appointment for their after hair transplant care is between months ten to eleven after their hair transplant surgery, when transplanted hair grows to its final thickness and length. At last session Dr. Parsa Mohebi evaluates the transplanted hair grafts and assesses the finial size and condition of donor scar. This visit is a good time for patients who want to consider a repeat surgery to increase the density of hair or cover the areas that has not been completely covered with first hair transplant surgery due to the limited scalp laxity or extended balding area. All patients who are planning for a repeat surgery do not have to wait that long and a repeat surgery could be done any time after month 5 after the initial hair transplant procedure.

At US Hair Restoration, a LA hair transplant surgery center, patients can also be seen as needed in addition to the above mentioned visits.

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About the Author

Dr. Parsa Mohebi is the medical director for US Hair Restoration. Re-establishing a patients’ self image and self-esteem by using the most modern medical and surgical approach is one of Dr. Mohebi’s goals. He and his staff are highly committed to using the highest techniques and devices.
Dr. Parsa Mohebi is personally involved in all stages of patient care. Dr. Mohebi is collaborating with many academic centers on the topics of hair growth, gene therapy techniques and hair multiplications. Dr. Mohebi performed surgical internship at University of North Dakota followed by residency at University of New Mexico and York Hospital.
Dr. Mohebi then continued his aspirations in surgical research by joining the Department of Surgical Sciences at Johns Hopkins School of Medicine. It was there that he performed several studies on wound healing and hair growth using growth factors and gene therapy methods.
His main focus has been dedicated towards the research of hair growth, hair multiplication, wound healing and psychology of hair loss. Dr. Mohebi completed a fellowship in surgical hair restoration at NHI.
Dr. Mohebi has many publications and presentations at national and international levels on hair loss, hair restoration and wound healing. He is involved in improving surgical methods and techniques on a daily basis. He is also the inventor of the Laxometer, a device that measures the mobility of the scalp before hair transplant procedure. Laxometer increases a surgeon’s accuracy and helps minimize the widening of scar tissue.

Male and Female Pattern Baldness

Considering Hair Transplant? Insider Tips Here

Author: Michael Pavlos

Everyone has heard of or even seen hair transplant horror stories, maybe in a magazine, online or even worse seen the obvious plugs in a elderly friend or relative. However hair transplant surgery has jumped leaps and bound in recent years to make it a viable, safe and not too risky option for those suffering with male pattern baldness, many celebrities such as Nicholas Cage, Brendan Fraser Mather MOcanhey, Dwayne Johnson (the Rock,WWE) Salman Khan (Bollywood) and even Italian Prime Minister Silvio Berlusconi are believed to have had hair transplantation surgery, although such is the stigma attached that none of them have admitted to it publicly, it only becomes obvious when studying before and after pictures.

History of Hair Transplant

The origins of hair transplant surgery stem from Japanese dermatologist, Dr. Okuda, who in 1939 published a revolutionary method in a Japanese medical journal of using small grafts that were similar to the way hair transplantation is performed today. This method involved using hair transplant grafts to correct lost hair from various body areas, including the scalp, eyebrow, and moustache areas.



In the late 50s one physician in particular, Dr. Norman Orentreich, began to experiment with the idea of relocating or transplanting the hair on the back and sides of the head to the balding areas. Dr. Orentreichs experiments showed that when bald resistant hairs from the back and sides of the head were relocated, they maintained their bald resistant genetic characteristic regardless of where they were transplanted.



This principle, known as Donor Dominance, established that hair could be transplanted from the bald resistant donor areas to the balding areas and continue to grow for a life time. This laid the foundation for modern hair transplantation. During the 60s and 70s hair transplants grew in popularity. However, the standard of care involved the use of larger grafts that were removed by round punches and often contained many hairs.



In the 80s hair restoration surgery evolved dramatically, as the large punch grafts were gradually replaced with a more refined combination of mini and micrografts. This combination mini micrografting hair transplantation procedure no longer used the punch to extract the bald resistant grafts. Rather a strip of bald resistant hair was surgically removed from the back of the head and then trimmed into mini and micrografts.

Types of Hair Transplant

There are two main methods of Follicular unit hair transplant surgery. Follicular unit Transplant commonly known as FUT or strip surgery\' and Follicular unit extraction, commonly known as FUE The main difference is the method of extracting the transplanted hair. FUT and FUE are really complimentary forms of HT, not competing methods of which one must make a choice.

FUT versus FUE

The 90s saw the gradual introduction of a very refined surgical procedure now known as follicular unit hair transplantation or FUT. This exacting and labour intensive procedure transplants hairs in their naturally occurring one, two, three, and four hair follicular unit groupings in which they grow naturally.



The concept of creating the entire hair restoration using exclusively follicular units was proposed by Dr. Robert Bernstein and was described in the 1995 Bernstein and Rassman publication Follicular Transplantation. Critical to the success of the follicular unit hair transplant procedure was the introduction of the binocular microscope by Dr. Bobby Limmer of San Antonio Texas in the late 1980s.



Dr. Limmer found that by using the microscope to examine the donor tissue he and his staff were able to successfully isolate and trim the naturally occurring follicular units into individual grafts. Dr. Limmer shared his techniques and findings with his colleagues and together with Drs. Bernstein, Rassman and Seager, was a persuasive advocate for the follicular unit hair.



The process involving follicular hair transplants is considered to be the most effective among hair restoration methods. In follicular hair transplant, the surgeon transplants hair from the permanent zone in the back of the scalp onto the affected areas.



If you need a large area covered, then you most likely want to go for FUT because it is the more economical in terms of number of grafts for price paid. If you absolutely, positively don\'t want strip surgery as you are worried about scarring, then FUE is your only alternative. Contrary to popular belief, both methods leave scars. FUT will leave a narrow line across the back of your head, whereas FUE will leave little unpigmented dots across the back of your head. The only difference is that the FUE scars are not concentrated together and therefore harder to detect when wearing hair very short.



There is no doubt that FUE procedures are harsher on the grafts than FUT procedures. Because of this the final growth yields tend to be lower for FUE compared to FUT. But BOTH procedures work for the most part.

Hair Transplant Cost

FUT surgeries are performed by reputable surgeons around the world however FUE is mostly available through a number of specialists, the vast majority of reputable ones that I know of are in the United States and Canada. Pricing for FUE from these reputable surgeons is currently close to $7- $11 US dollars per graft for FUE, and depending on what level on the Norwood Scale, a scale used to measure the progression of male pattern baldness, can be quite costly. Pricing for FUT from these same surgeons is normally in the range of $4-6 per graft, however in Asia and Eastern Europe prices can be even lower.

Does Cheaper Means Better?

Many of my clients do sometimes look to cut costs by using other surgeons especially in countries such as India, Pakistan, Thailand and Eastern Europe. Although Im sure there have been success stories via this route please remember in these countries there is little guarantee or action available to you if something does go wrong. I have seen hair transplant using the FUT method, although not a horror story in terms of scarring or suffering, it did not yield the expected results of a more established surgeon placing the same number of grafts (2,000). He is therefore left with poor hair coverage but now has lost the option to shave it all off due to huge smiley faced scar in the back of his head!

Check, Check and Check

I recommend considering hair transplant surgery only after you have tried the non-surgical treatments on the market. Then when you certain you wish to get a hair transplant I would advice thoroughly researching reputable doctors, of course price is always issue, but in the case of hair transplants it should not be the most important factor. Indeed the money saved is nothing compared to trauma of having to live with a badly scarred scalp for the rest of your life. If you decide to go for more budget surgeon, please do insist on seeing photos of the surgeons previous work and do not be afraid to ask for contact details of their previous patients.

