Master Plan

The essence of the “Master Plan” is to always consider that the patient may eventually go on to have extensive hair loss. By keeping this in mind during the surgical planning, the patient will never be caught “short of hair” in the long-term, and will always look natural. The key here is to plan the various surgeries in a timely manner and use only the amount of hair that is appropriate for the patient’s hair loss balding pattern for the present and for the worst case the doctor and the patient can come up with for future hair loss

The decisions that go into this planning are quite complex, but in the most general terms, it involves the following:

  1. Framing the face as the highest priority.
  2. Providing coverage for the front and top of the scalp before the crown.
  3. If the crown is transplanted early, be certain that there is enough hair in reserve for the front.
  4. Have each surgical procedure “stand on its own” with respect to looking natural.
  5. Check out the various parts of the scalp hair for hair loss using a bulk measurement device to estimate both the true nature of your hair loss and future predictions for it as well.
  6. Transplant only in large sessions to try to achieve your goals safely and in as few surgeries as possible.
  7. Use only surgical techniques that maximally conserve donor hair.
  8. When appropriate, use medication in conjunction with surgery, but never rely on the medication to work.

The following is a very brief discussion of these issues. Since the Master Plan is taken into account in all of our decisions, the ideas are integrated into all of our writing. Please refer to the references for more detailed information.

1. Framing the Face

For the majority of patients, establishing the frontal hairline is the single most important function of the hair transplant as this frames the face and restores balance to the patient’s facial features.The Master Plan dictates that the position of the hairline be appropriate for the patient’s lifetime. This can be assured by placing it in its normal, mature position. It should not be placed lower and certainly not higher than the normal location. On the other hand, the common practice of creating a hairline significantly above the mature hairline position with the intention of lowering it in a subsequent procedure should be avoided. The mid-line for the mature hairline is always one finger breath above the highest crease in the furrowed brow.

If the intent is to conserve hair in anticipation of a very limited donor supply, one should still maximize the cosmetic impact of the surgery. However, the position of the mid-portion of the frontal hairline should not be compromised, as this defines the “look” of the individual. Creating a hairline too high (in the hope of conserving donor hair) only accentuates the patient’s baldness by enlarging the forehead and distorting the normal facial proportions and often point to the obvious fact that the high hairline is a transplanted hairline.

2. Providing Coverage for the Front and Top of the Scalp

Another key element of the Master Plan is to be able to provide coverage to the front and top of the scalp in all cases, and the crown if there is adequate donor supply. The amount of hair needed to cover the front and top of the patient’s scalp will obviously vary depending upon the extent of baldness. However, there should always be an attempt to cover these areas in the first session, even if the coverage is relatively light.

3. Crown Coverage

In general, covering the crown should not be a goal of the first session if there is frontal balding, but should be addressed after the cosmetically more important front and top have been adequately or lightly transplanted. Since the front and top of the scalp are a single cosmetic unit, the transplant may stop after this area has been treated. The patient can then evaluate for himself the adequacy of coverage from the first procedure, and if he desires more fullness or greater density, a second session can be used to supplement the area transplanted in the first.When crown coverage is attempted in the first session, the patient’s options may be more limited, and the ability to produce an aesthetically balanced transplant may be diminished. The crown should be transplanted only if the doctor believes that there are enough donor reserves to transplant the front and top in the event that those areas become bald.

4. Each Procedure Should “Stand on its Own”

According to the Master Plan, barring significant further hair loss, the patient should be able to stop after each session and look completely natural. In other words, the hairline should be soft and feathered after one session and the transplant should look natural from all angles and views. A NHI physician will never say to you “I know the grafts look a little large, but just wait, after one more session it will be fixed.” A doctor should not have to correct his own work. He should get it right the first time. This doesn’t mean that the final density can be achieved after one session or that other procedures won’t be needed. What it means is that each session should appear natural from the outset and be able to stand on its own.The second part to this is that the entire area to be covered should be transplanted in each session. The old practice of performing the transplant in “sections” rather than all at once, should be avoided since this makes the patient look like “a work in progress” when, instead, he could have his transplant completed and get on with his life. (Please see: Fast Track)

5. Transplant in Large Sessions

The ability to safely transplant large number of grafts in a single session is one of the most important advantages of using follicular units. Not only do large sessions enable each procedure to stand on its own and allow the transplant to be completed in a shorter time frame, but they also conserve precious donor hair by minimizing the number of times hair has to be harvested from the donor area (Please see: Megasessions). The following chart illustrates the number of follicular unit grafts that we commonly transplant in the first session arranged according to the patient’s specific Norwood Classification. (Please see: Assessing Hair Loss).

Norwood ClassFollicular Units
3800-1500
3 Vertex1300-2400
3A1300-2000
41500-2500
4A1700-2500
5200-3000+
5A1800-2500+
62000-3000+
72500-4000+

 

If there is no additional hair loss, the second session is generally smaller than the first. In the second session, we usually transplant between 60-90% of the number of follicular units used in the first session, although this can vary depending upon the particular needs of the patient. If there were a third session, this would generally be 60-90% of the second.

The range of the total number of follicular unit grafts needed for a complete restoration varies greatly from person to person and depends upon a wide range of factors including the extent of balding, the patient’s hair characteristics and, of course, the patient’s goals. The following chart gives you a general idea of the number of individual follicular unit grafts needed for a complete restoration for patients in each Norwood Class.

Norwood ClassFollicular Units
31500+
3 Vertex1800+
3A1500++
42200-4000+
4A1800-3600+
52500-5000+
5A2000-4400+
63000-7000
76000-8000+

6. Maximally Conserve Donor Hair

The success of a “Master Plan” depends upon maximizing the donor supply in order for the restoration to look as full as possible and to have enough hair available to cover all the planned areas of the scalp. The numbers quoted above are all listed by a range because people with fine dark hair having the exact same balding pattern with a person with coarse light hair will require different amounts of hair. Coarse hair has 4 times the bulk per hair follicle as fine hair and light blonde hair (for example) requires less hair tha black hair against a white skin background. These assessments is the reason a doctor gets involved in the decision process for predicting numbers as it is not so simple to just look up your balding pattern and pick a number of grafts off of a chart. Follicular Unit Transplantation maximizes the donor supply through:

These three aspects of follicular unit transplantation are essential to give the best possible cosmetic result. Please click on these sections for more information.

7. Never Rely on Medication in the Surgical Planning

Medications such as Rogaine (minoxidil) and more important Propecia (finasteride) are playing an increasingly important role in managing patients with hair loss. However, at this point in time, drugs can not be counted on for long-term effectiveness. In addition, their long-term safety profiles are still unknown. Because of this uncertainty, it is prudent for physicians not to rely on these medications as part of any “Master Plan.” What this means is simply that the surgery should be performed under the assumption that the patient will not be using medication. Any benefit from medication will therefore be a “bonus” rather than essential for the transplant to look natural or complete. As we gain more long-term experience with these relative new drugs, this relatively conservation position will undoubtedly change. (Please see: Medications).