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About the Author

Michael has over 8 years experience in all areas of hair restoration and plastic cosmetic surgery. He has worked extensively throughout Australia and overseas and helps run a cosmetic plastic surgery clinic & hair transplant clinic in Sydney, Australia. Call 1300 733 092 for a free consultation.

Avoiding Pitfalls in Planning a Hair Transplant (part 2)

Author: Robert M. Bernstein, M.D.

Patient Assessment

Donor Supply

In performing a hair transplant, the physician must balance the patient?s present and future needs for hair with the present and future availability of the donor supply.  It is well known that one?s balding pattern progresses over time. What is less appreciated is that the donor zone may change as well.   

The patient?s donor supply depends upon a number of factors including the physical dimensions of the permanent zone, scalp laxity, donor density, hair characteristics, and most importantly, the degree of miniaturization in the donor area - since this is a window into the future stability of the donor supply.

The size of the donor area is determined by both its width (height) and its length.  When assessing the potential width of the donor area, doctors usually assess the lowermost point that the balding will reach, i.e. the top part of the permanent zone.  However, it is equally important to pay attention to the inferior margin as well.  It is common for the hair to thin significantly at the nape of the neck as a person ages, producing an 'ascending hairline.'  Since this can significantly diminish the width of the donor area, any evidence that this process may occur should be taken into account in the planning.  Loss of the temporal points is another process that has a significant impact on the donor supply. Not only does it foreshorten the potential length of the donor strip but it often portends very significant baldness.   

Scalp laxity is another variable that affects the amount of available donor hair.  Very tight scalps significantly limit the amount of donor hair that can be removed through strip harvesting.  The constraint imposed by a tight scalp is not always apparent in the first session, but can plague the hair restoration down the line; therefore, it should be evaluated carefully in the initial patient assessment. A very loose scalp can present its own set of problems, as patients with very loose scalps often heal with widened donor scars. [18]   

The average donor density of a Caucasian is about 225 hairs/cm2. This can easily be measured using a hand-held instrument called a densitometer. (2) When the density of a Caucasian is below 180, a hair transplant should be undertaken with great caution. In this author?s opinion, when the maximum donor density is below 150/hair mm2, a person should generally not be transplanted, as there will not be enough donor hair to make the procedure cosmetically worthwhile and the risk of a visible donor scar is too great. (3) Exceptions would be an older person with very limited expectations and in races where the normal density is lower (i.e. Asians and Africans). 

Hair characteristics, particularly hair shaft diameter, are as important as the absolute number of hairs in determining the outcome of a procedure.  The amount of transplantable hair is related to both the number of movable hairs (determined by the size of the donor area, scalp laxity and donor density), multiplied by the hair shaft cross sectional area.  Since each hair in a person with coarse hair can have over 5 times the volume as a person with fine hair, the estimate (or actual measurement) of hair shaft diameter is important in determining the overall donor supply.  

Miniaturization, the progressive diminution of hair shaft diameter and length (the result of the action of DHT on the hair follicle) produces thinning on the front, top and crown of the scalp and is the hallmark of androgenetic alopecia.  But the back and sides of the scalp can miniaturize as well and when a significant portion of a patient?s donor area is miniaturized, the hair in this area can be rendered useless for a hair transplant. (Figures 1 and 2)

This condition, called diffuse unpatterned hair loss (or DUPA), is the most common type of hair loss seen in women and it is not uncommon in men.  It goes without saying, that every patient, male or female, in whom a transplant is being considered, should be evaluated for donor miniaturization using densitometry to make sure that the donor hair to be transplanted is stable. 

Recipient Demand

One should never assume that a person?s hair loss is stable. Hair loss tends to progress over time.  Even patients who show a good response to finasteride will eventually lose more hair.  It is always best to consider the reasonable worst-case scenario when assessing how bald the patient may become, so that the finite donor hair can be allocated properly. Although the Norwood classification is very helpful in staging the hair loss, it doesn?t take into account actual scalp dimensions. Just like the donor site, the recipient area should actually be measured.  Even within a single Norwood class, there is a vast difference between a patient with a narrow forehead and one with a very broad head with respect to the actual surface that needs to be covered, and thus the number of grafts required for the restoration. 

Designing the Hairline 

Hairline Position

In the adolescent, the hairline sits just above the upper brow crease formed by the upper border of the frontalis muscle directly below it.  The position of the normal adult male hairline is approximately 1.5cm above this crease at the midline). A common error is to place the newly transplanted hairline at the adolescent position, rather than one appropriate for an adult. Although the younger patient, first experiencing hair loss, may put considerable pressure on the doctor to place hair in the lower position, the physician should not yield to this demand. 

Under normal circumstances, as a patient ages, his density decreases and the natural hairline will move back somewhat.  However, a transplanted hairline is immutable. Therefore, when the transplanted patient continues to thin or bald (which he invariable will) the fixed low frontal hairline will begin to look out of place, since it is natural for a person with decreased overall hair volume to have a slightly receded hairline, rather than one that is still in the adolescent position. 

Hairline Shape

A similar logic applies when choosing the shape of the hairline.  As a male passes from adolescence to adulthood, his broad, flat hairline evolves into a more tapered shape with some recession at the temples.  A persistent low, broad hairline is enjoyed by those who also maintain their adolescent density. This situation is not present in those who are suffering from androgenetic alopeica; therefore, a transplanted flat hairline will not 'age well' over time and will look unnatural as the patient?s overall density decreases and particularly as the crown begins to thin. 

If a person is older, has maintained a high donor density, and has a small risk of extensive hair loss, a broader hairline is possible.  However, this is not this case for the person who is starting to bald at a young age, since he has a significant risk of extensive baldness and, more importantly, the extent of his future hair loss can not be known at the time the surgery is planned. 

Graft Distribution

The nuances of graft distribution and the multitude of problems that result from distributing grafts improperly are beyond the scope of this writing; however, there are two main but related themes that the hair transplant surgeon should be cognizant of when deciding where to place grafts. The first is to set a target area of coverage that takes into account the patient?s future balding pattern, as well as, his total donor hair supply.  The second is to forward weight the grafts, rather than distributing them evenly over the top of the scalp.

Extent of Coverage

The problem of deciding how much bald scalp a hair transplant should cover can be illustrated as follows.  As an example, take a patient whose total number of follicular unit grafts available to harvest is around 5,500.  The front part of the scalp has a surface area of about 50 cm2.  The top or mid-scalp has an area of about 150 cm2 and the vertex or crown about 175 cm2. However, the size of the bald crown can vary dramatically depending upon the extent of hair loss, reaching over 200cm2 in a Norwood Class VII patient. 

If the front and top of the scalp were transplanted using all of the patients donor hair, the transplanted density would be only 5,500grafts/200cm2 or 27.5 grafts/cm2 (less than 1/3 the density of the patient?s original hair). If the crown were covered as well, that would be 5,500 grafts/400cm2 or 12.5 grafts/cm2 (only 15the density of the patient?s original hair).  Using various manipulations, such as creating different densities in different parts of the scalp, a skilled surgeon can make 1/3 of the overall density look like a substantial amount of hair. However, working with only 15of the original density, can make the job of creating a natural look significantly more difficult, if not impossible.    

The way to avoid having a hair transplant with a look that is too thin, or see-through, is to limit the extent of coverage to the front and mid-scalp until an adequate donor supply and a limited balding pattern can be reasonably assured -  an assurance that can only come after the patient ages.  Until that time, it is best to avoid adding coverage to the crown.  

Another problem with transplanting the crown early is that as the crown expands additional hair will be needed to follow the expanding area of baldness outward, just to keep the first hair transplant looking natural. This may require considerable amounts of hair that will not be available to cover the front and mid-scalp if that were too bald as well. On the other hand, if the hair transplant was limited to the vertex transition point or VTP (see figure above), the restoration would look natural without further surgery no matter how far the hair loss in the crown progressed. The reason is that the front and top of the scalp represent a complete cosmetic unit, with the VTP as the natural posterior boundary - so it is natural for hair to cover this region of the scalp but not beyond.  

Density Gradients

Another way for surgeons to prevent a thin, see-through look is to avoid distributing the grafts evenly over the transplanted area. It goes without saying that only 1-hair grafts should be used at the hairline, with larger grafts behind them, but there are additional ways to produce the gradations of density to mimic the way hair grows in nature.  Specifically, the greatest density should be in the front part of the scalp (shown in brown) and particularly in the frontal forelock area (shown in dark brown).

The greater density in the front of the scalp forelock area can be created in two ways; by placing the recipient sites closer together in this location and by using larger follicular units in the area (i.e. 3- and 4- hair units rather than 1s and 2s).  These techniques may be use in combination to achieved greater density but, as will be discussed in the following section, if done to excess, may compromise growth.  

Summary

Follicular unit transplantation is a powerful hair restoration technique that allows the surgeon to create natural hair patterns and produce results that mimic nature. The success of the procedure depends greatly on proper patient selection, accurately assessing the patient?s donor supply, and distributing the grafts in a way that is appropriate for a person who will continue to age and eventually thin over time. With thoughtful planning, major mistakes can be avoided and our patients will be able to achieve the full benefit of this remarkable procedure. 


References

1. Orentreich N: Autografts in alopecias and other selected dermatological conditions. Annals of the New York Academy of Sciences 83:463-479, 1959.
2. Bernstein RM, Rassman WR, Szaniawski W, Halperin A: Follicular Transplantation. Intl J Aesthetic Restorative Surgery 1995; 3: 119-32.
3. Bernstein RM, Rassman WR: Follicular Transplantation: Patient Evaluation and Surgical Planning. Dermatol Surg 1997; 23: 771-84.
4. Bernstein RM, Rassman WR: The Aesthetics of Follicular Transplantation. Dermatol Surg 1997; 23: 785-99.
5. Gandelman M, et al: Light and electron microscopic analysis of controlled injury to follicular unit grafts. Dermatol Surg 2000; 26(1): 31.\
6. Bernstein RM, Rassman WR, Rashid N, Shiell R: The art of repair in surgical hair restoration - Part I: Basic repair strategies. Dermatol Surg 2002; 28(9): 783-94.
7. Bernstein RM, Rassman WR, Rashid N, Shiell R: The art of repair in surgical hair restoration - Part II: The tactics of repair. Dermatol Surg 2002; 28(10): 873-93.
8. Bernstein RM, Follicular Unit Hair Transplantation. In: Robinson JK, Hanke CW, Siegel DM, Sengelmann RD, editors: Surgery of the Skin, Elsevier Mosby, London UK. 2005.
9. Unger WP, Shapiro R. Hair Transplantation. New York: Marcel Dekker, Inc. 2004.
10. Bernstein RM, Rassman, WR. Follicular Unit Transplantation. In: Haber RS, Stough DB, editors: Hair Transplantation, Chapter 12. Elsevier Saunders, 2006: 91-97.
11. Norwood OT. Male pattern baldness: classification and incidence. So. Med. J 1975; 68:1359-1365.
12. Haas AF, Grekin RC: Antibiotic prophylaxis in dermatologic surgery. J Am Acad Dermatol 1995; 32: 155-76.
13. Otley CC. Perioperative evaluation and management in dermatologic surgery. J Am Acad Dermatol 2006; 54: 119-27.
14. Gandelman M, Bellio R, Barretto M: Beta-blockers and local anesthetics with vasoconstrictors: A dangerous association. Intl J Aesthetic Restorative Surgery 1995; 3 (2): 143-45.
15. Bernstein RM, Rassman WR: Limiting epinephrine in large hair transplant sessions. Hair Transplant Forum International 2000; 10(2): 39-42.
16. Skidmore RA, Patterson JD, Tomsick, RS: Local anesthetics. Dermatol Surg 1996; 22:511-522.
17. Phillips KA, Menard W: Suicidality in body dysmorphic disorder: A prospective study.  Am J Psychiatry, 2006; 163:1280-82. 
18. Bernstein RM, Rassman WR. The scalp laxity paradox. Hair Transplant Forum International 2002; 12(1): 9-10.

 Article Source:

About the Author

Dr. Bernstein is Clinical Professor of Dermatology at the College of Physicians and Surgeons of Columbia University in New York. He is recognized world wide for pioneering Follicular Unit Hair Transplantation. Dr. Bernstein’s hair restoration center in Manhattan is devoted to the treatment of hair loss using his state-of-the-art hair transplant techniques.

Densitometry and Video-Microscopy in the Hair Transplant Evaluation

Author: Robert M. Bernstein, M.D.

Densitometry is a technique that analyzes the scalp under high-power magnification to give information on hair density, follicular unit composition and degree of miniaturization. It can be used to help evaluate a patient\'s candidacy for hair transplantation and help predict future hair loss. More recently, video-microscopes have been developed that can project the image onto a computer screen and provide a permanent digital record. This paper describes the value of taking objective measurements, using densitometry or video-microscopy, in the hair transplant evaluation.

Background

One of the earliest methods of measuring hair density was devised by Bouhanna, who used camera attachments to create a 'phototrichogram,' an ultra close-up photograph of hair exiting the scalp. This method provided the capability to document the quality and quantity of hair shafts.  However, the disadvantage of this innovation was that an assessment could not be done until after the film had been developed. [1]

In 1993, Rassman introduced a small hand-held instrument, the Hair Densitometer, to make densitometry easy to perform during a consultation. [2, 3].  The hair densitometer is a self-contained, portable, device that houses a magnifying lens and an opening of predetermined size.  The hair is clipped short (~ 1-mm) and the unit is placed directly on the scalp.  An assessment is made from a standard 10mm2 field.  Multiple measurements taken from different parts of the scalp are often helpful, particularly if there is significant variability from one location to another. [4] An advantage of the hand-held densitometer is that it is inexpensive and readily available to be used during the consultation and can provide immediate information regarding a patient\'s candidacy for surgery.  

A number of other hand-held instruments to measure density have been developed with the similar basic elements of magnification, illumination and a calibrated field or ruler. With more recent technology, digital trichograms allow the physician to take quantitative measurements of hair shaft diameters and provide an immediate, permanent record of this information. [5-7]

The densitometer was initially used to quantify a patient\'s donor density, to estimate the total number of grafts that could be safely obtained from the donor area, and help predict the change in reserves over subsequent transplant sessions. [3] With the introduction of Follicular Unit Transplantation in 1995, these authors began to use densitometry to assess follicular unit composition (the number of terminal and miniaturized hairs that each individual unit contained) and follicular unit density (the spacing between units), as these additional factors were found to be important in the assessment of the donor supply and in the overall surgical planning of follicular unit transplantation procedures. [8-10]. The use of densitometry was soon expanded to guide the surgical treatment of those with racially distinct hair characteristics, to improve the diagnosis and treatment of balding women, and to further define the conditions of diffuse patterned and un-patterned hair loss. [10-12]

A number of other hand-held instruments to measure density have been developed with the similar basic elements of magnification, illumination and a calibrated field or ruler.  With more recent technology, digital trichograms allow the physician to take quantitative measurements of hair shaft diameters and provide an immediate, permanent record of this information. [5-7] [Figure 2]

The densitometer was initially used to quantify a patient\'s donor density, to estimate the total number of grafts that could be safely obtained from the donor area, and help predict the change in reserves over subsequent transplant sessions. [3] With the introduction of Follicular Unit Transplantation in 1995, these authors began to use densitometry to assess follicular unit composition (the number of terminal and miniaturized hairs that each individual unit contained) and follicular unit density (the spacing between units), as these additional factors were found to be important in the assessment of the donor supply and in the overall surgical planning of follicular unit transplantation procedures. [8-10].  The use of densitometry was soon expanded to guide the surgical treatment of those with racially distinct hair characteristics, to improve the diagnosis and treatment of balding women, and to further define the conditions of diffuse patterned and un-patterned hair loss.  [10-12]   

Miniaturization

Normally, follicular units contain 1-4 terminal hairs of uniform diameter and, occasionally, fine vellous hairs, with the two hair populations being clinically distinct.   In androgenetic hair loss, the action of DHT causes individual terminal hairs in some follicular units to miniaturize, where they begin to decrease in diameter and in length until they resemble vellous hairs. Eventually, these hairs will disappear.  In androgenetic alopecia, hairs in varying stages of involution (and thus of varying diameters) cause these two distinct populations of hairs to merge into one continuum.  The changes eventually cause visible thinning in affected areas, but may initially be detectable only through densitometry.

At first, miniaturization involves only one or two hairs in select follicular units, but eventually progresses to involve all the hair follicles in genetically susceptible areas.  It has been the observation of these authors that a shift from focal to generalized miniaturization precedes the actual loss of affected hairs, so that total hair counts remain relatively constant until end-stage baldness. [8]  Said another way, the progressive thinning associated with androgenetic hair loss (particularly in the early stages) is caused by a decrease in the hair shaft diameter of an increasingly larger number of hairs, rather than by the actual loss of individual hair follicles.

Miniaturization, unfortunately, can also occur in the back and sides of the scalp.  When it affects a person\'s donor area, it will have profound implications for surgery. Although miniaturization in the donor area is a relatively uncommon occurrence in men, it is quite common in women, explaining why so many more men with hair loss are candidates for surgery compared to women.  In all cases, donor miniaturization must be assessed prior to considering surgery.

Densitometry Measurements

Densitometry is extremely helpful in evaluating patients for hair transplantation. When determining which persons are candidates for hair transplantation, it can be used to measure the absolute donor hair density (i.e. # of hairs/mm2), the composition of follicular units (i.e. the number of 1-, 2-, 3- and 4-hair units), and the degree of miniaturization.

Although the precise hair density and composition of follicular units will not be known until after the donor strip has been completely dissected, at the time of the consultation, densitometry can tell the doctor the approximate hair density. This will enable him to determine how much hair will be obtained from a certain size strip or how large a strip will be needed for a required number of follicular unit grafts.  

Densitometry will also give information regarding the cosmetic impact of the hair restoration.  Other hair characteristics being equal, if a person has a high number of 3- and 4-hair grafts, he/she would be expected to have a fuller hair transplant than a person with predominately 1- and 2-hair follicular units. 

For example, a typical Caucasian would have follicular units in his/her donor area that contained, on average, 2.25 hairs each.  If there were 1 follicular unit per mm2 in the donor area (0.9 to 1.0 is normal) then one would need 2,500mm2 of donor tissue for a 2,500 graft procedure. A donor strip that was 1cm wide would need to be approximately 25cm long to contain 2,500 follicular unit grafts.  See the following table.

Stereo-microscopic dissection of the donor strip would yield approximately 141-hair grafts, 532-hair grafts and 333- and 4-hair grafts.  The single-hair grafts would be used to create a soft, natural frontal hairline and the 3- and 4-hair grafts would be used in the forelock area to create the appearance of central density. 

Small variations in follicular unit density can have a significant impact on the procedure. A person of similar hair shaft characteristics (i.e. hair diameter, color and wave) that had 2.0 hairs per follicular unit, also spaced 1mm apart, would require exactly the same size strip for a 2,500 graft procedure.  In this case, however, the follicular units would, on average, have less cosmetic value and the person should expect a thinner look from the surgery as only 17of the grafts contain 3- or 4- hairs.  In addition, the ability to create central density via graft sorting would be reduced.  On the other hand, with a donor density of 2.4 hairs per unit, 40of the grafts will contain 3- or 4-hairs and the ability of the surgeon to create density in the forelock area using only naturally occurring follicular unit will be significant

If we look at the total number of hairs contained in the follicular units, we note that for a 2,500 graft procedure, a person with 2.4 hairs per follicular unit will have 1,000 more hairs than a person with a density of 2.0.

Densitometry, therefore, gives the physician information regarding the number of single hair units that can be anticipated from a given size donor strip (without having to subdivide larger units) and the degree to which the larger follicular units can create central and forward weighting to enhance the aesthetic impact of the procedure. 

Donor Miniaturization 

Normally, the donor area shows little or no miniaturization and the density counts described above are useful in predicting both the short- and long-term outcome of the procedure.  However, if genetic hair loss affects the donor area, the situation changes dramatically. Once full-thickness terminal hair begins to miniaturize, the cosmetic value of the follicular unit begins to decrease and the value of the grafts will be diminished.  In other words, just because hair is transplanted, it doesn\'t make the hair transplant   permanent - the hair in the donor area must be permanent.     


Early detection of miniaturization in the donor area is a warning sign that the donor area is not stable and that the person may not be a good candidate for surgical hair restoration.   If any miniaturization is detected in a young person, i.e. under the age of 25, red flags should go up that their donor area may not be stable.  When miniaturization is noted in a teenager, the risk of developing diffuse un-patterned hair loss (see below) is significant.  In an older adult male, some miniaturization, perhaps up to 20 is consistent with being a good surgical candidate. 

Unlike men, adult women often have significant levels of miniaturization in the donor area, so the mere presence of miniaturization is not necessarily a contraindication to surgery.  However, miniaturization does indicate an unstable donor supply and one has to make a judgment regarding the risk/reward of the procedure. The physician needs to consider the absolute number of full terminal hairs that are available for the hair transplant, the risk of further miniaturization, the area that needs to be covered, and the risk of the surgery accelerating the hair loss.  This is particularly important to consider in women, since hair is often transplanted into an area that has a considerable amount of existing hair - some of which is at risk of being shed from the surgery. 

In women, when the risk of continued miniaturization of the donor area is added to the risk of the surgery accelerating hair loss in the area to be transplanted, a far fewer percentage of women are good candidates for surgery compared to men. To think otherwise is disingenuous. 
Diffuse Patterned and Un-patterned Alopecia

The importance of donor miniaturization as a factor affecting a person\'s candidacy for a hair transplant was emphasized almost a decade ago in the paper 'Follicular Transplantation: Patient Evaluation and Surgical Planning.'[4] In this writing, we described two conditions; 'Diffuse Patterned Alopecia' (DPA) and 'Diffuse Un-patterned Alopecia' (DUPA). These were first mentioned by O\'tar Norwood when he devised the classification of androgenetic alopeica that bears his name.  These two conditions, however, were not detailed in his paper and never received much attention. This was unfortunate because their understanding gives important insights into how to determine who will be a candidate for hair restoration surgery. [5]

Diffuse Patterned Alopecia (DPA) is characterized by diffuse thinning (miniaturization) in the front, top, and vertex of the scalp in conjunction with a stable permanent zone. DPA is usually associated with the persistence of the frontal hairline and, in the early stages, the thinning is relatively even across the top of the scalp. This contrasts with regular Norwood patients that have early hair loss at the temples and in the crown with balding that spares the top of the scalp. Patients with DPA can be good candidates for hair transplantation due to their stable permanent zone; however, they have an increase risk of shedding after the hair transplant, due to the diffuse miniaturization across the top of the scalp.  

In the less common Diffuse Un-patterned Alopecia (DUPA), the miniaturization process occurs over the entire scalp, so that the person lacks a stable permanent zone. People with DUPA tend to lose their hair at an early age, often beginning in their teens. In the early stages, there may be only a slight suggestion of decreased hair volume overall and actual thinning may only be noted through densitometry. Over time, the back and sides of the scalp can take on a transparent appearance, particularly when the hair is cut short. Because the donor area is not permanent, hair transplantation is contra-indicated in patients with Diffuse Un-patterned Alopecia.   

Although fully manifest diffuse un-patterned hair loss is relatively uncommon in men, there are many younger patients who have slightly increased degrees of miniaturization in the back and sides of the scalp, making the long-term stability of the donor area questionable. In these patients, the decision to recommend hair restoration surgery is particularly difficult.  As a general rule, if the decision is difficult, it is best postponed, since, over time, the stability of the donor area will become more obvious.  A mistake can leave the patient with transplanted hair that will thin over time and a donor scar(s) that may become visible.

Both Diffuse Patterned and Un-patterned alopecia also occur in women. However, in contrast to men, the DUPA pattern in women is much more common, possibly occurring 10 times as frequently as DPA.  As in men, female patients with DUPA are not good candidates for a transplant, except in the instance where the goal is solely to soften the frontal edge of a hairpiece. The high incidence of Diffuse Un-patterned Alopecia in women partly explains why many fewer women are good candidates for hair transplantation as compared to men. 

It is important to emphasize that other, non-genetic, causes of hair loss must be considered in cases where the balding pattern is diffuse.  These include anemia, thyroid disease, connective tissue disease, gynecological conditions, severe emotional events, and medications. Although the presence of miniaturization likely points toward a hereditary cause of the hair loss, with diffuse hair loss other etiologies must always be entertained.

Conclusion

Densitometry is an important tool for the evaluation of hair loss and for assessing candidacy for hair transplantation.  Measuring donor density and assessing the degree of miniaturization in the donor area should be an integral part of the evaluation of every patient in which surgical hair restoration is considered. This will enable physicians to better select those who are good candidates for a hair transplant and help identify those patients in whom the procedure is contraindicated.  For patients having a hair transplant, these measurements will enable the physician to better estimate the size of the donor strip and be better able to anticipate the aesthetic outcome of the hair restoration procedure.  

References

1. Bouhanna P: Phototrichogram: a technique for the objective evaluation of the diagnosis and course of diffuse alopecia. In W Montagna et al. (eds). Hair and Aesthetic Medicine. Roma, Salus Ed. 1983: 277-280.

2. Rassman WR, Pomerantz, MA. The art and science of mini-grafting. Int J Aesthet Rest Surg 1993; 1:27-36.

3. Rassman WR, Carson S. Micro-grafting in extensive quantities; the ideal hair restoration procedure.  Dermatol Surg 1995; 21:306-311.

4. Bernstein RM, Rassman WR, Seager D, Shapiro R, et al.  Standardizing the classification and description of follicular unit transplantation and mini-micro-grafting techniques. Dermatol Surg 1998; 24: 957-63.

5. Stough DB, Haber RS. Hair Replacement: Surgical and Medical. St. Louis: Mosby-Year Book, Inc., 1996: 139-140.

6. Van Neste D, Dumortier M, De Coster W: Phototrichogram analysis: technical aspects and problems in relation to automated quantitative evaluation of hair growth by computer assisted image analysis. In Van Neste D, Lachapelle JM, Antoine JL (eds). Trends in Human Hair Growth and Alopecia Research. Dordrecht, Kluwer Acad. Pub, 1989: 155-165.

7. Hayashi S, Hiyamoto I, Takeda K: Measurement of human hair growth by optical microscopy and image analysis. Br J Dermatol 1991; 125:123-129.

8. Bernstein RM , Rassman WR, Szaniawski W, Halperin A: Follicular Transplantation. Intl J Aesthetic Restorative Surgery 1995; 3: 119-32.

9. Bernstein RM, Rassman WR: The logic of follicular unit transplantation. Dermatologic Clinics 1999; 17 (2): 277-95.

10. Bernstein RM, Rassman WR: Follicular Transplantation: Patient Evaluation and Surgical Planning. Dermatol Surg 1997; 23: 771-84.

11. Bernstein RM, Rassman WR: The Aesthetics of Follicular Transplantation. Dermatol Surg 1997; 23: 785-99.

12. Norwood OT. Male pattern baldness: classification and incidence. So. Med. J 1975; 68:1359-1365.

 Article Source:

About the Author

Dr. Bernstein is Clinical Professor of Dermatology at Columbia University in New York. Dr. Bernstein\'s hair restoration center in Manhattan is devoted to the treatment of hair loss using his state-of-the-art hair transplant techniques. To read more publications on hair loss, visit http://www.bernsteinmedical.com/.

From Scalp to Brow: Eyebrow Transplants are Hair Transplants Too

Author: Robert M. Bernstein, M.D.

Eyebrow reconstruction as a hair transplant technique is based on the technology first reported by Krusis in Germany in 1914 and later by the Japanese in the 1930 and 40s. In 1943, Tamara reported that single-hair grafts should be used for the hair restoration as these would look the most natural. Nearly a half-century later, when the most advanced type of scalp hair transplantation consists of using naturally occurring follicular units containing 1-4 hairs, the most refined type of eyebrow transplant still consists of using individual hair follicles.

The advance in eyebrow hair restoration lies, therefore, not in the use of individual hairs - this has been known for a long time - but in the adoption of techniques used in scalp hair transplantation that enable the physician to carefully isolate these individual hair follicles from the donor scalp.

The specific technique is called stereo-microscopic dissection, and it enables the surgeon to generate a hair follicle that contains all the essential anatomic structures necessary for maximum survival and growth, but that is devoid of the excess tissue that makes traditional grafts too cumbersome for the nuanced restoration of the eyebrows.

A carefully dissected single-hair micro-graft, trimmed of excess epidermis, dermis and fat, has the flexibility to be inserted into the tiny opening made with a fine hypodermic needle and placed at an angle almost flush with the skin - two techniques that are essential for the most natural restoration. The tiny recipient sites allow the grafts to be placed very close together. However, when closely placed grafts are angled so acutely, the base of one follicle literally lies under the shaft of the next, so that any extra volume to the graft can leave an unnatural lumpiness on the brow. The slender, microscopically dissected grafts have no volume other than the functional follicle, so they are perfectly suited for this closely spaced, acutely angled graft placement.

The Hair Cycle

The normal hair cycle varies from months to years; depending upon the part of the body the hair is located. Each hair regenerative cycle has a growth phase called anagen and a resting phase called telogen. The anagen phase for scalp hair ranges from 3-6 years while the anagen phase of the eyebrow hair is significantly shorter. The rate of growth for scalp hairs ranges from .30-.41 mm per day (about a half inch per month), while the growth rate of the eyebrow hair is half of that.

When scalp hair is transplanted to the eyebrow, the longer hair cycle of the scalp hair makes it grow to a cosmetically unacceptable long length. This necessitates frequent trimming of the eyebrows that is not only a nuisance, but that produces a cut end that is less elegant than the finely pointed tip of an uncut hair.

Over time, the transplanted hair will assume some of the characteristics of the site that it was transplanted into and the length of the transplanted hair will begin to gradually decrease. It is not known if the transplanted follicles will eventually assume the full characteristics of the surrounding eyebrow hair, but work by Wang et al. suggests that influences of the recipient are more significant than was previously thought.

Indications for Eyebrow Hair Restoration and Reconstruction

A variety of conditions can result in a loss or alteration of the eyebrows. Probably the most common is self induced - caused by repeated plucking of the eyebrows for aesthetic reasons, or less often from a compulsive disorder called trichotillomania. Those who pluck hair as an obsessive-compulsive disorder (OCD) should not be transplanted without addressing the OCD first, since transplanting the eyebrow will fail as the patient returns to old habits.

Other forms of physical trauma that may result in loss of eyebrows include car accidents, burn injuries, defects from surgical procedures, and radio- and chemotherapy. Burns or trauma may result in the formation of scar tissue that initially precludes hair transplantation. In these cases, reconstructive surgery may be necessary before the eyebrow hair transplant can be accomplished. Thickened scars may respond to injections of corticosteroids and, once thin, may readily support the growth of transplanted hair.

Women with eyebrows that they deem to be too thin occasionally have them tattooed, but this almost invariably looks unnatural. The situation worsens as the pigment is engulfed by macrophages and brought deeper into the dermis causing the black-brown color to take on a bluish hue. The pigment can be successfully removed with lasers, but then the once thin eyebrows become totally devoid of hair.

A common dermatologic condition that may cause the loss of the eyebrows (and eyelashes as well) is alopecia areata. This is a genetic, auto-immune condition that manifests with the sudden onset of discrete, round patches of hair loss with normal underlying skin. It can be treated with injections of cortisone, but tends to re-occur.

Systemic diseases may also cause the loss of one\'s eyebrows and there are also congenital abnormalities that are associated with the absence of eyebrows and/or eyelashes.

In some patients, the disappearance of one\'s eyebrows is a normal occurrence with age and genetic hair loss results from the progressive thinning (miniaturization) of the hair until it is barely noticeable.

For any eyebrow transplant procedure to be successful, one must be certain that the underlying condition that caused the hair loss in the first place has been corrected. Once the hair loss is stable, hair restoration may be contemplated.

The Design

Persons who seek eyebrow hair restoration (or any hair transplant, for that matter) generally have particular desires, goals and prejudices on what the ideal shape of their hair should be. Creating natural looking eyebrows can be a difficult task because of the differences between a patient\'s prejudices and normal eyebrow design. Eyebrows are as different as faces, so 'normal' is a relative term. If beauty is the focus for females, there are rules that can be applied to help define a beautiful eyebrow. Men, who are not satisfied with their eyebrow shape, often want their eyebrows to have a special character, such as the look of Albert Einstein. Some men think that bushy eyebrows are the most desirable as they represent male virility or genius. Women, on the other hand, want delicacy and more well defined shapes. These differences in the preferences of each sex must be understood and incorporated in the design of the restoration from the outset.

Beauty is not just determined by a specific angle or a precise number of grafts. The art of the restoration requires that the surgeon gets 'inside the head' of the patient and understands what he or she wants to achieve. In contrast to balding men, who often cannot remember where their hair was when they were young and who are thus open to any design that will give them hair, the person seeking eyebrow restoration often has very specific ideas in mind. The doctor\'s job is to moderate the patient\'s perspective and make sure that it is reasonable. Mistakes are in full view and can leave a patient with a problem that may require years of plucking to correct.

Proper angulation is the most important aspect of any eyebrow transplant. The hair in the upper part of the central edge of the eyebrow usually points upward to the hairline, while the hair on the lateral aspects points horizontally, towards the ears. The hair in the upper part of the eyebrow should be pointed slightly downward and the lower portion slightly upward, so that they will converge in the middle, forming a slight ridge and resembling the pattern of a feather.

The eyebrows must be put in flat, or they will stick out pointing forward. The surgeon controls the direction and the distribution as the hair is transplanted into the eyebrow, and fine skills are required to densely pack single hairs into the small needle tracks that make for an undetectable wound.

The Technique

The outline of the eyebrow transplant should be carefully delineated using a fine surgical marker according to the design that the doctor and patient had agreed upon during the consultation. Markings should also be used to indicate the directional change of the hair as one moves medial to lateral. It is often helpful to make these markings above the brow (outside the area that will be transplanted) so that they are not lost as the sites are being made.

Once the markings are complete, the patient should be given a mirror to make sure that this is what they had discussed and that the design is satisfactory. At this point we find it helpful for the physician to leave the room (another staff member should still be present) to give the patient a few minutes to reflect on the design.

A small amount of anesthetic should first be injected in the supra-trochlear and supra-orbital notches to create a nerve block to numb the medial and lateral aspects of the brow. Local infiltration using a mixture of xylocaine or bupivicaine and epinephrine can further anesthetize the area and provide rigidity to the eyebrows. Tumescence enables the physician to keep the recipient sites more superficial and at a more acute angle and minimizes bleeding. Due to the small volume of fluid needed, a separate tumescent mixture is generally not necessary. The use of corticosteroids and other particulate solutions should be avoided when injecting around the eyes.

Recipient sites should be created using 20-22g needles (or equivalent instruments), depending upon the coarseness of the hair. If the patient\'s scalp hair is very light and fine, 2-hair grafts can be used in the central part of the brow to create extra density, but these grafts should not be placed near the edges.

Recipient sites should be created holding the instrument as flat as possible to the skin surface, as there is always some elevation of the graft in the normal process of healing. In making the sites, the instrument should be gripped between the thumb and the first and second fingers and held nearly flush to the skin surface. The instrument should not be held like a pencil, as this will not allow the angle to be significantly acute.

The number of grafts needed for the eyebrow hair transplant can vary greatly from as few as 75 per brow to as many as 350. Men generally require significant more grafts than women. It is helpful to make the recipient sites first so that one can determine exactly how many hairs need to be harvested. It is important to remember that follicular units will yield 2-3 grafts on average, depending upon the patient\'s donor density.

If the donor hair is obtained from a strip, then one should excise 1 cm2 of tissue for every 200 grafts required (since there are approximately 100 follicular units averaging 2.3 hairs each per cm2). If hair is obtained via follicular unit extraction, then the staff should dissect the grafts into individual hairs as they are removed from the scalp, so that the doctor can determine exactly how many are needed.

In women, the finer hair in the area over the ears should generally be harvested. In men with fine hair and coarse eyebrows, the area adjacent to the occipital protuberance is usually the coarsest hair on the scalp and may be the best match.

The grafts should be inserted using fine jeweler\'s forceps under loop magnification. The hair must be literally stuffed, rather than inserted, into the sites, as the site is too small to accommodate both the graft and the forceps.

No dressing is required post op and the patient is instructed to sleep with his/her head elevated. The following morning, the patient should gently irrigate the transplanted area to remove any dried crusts. This should be done in the shower at least three times the day following surgery and twice daily for a week. After each shower, an antibiotic ointment should be applied to the brow to help soften any crusts and enable to them to be more easily removed with the next washing. There is often bruising after the surgery that may take a week or more to subside to normal. Bruising is usually most apparent in older patients with significant sun damage.

As the transplanted hairs grow they will require occasional trimming. Using a gel or wax will help them keep the hairs flat as the hair has a tendency be unruly, particularly when they first start to grow. As mentioned above, the hair growth will tend to slow down over time and the hair will begin to assume some of the characteristics of the surrounding hair due to influence of the recipient site.

Patients should understand that two or more sessions may be required to achieve a desired look. Sessions are best spaced a minimum of eight months apart so that the doctor may have the benefit of seeing the first session actually grow in before planning the second.

Challenges of Eyebrow Transplants

When eyebrows are transplanted using scalp hair, they invariably retain some of their donor area hair characteristics of shape, shaft thickness and growth rates. If a person has coarse hair and fine eyebrows, a transplant from the scalp may not be a good match, particularly for a woman who requires delicacy of the new transplanted eyebrow. It is possible to decrease the diameter of the hair shaft by trimming off part, or all of the bulb, but this risks producing an irregularly shaped hair.

Curly eyebrows from an African American kinky haired person with coarse hair may not produce the directional control that the patient needs in a transplant (as African hair has a strong character, particularly in the coarse haired person). As such, some people may not be good candidates for an eyebrow transplant. With newer placing techniques, it is now possible to place the hair so that the curve is oriented in the appropriate direction.

As part of the normal healing process, wounds tend to contract. As a consequence, the cylindrical defect created by the transplanted hair will tend to contract and orient itself more vertically. This will tend to lift the hair slightly away from the skin giving the brow a bushier, unruly appearance. Making the recipient sites at a very acute angle can partially compensate for this, but some elevation may still occur.

Conclusion

Eyebrow transplantation is a safe, out-patient procedure that can significantly enhance one\'s appearance. It is particularly helpful for those individuals who have defective eyebrows caused by disease, accidents or that have been self-induced. However, eyebrow restoration is a nuanced procedure that demands technical skills and artistic knowledge beyond that required for the treatment of a balding scalp. For those physicians who have the aesthetic inclination and who are interested in taking time to develop the special skills necessary for this procedure, eyebrow restoration can produce a significant improvement in the appearance of select patients.

Source:

About the Author

Dr. Bernstein is Clinical Professor of Dermatology at Columbia University in New York. Dr. Bernstein\'s hair restoration center in Manhattan is devoted to the treatment of hair loss using his state-of-the-art hair transplant techniques. To read more publications on hair loss, visit http://www.bernsteinmedical.com/.

12 Common Mistakes Made During Hair Transplants

Author: Robert M. Bernstein, M.D.

INTRODUCTION -

Although follicular unit transplant eliminates many of the shortcomings of older surgical hair restoration techniques, such as a 'pluggy' look, a 'moth-eaten' donor area or midline scalp reduction scars, poor aesthetic judgment and techniques that compromise graft growth can still lead to problems. Perhaps because follicular unit transplant requires large numbers of grafts (using a significant portion of the donor area at one time), because so many staff members are involved in the process, and because some of the problems of small graft procedures are very difficult to correct, improperly performed follicular unit hair transplantation can pose a greater risk to patients than traditional grafting. The risk is compounded by the fact that many physicians perceive follicular unit transplant as a safe, risk-free procedure and describe it to patients as such.

The remainder of this section will focus on some of the most common mistakes made by follicular unit transplant practitioners, particularly in the areas of planning, hair transplant design and handling large numbers of small grafts. These problems and how they may be avoided are summarized below.

1. Operating on patients that are too young or prior to medical therapy
2. Failing to identify low donor density prior to surgery
3. Failing to identify a tight scalp
4. Harvesting a donor strip that is too wide
5. Placing the donor incision too low or too high
6. Using a multi-bladed knife
7. Crushing grafts during insertion
8. Allowing grafts to dry
9. Placing the frontal hairline too far forward
10. Creating a hairline that is too broad
11. Angling hair in the wrong direction
12. Attempting to cover an area that is too large

Operating on Patients That Are Too Young or Before Medical Therapy -

Patents in their early twenties have their flat adolescent hairline and original density fresh in their memory. A hair restoration designed with enough frontal and temporal recession to look good ones entire life will rarely satisfy a younger patient. Creating a density that is ideal for a younger person will not leave enough hair in reserve if there is further loss. In addition, at this age the extent of future balding is difficult to even reasonably anticipate. For these reasons, a hair transplant should rarely be considered in patients with androgenetic alopecia younger than 25 years old.

Often a hair restoration doctor begins medical therapy and schedules surgery at the same time. However, if there is a possibility that using a medication, such as finasteride (Rogaine), can make hair transplantation unnecessary, then the medication should be used for at least a year before any decision on surgery is reached. Medication should be the first line of therapy for all younger patients with androgenetic alopecia, regardless of the degree of their hair loss.

Failing to Identify Low Donor Density Prior to Hair Transplant Surgery -

Assessing a potential patients\' donor supply with densitometry is of vital importance and cannot be stressed enough. A low donor density, generally less than 1.5 hairs per mm2, usually indicates that donor supply is insufficient to create adequate density or coverage, rendering the surgical hair restoration procedure inadvisable. An exception might be an older person with very conservative goals. High miniaturization in the donor area, particularly in a person under the age of 30, suggests Diffuse Unpatterned Hair Loss (DUPA) and is a contraindication to surgery.

Transplanting patients with low donor density will also risk a visible scar if the hair is worn short. Follicular unit extraction is not appropriate in such cases, since it further limits the total available hair. In fact, since the contrast between bald and non-balding scalp in patients with low donor density is naturally low, their best option tends to be wearing their hair short, to decrease the contrast even more (rather than having hair transplant surgery).

Failing to Identify a Tight Scalp (Scalp Laxity) -

Assessing scalp laxity is an underappreciated aspect of the patient evaluation, probably because it is difficult to quantify. However, a tight scalp severely limits the total amount of harvestable donor hair and can constitute a contraindication to surgery, except when hair transplantation patients have extremely conservative goals or are expected to experience only limited balding. The constraints that low scalp laxity impose generally manifest themselves after the first transplant session. Though laxity should be judged in the pre-op evaluation, the intra-operative assessment, made while suturing, is most accurate in predicting future difficulties. Therefore, every operative report should include a record of the ease of closure and intra-operative suture tension.

Harvesting a Donor Strip That Is Too Wide -

In large sessions, it can be tempting to take a slightly wider donor strip in order to conserve on length. A strip that is 25 cm by 1 cm, for instance, can be shortened by 6 cm if widened by just 3 mm--and yield the same amount of hair. However, a wide strip puts unnecessary tension on the donor closure and is probably the most common cause of widened scars. If larger sessions are appropriate, and the scalp lacks adequate mobility, the hair restoration doctor should consider a longer incision rather than a wider one.

If a wide donor strip has been identified as the likely cause of a stretched scar, it is advisable to wait at least eight months, to give the scar a chance to mature and regain some of its original laxity. When the next excision is made, the strip should measure at least 3-6 mm narrower than the previous one. Attempts to remove the entire width of the old scar invariably lead to a reoccurrence, or worsening, of the old scar. To facilitate healing, the new excision should extend to the hair transplant patient\'s hair-bearing edge.

Unfortunately, attempts to re-excise scars commonly result in either no improvement or an even wider defect. For this reason, many doctors use follicular unit extraction to place hair directly into the scar as a primary method of treatment.

Placing the Donor Incision Too Low -

The location of the donor incision greatly affects scalp mobility. The ideal position for it is in the mid-portion of the permanent zone that lies, in most people, at the level of the external occipital protuberance and the superior nuchal line. The muscles of the neck insert into the inferior portion of this ridge, so an incision below this anatomic landmark will be impacted by the muscle movement directly beneath it. A stretched scar in this location is extremely difficult to repair since re-excision, even with undermining and layered closure tends to heal with a wider scar. To compound the problem, one is more likely to cut through fascia with a low donor incision; and once the fascia has been violated, the risk of widening the scar rises considerably.

In addition to the slightly greater risk of a widened scar, the main problems of harvesting hair too high are lack of permanence of the transplanted hair (since it may be subject to androgenic alopecia) and future visibility of the scar were the donor fringe to narrow further. Incisions made too high are best left untreated, unless the scar is wide and poor surgical technique has been identified as the cause. The temptation to transplant permanent donor hair into a high scar should be resisted, as progressive balding would isolate the hair-bearing scar, presenting new cosmetic problems.

Interestingly, in the case of young hair transplant patients with traumatic scars and hair-loss patterns that are still unclear, Follicular Unit Extraction can function as a hedge against this risk. If the hair is harvested from the immediate vicinity of the scar, any future balding will affect the transplanted hair in the scar at the same rate as the hair surrounding it.

Using a Multi-Bladed Knife -

In order to save time, a hair restoration doctor performing large transplants may use a multi-bladed knife (one with three or more blades) for harvesting donor tissue. The resulting pre-sliced multiple thin strips are much easier to work with than a single intact strip. Unfortunately, harvesting this way causes unacceptable levels of follicular transection while destroying the naturally occurring follicular unit and is therefore incompatible with follicular unit transplant.

Crushing Grafts During Insertion -

Proper placing technique necessitates the use of forceps to grasp the graft by the fat below the bulb or by the dermis alongside the hair shaft in order to avoid damaging the germinative components of the follicle. Though placers often exercise enormous care while initially grasping the graft, there is a tendency to become rougher when repositioning the forceps for further inserting, replacing a popped graft or transferring grafts from the holding solution to the fingers. Since follicular units and other small grafts are particularly susceptible to crush injury after a hair transplant, improper handling can more than negate the benefits of careful stereo-microscopic dissection.

Allowing Grafts to Dry -

An elegant study using electron microscopy has shown that desiccation is by far the most significant form of injury to grafts and makes them much more susceptible to other forms of injury, such a mechanical trauma and warming. Grafts should therefore be kept well-hydrated with chilled isotonic solution (such as Ringer\'s lactate) from the moment the tissue is harvested until the time they are reinserted into the scalp.

Placing the Frontal Hairline Too Far Forward (Too Low) -

Despite the fact that individual follicular units at the hairline in themselves look natural, their proper placement is no less important than in traditional grafting. The frontal hairline should be placed no lower than 1.5 cm above the upper brow crease. Particularly if the underlying skin is normal, follicular units placed too low can be removed with an alexandrite (755 nm) or diode (800, 810 nm) laser. Electrolysis is more difficult and time-consuming with transplanted follicles, but should also be considered. Punch excision is too imprecise for very small grafts and risks scarring.

Creating a Hairline that is Too Broad -

Since significant temporal recession is characteristic of the normal adult male hairline, a broad, flat transplanted hairline will not age well and can cause cosmetic problems if baldness becomes extensive. The treatment is the same as with low hairlines, but it should be noted that if grafts larger than follicular units were used, and/or if there is scarring of the recipient skin, punch excision with reutilization of the hair may be indicated.

Angling Hair in the Wrong Direction -

As noted earlier, in the front and top part of the scalp, hair grows in a distinctly forward direction, changing to a radial pattern as it approaches the crown. It emerges from the scalp at an acute angle, with the hair lying practically flush to the skin at the temples.

There has been a tendency among some hair restoration doctors to transplant grafts perpendicular to the skin -- probably due to the fact that the mechanics of the old plug procedures made sharp angling technically difficult. The cosmetic consequence of this is most apparent at the frontal hairline. When the hair is perpendicular, the viewer\'s eye is guided to the base of the hair shaft where it inserts into the skin; conversely, when hair is transplanted in its natural, forward-pointing position, it is bowed by grooming and the eye settles on the body of the hair shaft.

When grafts at the frontal hairline are transplanted in a radial direction, combing the hair in any style becomes problematic and invariably results in an unhappy patient. As with low or broad hairlines, hair that is angled in the wrong direction, particularly in the frontal hairline, should be removed.

Attempting to Cover an Area That Is Too Large -

Attempting to cover an area greater than the donor supply can adequately fill may leave cosmetically important areas thin or un-transplanted. In general, the first region to bald is the area where you should be most hesitant to transplant. Recession at the temples and thinning in the crown are usually the earliest manifestations of baldness, but they are acceptable, especially as patients age, so these areas may be left un-transplanted. The central forelock region, however, is generally late to bald, but when balding occurs, the patient loses the frame to his face and its restoration becomes essential.

Whether or not these areas need coverage at the time of the initial transplant, an adequate amount of hair must always be reserved for critical areas, such as the forelock and top of the scalp. If donor reserves are limited, the transplantation of less critical areas should be postponed or avoided all together.

SUMMARY -

Developed within the past decade, Follicular Unit Transplantation has emerged as both the standard and the cutting edge in hair transplant surgery. In conserving donor hair, achieving optimal coverage and creating a natural look, follicular unit transplant represents a considerable advance over earlier methods of hair restoration. Appropriately, it also demands considerably more from its practitioners. Surgical hair restoration teams must develop the skill and stamina for the delicate handling of large numbers of follicular unit grafts, while surgeons must cultivate a keen aesthetic sensibility with regard to transplant design and graft placement.

In view of the psychological aspects of hair loss, Follicular Unit Transplantation requires a thorough preoperative assessment to understand the patient\'s expectations, a careful examination to determine if surgery is appropriate and, most importantly, the establishment of realistic goals. If the surgical route is chosen, meticulous attention to detail is required in every aspect of the procedure so that these goals may be realized. It is a daunting task for the hair restoration doctor and surgical team to develop the necessary expertise for perfecting Follicular Unit Transplantation; but when they do, their work can benefit patients for their lifetime.


REFERENCES -

{for a complete list of references, please visit http://www.bernsteinmedical.com/resources/FUHT2005-5.php}

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About the Author

Dr. Bernstein is Clinical Professor of Dermatology and is recognized worldwide for pioneering Follicular Unit Hair Transplantation. Dr. Bernstein\'s hair restoration center in Manhattan performs Follicular Unit Transplants and other hair restoration procedures. To read more publications on hair loss, visit http://www.bernsteinmedical.com/.

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